Burn Injury 4

Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

CARE OF PATIENTS WITH BURNS

Chapter 28


Burns

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

● Occur when there is injury to tissues of the body caused by heat, chemicals, electrical current, or radiation

● Should be viewed as preventable

Burns can cause: fluid and protein loss, sepsis, changes in metabolic, endocrine, respiratory, cardiac, hematologic, and immune functioning.

A lack of or delay in wound healing is a key factor for all systemic problems and a major cause of disability and death among patients who are burned.


Burns: skin changes


Epidermis (outer layer of the skin)● 0.15 mm thick but thinner in older adults● layer can grow back after a burn injury ● no blood vessels → nutrients are diffused from the dermis

Dermis ● Thicker than epidermis● made up of collagen, fibrous connective tissue, and elastic fibers● contains blood vessels, sensory nerves, hair follicles, lymph vessels, sebaceous

glands and sweat glands● skin cannot restore itself when entire layer of dermis is burned

Subcutaneous tissue lies beneath the dermis● with deep burns, the subcutaneous tissue may be damaged, leaving bones,

tendons, and muscles exposed


Causes and Types of Burn Injury

● Dry heat (flame): caused by open flame. Common in house fires and explosions. Ignited clothing from open flame accounts for the most injuries. Explosions usually result in flash burns because they produce a brief exposure to very high temperatures

● Moist heat (scald): contact with hot liquid or steam● more common among older adults● Hot liquid spills usually burn the upper, front areas of the body● Immersion scald injuries usually involve the lower body

● Contact: ● Chemical ● Electrical burns: entry and exit site


Types of Burn InjuryElectrical Burns


● Severity of injury depends on○ Amount of voltage○ Tissue resistance○ Current pathways○ Surface area○ Duration of the flow




● Current that passes through vital organs will produce more life-threatening sequelae than current that passes through other tissue

● Electrical sparks may ignite patient’s clothing, causing a combination of thermal flash injury




● Severity of injury can be difficult to assess, as most damage occurs beneath skin○ “Iceberg effect”

● Electrical current may cause muscle spasms strong enough to fracture bones


Functional Changes

● Skin is a protective barrier and any break can increase the risk for infection● May also cause fluid and electrolyte imbalance → evaporation through

burned skin occurs 4x rapidly compared to intact skin● the rate of evaporation is in proportion to total body surface area burned and

depth of injury● burns reduces excretory ability → full thickness burns destroys sweat glands● pain

● partial thickness burns: nerve endings are exposed, increasing sensitivity and pain

● full thickness burns: nerve endings are completely destroyed, wounds may not transmit sensation except when sharp stimulus is applied, patients often have a dull or pressure type pain

● Vit D activation: ● Partial thickness burns: reduces the activation of Vit D● Full thickness burns: function is completely lost

● Temperature: heat source that exceeds the skin’s capacity to dissipate causes cell destruction and results in burns

● Psychosocial problems: reduced self image due to change in appearance


Classification of Burn Injury


● Severity of injury is determined by ○ Depth of burn: how deep into the skin the burn goes○ how much body surface area is involved

● Degree of tissue damage is related to the agent causing the burn and to the temperature of the heat source, and how long the skin is exposed to it

● Watch location, thin areas like eyelids, ears, tops of the hands and feet● older adults have thinner skin which increases their burn severity even at low

temperatures and short durationSuperficial: Epidermis ● superficial thickness wounds have the least damage because only the

epidermis is injured○ Extent of burn in percent of TBSA( total body surface area)○ Location of burn○ Patient risk factors


Identify the Burn DepthSuperficial/Partial Burns


Superficial

● involves the epidermis, blistering, healing is rapid

● Superficial burns damage only the top layer of the skin- the epidermis

■ *the area heals rapidly in 3 - 6 days without a scar or other complication

■ No scar formation○ Caused by prolonged exposure to low intensity heat (sunburn) or short flash

exposure to high intensity heat. ○ Redness with mild edema, pain, and increased sensitivity to heat occurs○ Desquamation (peeling of dead skin) occurs for 2 or 3 days after the burn


