A&C3 exam 2: burns

Burns

Damage to the skin or deeper tissues caused by heat, cold, chemicals, electrical current, or radiation.

- effect of burns is influenced by the temperature, duration of contact time, and the tissue type of injured

Thermal Burns

Caused by: Flame, flash, scald, or contact with hot objects (most common)

- severity of the injury depends on the temperature ofthe burning agent and duration of contact time.

Chemical Burns

Result from tissue injury and destruction from acids, alkalis, and organic compounds.

- Common areas affected: skin and eyes

- Alkali burns can be difficult to manage because they adhere to the tissue causing protein hydrolysis and melting.

Smoke and Inhalation Injuries

Results from breathing noxious chemicals or hot air which can damage the respiratory tract.

- Types: Upper airway injury & Lower airway injury

- Rapid initial and ongoing assessment is critical (important)

- Airway compromise and pulmonary edema can quickly develop within hours of injury

Metabolic asphyxiation in smoke/inhalation injuries

Major predictor of mortality in burn patients

- Carbon monoxide poisoning

- Inhaled CO displaces O2

- Hypoxia

- Carboxyhemoglobinemia

- Death

Upper airway injuries

- Presence of facial burns

- Singed nasal hair

- Hoarseness, painful swallowing

- Darkened oral/nasal membranes

- Carbonaceous sputum

- History of being burned in in-closed space

- Clothing burns around chest & neck

Lower airway injury

Injury to trachea, bronchioles, and alveoli

- Related to length of exposure

- Pulmonary edema may not appear until 12-48hrs after injury

- Manifests as ARDS

Electrical Burns

Result of intense heat generated from an electric current.

- Severity depends on the amount of voltage, tissue resistance, current pathways, surface area in contact with the current, and length of time flow was sustained

- Most damage occurs beneath the skin most damage occurs beneath the skin

Ice burg effect

The external injury appears to be small, but the internal injuries may include extensive destruction of the underlying tissue

- Electrical current may cause muscle spasms strong enough to fracture bones

Electrical burns and cardiac

Patients are at risk for dysrhythmias or cardiac arrest, severe metabolic acidosis, and myoglobinuria

- Myoglobin and hemoglobin from damaged RBCs travel to the kidneys = Acute tubular necrosis (ATN) = eventual acute kidney injury

Classification of burns: depth

1st, 2nd, 3rd, 4th

First degree burn

Superficial

- Damage in epidermis

- Dry with blanchable redness

Second Degree Burn

Partial Thickness

- Epidermis and dermis

- Red, moist, shiny, fluid filled vesicles

Third degree burn

Full Thickness

- Involves all skin elements, nerve endings, fat, muscle, bone

- Dry waxy white, leathery or charred black color

- Non-blanchable, No pain

Fourth Degree Burn

Full thickness

- Extends to muscles, ligaments, bones

- Worst burn

- Lack of PAIN

Classification of Burn Injury 2

Extent of Burn

Two common tools for determining TBSA affected, or the extent of a burn wound are

- Lund-Browder chart

- Rule of Nines

Lund- Browder chart

Consider the patient's age in proportion to relative body-area size

Rule of Nines

Often used for initial assessment of burn patient because it is easily to remember

Classification of Burn Injury 3

Location of Burn

Severity of burn injury is determined by location of burn wound

- Face, neck, chest → respiratory obstruction

- Hands, feet, joints, eyes → self-care

- Ears, nose, buttocks, perineum → infection

Patients that have difficulty recovering from the burn injury

- Preexisting heart, lung, or kidney disease - poorer prognosis

- Diabetes or peripheral vascular disease - delayed healing

- General physical weakness from any chronic disease

- Who have fractures, head injuries, or trauma

Prehospital and Emergency Care

At the scene of injury, priority is given to removing the person from the source of the burn and stopping the burning process.

- Remove any chemical particles from the skin and flush with copious amounts of water

- If responsive, assess and monitor the ABC's

- If the burn is large, an electrical or inhalation burn is suspected, or if unresponsive.

