timby/smith: introductory medical-surgical nursing, 10/e 01/25 pg 1054

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Timby/Smith: Introductory Medical-Surgical Nursing, 10/e 01/25 PG 1054

Timby/Smith: Introductory Medical-Surgical Nursing, 10/e 01/25 PG 1054

Chapter 66: Caring for Clients with Burns By: P.K. Williams, RN


05 Objectives: 02/25 Pg 1053 05 Objectives: 02/25 Pg 1053

On completion of this chapter, you will be able to:

1. Explain how the depth and percentage of burns are determined.

2. Name three life-threatening complications of serious burns.

3. Differentiate between open and closed methods of wound care for burns.

4. Name three sources of skin grafts.

5. Describe nursing management for the client with a burn injury.


15 Words to Know 03/25 Pg 105315 Words to Know 03/25 Pg 1053

• Allograft Autograft Closed method

• Debridement Epithelialization Eschar

• EscharotomyHeterograft Open method

• Full-thickness-graft Hyperbaric oxygen treatment

• Slit graft Split-thickness-graft

• Stridor Tachypnea


Burn Injuries*** 04/25 Pg 1053 Burn Injuries*** 04/25 Pg 1053

• Pathophysiology, Etiology: Heat; Chemicals; Electricity

– Heat: Cell damage; Protein coagulation

• Severity: Temperature of heat source; Duration of contact; Thickness of tissue exposed; Burn location

– Chemicals: Liquefy tissue; Loosen cell attachment***

– Electrical: Cardiac dysrhythmias; Central nervous system complications***


Question 05/25 Pg 1053 Question 05/25 Pg 1053

Is the following statement true or false?

A burn’s severity is affected by the temperature of the heat source.


Answer 06/25 Pg 1053 Answer 06/25 Pg 1053

True.

A burn’s severity is affected by the temperature of the heat source. Additional factors, which affect a burn’s severity include duration of contact, thickness of tissue exposed to the heat, and the location of the burn.


Burn Injuries*** 07/25 Pg 1053 Burn Injuries*** 07/25 Pg 1053

• Pathophysiology

– Effect of inflammatory process

– Neuroendocrine changes; Edema

– Fluid, electrolyte status alteration

– Anemia; Hemoconcentration

– Factors affecting mortality


Depth of Burn Injury*** 08/25 Pg 1053 Depth of Burn Injury*** 08/25 Pg 1053

• Color

• Skin Characteristics

• Sensation in Burn Area

• ClassificationSuperficial 1st Drg

Partial thickness 2nd Drg

Full thickness 3rd Dr

Through adipose tissue 4rth Drg


Depth of Burn Injury 04/25 Pg 1053 Depth of Burn Injury 04/25 Pg 1053

Figure 66-2 Left: Deep partial-thickness burn

Right: Superficial partial-thickness burn




Burns can affect fluid balance.



True.

As a response to the trauma of a burn, fluid shifts, which results in edema. Not only does it result in edema, the fluid is trapped and unavailable to the rest of the body. Decreased blood pressure (due to decreased fluid volume) can result in irreversible shock.


Zones of Burn Injury 12/25 Pg 1054 Zones of Burn Injury 12/25 Pg 1054

• Zone of Coagulation

• Zone of Stasis

• Zone of Hyperemia


Burn Injury ExtentBurn Injury Extent• Rule of Nines***

• Percentage of TBSA Burned

• Client’s Palm: 1% of TBSA

13/25 Pg 1056


Burn Injuries 14/25 Pg 1053 Burn Injuries 14/25 Pg 1053

• Assessment Findings: Signs and Symptoms

– Light pink to black skin color; Edema; Blistering; Pain; Compromised breathing; Symptoms of hypovolemic shock; Entrance, exit wounds

• Diagnostic Findings: Physical inspection; Radiographs

• Medical Management: Potential life-threatening complications: Inhalation injury; Hypovolemic shock; Infection

– Major burns: Transport to regional burn center




An infection within a burn wound can be life-threatening.



True.

An infection within a burn wound can be life-threatening. Outcome of a burn injury depends on the initial first aid and subsequent acute treatment. Three complications of burns can be life-threatening: inhalation injury, hypovolemic shock, and infection.


Burn Injury Medical Management 17/25 Pg 1056 Burn Injury Medical Management 17/25 Pg 1056

• Initial First Aid: First priority: Prevent further injury; Observe for respiratory difficulty

• Acute Care: Assess extent of burn injury, additional trauma

– Interventions: Ventilation; Fluid resuscitation

•Endotracheal tube; Bronchoscopy

• Mechanical ventilation; Tracheostomy; Hyperbaric oxygen treatment

• IV analgesics; Tetanus immunization


Burn Injury Wound Management 18/25 Pg 1058 Burn Injury Wound Management 18/25 Pg 1058

• Infection prevention measures; Debris Removal

• Open Method: Exposes burned areas to air;*** Used only for areas where it is difficult to apply dressings (face, perineum)

– Isolation; Sterile environment; Escharotomy

• Closed Method: Current, preferred method***

– Use of dressings: Nonadherent; Absorbent; Occlusive, semiocclusive; Dressing changes

• Antimicrobial Therapy: Silver sulfadiazine; Mafenide; Silver nitrate; Acticoat


Burn Injury Surgical Management 19/25 Pg 1059 Burn Injury Surgical Management 19/25 Pg 1059

• Surgical Management: Debridement

– Removal of necrotic tissue

– Four ways: Naturally; Mechanically; Enzymes; Surgery

– Disadvantage: Bleeding

– Covering of healthy tissue: Skin graft; Temporary skin substitute; Cultured skin


Surgical Management: Skin Grafting 20/25 Pg 1053 Surgical Management: Skin Grafting 20/25 Pg 1053

• Purpose: Lessen infection; Minimize fluid loss; Hasten recovery; Reduce scarring; Prevent loss of function

• Keratinocytes regenerate epidermis

• Used for deep partial-thickness and full-thickness burns

• Unassisted Healing: Granulation tissue; Contractures; Chronic open wounds



• Sources for Skin Grafts

– Autograft: Client’s own skin

– Allograft: Human skin from cadaver

– Heterograft: Animal skin

• Types of Autografts

– Split-thickness; Full-thickness; Slit

– Disadvantages; Pressure garments; Sunscreen



• Skin Substitutes

– Cover wound; Promote healing

– Direct interaction with body tissues

– Applied soon after skin is healed and débrided

• Cultured Skin

– Culture client’s skin; Collagen

– Disadvantage: Pigmentation mismatch


Burn Injury Wound Management 23/25 Pg 1062 Burn Injury Wound Management 23/25 Pg 1062

Figure 66-9 Biobrane dressing applied to lower

extremity partial-thickness burn


Burn Injury Nursing Management 24/25 Pg 1053 Burn Injury Nursing Management 24/25 Pg 1053

• Assessment

– Wound; Client’s status

– Calculation and infusion—fluid replacement requirements

– Treatment of shock; Pain relief

• Wound care: Antimicrobials; Dressings; Monitoring for infection; Emotional support

– Client teaching: Exercise; Pressure garments; Skin care measures


End of Presentation & BEGIN NCLEX

By: P.K Williams, [email protected] 25/25 Pg 1053

timby/smith: introductory medical-surgical nursing, 10/e 01/25 pg 1054

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