BURN LECTURE

M. Catherine Hough RN, Ph.D

University of North FloridaCollege of Health

Department of Nursing

REVIEW OF SKIN FUNCTIONS

• Functions of the Skin– Protection– Heat Regulation– Sensory perception– Excretion– Vitamin D Production– Expression

Cross section of Skin

CLASSIFIATION OF BURNSRx of burn is R/T the severity of the burn -

severity is determined by:• depth of the burn• extent o the burn (% of total body surface area

(TBSA)• location of the burn• patients risk factors

CLASSIFIATION OF BURNS...

• Partial Thickness - characterized by varying depth from epidermis (outer layer of skin) to the dermis (middle layer of the skin)– Superficial - includes only the epidermis (First Degree)– Deep - involves entire epidermis and part of the dermis

(Second Degree)

• Full Thickness - includes destruction of the epidermis and– the entire dermis as well as possible damage to the SQ, muscle and bone

(Third and Fourth Degree)

Classification…

• Clinical Appearance – Superficial – 1st degree– Erythema, blanching on pressure, pain & mild swelling, no vesicles or

blisters (although after 24 hours the skin may blister and peel

• Clinical Appearance – Deep – 2nd degree– Fluid-filled vesicles that are red, shiny, wet (if vesicles have ruptured),

severe pain caused by nerve injury, mid-to-moderate edema

• Clinical Appearance – Full-thickness – 3rd degree– Dry, waxy, leathery, or hard skin, visible thrombosed vessels,

insensitivity to pain and pressure of nerve distruction, possible involvement of muscles, bone and tendons.

MINOR BURNS

• < 10% of BSA of Partial Thickness Burn

• < 2% of BSA of a Full Thickness Burn

MODERATE BURNS

• 15-25 % of BSA of Partial Thickness Burn

• <10% of BSA of a Full Thickness Burn

MAJOR BURNS

• > 25% of BSA of a partial thickness

• > 10% of BSA of a full thickness

• Age > 65 or < 2

Lund-Bowder Chart

Rule of Nines

Types of Burns

• Thermal Burns• Chemical• Electrical• Inhalation• Radiation

PERIODS OF TREATMENT

• Emergent• Acute• Rehabilitation

STAGES OF BURNS

Hypovolemic Stage - begins @ onset of burn and lasts for the first 48 hours

– Rapid fluid shifts - from the vascular compartments into the interstitial spaces

– Capillary permeability with burns increases with vasodilation fluid loss deep in wounds (initially sodium and H2O then

protein loss) Hemoconcentration - Hct increases – Low blood volume, oliguria– Hyponatremia - loss of sodium and fluid– Hperkalemia - damaged cells release K+, oliguria– Metabolic acidosis

STAGES OF BURNS ...

Diuretic Stage - begins @ 48 - 72 hours after burn injury

• Capillary membrane integrity returns• Edema fluid shifts back into vessels - blood volume increases• Increase in renal blood flow - result in diuresis (unless renal damage)• Hemodilution - low Hct, decreased potassium as it moves back into

the cell or is excreted in urine with the diuresis• Fluid overload can occur due to increased intravascular volume• Metabolic acidosis - HCO3 loss in urine, increase in fat metabolism

I. EMERGENT PERIOD

• First 24 - 48 hours • Maintain airway, fluids, analgesia, temperature,

wound

• Assessment:–Objective: how burn occurred, when, duration,

type of agent – Subjective: previous medical problems, size and

depth of burn, age, body part involved, mechanism of injury

EMERGENT PERIOD ...

Factors determining severity of burns: • size of burn • depth of burn • age• body part effected• mechanism of injury• history of cardiac, pulmonary, renal, or hepatic diseases • injuries sustained @ time of burns• duration of contact with burning agent• size & depth of burn • “Rule of Nines”

NURSING DIAGNOSIS

• Airway clearance• Ineffective fluid volume (deficit or excess)• Hypothermia• High risk for pain (with partial thickness burns)• Skin integrity, impaired• Anxiety• Knowledge deficit

INTERVENTIONS

• Maintain patent airway - watch for laryngeal edema– Escharotomy may be needed– 100% FiO2 mask

– intubation for inhalation is often required–may inquire emergent tracheostomy –may require ventilatory assistance

Tracheostomy to Prevent Airway Obstruction

Interventions - Fluid Therapy

• Start with two large bore IV’s – suture in place

• Jugular or subclavian line– unburned tissue– burned tissue

• Cutdown final measure

Interventions - Fluid Therapy...Fluid Replacement• Crystalloid Solutions

• NS• LR• D5%/NS

• Collid Solutions• Albumin• Dextran

Formulas to Calculate Fluid

Parkland Crystalloids LR: 4ml/kg/% burn; ½ given 1st 8hrs; ¼ given each next 8 hrs

