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Burns _ o

estruction of th .
- Cau e sk,n th
ses acute infla at causes loss -
- Acute inflarn rn . rnmat1on and tlssu of intracellular flui
major fluid h.;_tron releases chem· e destruction d and electrolytes
s hdna ' e dema and r real med'•ators that I
CLAsSIFICATION OF 8 educed IV llolurne ncrease capillary Permeab'li
1. Accordin ' URNS: ' ty causing
g to mechanism f .
a. Thermal B o lnJury
- urns- Contact
Flame, Hot liquid S . or exposure With:
b. Ch · s, em,solids (T )
- Str:;~~i~~rnAsl-kC~ntact with: ar • Semi-liquids (steam), Hot objects
c· Radiation a , alls' 0rga n,c . Compound
- Associativ . urns- Caused by exposure t .
Sunburn e With: Use of ionizing radiation~ a _radd1oactive source
2 A in •n ustry thera
. ccording to burn depth , peutic radiation sources in medici
a S ne,
· uperficial p rt· 1
(1•t degree burns~ ,a -thickness injuries
b. Deep part· I .
(2nd d ,a -thickness injuries
egree burns)
~3•d/F~!l•thickness injuries
3 . 4 degree burns)
. According to Extent of bod . .
a. Rule of Nines- B d . Ys_u~ace lnJured determined by:
E o Y is d1v1ded into anatomic I .
asy, requiring no diagrams to deter . a sections each represents 9% of the TBSA
b. Lund and Brower Method mtne the percentage of TBSA injured

Major Burns
Emergent phase/ Resuscitative phase - 24-48h
Hypovolemi~- chief concern x 48hrs after ma·o/:urn
Greatest fluid loss 1st 12 hours (peak 6-8hrs/
Burns causes capillaries of damage area> dilate
Increased permeability> IVC > ITC > edema and blistering
CHONs, plasma and electrolytes shift to ITC· RSC · .
Acute dehydration results and poo I , rt . in IVC > increased blood viscosity > increased Hct
r rena pe uston
Distributive Shock results- common cause of death

Physiologic Responses
Cardiovascular Response
Hypovolemia- perfusion & 0 2 delivery
Cardiac output - fluid loss continues & vascular volume decreases (onset of BURN SHOCK)
SNS- release catecholamines-vasoconstriction, increase pulse rate
Myocardial contractility-suppressed by release of inflammatory cytokine necrosis factor

Effects on Fluids, Electrolytes and blood volume


Circulating blood volume decreases
3·5 Lor more over 24-hour period evaporative fluid loss
Serum Na levels vary in response to fluid resuscitation. Usually- hyponatremia. Common during 1st week
of acute phase, water shifts from interstitial-vascular space
Hyperkalemia- results from massive cell destruction
Hypokalem ia- may occur later w/ fluid shifts·& inadequate potassium replacement
On the contrary, Hct increases due to plasma loss
Blood transfusions are required periodically to maintain adequate Hgb levels for 0 2 delivery
Thrombocytopenia, prolonged clotting & prothrombin times

