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Transcript of 124 071912
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N124Prof. MGAP Batalla
7/19/12
Nursing Care of the Burn Patient
Anatomy and Physiology of the Skin
Skin
-
Largest organ
-
Parts: epidermis and dermis
-
Functions:
o Maintains body temperature
o
Acts as a barrier to water loss
o Produces Vit. D
Every 15 minutes in the sun
o Prevents microbes from entering the body
o Protects against environment
o Cosmetic
Burn
-
Injury that is d/t tissue damage or loss
-
Extent depends on:
o Temperature
o
Causticity of the burning agent
o
Duration of tissue contact with source (
length of exposure)
1 sec with hot tap water at 69
degrees Celsius: full thickness
burn
15 sec with hot water 15 degrees
Celsius: full thickness burn
Zones of injury
Jacksons thermal wound theory: zones of injury
-
Areas extending outward from the center area of
injury that sustain various degrees of damage
1.
Zone of coagulation
Most severe damage
Irreversible death occurs (no more
blood supply)
2.
Zone of stasis
Impaired circulation
Potentially salvageable
48-72 hours to determine extent
of damage
3.
Zone of hyperemia
Vasodilation and increased blood
flow
Minimal cell involvement
Early spontaneous recovery
Classification of burn injuries
Burn severity
Factors:
-
Depth and size
-
Body surface area burned
-
Age
- Preexisting medical condition
-
Associated trauma
o Blast
o fall
o Airway compromise
o Child abuse
Types of burn injuries
1.
Thermal burn
a.
From scalds, steam, and contact with
heat
b.
Tanning machines, radiation therapy
2.
Chemical
3.
Electrical
4.
Radiation
Depth classification
1.
Superficial (1stdegree)
a.
2 3 layers of the epidermis
b.
Usually heals in 2-7 days
c.
E.g. sunburn, minor steam burns
d.
Assessment findings
i.
Reddening
ii.
Tenderness and pain
iii.
Increased warmth
iv.
Blanches with pressure
v.
Edema may occur
vi. w/o blistering
2.
Partial thickness (2nd
degree)
a.
Upper third of the dermis
i. Superficial
1.
Light to bright red or
mottled
2.
Shiny appearance
3.
May contain bullae,
moist/wet weeping
4.
Very painful (due to
exposed nerve endings)
5.
Heals in 7-21 days
ii.
Mid-dermal
1.
Half the dermis is
destroyed
2.
Heals in 4-6 weeks
iii.
Deep-dermal
1.
Involves majority of the
dermal layer
2.
Red and dry with white
areas in deeper parts
3.
Healing is 4-10 weeks or
longer
4.
There is a certain degree
of pain (unlike 3rd
degree, no pain)
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3.
Full thickness (3rddegree)
a. All skin layers and sq fat are destroyed
b.
Painless
c.
Pain d/t intermixing with 2nd
degree burn
d.
Thick , dry, leathery
e.
Pale white/pearly grey/charred black, red,
brown
f.
Requires grafting
Size of injury
1.
Rule of nines
a.
The body surface is divided into areas
representing 9% or multiple
i.
9% head
ii.
9% arm
iii.
1% perineum
iv.
18% leg
v.
18% posterior trunk
vi.
18% anterior
2.
Palm rule
a. 1 % of body surface
3.
Lunder and browder
a.
Depends on age
*estimating TBSA (total body surface area) for fluid loss;
1stdegree burn is not included
Special considerations
-
Location
-
Age
o 60
Pediatric burns
-
thin skin
-
Delicate balance
- Large surface/volume ration
o Rapid fluid loss
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Immature immunological response/sepsis
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Always consider possibility of child abuse
Geriatric burns
-
less myocardial reserve
-
fluid resuscitation diff
-
PVD, DM,
o Slow healing
COPD
Complication of airway injury
poor immunological response
o Increase risk for sepsis
% of mortality is approx.: age + % BSA burned
Burn configuration
- circumferential burns can cause total occlusion of
circulation to an area d/t edema
Minor burn criteria
- 3 degree < 2% BSA
- 2nd
degree < 15 % BSA (10 % BSA
-
2 >30 % BSA (>20 % BSA pedia)
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Burns with respiratory injury
-
Underlying health problems
-
Hands, face, feet or genitalia
-
Burns complicated by other trauma
Phases of burn management
1.
Resuscitation phase
2.
Acute phase
3.
Rehabilitation phase
Goals of initial burn management
1.
Save lives
2.
Minimize disability
3.
Prepare for definitive care
Initial Burn Management
-
ABC!
Respiratory Management
-
Circumferential full-thickness eschar to chest wall
can lead to decreased chest wall expansion and
compliance = chest wall restriction = CO2 retention
o Eschar
Black gulaman (Centillo, 2012)
Tough inelastic mass of burnt
tissue
May cause compartment
syndrome
Escharotomies may increase
compliance (too relieve pressure
of the burn area)
Circulatory Management
-
IV access
-
Fluid restriction
-
Continuous ECG monitoring
-
Urine output, HR, BP and LOC monitoring
Parkland Formula
o
50% of calculated amount of fluid is given
in the first * hours after injury
o 25% is given in the second 8 hours
o 25% in the third 8 hours
Lactated Ringers: fluid resuscitant of choice, for plasma
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Wound debridement
o Removal tissue and eschar
Natural
Mechanical
surgical
-
Skin grafting
o
Full thickness skin graft
o Sources
Homografts
From dead people
Heterografts
From animals
Autografts
From self
Biosynthetic
Artificial
Synthetic dressing (nylon
with collagen derivative)
Psychosocial Problems of the Burn Patient
Acute phase
- Facing reality of burn trauma
-
Grieving over obvious losses
o Depression
o Regression
o
Manipulative behavior
o Withdrawal
o Anger
Rehab phase
-
Include the patient in decision making
-
Help patient set realistic self goals