BURNS

MANAGEMENT OF PATIENTS WITH BURNS

Ø Results in 10-20 thousand deaths annually

Ø Survival best at ages 15-45

Ø Children, elderly, and diabetics

Ø Survival best burns cover less than 20 -25%% of TBSA

WHAT IS A BURN?

Ø Burn is an injury to the skin and other organic tissues primarily caused by heat and /or radiation, electricity, friction, chemicals or extreme cold

Ø Wounds caused by exposure to:

   1.  Excessive heat - water at >47.1^oC, friction, steam

   2.  Chemicals

   3.  fire/steam

   4.  Radiation

   5.  Electricity

   6.  Extreme cold (ice)

                                               CHEMICAL BURN

                                                  Electrical  Burn

FROSTBITE

                                                  RADIATION BURN

BURN WOUND ASSESSMENT

Ø Classified according to depth of injury and extent of body surface area involved.

Ø Burn wounds differentiated depending on the level of dermis and subcutaneous tissue involved

    1.  Superficial (first-degree)

    2.  Deep (second-degree)

    3.  Full thickness (third and fourth degree)   

SUPERFICIAL BURNS
 (FIRST DEGREE)

Ø Epidermal tissue only affected

Ø Erythema, blanching on pressure, mild swelling no vesicles or blister initially

Ø Not serious unless large areas involved

DEEP (SECOND DEGREE)

Ø Involves the epidermis and deep layer of the dermis

Ø Fluid-filled vesicles –red, shiny, wet, severe pain

Ø Hospitalization required if over 25% of body surface involved i.e. tar burn, flame.

FULL THICKNESS (Third degree)

THIRD DEGREE

FULL THICKNESS (FOURTH DEGREE

Ø Full-thickness extends to muscle or bone

Ø Commonly seen with high voltage electric injury or severe thermal burns

Ø Hospital admission, maybe surgical amputation of the affected extremity

PATHOPHYSIOLOGY

Ø Heat may be transferred through conduction or electromagnetic radiation.

Ø Tissue destruction results from coagulation, protein denaturation, or ionization of cellular contents.

Ø The skin and the mucosa of the upper airways are the sites of tissue destruction. Deep tissues, including the viscera, can be damaged by electrical burns or through prolonged contact with a heat source.

Ø Disruption of the skin can lead to increased fluid loss, infection, hypothermia, scarring, compromised immunity, and changes in function, appearance, and body image.

Ø The depth of the injury depends on the temperature of the burning agent and the duration of contact with the agent.

nFor example,in the case of scald burns in adults, 1 second of contact with hot tap water at 68.9°C (156°F) may result in a burn that destroys both the epidermis and the dermis, causing a fullthickness(third-degree) injury. Fifteen seconds of exposure to hot water at 56.1°C (133°F) results in a similar full-thickness injury.

Ø Temperatures less than 111°F are tolerated for long periods without injury.

Ø Burns caused by fire can cause the burns patient to inhale smoke which alters the ventilation-perfusion ratio and tissue hypoxia

Ø Fluid loss, if not quickly corrected can lead to severe hypovolaemia and ultimately burn-shock.

CLINICAL MANIFESTATIONS

Ø Clients with major burn injuries and with inhalation injury are at risk for respiratory problems

Ø Inhalation injuries are present in 20% to 50% of the clients admitted to burn centers

Ø Burns of the lips, face, ears, neck, eyelids, eyebrows, and eyelashes are strong indicators that an inhalation injury may be present

Ø Change in respiratory pattern may indicate a pulmonary injury. 

Ø The client may:  become progressively hoarse, develop a brassy cough, drool or have difficulty swallowing, produce expiratory sounds that include audible wheezes, crowing, and stridor

Ø Upper airway edema and inhalation injury are most common in the trachea and main stem bronchi

Ø Auscultate these areas for wheezes

Ø If wheezes disappear, this indicates impending airway obstruction and demands immediate intubation

Ø Cardiovascular compromise will begin immediately which can include shock (Shock is a common cause of death in the emergent phase in clients with serious injuries)

Ø Obtain a baseline EKG

Ø Monitor for edema, measure central and peripheral pulses, blood pressure, capillary refill and pulse oximetry

Ø Changes in renal function are related to decreased renal blood flow

Ø Urine is usually highly concentrated and has a high specific gravity

Ø Urine output is decreased during the first 24 hours of the emergent phase

Ø Fluid resuscitation is provided at the rate needed to maintain adult urine output at 30 to 50- mL/hr.