Colloids 20-60% of calculated plasma volume

D5% in Water Amount to replace estimated evaporative losses

Brooke

Crystalloids LR: 2ml/kg/% burn; ½ given 1st 8 hrs; ½ given during next 16 hrs

Colloids 0.3 to 0.5 ml/kg/% burn

D5% in Water Amount to replace estimated evaporative losses

SIGNS OF ADEQUATE FLUID RESUSCITATION

• Clear sensorium• Pulse < 100 bpm• U/O 30-50 cc/hour• SBP > 90-100 mm Hg• Blood pH within normal range 7.35 - 7.45• Respirations 16-20

II. ACUTE PERIOD

• End of emergent period until burns heal• Focus shifts to care of wounds and prevention of

complications• Actual range of phase depends on degree and extent

of burn• Assessment:

Subjective - pain and anxietyObjective - complete assessment every 8 hours, dietary intake, motor ability, I&O, weight

NURSING DIAGNOSIS

• Skin integrity, impaired• Infection, high risk for• altered nutrition• Pain, acute (with partial thickness burns)• Fluid Volume Deficit• Anxiety• Hypothermia

Pain Control

• Morphine Sulfate 5-10 mg IV every 1-3 hours

• Combination therapy for painful procedures:– Diprivan– Valium– Haldol– Versed– …

NURSING DIAGNOSIS ...

• Impaired skin integrity R/T thermal injury• Coping, ineffective individual/family• Body Image Disturbance• Altered nutrition: less than body requirements R/T increased

catabolism and metabolism• Mobility, Impaired R/T pain, impaired joint movement, scar

formation• Self-care Deficit• High risk for infection R/T denuded skin, presence of pathogenic

organism, & altered immune response

INTERVENTIONS

• Releiving anxiety, denial, regression, anger, depression

• Wounds - refer to wound care • Nutrition (Nutritional assessment, pre albumin

levels, large protein requirement, carbohydrates and fats for energy, mega vitamins, TPN, enteral tube feedings any follow (~5,000 kcal/day)

• Pain - around the clock management• Prevention of infection - refer to wound care

ORGANISMS:

• Staphylococcus aureus• Pseudomonas

Infection is usually the cause of any deterioration

SIGNS OF SEPSIS:

• Change in sensorium• Fever• Tachyapnea• Paralytic ileus• Abdominal distention• Oliguria

WAYS TO PREVENT INFECTIONS:

• Gowns, masks, gloves• Sterile linen• Person with URI should not come in

contact with patient

WOUND CAREGoals:

• clean & debride the area of necrotic tissue• minimize further destruction of viable skin• promote wound re-epithelialization• promote patient comfort

WOUND CARE:

• Burn wound is unique

• Burn wound sepsis– gram +– gram (pseudomonas)– fungal (candida albicans)

WOUND CARE...• Nutrition– collagen primary structure in healing by secondary

intention– need increased protein– may need up to double the normal calorie requirements

• Inadequate blood supply• Burn wound disorders– scarring, contractures, keloids, failure to heal

WOUND CARE ...

• GOALS:

• close wound ASAP• prevent infection• reduce scarring and contractures• provide for comfort

WOUND CARE ...

• Wound cleaning: • at bed side hyrotherapy tanks, tubbing, spray

tables

• Debridement: • mechanical, surgical, enzymatic

• Topical antibacterial therapy - • sulfonamide

WOUND CARE ...

Open Technique or Exposed - more often used with burns effecting the:– face– neck– perineum– broad areas of the trunk

• Partial thickness - exudate dries in 48 to 72 hours forming a hard crust that protects the wound.

• Full thickness - dead skin is dehydrated and converted to black leathery escar in 48 to 72 hours. Loose escare is gradually removed with hydrotherapy &/or debridement

WOUND CARE ...

• Closed Technique

• Wound is washed and sterile dressings changed (may be q shift, daily)

• Dressing consists of gauze &/or ace wraps impregnated with topical ointments

WOUND CARE ...

• Semi-Openconsists of covering the wound with topical antimicrobial agents and gauze

ADVANTAGE:– speeds debridement– develops granulation tissues faster– makes skin grafting possible sooner

WOUND CARE ...

Biological Dressings:• Homeografts - same species (cadaver skin)

• temporary (3 days to 2 weeks) then body rejects

• Heterografts - another species (pig skin) • temporary coverage (3days to 2 weeks)

• Autografts - patients own skin • can be temporary or permanent coverage

• Cultured Epithelial Autographs • permanent

Wound Care - GRAFTING

• Indications for Grafting:– full thickness burns– priority areas (face)– wound bed pink firm, free of exudate– bacterial count < 100,000/gram of tissue

• Care of Grafts - assess, assess, assess

Skin Grafting

Cultured Epithelial Autografts

III. REHABILITATION PERIOD

• Care of healing skin - wash daily, cover with cocoa butter or other barrier

• Pressure garments, ace wraps - helps prevent scaring and contractures

• Promote mobility - positioning, exercise, splinting, ADL• Rehab period can last for months to even years

Primary Prevention Strategies

Safety Education: • Wear sun-screen• Fireproof your home– Install smoke alarms – check routinely– Plan emergency exits– Have regular fire drills

• Check wiring in home; safety caps on unused outlets if you have children

• Teach children safety rules for matches, fires, electrical outlets, cords, etc.