Table 28-1



Identify the Burn DepthDeep Partial Burn


Partial Thicknessinvolves the entire epidermis and varying depths of dermis

Superficial Partial Thickness● injury to the upper third of the

dermis, leaving good blood supply

● Red, moist, blanch when pressure is applied

● Blisters: small blisters are left intact unless its on a joint and large blisters are debrided

● Increase pain sensation: nerve endings are exposed and any stimulation (touch or temperature) cause intense pain

● Heal 10-21 days ● no scar● some minor pigment changes

can occur

Deep Partial Thickness● Extend deeper in the skin dermis,

fewer healthy cells remain● Blisters do not usually form● Wound surface is red and dry

with white areas in deeper parts (dry because fewer blood vessels are patent)

● Blanches slowly or not at all● Edema is moderate● Pain is less than superficial

because more nerve endings have been destroyed

See next slide


Deep Partial Burn

○ Deep Partial: Involves the epidermis and dermis, redness or white to skin, moderate edema■ *Takes 3-6 weeks to heal■ *Scar formation does occur■ A few healthy cells remain■ These wounds can progress to full thickness wounds when tissue damage

increases with infection, hypoxia, or ischemia■ Surgical intervention with skin grafting can reduce healing time


Identify the Burn DepthFull Thickness


Full Thickness Burns

○ Full Thickness: Involves the epidermis, dermis, and fat ■ wound may be waxy white, deep red, yellow, brown, black■ hard, dry, leathery eschar that forms from coagulated particles of destroyed

dermis■ Thrombosed vessels may be visible beneath the surface of the burn■ These dermal blood vessels are heat coagulated, causing the burned tissue to be

avascular (without blood supply)■ Sensation is reduced or absent because of nerve ending destruction■ Healing time depends on establishing good blood supply in the injured areas.

This can take weeks to months. ● Fatty tissue and blackened skin (eschar?) can be seen● Eschar: dead tissue; it must be slough off or be removed from the wound before healing can occur● Edema is severe under the eschar● When the injury is circumferential (completely surrounds an extremity or the chest), blood flow and

chest movement for breathing may be reduced by tight eschar. ● May see muscle or bone involved● The deeper it is, the less pain is felt: the nerve endings are destroyed● Will not heal on its own, skin and blood vessels are destroyed● Escharotomies (incision through the eschar) or fasciotomies (incision through eschar and fascia) may

be needed to relieve pressure and allow normal blood flow and breathing● Patient will require a skin graft


Sample Question # 1

The nurse assesses the wound of a client burned as a result of stepping into a bathtub filled with very hot water. Which assessment finding of the burned areas on the tops of both feet does the nurse use as a basis to document a probable full-thickness injury?

A Most of the wounded area is red.

B The client reports that the area hurts when touched.

C The area does not blanch when firm pressure is applied.

D Thrombosed blood vessels are visible beneath the skin surface.


Vascular Changes from initial injury until 24 hrs

● Disruption occurs at the burn site immediately after injury, vessels are occluded and blood flow is reduced or stopped

● blood vessel thrombosis occurs, causing necrosis and can lead to deeper injuries ● Fluid shift: also known as third spacing or capillary leak syndrome

● a continuous leak of plasma from the vascular space into the interstitial space**the loss of plasma and proteins causes decrease BP and blood volume**leakage causes extensive edema even in areas that are not burned● Imbalances of fluids, electrolytes, and acid-base occur as a result of fluid shift and

cell damage● Hypovolemia● Metabolic Acidosis● Hyperkalemia: direct cell injury that releases large amounts of cellular potassium● Hyponatremia● Hemoconcentration (elevated blood osmolarity, H&H): develops from vascular

dehydration. This increases blood viscosity, reducing flow through small vessels and increasing tissue hypoxia


Vascular Changes 24 hours after

● Fluid remobilization starts, 24 hours after the capillary leak stops● diuretic phase begins at about 48 - 72 hrs after the burn → capillary membrane

integrity returns and edema fluid shifts from interstitial space back into the intravascular space

