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BurnsLinda Copenhaver
04/19/23 2
Introduction
Incidence of Burns
450K in U.S. seek medical care annually
Approximately 45K are hospitalized Which setting do most burn trauma
injuries occur? How many Burn Trauma centers in
U.S.?
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Types of Burn Injury
Thermal Chemical Electrical-what type considered
here? Which state has highest incidence of ____ injuries?
Radiation
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Thermal Burns( Most Common) Caused by flame, flash, scald, or
contact burns
STOP & DROP Roll to shut off O2 supply to
fire Flush or immerse in cold
water DO NOT use ICE on deep
burns, just localized, superficial burns
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Chemical Burns
Remove person from contact with agent
Flush with water continuously
Remove affected clothing if possible
Alkaline agents worse than acid, process keeps going
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Electrical burns Coagulation necrosis Severity depends on voltage, amount of
resistance, time,
and current
pathways.
Electrical Burn–Back
Fig. 25-2 B
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Frequently only entry (yellow-white) and exit (blow out) wounds are visible
Current practice: Now refer to contact points vs entry and exit points.
Extensive tissue damage is masked
How can we evaluate “masked tissue damage”???
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Electrical Burns (cont) Patient at risk for arrhythmias
due to _____, metabolic acidosis due to _____, and acute tubular necrosis due to ______.
Current can be so strong to
fracture long bones and cause respiratory muscles to contract
Cross Section of Skin
Fig. 25-3
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Depth of Burns Superficial Partial Thickness Burn (1st
degree) Epidermis involvedSunburn, UV light, mild radiation,Pink to redSlight edemaMild pain
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Depth of Burns Deep Partial Thickness (2nd)
Epidermis and some of dermis, is painful, red, blisters
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Depth of Burns
Deep Partial Thickness (2nd)
Epidermis and Dermis
Very Painful, edema, pale
Moist or dry, but more commonly wet
Blisters
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Depth of Burns (cont) Full Thickness Burns (3rd)
Epidermis, Dermis, and Subcutaneous tissue burned
Nerve endings destroyed Little or no pain
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Depth of Burns (cont)
Full thickness (4th degree) Involves past the 3 layers
down to the bone and/or organs
Rule of Nines Chart; quick & easy
Fig. 25-4 B
Lund-Browder Chart; More accurate
Fig. 25-4 A
Burn Unit Referral Criteria
Deep Partial Thickness burns > 10% TBSA Burns that involve the face, hands, feet,
genitalia, perineum, or major joints Full thickness burns in any age group Electrical burns, including lighting Inhalation burns requiring intubation Chemical burns that involve deep and
extensive TBSA burned
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Medical/Nursing Management of Burns I. Emergent Phase
Period of time from onset of burns to the beginning of fluid remobilization
Usually lasts 24-48 hours
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Emergent Phase (cont)
Also called FLUID ACCUMULATION PHASE
The greatest initial threat to a major burn victim is hypovolemic shock
Let’s do the Patho on p. 479 Lewis…this is a DING DING!
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What are the Priorities in this patient??? Is this patient a candidate for a
major burn center?
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Nursing Care During Emergent Phase Impaired Gas Exchange r/t
tissue hypoxia secondary to carbon monoxide poisoning
Note: CO poisoning is the MOST immediate cause of death from fire.
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Signs & Symptoms of Carbon Monoxide Poisoning Edema of Airway Hoarseness Dysphagia Stridor Copius Secretions usually
black tinged Skin will appear cherry red
Cherry red skin appearance
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Interventions for CO Poisoning: Assess for S&S CO poisoning (mild to
severe) Humidified O2 100% via face mask High Fowler’s Position TCDB q 1 hour Intubation & Ventilation Bronchodilators for bronchospasm One other thing…..does anyone
know???
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Nursing Care during Emergent Phase (cont) Impaired Gas Exchange r/t
mucosal edema throughout respiratory tract secondary to smoke inhalation, hot air, chemical gases
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Interventions: Early intubation to prevent
trach placement Ventilation Humidified O2 100% ABG’s Bronchodilators
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Questions to Ask Burn Victims Were you in an enclosed
space? Were you standing up? Was it a flame and chemical
fire? Are you having difficulty
breathing?
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What are your #1 priorities in this patient?
