Care of Patients with Burns
Rule of Nines
The most rapid method for calculating the size of a burn injury in adult patients whose weights are in normal proportion to their heights. Head: -Anterior 4.5% -Posterior 4.5% -Total: 9% Arms: -Anterior 4.5% -Posterior 4.5% -Total for one arm 9% -Total for both arms 18% Trunk: -Anterior 18% -Posterior 18% -Total: 36% Groin: -1% Legs: --Anterior 4.5% -Posterior 4.5% -Total for one leg 9% -Total for both leg 18% Total 100%
Immune Assessment
The patient with a burn injury is at risk for infection because of open wounds and reduced immune function. -BURN WOUND SEPSIS IS A SERIOUS COMPLICATION OF BURN INJURY, AND INFECTION IS THE LEADING CAUSE OF DEATH DURING THE ACUTE PHASE OF RECOVERY. Enforce meticulous hand washing by all health care personnel -USE ASEPTIC TECHNIQUE FOR WOUNDS AND DURING INVASIVE MONITORING TO PREVENT INFECTIONS
General Management for All Types of Burns
-Assess for airway patency -Administer oxygen as needed -Cover the patient with blanket -Keep the patient on NPO status -Elevate the extremities if no fractures are obvious -Obtain VS -Initiate an IV line, and begin fluid replacement -Administer tetanus toxoid for prophylaxis -Perform a head-to-toe assessment
Minimizing Weight Loss
-Nasoduodenal tube feedings are often started soon after admission -Encourage patients who can eat solid foods to ingest as many calories as possible -Consider the patient's preference with diet planning and food selection -Encourage patients to request food whenever they feel they can eat -OFFER FREQUENT HIGH-CALORIE, HIGH-PROTEIN SUPPLEMENTAL FEEDINGS
Radiation Injuries
-People are exposed to large doses of radioactive material
Examine the wounds for these signs of infection:
-Pervasive odor -Color changes--Focal, dark red, brown discoloration in the eschar -Change in texture -Purulent drainage -Exudate -Sloughing grafts -Redness at the wound edges extending to nonburned skin
Superficial Burn
-Pink to red -Mild edema -Painful -No blisters -No eschar -Healing takes 3-6 days -No grafts required Examples: -Sunburn -Flash burns
Superficial Partial-Thickness Burn
-Pink to red -Mild to moderate edema -Painful -Blisters present -No eschar -Healing takes about 2 weeks -No grafts required Examples: -Scalds -Flames -Brief contact with hot objects
Maintaining Mobility
-Positioning is critical for patients with burn injuries because the position of comfort for the patient is often one of join flexion , which leads to contracture development -Splints and other devices may help the patient maintain good positioning -Range-of-motion exercises are performed actively at least three times a day -Ambulation is started as soon as possible after the fluid shifts have resolved--Ambulation inhibits bone density loss, strengthens muscles, stimulates immune function, promotes ventilation, and prevents many complications -Pressure dressings are applied after grafts heal to help prevent contractures and tight hypertrophic scars, which can inhibit mobility--These dressings also inhibits venous stasis and edema in areas with decreased lymph flow
Psychological Problems that require intervention
-Post-traumatic stress disorder -Sexual dysfunction -Severe depression
Deep Partial-thickness Burn
-Red to white -Moderate edema -Painful -Blisters are rare -Eschar is soft and dry -Healing time is 2-6 weeks -Grafts can be used it healing is prolonged Examples: -Scalds -Flames -Prolonged contact with hot objects -Grease -Chemicals These wounds can convert to full-thickness wounds when tissue damage increases with infection, hypoxia, or ischemia.
