Burns Flashcards
First Degree Burns
Superficial injuries that involve outermost layer of skin (sunburn)
Second Degree Burns
Involve entire epidermis and varying portions of dermis, painful with blisters
Third Degree Burns
Total destruction of the epidermis, dermis and underlying tissue, lack of sensation
Fourth Degree Burns
Deep burn necrosis, extends into deep tissue, muscle or bone
Factors in Determining Burn Depth
how the injury occured, causative agent, temperature of agent, duration of contact with agent, thickness of the skin at the injury
Rule of nines
most common method for TBSA estimation, based on anatomic regions
Lund and browder
recognizes % of TBSA of various anatomic parts
Palmer
used to estimate extent of scattered burns, size of patient’s hand, including fingers is 1% TBSA
Patho of Burns
chemical injury, heat transfer from one site to another, thermal, electrical (skin and upper airway mucosa are most common), radiation
Major Burn Injury
Burns more than 30% may produce a local and
systemic response and are considered major burns
Systemic response includes release of cytokines and other mediators into systemic circulation
Fluid shifts and shock result in tissue hypoperfusion and organ hypofunction
Effects of MBI
Fluid and electrolyte shifts
Cardiovascular effects
Pulmonary injury
o Upper airway
o Lower airway
o Carbon monoxide poisoning
o Restrictive defects
Renal and GI alterations
Immunologic alterations
Effect on thermoregulation
Phases of burn injury
Emergent/ rescusitative, acute/ intermediate, rehab
Emergent
Onset of injury to completion of fluid
resuscitation
Acute/intermediate
From beginning of diuresis to wound closure
Rehab
From wound closure to return to optimal physical and psychosocial adjustment
On the scene care
Prevent injury to rescuer
Stop injury: extinguish flames, cool the burn,
irrigate chemical burns
ABCs: establish airway, breathing, and circulation
Start oxygen and large-bore IVs
Remove restrictive objects and cover the wound
Do assessment surveying all body systems and obtain a history of the incident and pertinent patient history
Note: Treat patient with falls and electrical injuries as for potential cervical spine injury
Emergent Care in the hospital
Patient is transported to emergency department
Fluid resuscitation is begun
Foley catheter is inserted
Patient with burns exceeding 20% to 25% should have an NG
tube inserted and placed to suction
Patient is stabilized and condition is continually monitored
Patients with electrical burns should have ECG
Address pain; only IV medication should be administered
Psychosocial consideration and emotional support should be given to patient and family
Nursing management of emergent phase
ABC
Vital signs and hemodynamic status
Monitor for fluid volume deficit
Assess extent of the burn
Emergent potential complications
Acute respiratory failure
Distributive shock
Acute kidney injury
Compartment syndrome
Paralytic ileus
Curling’s ulcer
Acute/intermediate
48 to 72 hours after injury
Continue assessment and maintain respiratory and circulatory support, fluid and electrolyte balance, GI and renal function
Prevention of infection, burn wound care, pain
management, modulation of the hypermetabolic response, and early positioning/mobility
Nursing Management during Acute/intermediate
Restoring fluid balance
Preventing infection
Modulating hypermetabolism
Promoting skin integrity
Relieving pain and discomfort
Promoting mobility
Strengthening coping strategies
Supporting patient and family processes
Monitoring and managing complications
Complications during Acute/ Intermediate
ARDs/ARF, HF, pulmonary edema, sepsis, delirium, visceral damage with electrical burns
Rehab
Rehabilitation is begun as early as possible in the emergent phase and extends for a long period after the injury
Focus is on wound healing, psychosocial support, self-image, lifestyle, and restoring maximal functional abilities so that the patient can have the best quality life, both personally and socially
The patient may need reconstructive surgery to improve function and appearance
Vocational counseling and support groups may assist the patient
Fluid resuscitation for burns
manages shock, Maintain blood pressure of greater than 100 mm Hg
systolic and urine output of 30 to 50 mL/hr;
maintain serum sodium at near normal levels
Consensus Formula
2-4ml/kg
Evans formula
1ml/kg/% BSA of crystalloids + 1ml/kg/% BSA colloids + 2000 ml glucose in water
Brooke Army formula
2mls x TBSA X weight, half the amount given in 1st 8 hrs
Parkland Baxter formula
4 mls X TBSA X weight, half the amount given in 1st 8 hrs
Hypertonic saline formula
0.5 mmol sodium per kg of body weight per TBSA
F&E Shifts- emergent
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
Acute F&E shift
Fluid reenters the vascular space from the interstitial
space
Hemodilution
Increased urinary output
Sodium is lost with diuresis and due to dilution as
fluid enters vascular space: hyponatremia
Potassium shifts from extracellular fluid into cells:
potential hypokalemia
Metabolic acidosis
Burn Wound Care
Wound cleaning
o Hydrotherapy
Use of topical agents
Wound debridement
o Natural debridement
o Mechanical debridement
o Surgical debridement
Wound dressing, dressing changes, and skin grafting
Burn Psychosocial support
Patient’s outlook, motivation, and support system are important to overall well-being and ability to progress
Psychological support of patient and family
Early consultation with mental health professionals
Discharge planning for reintegration
Support groups
Organizations
Burn Pain
Burn pain has been described as one of the most severe forms of acute pain
Pain accompanies care and treatments such as wound cleaning and dressing changes
Types of burn pain
o Background or resting
o Procedural
o Breakthrough
Burn Pain Management
Analgesics
o IV use during emergent and acute phases
o Morphine
o Fentanyl
o Other
Role of anxiety in pain
Effect of sleep derivation on pain
Nonpharmacologic measures
Nutritional Support for Burns
Burn injuries produce profound metabolic
abnormalities, and patient with burns have great nutritional needs related to stress response, hypermetabolism, and requirement for wound healing
Goal of nutritional support is to promote a state of nitrogen balance and match nutrient utilization
Nutritional support is based on patient preburn status and % of TBSA burned
Enteral route is preferred. Jejunal feedings are
frequently used to maintain nutritional status with a lower risk of aspiration in a patient with poor appetite, weakness, or other problems
Home Care instruction for Burns
Mental health, Skin and wound care, Exercise and activity, Nutrition, Pain management, Thermoregulation and clothing, Sexual issues
