III. BURNS

A. Occurrence:

The risk of death increases in

the very OLD and the very YOUNG

Where do most burns occur?

HOME, CURLING IRONS, IRONS,

STOVES, WATER HEATER B. Pathophysiology:

After a burn many different

pathophysiology changes occur.

1. Why does plasma seep out into

the tissue?

Increased CAPILLARY

permeability (VESSELS LEAKING)

2. When does the majority of

this occur? FIRST 24 HOURS DUE

TO FLUID VOLUME DEFICIT

3. When does the pulse increase?

Anytime you’re in a FLUID

DEFICIT , the pulse will

INCREASE

4. Why does the cardiac output

decrease? Less VOLUME to pump

out.

5. Why does the urine output

decrease?

Kidneys are either trying to

HOLD on to fluid or they

aren’t being PERFUSED.

6. Why is epinephrine secreted?

Makes you VASOCONSTRICTION,

shunts blood to vital organs

7. Why are ADH and aldosterone

secreted?

Retain SODIUM & WATER with

aldosterone and

Retain WATER with ADH

Therefore, the blood volume

will go UP. C. Miscellaneous Information:

1. Airway Injury:

What is the most common

airway injury? CARBON MONOXIDE

poisoning

Normally, oxygen binds with

HEMOGLOBIN Carbon monoxide

travels

much faster than oxygen….

Therefore, it gets to the

hemoglobin first and

binds….Can oxygen bind now?

NO, NO PLACE FOR IT

Now the client is HYPOXIC.

Tx: HYPOXIA

From this information, do you

think it would be important to

determine if the burn

occurred in an open or closed

space? CLOSED SPACE, INHALED

MORE CARBON MONOXIDE

When you see a client with

burns to the neck/face/chest

you had better think what?

AIRWAY, UPPER BODY BURNS

BREATHING PROBLEMS OCCUR

*What might the physician do

prophylactically? ET TUBE FIRST

TO PREVENT SWELLING. 2. Classification of Burn Injury:

A client is burned over 40%

of their body. How do you think

this is determined? RULE OF

NINES

Estimate of Total Body Surface

Area

A common formula is called

the RULE OF NINES *TESTING STRATEGY*

Least invasive first D. Tx: Clients with burns > 20-25%

TBSA

1. Fluid Replacement:

One of the most important

aspects of burn management is

FLUID REPLACEMENT

Is it important to know what

time the burn occurred? YES

Why? Fluid therapy (for the

first 24 hours) is based on the

time the injury

OCCURED, not when the treatment

was STARTED.

Common rule: Calculate what is

needed for the first 24 hours

and give half of

the volume calculated during

the first 8 hours. This is the

PARKLAND Formula.

To calculate fluid

replacement properly you also

need to know the client’s

WEIGHT (in kilograms) and TBSA

affected. *1 kg = 2.2 pounds

If the client is restless it

could suggest three problems:

inadequate fluid replacement,

pain, or hypoxia.

*Nurse’s Priority: HYPOXIA -

AIRWAY

Which of the following would

you choose to determine if a

client’s fluid volume is

adequate? Their weight or their

urine output? URINE OUTPUT.

Parkland Formula

(4ml of LR) X (body weight in

kg) X (% of TBSA burned) =

total fluid requirement for the

first 24 hours after burn

1st 8 hours = ½ of total volume

2nd 8 hours = ¼ of total volume

3rd 8 hours = ¼ of total volume NCLEX® Critical Thinking

Exercise:

A client weighing 235 lbs. has

a 30% total body surface area

burns. The physician’s

prescription is: Titrate

IV fluids to maintain urinary

output at 0.5 ml/kg/hr. What is

the desired output?

Record your answer as a whole

number.

235 / 2.2 = 106.818181

106.818181

X 0.5 ml/kg/hr

= 53. 409 = 53 ml/hr

*TESTING STRATEGY*

Pain never killed anyone. . Emergency Management:

A client was wrapped in a

blanket to stop the burning

process. Since the flames are

gone does that mean the burning

process has stopped? NO

What else could have been

done to stop the burning

process? COOL WATER

The blanket helped

by…Holding in the BODY HEAT

and kept out GERMS

Remove jewelry? Because

SWELLING will occur, metal gets

hot.

Clothing? Remove non-adherent

clothing and COVER THE BURNS

with a clean dry cloth.

Signs of airway injury:

SINGED FACIAL/NOSE HAIR,

BLISTERED LIPS, ORAL MUCOSA

Do you think there is more

death with upper or lower body

burns? UPPER

A client’s respirations are

shallow. You know they are

retaining what? CO2

Therefore, which acid-base

imbalance will they have?

