Burns

Natural Debridement

-Dead tissue separates from the underlying viable tissue spontaneously -Bacteria that are present at the interface of the burned tissue and the viable tissue underneath gradually liquefy the fibrils of collagen that hold the eschar in place from week 1-2 post burn -Proteolytic and other natural enzymes cause this natural debridement

Surgical Debridement

-Early surgical excision to remove devitalized tissue along with early burn wound closure is one of the most important factors contributing to survival of patients with major burn injuries -Early excision is carried out before the natural separation of eschar is allowed to occur -Aggressive surgical wound closure has reduced the incidence of burn wound sepsis -Operative procedure involves either primary excision (surgical removal of tissue) of the full thickness of the skin down to the fascia (tangential excision) or shaving the burned skin layers gradually down to freely bleeding, viable tissue

Burn edema

<25% TBSA localized blisters Loss of ciliary integrity and fluid shift are localized to the burn itself Blisters >25% TBSA systemic edema 18-24 hours after injury, resolving in 7-10 days Reduce by avoiding excessive fluid during early post burn period

Pain management

Acute phase: intensity remains high until the skin heals or skin grafts are put in place due to procedural pain Pain meds given IV only IV opioid treatment (morphine sulphate) Fentanyl (short duration) and nitrous oxide can be given for procedural pain Can be given PCA pump Pain remains from weeks to months due to wound cleaning, debridement, physical therapy etc. Tissue healing: Tingling, itching and tightness of contracting skin Clean sheets are placed under and over patient to decrease pain from air currents on nerve endings Anxiety must be treated during all phases of burn care with sedation with anxiolytic medications: Ativan and Versed

Wound Dressing

After cleaning and the prescribed topical agent is applied, the wound is then covered with layers of gauze Light dressing applied over joints Circumferential dressings are applied distally to proximally Fingers and toes are wrapped individually Superficial burns to the face are cleaned, topical agent applied and left open to air Different wound areas may require a variety of wound care techniques

Inhalation Injury

Below the glottis Caused by inhaling incomplete or noxious gases Causing irritation to the alveolar tissue Loss of ciliary action, hypersecretion, severe mucosal edema and bronchospasm Carbon particles in sputum is cardinal sign

Topical Antibiotic Therapy

Best method of local care in extensive burn injury Reduces the number of bacteria at the wound Promotes the open, dirty wound to a closed, clean wound Most commonly used: Polysporin, silver nitrate, madenide acetate (Sulfamylon), and silver sulfadiazine (Silvadene) Newer product: Acticoat Antimicrobial Barrier Dressing is kept wet with sterile water for a controlled, sustained release of silver over the wound to provide an antimicrobial barrier Previously applied topical agent need to be thoroughly removed before reapplication

Fluids, Electrolytes and Blood Volume

Burn Shock: Evaporation of fluid loss can be 3 to 5 L in the first 24 hr. Hyponatremia in the first 7 days of acute phase the fluid shifts from interstitial to the vascular space Hyperkalemia occurs immediately after a burn from massive cell destructions Hypokalemia occurs later due to fluid shifts during anaerobic metabolism due to the increase of lactic acid levels and metabolic acidosis Decreased red blood cells due to immediate damage, blood loss during surgery if needed, and wound care. Blood transfusions may be required to ensure adequate hemoglobin Increase risk of bleeding due to decreased platelets and prolonged clotting

Tetanus Toxoid

Burn patients are at high risk of developing tetanus, since tetanus can present with only slight wounds or shallow burns. Tetanus prophylaxis: Patient immunization history is taken Tetanus vaccine plus anti-tetanus immunoglobulin given if immunization hx is unknown or inadequate Booster given at 4 weeks and 6 months

Infection Protection

Burn wound is an excellent medium for bacterial growth and proliferation The burn eschar has no blood supply Typical burn wound is initially colonized predominantly with gram-positive organisms which are replaced by antibiotic-susceptible gram-negative within a week of the burn injury Primary source of bacterial infection: GI tract Infection impedes burn wound healing by promoting excessive inflammation and damaging tissue Infection control is a major role of the burn team in providing appropriate burn wound care

A worker is involved in an explosion of a steam pipe and receives a scalding burn to the chest and arms. The burned areas are painful, mottled red, weeping and edematous. Which should the nurse conclude is an appropriate classification of these burns?

