BURNS 2009

DEPTH OF WOUND

Temperature of burning agent and Duration of contact determines depth of wound:

• Eg: 1 sec of contact with hot tap water at 156 degrees F : full thickness burn

• Eg: 15 sec of contact to hot water 133 degrees F: full thickness burn

DEPTH OF WOUNDDEGREES: 1st, 2nd, 3rd degreeTHICKNESS: layers of skin burned• Superficial partial thickness, deep partial thickness, full thicknessRULE OF NINES: system of assigning percentages in multiples of nine to major

body surfacesLUND AND BROWDNER METHOD: estimating extent of burned area recognizing

effects of body growthPALM METHOD: useful for scattered burns; size of pt’s palm used to assess extent

of burn injury

ASSESSMENT

• SUPERFICIAL THICKNESS: – Involves only the epidermis– Pink to Red, mild edema, painful, no blisters, no

eschar, heals in 3-5days, no grafts– EXAMPLE: sunburn, flash burns

ASSESSMENT

• FIRST DEGREE OR SUPERFICIAL PARTIAL THICKNESS BURN– involves upper third of the dermis; – skin is pink to red, painful, mild to moderate

edema, yes blisters, no eschar. Complete recovery within 10-21 days.

– CAUSED BY: scalds, flames, brief contact with hot objects

ASSESSMENT– SECOND DEGREE OR DEEP PARTIAL THICKNESS:– Caused by: flames, prolonged contact with hot

objects, tar, grease, chemicals – Red to white color, moderate edema, painful, rare

to have blisters, eschar soft and dry, heals 2-6 wk, grafts used if healing is prolonged

ASSESSMENT

• THIRD DEGREE OR FULL THICKNESS;• Caused by: flame, prolonged exposure to hot

liquids, electric current, chemicals, grease• Destruction of entire epidermis and dermis• Black, brown, yellow, white, red, severe

edema, yes and no to pain, eschar (burn crust), heals in weeks to months requiring grafts

ASSESSMENT:

DEEP FULL THICKNESS• Extends beyond the skin into the underlying

fascia and tissues, damages muscle, bone, tendons

• Black, no edema, no pain, no blisters, eschar, takes weeks to months to heal, requires grafts, may need amputation

• Caused by: flames, electricity, grease, tar, chemicals

WHO ARE AT HIGHEST RISK FOR BURNS?

• Age of victim

Primary survey on the sceneFIRST PRIORITY: prevent injury to rescuer then

ABC’S:– Airway, C-spine immobilization– Breathing– Circulation– Deficits (neurological)– ExposeSTOP THE BURNING PROCESS

SURVEY CONTINUED

• Secondary survey– Head to toe assessment

• Pertinent history– Mechanism of injury– Medical history: AMPLE

EMERGENT PHASE OF BURN INJURY

• EMERGENT PHASE: first phase begins at onset of injury and goes to 48 hours

• GOALS: – Secure airway– Support circulation by fluid replacemnt– Provide comfort with analgesics– Prevent infection through wound care– Maintain body temperature– Provide emotional support

AIRWAY MANAGEMENT

• POTENTIALLY SERIOUS INJURY:– Mouth burn– Singed nasal hairs

• SMOKE INHALATION– Burns of the lips, face, ears, neck, eyelids,

eyebrow, eyelashes– Carbonaceous particles in the nose, mouth,

sputum– Edema of the nasal septum– Smoky smell to client’s breath

ASSESSMENT OF RESPIRATORY PATTERN INDICATES A PULMONARY INJURY

Change in resp pattern means pulmonary injury• increased hoarsenes• Brassy cough• ****drooling or difficulty swallowing

– Indicates oropharyngeal edema– Can proceed to pulmonary failure; may NEED INTUBATION

• Audible wheezing, crowing, stridor– Wheezing means obstruction– Sounds disappear– IMPENDING AIRWAY OBSTRUCTION NEEDING INTUBATION

