Burns

 Injury to

tissue caused by heat, chemicals, electric current, or radiation.  500,000 in US every year are treated for burn injury  40,000 will require hospitalization  Most burns can be prevented

Gerontologic considerations
o

risk because of reduced mobility, changes in vision, q sensation in hands & feet, thinning of skin

Major burn is considered >25% TBSA burned Minor burn <15% younger than 40 , 10% of TBSA if older than 40 years

Types of Burn injury

Thermal  Most common type of burn injury  Caused by:  flame, flash, scald, or contact with hot objects  Cold thermal  frostbite


Types of Burn injury

Chemical  Most commonly caused by acids  Alkali burns more difficult to treat  Remove the patient from the burning agent  Remove clothing containing the chemical  Lavage with copious amounts of water


Types of Burn injury



Electrical

Can cause cardiac arrest  Initiate CPR  Metabolic acidosis develops within minutes  Administer sodium bicarb based on ABGs  Myoglobin can cause ATN  Infuse Ringers Lactate and osmotic diuretic


Type of Burn Injury

Radiation Burn


Exposure to radioactive source Nuclear radiation accidents Ionizing radiation in industry Therapeutic irradiation Sunburn Amt of radioactive energy received is r/t time, distance, shielding, strength of radiation source, and duration of exposure

Types of Burn injury

Inhalation injury  Carbon monoxide poisoning Treat with 100% humidified oxygen Assess for facial burns, singed nasal hair, hoarseness, painful swallowing, & darkened oral & nasal membranes manifestations may be delayed respiratory distress syndrome


Risk Factors
Males 20-40 years of age  Fire/flame account for 60% of burns  Carelessness with Cigarettes r/t alcohol/drug use  30% of burn related deaths attributed to structural fires  Toddlers 2-4 years of age have higher incidence of scald injury


Prevention
 See

Box: 50-1 on p. 1241  Teach Home Safety measures  Smoke detectors!!!!!  Fire extinguishers that work!!!!

Pathophysiology
Injury to Skin  Fluid Shifts  Pulmonary System  Myocardial Depression  Altered Skin Integrity  Immunosuppression  Psychological Response


Classification of Burn Injury

Depth

Partial thickness (1)  Hyperemia, intact tactile & pain sensation Partial thickness (2nd)  Wet, Red, shiny vesicles, edema, severe pain Full thickness (3rd)  Dry, pale, waxy, leathery skin, thrombosed vessels, insensitivity to pain, eschar Full thickness (4th)  Skin charred, or completely burned away

Clinical Manifestations
Hypothermia  Fluid & electrolyte Imbalances  Alterations in Respiration  Decreased CO  Pain responses  Altered Level of Consciousness  Psychological Alterations


Classification of Burn Injury

Assess burn severity  Extent

Rule of Nines for initial assessment Lund & Browder chart Palm method Burn diagram (Berkow formula)

Location direct relationship to severity  Patient risk Factors


Older adult heals/obese pts more slowly and

has more co-morbidities than younger patients

Rule of Nines

Phases of Burn Injury



Resuscitative Phase

      

Usually lasts 36-48 hours after injury Begins with fluid loss and edema Hypovolemic shock a threat because of intravascular depletion*** Second and Third spacing occur Increased insensible losses RBCs hemolyzed & capillaries thrombose Sodium & Potassium shifts

Clinical Manifestations
Pain if partial thickness  Hypovolemia and dehydration  Shivering  Blister formation  Altered mental status  Decreased blood pressure  Increased pulse


Complications
Cardiovascular system  Arrhythmias & cardiogenic shock  Ischemia necrosis gangrene Respiratory system  Edema & inhalation injury Renal system  q blood flow to the kidneys ATN  Occlusion of renal tubules from myoglobin

Nursing Care: Resucitative Phase



Airway!!!!!
Non- rebreather face mask

Naso or endotracheal intubation High fowlers Central line for IV fluid Hyperbaric oxygen Indwelling catheter Monitor ECG

Nursing Care: Resuscitative Phase

NPO initially to prevent aspiration  Fluids Established IV access: lactated Ringers Replace to produce 30-50ml u/o per hour Parkland formula: 4ml/kg per % of TBSA burned = total fluid replace for 1st 24 after burn injury given in first 8 hours given in second 8 hours given in third 8 hours


Fluid resuscitation question?



Calculate the 24 hour IV fluid intake for a 70 kg. male who has sustained burns on 50% of his body?

Nursing Care: Resuscitative Phase

Drug therapy Analgesics: Morphine drug of choice Sedatives: Haldol Tetanus GI support: Zantac, Tagamet, Nystatin  Nutrition Hypermetabolic state


Nursing diagnoses: Resuscitative Phase

Impaired gas exchange  Deficient fluid volume  Ineffective tissue perfusion: renal  Ineffective tissue perfusion: peripheral  Acute pain  Anxiety  Impaired Physical mobility  Disabled family coping


Acute Phase of Burn Injury

Acute Phase  Fluids mobilize  Diuresis occurs  Edema subsides  Bowel sounds return  Epithelialization begins  Partial thickness heal from edges & below  Full thickness require skin grafting

Complications during Acute Phase

 Infection

* Culture  CV & Respiratory  Neurologic  Musculoskeletal  Gastrointestinal: Curlings ulcer  Endocrine

Wound Care
Remove burned clothing Cover with dry sheet and blanket Infection a threat Wound cleansing : hydrotherapy Debridemet = Removal of loose necrotic skin

Mechanical wet to dry Surgical: tangential or fascia Enzymatic

Wound Care


Antimicrobials: Silvadene, Sulfamylon, Bactroban, Neomycin, Bacitracin

Wound treatment: open or multiple dsg  Other eye care with warm saline artificial tears. o hands and arms Early ROM can be done during hydrotherapy


Nursing Management in Acute Phase

Wound Care  Enzymatic debridement Collagenase, Elase, Accuzyme  Excision and grafting: Autograft , Homograft, Heterograft  Cultured Epithelial Autographs  Artificial Skin: Integra and Alloderm Pain Management Physical and Occupational therapy Nutritional therapy Psychosocial Care

Nursing Diagnoses during Acute Phase

         

Impaired gas exchange Ineffective airway clearance Hypothermia Risk for infection Risk for stress ulceration Imbalanced nutrition: less than body requirements Acute pain Impaired physical mobility Disturbed personal identity Disabled family coping

Rehabilitative Phase of Burn Injury

Wounds are covered with skin or healed  Goal is to assist pt. to resume functional role  Wounds heal by primary intention or grafting  Flat & pink raised & hyperemic 4-6 weeks later


Burns
Emotional needs of: Patient Family Staff