Lung Injury
lung irritation due to by-prods of burning material » chemical pneumoniti~ & s~oke poisoning .
Loss of bronchial epithelium & surfactant » sloughing of tracheal & bronchial ep1th » hemorrhagic
tracheobronchitis
Thermal injury: edema & bl" t .
Manifestations: Hoars is er formation of airways.
P I eness, productive h .
u monary Response coug , singed nasal hairs agitation fl .
Inhalation injury- lead· • • anng nostrils
Relea . . ing cause of death
. se of histamine, serotonin & thro
~Yrcu~ferential full thickness chest bur:sboxane➔ bronchoconstriction; chest contraction seconda
pox1a- catecholamine I ry to
H re ease, periph I bl
ypermetabolism + catecholam· I era ood flow, oxygen delivery
me re ease lead to ·
tissue 0 2 consumption
RENAL RESPONSE
Renal function may be altere
During a major burn th b dd as a result of decrease blood volume
I . • e O Y responds initially b h ·
g omerular filtration rate caus· • . Y s untmg blood from the kidneys and decreasing
.
0 estruct1on mg o 11guna
of RBC at th . .
When muscle damage e mJury site results in free hemoglobin in the urine
occurs, myoglobins a I df
If there is inadequate bloOd fl h re re ease rom the muscle cells and excreted by the kidney
tubules, resulting in ac t th
bow t rough_ e kidneys, the hemoglobin and myoglobin occlude the renal
u e tu ular necrosis and renal failure
GI RESPONSE
Blood flow to the mesenteri b d . I d. . . .
gastrointesf d f . : e. is a so iminished leading to the development of intestinal ileus and
I
ma ys unction in clients with severe burns
May cause. two potential gast rom · t es t·mal compl1cat1ons:
. . Paralytic ileus ( absence of intestinal peristalsis)
and Curling's ulcer
ManifeSt ations of paralytic ileus due to burn trauma: Decreased peristalsis and decrease bowel sounds
Gastr~c diste~tion and nausea may occur leading to vomiting unless gastric compression is initiated
Gastnc bleeding secondary to massive physiologic stress may be signaled, by occult blood in the stool,
regurgitation of the coffee ground material from the stomach or bloody vomitus. These signs suggest
gastric or duodenal erosion ( Curling's ulcer)

METABOLIC RESPONSE
Inability to regulate body temperature due to loss of skin
Burn patients may therefore exhibit low body temperature in early burns after injury
Then, hypermetabolism resets core temperature, burn patients become hyperthermic for much of t he
post burn period, even in the absence of infection
Burn injury triggers a hypermetabolic state which is manifested by a negative nitrogen balance with
increased protein degradation and urea excretion, hyperglycemia and hyperlactatemia.

Treatment ( Stage 2) State of Diuresis


Begins in 48-72hrs after the bu·rn injury
Circulatory overload ls the chief concern due to fluid shifting back from IT > IV
Diuresis begins- VS, LOC and UO have to be monitored
Dehydration occurs (Na and K deficit)

Treatment (Stage 3)
• Ca and K deficit and negative nitrogen balance (loss of CHON)
GOAL: return patient to productive life
wearing elastic garments to decrease scarring and cosmetic surgery
Psychological counseling

Management of burns
C· Contain E· Extinguish/ Evacuate
RACE - R- Rescue/ Remove A-Alarm
A Emergent/Resuscitative Phase
0~ THE CARE SCENE: EMERGENCY PROCEDURES AT BURN SCENE
EMERGENCY CARE: (ABC) GOALS:
· 1. Provide a patent airway
2. Provide pain relief
3. Minimize wound contamination
4. Transport quickly
Initial Care:
1. extinguish fi
2. remove tre
3 non-adh
. establish Pat erent smolderi
4. assess & .. _ent airway: check &ng ~lothing
S ln1t1ate t f . ,or lnhal .
6. remove tight fitti: ~r injuries requirin a~1on bu_rns
7. cover burn With rn g !eweJry & clothing g mrned,ate attention
. cover u b o,st, sterile
8. transpo~ urned areas With waor clean cover
to nearest facility rm dry cover
B. EMERGENCY
Primary goaf· prCARE IN THE HOSPITAL
I • event hy
. AIRWAY AND B povolemic (burn) sh
II. FLUID REPLAc REATHING ock and to prevent vital organ functioning by:
GUIDELINES ANOEMENT THERAPY
FORMULA F
Formula: It OR FLUID REPLACEMENT
EVANS· 1 24hrs nd
· saline 2 24 hrs
lml/kg/% .S ml/kg/%
Colloid lml/kg/%
osw .Sml/kg/%
BROOKE 2000ml 2000ml
LR 1.Sml/kg/% 0.7Sml/kg/%
Colloid 0.Sml/kg/% 0.2Sml/ kg/%
DSW 2000 ml
Baxter 1000 ml
LR 4ml/kg/%
(Parkland) DSW+colloids+
K