Radiation Burns
-Remove the patient from the radiation source -If the patient has been exposed to radiation from an unsealed source, remove his/her clothing (using tongs or lead protective gloves) -If the patient has radioactive particles on the skin, send him/her to the nearest designated radiation decontamination center. -Help the patient bathe or shower
Resuscitation Phase of Burn Injury
-1st phase of a burn injury -The injury is evaluated and the immediate problems of fluid loss, edema, and reduced blood flow are assessed
Systemic Signs of Infection
-Altered level of consciousness -Changes in VS (Tachycardia, Tachypnea, Temperature, Instability, Hypotension) -Increased fluid requirements for maintenance of a normal urine output -Hemodynamic instability -Oliguria -GI dysfunction (Diarrhea, Vomiting, Abdomina distention, Paralytic ileus) -Hyperglycemia -Thrombocytopenia -Change in total white blood cell count (above normal or below normal) -Metabolic acidosis -Hypoxemia
A change in respiratory pattern may indicate a pulmonary injury. The patient may:
-Become progressively hoarse -Develop a brassy cough -Drool or have difficulty swallowing -Produce sounds on exhalation that include audible wheezes, crowing and stridor -ANY OF THESE CHANGES MAY MEAN THE PATIENT IS ABOUT TO LOSE HIS OR HER AIRWAY -FOR A BURN PATIENT IN THE RESUSCITATION PHASE WHO IS HOARSE, HAS A BRASSY COUGH DROOLS OR HAS DIFFICULTY SWALLOWING, OR PRODUCES AN AUDIBLE BREATH SOUND ON EXHALATION, IMMEDIATELY APPLY OXYGEN AND NOTIFY THE RAPID RESPONSE TEAM
Diuretic Stage
-Begins at 48 to 72 hrs. after burn injury as capillary membrane integrity returns and edema fluid shifts from the interstitial space into the intravascular space -Blood volume increases, leading to increased kidney blood flow and diuresis -Hyponatremia develops because of increased kidney sodium excretion and the loss of sodium from wounds. -Hypokalemia results from potassium moving back into the cells and also being excreted in urine. -Anemia often develops as a result of hemodilution
Deep Full-Thickness Burn
-Black -Edema is absent -Pain is not present -No blisters present -Eschar is hard and inelastic -Takes weeks to months to heal -Grafts required Examples: -Flames -Electricity -Grease -Tar -Chemicals Amputation may be needed when an extremity is involved
Full-Thickness Burn
-Black, brown, yellow, white, and red -Severe edema -Pain can be present or not present -No blisters present -Eschar is hard and inelastic -Takes weeks to months to heal -Grafts are required Examples: --Scalds -Flames -Prolonged contact with hot objects -Tar -Grease -Chemicals -Electricity The eschar is dead tissue; it must slough off or be removed from wound before healing can occur.
Electrical Injuries
-Burns occurring when an electrical current enters the body -Grand masquerader--because the surface injuries may look small but the associated internal injuries can be huge Burn injuries from electricity can occur in one of three ways: 1. Thermal burns--Clothes ignite from heat or flames produced by electrical sparks 2. Flash burns 3. True electrical injury--Direct contact is made with an electrical source
Inflammatory Compensation
-Can be helpful by triggering healing in the injured tissues. -Responsible for some of the serious problems that occur with the fluid shift
Moist Heat (Scald) Injuries
-Caused by contact with hot liquids or steam
Dry Heat Injuries
-Caused by open flame
Pulmonary Fluid Overload
-Circulatory from fluid resuscitation may cause left-sided congestive heart failure. -Excess lung tissue fluid makes gas exchange difficult--THE PATIENT IS SHORT OF BREATH AND HAS DYSPNEA IN THE SUPINE POSITION. CRACKLES ARE HEAR ON AUSCULTATION -When symptoms of pulmonary edema are present--ELEVATE THE HEAD OF BED AT LEAST 45 DEGREES, APPLY HUMIDIFIED OXYGEN, AND NOTIFY THE BURN TEAM OR THE RAPID RESPONSE TEAM
Local Signs of Infection
-Conversion of a partial-thickness injury to a full-thickness injury -Ulceration of heath skin at the burn site -Erythematous, nodular lesions in uninvolved skin and vesicular lesions in healed skin -Edema of health skin surrounding the burn wound -Excessive burn wound drainage -Pale, boggy, dry, or crusted granulation tissue -Sloughing of grafts -Wound breakdown after closure -Odor
Cardiac Changes Resulting from Burn Injury
-Heart rate increases -Cardiac output decreases (the initial fluid shifts and hypovolemia that occur after a burn injury.
