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Clients with burns

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					Clients with burns
    Factors associated with burns
        Age
            Young and elderly
      Careless smoking
      Alcohol and drugs

      Disabilities

      Occupations
Types of burns
    Thermal

    Chemical

    Electrical

    Radiation
Thermal burns
    Results from:
        Dry heat
             Flame
        Moist heat
             Steam or hot liquids
    Most common type of burn
Chemical burns
  Direct skin contact with acid or alkaline
   agents
  Alkali burns are deeper
  What are some sources of chemical
   burns?
Electrical burns
  Severity depends on the type and duration of
   current and amount of voltage
  Destructive process
        Hard to assess
        Destructive process is concealed and persists for
         weeks
        Travels along path of least resistance
             Muscles, bones, nerves
        Impaired blood flow causes necrosis of tissues
             Can get gangrene in the wound
Radiation burns
  Often from a sunburn
  Radiation treatments for cancer
  Functions of the skin are left intact
Depth of burns
    Superficial: First degree
      Involvement of only the epidermal layer
      Causes
          Sunburn
          Ultraviolet light

          Minor flash injuries

          Mild radiation burns
   Appearance of burn
     Skin may be pink to red
     Slight edema

     Mildly painful

   Treatment
     Mild analgesia, water soluble lotions
     These burns heal in 3-5 days
Partial thickness burns:
second degree
    Superficial partial thickness or deep partial
     thickness
        Depends on the depth of the burn through the
         dermis
    Causes
        Superficial
             Flash flame, dilute chemical agents, hot surface
        Deep
             Hot liquids, flash or direct flame, radiant energy,
              chemical agents
   Appearance of burns
       Blisters
 Severe pain to air heat
 Treatment
     Analgesics, grafting may be necessary
     Burns heal in 21-28 days
Full thickness burns: third
degree
  All layers of the skin, may extend into
   subcutaneous fat, muscle, bone
  Causes
        Prolonged contact with flames, steam,
         chemicals, high voltage electrical current
   Appearance of burns
     Pale, waxy, yellow, brown, mottled,
      charred, nonblanching red
     No sensation of pain or light touch

     Treatment
           Skin grafting
Extent of burn
    Total body surface area (TBSA)
        Extent of burn is expressed as a
         percentage of the TBSA
    Rule of 9’s
      Rapid method of estimation
      Body is divided into 5 areas
           Head, trunk, arms, legs and perineum
           Percentages that total a sum of nines is
            assigned
Example
  Client has burns to anterior trunk and
   right anterior leg
  Anterior trunk – 18%
  Right ant. Leg – 9%
  Total – 27% of total body surface
   American Burn Association
       Uses depth and extent of burn to classify them
            Minor
            Moderate
            Major
              – When there are burns to the head, hands, feet, perineum,
                and joints
              – All inhalation injuries
              – Electrical injuries
              – Burns covering large body areas
              – Injuries to high risk patients
 What happens before
the client comes to the
        hospital?
Pre hospital care
  Stop the burning process
  Stabilize the client
      CPR
      Initiate fluid replacement

      Cover client
            Prevent heat loss
Priorities at the scene
    Respiratory status
        Ventilation
             Burns of face, neck, anterior chest require
              prophylactic intubation
        Watch for hoarseness, dyspnea, tachypnea
         stridor, cyanosis, wheezing, crackles
   Hemodynamic status
       Start large bore IV at the scene
            Burns of more than 20% require fluid
             replacement
       Keep patient warm
   CPR
Emergency department care
    Take history of burn
      Time
      Cause
      Early tx
      Past medical hx
      Age
      Medications
      Body weight
   Classify the burn
     Extent
     Depth

   Estimation of burn extent
       Rule of 9’s
When should a patient be
transferred to a burn unit?
    Burn covering 10% + of body surface <
     10y/o >50y/o
    Burn covering 20% of body surface 10-50y/o
    Burn involving hands, face, feet, eyes ears of
     perineum
    Inhalation injury
    Electrical injury
    Burn with extenuating circumstances
Stages of burn injury
    3 stages
      Emergent/resuscitative stage
      Acute stage

      Rehabilitative stage
Emergent stage
  1st   48 – 72 hours
    Estimate the extent of the burn
    First aid and wound care

    Fluid resuscitation

    Determine whether to transfer to burn unit

    Assessment of other injuries
Acute stage
  This stage begins with diuresis and lasts
   until all full thickness wounds are
   covered with skin grafts.
  Parental and enteral nutrition is began
  Aggressive tx to prevent infection
  Pain management
Rehabilitative stage
  This stage begins with wound closure
  Focus on client returning to a useful
   place in society
  Restoring joint function
  Emotional support
   Care in all three stages is done through
    a multidisciplinary approach.
     Nurses
     Physicians
     PT
     Social workers
     OT
     RD
Body Systems and Burns

