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Burns

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Burns Anatomy of the Skin Burns
More than two million people in the United States suffer thermal injuries each year. Approximately 100,000 of them must be admitted to the hospital. Most burns are thermal. They result from flame, explosions and contact with hot metal or liquid. Other causes are electricity, caustic chemicals or radioactive energy.

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Burns - Pathophysiology
The immediate effect of a burn is the destruction of the protective skin area. This leads to serious disruption of homeostasis as a result of increased capillary permeability, diffusion of vascular components into the extravascular tissue, imbalance of electrolytes & diminished blood volume. Multi-system trauma.

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Burn Pathophysiology
During the 48 hours immediately following the injury the patient must be monitored closely for signs of burn shock. The insult begins with destruction of the epidermis, the outer most layer of the skin, eliminating the body's barrier to water evaporation and allowing fluid loss. The greatest loss of fluid, electrolytes, and protein, however, is caused by volume shifts from the intravascular to the extravascular compartment secondary to an increase in capillary permeability.

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Burn Pathophysiology
Heat effects and the release of vasoactive substances from the injured area add to this increase in permeability also know as capillary leaking.

The resulting fluid shifts are directly proportional to the depth and extent of the burn. It is important to keep in mind that all burns are not alike . The first determination in caring for the burned patient is to determine the severity of the burn. Treatment/fluid therapy is going to be directly related to severity.

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Burn Severity
Severity is based on. Size of the burn. Depth of the burn. Individual's age past medical history. Part of the body that has been burned. The size of the burn is expressed as a percentage of total body area. There are two basic methods to determine the percentage of burns. Both require the use of diagrams.

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Rule of Nines
The body is divided into portions totaling 100%. Advantage of using Rule of Nines. Fairly rapid, easy. No charts required. Disadvantage. It is fairly inaccurate, especially when dealing with children because it doesn't allow for body proportion differences.

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Berkow Method
Advantage Accurate for all ages Disadvantages Requires time to calculate Requires table for all ages

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Depth of a Burn
Will be dependent on the temp. & the duration of contact Expressed in terms of 1st, 2nd or 3rd degree which is the older method OR Full thickness or partial thickness Differential diagnosis of burn depth

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Partial/deep Partial Thickness
Skin will either have normal or increased sensitivity. Large thick wall blisters which will increase in size.

Skin is red, will blanch. Normal or firm skin texture. These types of burns are very painful, but will heal on their own if they sustain no further damage.

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Partial Thickness - 1st Degree Partial Thickness - 2nd Degree Full Thickness
Anesthetic. Non painful because all the nerve endings have been destroyed). If blisters are present, they will be thin walled & won't increase in size. The skin will be white, brown, black, or red. N0 blanching. Firm or leathery skin texture. Full thickness burns or 3rd degree burns will not regenerate & grafting is required.

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Full Thickness - 3rd Degree Age of the Patient
Patients less than 2 yrs. old or those over 60 yrs. old tend to have a higher mortality rate. Infants tend to have a very poor antibody response & fluid requirements can be very tricky with them. Older patients may have illnesses that are either present or latent. Once a a burn injury is sustained the illnesses are exacerbated and complicate the situation.

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Parts Of The Body
Burns of the head, neck, & chest can lead to a higher incidence of respiratory problems. Assess for signs of respiratory distress such as coughing or bronchospasm. Burns of the neck are prone to contractures. These patients are usually not given a pillow or they lay flat with a towel roll under the neck. Burns of the perineum are very susceptible to infection.

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Complications of Burns
All Burns result in complications Common Complications

Septicemia (can occur at any time during convalescence) Renal Failure Pneumonia Heart disease
Metabolic Complications

Diabetes (Stress Diabetes) Curling's Ulcer (A stress ulcer specific to burns)

Adrenocortical insufficiency
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Emergency Treatment for Burns
Eliminate the heat source - Stop the burning process. Smother the flames & immerse the burned part in water, not ice water. Smoldering clothing should be removed if it is not adherent to the skin. Cover individual with a clean blanket or sheet. If it is a chemical burn flush the area with copious amounts of water. The guidelines are to stand in the shower for 20 min. Do not apply any greases or ointment to the burned area.