Contact Burn Injuries
-Hot metal, tar, or grease contacts the skin, often leading to a full-thickness injury
Management of Chemical Burns
-If dry chemicals are present on skin or clothing. DO NOT WET THEM -Brush off any dry chemicals present on the skin or clothing -Remove the patient's clothing -Ascertain the type of chemical causing the burn -Do not attempt to neutralize the chemical unless it has been positively identified and the appropriate neutralizing agent is available
Fluid Resuscitation of the Burn Patient
-Initiate and maintain at least one large-bore IV in an area of intact (If possible) -Coordinate with physicians to determine the appropriate fluid type and total volume to be infused during the first 24 hours postburn -Administer one half of the total 24-hour prescribed volume within the first 8 hours postburn and the remaining volume over the next 16 hours. -Assess IV access site, infusion rate, and infused volume at least hourly Monitor these vital signs at least hourly: -Blood pressure -Pulse rate -Respiratory rate -Breath sounds -Voice quality (if not intubated) -Oxygen saturation -End-tidal carbon dioxide levels Assess urine output at least hourly: -Volume -Specific gravity -Color -Character -Presence of protein Assess for fluid protein: -Formation of dependent edema -Engorged neck veins -Rapid, thready pulse -Presence of lung crackles or wheezes on auscultation -Measure additional body fluid output hourly
Skin Changes Resulting from Burn Injury
-It is a protective barrier against and microbial invasion--Burns break this barrier greatly increasing the risk for infection -The skin helps maintain the delicate fluid and electrolyte balance essential for life--After a burn injury, massive fluid loss occurs through evaporation
Pulmonary Changes Resulting from Burn Injury
-Respiratory problems are caused by super heated air, steam, toxic fumes, or smoke. -SUCH PROBLEMS ARE A MAJOR CAUSE OF DEATH IN PATIENTS WITH BURNS AND ARE MOST LIKELY TO OCCUR WHEN THE BURN TAKES PLACE INDOORS. Respiratory failure with burn injuries can result from airway edema during fluid resuscitation, pulmonary capillary leak, chest burns that restrict chest movement, and carbon monoxide poisoning. Heat can reach the upper airway, causing an inflammatory response that leads to edema of the mouth and throat with the potential of airway obstruction.
Chemical Burn Injuries
-Results of accidents in homes or industry -Chemicals directly contact the skin and epithelial tissues or are ingested
Electrical Burns
-Separate the patient from the electrical current -Smother any flames that are present -Initiate cardiopulmonary resuscitation -Obtain an ECG
Fluid Remobilization
-Starts at about 24 hrs. after injury when the capillary leak stops
Managing Pain
-The priority nursing actions include continually assessing the patient's pain level, using appropriate pain-reducing strategies and preventing Drug therapy usually requires opioid analgesics: -Morphine sulfate -Hydromorphone (Dilaudid) -Fentanyl When these agents are given IM or subcutaneously, they remain in the tissue spaces and do not relieve pain The IV route is used for giving opioid drugs because of problems with absorption from the muscle and stomach!!!
Respiratory assessment in Resuscitation Phase of Burn Injury
-Upper airway edema and inhalation injury are most common in the trachea and mainstem bronchi. -Auscultation of these areas may reveal wheezes which indicate partial obstruction -Patients with severe inhalation injuries may have such a rapid obstruction that within a short time, they cannot force air through the narrowed airways. As a result the wheezing sounds disappear --THIS FINDING INDICATES IMPENDING AIRWAY OBSTRUCTION AND DEMANDS IMMEDIATE INTUBATION.
