nursing management of burns
TRANSCRIPT
![Page 1: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/1.jpg)
Burns Prepared
Aseem.B,MBA,MSN, PGDHA
Assistant Professor,
SP Fort College of Nursing, Trivandrum
![Page 2: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/2.jpg)
![Page 3: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/3.jpg)
Definition
• Burns are a result of the effects of thermal injury on the skin and other tissues
• Human skin can tolerate temperatures up to 42-440 C (107-1110 F) but above these, the higher the temperature the more severe the tissue destruction
• Below 450 C (1130 F), resulting changes are reversible but >450 C, protein damage exceeds the capacity of the cell to repair
![Page 4: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/4.jpg)
• A burn injury occurs as a result of destruction of the skin from direct or indirect thermal force.
• Burn are caused by exposure to heat, electric current, radiation or chemical.
• Scald burn result from exposure to moist heat (steam or hot fluids) and involve superficial.
![Page 5: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/5.jpg)
Types
1. Thermal burns.2. Chemical burns3. Electrical burns 4. Radiation burns
![Page 6: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/6.jpg)
Mammootty's kind hearted gesture gives hope to acid attack victim.
![Page 7: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/7.jpg)
![Page 8: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/8.jpg)
incidence• About 2.4 million people suffer burns annually• Account for an estimated 700,000 ER visits per
year and 45,000 require hospitalizations• Between 8,000-12,000 burn patients die, and
approximately one million will sustain substantial or permanent disabilities
![Page 9: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/9.jpg)
9
![Page 10: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/10.jpg)
10
![Page 11: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/11.jpg)
11
![Page 12: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/12.jpg)
Classification According to Depth
• First-degree Burns (mild): epidermis Pain, erythema & slight swelling, no blisters Tissue damage usually minimal, no scarring Pain resolves in 48-72 hours
![Page 13: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/13.jpg)
• Superficial Second-degree Burns: entire epidermis & variable dermis
Vesicles and blisters characteristic Extremely painful due to exposed nerve
endings Heal in 7-14 days if without infection
![Page 14: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/14.jpg)
Superficial
![Page 15: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/15.jpg)
Partial thickness (second degree)
![Page 16: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/16.jpg)
16
Full thickness (3°burn)
![Page 17: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/17.jpg)
• Midlevel to Deep Second-degree Burns: Few dermal appendages left There are some fluid & metabolic effects
![Page 18: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/18.jpg)
• Full-thickness or Third-Degree: • entire epidermis and dermis, no residual
epidermis Painless, extensive fluid & metabolic deficits Heal only by wound contraction, if small, or if
big, by skin grafting or coverage by a skin flap
![Page 19: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/19.jpg)
![Page 20: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/20.jpg)
20
Blister may ↑size because continuous exudation and collection of tissue fluid
![Page 21: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/21.jpg)
21
Eschar:composed of denatured protein
![Page 22: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/22.jpg)
Burn Photos
Chemical (Acid) Burns
Radiation (Flash) Burns
![Page 23: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/23.jpg)
Burn Photos
Electrical Burns Entrance Wounds
Electrical Burns Exit Wounds
Entrance wound of electrical burns from an overheated tool
Severe swellingpeaks 24-72 hrs after
Electrical burns mummified1st 2 fingers later removed
![Page 24: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/24.jpg)
Chemical Burn
![Page 25: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/25.jpg)
![Page 26: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/26.jpg)
![Page 27: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/27.jpg)
Pathologic Features
• Zone of coagulation (necrosis): Superficial area of coagulation necrosis and cell death on exposure to temperatures >450 (primary injury)
• Zone of stasis (vascular thrombosis): Local capillary circulation is sluggish, depending on the adequacy of the resuscitation, can either remain viable or proceed to cell death (secondary injury)
• Zone of hyperemia (increased capillary permeability)
![Page 28: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/28.jpg)
![Page 29: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/29.jpg)
29
Zone of injury
![Page 30: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/30.jpg)
Burns Assessment/Physiology/ Classification
Based on:• Depth/Degree of injury,• Percent of body surface areas involved,• Location of the burn, • Association with other injuries.
![Page 31: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/31.jpg)
Classification According to Extent
• Mild: 10%• Moderate:
10-30%• Severe: > 30%
• Hospitalization for > 10% of body surface area
• Rule of nines-An estimated of the TBSA involved as a result of a burn.
• The rule of nines measures the percentage of the body burned by dividing the body into multiples of nine.
• The initial evaluation is made upon arrival at the hospital.
