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Module 16: Integumentary Disorders- Burns
Marnie Quick, RN, MSN, CNRN
Etiology/Pathophysiology
1.
Normal skin physiology as it relates to burns.
a. Layers of skin- (p. 414 Fig 15-1)
1) Epidermis; dermis; subcutaneous tissue; muscle; bone
2.
Risk factors
a. 73% of all fire related death in home.
b. Age, smoking, alcohol/drugs, physical/mental impairment,
occupation
3.
Types of burn (p.412 Table 15-2; Box 15-1)
a.
Thermal
1)
Exposure to moist (steam/liquid) or dry (flames) heat.
2)
Most common cause of burns.
3)
Stop, drop and roll; stop the burning process; cool water,
not ice as it vasoconstricts; cover to prevent hypothermia.
b.
Chemical
1)
Direct skin contact acid or alkaline
2)
Destroys tissue protein resulting necrosis
3)
Oxidizing, corrosive, protoplasmic poisons
4)
Severity dependent on type, concentration, mechanism,
duration of contact, and amount of body surface exposed.
5)
Neutralize or dilute; remove clothing; call poison control.
c.
Electrical
1)
Direct or alternation current; lightning
2)
Severity depends on type and duration current and amount
of voltage.
3)
Electricity follow path of least resistance- first being
muscles, bones, blood vessels and then nerves.
4)
Lightning results in entry-exit wounds; exit is usually blow
out type; flash-over effect when current travels over moist
skin. Most electrical burns of extremities develop gangrene
with resultant amputation.
d.
Radiation
1)
Sunburn; x-rays; radioactive agents such as cancer
treatments.
2)
Shield the skin appropriately; limit exposure time; move
away from radiation source.
4.
Classification of burn (p. 413 Table 15-2)
a. Depth of burn
1)
Combination of temperature and length of contact.
2)
Superficial (1st degree)
a) Only epidermal layer
b) Sunburn; ultraviolet light
c) Red, local edema, pain, no scaring
d) 3-6 days to heal
3)
Superficial partial-thickness (2nd degree) (P414 Fig 15-2)
a) Bright red, moist with blisters, blanch on pressure,
has touch and pain sensation
b) Heal 21 days with minimal scarring
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4)
5.
6.
Deep partial-thickness (2nd degree)
a) Entire dermis, still have- hair follicles and sebaceous
glands
b) Pale, waxy with large blisters or blisters appear
tissue paper like.
c) Less painful than superficial, but have pressure
sensation. Edges of burn may be very painful.
d) May convert to full-thickness burn.
e) Healing- more than 21 days, may need grafting.
5)
Full-thickness (3rd degree) (p414 Fig 15-3)
a) All layer of skin; may extend into fat, connective
tissue, muscle, and bone
b) Prolonged contact flame, moist/dry heat, electrical
current.
c) Pale, waxy, yellow, brown, mottled, charred, or
nonblanching red—dry, leathery and firm to touch.
Hair easily pulled out.
d) NO sensation perceived neither pain nor touch, may
have sensation at the edge of burn.
e) Require skin graft to heal!
b. Extent of burn
1)
Percent of total body surface (TBSA)
2)
Rule of nines (p 415 Fig 15-4)
3)
Laund and Browder (p416 Fig 15-5) determines surface
area according to age; is considered most accurate.
4)
American Burn Association- minor, moderate, major burn
(p. 417 Table 15-3)
a) Minor- criteria on p 417; usually treated outpatient
b) Major- criteria on p. 417; requires treatment in a
Burn Center
Wound healing- physiology similar to other wound healing, but slower.
Burns and the older adult (p. 430)
Common Manifestations/Complications-Major burn (p 418 Fig 15-6)
1.
Integumentary systema. Described above with cause, depth, and extent of burn.
b. Eshar formation- necrotic tissue that forms over a burn. It is hard,
leathery, and rigid. Must be removed (debrided) for healing to take
place.
2.
Cardiovascular system
a. Burn shock (hypovolemic shock) occurs within 24-36 hrs.
b. Damage to blood vessels cause increased capillary permeability; this
causes H2O, Na and serum albumin to move into intestinal spacethird spacing. Because of this shift, Hct and blood viscosity increases
in this stage as water is moved out of blood.
c. Cardiac- over 40% burn cause decrease in cardiac contractibility and
cardiac output. Electrical burns can cause arrhythmias/cardiac arrest
d. Compartment syndrome occurs as edema (plasma protein and
sodium escapes into interstitium) compresses blood vessels and
nerves. Most frequently seen with circumferential burns about
extremities or torso.
3.
Respiratory system (p.420 Table 15-4)
a. Direct inhalation injury or systemic response (such as ARDS).
