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BURN INJURY

NUR 217
Functions of the Skin

Protection Function
Sensory Function
Water/ Electrolyte Balance
Temperature Regulation
Excretory Organ
Produces & Absorbs Vitamin D.
Body Image
Burns

Wounds produced by various kinds of


thermal, electrical, radioactive, or chemical
agents which kill cells by changing the
protein substance of the cell.

The depth of the injury depends on the:


Temperature of the burning agent.
Duration of contact with agent.
Question:

Tell whether the following statement is true


or false.
Electric burns can cause significant
internal damage.
Answer:
True.
Rationale: The devastating effects of
electric burns can cause lifelong
neurovascular problems. Entry and exit
wounds exist with a true electric burn. An
electric current immediately contracts
muscles as it travels through the body, and
cardiac dysrhythmias and spinal injuries
often result from the muscular contraction.
Major Goals
Prevention
Institute life saving measures.
Prevention of disability & disfigurement.
Rehabilitation.
Reconstructive surgery
Rehabilitation programs
Emergency
Management Of Burns
Apply cold but never ice
Cover burn
Avoid ointments & salves
If corrosive material, irrigate immediately
If chemicals in or near eyes, flush with
cool water
If clothes on fire, STOP, DROP and ROLL
Transport to nearest ED
Survival/ Prognosis
Survival Prediction
The best survival expectancy is obtained in
children and young adults ages 5 40 years.

Prognosis depends on
Depth of the burn.
Extent of the burn.
Condition of the patient.
Age of the patient.
Pulmonary
Patho-physiology

Carbon monoxide poisoning


Smoke inhalation
Upper airway injury
Restrictive defects
Zones of burn injury
Zone of Coagulation

Zone of Stasis

Zone of Hyperemia
Estimated Percentage of BSA

Rule of Nines:
Adult
Child adapted rule of nines
Lund and Browder method
See figures
Palm method
Patients palm is approximately 1%
Characteristics of Burns

Superficial partial-thickness similar to


first degree
Deep partial-thickness similar to second
degree
Full-thickness similar to third degree
Question:

Which of the following is not considered a


characteristic of a deep partial-thickness
burn?
Weeping surface
No edema
Broken epidermis
Mottled, red base
Answer:

No edema

Rationale: Characteristics of a deep


partial-thickness burn include a broken
epidermis, edema, a mottled, red base,
and a weeping surface.
Stages of Burn
Patho-physiology
The patho-physiology & management of burns
may be divided into 3 stages/ phases.
Phase 1- Emergent/ Immediate
Phase 2- Acute/ Intermediate
Phase 3- Rehabilitation/ Long term.
Even though these stages overlap, in general
they may be identified. Usually stages most
apparent as you look back at patient progress.
Phase 1 Emergent/
Immediate Resuscitative
Duration- from onset of injury to completion of
fluid resuscitation
Priorities- A, B, Cs
First aid.
Prevention of shock.
Prevention of respiratory distress.
Wound assessment & initial care.
Detection & treatment of accompanying injuries.
Pulmonary Function

Criteria that indicates possible pulmonary


damage
History: Indicating burn occurred in an enclosed
area,
Burns of the face, neck
Singed nasal hair
Hoarseness, voice change, dry cough, sooty
sputum.
Bloody sputum, labored respirations, erythema &
blisters of oral or pharyngeal mucosa.
Fluid Management

The most important parameters in


assessing fluid resuscitation adequacy
are:
Urinary output of 30 to 50 mL/hr
Blood pressure to maintain cardiac output.
Pulse rate
Fluid Replacement
May use formulas as a guide:
Consensus Formula (LR solution or other saline solution)
Brooke Army Formula (colloids, electrolytes, glucose)
Parkland/ Baxter Formula (LR solution)
Hypertonic Saline Solution (Concentrated NaCl & LR)
Parkland /Baxter formula
Patient is 70kg (168#); 50% BSA burn
2-4 mL/kg/% of burn:
2 X 70 X 50 = 7,000ml/24 hrs
24 hours start at time of injury
1st 8 hrs (1/2) 3,500 or 437 ml/hr
Next 16 hrs (remainder) 3,500 or 219 ml/hr
Lactated Ringers
Pain Management

IV Morphine is usually prescribed.