C. Deep partial- thickness et destruction of epidermis & upper layers of dermis

Chemical

Caused by an acid or base Can cause a reaction to the skin or within the body Acids damage and kill cells by coagulating cells Bases damage and kill by liquefying cells Strong acids, drain cleaners (lye), paint thinner, hydrochloric acid, gasoline

Thermal

Caused by an external heat source Open flame, scald from steam or hot liquid, or by direct contact with a hot object like a hot cooking pan

Radiation

Caused by exposure to radiation Thermal radiation, radio frequency energy, ultraviolet light and ionizing radiation

Pulmonary response- Carbon monoxide

Combines with hemoglobin forming carboxyhemoglobin which competes with oxygen for hemoglobin binding sites Affinity for CO2 is 200 times greater than oxygen Treat early with 100% oxygen

Full Thickness (3rd degree)

Complete epidermis & dermis damage Portion of subcutaneous fat, may involve connective tissue, bone & muscle Caused by sustained flame, electrical, chemical or steam No pain Skin leathery, cracked, avascular White, cherry red or black Cannot self-regenerate, needs skin graft

A nurse is caring for a client who has disturbed body image as a result of a burn injury. Which is the most important nursing intervention for this client?

Conveying a positive attitude toward the client

Deep Partial Thickness (2nd degree)

Damages entire epidermis, part of dermis, leaving hair and sweat glands intact Caused by hot liquid or solids, flames, chemicals, electrical injury Sensitive to pressure Skin dry, pale, waxy with no blanching 30 days to months healing time Late hypertrophic scarring Marked contracture formation

Renal Function

Decreased urine output due to decreased cardiac output initially. Increased urine output after adequate fluid replacement. Acute renal injury Red or Brown urine Hemoglobinuria Excretes myoglobin Kidney Failure

pulmonary changes

Direct airway injury Inhalation injury Carbon Monoxide poisoning Smoke inhalation damaging epithelial cells in lower respiratory tract Alveolar damage Pulmonary edema Decrease oxygen diffusion

A nurse is caring for a client who experienced serious burns in a fire. Which relationship between a client's burned body surface area and fluid loss should the nurse consider when evaluating fluid loss in a client with burns?

Directly proportional: There is a greater extravasation of fluid into the tissues as the amount of tissue volume increases. Thus the relationship of fluid loss to body surface area is directly proportional.

Burn edema

Edema causes pressure on blood vessels and nerves in distal extremities causing obstruction of blood flow and ischemia, known as compartment syndrome Physician may perform an escharotomy, involving surgical incision into eschar which permits the cut edges to separate and restore blood flow to tissues distal to burns May be done in the ER at bedside

Pulmonary response- Restrictive defects

Edema develops under full-thickness burns on neck and thorax. Chest excursion may be restricted, causing decreased tidal volume. Escharotomy is needed to improve ventilation and oxygenation.

Superficial Partial Thickness (2nd degree)

Epidermis and minimal dermis damage Caused by hot liquids, flash flame Sensitive to pain Moist, blisters, pink or mottled red skin Blanches to light pressure 3-4 weeks healing time, minimal scarring

Location of Burn

Face, neck and chest or back can lead to respiratory complications such as mechanical obstruction Hands, feet, joints and eyes may cause difficulties with self care abilities and jeopardize future function Ears and nose are susceptible to infection Circumferential burns to extremities can cause circulatory compensation distal to the burn

Degree of burns

First Superficial Second Superficial partial thickness Deep partial thickness Third Full thickness