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Emergency Treatment of Burns
Maintaining an open airway is imperative. Suspect inhalation injury if. The burn occurred in an enclosed area. Facial or chest burns. Exposure to noxious fumes. Observe for darkened mucosa in the mouth, red, swollen, mucosa. Assess nose for singed nasal hair. This can also be fairly indicative for inhalation injury. Assess for any hoarseness, sneezing, coughing. Can also indicate respiratory damage.

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First Aid Measures
Maintain a patient airway. Stop any bleeding. Treat shock. Not all go into burned shock but do anticipate it. Assessing Respiratory Function. If congested, have the patient cough to clear respiratory passages.

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Admission to the ER
On admission, these patients should be greeted by name because they are usually alert & anxious. Start an IV. CL may be put down at this point. An indwelling catheter will be inserted. Obtain blood samples. Give tetanus toxoid. Burn patients autocontaminate themselves. Obtain a brief hx. from the pt. or family member. Vital signs.

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Admission to The ER
PE to determine if other injuries If explosion, they may have fractures Estimate extent of burned area - Important for fluid replacement Obtain wound cultures Put down an NG Tube

Prevents paralytic ileus Weigh If facial or neck burns, measure the circumference of the head & neck Swelling can cause constriction of the trachea

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Fluid Therapy
Fluid therapy is the most important aspect of initial care for the burned patient during the emergent period. A severe burn causes many systemic changes. The most significant is A FLUID SHIFT. When burns occur there is a change in the distribution of body fluid. The amount of change is going to be dependent on the severity of the burn. With prolonged exposure to heat capillaries are damaged & they become permeable to fluid. They let fluid leak out of the capillaries & into the interstitial spaces resulting in edema and blister.

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Fluid Therapy
The fluid leak, which is caused by increased capillary permeability continues for 24 to48 hrs. post burn. It will be during this 1st 24 to 48 hrs. that hypovolemic shock will be a risk. In full thickness burns, where the skin is like leather, the fluid actually does not escape the body. It is still retained, but it cannot be mobilized. After 48 hrs. the capillaries tend to heal & the fluid is remobilized back into the intravascular space.

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Fluid Therapy
Fluid requirements are going to be determined by the area & the depth of the burn. Fluids that are used during this period will usually be. Lactated Rinqers because of it's electrolyte concentration. Albumin will pull that fluid in the interstitial spaces in the intervascular. D5W. Whole blood is usually not given because plasma is being lost, not whole blood. THE PURPOSE OF FLUID THERAPY THE lST 24 to 48 HRS. IS TO PREVENT HYPOVOLEMIC.

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Indications for Fluid Therapy
Total Burn over 20%. Age: Less than 2 yrs. old or greater than 60 yrs. old. Titration of fluid Therapy. 1) urine output ql hr. (between 30 to 60 cc/hr.). 2) pulse q l hr. 3) B/P q 1 hr. 4) CVP. 5) Hct. q 6.

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Formulas for Fluid Replacement
Evans Formula. Colloids 1 ml./kg. of body wt/%/burn. Physiologic Saline 1 ml/kg. of b. wt./% of burn. H20 Dependent on age & insensible loss.

1/2 of total is given the 1st 8 hrs. and the remainder given the next 16 hrs.
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Formulas for Fluid Replacement
Brooke Formula. Colloids .5 ml/kg/% of body surface burned. Lactated Ringers 1.5 ml/% of body wt/% burn. H20 Again dependent. 1/2 total amount given 1st 8 hrs. 1/4 of total the 2nd 8 hrs. 1/4 the third 8 hrs.

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Nursing Assessment Emergent/resuscitative Phase
Focus and monitor ABC’s. Vital signs. Peripheral pulses on burned extremeties. extremeties. Monitor fluid intake and output. Body temperature,tetanus, past medical problems.

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Nursing Interventions – Emergent/resuscitative Phase
Promote gas exchange and airway clearance 02, turning, deep breathing, positioning Restore fluid and electrolye balance IV’s Elevate burned extremities Maintain body temperature Heat lamps, blankets Minimizing pain and anxiety IV analgesics Emotional support to patient and family

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Nursing Interventions – Emergent/resuscitative Phase
Manage potential complications ABC Shock Renal failure Paralytic ileus Curlings Ulcer Antacids Histamine blockers

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Wound Care/intermediate Phase
Fluid resuscitation techniques have greatly reduced the number of deaths from burn shock.