● Diuresis: due to increased kidney blood flow unless kidney has been damaged● Hyponatremia: increased sodium excretion and the loss of sodium from wounds● Hypokalemia: potassium moves back into the cells and is also excreted in urine● Anemia results from hemodilution, but generally not severe enough to require blood

transfusion● Transfusions are given only if necessary: only if hematocrit is less than 20% to 25%

and patient has manifestations of hypoxia● Metabolic acidosis occurs due to loss of bicarbs


Cardiac Changes

● HR increases and Cardiac output decreases because of the initial fluid shifts and hypovolemia that occur

● CO may remain low until 18-36 hours after burn injury● CO increases with fluid resuscitation● Proper fluid resuscitation and oxygen support prevent further complications


Pulmonary Changes

● Direct injury to the lung from contact with flames rarely occurs● Respiratory problems are caused by superheated air, steam, toxic fumes, or smoke.

Such problems are a major cause of death in patients with burns and are most likely to occur when the burn takes place indoors

● Respiratory failure: results from airway edema during fluid resuscitation, pulmonary capillary leak, chest burns restricting chest movements, and carbon monoxide poisoning

● Inhalation injury can occur in the upper and major airways, and lung tissue● upper airway (mouth and throat) is affected when inhaled smoke/irritants cause

edema and obstruct trachea● Chemicals and toxic gases causes more airway injury than heat● Lung tissue injuries result from toxic damage to the alveoli and capillaries. Leaking

capillaries cause alveolar edema which can lead to respiratory distress and pulmonary failure. This can lead to acute pulmonary insufficiency and infection.


GI Changes

● Decreased blood flow to the GI tract● Impaired mucosal integrity ● Impaired motility

● Peristalsis decreases● Paralytic ileus may develop● Abdominal distension: collection of secretions and gases● Curlings ulcer: acute gastroduodenal ulcer that occurs with the stress of severe injury

due to the reduced GI blood flow and mucosal damage● Mucus lining is destroyed, increasing hydrogen ion production, resulting in ulcers● Give histamine blockers, PPIs, GI protectants, and early enteral feeding


Metabolic and Immunologic Changes

Metabolic Changes● Hypermetabolism: increased secretion of catecholamines, ADH, aldosterone,

cortisol.● Patient’s oxygen use and caloric needs are high with hypermetabolism● increases core body temperature: low grade fever●

Immunologic Changes● Increased risk for infection: the burn injury disrupts or destroys the protective

barrier of the skin● Inflammatory response is activated and often suppresses all types of immune

functions● Immune function is further reduced from topical and steroid antibiotics, general

anesthesia, blood transfusion, and the stress of surgery


Compensatory Changes

● any tissue injury can disrupt homeostasisInflammatory compensation● GOOD: helps trigger healing in the injured tissue● BAD: it causes fluid shifts ● Inflammatory compensation is intended to function on a local and short term basis.

When it is widespread or persistent, they can cause severe tissue damage.

SNS compensation● Stress response that occurs when any physical or psychological stressors are present● SNS compensation is most evident in cardiovascular, respiratory, and GI systems


Classification of Burn Injury

Extent of Burn - determined by TBSA○ Why is it important to know?

■ Determines the amount of fluids and calories the patient will need


Classification of Burn InjuryExtent of Burn


● Two commonly used guides for determining the total body surface area○ Lund-Browder chart

• Considered more accurate: takes age into consideration○ Rule of Nines

• Used for initial assessment• More general, quicker


Rule of Nines Chart


Know how to determine percentage of burns


Types of Burn InjurySmoke Inhalation Injuries


● From inhalation of hot air or noxious chemicals● Cause damage to respiratory tract● Major predictor of mortality in burn victims● Need to be treated quickly


Classification of Burn InjuryLocation of Burn


● Severity of burn injury is determined by location of burn wound○ Face, neck, chest → respiratory obstruction