![Page 32: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/32.jpg)
Rule of nine
![Page 33: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/33.jpg)
For small children, the head represents a greater portionof the body mass than adults. Lund and Browder first described a method for compensating for the differences and the Lund and Browder Chart is used to calculate Body Surface Area (BSA) in children.
If the chart is unavailable, one can estimate body surface area and adjust for age, as :follows
.
![Page 34: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/34.jpg)
34
Factors determining severity of burns
• Size of burn• Depth of burn• Age of victim• Body part involved• Mechanism of injury• History of cardiac, pulmonary, renal, or
hepatic disease • Injuries sustained at time of burn.
![Page 35: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/35.jpg)
35
Effects of a severe burn
1. Cardiovascular2. Respiratory3. Immune4. Integumentary5. Gastrointestinal6. Urinary
![Page 36: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/36.jpg)
Cardiovascular system
• Blood pressure falls-fluid leaks from intravascular to interstitial (sodium and protein)
• Hypotension• tachycardia• Blood flow in intravascular is concentrated and
cause static.• Cardiac output ↓, • Due to that tissue perfusion ↓,
![Page 37: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/37.jpg)
Hematologic changes
• Thrombocytopenia, abnormal platelet function, depressed fibrinogen levels, deficit plasma clotting factors.
• Life span ↓RBC.• Blood loss during diagnostic and therapeutic
procedure.
![Page 38: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/38.jpg)
Respiration system
• Majority of deaths from fire are due to smoke inhalation.
• Pulmonary damage can be from direct inhalation injury or systemic respond to the injury.
• Damage to cilia and cell in the airway-inflammation.
• Mucociliary transport mechanism not functioning-bronchial congestion and infection.
• Pulmonary edema, fluids escape to interstitial. • Airway obstruction
![Page 39: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/39.jpg)
![Page 40: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/40.jpg)
Gastrointestinal
• Burn >20% experience ↓peristalsis, gastric distention and ↑risk of aspiration.
• Paralytic ileus due to secondary to burn trauma.• Stress ulcer (stomach/duodenum) due to burn
injury.• Indication of stress ulcer-malena stool or
hematemesis.• These signs suggest gastric or duodenal erosion
(Curling`s ulcer)• Gastric distention and nausea may lead to vomiting.
![Page 41: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/41.jpg)
CURLING’S ULCER
• Acute ulcerative gastro duodenal disease• Occur within 24 hours after burn• Due to reduced GI blood flow and
mucosal damage• Treat clients with H2 blockers,
mucoprotectants, and early enteral nutrition
• Watch for sudden drop in hemoglobin
4/1/2011 41
![Page 42: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/42.jpg)
Immunologic changes
• Skin barrier to invading organisms s destroyed, circulating levels of immunoglobulins are ↓
• Changes in WBC both quantitative and qualitative.
• Depression of neutrophil, phagocytic and bactericidal activity is found after burn injury.
• All this changes in the immune system can make the burn patient more susceptible to infection
![Page 43: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/43.jpg)
PHASES OF BURN INJURIES
• Emergent (24-48 hrs)• Acute• Rehabilitative
![Page 44: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/44.jpg)
MANAGEMENT OF THE BURN INJURYPhases of Management
Emergent phase - begins at the time of injury and ends with the
restoration of capillary permeability, usually at 48-72 hours after the injury
- the 1˚ goal is to prevent hypovolemic shock and preserve vital organ functioning
- includes prehospital care and emergency room care
![Page 45: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/45.jpg)
Acute phase
- begins when the client is hemodynamically stable, capillary permeability is restored, and diuresis has begun
- usually begins 48 - 72 hours after the time of injury- emphasis during this phase is placed on restorative
therapy, and the phase continues until wound closure is achieved
- the focus is on infection control, wound care, wound closure, nutritional support, pain management, and physical therapy
![Page 46: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/46.jpg)
Resuscitative phase
- begins w/ the initiation of fluids and ends when capillary integrity returns to near normal levels and the large fluid shifts have decreased
- the amount of fluid administered is based on the client’s weight and extent of injury
- most fluid replacement formulas are calculated from the time of injury and not from the time of arrival at the hospital
- the goal is to prevent shock by maintaining adequate circulating blood volume and maintaining vital organ perfusion
![Page 47: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/47.jpg)
Resuscitative phase
- begins w/ the initiation of fluids and ends when capillary integrity returns to near normal levels and the large fluid shifts have decreased
- the amount of fluid administered is based on the client’s weight and extent of injury
- most fluid replacement formulas are calculated from the time of injury and not from the time of arrival at the hospital
- the goal is to prevent shock by maintaining adequate circulating blood volume and maintaining vital organ perfusion
![Page 48: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/48.jpg)
Rehabilitative phase
- final phase of burn care- overlaps the acute care phase and goes well
beyond hospitalization- goals of this phase are designed so that the
client can gain independence and achieve maximal function
![Page 49: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/49.jpg)
Diagnosis
• A detailed history and physical examination is the first step. The physician will evaluate the type, duration, and timing of the burn; the burn location and severity; and associated dehydration, disfigurement, and infection.
