Burns Flashcards
Burn: Definition
injury resulting in tissue loss or damage
can be caused by exposure to:
- thermal
- electrical
- chemical
- radiation
severity depends on:
- duration of contact w/ source
- temperature of burn
- location of burn
Types of Burn Injury
Thermal burns: flame, flash, scald, contact w/ hot objects
Chemical burns: acids, alkalis, organic compounds
Smoke and Inhalation: inhalation of smoke/hot air/noxious chemicals
Electrical burns: intense heat generated from electrical current
Cold thermal injury: frostbite
Classification of Burn Injury
- depth of burn
- extent of burn
- location of burn
- pt risk factors (comorbidities)
Depth of Burn
- partial thickness burns
- full thickness burns
Partial Thickness Burns
superficial partial thickness:
- erythema
- blanching on pressure
- pain
- mild swelling
- no vesicles or blisters
deep partial thickness:
- fluid-filled vesicles that are red, shiny, wet
- severe pain caused by nerve injury
- mild to moderate edema
Full Thickness Burns
- dry
- waxy
- white
- leathery
- hard skin
- visible thrombosed vessels
- no pain b/c of nerve destruction
- possible involvement of muscles, tendons, and bones
Guides for Determining Total Body Surface Area Affected
Lund-Browder chart
Rule of Nines
Complications of Electrical Injury
- cardiac dysrhythmias or cardiopulmonary arrest
- hypoxia secondary to paralysis of the respiratory muscles
- deep tissue necrosis
- compartment syndrome
- long bone or vertebral fractures
- rhabdomyolysis and acute renal failure
- acute cataract formation
- neuro deficits (peripheral neuropathy, seizures, deafness, motor/sensory deficits)
- SCI/TBI from shock throwing pt
Abuse and Neglect: Vulnerable Populations
children
elderly
disabled persons
mentally impaired persons
Abuse and Neglect: Role of Nurse
- thorough assessment and detailed hx
- document with written and photos
- report or provide resources
Phases of Burn Managment
- Prehospital Care
- Emergent Phase (first 48-72hrs after initial burn)
- Acute Phase
- Rehabilitation Phase
Prehospital Care
at the scene, priority is:
- removing person from the source of burn
- stopping burning process
- establish airway
Treatment of Burns
- flush thermal burns with lots of water
- brush off dry chemicals
- ABC’s
- elevate burned limb above the heart to decrease pain and swelling
Emergent Phase
- occurs from the time of burn to 3 or more days
- primary concern is onset of hypovolemic shock and edema formation
pathophysiology:
- fluid and electrolyte shifts (Parkland Formula to determine how much fluid pt is going to get in first 24hrs)
- Inflammation and healing
- immunologic changes
Parkland Formula
4 mL x BSA burned % x weight in kgs
first half of total is given in first 8 hours
second half of total is give in remaining 16hrs
Burns: Clinical Manifestations
- shock from pain and hypovolemia
- difficult for nurse to visualize severe dehydration d/t edema
- shivering (d/t heat loss, anxiety pain)
Complications of Burns in Emergent Phase
cardiovascular
respiratory
urinary
Cardiovascular Complications
- dysrhythmias (esp w/ electrical shock)
- hypovolemic shock > irreversible shock
- circulation to extremities can be impaired by circumferential burns and edema > compartment syndrome
Respiratory Complications
upper respiratory tract:
-results from direct heat injury or edema formation and can lead to mechanical airway obstruction and asphyxia
inhalation injury:
- direct insult at the alveolar level secondary to inhalation of chemical fumes or smoke
- results in interstitial edema that prevents the diffusion of oxygen
- pneumonia
- pulmonary edema
Urinary Complications
- acute tubular necrosis (ATN)
- hypovolemia > poor blood flow to kidneys > renal ischemia > acute renal failure
- occlusion of renal tubules d/t myoglobin and hemoglobin released into bloodstream w/ full-thickness and electrical burns (then leads to AKI and rhabdomyolysis)
- adequate hydration is critical
Nursing Management
- airway
- fluids
- wound care (debridement and removing necrotic tissue to prevent infection)
- drug therapy: analgesics and sedatives, tetanus, antimicrobials)
- nutritional therapy
