Integumentary: Burns

Marnie Quick, RN, MSN, CNRN

Skin layers, hair follicle, nerves, sweat glands

Types of burns Thermal Chemical Smoke and inhalation Electrical Radiation

Thermal burn

Cool burn with cold water until pain is relieved- Do not apply to more than 20% body surface- hypothermia may occur

Chemical burn from sulfuric acid

Smoke & Inhalation: Which is this?- CO; injury above glottis; below glottis

Electrical burns

Depth of Burn

Depth of burn: Superficial partial (old 1st) Deep partial-thickness (old 2nd) Full-thickness (old 3/4th)

Deep partial-thickness burn- note blisters

Partial-thickness (Second degree burn)

Full-thickness

Extent of Burn: *calculate total burn with rule of 9’s-- ½ of ant trunk=9% and ¼ of arm=3% **TOTAL area burn=12% Rule of Nines Lund & Browder- age

Location of Burn Location of the burn is related to the severity of

the injury: Face, neck, chest → respiratory obstruction Hands, feet, joints, eyes → self-care Ears, nose → infection

Circumferential burns of the extremities can cause circulatory compromise

Patients may also develop compartment syndrome

Phases of Burn Management Prehospital care Emergent (resuscitative- fluid) Acute (wound healing) Rehabilitative (restorative)

Emergent/resuscitative

Onset injury to successful fluid resuscitation Major concern- Fluid Resuscitation- prevent

hypovolemic shock 2 large bore IV’s in unburned area to restore bl

vol due to inc capillary permeability> 3rd spacing Guidelines burns >20% TBSA- Parkland formula

or Modified Brooke formula Need Weight and % TBSA burned to calculate

Lactated Ringers solution 1st 24 hrs then add 5% Dextrose to crystalloid fluid

50% of formula volume in first 8 hrs; rest over next 16 hrs; then maintain urinary output

Hourly output 30-50 cc/hr (foley); heart rate less than 120/min; SBP> 90;hemodynamic monitoring

Elevate edematous part; escharotomy

Effects of Burn Shock

Third spacing

Burn with escarotomy

Escarotomy

Elevate arms to decrease swelling also note escarotomy of arms and chest- assess CMS (circulation/motor/sensory)

Before the escharotomy, how would this eschar affected his respirations?

What are the Priorities in this patient??? Meet criteria for Burn Unit Referral?

What do you assess for here???

Complications in emergent phase

Cardiovascular Respiratory

Upper/inhalation/lower Urinary

Renal blood flow/GFR decrease causing release ADH

Myoglobinurea- dark urine may block renal tubules

Summary:

Acute Phase

Start of diuresis and ends with closure of burn Major concern in this stage- infection Most common cause infection- pts own GI track Wound management-

hydrotherapy, debridement of eschar topical antimicrobial creams (open/closed method) splints/exercise prevent contractures; Excision/grafting of 3rd degree (temporary cover 2nd )

Decreasing of third spacing- Note edema of the face decreasing

Hydrotherapy: Hubbard Tank

Clean/debridement

Rt tank or Lt surgery

Topical broad spectrum antimicrobials Open method

Separate skin; use of splints Closed method

Skin will grow together if not separated

Several patients utilizing closed method Who is that nurse with white stockings& cap?

Removal of necrotic tissueEschar removed until viable tissue

Donor sites:after harvesting healed donor site

Grafting (Lewis 484 Table 25-13)

Permanent- if no infection Autograft CEA Integra/AlloDerm

Temporary grafts Homograft- cadaver Heterograft- animal Synthetic

Grafting

Application of Cultured Epithelial Autograft

Cultured epithelial autografts Grown from biopsies

obtained from the patient’s own skin

Used in patients with a large body surface burn area or those with limited skin for harvesting

Pressure garments

What are your assessment findings?

What are your nursing priorities for this patient?