Ø Measure BUN, creat and NA levels

Ø Sympathetic stimulation during the emergent phase causes reduced GI motility and paralytic ileus

Ø Auscultate the abdomen to assess bowel sounds which may be reduced

Ø Monitor for n/v and abdominal distention

Ø Clients with burns of 25% TBSA or who are intubated generally require a NG tube inserted to prevent aspiration and removal of gastric secretions

CALCULATION OF BURNED BODY SURFACE AREA

TOTAL BODY SURFACE AREA (TBSA)

Ø Superficial burns are not involved in the calculation

Ø Lund and Browder Chart is the most accurate because it adjusts for age

Ø Rule of nines divides the body – adequate for initial assessment for adult burns

Ø Palm Method

RULES OF NINES

Ø Head & Neck = 9%

Ø Each upper extremity (Arms) = 9%

Ø Each lower extremity (Legs) = 18%

Ø Anterior trunk= 18%

Ø Posterior trunk = 18%

Ø Genitalia (perineum) = 1%

THE RULE OF NINES ISN’T ALWAYS THE RULE

Ø The Rule of Nines provides reasonable estimates of body surface area for patients ranging from 10 to 80 kg.

Ø For obese patients weighing more than 80 kg, a rule of fives is proposed:

·        5% body surface area for each arm

·        5 x 4 or 20% for each leg

·        10 x 5 or 50% for the trunk

·        and 2% for the head

VASCULAR CHANGES RESULTING FROM BURN INJURIES

Ø Circulatory disruption occurs at the burn site immediately after a burn injury

Ø Blood flow decreases or cease due to occluded blood vessels

Ø Damaged macrophages within the tissues release chemicals that cause constriction of vessel

Ø Blood vessel thrombosis may occur causing necrosis

Ø Macrophage: A type of white blood that ingests (takes in) foreign material. Macrophages are key players in the immune response to foreign invaders such as infectious microorganisms.

FLUID SHIFT

Ø Occurs after initial vasoconstriction, then dilation

Ø Blood vessels dilate and leak fluid into the interstitial space

Ø Known as third spacing or capillary leak syndrome

Ø Causes decreased blood volume and blood pressure

Ø Occurs within the first 12 hours after the burn and can continue to up to 36 hours

FLUID IMBALANCES

Ø Occur as a result of fluid shift and cell damage

Ø Hypovolemia

Ø Metabolic acidosis

Ø Hyperkalemia

Ø Hyponatremia

Ø Hemoconcentration (elevated blood osmolarity, hematocrit/hemoglobin) due to dehydration

FLUID REMOBILIZATION

Ø Occurs after 24 hours

Ø Capillary leak stops

Ø Leads to diuretic stage where edema fluid shifts from the interstitial spaces into the vascular space

Ø Blood volume increases leading to increased renal blood flow and diuresis

Ø Body weight returns to normal

Ø See Hypokalemia

CURLING’S ULCER

Ø Acute ulcerative gastro duodenal disease

Ø Occur within 24 hours after burn

Ø Due to reduced GI blood flow and mucosal damage

Ø Treat clients with H2 blockers, mucoprotectants, and early enteral nutrition

Ø Watch for sudden drop in hemoglobin

Ø Patient may be at risk of ileus

MANAGEMENT OF BURNS

Ø Classified according to the phases of burn injuries

Ø Emergent (24-48 hrs)

Ø Acute /Rescusitative ( Commences from 48 to72 hours post burns)

Ø Rehabilitative -Rehabilitation, reconstruction, and reintegration; although this begins during the resuscitation period, it becomes time consuming and involved toward the end of the acute hospital stay

GOALS

Ø Prevent complications (contractures)

Ø Maintain respiratory function

Ø Promote wound healing

Ø Drugs - Anti-infective , Analgesics, No aspirin

Ø Strict surgical asepsis

Ø Emotional support

EMERGENT PHASE

Ø From onset of injury to completion of fluid resuscitation and measures to counter inhalational injury.

Ø Immediate problem is fluid loss, edema, reduced blood flow (fluid and electrolyte shifts)

GOALS:

   1.  Secure airway

   2.  Support circulation by fluid replacement

   3.  Keep the client comfortable with analgesics

   4.  Prevent infection through wound care

   5.   Maintain body temperature

   6.  Provide emotional support

EMERGENT PHASE

Ø Knowledge of circumstances surrounding the burn injury

Ø Obtain client’s pre-burn weight (dry weight) to calculate fluid rates

Ø Calculations based on weight obtained after fluid replacement is started are not accurate because of water-induced weight gain

Ø Height is important in determining body surface area (BSA) which is used to calculate nutritional needs

Ø Know client’s health history because the physiologic stress seen with a burn can make a latent disease process develop symptoms