Emergent/resuscitative phase

First priority: Initial assessment and treatment of life threatening injuries Cervical spine immobilization ABCDE's: Airway- Patent airway must be established immediately, administer 100% humidified oxygen if needed. Breathing- Must be assessed immediately- respiratory rate, depth and dyspnea, obtain SpO2 reading Circulation- Assess for any obvious arterial bleeding, cap refill, skin color, temp Apical pulse and BP monitored frequently- tachycardia and slight hypotension are expected Burn patient is usually awake and alert initially- can assess neurological status Secondary head to toe assessment is completed to ID any potential life threatening injuries Prevention of shock is very important at this stage! Disability- AVPU scale (Alert, Verbal, Pain Stimuli, Unresponsive) to determine LOC. Exposure/ Environmental Control- Remove non-adherent clothing and jewelry to prevent tissue damage and cover in a dry sterile sheet to prevent further contamination ** Patient remains NPO and HOB remains elevated to prevent aspiration of vomit (paralytic ileus normally results from the stress of injury)

Wound Cleaning

Goal: to remove bacteria and debris with as little chemical and mechanical force as possible to prevent trauma to the healthy tissue Always cleanse the wound before applying a new dressing with sterile normal saline to decrease the risk of cross contamination Unburned areas, including hair, should be washed regularly Small intact blisters may be left but the fluid should be aspirated with a needle and syringe and discarded Blisters larger than 2cm in diameter should be debrided 1-2 days postburn Blisters caused by chemical injuries need to be removed immediately because they obstruct the dilution of the chemical Usually performed daily to wound areas not undergoing surgical intervention More frequent cleaning and debridement may be needed when the eschar begins to separate from the viable tissue beneath (~1.5-2 weeks post burn) After the wound is cleansed, the prescribed method of dressing care is performed Goal of the dressing is to protect the wound from overwhelming proliferation of pathogenic organisms and invasion of deeper tissues until either spontaneous healing or skin grafting can be achieved Patient is assessed for signs of chills, fatigue, changes in hemodynamic status and pain unrelieved by analgesic medications or relaxation techniques

A nurse is evaluating a client's fluid loss resulting from extensive burns. What is the most valuable blood test to use when monitoring a client's fluid loss?

Hematocrit: Increased indicates hemoconcentration secondary to fluid loss

Acute Phase: Fluid and Electrolyte Changes

Hemodilution (decreased hematocrit): Blood cell concentration is diluted as fluid enters the intravascular compartment, loss of RBCs at burn site. Increased urinary output: Fluid shifts to intravascular compartment, increases renal blood flow .:. Increased urine formation. Sodium deficit: Due to diuresis, Na lost with water Potassium deficit: K+ shifts into cells from extracellular compartment on day 4-5 post burn injury Metabolic acidosis: Decreased Na depletes fixed base, relative CO2 content increases

Disorders of Wound Healing

Hypertrophic scarring: more common in children and dark skinned patients Characterized by an overabundant matrix formation, especially collagen More likely to occur with deep dermal burns Compression measures are initiated early in the nursing care as prevention, but focused on in the rehab phase of care Keloids: Overgrowth of granulation tissue that extends beyond the wound surface Failure to heal: Caused by infection, underlying disease, shearing, pressure etc. Serum Albumin < 2g/dL is a factor Contractures: Wound tissue shortens because of force exerted by the fibroblasts and the flexion of muscles in natural wound healing

A client with 35% of total body surface area burned in a fire is now 48 hours postburn. The nurse concludes that the client is moving from the emergent to the acute phase of burn management. Which response supports this conclusion?

Hypokalemia

GI Changes

Ileus is the result of a stress ulcer formation due to stress response of histamine released in acute inflammatory response Paralytic ileus Decrease peristalsis Decreased bowel sounds Curling's ulcer: Distention Gastric bleeding Regurgitation Bloody vomit Abdominal compartment syndrome: Distention Decreased urine output Hypotension

Pathophysiological changes with burns

Immediate inflammatory response due to cell injury Releasing histamine and chemotactic Synthesize mediators such as prostaglandins and leukotrienes Sympathetic nervous system or "fight or flight" response is activated Thirst Gastrointestinal hypomotility Adrenal gland stimulation Hepatic stimulation Vasoconstriction

Cardiovascular response

Immediately hypovolemia Decrease cardiac output Decrease blood pressure SNS releases catecholamines Suppress myocardial conductivity Hypovolemic Shock Impaired cardiac function improved within 24-30 hours post injury with electrical burns: ECG changes Myocardial infarction Cardiac dysrhythmia such as ventricular fibrillation

