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BURNS Burn injury- is a result of heat transfer from one site to another.

Burns are characterized by degree, based on the severity of the tissue damage. The severity of burn injury if determined by multiple factors: - age of patient - Depth of burn - Extent of Body Surface Area injured - Presence of inhalation injury ( e.g. carbon monoxide) - Location of injury (face, chest) - Presence of past and medical history Superficial Burns Very painful, dry, red burns which blanch with pressure. They usually take 3 to 7 days to heal without scarring. Also known as first-degree burns. The most common type of first-degree burn is sunburn. First-degree burns are limited to the epidermis, or upper layers of skin. Superficial Partial-Thickness More commonly referred to as second-degree burns. Blister, Redness Moist Painful edema Reepithelialisation within 14 days with minimal to no scarring Deep Partial-Thickness Grey-white Waxy Dry Painful to pressure Recovery in 2-4 weeks Has some scarring, depigmentation and contractures Infection may convert it to full thickness

Full Thickness Destruction of the epidermis, dermis, underlying tissues, muscles and bones Skin is waxy white to charred black, leathery Painless Healing is very slow Requires skin grafting Severe scarring occurs; contractures

TYPES OF BURNS a. Flame burns - fires b. Scald burns - typically result from hot water, grease, oil - Immersion scalds tend to be worse than spills, because the contact with the hot solution is longer c. Electrical burns; - thermal injuries resulting from high intensity heat. - E.g lightening injuries - There may be brain or heart damage or musculoskeletal injuries associated with the electrical injuries. d. Chemical burns - Most often caused by strong acids or alkalis. Unlike thermal burns, they can cause progressive injury until the agent is inactivated. - Flush the injured area with a copious amount of water while at the scene of the incident. CHEMICAL BURN Estimation of % Total Body Surface Area (TBSA) burn Rules of Nines Adults Rules of Nines Children LOCAL AND SYSTEMIC RESPONSES TO BURNS Burns that do not exceed 25% TBSA produce a primarily local response. Burns that exceed 25% TBSA may produce both a local and a systemic response and are considered major burn injuries. Systemic response- is caused release of cytokines and other mediators into the systemic circulation -Vasodilation, capillary permeability Pathophysiologic changes during initial burn shock period: Tissue hypoperfusion Organ hypofxn secondary to cardiac output Hypermetabolic phases Hemodynamic instability results from: Loss of capillary integrity Shift of fluid from the intravascular space to the interstitial spaces.

Fluid leaks occurs in the first 24-36 hours after burn injury, peaks at 6-8 hrs Cardiovascular Alterations Hypovolemia Decreased cardiac output Decreased BP Elevated hematocrit Fluid and Electrolytes Alterations Edema formation Hyperkalemia Hyponatremia large amount of Na is lost in trapped edema fluid (emergent phase) As fluids shift from interstitial to intravascular spaces ( acute phase) During diuresis Pulmonary alterations Bronchocontristion Hypoxia Carboxyhemoglobin

Indicators of upper airway injury: Burns of the face and neck Singed nasal hair Stridor, dry cough Sooty or bloody sputum Labored breathing/tachypnea Hoarseness, high pitch voice Erythema & blistering of oral or pharyngeal mucosa Renal Alterations Decreased renal function Increased BUN and creatinine levels Hemoglobinuria Myoglobinuria Gastrointestinal Paralytic ileus (absence of intestinal peristalsis) Curlings ulcer ( due to gastric bleeding secondary to massive physiologic stress Others: sepsis and infection Inability to regulate body temperature

MANAGEMENT PHASES: EMERGENT/RESUSCITATIVE From onset of injury to completion of fluid resuscitation ACUTE/INTERMEDIATE From beginning of diuresis to near completion of wound closure REHABILITATION PHASE From wound closure to return to individuals optimal level of physical and psychosocial adjustment EMERGENT/RESUSCITATIVE Shock phase Fluid shift Manifestations: Decreased BP Decreased urine output Edema Dehydration Hyperkalemia Management: First Aid ABC O2 therapy At the burn Scene: Extinguish flames Cool the burn Remove constrictive clothing Cover the wound Irrigate chemical burns Prevention of shock Fluid replacement Estimated fluid loss is based on the estimated percentage of burned area. Parkland formula : 4 ml %TBSA Wt (kg) half over 8 hrs half over 16 hrs