Specialists are focusing on better ways to care for the burn wound. Local care of the burn is not considered a life-saving measure therefore, it may be delayed until all first aide measures have been initiated.
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Goals of Wound Care
Cleanse the wound & decrease any dead tissue & debris. Dead tissue & debris serve as a wonderful medium for bacterial growth). Prevent further destruction of viable skin. Begin preparation for a suitable grafting surface. Burned tissue develops Eschar (debris, dead tissue & remnants that collect on the surface of the burned area and has a whitish color). Before healing can take lace, all of the eschar has to be removed. Can be a very time consuming & lengthy process.

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Terminology
Debridement - Removing of dead tissue Surgically - Short hospital stay, faster cover up, deceased risk of infection, decreased pain Mechanical method of removing eschar Wet to dry dressings Purpose of doing wet-to-dry dressings is to remove eschar Enzymatic/Chemical removal of eschar Travase Ointment selectively digests the dead debris

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Terminology
Escarotomy. Done when circulation is compromised due to fluid buildup. The process of incising through the eschar to layer of viable tissue. Result is immediate opening and release of tissue. When the fluid shifts back, the gap closes up. Done without anesthesia.

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Escharotomy Infection Control
Infection control begins at admission & continues until grafting is completed Septicemia can occur at any time during hospitalization Controversy as to whether antibiotics should be initiated immediately

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Pain Relief
Of extreme importance. Partial thickness burns are extremely painful.

Analgesics are always given IV (IM will probably not be absorbed). Morphine Sulfate is the drug of choice. Trend is to give patients continuous Morphine drip as they have a much better response.
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Daily Debridement
Put on a shower table, or into a Hubbard tank. Wound is rubbed gently with 4 x 4’s. Loss of protective layer of skin results in easy chilling. Burn patients most comfortable in a unit that is at least 84 degrees. There is some controversy that exists over whether or not to debride or remove blisters. An air current alone will cause tremendous pain. Keep them out of drafts &covered as much as possible. No shaving of burned area.

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Hubbard Tank Shower Chair Medications
In the past, topical antimicrobial agents such as Silvadene and sulfamylon have been the mainstays of therapy. Most popular is Silvadene.

Effective against a wide range of bacteria. Easy to use, Relatively painless, some patients say it has a cooling effect on the burn.
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Medications
Sulphamylon. Also effective against a wide range of bacteria, especially pseudomonas & staph. It is very easy to apply but it tends to be very painful & some patients complain that it burns for 15 to 16 min. after application. It also tends to cause metabolic acidosis.

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Medications
Silver Nitrate. Not used much any more. It is a liquid & requires the use of moist dressing. The dressings have to stay wet all of the time. If dressing are allowed to dry out, it further burns the skin & increases the damage that's already been done. Another side effect is it turns everything brown that it comes in contact with.

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Additional Aspects of Wound Care
Deep second degree burns were treated with these creams and periodic debridement and allowed to heal without grafting, but this technique produced excessive scarring. Research also showed that using antimicrobial agents to treat very large burns did not improve survival rates significantly. The removal of dead burned tissue by sharp dissection into viable tissue within 72 hours after injury has now become common.

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Positive Aspects of Early Excision
Patients with TBSA of less than 20 % heal faster when treated in this manner, shortening their hospital stay. Reduces the need for painful wound debridements. Covering the wound helps slow the increase in metabolic rate that occurs with burn trauma and decreases pain. Fewer problems with infection. Results in less severe scarring, so that less reconstructive surgery is needed.

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Choosing Candidates for Early Excision
Any patient with burns that will take longer than three weeks to heal is considered for early excision. The type, extent, and location of the burn are also important. Excision of flat surfaces of the trunk, the arms and legs and abdomen yields the best results. The final decision depends on the depth of injury, the patient reponse to resuscitation, and contraindications to surgery and general anesthesia.

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Closing the Burn Wound
The best cover for a wound is the patient's own skin. Patients with major burns, may not have enough intact skin to serve as donor sites. Sometimes a small piece of skin can be meshed and expanded to cover the wound. Grafts can being full thickness or split thickness. Full thickness grafts are more cosmetically pleasing. Split thickness grafts can cover a larger area. When this isn't possible other coverings must be used.

