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D semester

Burns are Injury to the tissues of the body
6 Types:

Smoke Inhalation and Injury

most common burn

thermal burn

Major Causes of burns

Carelessness with cigarettes and matches
Hot water
Cooking accidents
Space heaters/radiators
Improper storage of flammables
Frayed electrical wires
Improper use of extension cords/outlets

causes of thermal burns

Contact w/ hot objects

chemical burn

Tissue injury and destruction from necrotizing substances
Tissue destruction can last for up to 72 hours
Skin, eyes, and respiratory system* may be affected
Burning process continues until chemical is removed
Scrape away dry chemicals-
Lavage area with lots of water between 20 min-2 hours

smoke inhalation and injury is Hot air or noxious fumes/chemicals inhaled.
Three Types are:

Carbon Monoxide Poisoning (main cause of death because c02 binds with hemoglobin and hypoxia is not evident)
Inhalation Injury above the Glottis(not in lungs-thermal burn from steam or hot air causing edema to swell off the airway-watch for hoarseness)
Inhalation Injury below the Glottis(dep on depth of burn, far enough down can get pulmonary edema that may not show up for 12-24 hrs-watch rate and depth

electrical burns:

Coagulation necrosis caused by intense heat of electrical current
Direct damage to nerves and vessels causing tissue necrosis and death
Severity Factors:
Voltage, tissue resistance^, current pathways, surface contact area, length of time** May only see entrance and exit burn with vital organ damage inside

classifying the severity of burn injuries

Depth of burn
Extent of burn is calculated in percent of body surface area (TBSA)
Location of burn
Patient risk factors

classification: depth

Skin is divided into Three Layers:
Subcutaneous Tissue
American Burn Association:
No longer uses 1st, 2nd, and 3rd degree
Now use Superficial, Partial-Thickness, and Full-Thickness

which type of burn cannot regenerate new skin?

full thickness

superficial partial thickness s/s

Redness, blanching on pressure
No blisters at first
Tactile sensation intact
Involves only epidermis

deep partial thickness s/s

Blisters/wet, pink
Severe pain, edema
Epidermis and Dermis involved

full thickness s/s

Dry, waxy-white*, leathery, or hard skin
Insensitive to pain - extensive nerve damage
All skin elements and nerve endings destroyed

: partial-thickness burn due to
Immersion in hot water..cause may be due to

child abuse

The extent of the burn is measured by:

Assessing total body surface area (TBSA) affected:
using-Lund -Browder Chart
Most accurate
Takes into account the patient's age
Palmar Method
Pt. palm roughly 1% TBSA
Good for small (<15%) or large burns (>85%)
Rule of Nines Chart
Easier to remember
Used frequently as the initial assessment*

lund and browder chart

takes into account the age of the burn victim when assessing the extent of the burn

wallace rule of 9s

child 18% head, 13.5% legs
adult 9% head, 18% legs

location of burns

Burns to face, neck, and/or circumferential torso may lead to respiratory problems
Hands, feet, joints, and eyes jeopardize function
Burns to perineal, area nose, and ears are prone to infection*
Circumferential burns to extremities can compromised circulation

PT risk factors with burns

Older Adults-thin skin with less vascularity, deeper burns with reduced healing
Children-bigger body surface area for their size
Preexisting :CV, Resp., or Renal Disease have more difficulty healing and therefore are at higher risk.
Poor overall physical health

phases of burn management

*Emergent - Resuscitative(life threatening concerns immed-72 h)
*Acute - Wound Healing(start mobilizing fluids and diuresing 2weeks-8 months)
*Rehabilitative - Restorative(when acute ends, rehab starts)

prehospital care of burn victim

*Remove patient from source of burn (scene safety always first)
Stop the burning process
Chemical - remove substance and lavage with water
Small thermal - < 10% clean, cool tap water
Large thermal - ABC's, don't immerse with water, cover with dry sheet or blanket
Begin fluid replacement and pain management-morphine

emergent phase care of burn victim

Usually lasts 48-72 hours*
Hypovolemic shock is greatest threat (fluid and electrolyte shifts with big inflammatory response)
Massive fluid shifts out of blood vessels due to increased capillary permeability - primary cause of hypovolemia and edema
Insensible loss increased to 200-400 ml/hour**
Elevated hematocrit secondary to intravascular fluid loss
Because of fluid shifts Decreased serum Na, increased serum K
May lead to burn shock

Toward the end of the emergent phase, if fluid replacement is adequate,

the capillary membrane permeability is restored. Fluid loss and edema formation cease. The interstitial fluid gradually returns to the vascular space. Diuresis occurs with LOW urine-specific gravities.

cardiovascular complications in the emergent phase

Hypovolemic Shock*
Arrhythmias**(esp with electrical burns and with hyperkalemia)
Edema - compromises blood flow
Ischemia - parasthesia(nerves die) - necrosis - eventual gangrene
Treatment: Escharotomy
Scalpel incision to release pressure

respiratory complications of the emergent phase

Upper respiratory tract Injury
Inhalation Injury
Predisposed to respiratory tract infection
Circumferential burns

Most burn patients are alert. Unconsciousness or altered mental status is usually a result of

hypoxia associated with smoke inhalation, head trauma, or excessive sedation or pain medication.