The priority problems for the patient with burn injuries in the resuscitation phase who has sustained a burn injury greater than 25% of the TBSA are:
1. Potential for inadequate oxygenation related to upper airway edema, pulmonary edema, airway obstruction, or pneumonia 2. Hypovolemic shock related to increase in capillary permeability, active fluid volume loss, electrolyte imbalance, and inadequate fluid resuscitation 3. Potential for organ ischemia (Brain, heart, kidney, gastrointestinal) related to hypovolemia and hypotension 4. Acute and Chronic Pain related to tissue injury, damaged or exposed nerve endings, debridement, dressing changes, invasive procedures, and donor sites 5. Potential for acute respiratory distress syndrome (ARDS) related to inhalation injury
The Priorities for Management during Resuscitation Phase
1. Secure the airway 2. Support circulation by fluid replacement 3. Keep the patient comfortable with analgesics 4. Prevent infection through careful wound care 5. Maintain body temperature 6. Provide emotional support
Third Spacing (Capillary Leak Syndrome)
A continuous leak of plasma from the vascular space into the interstitial space
Amniotic Membrane
A form of biologic dressing used on burn wounds Its large size, low cost, and availability have helped with its success. The membrane requires frequent changes because it does not develop a blood supply and it disintegrates in about 48 hours
Teaching for Self-Management
A weekly plan for patient education is outlined; a positive outcome is progression toward independence for the patient and family Allow patients and family members to first observe dressing changes, then to assist in performing the changes, and finally to change the dressings independently under your supervision In addition to details about dressing changes, explain: -Signs and symptoms -Drug regimens -Proper use of prosthetic and positioning devices -Correct application and care of pressure garments -Comfort measures to reduce pruritus -Dates for follow-up appointments
Curling's Ulcer
Acute gastroduodenal ulcer that occurs with the stress of severe injury -May develop within 24 hrs. after a severe burn injury because of reduced GI blood flow and mucosal damage.
Artificial Skin
An alternative approach to closure of the burn wound The substance has two layers, a Silastic epidermis and a porous dermis made from beef collagen and shark cartilage
Parkland Formula
Crystalloid only (Lactated Ringer's) 4 mL/kg/% TBSA burn Fluid replacement formulas are calculated from the time of injury and not from the time of arrival at the hospital.
Acute Phase of Burn Injury
Begins about 36 to 48 hours after injury and lasts until wound closure is complete Priority nursing interventions: -Assess the cardiovascular systems to maintain these systems and to identify or prevent complications The patient may develop pneumonia that can result in respiratory failure requiring mechanical ventilation The patient is at risk for infection and sepsis, which affect cardiovascular function
Biosynthetic Wound Dressings
Biosynthetic wound dressings are a combination of biosynthetic and synthetic materials
Mechanical Debridement
Burn wounds are debrided and cleaned one or two times each day during hydrotherapy (The application of water for treatment) Hydrotherapy is most often performed by showering the patient on a specially designed shower table, or washing only small areas of the wound at the bedside
Carbon Monoxide Poisoning
CO also causes the oxyhemoglobin dissociation curve to shift to the left, which impairs oxygen unloading at the tissue layer. The vasodilating action of carbon monoxide causes the "cherry red" color (or at least the absence of cyanosis) in these patients 1-10% (Normal): -Increased threshold to visual stimuli -Increased blood flow to vital organs 11-20% (Mild Poisoning): -Headache -Tinnitus -Nausea -Drowsiness -Vertigo -Altered mental state -Confusion -Stupor -Irritability -Decreased blood pressure -Increased and irregular heart rate -Depressed ST segment on ECG and dysrhythmias -Pale to reddish purple skin 41-60% (Severe Poisoning): -Coma -Convulsions 61-80% (Fatal poisoning): -Death
Kidney/Urinary Assessment
