Download BURNS - Sarah G. Bishop, RN

BURN INJURY
Sarah Bishop, Troy Davis, Laura Kiss-Illes
Pathophysiology
 Burns are caused by a transfer of energy from a heat source to the body.
 Disruption of the skin can lead to increased fluid loss, infection, hypothermia,
scarring, compromised immunity, and change in function and appearance of
body.
 The depth of the injury depends on the temperature of the burning agent and
the duration of contact with the agent.
 Types
 Thermal (includes electrical)
 Radiation
 Chemical
 http://www.youtube.com/watch?v=46hOeiN3Z3E
Physiologic Changes
 Burns less than 25% total body surface area (TBSA) produce primarily a local response.
 Burns more than 25% may produce a local and systemic response, and are considered
major burns.
 Systemic response includes release of cytokines and other mediators into systemic
circulation.
 Fluid shifts and shock result in tissue hypoperfusion and organ hypofunction.
 Fluid and electrolyte shifts
 Fluid reenters the vascular space from the interstitial space
 Hemodilution
 Increased urinary output
 Sodium is lost with diuresis and due to dilution as fluid enter vascular space: hyponatremia
 Potassium shifts from extracellular fluid into cells: potential hypokalemia
 Metabolic acidosis
Risk Factors
 Men have greater than twice the chance of burn injury than women
 Elderly because of reduced mobility, coordination, strength, and sensation.
Vision changes also place them at high risk.
 Diabetics with neuropathy because they have decreased sensation
 Those with high risk jobs dealing with high heat
 Young Children
General Goals Related to Burns
 Prevention
 Institution of lifesaving measures for the severely burned person
 Prevention of disability and disfigurement through early specialized and
individualized care
 Rehabilitation through reconstructive surgery and rehabilitation programs
Burn Severity
Severity of Burn Injury
Superficial Partial
Deep-Partial
Full Thickness
Factors to consider
 How the injury occurred
 Causative agent
 Temperature of agent
 Duration of contact with the agent
 Thickness of the burn
Phases of Burn Injury
 Emergent or resuscitative phase
 Onset of injury to completion of fluid resuscitation
 Acute or intermediate phase
 From beginning of diuresis to wound closure
 Rehabilitation phase
 From wound closure to return to optimal physical and psychosocial adjustment
Emergent or Resuscitative Phase
 Prevent injury to rescuer
 Stop injury: extinguish flames, cool the burn, irrigate chemical burns
 ABCs: Establish airway, breathing, and circulation
 Start oxygen and large-bore IVs
 Remove restrictive objects and cover the wound
 Do assessment surveying all body systems and obtain a history of the
incident and pertinent patient history
 Note: treat patient with falls and electrical injuries as for potential cervical
spine injury
Emergent or Resuscitative Phase Cont.
 Patient is transported to emergency department
 Fluid resuscitation is begun
 Foley catheter is inserted
 Patient with burns exceeding 20–25% should have an Ng inserted and
placed to suction
 Patient is stabilized and condition is continually monitored
 Patients with electrical burns should have ECG
 Address pain; only IV medication should be administered
 Psychosocial consideration and emotional support should be given to
patient and family
Acute of Intermediate Phase
 48–72 hours post injury
 Continue assessment and maintain respiratory and circulatory support
 Prevention of infection, wound care, pain management, and nutritional
support are priorities in this stage
Rehabilitation Phase
 Rehabilitation is begun as early as possible in the emergent phase and
extend for a long period after the injury.
 Focus is upon wound healing, psychosocial support, self-image, lifestyle,
and restoring maximal functional abilities so the patient can have the best
quality life, both personally and socially.
 The patient may need reconstructive surgery to improve function and
appearance.
 Vocational counseling and support groups may assist the patient.
Treatments and Nursing Management

Management of shock
 Fluid resuscitation
 Maintain blood pressure of greater than 100 mm Hg systolic and urine output of 30–50
mL/hr, maintain serum sodium at near-normal level