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4.
5.
6.
7.
b. In direct upper airway thermal injury- look for soot, burn on nasal
hairs, etc; edema peaks 24-48 hrs which can cause laryngeal spasms
resulting in respiratory arrest. This can occur in with individuals
burned in an enclosed space (such as a room) where the individual
breaths in the heated air. There may be no outward signs of burn.
c. Bronchial congestion and infection
d. Interstitial pulmonary edema; alveolar collapse
e. Carbon monoxide poisoning- 200 time greater affinity for hemoglobin
than O2- (CO displaces) hypoxia resulting in headache to coma
symptoms.
Gastrointestinal system
a. Paralytic ileus with distention- increased risk of aspiration
b. Stress ulcer (Curling’s ulcer)—assess pH
c. Ischemia of intestine increases intestinal mucosal permeability and
bacteria can cause systemic sepsis, ARDS, & multiple organ failure.
Urinary system
a. Renal blood flow and GFR decreased causing release ADH- resulting
in decreased urinary output causing serum creantinine and BUN to
increase.
b. Myoglobinuria- damaged erythrocytes in urine (cause dark brown
urine) may block renal tubules resulting in renal failure.
Immune system
a. Capillary leak- serum levels of all immunoglobulin decreased.
b. State of acquired immunodeficiency- opportunistic infections can be
fatal.
c. Most common source of infection/septicemia is clients own intestinal
tract
Metabolism
a. BMR increases- twice normal rate, more if complications occur.
b. Body weight and body temperature drop.
c. Shivering will increase metabolism.
d. Hypermetabolism continues until after wound closure.
Therapeutic Interventions
1.
Diagnostic tests
a. Urinalysis, CBC, serum electrolytes, renal function, total protein,
albumen, CPK, blood glucose, EKG
b. Serial chest X-rays, ABG’s, pulse oximetry, carboxyhemoglobin
levels, arterial line
c. Fluid status- hemodynamic monitoring
2.
Stages (p.421 Fig. 15-7)
a. Stage one: Emergent/Resuscitative Stage
1)
Onset injury to successful fluid resuscitation.
2)
Major concern throughout this stage is fluid resuscitationprevention of hypovolemic shock.
3)
First treatment is to limit severity of burn.
4)
Prevent heat loss through burn- keep environment warm.
5)
If respiratory involved- intubation/ventilator with
PEEP/humidified O2; bronchodilators, mucolytic agents to
liquefy secretions, suction as needed/incentive
spirometry/cough/deep breath; HOB 30 degrees.
6)
Assess for ARDS
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7)
3.
Fluid resuscitation- at least 2 large bore IV lines in
unburned area to restore blood volume due to increased
capillary permeability- leaking fluid causing third spacing.
8)
Guidelines to replace all burns >20% TBSA using Parkland
formula or Modified Brooke formula (p.423)
9)
Need weight in kg and % of TBSA to calculate fluid
replacement using any of the formulas.
10) Lactated Ringer’s solution- 1st 24 hrs; then add 5% dextrose
to the crystalloid fluid at this stage.
11) 50% of the formula volume in first 8 hrs; rest over 16 hrs;
second 24 hrs to maintain urinary output.
12) Hourly output used as indicator of effective fluid
resuscitation (30-50 cc); heart rate less than 120/min.
13) Hemodynamic monitoring!
b. Stage two: Acute
1)
Start of diuresis and ends with closure of the burn wound.
2)
Major concern throughout this stage is infection.
3)
Wound management- infection is usually from patients’ own
GI track. Use of hydrotherapy; systemic and topical
antimicrobial creams (open or closed method);
splints/exercise to prevent contractures; excision and
grafting of full-thickness burns (some split-thickness also
need grafting).
4)
Nutritional therapy- central line with TPN; once bowel
sounds return- enteral feedings. Colloids (albumin, FFP,
dexdran) can be given in this stage to expand plasmacapillary permeability has returned to normal, so now it is
helpful. Burn patients have high caloric needs due to energy
expenditure from increase in metabolism and decrease body
temperature.
5)
Pain control- especially painful 2nd degree burns and when
performing painful procedures as ROM and debridement.
c. Stage three: Rehabilitative
1)
Wound closure to highest level of function- years.
2)
Major concern at this stage is psychosocial adjustment.
3)
Prevent contractures-exercise and skin surfaces growing
together.
4)
Prevent/reduce hypertrophic scares- pressure garments.
5)
Potential for repeated cosmetic surgeries.
6)
Return to work/living.
Medications
a. Pain control
1)
Morphine or Fentanyl- prior to hydrotherapy or exercising
routine.
