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Nursing Care & Interventions in The Client With Burn Injury: Keith Rischer RN, MA, CEN
Nursing Care & Interventions in The Client With Burn Injury: Keith Rischer RN, MA, CEN
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Today’s Objectives…
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Burn Injury: Patho
Skin
• Epidermis
• Dermis
Purposes
Skin destruction
• Fluid/protein loss
• Sepsis
• Multi-system changes
Dependant on age
Health
Depth of injury
Body area involved
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Depth of Burn Injury
Superficial-thickness
• Epidermis only
Partial-thickness
• Epidermis + partial
Dermis
Full-thickness
• Epidermis + all dermis
+ underlying
tissue/muscle/bone
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Assessment: Superficial-thickness
Pain
Redness
Heals in 3-5 days
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Assessment: Partial-thickness
Red-blanch
• No blanch with deeper burn
Blister and broken
epidermis
Painful
Heal in 10-21 days
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Assessment: Full-thickness
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Burns: Vascular Changes
Fluid shift
• Capillary leakage
• First 12 hours
Lasts 24-36 hours
• Lyte & acid base imbalance
Hypovolemia
Hyperkalemia, hyponatremia
Fluid remobilization
• Diuretic stage (48-72 hours)
Hyponatremia
hypokalemia
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Burns: Body System Assessment
Cardiac
• HR increase
• CO decreased initially
Respiratory
• Airway edema
• pulmonary cap. leakage
GI
• Paralytic ileus
Metabolic
• Increased due to catecholamines, cortisol and SNS
• Caloric needs double or triple
Immune
• Diminished response
• Increased risk of infection 9
Burns: Emergency Management
Primary Survey
Airway
• Breathing
• Circulation
• C-Spine immobilization
(when indicated)
Secondary Survey
• Complete head to toe exam
• % of TBSA
• Depth of burn
• Part(s) of body burned
• Rule out other serious or life
threatening injuries
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Inhalation Injury: Assessment
Symptoms
Signs
CO Poisoning Wheezing
•HA Dyspnea
•Nausea Disorientation
•Alterered LOC Obtunded
• Confusion Coma
• Coma
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Burn Classification
Minor
• <15% partial thickness
Moderate
• 15-25% partial
thickness
• <10% full thickness
Severe
• >25% partial thickness
• >10% full thickness
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ABA Burn Referral Guidelines
2° Burns > 10% TBSA
Burns involving the
face, hands, feet,
genitalia, perineum, &
major joints
3° Burns in any age
group
Electrical Burns
• lightning injuries
Chemical Burns
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Laboratory Findings: First 48 hours
Hgb/Hct
Glucose
Sodium
Potassium
BUN/creatinine
Albumin
ABG’s
• pO2
• pCO2
• pH
• CO
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Nursing Diagnostic Priorities: First 48 Hours
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Fluid Resuscitation
Nursing interventions
• Large bore IV/central IV access
• Lactated ringers
Nursing Assessment
• I&O
Urine output
• Daily weight
• Oxygenation needs
• Fluid overload
• VS
• Labs
Creatinine
Albumin
lytes
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Nursing Diagnostic Priorities: First 48 Hours
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Assessment Priorities: After 48 Hours
Cardiopulmonary
• Pneumonia
Neuroendocrine
• Increased metabolic demands
Immune (risk of infection)
• Local
• Systemic
VS
Altered LOC
u/o
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Nursing Diagnostic Priorities: After 48 Hours
Debridement
• Hydrotherapy
Wound dressings
• Antibiotic ointment
• Biologic
• Synthetic
Skin grafts
• Autograft
• Artificial
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Dressings: Topical Antibiotics
Silver Sulfadiazine
• Most frequently used topical
• Gram negative/positive organisms
• Penetrates eschar well
• Applied with a gloved hand, tongue depressor
or impregnated in gauze
Bacitracin
• Acceptable for use with superficial burns
• Least expensive antimicrobial agent
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Dressings
Decrease pain
Absorb drainage
Preserve joint mobility
and allow ROM
Provide protection and
isolation of wound from
environment
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Nutrition
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Enteral Feedings
Preferred route
• Safety
• Better utilization of nutrients
• Gut integrity
• Lower cost
Parenteral (TPN)
• Nonfunctional guts
• High risk for sepsis
Objectives
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Psychological Issues & Follow Up
Inpatient
• PTSD
• Disfigurement
• Sexual issues
• CD
Outpatient
• Ongoing therapy
• Support groups
• Burn Camp
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