RESPIRATORY ACIDOSIS 3. Medication Management:

a. Albumin:

You know that albumin holds

onto FLUID in the VASCULAR

SPACE

space.

Vascular volume? INCREASE

VASCULAR VOLUME

Kidney perfusion? INCREASE

BP? INCREASE

Cardiac output? INCREASE

Will this help correct a

fluid volume deficit? YES

Because we are putting

more fluid where? FLUID

VASCULAR

When you start giving a

client albumin, you know that

the vascular volume will

INCREASE. INCREASE WORKLOAD IN

THE HEART

Therefore, what will happen

to the workload of the heart?

FLUID VOLUME EXCESS

If you stress the heart TOO

MUCH:

The client could be thrown into

fluid volume EXCESS

If this occurs, what will

happen to Cardiac output?

DECREASE

Lung sounds? WET

In a client who is receiving

fluids rapidly, what is a

measurement you could take

hourly (hint: heart) to ensure

you’re not overloading the

client? CVP – CENTRAL VENOUS

PRESSURE b. Pain Management:

A client has an order for

morphine that states:

“Morphine 2mg IVP or Morphine

4mg IVP Q 2 hours PRN pain.”

If the client is complaining of

pain (4/10) what

dosage would the nurse give to

the client? 2MG MORPHINE IVP

FIRST

Give the LESS amount of

narcotics necessary to relieve

someone’s pain.

Why are IV pain meds

preferred over IM with burns?

ACT QUICKLY – ASSESS

RESPIRATION FIRST

_______________________________

___________ c. Immunization:

1) Tetanus Toxoid: ( TETANUS

IMMUNE GOBLIN immunity)

*takes 2-4 weeks to develop

their own immunity

2) Immune globulin: think

IMMEDIATE protection

( PASSIVE immunity) E. Complications:

1. Circulatory System:

A client has a

circumferential burn on their

arm.

What does this mean? ALL THE

WAY AROUND THE ARM

What should you be checking?

CIRCULATION

If a client’s vascular check

in their arm is bad what is the

name of the procedure

to relieve pressure?

Escharotomy- relieves the

PRESSURE and restores the

CIRCULATION

, cut through the eschar.

Fasciotomy- relieves the

PRESSURE and restores the

CIRCULATION, but the cut is

much deeper into the tissue,

cut goes through the eschar and

the fascia. 2. Renal System:

A foley catheter was inserted

so you could measure urine

output.

How often will this need to be

monitored? EVERY HOUR

Is it possible that when you

insert the catheter that no

urine will return? YES

Why? Kidneys are either

attempting to CONSERVE the

fluid or they are not

being PERFUSION adequately.

What would you do if the

urine is brown or red? Call the

PHYSICIAN

What drug might be ordered to

flush out the kidneys? MANNITOL

- DIURETIC

If there is no urine output

or if it is less than

30mL/hour, you would start

worrying about? KIDNEY FAILURE

After 48 hours, the client

will begin to diurese. Why?

Because fluid is going

back into the VASCULAR space.

Now we have to worry about

fluid volume

EXCESS

So what will happen to urine

output now? INCREASE

Circulatory check: 1. 2. 3. 4. Hurst Review Services 27 3. Electrolyte Imbalance:

The client’s serum K+ level

is 5.8

Where do we find most of our

K+? INSIDE the cell

With a burn, what happens to

cells? RUPTURE

So, what happens to the

number of K+ in the serum

(vascular space)? INCREASE

Electrolyte imbalance?

HYPERKALEMIA 4. GI System:

Why do you think

Carbonate/Magnesium Carbonate

(Mylanta®), Pantoprazole

(Protonix®), or Famotidine

(Pepcid®) are ordered?

To prevent a STRESS ULCER,

CURLING’S ULCER

Why do you think the doctor

wants the client to be NPO and

have an NG tube

hooked to suction?

Because they could develop a

PARALYTIC ILEUS – 1. DECREASED

VASCULAR VOLUME. 2. PART OF

NORMAL STRESS RESPONSE. 3.

HYPERKALEMIA

If a client doesn’t have bowel

sounds, what will happen to the

abdominal girth?

INCREASE

Do you think the client will

need more or less calories?

