III.

BURNS
A. Occurrence:
The risk of death increases in the very
OLD and the very YOUNG
Where do most burns occur? HOME,
CURLING IRONS, IRONS,
STOVES, WATER HEATER
B. Pathophysiology:
After a burn many different
pathophysiology changes occur.
1. Why does plasma seep out into the
tissue?
Increased CAPILLARY permeability
(VESSELS LEAKING)
2. When does the majority of this
occur? FIRST 24 HOURS DUE TO
FLUID VOLUME DEFICIT
3. When does the pulse increase?
Anytime youre in a FLUID
DEFICIT , the pulse will INCREASE
4. Why does the cardiac output
decrease? Less VOLUME to pump
out.
5. Why does the urine output
decrease?
Kidneys are either trying to HOLD on
to fluid or they arent being
PERFUSED.
6. Why is epinephrine secreted?
Makes you VASOCONSTRICTION,
shunts blood to vital organs
7. Why are ADH and aldosterone
secreted?
Retain SODIUM & WATER with
aldosterone and
Retain WATER with ADH
Therefore, the blood volume will go
UP.
C. Miscellaneous Information:
1. Airway Injury:
What is the most common airway
injury? CARBON MONOXIDE
poisoning
Normally, oxygen binds with
HEMOGLOBIN Carbon monoxide
travels
much faster than oxygen. Therefore,
it gets to the hemoglobin first and
binds.Can oxygen bind now? NO,
NO PLACE FOR IT
Now the client is HYPOXIC.
Tx: HYPOXIA
From this information, do you
think it would be important to
determine if the burn
occurred in an open or closed space?
CLOSED SPACE, INHALED MORE
CARBON MONOXIDE
When you see a client with burns
to the neck/face/chest you had better
think what?

AIRWAY, UPPER BODY BURNS

BREATHING PROBLEMS OCCUR
*What might the physician do
prophylactically? ET TUBE FIRST
TO PREVENT SWELLING.
2. Classification of Burn Injury:
A client is burned over 40% of
their body. How do you think this is
determined? RULE OF NINES
Estimate of Total Body Surface Area
A common formula is called the
RULE OF NINES
*TESTING STRATEGY*
Least invasive first
D. Tx: Clients with burns > 20-25%
TBSA
1. Fluid Replacement:
One of the most important aspects
of burn management is FLUID
REPLACEMENT
Is it important to know what time
the burn occurred? YES
Why? Fluid therapy (for the first 24
hours) is based on the time the injury
OCCURED, not when the treatment
was STARTED.
Common rule: Calculate what is
needed for the first 24 hours and give
half of
the volume calculated during the first
8 hours. This is the PARKLAND
Formula.
To calculate fluid replacement
properly you also need to know the
clients
WEIGHT (in kilograms) and TBSA
affected. *1 kg = 2.2 pounds
If the client is restless it could
suggest three problems: inadequate
fluid replacement,
pain, or hypoxia.
*Nurses Priority: HYPOXIA AIRWAY
Which of the following would you
choose to determine if a clients fluid
volume is
adequate? Their weight or their urine
output? URINE OUTPUT.
Parkland Formula
(4ml of LR) X (body weight in kg) X
(% of TBSA burned) = total fluid
requirement for the first 24 hours after
burn
1st 8 hours = of total volume
2nd 8 hours = of total volume
3rd 8 hours = of total volume
NCLEX Critical Thinking
Exercise:
A client weighing 235 lbs. has a 30%
total body surface area burns. The
physicians prescription is: Titrate

IV fluids to maintain urinary output at

0.5 ml/kg/hr. What is the desired
output?
Record your answer as a whole
number.
235 / 2.2 = 106.818181
106.818181
X 0.5 ml/kg/hr
= 53. 409 = 53 ml/hr
*TESTING STRATEGY*
Pain never killed anyone.
. Emergency Management:
A client was wrapped in a blanket
to stop the burning process. Since the
flames are
gone does that mean the burning
process has stopped? NO
What else could have been done to
stop the burning process? COOL
WATER
The blanket helped byHolding in
the BODY HEAT and kept out
GERMS
Remove jewelry? Because
SWELLING will occur, metal gets
hot.
Clothing? Remove non-adherent
clothing and COVER THE BURNS
with a clean dry cloth.
Signs of airway injury: SINGED
FACIAL/NOSE HAIR, BLISTERED
LIPS, ORAL MUCOSA
Do you think there is more death
with upper or lower body burns?
UPPER
A clients respirations are shallow.
You know they are retaining what?
CO2
Therefore, which acid-base imbalance
will they have? RESPIRATORY
ACIDOSIS
3. Medication Management:
a. Albumin:
You know that albumin holds onto
FLUID in the VASCULAR SPACE
space.
Vascular volume? INCREASE
VASCULAR VOLUME
Kidney perfusion? INCREASE
BP? INCREASE
Cardiac output? INCREASE
Will this help correct a fluid
volume deficit? YES Because we are
putting
more fluid where? FLUID
VASCULAR
When you start giving a client
albumin, you know that the vascular
volume will