● from inhalation of chemicals or indirect heat to the area - causes inflammation which can lead to obstructions

○ Hands, feet, joints, eyes → self-care deficit○ Ears, nose, buttocks, perineum → infection

● There can be contamination from urine and feces: buttocks and perineum● Ear and nose have a poor blood supply


Classification of Burn InjuryLocation of Burn


● Eschar formation can cut off blood supply and interfere with healing○ Circumferential burn to the chest area: interfere with

breathing, constrict the chest wall to move○ make sure the pt is breathing and doesn’t develop

● Patients may also develop compartment syndrome


Classification of Burn InjuryPatient Risk Factors


● Pre-existing cardiovascular, respiratory, and renal diseases contribute to poorer prognosis

● Diabetes mellitus and peripheral vascular disease contribute to poor healing and gangrene● will be more difficult to recover


Classification of Burn InjuryPatient Risk Factors


● Physical debilitation renders patient less able to recover○ Alcoholism ○ Drug abuse○ Malnutrition

● Concurrent fractures, head injuries, or other trauma leads to a more difficult time recovering○ Difficult time to recover


Resuscitation/Early Phase of Burn Injury

● Continues for about 24 to 48 hours

● The resuscitation phase is the first phase of a burn injury. It begins at the onset of injury and continues for about 24 to 48 hours. During this phase, the injury is evaluated and the immediate problems of fluid loss, edema, and reduced blood flow are assessed. The priorities for management during this period are to (1) secure the airway, (2) support circulation by fluid replacement, (3) keep the patient comfortable with analgesics, (4) prevent infection through careful wound care, (5) maintain body temperature, and (6) provide emotional support.

■ Vascular changes that occur:● Fluid shifts from vascular to interstitial space ● capillary leak syndrome● concerned with the systemic effects of the burn: ABC’s are priority


Goals of management?

General Management for All Types of Burns

• Assess for airway patency.

• Administer oxygen as needed.

• Cover the patient with a blanket.

• Keep the patient on NPO status.

• Elevate the extremities if no fractures are obvious.

• Obtain vital signs.

• Initiate an IV line, and begin fluid replacement.

• Administer tetanus toxoid for prophylaxis.

• Perform a head-to-toe assessment.



Specific ManagementFlame Burns

• Smother the flames.

• Remove smoldering clothing and all metal objects.Chemical Burns

• If dry chemicals are present on skin or clothing, DO NOT WET THEM.

• Brush off any dry chemicals present on the skin or clothing.

• Remove the patient's clothing.

• Ascertain the type of chemical causing the burn.

• Do not attempt to neutralize the chemical unless it has been positively identified and the appropriate neutralizing agent is available.



Electrical Burns

• At the scene, separate the patient from the electrical current.

• Smother any flames that are present.

• Initiate cardiopulmonary resuscitation.

• Obtain an electrocardiogram (ECG).Radiation Burns

• Remove the patient from the radiation source.

• If the patient has been exposed to radiation from an unsealed source, remove his or her clothing (using tongs or lead protective gloves).

• If the patient has radioactive particles on the skin, send him or her to the nearest designated radiation decontamination center.

• Help the patient bathe or shower.



● Concerned with the systemic effects of the burn○ ABC is a priority

● Airway/respiratory first○ Assess for signs of inhalation injuries: facial involvement,

singed hair on face, mouth is black


BreathingKey signs that your patient is deteriorating for inhalation injury

● Hoarseness, brassy cough, difficulty swallowing, drooling, stridor → wheezing● Look at respiratory effort (use of accessory muscle)● If patient shows signs of inhalation injury, what will you as the nurse do?