Patient #1 Patient #2
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Emergent Phase (cont)
Ineffective Breathing pattern r/t constriction of chest/trachea secondary to the effects of full thickness burns.Assess for signs of
constrictionEscharotomies with
circumferential burns of chest
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Escharotomy of chest and arm What is the pathophysiology here?
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Emergent Phase (cont)
Fluid Volume Deficit (intravascular) r/t massive fluid shift to interstitial spacesAssess fluid needs:
Brooke FormulaEvans Formula
Parkland Baxter Formula Most widely used
Formula
LR 4ml X kg body weight X TBSA % burned
½ total amount given 1st 8 hours ¼ total amount given next 8 hours ¼ total amount given next 8 hours
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Okay Nurses Let’s Calculate
What would the fluid replacement be for a patient who weighed 60kg and had 30% TBSA burned???
1st 8 hours= _____ or ____ml/hr 2nd 8 hours= _____ or _____ml/hr 3rd 8 hours= ______ or _____ml/hr
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Crystalloids used such as LR, 0.9NS, D5NS
Colloids (albumin, dextran, FFP) used to expand plasma.
Colloids not given until after capillary permeability decreases and returns to normal…..WHY?
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Insert foley catheter to monitor output. What should urine output be in an adult???
Frequent vital signs SBP>100 Pulse<100 RR 16-20
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Emergent Phase (cont)
Monitor Electrolytes and Hematocrit; tells you about fluid shift. What should Hct be doing as
time progresses???
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Emergent Phase (cont)
Potential for Infection r/t loss of skin and micro invasion
Meticulous hand washing Sterile technique during dressing
changes & wound care Hair near burned areas shaved
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Potential for Infection r/t loss of skin and micro invasion (cont)
Blisters popped or not???Tetanus Toxoid I.M. given to
all major burn victims to fight
anaerobic contamination of burn wound
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Hydrotherapy in cart (water is heated to approximately 104 degrees)
< 30 minutes to prevent _____
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Hydrotherapy Cart
What does hydrotherapy accomplish?
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Wound Care
Open Method Apply topical chemotherapy
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Topical Meds/Antimicrobials
Silvadene cream
Silver Nitrate or silver impregnated dressings such as Silverlon or Acticoat
Sulfamylon cream
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Wound Care (cont) Closed Method
Apply topical chemo and wrap with gauze, fluffs, kerlix
Assess for
constriction;
circulation
checks
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Emergent Phase (cont)
Elevate burned arms on pillows Give pain meds 30 minutes
prior to treatments Wrap distal to
proximal
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Emergent Phase (cont) Alteration in body temp
(hypothermia) r/t loss of skin
Set thermostats at warm temp in room (~85 degrees)
Maintain body temp above 37 (98.6) degrees C; patient outcome on POC:
Patient will maintain body temp of 38 (100.4)
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Emergent Phase (cont) Potential for injury r/t effects of
stress response:
Stress diabetes What is the patho here???
Curling’s ulcer (associated with burn trauma patients)
Gastroduodenal ulcer caused by increased gastric acid secretion
So which meds would nurse anticipate in the POC?
• Sliding scale and routine insulin sc
• H2 blockers for GI ulcer prevention:
• Pepcid, Protonix, Zantac04/19/23 50
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Emergent Phase (cont) Potential for injury r/t effects of
stress response:Paralytic ileus (stress related)
NPO, NG tube to suctionDelirium (psychological stress)Inderal given for anxiety, pain
and tachycardia
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Emergent Phase (cont) Compartment syndrome r/t the
effects circumferential burns
Circulation is impaired
Edema formation
Occluded blood supply
Ischemia
Necrosis
Gangrene
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Emergent Phase (cont)
What is the treatment?Escharotomy
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Emergent Phase (cont)
Renal Failure
Hypovolemia (Why?) blood flow to kidneys
Renal ischemia ARF may develop
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Emergent Phase (cont) Renal Failure
Full thickness & electrical burns
Myoglobin from muscle cells released
Urine myoglobin q 6 hours Blocks renal tubules
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Emergent Phase (cont)
What is the treatment for these 2 renal problems????
