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Andrew D. Beluso, RN
Cell destruction of the layers of the skin and the resultant depletion of fluid and electrolytes. Burn size 1. Small burns: body¶s response is localized to the injured area 2. Large or extensive burns:
a. consist of 25% or more of the total body surface area (TBSA) b. body¶s response to injury is systemic c. affect all of the major systems of the body
b. Minor Burns a.Characteristics 1. d. face. g. f. The client has no preexisting medical condition at the time of the burn injury No other injury occurred with the burn . Partial thickness burns are no greater than 15% of the TBSA in the adult Full thickness burns are < 2% of the TBSA in the adult Burn areas do not involve the eyes.o. hands. e. feet. or perineum There are no electrical burns or inhalation injuries The client is an adult younger than 60 y. c. ears.
b. d. pulmonary. f. e. Moderate Burns a. hands.Characteristics 2. c. The client has no chronic cardiac. ears. g. feet. Partial thickness burns are deep and are 15% to 25% of the TBSA in the adult Full thickness burns are 2% to 10% of the TBSA in the adult Burn areas do not involve the eyes. or perineum There are no electrical burns or inhalation injuries The client is an adult younger than 60 y.o. face. or endocrine disorder at the time of the burn injury No other complicated injury occurred with the burn .
pulmonary. hands. b. face. or perineum The burn injury was an electrical or inhalation injury The client is older than 60 y. or metabolic disorder at the time of the burn injury Burns are accompanied by other injuries . d. g. f.o. e.Characteristics 3. feet. The client has a chronic cardiac. ears. Major Burns a. c. Partial thickness burns are > 25% of the TBSA in the adult Full thickness burns are > 10% of the TBSA Burn areas involve the eyes.
Should be reevaluated after initial wound debridement 1 18 18 .Provides a more accurate estimate of the burn size .Uses a diagram of the body divided into sections.Modifies percentages for body segments acc. to age .Estimating the extent of injury Rule of nine 9 9 18 9 Lund and Browder Method . with the representative % of the TBSA for ages throughout the lifespan .
Itching and pink skin persist for about a week. Scarring may occur. epidermis peels. May be yellowish but soft and elastic ± may or may not be sensitive to touch. Relieved by cooling. Heals spont. wound moist and painful. Takes several weeks to heal. elastic. Superficial layers of skin are destroyed. heals spontaneously. . which subsides quickly. No scarring. weeping. Second degree Superficial: Pink or red. sensitive to cold air. If it does not become infected w/in 10 days . blisters form (vesicles). Hair does not pull out easily Takes several weeks to heal.2 weeks. edematous. Scarring may occur.Assessment of Burn Injury Extent / Degree Assessment of Extent First Degree Pink to red: slight edema. Deep dermal: Mottled white and red: edematous reddened areas blanch on pressure. Sunburn is a typical example. Pain may last up to 48 hours. Reparative Process In about 5 days.
Assessment of Burn Injury Extent / Degree Third degree Assessment of Extent Destruction of epithelial cells ± epidermis and dermis destroyed Reddened areas do not blanch with pressure.. Expect scarring and loss of skin function. grafting is required. Area requires debridement. endocrine. muscles. AGE AND GENERAL HEALTH Mortality rates are higher for children < 4 y. particularly those < 1 y.o. Reparative Process Eschar must be removed. Not painful.o. such as cardiac. formation of granulation tissue. fat. and renal d/o. and for clients over the age of 60 years. coloration varies from waxy white to brown. 1. leathery devitalized tissue is called eschar. Mortality rate is higher when the client has a preexisting disorder at the time of the burn injury . Debilitating disorders. inelastic. Granulation tissue forms to nearest epithelium from wound margins or support graft. and grafting. and bone. respiratory. For areas larger than 3-5 cm. Destruction of epithelium. negatively influence the client¶s response to injury and treatment.
or organic compounds b. hot liquids. x-rays. Chemical Burns: a. or radioactive source . and long bone or vertebral fractures Radiation Burns: caused by exposure to UV light. Caused by heat generated by electrical energy as it passes through the body b. Alternating current is more dangerous than direct current because it is associated with CP arrest. ventricular fibrillation. particularly in high voltage electrical injuries d. Results in internal tissue damage c.TYPES OF BURNS Thermal Burns: caused by exposure to flames. steam or hot objects A. tetanic muscle contractions. Systemic toxicity from cutaneous absorption can occur B. Cutaneous burns cause muscle and soft tissue damage that may be extensive. Electrical Burns: a. Caused by tissue contact with strong alkali.
facial burns .flaring nostrils . Carbon Monoxide Poisoning : CO is colorless. toxic fumes.erythema . Smoke inhalation injury : results from inhalation of superheated air.hoarse voice .stridor.INHALATION INJURIES A.tachycardia B. wheezing and dyspnea . steam. or smoke : Assessment .agitation and anxiety .singed nasal hair .swelling of oro / nasopharynx . odorless and tasteless gas that has an affinity for Hgb 200 times greater than that of oxygen : O2 molecules are displaced and carbon monoxide reversibly binds to Hgb to form carboxyhemoglobin : can lead to coma and death .sooty sputum and cough .