INCREASE. INCREASE
WORKLOAD IN THE HEART
Therefore, what will happen to the
workload of the heart? FLUID
VOLUME EXCESS
If you stress the heart TOO
MUCH:
The client could be thrown into fluid
volume EXCESS
If this occurs, what will happen to
Cardiac output? DECREASE
Lung sounds? WET
In a client who is receiving fluids
rapidly, what is a measurement you
could take
hourly (hint: heart) to ensure youre
not overloading the client? CVP
CENTRAL VENOUS PRESSURE
b. Pain Management:
A client has an order for morphine
that states: Morphine 2mg IVP or
Morphine
4mg IVP Q 2 hours PRN pain. If the
client is complaining of pain (4/10)
what
dosage would the nurse give to the
client? 2MG MORPHINE IVP FIRST
Give the LESS amount of narcotics
necessary to relieve someones pain.
Why are IV pain meds preferred
over IM with burns?
ACT QUICKLY ASSESS
RESPIRATION FIRST
_______________________________
___________
c. Immunization:
1) Tetanus Toxoid: ( TETANUS
IMMUNE GOBLIN immunity)
*takes 2-4 weeks to develop their own
immunity
2) Immune globulin: think
IMMEDIATE protection
( PASSIVE immunity)
E. Complications:
1. Circulatory System:
A client has a circumferential burn
on their arm.
What does this mean? ALL THE WAY
AROUND THE ARM
What should you be checking?
CIRCULATION
If a clients vascular check in their
arm is bad what is the name of the
procedure
to relieve pressure?
Escharotomy- relieves the
PRESSURE and restores the
CIRCULATION
, cut through the eschar.
Fasciotomy- relieves the PRESSURE
and restores the

CIRCULATION, but the cut is much

deeper into the tissue,
cut goes through the eschar and the
fascia.
2. Renal System:
A foley catheter was inserted so
you could measure urine output.
How often will this need to be
monitored? EVERY HOUR
Is it possible that when you insert
the catheter that no urine will return?
YES
Why? Kidneys are either attempting to
CONSERVE the fluid or they are not
being PERFUSION adequately.
What would you do if the urine is
brown or red? Call the PHYSICIAN
What drug might be ordered to
flush out the kidneys? MANNITOL DIURETIC
If there is no urine output or if it is
less than 30mL/hour, you would start
worrying about? KIDNEY FAILURE
After 48 hours, the client will begin
to diurese. Why? Because fluid is
going
back into the VASCULAR space. Now
we have to worry about fluid volume
EXCESS
So what will happen to urine output
now? INCREASE
Circulatory check:
1.
2.
3.
4.
Hurst Review Services 27
3. Electrolyte Imbalance:
The clients serum K+ level is 5.8
Where do we find most of our K+?
INSIDE the cell
With a burn, what happens to cells?
RUPTURE
So, what happens to the number of
K+ in the serum (vascular space)?
INCREASE
Electrolyte imbalance?
HYPERKALEMIA
4. GI System:
Why do you think
Carbonate/Magnesium Carbonate
(Mylanta), Pantoprazole
(Protonix), or Famotidine (Pepcid)
are ordered?
To prevent a STRESS ULCER,
CURLINGS ULCER
Why do you think the doctor wants
the client to be NPO and have an NG
tube
hooked to suction?