○ Interventions■ Give oxygen■ Call Rapid Response! prepare for intubation

● Make sure there is intubation equipment at the bedside■ Once they are showing signs of inhalation injury, there are at risk for

respiratory arrest/failure, the airways getting more narrow■ Suction■ HOB elevated: Sit patient up, turning pt frequently ■ Encourage patient to use incentive spirometer■ Monitor ABG’s labs


Factors Determining Airway Obstruction or Inhalation Injury

• Patients who were injured in a closed space

• Patients with extensive burns or with burns of the face

• Intra-oral charcoal, especially on teeth and gums

• Patients who were unconscious at the time of injury

• Patients with singed scalp hair, nasal hairs, eyelids, or eyelashes

• Patients who are coughing up carbonaceous sputum

• Changes in voice such as hoarseness or brassy cough

• Use of accessory muscles or stridor

• Poor oxygenation or ventilation

• Edema, erythema, and ulceration of airway mucosa

• Wheezing, bronchospasm


Factors Determining Airway Obstruction or Inhalation Injury

A change in respiratory pattern may indicate a pulmonary injury. The patient may:

• Become progressively hoarse

• Develop a brassy cough

• Drool or have difficulty swallowing

• Produce sounds on exhalation that include audible wheezes, crowing, and stridor

Any of these changes may mean the patient is about to lose his or her airway. Immediately apply oxygen and call Dr


Circulation

● C - Patient is at risk for hypovolemic shock: big cause of death in this phase○ Fluid resuscitation must be started immediately!○ Monitor edema, urine output, vital signs (BP, pulse)○ To determine how much fluid infusion the pt needs we use Parkland formula


Fluid Resuscitation of the Burn Patient

• Initiate and maintain at least one large-bore IV in an area of intact skin (if possible).

• Coordinate with physicians to determine the appropriate fluid type and total volume to be infused during the first 24 hours postburn.

• Administer one half of the total 24-hour prescribed volume within the first 8 hours postburn and the remaining volume over the next 16 hours.

• Assess IV access site, infusion rate, and infused volume at least hourly.



Monitor these vital signs at least hourly:

• Blood pressure

• Pulse rate

• Respiratory rate

• Breath sounds

• Voice quality (if not intubated)

• Oxygen saturation

• End-tidal carbon dioxide levels



Assess urine output at least hourly:

• Volume

• Specific gravity

• Color

• Character

• Presence of protein

Assess for fluid overload:

• Formation of dependent edema

• Engorged neck veins

• Rapid, thready pulse

• Presence of lung crackles or wheezes on auscultation

Measure additional body fluid output hourly


Application of Parkland Formula

● A Patient weighing 154 lbs has a burn with a TBSA of 50%. The patient was found at home at 8am and arrived to the hospital at 10am.○ How much fluid should be administer in the first 8 hours? Calculate the

rate.

● 4 x patient weight in kg x TBSA : this will give you the total volume of fluid● First 8 hours administer half of the total volume● Must infuse within the first 8 hours: time starts from when the burn injury

occurred, not the time they arrived at the hospital.● Rate divided by 6 instead of 8● EX. A Patient weighing 154 lbs has a burn with a TBSA of 50%. The patient

was found at home at 8am and arrived to the hospital at 10am.


Application of Parkland Formula

○ How much fluid should be administer in the first 8 hours? Calculate the rate.

○ 154 lbs= 70kg ○ 4ml x 70kg x 50% = 14,000○ 14,000 : 2 = 7,000 ml○ 7,000ml : 6h = 1,167 ml/h


Evaluation after Giving Fluids

● Monitor their response: Urine output is a key indicator, Vital signs (BP, HR)

● Patient will have a foley catheter to measure UOP accurately● Facial Edema Before and After Fluid Resuscitation

● Treat pain: Morphine, Dilaudid○ Monitor closely○ PCA pump

P - PainStrong pain meds: if pt will have a respiratory depression he

has to be intubated


Facial Edema Before and After Fluid Resuscitation


Escharotomy Fasciotomy

Surgical Management of Burns

Escharotomy Fasciotomy


Incision made through tight eschar to relieve pressure and allow normal blood flow and breathing.

A surgical procedure in which an incision is made through the skin and subcutaneous tissues into the fascia of the affected compartment to relieve the pressure in and restore circulation to the affected area in the patient with acute compartment syndrome.