Demerol is sometimes used.
Avoid SQ and IM routes why?
Pain is more severe in partial thickness
burns as compared to full thickness burns.
May use Ketamine anesthesia.
Patient Controlled Analgesia (PCA) may
be used.
GI Disturbances

Gastric dilatation & paralytic ileus occurs


frequently.
Observe for :
Vomiting.
Distention of abdomen.
Diarrhea.
Result of a neuro-endocrine response to
stress, hypovolemia or septicemia.
Nursing Diagnosis
Phase 1

Potential compromised airway.


Altered respiratory function.
Hypovolemia & electrolyte imbalance.
Decreased resistance to infection.
Pain and anxiety.
Hypothermia
Decreased gastric function.
Potential development of complications.
Infection in burn injuries

The primary source of bacterial infection


appears to be the pts own intestinal
tract.
A major secondary source of infection is
the pts environment.
Antibiotics given prophylactically
Phase 2
Acute/ Intermediate
Duration- from beginning of diuresis to
near completion of wound closure.
Priorities-
Wound care and closure.
Prevention & treatment of complications
(infection)
Nutritional support.
Signs of
Burn Wound Sepsis
10 (5) bacteria/ Gm tissue.
Inflammation.
Sludging & thrombosis of dermal blood
vessels.
Clinical symptoms of sepsis
Skin Grafts

Advantages of Skin Grafts


Cover the wound.
Decrease infection.
Decrease pain.
Prevent contractures.
Allows for earlier healing.
Types of Skin Grafts

Homografts
Allografts
Cadaver skin
Xenografts
Heterografts
Pig skin
Autografts
Own skin
Exposure Method
No dressing
Advantages
No painful dressing changes.
Less equipment.
Infection can be detected early.
Large number of patients can be treated.
Disadvantages
Not suitable for burns of the hands & feet.
Unsuitable in patient transport.
Less effective when other injuries exists.
Additional metabolic stress: hypothermia issues.
Open Method
+ Topical Agent

Consist of a combination of the exposure method + the


application of a topical agent.
Advantages
Wound assessment is easier.
Physical therapy occurs earlier.
Temperature is easier to control.

Disadvantages
Delay in eschar separation.
Increase risk of sepsis.
Increase in patient discomfort.
Criteria for Topical Agents
Effective against Gm Neg organisms.
Clinically effective.
Penetrates eschar>>>> but not
systemically toxic.
Does not lose its effectiveness.
Cost effective, available & acceptable to
patient.
Inexpensive & easy to apply.
Topical Chemotherapy
Silver Sulfadiazine (Silvadene)

Silver Nitrate Solution

Mafenide Acetate (Sulfamylon Acetate)


Problems/
Complications of Burns
Shock
Infection
Respiratory distress
Cardiovascular disturbances
Renal disturbances
Fluid & electrolyte imbalances
Psychiatric derangements
Phase 3
Rehabilitation/ Long term

Duration-
from major wound closure to return to
individuals optimal level of physical &
psychosocial adjustment.
Priorities-
Prevention of scars & contractures.
Physical, occupational & vocational
rehabilitation.
Functional & cosmetic reconstruction.
Psychosocial counseling.
Phase 3
Nursing Diagnoses

Activity intolerance
Knowledge deficit
Ineffective individual coping
Body image disturbance
Total Parenteral Nutrition
TPN solutions contain
Water
Amino acids
Glucose
Vitamins
Electrolytes
Concentrations provide enough calories to
meet the pts daily nutritional needs
TPN Indicated:
10% deficit in body wt.
Inability to take oral food or fluids within 7
post- op days.
High metabolic or Hyper-catabolic
situations
Major infection with fever.
Major burns.
TPN Nursing Diagnoses

Altered nutrition, less than body


requirements.
High risk for infection.
Fluid volume excess
High risk for fluid volume deficit.
High risk for activity intolerance.
Question

Which of the following phases of burn care


encompasses the beginning of diuresis to
near completion of wound closure?
Emergent
Acute
Rehabilitation
Recovery
Answer

Acute

Rationale: The acute/intermediate phase


of burn care encompasses the beginning
of diuresis to near completion of wound
closure.

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