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Emergent Phase (cont)
Cardiac Function
Arrhythmias due to electrolyte imbalance or electrical burns
Hypovolemic shock due vascular bed depletion
Important points…2 Large bore IV sites initially until central line can be placed (16 gauge preferable)
LR preferred over 0.9NS Why? ___________________
Most burn trauma patients will be conscious unless what? ______
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Summary of Emergent Phase:
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II. Acute Phase (weeks to months) Begins after 48-72 hours Fluid begins to shift interstitial
spaces back into bloodstream or intravascular space
Diuresis occurs Ends when TBSA burned is
<20% by grafting or wound healing
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Nursing Care During Acute Phase Skin/systemic infection r/t
Loss of normal skinFormation of escharSuppression of immune
systemMetabolic/hormonal
alterations
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Acute Phase Interventions for
Skin/Systemic Infection:
Hydrotherapy cart shower to debride
Open/Closed dressing changes
Topical antimicrobialsWeekly culturesSystemic antibiotics
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Acute Phase (cont) Excision & Grafting
Removal of necrotic tissue Eschar is removed until viable
tissue is reached
The RN just received report on the burn unit. Which client requires the most immediate assessment or intervention? a) 22 yo old admitted 4 days previously with
facial burns due to a house fire who has been crying since recent visitors left
b) 34 yo who returned from skin graft surgery 3 hours ago and is c/o 8 out of 10
c) 45 yo with deep partial thickness leg burns who has temp of 102.6 and a bp of 98/46
d) 57 yo who was admitted with electrical burns 24 hours ago and has K+ level of 5.6mEq/L
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Acute Phase (cont)
Reasons for Grafting (priorities)
Survival Function Cosmetic
Synthetic Grafts BIOBRANE
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Types of Grafts
Autograft or Autologous self
Heterograft Different species
Pig, bovine Homograft
Cadaver Which are temporary vs
permanent?
New Advanced Grafts
Cultured Epithelial Autograft (CEA) Patient’s own skin cells grown in
culture dish—Permanent Cost of CEA---$145K for 15 small pieces
of CEA
Latest in Skin Grafting--More options for Permanent Grafts
New Advanced Grafts
Integra
Bovine collagen and glycosaminoglycan bonded to silicone membrane-Permanent
AlloDerm Acellular dermal matrix derived from
donated human skin-Permanent
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Acute Phase (cont)
GRAFTING
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Acute Phase (cont)
GRAFTING
Dermatome-harvesting donor skin from thigh
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Acute Phase (cont)
Can you describe this???
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Acute Phase (cont) Potential for fluid volume excess r/t
fluid shift from interstitial back to intravascular space Daily weights Monitor lab values-Which ones? Auscultate lungs Fluids as ordered Avoid free water-dilutional
hyponatremia
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Acute Phase (cont)
Alteration in Nutrition r/t hypermetabolismGoals are to minimize
energy demands and to..Provide adequate calories
to promote wound healing
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Acute Phase (cont)
Interventions for altered nutrition:
Monitor bowel soundsHigh Protein High CHOAssess food preferencesDaily calorie countTPN as ordered
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Acute Phase (cont) Ineffective Coping r/t long rehab
process with multiple surgeries and change in lifestyle/social isolation
Include family in plan of care Assess client’s readiness to talk Allow client to work through grief
process Give honest, accurate information
A client with deep partial and full thickness TBSA burned is 28% is receiving hydrotherapy. The nurse should assess for which of the following complications?
a) hypernatremia b) dehydration c) edema d) hypothermia
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Acute Phase (cont)
Self-care Deficit r/t restricted movement/contractures/muscle atrophy
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Interventions
Assist with positioning ROM exercises Support O.T. & P.T. efforts Always maintain eye contact with
client
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III. Rehabilitation Phase From wound closure to optimal level of
physical and psychosocial adjustment
Potential for impaired home maintenance/integration back into social and work environment
Discuss grief process, self-concept, resocialization process
Sexuality issues, will I be a productive person? Will I be a good parent/partner?
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Rehabilitation Phase
Instruct client on skin care:
Skin will itch, be dry, have a tight feeling
Use Vaseline Intensive Care ES lotion, mild soaps
Use Benadryl for itchingAvoid direct sunlight (will cause
hyperpigmentation)
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Rehabilitation Phase
Instruct client on skin care:
Skin may be hypo or hyper sensitive to cold/heat/touch
Diet (high protein, vitamins) Exercise to prevent contractures Instruct client on S & S of infection
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Rehabilitation Phase Instruct client to wear JoBST
pressure garment up to 1 year
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Rehabilitation Phase
Instruct client on skin care:Need to wear Jobst to
prevent keloid formation
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