Acute Phase
begins w/ mobilization of extracellular fluid and subsequent diuresis (fluid shifts back into vasculature and pt pees it all out)
phase ends when the burned area is completely covered by skin grafts or when wounds are healed
may take weeks or many months
Acute Phase: Pathophysiology
- diuresis from fluid mobilization makes pt less edematous
- bowel sounds return
- some wound healing begins as WBCs surround the burn and phagocytosis occurs
- necrotic tissue begins to slough off
- dressing changes 2-3x a day w/ debridement and cleaning
- full thickness burns must be covered by skin grafts
Lab Values
Sodium:
- hyponatremia can occur from extended hydrotherapy (bath water pulls sodium from open burns)
- hypernatremia may be seen following successful fluid replacement if copious amounts of hypertonic solutions were required
Potassium:
-hyperkalemia is seen if pt has renal failure (as result of rhabdomyolysis or hypovolemic shock), adrenocortical insufficiency, massive deep muscle injury w/ large amounts of potassium released from damaged cells
Complication of Burns
- infection
- cardiovascular complications
- respiratory complications
- neurological
- musculoskeletal (b/c of actual injury to muscle/tendons from burn)
- GI
- endocrine
Hydrotherapy
help slough off necrotic skin
good to see pink skin and bleeding, bleeding indicates perfusion so skin grafts will take better
Skin Grafting
- synthetic grafts if real skin isn’t available
- autographs from pt’s back or upper thigh (creates another wound)
- cadaver grafts
skin is put through mesher to cover larger areas
Nursing Management
- wound care
- excision and skin grafting
- pain management
- physical and occupational therapy (to prevent skin contractures)
- nutritional therapy
- psychosocial care
Rehabilitation Phase
begins when pt’s burn wounds have healed and the pt is able to resume a level of self care activity
can occur as early as 2 weeks or 7-8 months after burn injury
rehab is focused on new normal for pt and making them independent
Pathophysiology of Skin Grafts/Healing
- burn wounds heal either primary intention or by grafting
- new skin appears flat and pink
- in about 4-6wks, the area becomes raised and hyperemic
- if adequate ROM is not instituted, new tissue will shorten > contracture
Scarring
two components:
- discoloration
- contour
pt typically experiences discomfort from itching when healing is occurring (give benedryl to prevent scratching)
newly formed skin is extremely sensitive to trauma
grafted areas are more hyposensitive until peripheral nerve regeneration occurs
protect healed burns from direct sunlight for 6-9 months to prevent hyperpigmentation and sunburn injury
Complications in Rehab Phase
- skin and joint contractures
- hypertrophic scarring
- pt will prefer flexed position for comfort from pain but this will predispose them to contracture
Stages of Post Burn Psychological Adaptation
- survival anxiety
- search for meaning
- investment in recuperation
- investment in rehabilitation
- reintegration of identity
Survival Anxiety
- lack of concentration
- easy startle response
- tearfulness
- social withdrawal
- inappropriate behavior
- needs repeated instructions
- needs times to verbalize concerns and fears
- high anxiety
Search for Meaning
- repeatedly recounts events leading to injury and tries to determine logical explanation that’s emotionally acceptable
- nurse should avoid judgement, listen actively, participate in discussion w/ pt
Investment in Recuperation
- pt is cooperative w/ tx regimen
- motivated to be independent
- takes pride in small accomplishments
nurse should:
- educate pt and family about discharge goals
- praise pt and provide verbal encouragement
Investment in Rehabilitation
- self-confidence increases
- focused on achieving preburn function as possible
- depression may occur as new losses in function are realized
nurse support is limited in this phase (pt is usually already discharged and in outpatient rehab)
-praise, support, continued info
Reintegration of Identity
- pt accepts losses
- recognizes that changes occurred
- adaptation is completed
- staff involvement is terminated
