Burns

Linda Copenhaver

07/02/20 1
 Introduction
 Incidence of Burns

1 million seek medical care

annually
 Approximately 100K are

hospitalized, 70K require ICU

stays

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 Bonus' Site - KitchenOilFire.wmv

07/02/20 3
 Types of Burn Injury
 Thermal
 Chemical
 Electrical
 Radiation

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 Thermal Burns( Most Common)
 Caused by flame, flash, scald, or
contact burns

 STOP & DROP

 Roll to shut off O2 supply to

fire
 Flush or immerse in cold

water
 DO NOT use ICE on deep

burns, just localized,

07/02/20 superficial burns 5
 Thermal Burns (cont)
 Cover patient with a
clean cover
 Do NOT pull off clothing;
instead cut off clothing if
possible…WHY?
 Keep NPO and transport

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  Chemical Burns

Remove person from

contact with agent
Flush with water

continuously
Remove affected clothing if

possible

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  Electrical burns
 Coagulation necrosis
 Severity depends on voltage, amount of

resistance, time,
and current
pathways.

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  Frequently only entry (yellow-white)
and exit (blow out) wounds are visible

 Extensive tissue damage is masked

 Howcan we evaluate “masked tissue

damage”???

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 Electrical Burns (cont)
 Patientat risk for arrhythmias
due to _____, metabolic
acidosis due to _____, and
acute tubular necrosis due to
______.

 Current can be so strong to

fracture long bones and cause
respiratory muscles to
contract
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 Interventions for Electrical
Burns
 Turn off source of
electricity if possible
 Remove current with dry
piece of wood
 Initiate CPR and
Transport

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07/02/20 12
 Depth of Burns

Superficial Partial Thickness Burn (1st
degree)
Epidermis involved
Sunburn, UV light, mild radiation,

Pink to red

Slight edema

Mild pain

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 Depth of Burns
 Deep Partial Thickness (2nd)
 Epidermis and dermis, is painful, red,
blisters

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 Depth of Burns
Deep Partial Thickness (2nd)
Epidermis and Dermis
Very Painful, edema, pale
Moist or dry
Blisters present

07/02/20 15
 Depth of Burns (cont)
 Full Thickness Burns (3rd)
 Epidermis, Dermis, and

Subcutaneous tissue burned

 Nerve endings destroyed

 Little or no pain

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 Depth of Burns (cont)
 Full thickness (4th degree)
 Involves past the 3 layers

down to the bone and/or

organs

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 Extent of Burns
 Rule of Nines
Easy to remember, quick method

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  Lund & Browder
 More accurate, more time spent
calculating TBSA burned

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 Burn Unit Referral Criteria
 Deep Partial Thickness burns>10% TBSA
 Burns that involve the face, hands, feet,
genitalia, perineum, or major joints
 Full thickness burns in any age group
 Electrical burns, including lightning
 Inhalation burns requiring intubation
 Chemical burns that involve deep and
extensive TBSA burned

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 Survival Prediction
 Depth of Burns
 Extent of Burns
 Location of Burns
 Age of Client
 Risk Factors
 Major vs Minor Burns

07/02/20 21
 Medical/Nursing
Management of Burns
 I. Emergent Phase

Period of time from onset

of burns to the beginning
of fluid remobilization
Usually lasts 24-48 hours

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 Emergent Phase (cont)
 Also called FLUID
ACCUMULATION PHASE
 The greatest initial threat to a
major burn victim is hypovolemic
shock
 See outline for details…this is a
DING DING!

07/02/20 23
 Burning Question…..
 The nurse knows that in a patient
who has full thickness burns, that
the burns must involve the:

a) Muscle
b) Dermis
c) Tendons
d) Bone

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 What are the Priorities in
this patient???
 Is this patient a candidate for a
major burn center?

07/02/20 25
 Nursing Care During
Emergent Phase
 Impaired Gas Exchange r/t
tissue hypoxia secondary to
carbon monoxide poisoning

 Note: CO poisoning is the

MOST immediate cause of death
from fire.