Burn wound care
 Wound cleaning
 Hydrotherapy
 Use of topical agents
 Wound debridement
 Natural debridement
 Mechanical debridement
 Surgical debridement
 Wound dressing, dressing changes, and skin grafting
Treatments and Nursing Management
 Burn wound care
 Wound cleaning
Hydrotherapy
 Use of topical agents
 Wound debridement
Natural debridement
Mechanical debridement
Surgical debridement
 Wound dressing, dressing changes, and skin grafting
Treatments and Nursing Management
 Pain Management
 Analgesics
 Burn pain has been described as
one of the most severe forms of
acute pain
 Role of anxiety in pain
 Pain accompanies care, and
treatments such as wound
cleaning and dressing changes
 Nonpharmacologic measures
 Types of burn pain
 Background or resting
 Procedural
 Breakthrough
 Effect of sleep derivation on pain
Treatment and Nursing Management
 Nutritional Support
 Burn injuries produce profound metabolic abnormalities, and patient
with burns have great nutritional needs related to stress response,
hypermetabolism, and requirement for wound healing.
 Goal of nutritional support is to promote a state of nitrogen balance
and match nutrient utilization.
 Nutritional support is based upon patient preburn status and % of TBSA
burned.
 Enteral route is preferred. Jejunal feedings are frequently utilized to
maintain nutritional status with lower risk of aspiration in a patient with
poor appetite, weakness, or other problems.
Treatment and Nursing Management
 Other care to consider
 Pulmonary care
 Psychological support of patient and family
 Patient and family education
 Restoration of function
Medications
 Analgesics
 IV use during emergent and acute phases
 Morphine
 Fentynal
 Other
 Fluids
Lab/Diagnostic Tests
 Labs
 Potassium (will be high initially, then will be low)
 Sodium (will be low)
 Blood pH (metabolic acidosis)
 Hematocrit (will be high)
 Diagnostics
 Determine what percentage of your total body surface area (TBSA) is involved.
 Rule of nines, Lund and Browder method, Palm method
 Depending on the severity of the burn and the circumstances that caused it, you
may need lab tests, X-rays or other diagnostic procedures.
Nursing Diagnosis
 Impaired gas exchange r/t carbon monoxide poisoning, smoke inhalation, and
upper airway obstruction AEB labored breathing, hoarseness and dry cough
 Goal
 Maintenance of adequate tissue oxygenation
 Interventions
 Provide humidified oxygen
 Assess breath sounds/respiratory rate/rhythm/depth/symmetry. Monitor patient for signs of hypoxia
 Monitor ABGs, pulse oximetry
 Prepare to assist with intubation
Nursing Diagnosis
 Ineffective airway clearance r/t edema and effects of smoke inhalation AEB bloody
sputum and difficulty getting rid of secretions, O2 <90%
 Goal
 Maintain patent airway and adequate airway clearance
 Interventions
 Maintain patent airway through proper positioning, removal of secretions, and artificial
airway if needed.
 Provide humidified oxygen
 Encourage patient to turn, cough, deep breathe. Encourage patient to use incentive spirometry
 Suction as needed
Nursing Diagnosis
 Fluid volume deficit r/t increased capillary permeability and evaporative losses from
burn wound AEB decreased urine output
 Goal
 Restoration of optimal fluid and electrolyte balance and perfusion of vital organs
 Interventions
 Observe vital signs, urine output, and be alert for s/s of hypovolemia or fluid overload.
 Monitor urine output hourly, daily weights
 Maintain IV lines
 Observe for symptoms of deficiency or excess of serum electrolytes (sodium, potassium, calcium,
phosphorus, and bicarbonate)
Patient/Family Teaching
 Teach about the injury, treatment, complications and planned follow-up care to
reduce anxiety of family and patient
 Assess psychological reactions to burns and address patient’s fears and concerns
(providing them with support and available health care teams that can help. Also
journal keeping may be helpful)
 Available support groups (usually located at burn facility)
 Home/self-care. Prepare patient and family for the care that will continue at home,
which include: measures and procedures they will need to perform (wash small areas
of clean, open wounds that are healing slowly with mild soap and water and apply
topical agent/dressing), written/verbal instructions about pain management, nutrition,
and prevention of complications; information about exercises and use of pressure
garments and splints. How to recognize abnormal signs and to report them to physician
Case Study
 Bill is a 54-year-old Asian male who sustained a full-thickness burn to 20% of his body
while at work 3 days ago. He was exposed to a hot liquid at temperatures
exceeding 180°F.
 The burn occurred primarily on his right arm, hand, and right side of his chest.
 He is currently hospitalized in a burn unit and is in stable condition.
 How do thermal burns reduce irreversible cellular injury?
 What is the impact of this degree and extent of burn on Bill’s cardiovascular
system
 What is the role of escar formation in a full thickness burn?
 How are full thickness burns different than partial thickness burns with
regard to clinical manifestations?
 What complications are likely given the severity
 Would the burn Bill sustained be classified as minor, moderate, or major
given the American Burn Association Classification?