Burn Lecture Notes

A. CLASSIFICATION OF BURNS • Partial thickness - characterized by varying depth from epidermis (outer layer of skin) to the dermis (middle layer of skin)  Superficial - includes only the epidermis  Deep - involve entire epidermis and part of the dermis • Full thickness - includes destruction of the epidermis and the entire dermis as well as possible damage to the SQ, muscle and bone B. REVIEW OF SKIN FUNCTIONS • Functions of the skin

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Protection - intact skin is the first line of defense against bacterial and foreign-substance invasion Heat regulation Sensory preception Excretion Vitamin D production Expression - important with body image - fear of disfigurement

C. STAGES OF BURNS: • Hypovolemic state - begins at the onset of burn and lasts for the first 48 hours - 72 hours  Rapid fluid shifts - from the vascular compartments into the interstitial spaces  Capillary permeability with burns increases with vasodilation  Fluid loss deep in wounds  Initially Sodium and H2O  Protein loss - hypoproteninemia  Hemoconcentration - Hct increases  Low blood volume, oliguria  Hyponatremia - loss of sodium with fluid  Hyperkalemia - damaged cells release K, oliguria  Metabolic acidosis • Diuretic Stage - begins 48 - 72 hours after burn injury:  Capillary membrane integrity returns  Edema fluid shifts back into vessels - blood volume increases  Increase in renal blood flow - result in diuresis (unless renal damage)  Hemodilution - low Hct, decreased potassium as it moves back into the cell or is excreted in urine with the diuresis  Fluid overload can occur due to increased intravascular volume

 Metabolic acidosis - HCO3 loss in urine, increase in fat metabolism E. Fluid shifts resolving - pt still acutely ill 2. malnutrition 3. anemia - develops from the loss of RBC

Three periods of treatment - Emergent, Acute, Rehabilitation: I. EMERGENT (first 24-48 hrs) immediate problems
• Maintain airway, fluids, analgesia, temperature, wound • Assessment: ○ Objective  how burn occurred, when  duration  type of agent ○ Subjective:      previous medical problems size and depth of burn age body part involved mechanism of injury

• Factors Determining Severity of Burns: ○ Size of Burn Depth of Burn ○ Age ○ Body part effected ○ Mechanism of Injury ○ History of cardiac, pulmonary, renal or hepatic diseases ○ Injuries sustained at time of burn
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Duration of contact with burning agentc. Size & Depth of Burn - "Rule of Nines" Divide body surface into multiples of nine MAJOR BURN: > 25% of BSA of a partial thickness > 10% of BSA of a full thickness

• d. Age < 2 years old or > 60 years old, the mortality rates increases

e. Body part involved - not all are equal

Cosmetic and functional concerns Face, eyes, ears, feet, hands, perineum Limbs, neck and chest - burns can produce a tourniquet effect • f. Mechanism of injury - identify causative agent (Flame, contact, scalds, chemical, electrical) • g. Nursing diagnosis:

○ Airway clearance, ○ ineffective Fluid volume deficit Fluid volume excess ○ Hypothermia ○ Infection, ○ high risk for Pain (with partial thickness burns) ○ Skin integrity, impaired ○ Anxiety Knowledge • h. Interventions: ○ maintain a patent airway - watch for laryngeal edema, 100% FiO2 mask (increase in carboxyhemoglobin) intubation for inhalation most often required ○ maintain circulation - fluid resuscitation - crystalloids and colloids Crystalloids - may be isotonic or hypertonic 1. Isotonic - most common are lacted Ringers or NaCl (0.9%) - these do not generate a difference in osmotic pressure between the intravascular and interstitial spaces - subsequently LARGE amounts of fluid are required 2. Hypertonic salt solutions create an osmotic pull of fluid from the interstitial space back to the depleted intravascular space (helps decrease the amount of fluid needed during resuscitation. decreases the development of burn tissue edema, pulmonary edema, and CHF) Colloids - replacement begins during the second 24 hours following the burn to replace intravascular volume ONCE CAPILLARY PERMEABILITY SIGNIFICANTLY DECREASES

• General Indications for Fluid Resuscitation: 1. Burns > 20% of BSA with adults  2. Burns > 10% of BSA with children  3. Age >65 or < 2