Because they could develop a

PARALYTIC ILEUS 1.
DECREASED VASCULAR
VOLUME. 2. PART OF NORMAL
STRESS RESPONSE. 3.
HYPERKALEMIA
If a client doesnt have bowel sounds,
what will happen to the abdominal
girth?
INCREASE
Do you think the client will need
more or less calories? MORE
CALORIES, HYPERMETABOLIC
STATE, PROTEIN, VITAMIN C
The NG tube will be removed
when you hear what? BOWEL
SOUNDS
When you start GI feedings, what
should you measure to ensure that the
supplement was moving through the
GI tract? RESIDUALS
What is some lab work you could
check to ensure proper nutrition and a
positive
nitrogen balance? PRE-ALBUMIN,
total protein, or albumin.
SENSITIVE- PRE-ALBUMIN
Antacids: Aluminum Hydroxide Gel
(Amphogel), Magnesium Hydroxide
(Milk of
Magnesium)
H2 Antagonist: Ranitidine (Zantac),
Famotidine (Pepcid), Nizatidine
(Axid)
Proton Pump Inhibitors:
Pantoprazole (Protonix),
Esomeprazole (Nexium)
5. Integumentary System:
a. Contractures:
Since the client has partial thickness
and full-thickness burns, is it possible
that
they could have problems with
contractures? YES
If they have burns on their hands,
what are some specific measures that
may
be taken?
Wrap each EACH FINGER separately.
Use SPLINTS to prevent contractures.
Neck Position? HYPER-EXTEND
b. Infections:
With a perineal burn, the #1
complication is INFECTION.
What is eschar? DEAD TISSUE
Does it have to be removed? YES
If its not removed can new tissue
regenerate? NO
What likes to grow in eschar?
BACTERIA poykilothermic- get
ambient room temp

Classification of Burns:
Superficial thickness: formally called
first degree burn; damage only to
epidermis
Partial thickness: formally called
second degree burn; damage to entire
epidermis and varying
depths of the dermis.
Full-thickness: formally called third
degree burn; damage to entire dermis
and sometimes fat
Fourth degree: gets down to the bone
c. Tx:
What type of isolation will you use
with the burn client? PROTECTIVE
ISOLATION
Sutilanis (Travase) or
Collagenase (Santyl): enzymatic
drug eats dead tissue
Dont use on face CAUSE
SCARRING
Dont use if pregnant
Dont use over large nerves
Dont use if area is opened to a body
cavity
Hydrotherapy is also used to
DEBRIMENT
a
Why should these drugs be
alternated?
Bacteria will build or .
Broad spectrum antibiotics are
avoided to prevent SUPER
INFECTION
Broad spectrum antibiotics may be
used until the wound cultures have
returned.
When giving-mycin drugs.we
WORRY when the clients BUN or
creatinine

increases or if the client complains of

any hearing loss. Mycin drugs can
lead to
ototoxicity (irreversible hearing loss)
and/or nephrotoxicity.
Check their BUN and creatinine; if
they are increasing, assume they are
nephrotoxic.
Common drugs used with burns:
a. Silver Sulfadiazine (Silvadene)soothing, apply directly, if rubs off
apply more, can lower the WBC, can
cause a rash
b. Mafenide Acetate (Sulfamylon)can cause acid base problems, stings,
if
it rubs off apply more
c. Silver nitrate-keep these dressings
wet; can cause electrolytes problems
d. Povidone-Iodine (Betadine)stings, stains, allergies, acid-base
problems
30 Hurst Review Services
d. Grafting:
Remove the burned dead tissue
until healthy tissue is seen.
Good skin is taken from healthy
donor site and placed over burned
area.
Now donor site is an open wound,
so a transparent dressing is applied
until
bleeding stops.
Then the donor site can be left
open to air.
If client is well nourished, they can
reharvest from same donor site every
1214 days.

If the skin graft should become

blue or cool what would this mean?
Sometimes the doctor will order for
you to roll sterile Q-tips over the graft
with steady, gentle pressure from the
center of the graft out to the edges.
Why?
e. Chemical and Electrical burns:
1) Chemical burn? First remove client
from chemical and begin FLUSH
WITH WATER.cause damage for
72hr, neutralize it.
How long do you flush? 15-20MINS
2) Electrical burn 2 wounds. What
are they? ENTRANCE and EXIT
WOUND <1000V is low voltage
What is the first thing you do for an
electrical injury? CONTINOUS
HEART MONITOR FOR FIRST 24
HOURS.
What arrhythmia is this client at
high risk for? V-FIB will need ECG
With electrical burns myoglobin
and hemoglobin can build up and
cause
KIDNEY damage.
The client may be placed on a
spine board with a c-collar. Why?
Electrical injuries occur in HIGH
places, muscle contractions
can cause fractures, and the force of
the electricity can actually throw the
victim forcefully.
Are amputations common? YES
Why? THE CIRCULATORY
SYSTEM IS DESTROYED
Other complications of electrical
wounds: cataracts, gait problems, and
just about any type of neurological
deficit.