07/02/20 26
 Signs & Symptoms of
Carbon Monoxide
Poisoning
 Edema of Airway
 Hoarseness
 Dysphagia
 Stridor
 Copius Secretions usually
black tinged
 Substernal Retractions
07/02/20 27
 Interventions for CO
Poisoning:
 Assess for S&S CO poisoning
(mild to severe)
 Humidified O2 100% via face mask
 High Fowler’s Position
 TCDB q 1 hour
 Intubation & Ventilation
 Bronchodilators for
bronchospasm
 One other thing…..does anyone
know???
07/02/20 28
 Nursing Care during
Emergent Phase (cont)
 Impaired Gas Exchange r/t
mucosal edema throughout
respiratory tract secondary
to smoke inhalation, hot air,
chemical gases

07/02/20 29
 Interventions:
 Early intubation to prevent trach
placement
 Ventilation

 Humidified O2 100%

 ABG’s (respiratory acidosis or

alkalosis?)
 Bronchodilators

 Serial CXR’s and fiberoptic

07/02/20bronchoscopy 30
  What do you assess for here???

07/02/20 31
 Question:
 A client has sustained deep partial
thickness burns to the anterior trunk and
the anterior aspect of both arms. The
nurse should expect the client’s
immediate care would be conducted:
 a) on an outpatient basis

 b) in a home health setting

 c) on an inpatient surgical unit

 d) in a burn unit

07/02/20 32
 Questions to Ask Burn
Victims
 Were you in an enclosed
space?
 Were you standing up?
 Was it a flame and chemical
fire?
 Are you having difficulty
breathing?

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 What are your #1 priorities
in this patient?
Patient #1 Patient #2

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 Emergent Phase (cont)
 Ineffective Breathing pattern r/t
constriction of chest/trachea
secondary to the effects of full
thickness burns.
Assess for signs of

constriction
Escharotomies with

07/02/20 circumferential burns of chest 35

 Escharotomy of chest and
arm
 What is the pathophysiology here?

07/02/20 36
 Emergent Phase (cont)
 Fluid Volume Deficit
(intravascular) r/t massive
fluid shift to interstitial
spaces
 Assess fluid needs:
 Brooke Formula
 Evans Formula

07/02/20 37
  Parkland Baxter Formula
 Most widely used

 Formula:

LR4ml X Kg body weight X

TBSA% burned

½ that total amt. given 1st 8

hours
¼ that total amt. given each next
8 hours
07/02/20 38
 Okay Nurses Let’s
Calculate…
 What would the fluid
replacement be for patient who
weighed 60kg and had 30%
TBSA burned???

1st 8 hours= _____or ____cc/hr

2nd 8 hours= _____or ____cc/hr
3rd 8 hours= _____or ____cc/hr
07/02/20 39
  Crystalloids used such as LR,
0.9NS, D5NS

 Colloids (albumin, dextran,

FFP) used to expand plasma.

 Colloids not given until after

capillary permeability
decreases and returns to
normal…..WHY?
07/02/20 40
  Insert foley catheter to monitor output.
What should urine output be in an
adult???

 Frequent vital signs

 SBP>100
 Pulse<100

 RR 16-20

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 Emergent Phase (cont)
 Assess Neuro status
 Neuro vital signs, WHY???

 Monitor Electrolytes and

Hematocrit; tells you about fluid
shift.
 What should Hct be doing as
time progresses???
07/02/20 42
 Emergent Phase (cont)

 Potential for Infection r/t loss

of skin and micro invasion

 Meticulous hand washing

 Sterile technique during dressing

changes & wound care

 Hair near burned areas shaved

07/02/20 43
  Potential for Infection r/t loss of
skin and micro invasion (cont)

Blisters popped or not???

Tetanus Toxoid I.M. given to

all major burn victims to fight

anaerobic contamination of
burn wound

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  Hydrotherapy in cart (water is
heated to approximately 104
degrees)

 < 30 minutes to prevent _____

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07/02/20 46
 Hubbard Tank (old
method)

07/02/20 47
 Hydrotherapy Cart
 What does hydrotherapy
accomplish?

