Week 6 Nursing management of patients with burn injury

Why are burns one of the most complex traumas?

usually involve multiple systemic trauma and mechanism of injury can be thermal, radioactive, electrical, chemical, or a mixture

Function of skin

• protective barrier

• thermoregulation

• vitamin d synthesis

which layer of the skin produce pigment and protect immune system?

epidermis

which layer of the skin contains nerve endings, oil, swear glands, and hair follicles?

dermis

which layer of the skin is made up of fat, connective tissue and larger blood vessels?

subcutaneous tissue

Burn degree types

first, second, third, fourth

1st degree burn involves

• superficial injuries that involve outermost layer of skin

• ex: sunburn

2nd degree burn involves

• entire epidermis and portions of the dermis

• ex: painful with blisters

3rd degree burn (full thickness) involves

destruction of the epidermis, dermis, and underlying tissue, lack of sensation d/t nerve damage

4th degree burns (full thickness) involves

deep burn necrosis, extends into deep tissue, muscle, or bone

Methods to estimate Total Body Surface Area (TBSA) Burned

**Rule of Nines- most common; based on anatomic regions

• Lund and Browder methods

• Palmer method

Rule of Nines Adult

• most common way to calculate body surface area burned

• Head= 9%

• chest= 9%

• abdomen= 9%

• left anterior leg= 9%

• right anterior leg= 9%

• besides head and arms, x 2 if back is burned too

• left arm= 4.5%

• right arm= 4.5%

Rule of Nines infant

• Head and neck= 21%

• each arm= 10%

• abdomen= 13%

• back= 13%

• buttocks= 5%

• each leg= 13.5%

• genital area= 1 %

Physiologic changes by burns

• fluid and electrolyte shifts

• fluid shifts and shock result in tissue hypoperfusion and organ hypofunction

• cardiovascular effects

• pulmonary injury

• renal and GI alterations

• immunologic alterations

• effect on thermoregulation

• release of cytokines and other mediators into the systemic circulation

Burns of more than __% may produce a local and systemic response and are considered major burns

30%

Burns can cause what type of pulmonary injury

• upper airway

• lower airway

• carbon monoxide poisoning

• restrictive defects

Phases of Burn injury

• Emergent or resucitative phase

• Acute or intermediate phase

• Rehabilitation phase

Emergent or resuscitative phase of burn injury is

onset of injury to completion of fluid resuscitation

Acute or intermediate phase of burn injury is

from the beginning of diuresis to wound closure

Rehabilitation phase of burn injury is

from wound closure to return to optimal physical and psychosocial adjustment

On the Scene Care in Emergent or Resuscitative Phase

• prevent injury to the rescuer

• stop injury: extinguish flames, cool the burn, irrigate chemical burns

• ABCs: establish airway, breathing, circulation

• start oxygen and large-bore IVs

• remove restrictive objects and cover the wound

• do an assessment surveying all body systems and obtain a history of the incident and pertinent patient history

Emergent or Resuscitative Phase steps

• pt is transported to emergency department

• fluid resuscitation begins

• foley catheter is inserted

• pts with burns exceeding 20-25% should have an NG tube inserted and placed to suction

• pt is stabilized and condition is continually monitored

• pts with electrical burns should have ECG

• address pain; only IV medication should be administered

• psychosocial consideration and emotional support should be given to pt and family

Acute or Intermediate phase time frame

48-72 hours after burn injury

Acute or Intermediate phase focus

• continuous pt assessment

• GI & renal function checks

• respiratory support

• circulatory stability

• fluid & electrolyte balance

• infection prevention

• burn wound management

• pain management

• control hypermetabolic response

• positioning

• early mobility

Rehabilitation Phase focus

• rehab is begun in all stages

• focus= wound healing, psychosocial support, self-image, lifestyle, and restoring maximal functional abilities

• pt may need reconstructive surgery to improve function and appearance

• vocational, psychological counseling, and support groups may assist the [t

• include family as indicated

Nursing management of Pt: Acute phase

• restoring fluid baalnce

• prevent infection

• modulating hypermetabolism

• promoting skin integrity

• relieving pain and discomfort

• promoting mobility

• strengthening coping strategies

Nursing management of Pt: Intermediate & rehabilitation phases

• strengthening coping strategies

• support patient and family processes

• monitoring and managing complications

Why fluid resuscitation?

• fluid shifts occur from intravascular to interstitial D/T inflammatory response

• fluid shifts from cells and other areas to compensate for fluid loss, causing general dehydration s/s

• fluid evaporates from burn injury

Management of fluids

• required in adults with >20% burn

• child > 10% burn

• any burn in ages <2 or >60

Fluid replacement goals

• BP >100 systolic

• pulse <110 adult

• urine output >30cc/hr adults

How do we decide how much fluid to give?

• Burn surface area

• first 8 hrs, most fluids lost to fluid shift & evaporation- 50% fluids needed replaced in that time

• next 50% replaced in the following 16 hrs

• usually isotonic solution- Lactated Ringers because cell stays the same

• may replace blood loss with PRBCs

What do we want to see with fluid resuscitation?

• appropriate BP and pulse

• relief of nausea and ileus- 24 hrs

S/S Burn shock

• decreased blood pressure

• increased pulse

• increased hematocrit

• decreased level of consciousness

• decreased urine output

• edema at site of burn injury

• Na+ deficit

• K+ may be excess from cell destruction

• metabolic acidosis

Management of Shock

• maintain blood pressure >100 systolic and urine output of 30-50 mL/hr

• maintain serum sodium at near-normal levels

Fluid and Electrolyte shift- Emergent Phase

• generalized dehydration

• reduced blood volume and hemoconcentration

• decreased urine output

• trauma causes release of potassium into extracellular fluid: hyperkalemia

• sodium traps in edema fluid and shifts into cells as potassium is released: hyponatremia

• metabolic acidosis

Fluid and Electrolyte shift- Acute Phase

• fluid re-enters the vascular space from the interstitial space

• hemodilution

• increased urinary output

• sodium is lost with diuresis and d/t dilution as fluid enters vascular space: hyponatrenua

• potassium shifts from extracellular fluid into cells: potential hypokalemia

• metabolic acidosis

4 Cs in Burn wound care are

• cooling

• cleaning

• covering

• comforting

Burn wound cleaning is done with

• hydrotherapy

• antibacterial products

• wash solutions

• topical agents

Debridement methods for Burn Wounds include

• autolytic

• mechanical

• surgical

Burn wound closure & care

• dressing application

• dressing changes

• skin grafting

Types of burn pain include

• background or resting

• procedural

• breakthrough

Analgesics used for burn pain management

• IV use during emergent and acute phases

• morphine

• fentanyl

Goal of nutritional support with burn wounds is

promote a state of nitrogen balance and match nutrient utilization

Routes for administering nutrition in burn wound patients

• enteral route is preferred

• jejunal feedings are frequently used for lower risk of aspiration