● Escharotomy - eschar can cut off blood supply and interfere with healing, can be done at the bedside

● Fasciotomy - under anesthesia

**Although a patient may come in with a horrific burn injury, we’re more worried about systemic effects that are acutally more detrimental



Acute Phase of Burn Injury

● Begins about 36 to 48 hr after injury; lasts until wound closure is completed○ Fluid starts to shift back from interstitial into the

vascular space○ Urine output will increase even more

● Goals of management?○ Concern about infection○ Wound care○ Nutrition○ Mobility



Infection prevention■ Sterile technique■ No flowers in the room■ At risk for pseudomonas■ Minimize visitors: children and those with illness should not be allowed■ Immunization: Depends on pt immunization status, tetanus ( burn wound

is breeding ground for the organism)■ Only give systemic antibiotics and only if patient is showing signs of

infections■ Signs of infection: look at the wound, temperature■ Hyperinflammatory response: high temperature - give nsaids, tylenol,



Wound care:● Debriding: remove dead tissue, ensure viable tissue to

promote healing● Risk for hypothermia - because skin is removed● Premedicate with pain medication before wound care ● Once debrided, a topical ointment is applied → Silvedine



Nutrition● Requires a lot of calories → hypermetabolic state

burns more calories● Can exceed 5,000 calories/day● High protein, high protein supplements ● Can request food at any time, consider the patients

preferences● Promotes healing



Mobility:

○ Prevent contractures: ROM to the affected extremity

○ Scar formation can limit the range of motion ability

○ Out of bed as soon as possible


Rehabilitative Phase of Burn Injury

● Begins with wound closure, ends when patient returns to highest possible level of functioning

● Emphasis on psychosocial adjustment, prevention of scars and contractures, resumption of preburn activity

● Social work, referrals


Rehabilitative Phase of Burn Injury (cont’d)

● This phase may last years or even a lifetime if patient needs to adjust to permanent limitations


A patient arrives to the ED with superficial facial burns from an explosion in his apartment building. He has productive carbonaceous sputum with labored respirations and singed hair.Based on these findings what is the highest priority of care for this patient?

○ Airway!○ Patient is showing signs of inhalation injury: carbonaceous sputum,

singed hair, labored respirations


Which symptoms may indicate a pulmonary injury from the inhalation? (Select all that apply.)

A. Development of a brassy coughB. DroolingC. Clear speechD. Audible wheezeE. Clear breath sounds

(cont’d)


Twenty minutes later, assessment of the patient reveals loud wheezing on exhalation. What is the nurse’s best action at this time?

A. Check the patient’s SaO2 with pulse oximetry.B. Apply oxygen and call the Rapid Response Team.C. Call a CODE and bring the crash cart to the room.D. Call respiratory therapy for a treatment with a bronchodilator.

(cont’d)


AUDIENCE RESPONSE SYSTEM QUESTIONS

Chapter 28


Question 1

A patient is admitted to the ED with burns to his lower legs and hands after a gas can exploded. What is the initial nursing priority on admission?

A. Assess and treat his pain. step 4B. Use the rule of nines to estimate his percent of body surface area

burned. step 2C. Evaluate his airway and circulation. step 1D. Place two IV catheters and initiate fluid resuscitation. step 3


Question 2

It has been 12 hours since a patient has been admitted for burns to his face and neck and for inhalation injuries. He had been wheezing audibly, but at this time the nurse notes that his wheezing has stopped. What should the nurse do?

Document this improvement in the patient’s condition. Re-assess his breathing in an hour.Check the patient’s SPO2 level.Notify the physician immediately.


Question 3

A patient has been receiving dressing changes with silver sulfadiazine (Silvadene) for burn injuries over both lower arms. The nurse notices that the patient’s white blood cell count has dropped significantly over the past 4 days. What may this change indicate?

A. The patient’s infection is improving.B. The patient is having an allergic reaction to the silver sulfadiazine.C. The patient has kidney disease.D. The patient has an electrolyte imbalance.

Burn Injury 4

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