MORE CALORIES, HYPERMETABOLIC

STATE, PROTEIN, VITAMIN C

The NG tube will be removed

when you hear what? BOWEL

SOUNDS

When you start GI feedings,

what should you measure to

ensure that the

supplement was moving through

the GI tract? RESIDUALS

What is some lab work you

could check to ensure proper

nutrition and a positive

nitrogen balance? PRE-ALBUMIN,

total protein, or albumin.

SENSITIVE- PRE-ALBUMIN

Antacids: Aluminum Hydroxide Gel

(Amphogel®), Magnesium

Hydroxide (Milk of

Magnesium®)

H2 Antagonist: Ranitidine

(Zantac®), Famotidine

(Pepcid®), Nizatidine (Axid®) Proton Pump Inhibitors:

Pantoprazole (Protonix®),

Esomeprazole (Nexium®) 5. Integumentary System:

a. Contractures:

Since the client has partial

thickness and full-thickness

burns, is it possible that

they could have problems with

contractures? YES

If they have burns on their

hands, what are some specific

measures that may

be taken?

Wrap each EACH FINGER

separately.

Use SPLINTS to prevent

contractures.

Neck Position? HYPER-EXTEND b. Infections:

With a perineal burn, the #1

complication is INFECTION.

What is eschar? DEAD TISSUE

Does it have to be removed?

YES

If it’s not removed can new

tissue regenerate? NO

What likes to grow in eschar?

BACTERIA

Classification of Burns:

Superficial thickness: formally

called first degree burn;

damage only to epidermis

Partial thickness: formally called

second degree burn; damage to

entire epidermis and varying

depths of the dermis.

Full-thickness: formally called

third degree burn; damage to

entire dermis and sometimes fat c. Tx:

What type of isolation will

you use with the burn client?

PROTECTIVE ISOLATION

Sutilanis (Travase®) or

Collagenase (Santyl®):

enzymatic drug→ eats dead

tissue

Don’t use on face – CAUSE

SCARRING

Don’t use if pregnant

Don’t use over large nerves

Don’t use if area is opened to

a body

cavity

Hydrotherapy is also used to

DEBRIMENT

a

Why should these drugs be

alternated?

Bacteria will build or .

Broad spectrum antibiotics

are avoided to prevent SUPER

INFECTION

Broad spectrum antibiotics may

be used until the wound

cultures have returned.

When giving-mycin drugs….we

WORRY when the client’s BUN or

creatinine

increases or if the client

complains of any hearing loss.

Mycin drugs can lead to

ototoxicity (irreversible

hearing loss) and/or

nephrotoxicity.

Check their BUN and creatinine;

if they are increasing, assume

they are nephrotoxic.

Common drugs used with burns:

a. Silver Sulfadiazine

(Silvadene®)- soothing, apply

directly, if rubs off

apply more, can lower the WBC,

can cause a rash

b. Mafenide Acetate

(Sulfamylon®)- can cause acid

base problems, stings, if

it rubs off apply more

c. Silver nitrate-keep these

dressings wet; can cause

electrolytes problems

d. Povidone-Iodine (Betadine®)-

stings, stains, allergies,

acid-base problems

30 Hurst Review Services d. Grafting:

Remove the burned dead tissue

until healthy tissue is seen.

Good skin is taken from

healthy donor site and placed

over burned area.

Now donor site is an open

wound, so a transparent

dressing is applied until

bleeding stops.

Then the donor site can be

left open to air.

If client is well nourished,

they can reharvest from same

donor site every 12-

14 days.

If the skin graft should

become blue or cool what would

this mean?

Sometimes the doctor will

order for you to roll sterile

Q-tips over the graft

with steady, gentle pressure

from the center of the graft

out to the edges.

Why? e. Chemical and Electrical burns:

1) Chemical burn? First remove

client from chemical and begin

FLUSH WITH WATER.

How long do you flush? 15-

20MINS

2) Electrical burn→ 2 wounds.

What are they? ENTRANCE and

EXIT WOUND

What is the first thing you

do for an electrical injury?

CONTINOUS HEART MONITOR FOR

FIRST 24 HOURS.

What arrhythmia is this

client at high risk for? V-FIB

With electrical burns

myoglobin and hemoglobin can

build up and cause

KIDNEY damage.

The client may be placed on a

spine board with a c-collar.

Why?

Electrical injuries occur in

HIGH places, muscle

contractions

can cause fractures, and the

force of the electricity can

actually throw the

victim forcefully.

Are amputations common? YES

Why? THE CIRCULATORY SYSTEM IS

DESTROYED

Other complications of

electrical wounds: cataracts,

gait problems, and

just about any type of

neurological deficit.