OSTE

NSG 255

Kim Nelson, Nikki Moor, Jen Moser, Brittany Orr, Steph Nadeau

BURNS

“Each year, more than 2 million Americans suffer burn injuries. Only about 1% of these

people require hospitalization for severe burns. But for these

unfortunate people, the nursing care provided in the first few hours after injury

is crucial. Your interventions can help determine a patient's ability to survive a

serious burn and make a functional recovery.”

(Wiebelhaus & Hansen, 2001)

Patient Profile:

Sylvia, a 44-year-old woman from a nearby farm, was brought to the emergency department with extensive full-thickness burns to her upper body. Her stove exploded while she was manually lighting the oven with firewood and kerosene. Her 10 children remain at home and her husband is in the field, unable to be reached.

Case StudyPatient with Burns

Classifications of BurnsSuperficial Burns

• “1st Degree”

• Only epidermal damage

• Dry and painful to touch

• Presented as red or pink

• Does not blister, but swelling can occur

• No residual scarring

• Causes: Sunburn, ultraviolet light, flame exposure

• Heals 3-6 days

(Mendez-Eastman, 2005)

Partial Thickness Burn• “2nd Degree”• Superficial burn, moist and

blistered• Deeper burns are white and dry

and blanche with pressure and have reduced pain

• Treatment varies with degrees of involvement

• Intense pain and edema is common

• Painful to air and temperature• Residual scarring can vary

depending on depth on injury (pigment change to risk of contracture)

• Causes: Scalds – flame, oil, grease & Flame exposure

• Heals in 7- 20+ days

Full Thickness Burn• “3rd Degree”• Completely destroys

epidermis and dermis• Skin is tough, waxy,

brown, leathery and firm, numb to touch

• Edema may be massive• Residual scarring is

severe – grafting usually required

• Burn never heals to original state

(Mendez-Eastman, 2005)

Full thickness and Injury• “4th Degree”• most severe of them all• Involves subcutaneous

fat, fascia, muscle or bone

• Burn frequently has a charred appearance

• Reconstructive surgery is indicated

• Severe disfigurement is common

• Causes: Scalds from flame, steam, oil, grease, chemical, 7 high voltage electricity

(Mendez-Eastman, 2005)

Rule of Nines• Quick way to calculate the extent of burns • The system assigns percentages in multiples of nine to major body surfaces

(Mendez-Eastman, 2005)

• Thermal burn: Burning of tissue via direct contact with a heat source

• Hot water/steam• Flame

• Chemical Burn: tissue destruction via direct contact with chemical

• Gasoline• Desiccants: sulfuric acid• Reducing agent: Hydrochloric acid• Vesicants: mustard gas

• Electrical Burn: direct contact with electrical current• Entry and exit wounds

(Day, Paul, Williams, Smeltzer, Bare, 2007)

Types of Burns

• Zone of Coagulation: The inner zone - where cellular death occurs. Treatment will not influence the tissue as it is already dead. This sustains the most damage.

• Zone of Stasis: The middle area - has a compromised blood supply, inflammation, and tissue injury. Given the appropriate assessment and treatment, tissue can survive.

• Zone of Hyperemia: The outer zone - sustains the least damage and is most likely to heal regardless of treatment.

(Mendez-Eastman, 2005)

Zones of Burn Injury

• Smoke inhalation

• Hoarseness, cough, singed nasal hairs, oral burns, wheezing

• Carbon monoxide poisoning

• Fractures

• Trauma

Associated Injuries to all Burns

Pre-Hospital Priorities• First priority is to prevent injury to the rescuer

• Call 911

• Extinguish the flames: “stop-drop-roll”

• Cool the burn with cold water. DO NOT apply a cold soak for no longer than several minutes. DO NOT apply ice directly. These all halt the burning process

• Assess ABC’s (Airway, breathing, circulation)

• Remove restrictive objects: If possible remove clothing/jewelry immediately. Adherent clothing may be left in place once cooled.

• Cover the wound: Burns should be covered as quickly as possible to minimize bacterial contamination and decrease pain by preventing air from coming in contact with the injured surface. DO NOT use ointments or other medications on wound.

Full Thickness Burns•Circumferential burns to the extremities:

•Risk of compression of structures underneath the wound – edema•A combination of increased extravascular fluid in the wound, and underlying tissues can cause lack of elasticity in the wound•Blood flow is then compromised to viable tissue

•Interventions:•All extremities should be elevated to minimize edema formation•Extremities should be elevated hourly for signs of vascular compromise

(Norton, Randall-Bollinger, 2001)

Full thickness burn to face – patient intubated

Airway Management

• First assess breathing & ensure a patent airway by:• Proper positioning• Removal of any obstructions• Artificial airway if needed – endotrcheal tube (by qualified personnel only)

• Administer oxygen therapy – 100% humidified• After securing airway, turn attention to patients breathing• Assess/Auscultate for respiratory rate, pattern, depth, and breath sounds

(Cancio, 2005)