Emergent Phase (Resuscitative) phase

The time needed to resolve the immediate, life-threatening problems resulting from the burn injury

- Usually lasts up to 72 hours from the time burn occurred

- Primary concerns: Hypovolemic shock, edema

- Emergent phase ends when fluid mobilization and diuresis begin

During the emergent phase of burn injury, the nurse assesses for the presence of hypovolemia. In burn patients, hypovolemia occurs primarily as a result of?

Capillary permeability with fluid shift to the interstitium.

Third Spacing Phenomenon

Fluids move to areas that have minimal or no fluid

- Exudate, blister formation, edema in unburned areas

Emergent Phase: Clinical Manifestation

- Shock from hypovolemia

- Full-thickness and deep partial-thickness burns are painless

- Superficial to moderate partial-thickness burns are very painful

- Blisters

- Paralytic ileus

- Shivering

- Altered mental status

Emergent Phase: Cardiovascular Complications

- Dysrhythmias

- Hypovolemic shock

- Ischemia

- Paresthesia

- Necrosis

- Sludging

- Venous thromboembolism (VTE)

Emergent Phase: Respiratory Complications

- Respiratory distress

- Agitation, anxiety, restlessness, change in breathing pattern

Emergent phase: other cardiopulmonary issues

- Preexisting heart disease or lung disease are often increased the risk of complications

- Fluid replacement is too vigorous, watch for early signs of heart failure or pulmonary edema

- Preexisting lung disease are more likely to develop an infection

- Pneumonia: Leading cause of death in patients with an inhalation injury

Emergent phase: urinary complications

Acute Tubular Necrosis: the most common complication

Emergent phase: Electrical burns complications

- Myoglobin (from muscle cell breakdown)

- Hemoglobin (from RBC breakdown)

- Carefully monitor the adequacy of fluid replacement because this can reverse the obstruction of the tubules.

Emergent Phase: Airway Management

- Endotracheal intubation

- Ventilatory support

- Chest escharotomy

- Fiberoptic bronchoscopy

- Assess lower airway (6-12 hrs after injury)

- 100% humidified O2 when intubation is not done

- Encourage deep breathing and coughing every hour

- Reposition every 1 to 2 hrs

- Suctioning and chest physiotherapy

- Intubation and mechanical intubation

- Bronchodilators

- CO2 poisoning: 100% O2 until carboxyhemoglobin levels return to normal.

Emergent Phase: Fluid therapy

- 2 large-bore IVs must be in place for patients with burns that are 15% TBSA or more

- Central line for patients with burns greater than 30% TBSA for fluid and drug administration and blood sampling

- Arterial line

- Assess the fluid needs using Parkland Formula

- Electrical Burns need more fluids

- Osmotic Diuretic (Mannitol) to overcome high levels of hemoglobin and myoglobin in the urine.

Urine output assessment

0.5 - 1 ml/kg/hr; 75 to 100 ml/hr for electrical burn patients with evidence of hemoglobinuria or myoglobinuria

Cardiac parameters in burn patients

- Mean Arterial Pressure (MAP) > 65 mm Hg

- Systolic BP > 90 mm Hg

- HR < 120 beats/min

- MAP and BP are best measured by an arterial line

- Manual BP measurement is often invalid because of edema and vasoconstriction.

The nurse is caring for a 71-kg patient during the first 12 hours after thermal burn injury. Which outcome indicates adequate fluid resuscitation?

- Urine output is 46 ml/hr

- Heart rate is 94 beats/min

Fluid Resuscitation Recommendation

- First 24 hours: 2-4 ml Lactated Ringer's/kg/%TBSA burned

- 2nd 24 hours postburn: Colloidal solutions (e.g. 5% albumin)

How is replacement volume calculated?

Based on the patient's bodyweight and TBSA (ex. 0.3 to 0.5 ml/kg/%TBSA burned)

Parkland (Baxter) fluid replacement formula

4 ml lactated Ringer's solution per kilogram of body weight per percent of total body surface area (%TBSA) burned = Total fluid requirements for first 24 hours after burn

Emergent Phase: Wound Care

- Cleansing can be done on a shower cart, in a shower, or on a bed

- Debridement: May need to be done in the OR

- Loose necrotic skin is removed

Open method: wound care infection

Burn is covered with antimicrobial and has no dressing over the wound

Close method: wound care infection

- Multiple dressing change

- Sterile gauze dressings are impregnated with or laid over topical antimicrobial

- Dressing changed every 12 hrs to once every 14 days depending on the product.