07/02/20 48
 Wound Care
 Open Method
 Apply topical chemotherapy

07/02/20 49
  Advantages of Open
Method:

 No painful dressing changes

 Is visible for assessing wound

for signs of infections

 Less equipment which

means…
less ______

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  Disadvantages of Open Method:

 Not suitable for burns of hands

and feet
 More difficult to control body

temperature
 Difficulty when transferring

patient

07/02/20 51
 Topical Meds/Chemo
 Silvadene

 Silver Nitrate
 Sulfamylon
07/02/20 52
 Wound Care (cont)
 Closed Method
 Apply topical chemo and wrap with

gauze, fluffs, kerlix

 Assess for
constriction;
circulation
checks

07/02/20 53
 Emergent Phase (cont)
 Anxiety r/t loss of skin and
pain
 Allow verbalization of loss
 Explain all procedures

 Edema will subside in 2-4

days
 IV analgesics NOT I.M.s,

why???
07/02/20 54
 Emergent Phase (cont)
 Elevate burned arms on pillows
 Give pain meds 30 minutes

prior to treatments

07/02/20 55
 Emergent Phase (cont)
 Alteration in body temp
(hypothermia) r/t loss of skin
 Set thermostats at warm temp
in room
 Avoid drafts

 Heat lamp or warming lights

placed over bed prn as ordered

07/02/20 56
 Emergent Phase (cont)
 Potential for injury r/t effects of
stress response:

 Stress diabetes What is the

patho here???
 Curling’s ulcer (associated with
burn trauma patients)
 Gastroduodenal ulcer caused
by increased gastric acid
secretion
07/02/20 57
 Emergent Phase (cont)
 Potential for injury r/t effects
of stress response:
Paralytic ileus (stress related)

NPO, NG tube to suction

Delirium (psychological
stress)

07/02/20 58
 Emergent Phase (cont)
 Compartment syndrome r/t the effects
circumferential burns

Circulation is impaired
Edema formation
Occluded blood supply
Ischemia
Necrosis
07/02/20
Gangrene 59
 Emergent Phase (cont)
 What is the treatment?
 Escharotomy

07/02/20 60
 Emergent Phase (cont)
 Renal Failure

 Hypovolemia (Why?)
 blood flow to kidneys

 Renalischemia
 ARF may develop

07/02/20 61
 Emergent Phase (cont)
 Renal Failure

 Fullthickness & electrical

burns
 Myoglobin from muscle cells

released
 Hgb (from RBCs breakdown)

released into bloodstream

 Blocks renal tubules

07/02/20 62
 Emergent Phase (cont)
 What is the treatment for these 2
renal problems????

07/02/20 63
 Emergent Phase (cont)
 Cardiac Function

 Arrhythmias due to
electrolyte imbalance or
electrical burns
 Hypovolemic shock due

vascular bed depletion

07/02/20 64
  Summary of Emergent Phase:

07/02/20 65
 II. Acute Phase (weeks
to months)
 Begins after 48-72 hours
 Fluid begins to shift interstitial
spaces back into bloodstream or
intravascular space
 Diuresis occurs
 Ends when TBSA burned is
<20% by grafting or wound
healing

07/02/20 66
 Nursing Care During
Acute Phase
 Skin/systemic infection r/t
 Loss of normal skin

 Formation of eschar

 Suppression of immune

system
 Metabolic/hormonal

alterations
07/02/20 67
 Acute Phase
 Interventions for
Skin/Systemic Infection:

 Hydrotherapy cart shower

to debride
 Open/Closed dressing
changes
 Topical chemotherapy

 Weekly cultures

 Systemic antibiotics
07/02/20 68
 Acute Phase (cont)
 Rules for Treating Infection in Burn
Patients:

 Rule #1: Burn trauma patients will

be exposed to microorganisms no
matter how germ free the
environment

07/02/20 69
  Rule #2: No single antibiotic or
combo of antibiotics will fight all
organisms

 Rule #3: First the bug, then the drug

07/02/20 70
 Acute Phase (cont)
 Excision & Grafting
 Removal of necrotic tissue

 Eschar is removed until viable

tissue is reached

07/02/20 71
 Acute Phase (cont)
 Significant amount of blood loss
when excision occurs

 Hemostasis can occur

clots may form between the
graft and the
wound

07/02/20 72
 Operative Debridement

07/02/20 73
 Acute Phase (cont)
 Clotting problem may be
managed by excising wound
one day and grafting the
next day.