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Dermatone Graft - Mesh/partial Thickness Graft - Full Thickness Biologic Dressings
Fresh skin from a human cadaver (homograft or allograft) is considered the best biologic substitute. Clean burns can be covered with homograft at the bedside or in the operating room after excision. The graft adheres to the wound's surface and becomes vascularized. It may remain in place for approximated three to five weeks. In addition to providing temporary coverage, homograft can tell the likelihood of successful autografting.

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Biologic Dressings
Heterografting refers to transferring tissue between two different species. Pigskin is used most often.

Frozen pigskin is less likely than fresh to be rejected but raises the risk of infection. Therefore an antimicrobial dressing may be applied. Heterografts may be removed every three to four days so the wound can be cleansed and evaluated. Pigskin has many advantages. It is readily available, easily stored, and easy to apply and remove. It adheres well to the wound, limits pain, and prevents the loss of fluid, electrolytes, and heat.

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Biologic Dressings
Biobrane, a biosynthetic material meets many of the requirements of an ideal skin substitute. It is elastic, durable, and relatively inexpensive. Can be stored indefinitely and can be left on for 60-80 days.

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Nursing Care After Excision and Grafting
Keep newly grafted areas immobile and free from excessive pressure to prevent disruption of the graft. Elevate extremities to decrease post-op edema. Check for bleeding and signs of neurovascular impairment; increasing pain, numbness, tingling. Bulky pressure dressings applied in the OR will remain in place 2-3 days. Application of sterile saline or antibiotic solution every four hours to keep dressing moist may be ordered. Always use aseptic technique.

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Nursing Care After Grafting
After an autograft the donor site also requires special attention. Leave it open to air. Keep pressure off it. Apply a heat lamp as ordered. Assess both donor site and grafted areas often for signs of infection. Medicate for pain as needed.

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Donor Site Future for Burn Care
Several important advances have been made in the quest for the perfect skin substitute. Epithelial cells can now be grown in a test tube. A double layered artificial skin has also been developed. Both are in the investigative stages.

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Nutrition
Require a tremendous # of calories. Are placed on a high cal, high protein, high carbo and fat diet with vitamin supplements. With severe full thickness wounds there is an extremely high rate of metabolism because the body is trying to heal a wound it is literally incapable of doing. It is important to keep them in nitrogen balance so they are prime candidates for hyperalimentation. Foods & drinks containing Vit. C are good because Vitimin C aids in collagen formation.

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Emotional Aspects of Burn Injury Emotional Aspects of Burn Injury Additional Concerns
Scars Jobst stocking Massage Preventing contractures Proper positioning

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Nursing Assessment – Acute and Intermediate Phase
Hemodynamic alterations Observe EKG/lab for potassium imbalance Wound healing Assess peripheral pulses Gastric ph Focus on pain and psychosocial responses

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Nursing Interventions– Acute and Intermediate Phase
Restoring fluid balance Preventing infection Aseptic technique Wound cultures, WBC count Maintaining nutrition TPN High cal/protein diet Weight Encourage family to bring favorite foods

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Nursing Interventions– Acute and Intermediate Phase
Promoting skin integrity Note changes in wound healing Relieving pain and discomfort

Relaxation techniques Analgesic use Oral antipruritics, cool room, lubrication Splinting to prevent contractures
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Nursing Interventions– Acute and Intermediate Phase
Promoting physical mobility Early sitting and ambulation Elastic dressings when walking Passive and active ROM Strengthening coping strategies Truthful communication Acceptance of patient Include patient in care decisions

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Nursing Interventions– Acute and Intermediate Phase
Potential complications Congestive heart failure Pulmonary edema Crackles, elevate head of bed Sepsis Ards Dyspnea, change in respiratory pattern

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Nursing Interventions– Acute and Intermediate Phase
Visceral damage from electrical burns EKG Pain from deep muscle ischemia

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Rehabilitation Phase
Prevention of hypertrophic scarring Promoting activity tolerance Improving body image and self-concept selfContractures Teaching self-care self-

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Gerontologic Considerations
Higher incidence of morbidity and mortality Reduced mobility Vision changes Decreased sensation in hands and feet Thin skin, loss of elasticity

Chronic illness Decreased system functioning
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