"Parkland Formula" 4ml of Lacted Ringers x weight (Kg) x %BSA burned = ml of Lacted Ringers to be given during the first 24 hour period following the burn first 8 hours following the burn are the most crucial - need to half of the total, the second 8 hrs give onequarter or the remaining fluids, the last 8 hrs give the remaining one-quarter (with severe burn it is not uncommon to give greater than 20 thousand ml in a 24 hour period) colloid (protein) given after capillary integrity returns NPO - great thirst, ileus is common assess for adequate fluid replacement - HR < 120, BP - systolic >100, UO > 30 cc/hr pH 7.35 7.45, weight gain the first 72 hours during the diuretic phase UP is not a reliable indicator look at electrolytes analgesia - drug of choice is IV Morphine - NO IM or SQ wound care maintain body temperature - need to keep environment WARM, no drafts, heat lamps, sterile sheets emotional support - fear of dying, disfigurement, trauma SIGNS OF ADEQUATE FLUID RESUSCITATION: • Clear sensorium • Pulse < 120 beats per minute

• Urine output for adults 30 - 50 cc/hour • Systolic blood pressure > 100 mm Hg • Blood pH within normal range 7.35 - 7.45

II. ACUTE PERIOD • end of emergent period until burns heals

focus now shifts to care of wounds and prevention of complications. a. ASSESSMENT: Subjective  pain and anxiety Objective  complete assessment every 8 hours  Observe burn wound and donor sites for skin grafting,  dietary intake,  motor ability,  I&O,  weight NURSING DIAGNOSIS:  Skin integrity, impaired  Infection, high risk for  Altered nutrition  Pain, acute (with partial thickness burns)  Fluid Volume deficit  Anxiety  Hypothermia  Coping, ineffective individual  Coping, ineffective family  Body image disturbance  Knowledge deficit  Mobility, impaired  Self-Care deficit

• Actual range of this phase depends on degree and extent of burn

INTERVENTIONS: • relieving anxiety, denial, regression, anger, depression • wounds - REFER TO WOUND CARE

nutrition (Nutritional assessment, pre albumin levels, large protein requirement, carbohydrates and fats for energy, mega vitamins, TPN, enteral tube feedings) ileus is common

• pain - around the clock management prevention of infection - SEE WOUND CARE Organisms that usually infect burns are: a. Staphylococcus aureus b. Pseudomonas Infection is usually the cause of any deterioration Signs of sepsis: a. Change in sensorium b. Fever c. Tachyapnea d. Paralytic ileus e. Abdominal distention f. Oliguria Ways to prevent infection: a. Gowns, masks, gloves b. Sterile linen c. Persons with URI should not come in contact with patient WOUND CARE: 1. Burn wound is unique 2. Burn wound sepsis  gram +  gram- (pseudomonas),  viruses,  fungal (candida albicans) 3. Nutrition  collagen primary structure in healing by secondary intention,  need increased protein,  may need double the normal calorie requirements 4. Inadequate blood supply 5. Burn wound disorders:  scarring  contractures  keloids  failure to heal WOUND CARE PRINCIPLES: 1. GOALS  close wound asap  prevent infection  reduce scarring and contractures

 provide for comfort 2. Wound cleaning bed side hydrotherapy tanks tubbing spray table 3. Debridement mechanical surgical enzymatic 4. Topical antibacterial therapy mafenide (sulfonamide) sulfadiazine WOUND CARE - DRESSING THE BURN 1. Open technique or exposed - more often used with burns effecting the:  face,  neck  perineum and  broad areas of the trunk Partial thickness - exudate dries in 48 to 72 hours forming a hard crust that protects the wound.  Epithelialization occurs beneath the crust and may take 14 to 21 days to heal.  Crust then falls off spontaneously - leaving healed unscared surface Full thickness - dead skin is dehydrated and converted to black leathery escar in 48 to 72 hours. Loose escar is gradually removed with hydrotherapy &/or debridement 2. Closed technique Wound is washed and sterile dressings changed (may be q shift, daily). Dressing consists of gauze &/or ace wraps impregnated with topical ointments. 3. Semi-open consists of covering the wound with topical Antimicrobial agents and gauze. Advantage:  speeds debridement,  develops granulation tissues faster,  and makes skin grafting possible sooner. 4. Biological dressings  homografts - same species (cadaver skin)  temporary coverage heterografts - another species (pig skin)  temporary coverage autografts - patients own skin - permanent coverage WOUND CARE - GRAFTING 1. Indications for grafting  full thickness  priority areas  wound bed pink, firm, free of exudate  bacterial count < 100,000/gram of tissue 2. Care of grafts - assess

1. Care of healing skin - wash daily, cover with cocoa butter 2. Pressure garments, ace wraps - prevent scaring and contractures 3. Promote mobility - positioning, exercise, splinting, ADL

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