Emergent Phase: Other Care measures

- Perineum must be kept as clean and dry as possible

- Routine laboratory tests

- Early ROM exercises

Emergent Phase: Drug therapy

- Analgesics and sedatives

- Tetanus immunization given routinely to all burn patients

- VTE prophylaxis• Low-molecular-weight heparin or low-dose unfractionated heparin is started

- Those with high bleeding risk, VTE prophylaxis with sequential compression devices, or compression stockings recommended

Emergent Phase: Nutritional therapy

- Hypermetabolic state

- Early, continuous enteral feeding promotes optimal conditions for wound healing

- Supplemental vitamins and iron may be given

Acute Phase

- Begins with the mobilization of extracellular fluid and subsequent diuresis

- Ends when partial-thickness wounds are healed or full-thickness burns are covered by skin grafts

Acute Phase: Pathophysiologic Changes

- Necrotic tissue begins to slough

- Granulation tissue forms

- Partial-thickness burn wounds heal from edges and from dermal bed

- Full-thickness burns must have eschar removed and skin grafts applied

Acute Phase: Lab Values

- Hyponatremia

- Hypernatremia

- Hypokalemia

- Hyperkalemia

Why does hyponatremia happen in burns

Develop from excess GI suction and diarrhea

- Headache, irritability, confusion, vomiting, seizures, and even coma

- Water intoxication

Acute phase infections s/s

- Hypothermia or hyperthermia

- Increased heart and respiratory rate

- Decreased BP

- Decreased urine output

- Partial-thickness burns can change to full-thickness wounds in the presence of infection

Acute Phase: Musculoskeletal system Complications

Decreased ROM & Contractures

Acute phase: GI complications

- Paralytic ileus

- Diarrhea

- Constipation

- Curling's ulcer

Acute phase: Endocrine system complications

- ↑ Blood glucose levels

- ↑ Insulin production

- Hyperglycemia

Acute phase: wound care

- Enzymatic debridement: Speeds up removal of dead tissue from healthy wound bed

- Cleanse with soap and water

- Cover with antimicrobial creams

Acute phase: Excision and grafting

- Eschar is removed down to subcutaneous tissue or fascia

- Graft is placed on clean, viable tissue

- Wound is covered with autograft

- Donor skin is taken with a dermatome

Acute Phase: Excision and grafting

Cultured epithelial autographs (CEAs)

- Grown from biopsies obtained from the patient's own skin

- Used in patients with a large body surface burn area or those with limited skin for harvesting

A patient is to undergo skin grafting with the use of cultured epithelial autografts for full-thickness burns. The nurse explains to the patient that this treatment involves

Growing small specimens of the patient's skin into sheets to use as permanent skin coverage.

Acute Phase: Physical and occupational therapy

- Good time for exercise is during wound cleaning

- Passive and active ROM

- Splints should be custom-fitted

Rehabilitative Phase

The rehabilitation phase begins when wounds have healed & patient is engaging in some level of self-care

Rehabilitative phase pathophysiologic changes

- In approximately 4 to 6 weeks, the area becomes raised and hyperemic

- Mature healing is reached about 12 months

- Skin never completely regains its original color

- Newly healed areas can be hypersensitive or hyposensitive to cold, heat, and touch

Rehabilitative phase complications

Skin and joint contractures

- Most common complications during rehab phase.

- Positioning, splinting, and exercise should be used to minimize contracture.

Rehabilitation Phase Nursing/Interprofessional Management

- The role of exercise cannot be overemphasized

- Constant encouragement and reassurance

When teaching the patient in the rehabilitation phase of a severe burn about performing ROM, what explanations should the nurse give to the patient?

- Active and passive ROM maintains function of body parts

- ROM will reassure the patient that movement is still possible

- Movement promotes mobilization of interstitial fluid back into the vascular bed