• Fires in enclosed spaces should raise the suspicion for smoke–inhalation injury.
![Page 50: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/50.jpg)
Lab Tests
• Routine blood work for a patient with a burn injury includes a complete blood count, platelet count, clotting studies, liver function studies, and carboxyhemoglobin, electrolyte, blood urea nitrogen, glucose and creatinine levels.
• Urinalysis may reveal myoglobinuria and hemoglobinuria.
• If pt. is 35 or older, he’ll also need an electrocardiogram.
• Chest x-rays and arterial blood gas levels allow the evaluation of alveolar function.
![Page 51: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/51.jpg)
BURN INTERVENTIONS
•Maintain Airway• Fluid Resuscitation• Relieve Pain• Prevent Infection• Provide Nutrition• Prevent Stress Ulceration• Provide Psychologic Support• Prevent Contractures
![Page 52: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/52.jpg)
Management
PAIN MANAGEMENT• Administer morphine sulfate or meperidine
(Demerol), as prescribed, by the IV route• Avoid IM or SC routes because absorption
through the soft tissue is unreliable when hypovolemia and large fluid shifts are occurring
• Avoid administering medication by the oral route, because of the possibility of GI dysfunction
• Medicate the client prior to painful procedures
![Page 53: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/53.jpg)
FLUID IMBALANCES
• Occur as a resul t of f lu id sh i f t and ce l l damage
• Hypovolemia• Metabol ic ac idos is• Hyperkalemia• Hyponat remia• Hemoconcent ra t ion (e levated b lood
osmolar i ty, hematocr i t /hemoglobin) due to dehydrat ion
4/1/2011 53
![Page 54: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/54.jpg)
Formula for estimating fluid replacement
• Brooke (Modified) : lactated ringers solution : 2..0ml/kg/% TBSA burn: half given during first 8 hours and half given during next half hour
• Parkland (Baxter) lactated ringers solution 4ml /kg/% TBSA burn; half given first 8 hr, ¼
• Given each next 8 hr
![Page 55: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/55.jpg)
ESCHAROTOMY
• A lengthwise incision is made through the burn eschar to relieve constriction and pressure and to improve circulation
• Performed for circulatory compromise resulting from circumferential burns
• After escharotomy, assess pulses, color, movement, and sensation of affected extremity and control any bleeding with pressure
• Pack incision gently with fine mesh gauze for 24 hours after escharotomy, as prescribed
• Apply topical antimicrobial agents as prescribed
![Page 56: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/56.jpg)
NUTRITION
• Essential to promote wound healing and prevent infection
• Maintain nothing by mouth (NPO) status until the bowel sounds are heard; then advance to clear liquids as prescribed
• Nutrition may be provided via enteral tube feeding, peripheral parenteral nutrition, or total parenteral nutrition
• Provide a diet high in protein, carbohydrates, fats and vitamins
![Page 57: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/57.jpg)
ESCHAROTOMY&FASCIOTOMY
![Page 58: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/58.jpg)
FASCIOTOMY• An incision is made, extending through the SQ
tissue and fascia• Performed if adequate tissue perfusion does
not return after an escharotomy• Performed in OR under GA, after procedure
assess same as above
![Page 59: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/59.jpg)
Hydrotherapy cart shower
![Page 60: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/60.jpg)
Hubbard Tank (old method)
![Page 61: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/61.jpg)
Dermatome-harvesting donor skin from thigh (courtesy : google images)
04/15/2023 61
![Page 62: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/62.jpg)
04/15/2023 62
courtesy : google images
• For graft to SURVIVE and be effective:
– Recipient bed must have adequate blood supply
– Graft must be in close contact with recipient bed
– Graft must be firmly fixed or immobile– Free from infection
![Page 63: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/63.jpg)
Acid attack survivor laxmi courtesy : google images
![Page 64: Nursing management of Burns](https://reader034.vdocuments.site/reader034/viewer/2022052317/55c4a549bb61eb020b8b464f/html5/thumbnails/64.jpg)