SKIN ASSESSMENT

Ø Assess the skin to determine the size and depth of burn injury

Ø The size of the injury is first estimated in comparison to the total body surface area (TBSA).  For example, a burn that involves 40% of the TBSA is a 40% burn

Ø Use the rule of nines for clients whose weights are in normal proportion to their heights

IV FLUID THERAPY

Ø Infusion of IV fluids is needed to maintain sufficient blood volume for normal CO

Ø Clients with burns involving 15% to 20% of the TBSA require IV fluid

Ø Purpose is to prevent shock by maintaining adequate circulating blood fluid volume

Ø Severe burn requires large fluid loads in a short time to maintain blood flow to vital organs

Ø Fluid replacement formulas are calculated from the time of injury and not from the time of arrival at the hospital

Ø Diuretics should not be given to increase urine output. 

COMMON FLUIDS

Ø COLLOIDS:

·        Protenate or 5% albumin in isotonic saline (1/2 given in first 8 hr; ½ given in next 16 hr)

Ø CRYSTALLOIDS

·        LR (Lactate Ringer) without dextrose (1/2 given in first 8 hr; ½ given in next 16 hr)

·        hypertonic saline) adjust to maintain urine output at 30 mL/hr

·        lactated ringers only

FORMULA

Ø Consensus Formula

Ø Lactated Ringer’s solution (or other balanced saline solution): 2–4 mL× kg body weight × % total body surface area (TBSA) burned. Half to be given in first 8 hours; remaining half to be given over next 16 hours

Ø The following example illustrates use of the formula in a 70-kg

Ø (168-lb) patient with a 50% TBSA burn:

1. Consensus formula: 2 to 4 mL/kg/% TBSA

2. 2 × 70 × 50 = 7,000 mL/24 hours

3. Plan to administer: First 8 hours = 3,500 mL, or 437 mL/hour; next 16 hours = 3,500 mL, or 219 mL/hour

NURSING DIAGNOSIS IN THE EMERGENT PHASE

Ø Decreased CO

Ø Deficient fluid volume r/t active fluid volume loss

Ø Ineffective Tissue perfusion

Ø Ineffective breathing pattern

ACUTE PHASE OF BURN INJURY

Ø Lasts until wound closure is complete

Ø Care is directed toward continued assessment and maintenance of the cardiovascular and respiratory system

Ø Pneumonia is a concern which can result in respiratory failure requiring mechanical ventilation

Ø Infection (Topical antibiotics – Silvadene

Ø Tetanus toxoid

Ø Weight daily without dressings or splints and compare to pre-burn weight

Ø A 2% loss of body weight indicates a mild deficit

Ø A 10% or greater weight loss requires modification of calorie intake

Ø Monitor for signs of infection

      
DIET

Ø Initially NPO

Ø Begin oral fluids after bowel sounds return

Ø Do not give ice chips or free water lead to electrolyte imbalance

Ø High protein, high calorie

LOCAL AND SYSTEMIC SIGNS OF INFECTION- GRAM NEGATIVE BACTERIA

Ø Pseudomonas, Proteus

Ø May lead to septic shock

Ø Conversion of a partial-thickness injury to a full-thickness injury

Ø Ulceration of health skin at the burn site

Ø Erythematous, nodular lesions in uninvolved skin

Ø Excessive burn wound drainage

Ø Odor

Ø Sloughing of grafts

Ø Altered level of consciousness

Ø Changes in vital signs

Ø Oliguria

Ø GI dysfunction such as diarrhea, vomiting

Ø Metabolic acidosis

LAB VALUES

Ø Na – hyponatremia or Hypernatremia

Ø K – Hyperkalemia or Hypokalemia

Ø WBC – 10,000-20,000

Ø Haematocrit – May be increased

Ø New technology – Doppler Imaging (for estimating burn depth)

Ø Noncontact scanning technique that measures the entire burn wound surface.

Ø Color-coded perfusion map corresponds to varying burn depth.

Ø Accuracy up to 99%

Ø The latest, most accurate, most advanced modality of diagnosing burn depth

NURSING DIAGOSIS IN THE ACUTE PHASE

Ø Impaired skin integrity

Ø Risk for infection

Ø Imbalanced nutrition

Ø Impaired physical mobility

Ø Disturbed body image

PLANNING AND IMPLEMENTATION

Ø Nonsurgical management: removal of exudates and necrotic tissue, cleaning the area, stimulating granulation and revascularization and applying dressings.  Debridement may be needed

DRESSING THE BURN WOUND

Ø After burn wounds are cleaned and debrided, topical antibiotics are reapplied to prevent infection

Ø Standard wound dressings are multiple layers of gauze applied over the topical agents on the burn wound