Grafting of the burn wound

In deep partial thickness or full thickness extensive wounds, epithelium will not spontaneously regenerate Temporary skin grafts protect the burn wound from evaporative water and protein loss, as well as bacterial invasion Biologic Dressings: Temporary to protect granulation tissue until autograft (using patients own skin) can be used Debridement occurs with each dressing change Homograft: aka allograft- skin obtained by living or recently deceased humans Heterograft: aka xenograft- skin taken from animals

Dressing Changes

In patient's room 20 minutes post analgesic or in operating room post anesthesia Mask, face shield/eye protection, hair cover, disposable plastic apron or cover gown, and gloves are worn by the HCP removing the dressings Wounds are cleaned and debrided to remove debris, any remaining topical agent, exudate and dead skin Sterile scissors and forceps are used to trim loose eschar and encourage separation of devitalized skin

Loss of skin!

Inability to regulate body temperature Low body temperature due to loss of skin ~Metabolic rate compensates for the low temperature ~Increasing caloric needs ~Catabolism and nitrogen balance which slows tissue building Hyperthermic state results for postburn period

Pulmonary Response

Inhalation injury is the leading cause of death in fire victims. Early postburn period: Bronchoconstriction is caused by the release of histamine, serotonin and thromboxane. Catecholamine is released in response to stress of the burn injury, which alters peripheral blood flow. Decreased oxygenation peripherally. Later postburn period: Hypermetabolism and catecholamine continued release leads to increased tissue oxygen consumption Hypoxia 100% supplemental oxygen may be needed Upper Airway Injury: Caused by direct heat or edema Inflammation of the pharynx and larynx Excess interstitial fluid Direct heat injury does not usually damage below the bronchus due to rapid vaporization Treated with nasotracheal or endotracheal intubation

Dermal Substitutes

Integra Artificial Skin: Has epidermal and dermal layers, as well as a "neodermis" which is biodegraded and reabsorbed Allows for earlier excision and coverage of the burn wound, metabolic demands are reduced and the survivability of the patient is increased Alloderm: processed dermis from a cadavre, provides permanent dermal layer replacement Only the epidermis of the patient needs to be harvested.

Nutritional support

Metabolic response of the body: increased release of catecholamines, cortisol, glucagon and insulin Increased risk of infection, decreased rate of healing Increased catabolic hormones (break down large molecules)- most important intervention is adequate nutrition and calories to decrease catabolism (large amounts of energy are required for wound healing) Lipids needed for wound healing and absorption of fat soluble vitamins Carbohydrates needed so protein is not broken down for energy Enteral route> parenteral route (greater absorption) Feeding tubes start ASAP Daily calorie counts

Superficial burns (1st degree)

Minimal epithelial damage Example: sunburn Pain that usually resolves within 3-5 days Usually turns the skin red, dry Blanches with pressure Can blister after 24 hours Heals in 5-10 days with no scarring Can be treated with cold-water dressings

pain

Nocioceptive and neuropathic pain components Partial thickness burns: exposed nerve endings= excruciating pain when exposed to air Full thickness burns: nerve endings are destroyed, but wound margins are hypersensitive to pain 3 types of burn pain: Resting/ background pain- 24 hour pain Procedural pain- during wound care/ ROM Breakthrough pain- between doses of medication

Electrical

One of the worst types of burn injuries, can cause lifelong neurovascular problems A true electrical injury results when a current of electricity travels through the body and exits to the ground itself There is contact with the electrical source (an entrance wound), and contact with the grounding site (an exit wound) Electricity travels through areas of least resistance and destroys everything in its path (nerves & blood vessels, bones are destroyed last) Current immediately contracts muscles as it travels through the body and cardiac arrhythmias and spinal injuries often result

A nurse is caring for a client who sustained a partial-thickness burn to the lower leg accounting for 5% of the total body surface area 1 day ago. A primary short-term outcome established by the nurse and client is "The client's

Pain will remain at 2 or less on a scale of 1-10"

