Management of Patients With Burn Injury WEB

8/3/2019 Management of Patients With Burn Injury WEB

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Burns: Major Goals

1. Prevention2. Institution of lifesaving measures for

severely burned person.3. Prevention of disability and disfigurement

through early, individualized treatment

4. Rehabilitation through reconstructivesurgery and rehabilitative programs.


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Burn Classifications Superficial

Least destruction Only epidermis injured

Partial-thickness Epidermis destroyed Varying depths of dermis damaged/destroyed

Superficial partial-thickness Erythematous and moist with vesicles painful

Deep partial-thickness Red and waxy without blisters Moderate edema, lesser degree of pain Hypoxia and ischemia can cause extension of wound


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Burn Classifications

Full-thickness Entire epidermis and dermis involved No viable epithelial cells, grafts required

Hard, dry leathery eschar Deep full-thickness

Extend beyond skin into underlying fascia and tissues Muscle, bone and tendon damage with exposure to

surface Blackened and depressed, little or no sensation Early excision and grafting beneficial


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Illustrations of Burns

Superficial partial-thickness

Deep partial-thickness


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Illustration of Burns

Full Thickness Deep Full Thickness


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Burn Classification

Extent of Body Surface Area Injured Rule of Nines Lund-Browder Palm method


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Pathophysiology of Burn Injury

Tissue destruction can lead to: Fluid/protein losses Sepsis Multiple system disturbances

Metabolic Endocrine Respiratory Cardiac Hematologic Immune


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Pathophysiology of Burn Injury

Extent of local and systemic disruption dependson Age

General health status Extent of injury Depth of injury Area of body injured

(morbidity and mortality of burn clients is related to alack of or delay in healing)


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Vascular Changes

Fluid Shift Period of inflammatory response Vessels adjacent to burn injury dilate capillary

hydrostatic pressure and capillary permeability Continuous leak of plasma from intravascular space

into interstitial space Associated imbalances of fluids, electrolytes and

acid-base occur Hemoconcentration Lasts 24-36 hours


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Vascular Changes

Fluid remobilization Capillary leak ceases and fluid shifts back into

the circulation Restores fluid balance and renal perfusion

Increased urine formation and diuresis

Continued electrolyte imbalances

Hyponatremia Hypokalemia

Hemodilution


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Other System Changes Cardiac

Decreased cardiac output Need fluid resuscitation and support with O 2

Pulmonary Respiratory insufficiency as a secondary process Can progress to respiratory failure Aggressive pulmonary toilet and oxygenation

Gastrointestinal Decreased or absent motility (may need NG tube) Curlings ulcer formation H2 histamine blockers, mucoprotectants and enteral

nutrition


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Other System Changes

Metabolic Hypermetabolic state

Increased oxygen and calorie requirements Increase in core body temperature

Immunologic Loss of protective barrier

Increased risk of infection Suppression of humoral and cell-mediated

immune responses


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Compensatory Responses

Inflammatory Compensation Initiates healing Contributes to fluid shift ( capillary

permeability) Local tissue reaction due to release of

chemicals by wbcs Sympathetic Nervous System

Compensation Stress Response (Figure 71-8, p. 1625)


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Phases of Burn Injury

Emergent/Resuscitative First 48 hours

Acute Approximately 48 hours after injury to

complete wound closure Rehabilitative

Begins with wound closure and ends whenclient returns to highest possible level offunctioning


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Emergent/Resuscitative Phase

Goals: Maintain open airway Ensure adequate

breathing/circulation Limit extent of injury Maintain function of

vital organs

Prevent potentialcomplications

Transfer to BurnCenter Major burns

Very young or elderly Coexisting health

problems that couldaffect recovery

Circumstances thatincrease risk of acuteand long termcomplications


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Acute Phase

Interventions aimed at: Maintenance of cardiovascular/respiratory

system Nutritional status Burn wound care Pain control

Psychosocial interventions


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Rehabilitative Phase

Emphasis: Psychological adjustment of client Prevention of scars and contractures Resumption of pre-burn activity

Work Family

Social


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Clinical Manifestations of Burns

Respiratory Direct airway injury Carbon monoxide poisoning Thermal injury Smoke poisoning Pulmonary fluid overload External factors

Cardiovascular Hypovolemic shock and cardiac output Impaired circulation/tissue perfusion Potential for ECG changes


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Clinical Manifestations Renal/urinary

Changes R/T renal perfusion and debris Fluid shift GFR and urine output Fluid remobilization-- GFR and diuresis Tubular blockage from myoglobin and uric acid Fluid resuscitation should maintain output at 30-50

mL/hour Integumentary

Size of injury is important to diagnosis and prognosis Rule of Nines Lund-Browder method

Specific treatments dependent upon depth of injury


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Decreased CO, Deficient Fluid Volume,& Ineffective Tissue Perfusion

Interventions: Non-surgical

IV fluid therapy Plasma exchange Drug therapy

Surgical Escharotomy


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Ineffective Breathing PatternInterventions Non-surgical

Airway maintenance Promotion of ventilation Monitoring gas exchange Oxygen therapy Drug therapy Positioning and deep breathing

Surgical Tracheostomy Chest tubes escharotomy


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Acute Pain

Interventions: Non-surgical

Drug therapy (opioids) (anesthetic agents) Complimentary/alternative therapies Environmental manipulation

Surgical Early surgical excision of burn wound


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Impaired Skin IntegrityWound Care Management

Non-surgical Debridement

Mechanical Enzymatic

Cleaning

Stimulating granulation andrevascularization Dressings


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Dressings Standard

Multiple gauze layers over topical agent or antibiotic

Biologic Homograft (allograft) from cadaver

Heterograft (xenograft) from animal (pig) Amniotic membrane Cultured skin

Artificial skin Two-layer product which creates an artificial dermis

Synthetic dressing Solid silicone and plastic membrane Can see through to monitor wound status


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Impaired Skin IntegrityWound Care Management

Surgical management Surgical excision

Treatment of choice for deep partial-thicknesswounds

Wound coverings Permanent skin coverage by autograft

Split thickness Successive reharvesting Meshing of split thickness graft


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Risk for Infection

Non-surgical management Drug therapy

Tetanus Toxoid and Topical Antimicrobials

Organism specific drugs Isolation Environmental manipulation Secondary prevention/early detection

Surgical management Aggressive surgical incision of infected wound


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Additional Interventions

Imbalanced Nutrition Calculate calorie needs and provide adequate

calories and nutrients

Calorie requirements can exceed 5000 per day Impaired Mobility

Interventions to maintain pre-burn ROM and preventcontractures

Disturbed Body Image Grief counseling Encouraging independence

Management of Patients With Burn Injury WEB

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