Ø Blisters shouldn’t be left alone

REHABILITATIVE PHASE OF BURN INJURY

Ø Started at the time of admission

Ø Technically begins with wound closure and ends when the client returns to the highest possible level of functioning

Ø Provide psychosocial support

Ø Assess home environment, financial resources, medical equipment, prosthetic rehab

Ø Health teaching should include symptoms of infection, drugs regimens, f/u appointments, comfort measures to reduce pruritus

DEBRIDEMENT

Ø Done with forceps and curved scissor or through hydrotherapy (application of water for treatment)

Ø Only loose eschar removed

Ø Blisters are left alone to serve as a protector – controversial

Ø Surgical debridement may be needed for deep and extensive burns

Ø Maggot therapy

SKIN GRAFTS

Ø Done during the acute phase

Ø Used for full-thickness and deep partial-thickness wounds

Ø Can be autograft, homograft or heterograft

Ø Advanced burn care – Artificial skin and synthetic substitutes

POST CARE OF SKIN GRAFTS

Ø Maintain dressing

Ø Use aseptic technique

Ø Graft should look pink if it has taken after 5 days

Ø Skeletal traction may be used to prevent contractures

Ø Elastic bandages may be applied for 6 month to 1 year to prevent hypertrophic scarring.

MANAGEMENT OF BURNS PATIENT USING THE NURSING PROCESS

Ø ASSESSMENT

•         Assessment of respiratory and fluid status remains the highest priority

•         peripheral pulses is essential for the first few  postburn days

•         size, color, odor, eschar, exudate, abscess formation under the eschar, epithelial buds (small pearl-like clusters of cells on the wound surface), bleeding, granulation tissue appearance, status of grafts and donor sites, and quality of surrounding skin

•         pain and psychosocial responses, daily body weights, caloric intake, general hydration, and serum electrolyte, hemoglobin, and hematocrit levels

DIAGNOSES

Ø Risk for infection related to loss of skin barrier and impaired immune response

Ø Imbalanced nutrition, less than body requirements, related to hypermetabolism and wound healing needs

Ø Impaired skin integrity related to open burn wounds

Ø Impaired physical mobility related to burn wound edema, pain, and joint contractures

PLANNING AND GOALS

Ø Absence of infection,

Ø Attainment of anabolic state and normal weight,

Ø Improved skin integrity,

Ø Reduction of pain and discomfort and optimal physical mobility

IMPLEMENTATION
RISK FOR INFECTION

Ø Use asepsis in all aspects of patient care: hand hygiene , clean or sterile gloves for wound, Wear isolation gown or protective plastic apron , Wear mask and hair, Change invasive lines and tubings as recommended

Ø Screen visitors for respiratory, gastrointestinal, or integumentary infections.

Ø Provide isolation gowns for visitors without active infection and instruct in hand hygiene.

Ø Exclude plants and flowers in water from patient’s room.

Ø Inspect wound for signs of infection, purulent drainage, or discoloration.

Ø 5. Monitor white blood cell (WBC) count, culture and sensitivity results

IMPLEMENTATION
MAINTAINING ADEQUATE NUTRITION

Ø Provide high-calorie, high-protein diet; and nutritional supplements (supplemental vitamins and minerals) as prescribed.

Ø Monitor patient’s daily weight and calorie count.

Ø Administer enteral or parenteral nutrition per protocol if dietary needs are not met through oral intake.

Ø Daily weighing of patients

Ø Patients with anorexia should be encouraged.

Ø Administer antibiotics as prescribed.

Ø Provide regular linen changes and assist patient with personal hygiene.

Ø Monitor patient for decreased bowel sounds, tachycardia, decreased blood pressure, decreased urine output, fever, and flushing.

ACHIEVEMENT OF OPTIMAL PHYSICAL MOBILITY

Ø Position patient carefully to prevent flexed position in burned areas.

Ø Implement range-of-motion (ROM) exercises several times daily.

Ø Assist with early sitting and ambulation.

Ø Use splints and exercise devices recommended by occupational and physical therapists.

Ø Encourage self-care to the extent of the patient’s ability.

PREVENTION

Ø Keep matches and lighters out of the reach of children.

Ø Never leave children unattended around fire

Ø Install and maintain smoke detectors

Ø Develop and practice a home exit fire drill with all members of the household.

Ø Set the water heater temperature no higher than 120°F.

Ø Do not smoke in bed.

Ø Do not throw flammable liquids onto an already burning fire.

Ø Do not use flammable liquids to start fires.

Ø Do not remove radiator cap from a hot engine.

Ø Watch for overhead electrical wires and underground wires when working outside.

Ø Never store flammable liquids near a fire source

Ø Use caution when cooking.

Ø Keep a working fire extinguisher in your home.

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