The adequacy of fluid resuscitation is determined by following urine output totals, an index of renal perfusion. Output totals of 30 to 50 mL/hour have been used as goals. Other indicators of adequate fluid replacement are a systolic blood pressure exceeding100 mm Hg and/or a pulse rate less than 110/minute. Most fluid replacements are ISOTONIC SOLUTIONS. colloids (whole blood, plasma, and plasma expanders) and crystalloids/electrolytes (physiologic sodium chloride or lactated ringers solution Pain Management Opoids NSAIDS Anxiolytics Non-Pharmacologic Relaxation techniques Music therapy distraction Nutritional Support Hypermetabolism Increased cortisol level Feeding usually begins immediately or at least within 24 to 72 hours post burn injury. ACUTE/INTERMEDIATE PHASE Fluid accumulation phase Fluids in interstitial shift to intravascular Signs & symptoms: Increased urinary output Hemodilution Na deficit (diuresis) K deficit ( beginning 4th-5th day postburn, K shift to cells) MANAGEMENT: Infection Control Sources of infection Patients intestinal tract Environment Wound cleaning Topical antibiotics silver sulfadiazine (silvadene) mafenide acetate 5% (sulfamylon)

silver nitrate .5%

Wound dressing Light dressing (over joint areas to allow movement) Occlusive dressing( used overareas with new skin grafts) Wound debridement Removal of devitalized tissue Goals: Removal of tissue contaminated with bacteria or foreign body, thereby protecting the patient from invasion of bacteria Removal of devitalizedtissue or burned eschar in preparation for grafting and wound healing Wound Grafting Autograft (Patients own skin) Homografts/Allografts (from recently deceased humans) Heterografts/Xenorafts(from animals)

Nursing management: ASSESSMENT Signs of airway involvement: -burns of face, neck and chest, sooty sputum or hoarseness Vital signs, arterial blood gasses & breath sounds: -to establish a baseline of respiratory function Central venous pressure (CVP), pulmunary capillary wedge pressure (PCWP), urine output & specific gravity: - to establish baseline for assessment of circulation Estimated body surface area involvement and severity of burns NURSING DIAGNOSIS Impaired gas exchange related to damaged pulmonary tissue, smoke inhalation, and upper airway obstruction Fluid volume deficit related to fluid loss through burn wound and shift of fluid out of intravascular compartment Pain related to tissue and nerve injury and emotional impact of injury Acute respiratory failure, distributive shock, acute renal failure, compartment syndrome, paralytic ileus, Curlings ulcer

PLANNING Provide humidified oxygen.

Assess breath sounds, and respiratory rate, rhythm, depth, and symmetry. Monitor patient for signs of hypoxia. Humidified oxygen provides moisture to injured tissues; supplemental oxygen increases alveolar oxygenation. These factors provide baseline data for further assessment and evidence of increasing respiratory compromise. Maintain patent airway through proper patient positioning, removal of secretions, and artificial airway if needed. Maintain adequate pain relief. A patent airway is crucial to respiration Pain increases anxiety. Observe vital signs (including central venous pressure or pulmonary artery pressure, if indicated) and urine output, and be alert for signs of hypovolemia or fluid overload. Hypovolemia is a major risk immediately after the burn injury. Overresuscitation might cause fluid overload. Monitor urine output at least hourly and weigh patient daily. Maintain IV lines and regulate fluids at appropriate rates, as prescribed. Output and weight provide information about renal perfusion, adequacy of fluid replacement, and fluid requirement and fluid status. Adequate fluids are necessary to maintain fluid and electrolyte balance and perfusion of vital organs. Assess for decreasing urine output and cardiac output, or increasing pulse. Provide sterile technique in wound care & follow principles of infection control(gown, gloves, mask, hair covering) Observe rising of temperature & white blood cell count, & odor Such signs and symptoms may indicate distributive shock and inadequate intravascular volume. The client's ability to resist infection is compromised Indicative signs of infection Special procedure: Escharotomy An escharotomy is performed by making an incision through the eschar (dead tissue that falls off or sheds from healthy skin) to expose the fatty tissue below. Escharotomies relieve the constriction caused by swelling under circumferential burns and improve tissue perfusion. Escharotomy Chest: Limb: To allow respiratory movement

To restore circulation in limb with excess swelling under rigid escharotomy