esp.after several hours. ET intubation if obstruction occurs . causing a decrease in bronchial ciliary action and a decrease in surfactant : Assessment . Smoke Poisoning : Caused by inhalation of by-products of combustion : A localized inflammatory reaction occurs.C. w/c appear erythematous and edematous. during the first 24 to 48 hours : Monitored for airway obstruction. with mucosal blisters and ulcerations : Mucosal edema can lead to upper airway obstruction.ARDS can result D. sloughing of the tracheobronchial epithelium may occur. and hemorrhagic bronchitis may develop .mucosal edema in the airways .wheezing on auscultation . Direct Thermal Heat Injury : Can occur to the lower airways by the inhalation of steam or explosive gases or the aspiration of scalding liquids : Can occur to the upper airways.
PATHOPHYSIOLOGY OF BURNS BURN Vascular permeability Edema IV volume Hematocrit Viscosity Peripheral resistance Cardiac output .
The hematocrit level increases as a result of plasma loss. Followed by hypokalemia as fluid shifts occur and K+ is not replaced. Initially. F. Blood flow to the GIT is diminished. the body shunts blood from the kidneys. Immune system function is depressed. causing oliguria. Initially hyponatremia and hyperkalemia occur. and the losses continue until complete wound closure occurs If the intravascular space is not replenished with IV fluids. A. . resulting in immunosuppression and thus increasing the risk of infection and sepsis. Pulmonary hypertension can develop. D. B. E. and diuresis of the excess fluid occurs over the next days to weeks.HEMODYNAMIC / SYSTEMIC CHANGES A. Evaporative fluid losses through the burn wound are greater than normal. C. then the body begins to reabsorb fluid. this initial increase falls to below normal at the 3rd to 4th day postburn as a result of the RBC damage and loss at the time of injury. leading to intestinal ileus and GI dysfunction. resulting in a decrease in the arterial O2 tension and a decrease in lung compliance. hypovolemic shock and ultimately death will occur.
BURN INTERVENTIONS MAINTAIN AIRWAY FLUID RESUSCITATION RELIEVE PAIN PREVENT INFECTION PROVIDE NUTRITION PREVENT STRESS ULCERATION PROVIDE PSYCHOLOGIC SUPPORT PREVENT CONTRACTURES .
most fluid replacement formulas are calculated from the time of injury and not from the time of arrival at the hospital .the amount of fluid administered is based on the client¶s weight and extent of injury .the 1Û goal is to prevent hypovolemic shock and preserve vital organ functioning . usually at 48-72 hours after the injury .includes prehospital care and emergency room care 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 goal is to prevent shock by maintaining adequate circulating blood volume and maintaining vital organ perfusion .MANAGEMENT OF THE BURN INJURY Phases of Management of the Burn Injury Emergent phase .begins at the time of injury and ends with the restoration of capillary permeability.
wound closure.the focus is on infection control. and diuresis has begun .Acute phase .overlaps the acute care phase and goes well beyond hospitalization .emphasis during this phase is placed on restorative therapy. and physical therapy Rehabilitative phase . capillary permeability is restored.goals of this phase are designed so that the client can gain independence and achieve maximal function .final phase of burn care .72 hours after the time of injury . and the phase continues until wound closure is achieved .begins when the client is hemodynamically stable. wound care. pain management.usually begins 48 . nutritional support.
hypo CHON. hypo K. metabolic acidosis . renal output decreased. hypo CHON. metabolic acidosis DIURETIC PHASE ± Interstitial to Intravascular Hct decreased. hyper K. hypo Na. hypo Na.FLUID SHIFTING IN BURNS OLIGURIC PHASE ± Intravascular to Interstitial Hct increased. renal output increased.
Clear sensorium Urinary output is the most common and most sensitive assessment parameter for cardiac output and tissue perfusion If the Hgb and Hct levels decrease or if the urinary output exceeds 50ml/hr. Colloid is used during the 2nd day (5% albumin. or those with cardiac or pulmonary disease and compromised response to burn injury The amount of fluid administered depends on how much intravenous fluid per hour is required to maintain a urinary output of 30 . plasmate or hetastarch) .Stable vital signs . the elderly.50 ml/hr Successful fluid resuscitation is evidenced by: .Children with burns involving more than 10-15% TBSA .Patients with electrical injury.Palpable peripheral pulse .Adults with burns involving more than 15% .20% TBSA . a crystalloid (Ringer¶s lactate) solution is used initially.Adequate urine output .FLUID RESUSCITATION Indications: . the rate of IV fluid administration may be decreased Generally.
¼ colloid D5W maintenance Infusion Rate ½ in 1st 8 hours ½ in next 16 hours crystalloid only (lactated Ringer¶s) ½ in 1st 8 hours ½ in next 16 hours .Brooke and Parkland (Baxter) Fluid Resuscitation Formulas for 1st 24hrs after a Burn Injury Formula BROOKE 2ml/kg/% BSA + 2000ml/24hr (maintenance) PARKLAND (Baxter) 4ml/kg/% BSA for 24hr period Solution ¾ crystalloid.