2)
Give IV in acute stage due to fluid changes/shifts- No IM’s
b. Antimicrobial agents
1)
Systemic infection leading cause of death with burns.
2)
Topical antimicrobials broad spectrum- mafenide acetate
(Sulfamylon cream), sulfadiazine (Silvadene cream), and
silver nitrate 0.5%. May be used in open or closed
management. (p. 425- Medication Administration)
c. Tetanus prophylaxis given.
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4.
5.
d. Prevent gastric hyperacidity- prevent Curling’s ulcer; NG tube to
monitor every hour pH above 5; famotidine (Pepcid) in acute phase;
when bowel sound return, antacids.
Surgery
a. Escharotomy (p.426 Fig 15-8; and box at bottom of page)
1)
To relieve pressure from eschar formation.
2)
Prevent compartment syndrome from burn circumferential
constriction about chest or extremities.
3)
Nurse needs to assess CMS (circulation/motor/sensory)
4)
Assess lung expansion if torso affected; airway if neck
burned. Also assess ABG’s.
5)
Elevation of extremity may be necessary to relieve edema
b. Surgical debridement
1)
For full thickness burns.
2)
Debride to the level of viable tissue.
c. Autografting (p.427 Fig 15-9; 15-10)
1)
From individuals own donor site to debrided burns,
permanent.
2)
Full-thickness grafts; postage stamp; mesh grafts.
3)
Complications: lack of attachment, infection.
d. Biologic and biosynthetic dressings
1)
Homograft (cadaver human skin) or heterograft (animal
skin) serves as a temporary cover will slough off.
2)
Synthetic- Biobrane; hydrocolloid dressings; TransCyte.
Wound management
a. Goals- remove nonviable tissue; control microbial colonization;
promote reepithelialization; achieve wound coverage as early as
possible. May need grafting- required for 3rd degree burn.
b. Debriding the wound- mechanical and enzymatic.
c. Dressing the wound1)
Open method- topical antimicrobial cream open to air.
2)
Closed- topical antimicrobial and covered with gauze; must
wrap each finger and each toe separately to prevent from
growing together; do not use dressings on ears as cartilage
may come off when dressing changed. (p. 428 Fig 15-11).
3)
Gently clean ears- do not rub. Burns of ears are prone to
infections.
d. Positioning, splints, and exercise
1)
Prevent contractures- give pain medication prior to ROM
exercises.
2)
Functional positioning of body part with splints, etc.
3)
No pillow if burns about face/neck- skin may grow together
4)
Early ambulation.
e. Pressure support garments
1)
Pressure garments to reduce hypertrophic scarring by
providing even pressure on the skin.
2)
Wear 6 months to year post graft- 23 hrs a day.
f. Nutritional support
1)
Burn causes hypermetabolic state until wound closure.
2)
Heat loss from burn; increase adrenergic activity; pain; and
infection and other complications.
3)
4000-6000 Kcal/day- need nutritional consult.
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4)
TPN through central line; once bowel function return- NG
feeding; oral feedings.
Nursing Assessment Specific to Burns
1.
Health history: type of injury; cause; first-aid treatment; past medical
history; age; medications; and very important- body weight.
2.
Physical exam: Refer to complications for specific system assessment.
Pertinent Nursing Problems and Interventions
1.
Impaired Skin Integrity
a. Monitor healing process
b. Daily wound care
c. Care for eyes, lips, gently debride nose; skin care if NG tube; do not
use pillows; care with ears-may lose cartilage if rub too hard
d. Keep environment warm to prevent heat loss from loss of skin cover
2.
Deficient fluid volume
a. Assess BP and heart rate; hemodynamic monitoring; hourly output;
daily weight;
b. Also assess for fluid overload
c. Follow prescribed fluid replacement protocol
3.
Acute pain
a. Superficial and especially partial-thickness have pain!
b. Pain ending are burned off in full-thickness burn
c. Medicate before procedures- debridement, exercise, etc. Give pain
medication IV in emergent phase because when fluid shifts back to
normal may have overdose.
4.
Risk for infection
a. Assess for wound, systemic, urinary and lung infection
b. Culture all wounds per protocol
c. Isolation techniques per protocol
d. Burns about the ears and eyes may require drops to prevent
infection.
5.
Impaired physical mobility
a. ROM exercises- pain medication before
b. Apply splints as prescribed
c. Functional aliment important
6.
Imbalanced nutrition: less than body requirements
a. Maintain NG/IV nutrition- assess
b. Daily weight
c. Calorie count
7.
Powerlessness
a. Allow patient control
b. Set short term realistic goals
c. Prepare for possible multiple reconstructive surgeries
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