 Excised areas should be

soaked with antibiotic
solution

07/02/20 74
 Acute Phase (cont)
 Reasons for Grafting (priorities)

 Survival

 Function

 Cosmetic

 Synthetic Grafts
 BIOBRANE

07/02/20 75
 Types of Grafts
 Autograft or Autologous
 self

 Heterograft
 Different species

 Pig, bovine

 Homograft
 Cadaver

 Which are temporary vs

permanent?
07/02/20 76
 Latest in Skin grafting
 Integra- Bovine collagen which is
permanent

 Alloderm- derived from donated human

skin

 CEA (cultured epithelial autograft)-

unburned skin biopsied and sent to lab
to grow with epithelial growth factor
added.
07/02/20 77
 Graft Survival depends on:
 Recipient bed must have
adequate blood supply
 Graft must be in close contact

with recipient bed

 Graft must be immobilized

 Free from infection

07/02/20 78
 Acute Phase (cont)
 GRAFTING

07/02/20 79
 Acute Phase (cont)
 GRAFTING

07/02/20 80
 Dermatome-harvesting donor
skin from thigh

07/02/20 81
 Acute Phase (cont)
 For graft to SURVIVE and be effective:

 Recipient bed must have adequate

blood supply
 Graft must be in close contact with

recipient bed
 Graft must be firmly fixed or immobile

 Free from infection

07/02/20 82
 Acute Phase (cont)
 Can you describe this???

07/02/20 83
 Acute Phase (cont)
 Potential for fluid volume excess r/t
fluid shift from interstitial back to
intravascular space
 Daily weights

 Monitor lab values-Which ones?

 Auscultate lungs

 Fluids as ordered

 Avoid free water-dilutional

hyponatremia
07/02/20 84
 Acute Phase (cont)
 Alteration in Nutrition r/t
hypermetabolism
 Goals are to minimize

energy demands and to..

 Provide adequate calories

to promote wound healing

07/02/20 85
 Acute Phase (cont)
 Interventions for altered nutrition:

 Monitor bowel sounds

 High Protein High CHO

 Assess food preferences

 TPN as ordered

07/02/20 86
 Acute Phase (cont)
 Ineffective Coping r/t long rehab
process with multiple surgeries and
change in lifestyle/social isolation

 Include family in plan of care

 Assess client’s readiness to talk

 Allow client to work through grief

process
 Give honest, accurate information

07/02/20 87
 Acute Phase (cont)
 Self-care Deficit r/t restricted
movement/contractures/muscle
atrophy

07/02/20 88
 Interventions
 Assist with positioning
 ROM exercises
 Support O.T. & P.T. efforts
 Always maintain eye contact with
client

07/02/20 89
 III. Rehabilitation Phase
 From wound closure to optimal
level of physical and
psychosocial adjustment
 Potential for impaired home
maintenance

 Discussgrief process, self-

concept, resocialization
process

07/02/20 90
 Rehabilitation Phase
 Instruct client on skin care:

 Skin will itch, be dry, have

a tight feeling
 Use Vaseline Intensive
Care ES lotion, mild soaps
 Avoid direct sunlight (will
cause hyperpigmentation)
07/02/20 91
 Rehabilitation Phase
 Instruct client on skin care:

 Skin may be hypo or hyper

sensitive to cold/heat/touch
 Diet (high protein, vitamins)

 Exercise to prevent
contractures
 Instruct client on S & S of
infection
07/02/20 92
 Rehabilitation Phase
 Instruct client to wear JoBST
pressure garment up to 1 year

07/02/20 93
 Rehabilitation Phase
 Instruct client on skin care:
 Need to wear Jobst to
prevent keloid formation

07/02/20 94
 What are your
assessment findings?

07/02/20 95