Changes in kidney function with burn injury are related to decreased blood flow and to cellular debris. During the fluid shift: -Blood flow to the kidney may not be adequate for glomerular filtration -Urine output is greatly decreased compared with IV fluid intake -The urine is very concentrated and has a high specific gravity -Myoglobin is released from damaged muscle and circulates to the kidney--Most damaged cells release proteins that form uric acid. -A "SLUDGE" then forms that blocks kidney blood and urine flow and may cause KIDNEY FAILURE!!! Urine output is decreased during the first 24 hrs. of the resuscitation phase. Fluid resuscitation is provided at the rate needed to maintain urine output at 30-50 mL or 0.5mL/kg/hr Assess response to fluid resuscitation by: -Measuring urine specific gravity -Blood urea nitrogen (BUN), -Serum creatinine -Serum sodium levels -Hourly urine output -Examine the urine for color, odor, and the presence of particles or foam
Synthetic Dressings
Dressings are made of solid silicone and plastic membranes Transparent film is the dressing commonly used for the care of donor site wounds. This dressing type promotes faster healing with low infection rates, minimal pain, and reduced cost
Home Care Management
During the first weeks at home, the patient usually needs at least daily wound care, physical therapy, nutritional support symptom management, and drug therapy
Vascular Changes Resulting From Burn Injury
FLUID SHIFT occurs after initial vasoconstriction as a result of blood vessels near the burn dilating and leaking fluid into the interstitial space -The loss of plasma fluids and proteins decreases blood volume and blood pressure -Extensive edema -Excessive weight gain occurs in the first 12 hours after the burn and can continue for 24 to 36 hours Imbalances of fluid, electrolytes and acid-base: -Hypovolemia -Metabolic Acidosis -Hyperkalemia (Results from direct cell injury that releases large amounts of cellular potassium) -Hyponatremia (Sodium is trapped in the interstitial space and a sodium deficit occurs in the blood) -Hemoconcentraion (elevated blood osmolarity, hematocrit, and hemoglobin) develops from vascular dehydration--Increases blood viscosity, reducing flow through small vessels and increasing tissue hypoxia
Acids
Found in: -Bathroom cleaners -Rust removers -Chemicals for swimming pools -Industrial drain cleaners Damage tissue by coagulating cells and skin proteins, which can limit the depth of tissue damage
Alkalis
Found in: -Oven cleaners -Fertilizers -Drain Cleaners -Heavy industrial cleaners Damage the tissues by causing the skin and its proteins to liquefy
Cultured skin
Grown from a small specimen of epidermal cells from an unburned area of the patient's body.
Hemografts (Allografts)
Human skin obtained from a cadaver and provided through a skin bank Disadvantages to the use of homografts are the high costs and the risk for tranmitting a blood-borne infection
Cardiac Assssment
Hypovolemic shock is a common cause of death in the resuscitation phase in patients with serious injuries Cardiac manifestations are from: -Hypovolemia -Decreased cardiac output At first the patient has: -Tachycardia -Decreased blood pressure -Decreased peripheral pulses ECG changes can indicate damage to the heart as a result of electrical burn injuries or stress that induces a myocardial infarction
Fasciotomies
Incisions through eschar and fascia -Needed to relieve pressure and allow normal blood flow and breathing
Escharotomies
Incisions through the eschar -Needed to relieve pressure and allow normal blood flow and breathing
Auto-contamination
Infection that occurs in which the patient's own normal flora overgrows and invades other body areas, especially the GI tract
Cyanide Poisoning
May occur in patients burned in house fires -Elevated plasma lactate level is one indicator of cyanide toxicity in patients who do not have severe burns
Signs and Symptoms of Sepsis caused by Fungal
Onset: -Delayed Cognition: -Mild disorientation Ileus: -Mild Diarrhea: -Occasional Temperature: -Fever Hypotension: -Late WBC: -Neutrophilia Platelets: -Low
Signs and Symptoms of Sepsis caused by Gram-Positive
Onset: -Insidious, 2-6 days Cognition: -Severe disorientation and lethargy Ileus: -Severe Diarrhea: -Rare Temperature: -Fever Hypotension: -Late WBC: -Neutrophilia Platelets: -Normal
Signs and Symptoms of Sepsis caused by Gram-Negative
Onset: -Rapid, 12-36 hrs. Cognition: -Mild disorientation Ileus: -Severe Diarrhea: -Severe Temperature: -Hypothermia Hypotension: -Early WBC: -Neutropenia Platelets: -Low
Cross-contamination
Organisms from other people or environments are transferred to the patient
Laboratory Profile: Burn Assessment During the Resuscitation Phase
