Burn Injury

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


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 contains blood vessels, sensory nerves, hair follicles,

lymph vessels, sebaceous glands and sweat glands skin cannot restore itself


Types of Burn Injury

Dry heat Moist heat 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 patients 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


Classification of Burn Injury


Severity of injury is determined by Depth of burn: how deep into the skin the burn goes

Superficial: Epidermis Extent of burn in percent of TBSA( total body surface area) Location of burn Patient risk factors


Identify the Burn DepthSuperficial/Partial Burns


Superficial/Partial

involves the epidermis, blistering, healing is rapid 3-6 days for this injury to heal No scar formation


Table 28-1


Identify the Burn DepthDeep Partial Burn


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


Identify the Burn DepthFull Thickness


Full Thickness Burns

Full Thickness: Involves the epidermis, dermis, and fat Fatty tissue and blackened skin (eschar?) can be seen 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 Patient will require a skin graft


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 doesnt 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: ABCs 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 ABGs 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, were 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 (contd)

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

(contd)


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

A. Check the patients 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.

(contd)


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 patients condition. Re-assess his breathing in an hour.Check the patients 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 patients white blood cell count has dropped significantly over the past 4 days. What may this change indicate?

A. The patients 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

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