AIRWAY INJURY:CARBON MONOXIDE POISONING

• Carbon Monoxide (CO) found in smoke• CO causes tissue hypoxia when CO combines

with Hgb forming carboxyhemoglobin which competes with oxygen. Hgb likes CO better than O2

• vasodilating action of CO “cherry red color”

• TREATMENT: 100% O2

SMOKE POISONING

• Smoke poisoning or chemical injury from the inhalation of combustion by-products

CIRCULATORY MANAGEMENT

• Circulatory management– shock due to fluid loss– infuse with LR via large bore IV– weigh pt ASAP to determine fluid

replacement needs

FLUID SHIFT DURING THE EMERGENT PHASE

• Initial vasoconstriction of blood vesselsleak fluid third spacing

• Loss of plasma fluids and proteins blood volume BP extensive edema

wgt gain• Protein in the interstitial space the

movement of fluids out from the vascular space

FLUID SHIFT CONTINUES

• IMBALANCES OF F&E– Hypovolemia– Metabolic acidosis– ****Hyperkalemia– Hyponatremia– Hemoconcentration blood viscosity tissue

hypoxia

GUIDELINES/FORMULAS FOR FLUID REPLACEMENT IN BURN PATIENTS

See page 1634• Modified Brooke Formula• Parkland/Baxter Formula• Modified Parkland• Winski

• Calculated from time of inijury and not from the time of arrival at the hospital

FLUID REPLACEMENT: Parkland/Baxter Formula

• 4 ml LR x body wgt (kg) x % BSA burned = fluid replacement

• Give 1/2 calculated amt. in 1st 8hr.• Give 1/4 in 2nd 8 hr. period• Give 1/4 in 3rd 8 hr. period

FLUID REPLACEMENT

EXAMPLE: Pt weighs 70 kg (about 168 lbs)Burned 50% BSA

FORMULA: Using lactated Ringer’s solution: 2-4ml/kg/%TBSA • 2 X 70kg X 50% = 7000 ml/24 hours• Plan to administer first 8 hours 3500 ml or 437 ml/hour• Next 16 hours = 3500 ml or 219 ml/hour

SKIN ASSESSMENT• CALCULATING TBSA or total body surface area is the first step

in determining what amount of fluid will be given using the formula

• RULE OF NINES (see p 1630)– Most rapid– Can overestimate TBSA with this method

• LUND-BROWDER AND BERKOW method: (see page 1630-31) better at identifying differences from birth through adulthood

• BURN CENTER REFERRAL CRITERIA: – See page 1620– Helps determine where a client is best serviced medically

PULMONARY FLUID OVERLOAD

• Pulmonary edema can result from fluid resuscitation

CARDIOVASCULAR ASSESSMENT

• Immediately after the burn: SHOCK can develop

• ****Most common cause of death in emergent phase

• Invasive monitoring may be needed for BP measurement, cannot put on BP cuff

• ASSESSMENT: tachycardia, hypotension, decreased peripheral pulses, slow peripheral cap refill

RENAL/URINARY ASSESSMENT

• RENAL BLOOD FLOW during the fluid shift of the emergent period urine output

HOW DOES THIS EFFECT URINE SPECIFIC GRAVITY?

increased concentration leads to increased urine specific gravity

GATROINTESTINAL ASSESSMENT• During fluid shift • blood flow to vital organs • and sympathetic stimulation during emergent phase

GI motility and paralytic ileus• COMMON CHANGES WITH SEVERE BURNS: – bowel sounds or absent– N &V, abdominal distention– Usually intubated burn pts have NGT to prevent

aspiration and to remove gastric secretions– CURLINGS ULCER may develop within 24 hours

because of reduced GI blood flow

FLUID REMOBILIZATION• At about 24 hrs after injury capillary leak stops• Pt moves into DIURETIC STAGE: begins 48 hrs to 72 hrs after burn injury