Circulation• Hypovolemic shock – serious burn complication resulting

from:• Changes in capillary & interstitial hydrostatic

pressures• Causes fluid to leave the intravascular space and

migrate to the interstitial space• Results in rapid edema formation and a loss of

circulating vascular volume

• Fluid resuscitation is needed to maintain cardiac output and organ perfusion

(Osborn, 2003)

Fluid Resuscitation• A critical part of treatment during emergency stage due

to loss of volume from the vascular space after the injury

• During this period it is critical to administer enough fluid to maintain organ perfusion and cardiac output but to not overload the patient

• Guidelines:• Consider the size of the wound• Patients weight• Medical history

• Indicators of adequate fluid volume replacement:• Heart rate of less than 120 bpm• Systolic blood pressure of >100 mmHg• Strong peripheral pulses• Urine output of approx, 0.5ml/kg/hr

(Osborn, 2003)

• Effects on electrolytes:• Hyponatremia (sodium depletion in blood) – water shifts

from interstitial to the vascualr space• Hyperkalemia (excessive potassium in blood) – results

from massive cell destruction• Hypokalemia (potassium depletion) – may occur later

with fluid shifts and inadequate potassium replacement

• Not unusual to administer 400ml – 800ml/ hour for a major burn patient

• A variety of fluids have been recommended for use, such as colloids (whole blood, plasma, and plasma expanders)

• The most common fluid replacement formula is Ringers Lactate (contains small amounts of potassium chloride, calcium chloride, sodium lactate & large amounts of sodium chloride in water. This solution is an excellent extracellular replacement.

• Should titrate fluid resuscitation to urine output on a hr to hr bases

(Osborn, 2003)

Inhalation can be classified as 4 types of injuries:

1) Asphyxiation – injury that occurs as oxygen transport is interfered with or obstructed

2) Direct topical injury – results from direct contact with heat or chemical irritants

3) Systemic destruction – occurs when toxins cross alveolar capillary membranes, and damage to other organs

4) Stress & Inflammatory response – the body’s own defense mechanism, which constricts the airway

(Hansen, Weibelhaus & Hill, 2001)

Inhalation Injury

Inhalation InjurySigns:

•Singed nasal hairs, eyebrows, eyelashes

• Soot on face, mouth, and nares

• Depressed/changed mental status

• Wheezing or rails on auscultation

Interventions:

•Airway management

•100% humidified oxygen

•Edema control

(Hansen, Weibelhaus & Hill (2001)

Pain• Often painless because the nerves are destroyed

• May feel pain on other burn areas that are less damaged

•Interventions:• Administer oxygen or increase fluid administration (narcotics & analgesics may mask signs of hypoxemia or hypovolemia)• Intravenous narcotic analgesics and sedatives may be administered in small, frequent doses

•Medications:• Antibiotics: help prevent an infection• Analgesics - given once vital signs have stabilized • Tetanus shot: given if you had not had one in the past 5-10 yrs

(Day, Paul, Williams, Smeltzer, Bare, 2007)

HypothermiaRisk for hypothermia R/T skin microcirculation and open wounds:

Interventions:•Provide a warm environment (heat shield, space blanket, heat lights, or blankets)•Work quickly when wounds are exposed•Assess core body temperature frequently

(Day, Paul, Williams, Smeltzer, Bare, 2007)

SupportPatients psychological status:

•Assess patients emotional state and allow them to verbalize thoughts and feelings

•Provide recommendations to support psychological recovery – counselors, psychologists, social workers

Family’s psychological status:

•Provide psychological assessment, support, therapy and education

•Provide resources and references to assist the patients psychological recovery

“This is an on-going process that begins when the patient is able to communicate and extends well beyond their

discharge from the hospital”(Klein, 2009)

ReferencesCancio. L. (2005). Current concepts in the pathophysiology and treatment of inhalation

injury. Trauma, 7 (1), 19-35. Retrieved from CINAHL Plus Full Text database.

Day, R.A., Paul, P., Williams, B., Smeltzer, S.C., & Bare. B. (2008). Brunner & Suddarth’s textbook of medical-surgical nursing (1st ed.). Toronto: Lippincott Williams & Wilkins.

Klein, J. (2009). The Psychiatric Nurse in the Burn Unit. Perspectives in Psychiatric Care, 45(1), 71- 74. Retrieved from ProQuest Nursing & Allied Heath Source database.

Norton, J.A., Randall-Bollinger, R. (2001). Surgery: Basic Science and Clinical Evidence. New York: Springer.

Osborn, K. (2003). Nursing burn injuries. Nursing Management 34(5), 49-56. Retreived from ABI/INFORM Global database.

Weibelhaus, P., Hansen, S., & Hill, H. (2001). Helping patients survive inhalation injuries. RN, 64(10), 28-32. Retrieved from CINAHL Plus with Full Text database.

Wiebelhaus, P, Hansen, L. (2001). Managing burn emergencies. Dimensions of Critical Care Nursing, 20(4), 2-8. Retrieved from CINAHL Plus Full Text database.

Can you name and describe these burns?