       Allbody systems are
      affected by major burns
Cardiovascular
  Cardiovascular system goes into a state
   called “burn shock”
  Generally lasts 24 hours
  Fluid volume shift from intracellular to
   interstitial spaces
  Massive shift and patient becomes
   unstable
Why is there a shift?
  Loss of cell wall integrity at the burn
   site
  Causes fluid to leak out
  Result??
      Decrease in fluid volume
      Decreased cardiac output
   Edema of tissue
     Impairs peripheral circulation
     Can lead to ischemia and necrosis of
      tissues
 Decrease in B/P
 Vasoconstriction
 Increased viscosity of blood
 K+ leaves intracellular space
       Can lead to dysrhythmias
   When does burn shock end?
       When the fluid is reabsorbed in to the
        intravascular compartment
   When this occurs:
     Increased cardiac output
     Increased B/P

     Improved urinary output
 Patients need close monitoring
 Particular problem for those with pre-
  existing cardiac conditions and the
  elderly
Respiratory System
    Major problem is inhalation injuries
      Carbon monoxide
      Toxic gases

      Smoke

      Heat
   Degree of injury depends on:
     Duration of exposure
     Composition of the product

     Solubility in water

     Size of particulate of aerosol droplet
   Injury includes:
     Inflammation at site
     Destruction of affected cells

     Interstitial pulmonary edema

     Surfactant inactivated
Immune System
    Impaired immune system due to
     capillary leak
    Impairs cell mediated and humoral
     immune systems
          Humoral system
               Serum levels of immunoglobulins are
                diminished
          Cell mediated
               Decreased T-cell counts
      Results in acquired immune deficiency
          Increased Risk for Infection
Integumentary System
    Burns result in impaired normal
     physiologic functions of the skin
      Thermoregulation
      Synthesizer of Vitamin D

      Excretory organ

      Sensory organ

      Barrier against infection
Gastrointestinal System
       Hyperacidity causes erosion of the
        gastric and duodenal linings
         Curling’s ulcer
         S/S
             Abdominal pain
             Acidic gastric pH levels

             Hematemesis

             Melanotic stool

       Paralytic ileus
           S/S
               Gastric distention, nausea, vomitting absence
                of BS
Urinary System
    Massive fluid losses initially can cause:
      Dehydration
      Hemoconcentration

      Oliguria

      May result in renal failure

    Concern with this system if perineum
     has been burned?
Metabolism
       2 phases
           Ebb phase
                1st 3 days
                   –   Decreased O2 consumption
                   –   Fluid imbalance
                   –   Shock
                   –   Inadequate circulating volume
           Flow phase
                Occurs after adequate resuscitation has been
                 accomplished
                Increases cellular activity
                BMR (basal metabolic rate) can double the normal level
                Body weight and heat drop
                Will continue until after the wound is closed
Treatment
  Fluidresuscitation begins ASAP
  Can include fluids, blood and
   blood products
   Considerations when replacing fluids
     Patients weight
     Hours post burn

     Urine output (30-50 ml/hr)

     Extent of burn

     Inhalation injury

     Electrical injury

     Degree of burn

     Any delayed starts in fluid resuscitation
      measures
Fluids of choice
     1st   24 hours
       Lactated ringers
       Closely approximates body’s extracellular
        fluid
     2nd   24 hours
       LR discontinued
       Colloid started
             Albumin
             Plasmanate

             Dextrose in water solution
Invasive lines
  May need arterial line
  Pulmonary artery catheter
Other considerations
  Ventilatory management
  Baseline studies
  Important others
      Positioning
      TCDB

      Intubation if needed
Labs & Diagnostics
    Labs
      CBC
      Electrolytes
      UA
      ABG’s
      Pulse oximetry
      CXR
      EKG
Pharmacology
      Pain
          Narcotics
      Antimicrobial agents
          Topically
             0.5% silver nitrate
             1% silversulfadiazine

             10% mafenide acetate

          Systemically
               Indicated with infections and pre and post
                operatively with excision and grafting
 Tetanus
 Gastric hyperacidity prevention
     NG with hourly gastric pH levels. Keep
      above 5
     H2 blockers such as Zantac
Nutritional Support
     Enteral feeding starts within 24-48
      hours post burn
     Parenteral nutrition
           Given if EF contraindicated
              Curling’s ulcer
              Bowel obstruction

              Feeding intolerance

              Pancreatitis

              Septic ileus

       TPN through central line
Wound management
      Hydrotherapy
        Cleanse with mild soap
        Pre-medicate patient

      Debridement
        Removal of dead tissue
        Can be done
            Mechanically
            Enzymatically

            Surgically
Dressings
      Biological dressing
          Any temporary material that rapidly adheres to
           wound bed
          Prepare wound for permanent grafting
          Easy to apply and remove
               Homograft
                  – Human skin harvested from cadavers
                  – Expensive and hard to get
                  – Rejected within 14-21 days
               Heterograft
                  – Obtained from animals
                  – Needs to be changed frequently
                  – High risk of infection
               Synthetic materials
Surgical Management
  Debridement
  Escharotomy
        Hard crust that forms over wound
    Grafting
Preventing Scars, Keloids and
Contractures
  Positioning
  Splinting
  Exercise
  Support garments
Nursing Diagnosis
    Impaired skin integrity
    Fluid volume deficit
    Risk for infection
    Altered nutrition: less than body
     requirements
    Body image disturbance
    Impaired physical mobiltiy
    Altered tissue perfusion

				
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