PARKLAND FORMULA Example: Patient¶s weight: 70 kg.5ml x 70kg x 80% = 2800 ml colloid + 2000 ml D5W = 117 ml colloid/hour + 84 ml D5W/hour . % TBSA burn: 80% 1st 24 hours: 4ml x 70kg x 80% TBSA = 22.200 ml or 1.5ml colloid x weight in kg x TBSA + 2000ml D5W run concurrently over the 24 hour period 0.400ml of lactated Ringer¶s 1st 8 hours = 11.400 ml/hour 2nd 16 hours = 11.200 ml or 700 ml/hour 2nd 24 hours: 0.
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 NUTRITION Essential to promote wound healing and prevent infection Maintain nothing by mouth (NPO) status until the bowel sounds are heard. peripheral parenteral nutrition. fats and vitamins . carbohydrates.PAIN MANAGEMENT Administer morphine sulfate or meperidine (Demerol). then advance to clear liquids as prescribed Nutrition may be provided via enteral tube feeding. or total parenteral nutrition Provide a diet high in protein. as prescribed.
assess pulses. after procedure assess same as above .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. extending through the SQ tissue and fascia Performed if adequate tissue perfusion does not return after an escharotomy Performed in OR under GA. movement. as prescribed Apply topical antimicrobial agents as prescribed FASCIOTOMY An incision is made. color. and sensation of affected extremity and control any bleeding with pressure Pack incision gently with fine mesh gauze for 24 hours after escharotomy.
d.WOUND CARE 1. c. 2. debridement and dressing of the burn wounds Hydrotherapy a. Wounds are cleansed by immersion. b. enzymatic or surgical Deep partial. heat loss. to prevent increased sodium loss through the burn wound. Debridement a. pain and stress Client should be premedicated prior to the procedure Not used for hemodynamically unstable or those with new skin grafts Removal of eschar to prevent bacterial proliferation under the eschar and to promote wound healing May be mechanical. .or full-thickness burns: Wound is cleansed and debrided and topical antimicrobial agents are applied once or twice daily 3. showering or spraying Occurs for 30 minutes or less. The cleansing. c. b.
and poor cosmetic outcome Dressings are changed every 8 ± 12 hours Mobility limitations Prevents effective ROM exercises Wound assessment is limited . can promote webbing of digits. contractures.Open Method Versus Closed Method of Wound Care Method Advantages Disadvantages Increase chance of hypothermia from exposure OPEN Antimicrobial cream applied. Visualization of the and wound is left open to the wound air w/o a dressing Easier mobility and joint ROM Antimicrobial cream is applied every 12 hrs Simplicity in wound care CLOSED Gauze dressings are Decreases evaporative carefully wrapped from the fluid and heat loss distal to the proximal area of Aids in debridement the extremity to ensure circulation is not compromised No 2 burn surfaces should be allowed to touch.
rewet every 2-4 hours Stains everything including normal skin brown or black Monitor electrolyte balance carefully Cerium nitrate Povidone iodine Gentamycin Polymixin B ± Bacitracin ointment Mafenide acetate 10% cream or 5% solution (Sulfamylon) Silver nitrate (0.5% solution) Other topical dressings .TOPICAL ANTIMICROBIAL AGENTS FOR BURNS Silver sulfadiazine Most widely used agent and least common incidence of side effects May cause transient leukopenia that disappears 2-3 days of treatment Use with either open treatment. light or occlusive dressings Applied once or twice daily after thorough wound cleansing Painful during and for a while after application May cause metabolic acidosis. not used if >20% TBSA Cream must be reapplied 12 hours to maintain therapeutic effectiveness Solution concentration is maintained with bulky wet dressings.
WOUND CLOSURE Prevents infection and loss of fluid Promotes healing Prevents contractures Performed on the 5th to 21st day. depending on the extent of the burn AUTOGRAFTING Permanent wound coverage Surgical removal of a thin layer of the client¶s own unburned skin. which is then applied to the excised burn wound Monitor for bleeding following the graft because bleeding beneath an autograft can prevent adherence Immobilized after the surgery for 3-7 days to allow time to adhere and attach to the wound bed Care of the graft site Care of the donor site .
as dressings are transparent or translucent Monitor for wound exudate and signs of infection .TEMPORARY WOUND COVERINGS Biological Amnion Amniotic membranes from human placenta Dressing is changed every 48 hours Donated human cadaver skin is harvested w/in 24 hrs after death Monitor for wound exudate and signs of infection Rejection can occur w/in 24 hours Porcine skin is harvested after slaughter and preserved Rejection can occur w/in 24 ± 72 hours Replaced every 2-5 days until the wound heals naturally or until closure with autograft is complete Allograft (Homograft) Xenograft (Heterograft) Biosynthetic and synthetic Visual inspection of wound is possible.
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