– Edema fluid shifts from interstitial space into vascular space– blood volume renal blood flow and diuresis

specific gravity + urinary output– Body weight returns to normal – Hyponatremia from renal sodium excretion and loss of sodium from wound– Hypokalemia from K moving back to cells & potassium excreted in urine– Anemia: from hemodilution– protein lost from the wounds– Metabolic acidosis from loss of sodium bicarb in urine and increased

fat metabolism resulting from decreased carbohydrate intake

HANDLING LARGE PARTS OF THE BODY BEING BURNED

• Leads to massive systemic edema• Leads to compartment syndrome• Treated with escharotomy (surgical incision

into the eschar to relieve the constricting effect of the burned tissue

NURSING CARE CONTINUED• Insert NG tube: • Foley catheter: I&O, sp gr, urine glucose• Pain relief:

– opiods - morphine sulfate, hydromorphone (Dilaudid), fentanyl– Anesthetic agents: ketamine (Ketalar), pentobarbital sodium

(Nembutal), nitrous oxide OBSERVING STRICT PROTOCOLS• Continuous assessment of:

– extremity pulses and – ventilatory limitation

• Emotional support

ACUTE PHASE OF BURN INJURY

• Begins about 36-48 hrs after burn injury and lasts until wound closure is complete– Multidisciplinary approach– Maintenance of all systems– Burn wound care– Pain control – Psychosocial

WOUND CARE

• Hydrotherapy• Topical antibacterial therapy– Silvadene– Sulfamylon– Silver nitrate

WOUND DRESSING

• EXPOSURE METHOD: exposed to air, topical agent, no dressing

• OCCLUSIVE METHOD: topical agent followed by occlusive dressing on wounds and used to protect new skin grafts

WOUND DEBRIDEMENT

• DEBRIDEMENT: – Removal of tissue contaminated by bacteria– Removal of dead tissue (burn eschar)

• Natural Debridement• Mechanical Debridement

– Scissors/forceps/drsgs,debriding agents

• Surgical Debridement:– In OR, removing tissue, covering with graft

PURPOSE OF GRAFTING

• To cover the wound• To decrease the risk of infection• To prevent further loss of protein, fluid and

electrolytes• To decrease heat loss • To promote earlier function• To reduce contractures

GRAFTING BURN WOUND

• Autografts: graft of the patient’s own skin• Homografts: graft of skin obtained from living or recently

deceased humans• Heterografts: graft of skin taken from animals (usually pigs)• Biosynthetic: synthetic dressing composed of nylon combined

with collagen derivative• (eg) Biobrane, Opsite, Integra

NURSING CARE OF PT WITH AUTOGRAFT

• Occlusive dressing• OT makes splint• Observe for infection• If graft dislodged: sterile saline dressing• Keep pressure off site, elevate• Exercises begin 5-7 days after grafting• Donor site very painful

DISORDERS OF WOUND HEALING

• Hypertrophic scarring and keloid formation: form from excessive abnormal healing or inadequate tissue formation– TX: Compression, ace/jobst

• Wound contractures– Tx: splints, traction, ROM

PAIN

• Pain associated with burns is SEVERE• Nurses and caregivers need to anticipate

when pain will be worsened by dressing changes, debridement, hydrotherapy, physical therapy

• PCA with morphine help burn victims

EMOTIONAL SUPPORT

• ACUTE PHASE: – Facing reality of burn trauma– Grieving over obvious losses– Depression, regression, manipulative behavior,

withdrawal, anger

EMOTIONAL RESPONSE

• REHAB PHASE:– Include the patient in the decision making– Help patient set realistic self goals

NURSING DIAGNOSIS

• IDENTIFY PRIORITY NURSING DIAGNOSIS

PREVENTION

• Who is at risk?• Who needs to be taught?• What changes should be made in the home?• What kind of legislation should be promoted?• What education can be done in schools?