•check CVP VS Hct dur th st


Ill. Wound Care ' , mg erapy. 1 24 hrs half given 1" Bhrs then½ over 16hrs
Aseptic management
All clothing and jewelry removed
Elevate affected area

B. Acute/Intermediate
Wound Cleaning
Hydrotherapy
Limited to 20-30 minutes to prevent chills
Temperature of water: 37.s•c
Temperature of room: 26.6•c - 29.4"C

Goal: protect wound against bacterial proliferation


1. Topical Antibacterial Therapy- Promotes conversion of open, dirty wound to a clea n one
Criteria for choosing topical agent:
a. Effective against P. aeruginosa, S. aureus and even fungi
b. Clinically effective
c. Penetrates eschar but not systemically toxic
2 . Wound Debridement
Two goals:
a. Remove tissue contaminated with bacteria and foreign bodies ➔ to protect patient from
bacterial invasion
b. Remove devitalized tissue in preparation for grafting and wound healing

3. Wound Grafting
a. Autografts- Graft derived from one part of the patient's body and used on another part
Ideal means of covering burn wounds, Patient's own skin, Not rejected by patient's immune
system
b. Homografts (Allografts)- Graft transferred from one human (living o r cadaveric) to another
human
c. Heterografts (Xenografts)- Graft obtained from an animal of a specie (e.g.pigskin)
d. Biosynthetic and Synthetic Dressings
Pain Management
- Pain is inevitable d .
Burn Patients hav unng recovery frorn
a. Bockgrov e d~scribed three any burn injury
b. P nd/restmg Poi - E . types of Pain:
rocedurot pain D . n X1sts 24 hour
c 8 - unng s
. reokthrough po · procedures such
to control backg:n- Occurs When blood
Opioid administrar ound Pain
v::
~ou~d care or range of motion exercises
se so analgesic agents fall below level required
ion (IV route)- ex· .
Burn Care· N · Morphine sulfate
• urslng M
l. R . anagernent
~storing normal fl 1
'd
minimize r' k ~ balance- Monitor rv d . .
2 Ste ·1 is of rapid infusion· Obt . . an oral fluid intake; Use IV infusion pumps to
. n e technique used f ' ain intake, output, daily weights
Fresh fruits flow or wound care procedures
g rowt h ) ' ers, and1plants are n0 t · . .
permitted rn the patient's room (risk for microbial
~h~nge_li_nens regularly (sterile linens)
3. a1nta1ning adequate n . .
rich diet utrition- Nurse collaborates with dietitian to plan protein- and calorie-
4. Bed Cradle
S. Encourage to exp f 1·
. ress ee mgs about disfigurement immobility from scarring
6. Prov1de ROM ·· '
exercises, Hubbard tank, bed cradle, splints and Jobst clothing to prevent
complications
7
. Elevate extremities to promote venous drainage and decrease edema
8 - Maintain warm environment because patient unable to regulate body temperature
9. Promoting physical mobility
10. Monitor splinted areas, keep joints in flexed position

C. Rehabilitation Phase
• From major wound closure to return to individual' s optimal level of physical and psychosocial
adjustment
Priorities:
Prevention of scars & contractures
Physical, occupational & vocational rehabilitation
Functional & cosmetic reconstruction
Psychosocial counseling
Prevention of Hypertrophic Scarring
Require patient to wear a pressure garment
Instruct patient about the need for lubrication & protection of the healing skin.
Pressure garments are used at least a year after the injury.

Nursing Interventions
Nurse incorporates physical therapy exercises in patient's care
Provide diversional activities to tolerance for physical activity
Improve body image and self concept
Take time to listen & to provide realistic support.
Application of Cream to the Burn Wound
Hubbard Tank for Hydrotheraphy
Harvesting Donor Skin for Skin Grafting
Anti-Scar Support Garment