Autografts

Patient's own skin is used, preferred method of skin graft (no rejection!) Sheet graft: large pieces of skin, that can be expanded by meshing, to cover larger areas (less scarring) Care of patient with autograft: First dressing change is 3-5 days post surgery Patient begins exercising the grafted area 5-7 days post surgery Care of donor site: Moist gauze is applied at the time of surgery to maintain pressure and to stop any oozing Area will normally heal in 10-14 days

Wound Debridement

Performed by a HCP with advanced training and skills During procedure, the wound and surrounding skin are carefully inspected for: Color Odour Size Exudate Signs of reepithelialization Eschar Changes from previous dressing change As debris accumulates on the wound surface, it can impede keratinocyte migration, which delays the epithelization process Two goals of debridement: To remove tissue contaminated by bacteria and foreign bodies To remove devitalized tissue or burn eschar in preparation for wound healing or skin grafting

A nurse is caring for a client during the emergent phase of a severe burn injury. Which parenteral intervention prescribed by the health care provider should the nurse question?

Potassium as they have hyperkalemia from injured cells

A nurse places a client with severe burns on a circulating air bed. What is the primary reason why the nurse implements this action?

Prevent pressure on peripheral blood vessels. Circulating air bed disperses body wt over a larger surface reducing pressure against the capillary beds allowing for tissue perfusion.

Immunologic Defenses

Serious burns decrease resistance to infection. Impairment of the production and release of granulocytes and macrophages from bone marrow. Abnormal inflammatory responses alter levels of immunoglobulins and serum complement, impaired neutrophil function and decreased lymphocytes. High risk for sepsis.

Which is the most difficult problem for the nurse to manage when meeting the needs of an extensively burned client 3 days after admission?

Severe pain

A nurse is assessing a client during the first 24 hours after a burn injury. Which sign indicates to the nurse that fluid replacement therapy is adequate?

Slowing of a previously rapid pulse. Pulse rate decreases as intravascular volume normalizes

Biosynthetic and synthetic dressings

Temporary, more cost effective, sterile and available than biologic dressings Biobrane is most widely used, adheres directly to the wound fibrin and cells migrate into the dressing matrix within 5 days. Remains for 3-4 weeks. Biobrane can be laid on top of autograft until wound is healed

Rule of nines

The Rule of Nines estimates of the TBSA involved in a burn by using multiples of 9s and is used to help guide treatment decisions including fluids and to determine if the client needs to be transferred to a burn unit.

Hydrotherapy

The external use of water to soothe pain and minimize skin damage in a burn injury Mild burn injury: run cool water over burned skin for 5-10 minutes Severe burn injury: hydrotherapy promotes healing by softening and removing dead tissue to promote new tissue formation Hydrotherapy on a burn unit: Can start a few days after trauma, once patient has stabilized. Immersion hydrotherapy: the use of hydrotanks with sterilized water, which use a lift to assist patient in and out. Must be disinfected properly as risk for infection is high in burn patients and can be a serious side effect Shower hydrotherapy: less chance of infection, just as effective as immersion

Types of burns

Thermal (flame, scalding) Radiation (thermal radiation, UV: sunburn) Chemical (acids, alkalines) Electrical (short-circuits, lightening)

Occlusive Method

Thin gauze that is impregnated with a topical antimicrobial agent or that is applied after topical antimicrobial application Most often used over areas with new skin grafts Purpose is to protect the graft Remain in place for 3-5 days, then removed for examination of the graft Careful precautions are made when applying dressings to prevent two body surfaces from touching Functional body alignment positions are maintained by using splints or careful positioning of the patient

Mechanical Debridement

Uses surgical scissors and forceps to separate and remove the eschar Performed by skilled physicians, nurses or physiotherapists and is usually done with daily dressing changes and wound cleaning procedures Debridement is carried out to the point of pain and bleeding Pressure can be used to stop bleeding from small vessels Wet to dry dressings are not advocated in burn care Topical enzymatic debridement agents are available to promote debridement: To be used with topical antibacterial therapy to prevent bacterial invasion

Phases of burn care

·Emergent/ Resuscitative phase· ·Acute or Intermediate phase· ·Rehabilitation phase· *Each phase may overlap and span two or three phases (rehab begins on the 1st day after burn injury!)