Serum studies: Hemoglobin 12-16 g/dL (Women) 14-18 g/dL (Men) -Elevated as a result of fluid volume loss Hematocrit 37-47% (Women) 42-52% (Men) -Elevated as a result of fluid volume loss Urea nitrogen 10-20mg/dL -Elevated as a result of fluid Glucose 70-105 mg/dL -Elevated as a result of the stress response and altered uptake across injured tissues Electrolytes: Sodium 136-145 mEq/L -Decreased; sodium is trapped in edema fluid and lost through plasma leakage Potassium 3.5-5.0 mEq/L -Elevated as a result of disruption of the sodium-potassium pump, tissue destruction and red blood cell hemolysis Chloride 98-106 mEq/L -Elevated as a result of fluid volume loss and reabsorption of chloride in urine ABGs Pa02 80-100 mm Hg -Slightly decreased PaCO2 35-45 mm HG -Slightly increased from respiratory injury pH 7.35-7.45 -Low as a result of metabolic acidosis Carboxyhemoglobin 0-10% -Elevated as a result of inhalation of smoke and carbon monoxide Other: Total Protein 6.4-8.3 g/dL -Low; protein exudate is lost through the wound Albumin 3.5-5.0 g/dL -Low; protein is lost through the wound and through vascular membranes because of increased permeability
Herterografts (Xenografts)
Skin obtained from another species Pigskin is the most common heterograft and is compatible with human skin Pigskin is assessed daily for adherence and need for replacement
Rehabilitative Phase of Burn Injury
Technically begins with wound closure and ends when the patient returns to his or her highest level of functioning The emphasis is on the psychosocial adjustment of the patient, the prevention of scars and contractures, and the resumption of preburn activity, including resuming work, family, and social roles.
Gastrointestinal Assessment
The decreased blood flow and sympathetic stimulation to reduce GI motility and promote development of a paralytic ileus Other manifestations: -Nausea -Vomiting -Abdominal distention Patients with burns of 25% TBSA (Total Body Surface Area) or who are intubated generally require a nasogastric (NG) tube inserted to prevent aspiration and remove gastric secretions
Evaluation: Outcomes
The expected outcomes include that the patient should: -Maintain adequate oxygenation and circulation to all vital organs -Maintain a patent airway -Have cardiac output restored to normal -Have pain alleviated or reduced -Experience no further loss of skin integrity -Have wounds healed without complications -Remain free from infection by cross-contamination -Not experience sepsis -Maintain an adequate nutrient intake for meeting the body's calorie needs -Regain and maintain an optimal ability to move purposefully -Have a positive perception of his her own appearance and body functions
Gastrointestinal Changes Resulting from Burn Injury
The fluid shifts and decreased cardiac output that occur after injury divert blood flow to the brain, heart, and liver. -Peristalsis decreases, and a paralytic ileus may develop
Supporting a Positive Self-Image
The patient with a burn injury is expected to have a positive perception of his/her own appearance, body functions, and self-worth: -Willingness to touch the affected area -Adjustment to changes in body function -Willingness to use strategies to enhance appearance and function -Successful progression through the grieving process -Use of support systems -Engaging in decision making and independent activities fosters feelings of self-worth, which are closely linked to self image. -Plan and encourage the patient's active participation in self-care activities -Reconstructive and cosmetic surgery can be performed many years after the burn injury.
Sympathetic Nervous System Compensation
The stress response that occurs when any physical or psychological stressors are present -Most evident in cardiovascular, respiratory and GI systems
Fascial Technique
The surgeon cuts away the burn wound to the level of superficial fascia
Tangential Technique
The surgeon removes very thin layers of the necrotic burn surface until bleeding tissue is encountered
Pathophysiology of Burn Injury
The tissue destruction caused by a burn injury leads to many local and systemic problems: -Fluid and protein loss -Sepsis -Changes in metabolic -Changes in endocrine -Changes in respiratory -Changes in cardiac -Changes in hematologic -Changes in immune functioning -ALL BURN INJURIES ARE VERY PAINFUL
Thermal (Heat) Injury
Thermal burns to the respiratory tract are usually limited to the upper airway above the glottis Heat damage to the pharynx produce: -Edema -Upper airway obstruction If the upper airways were exposed to heat, INTUBATION may be performed as an early intervention before obstruction occurs