If inhalation injury has occurred, the upper airway is vulnerable to edema formation and obstruction of the airway.

urinary complications of the emergent phase

Hypovolemic shock...low blood flow to kidneys...kidney ischemia...ATN!
Myoglobin breakdown from damaged muscles...occluded tubules
If the patient is hypovolemic, kidney blood flow may decrease, causing renal ischemia. If it continues, acute renal failure may develop. With full-thickness and electrical burns, myoglobin and hemoglobin are released into the bloodstream and occlude the renal tubules.

collaborative care in the emergent phase

*Airway(humidified air, 02, encourage TCDB to prevent pneumonia, may bee on bipap or peep, may consider puttin gin an ET tube early to avoid emergency trach later, may want to do a bronchoscopy to see how deep it goes)
Wound Care
Pain/Anxiety Management
Early and aggressive nutritional support
DVT prophylaxis

With thick blood (high blood viscocity and ^ hematocrit)- Burn PT is prone to

pulmonary embolism, stroke, MI and DVT

fluid therapy in the emergent phase

IV access-2 large bore IVs
Any TBSA >15% - fluid therapy
10% in children
Fluid replacement depends on:
Size and depth of burn
Individual considerations
Usually use Crystalloids, could be Colloids or a combination of the two

Parkland is a common formula used for

Fluid replacement in burn victims
Goal: Urine output 0.5-1ml/kg/hr in adults
Physiologic indicators - HR, BP(>90 sys), MAP(at least 65 mmHG) lactate(checks for sepsis)
Care-Insert foley and closely monitor, I & O

parkland formula parameters

4ml x %TBSA burned x weight (kg)
Administer 50% in first 8 hours
50% in following 16 hours

Children need maintenance fluid added

wound care in emergent phase

*Cleansing and debridement in hydrotherapy tub one - two times per day
Possible surgical debridement of necrotic tissue
Must have sterile gloves, mask, and gown when changing dressings*
Keep room warm
Administer tetanus shot
Later: Allograft /Homografting (from somebody else)**
Goal: prevention of wound contamination and coverage of wound by skin

drug therapy in emergent phase

*IV Analgesics and Sedatives
Morphine, Fentanyl, Lorazepam, Midazolam
Antimicrobial Agents
Systemic Antibiotics
Topical Antibiotics
Silver sulfadiazine (silvadene), bacitracin, mupirocin (bactroban)

nutritional therapy in emergent phase

Hypermetabolic State - metabolism increases 50 - 100 %
Core temperature increased
May need up to 5000 kcal/day
May need tube feedings or TPN
Nutritional supplements

acute phase

*Mobilization of extracellular fluid
**Burned areas covered by skin grafts or healed
Takes weeks to many months

clinical manifestations in acute phase

Partial-Thickness Wounds
Eschar removed (hard dry debriedment)
Epithelial buds - eventually close wound*
Full-Thickness Wounds
Require surgical debridement
Skin grafting

lab values in acute phase

Must assess and follow electrolytes closely
Risk for hyponatremia
Hydrotherapy pulls Na from open wounds - GI suctioning - diarrhea*
Hyperkalemia - renal failure, deep muscle injury*
Hypokalemia - GI suctioning, vomiting, diarrhea*(fatigue muscle weakness, leg cramps)

acute phase complications

CV and Pulmonary (assess for pneumonia and ekg)
Neurologic(may have nerve damage, combative, withdrawn, reorientation)
Musculoskeletal-ROM affected, contractures, splints,
Endocrine-blood sugars could go up so may need supplemental insulin
GI System-paralytic ileus due to sepsis, constipated from pain meds or low mobility, diarrrhea from tube feeeding and antibiotics
Intensive care unit psychosis, delirium, prolonged use of sedatives
Skin is less supple and compliant as wounds heal and scarring occurs, ROM may be limited
BG may be elevated temporarily from increased cortisol levels

collaborative management in acute phase

Wound care
Excision and grafting
Pain management
Physical and occupational therapy
Nutritional therapy
Psychosocial care

wound care in acute phase

Prophylactic pain relief
Cleanse and debride area of necrotic tissue
Enzymatic Debridement
Collagenase (Santyl)
Excision and Grafting
Removal of necrotic tissue followed by application of a split-thickness autograft

Morbidity and mortality has improved due to

the early excision and grafting. Eschar is removed and graft is placed on healthy viable tissue to achieve good adherence
Hemostatsis is achieved by pressure and the application of topical thrombin or epinephrine and then autograft is applied

acute phase nursing care

Pain - continuous and treatment induced
Continuous pain medicine via morphine drip or slow release medication like MS Contin or Dilaudid
Antianxiety medications will potentiate medication
Fentanyl often used for treatment induced pain
Don't forget alternative methods for pain management

Rigorous PT and OT needed
Passive and active ROM

Adequate nutrition to support healing
Important to involve dietary to calculate daily caloric needs and provide guidance
High protein, high carb foods
Intubated patients will need enteral feeding
Weight loss should not exceed 10% bw

Reality of extent of injury is kicking in
Social worker consult

rehab phase

Patient's wounds are healed or covered by skin
Patient able to assume a level of self-care
2 weeks to 8 months after injury

rehab phase nursing care

Collagen fibers present in the new scar tissue - help healing and add strength
In 4-6 weeks areas become raised and hyperemic(red)
ROM - prevent new tissue from shortening and causing contractures
Use of splints*

Elastic pressure garments minimize

hypertrophic burn scarring

objectives: Patho of burns

inflammatory process causes capillary permeability, fluid shifts, edema, fluid volume goes down, hematocrit goes up and periferal vascular resistance goes up.hyponatremia, hypovolemic shock s/s:increased potassium, arrythmias due to potassium, CV problems, renal failure from myoglobin, temperature, resp-pulmonary edema, electrolyte imbalance, resp distress, pneumonia, emboli, malnutrition due to high metabolism, paralytic ileus. Nursing management: pain, fluid replacement, ABCs, debriedment, 2 large bore ivs, wound care, pt,ot and psych care, topical antibiotics

Nutritional therapy

-5000 calories day, protein intake ^, supplements, TPN, insulin for raise in blood sugar

Returning home:

teaching, home care, functional care for changing their house, respite care for caregiver, emphasize what they can do, encourage independence

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