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Chapter 57 Minor burn

Management of Patients With


Burn Injury Moderate, uncomplicated burn

Burn Injuries Major burn

Approximately 1.1 million people Methods to Estimate Total Body


require medical attention for Surface Area (TBSA) Burned
burns every year, and about 4,500 Rule of nines
persons die of burns and
associated inhalation injuries Lund and Browder method
every year.
Palm method
Most burns occur in the home.
Rule of Nines
Young children and the elderly are
at high risk for burn injuries. Pathophysiology of Burns

Nurses must play an active role in Burns are caused by a transfer of


the prevention of burn injuries by energy from a heat source to the
teaching prevention concepts and body.
promoting safety legislation.
Thermal (includes electrical)
Goals Related to Burns
Radiation
Prevention
Chemical
Institution of life-saving measures
Physiologic Changes
for the severely burned person
Burns less than 25% TBSA
Prevention of disability and
produce a primarily local
disfigurement through early
response.
specialized and individualized
care Burns more than 25% may
produce a local and systemic
Rehabilitation through
response and are considered
reconstructive surgery and
major burns.
rehabilitation programs
Systemic response includes
Classification of Burns (See Table
release of cytokines and other
57-1)
mediators into the systemic
Superficial partial-thickness circulation.

Deep partial-thickness Fluid shifts and shock result in


tissue hypoperfusion and organ
Full-thickness hypofunction.

Zones of Burn Injury Effects of Major Burn Injury

Factors to Consider in Fluid and electrolyte shifts


Determining Burn Depth
Cardiovascular effects
How the injury occurred
Pulmonary injury
Causative agent
Upper airway
Temperature of agent
Inhalation below the glottis
Duration of contact with the agent
Carbon monoxide poisoning
Thickness of the skin
Restrictive defects
Classification of Burns by Extent
of Injury (See Chart 57-4) Renal and GI alterations
Immunologic alterations Address pain; only IV medication
should be administered.
Effect upon thermoregulation
Psychosocial consideration and
Phases of Burn Injury emotional support should be
Emergent or resuscitative phase given to patient and family.

Onset of injury to completion of Acute or Intermediate Phase


fluid resuscitation 48-72 hours after injury
Acute or intermediate phase Continue assessment and
From beginning of diuresis to maintain respiratory and
wound closure circulatory support.

Rehabilitation phase Prevention of infection, wound


care, pain management, and
From wound closure to return to nutritional support are priorities
optimal physical and psychosocial in this stage.
adjustment
Rehabilitation Phase
Emergent or Resuscitative Phase:
On-the-Scene Care Rehabilitation is begun as early as
possible in the emergent phase
Prevent injury to rescuer. and extends for a long period
after the injury.
Stop injury: extinguish flames,
cool the burn, irrigate chemical Focus is upon wound healing,
burns. psychosocial support, self-image,
lifestyle, and restoring maximal
ABCs: Establish airway, breathing, functional abilities so the patient
and circulation. can have the best-quality life,
both personally and socially.
Start oxygen and large-bore IVs.
The patient may need
Remove restrictive objects and
reconstructive surgery to improve
cover the wound.
function and appearance.
Do assessment, surveying all body
Vocational counseling and support
systems, and obtain a history of
groups may assist the patient.
the incident and pertinent patient
history. Management of Shock: Fluid
Resuscitation
Note: Treat patients with falls and
electrical injuries as for potential Maintain BP above 100 mm Hg
cervical spine injury. systolic and urine output of 30-50
mL/hr. Maintain serum sodium at
Emergent or Resuscitative Phase
near-normal levels.
Patient is transported to
Consensus formula
emergency department.
Evans formula
Fluid resuscitation is begun.
Brooke Army formula
Foley catheter is inserted.
Parkland Baxter formula
Patients with burns exceeding 20-
25% should have an NG tube Hypertonic saline formula
inserted and placed to suction.
Note: Adjust formulas to reflect
Patient is stabilized and condition initiation of fluids at the time of
is continually monitored. injury.
Patients with electrical burns
should have an ECG.
Fluid and Electrotype Shifts: Pain Management
Emergent Phase
Burn pain has been described as
Generalized dehydration one of the most severe forms of
acute pain.
Reduced blood volume and
hemoconcentration Pain accompanies care and
treatments such as wound
Decreased urine output cleaning and dressing changes.
Trauma causes release of Types of burn pain
potassium into extracellaur fluid:
hyperkalemia. Background or resting

Sodium traps in edema fluid and Procedural


shifts into cells as potassium is
released: hyponatremia. Breakthrough

Metabolic acidosis Pain Management

Fluid and Electrolyte Shifts: Acute Analgesics


Phase IV use during emergent and acute
Fluid re-enters the vascular space phases
from the interstitial space. Morphine
Hemodilution Fentanyl
Increased urinary output Other
Sodium is lost with diuresis and Role of anxiety in pain
due to dilution as fluid enters
vascular space: hyponatremia. Effect of sleep derivation on pain

Potassium shifts from Nonpharmacologic measures


extracellular fluid into cells:
potential hypokalemia. Nutritional Support

Metabolic acidosis Burn injuries produce profound


metabolic abnormalities. Patients
Burn Wound Care with burns have great nutritional
needs related to stress response,
Wound cleaning hypermetabolism, and wound
Hydrotherapy healing.

Use of topical agents Goal of nutritional support is to


See Table 57-5 promote a state of nitrogen
balance and match nutrient
Wound débridement utilization.

Natural débridement Nutritional support is based on


patient’s preburn status and % of
Mechanical débridement TBSA burned.
Surgical débridement Enteral route is preferred. Jejunal
Wound dressing, dressing feedings are frequently used to
changes, and skin grafting maintain nutritional status with
See Table 57-6 lower risk of aspiration in a
patient with poor appetite,
Use of Biobrane Dressing weakness, or other problems.

Comparison of Integra Template Other Major Care Issues


and Split-Thickness Autograft
Pulmonary care
Psychological support of patient Visceral damage (electrical burns)
and family
Home Care Instructions
Patient and family education
Mental health
Restoration of function
Skin and wound care
Nursing Process: Care of the
Patient in the Emergent Phase of Exercise and activity
Burn Care: Diagnosis Nutrition
Impaired gas exchange Pain management
Ineffective airway clearance Thermoregulation and clothing
Fluid volume deficit Sexual issues
Hypothermia Elastic Pressure Garments
Acute pain

Anxiety

Potential
Complications/Collaborative
Problems

Acute respiratory failure

Distributive shock

Acute renal failure

Compartment syndrome

Paralytic ileus

Curling’s ulcer

Nursing Process: Care of the


Patient in the Acute Phase of Burn
Care: Diagnosis

Excessive fluid volume

Risk for infection

Imbalanced nutrition

Acute pain

Impaired physical mobility

Ineffective coping

Interrupted family processes

Deficient knowledge

Collaborative Problems/Potential
Complications

Heart failure and pulmonary


edema

Sepsis

Acute respiratory failure