Management of Patients with Burn Injury (BA) Test 3

Radiation burns

- UV rays from the sun or tanning booths x-rays - certain types of radiation therapy for the treatment of cancer - radio frequency energy and thermal radiation -The effects of radiation burns depend on the energy of the radiation as well as the intensity of exposure

Acute/Intermediate Phase

-48 to 72 hours after injury -Continue assessment and maintain respiratory and circulatory support -Prevention of infection, wound care, pain management, and nutritional support are priorities in this stage

Severity of Burns

-Age of pt. -Depth -TBSA -Inhalation? -Other injuries? -Location of burn -PMH

Managing Pain-

-Analgesics -IV use during emergent and acute phases -Morphine -Fentanyl Other -Role of anxiety in pain -Effect of sleep derivation on pain -Non-pharmacologic measures

Major burn-

-Any burn involving the respiratory tract or involving other major traumatic injury (i.e. broken bones, large lacerations, etc.) -2nd or 3rd degree burns involving the face, hands, feet, genitalia, or respiratory tract -Any 3rd degree burn covering more than 10% BSA -Any 2nd degree burn covering more than 30% BSA -Any 2nd or 3rd degree circumferential burn to any extremity -Any moderately classed burn in children less than 5 years or older than 55 years of age

Wound Grafting

-Autografts -Hemografts and xenografts -Biosynthetic and synthetic dressings (less costly)

Hypermetabolism/Nutritional Support

-Burn injuries produce profound metabolic abnormalities, and patient with burns have great nutritional needs related to stress response, hypermetabolism, wound healing. hypermetabolism - ↑ risk of infection and slows healing -Goal of nutritional support - promote a state of nitrogen balance and match nutrient utilization. Nutritional support - based on patient pre-burn 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.

Burns are caused by a transfer of energy from a heat source to the body Thermal Radiation Chemical Electrical

-Burns less than 25% TBSA produce primarily a local response. -Burns more than 33% 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 hypo-perfusion and organ hypo-function.

Effects of Major Burn Injury

-Cardiovascular effects-cardiac depression, stress ↑'s cardiac workload -Fluid and electrolyte shift-immediately after hyperkalemia, hyponatremia. > fluid leak 24-48 hrs.

Burns /Child

-Common and preventable -Young children ↑st risk -Mortality ↑st in younger than 6 yrs -3rd leading cause of death b/t 1 and 4 yrs

Fluid and Electrolyte Shifts—Emergent Phase

-Decreased urine output-oliguria -Release of potassium into extracellular fluid: d/t massive tissue destruction : hyperkalemia (hypokalemia later) -Edema in 4 hrs up to 18 hrs -Plasma loss: hyponatremia (seizures, coma, cardiac arrest) -Metabolic acidosis

Full thickness including fat, fascia, muscle, and /or bone (Fourth Degree)

-Extend into deep tissue, muscle or bone -Hair follicles, sweat glands destroyed -Prolonged exposure or high voltage electrical injury -Shock, myogloboniuria and hemolysis -Charred -Loss of extremities likely -Grafting is no benefit r/t depth and severity of wounds

Degree of burn

-First degree= Superficial -Second degree= Partial thickness -Third degree= Full thickness (deep dermal) -Fourth degree= Full thickness that includes fat, fascia, muscle and /or bone

Collaborative Problems and Potential Complications

-Heart failure and pulmonary edema -Sepsis -Acute respiratory failure -Visceral damage (electrical burns)

Factors to Consider in Determining Burn Depth/Classification

-How the injury occurred -Causative agent -Temperature of agent -Duration of contact with the agent -Thickness of the skin

Fluid and Electrolyte Shifts—Emergent Phase

-Hypovolemia-Intravascular volume is lost (capillary leaking) -Reduced blood volume and hemo-concentration (increase in the proportion of formed elements in the blood, as a result of a decrease in its fluid content)

Abuse

-In relation to the home environment, most burns occur in the kitchen involving food preparation and mealtimes. -Seasonal variance indicates the winter months as a time of increased risk. -Injury may occur whilst under the supervision, of one or both parents.

Superficial (First Degree)

-Involves Epidermis (possibly dermis) -Sunburn, superficial scald -Pain soothed by cooling -Minimal or no edema -Complete recovery within a few days -Oral pain meds , cool compresses

Partial Thickness (Second degree)

-Involves epidermis and part of dermis -Scalds, flash flame -Pain, hypersensitive to air -Blistered, weeping surface r/t disrupted epidermis, edema -Recovery- 2-3 weeks -May require grafting

Full thickness (Third degree

-Involves epidermis, dermis, sometimes subcutaneous fat, and may involve muscle and connective tissue -Flame, electrical current (entrance and exit wound), chemical contact, molten metal -Lacking feeling, shock, myoglobinuria, hemolysis -Dry, pale white, red, brown, leathery or charred -Edema -Eschar may slough, grafting necessary and scaring and contractures -May lose extremity -Capillary integrity loss

Management of Burn Shock—Fluid Resuscitation/ Burns 20% or > TBSA

-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 -Evans formula -Brooke Army formula -Parkland Baxter formula (4ml x wt in kg x %TBSA) Hypertonic saline formula (all use different formulas)

Abnormal Wound Healing

-May suffer from PTSD -Keloid scars (Normal scars begin 7-10 post injury) -Burn garments (burn anti-pressure garments) include gloves, face hoods, chin straps, jackets, pants, leotards, hose, or entire body suits (body gloves) which provide pressure to burned areas to help with healing.

Homecare

-Mental health -Skin and wound care -Exercise and activity -Nutrition -Pain management -Thermoregulation and clothing -Sexual issues

Gerontologic Considerations

-Mortality rates increase r/t age related changes -Fire/flame most common -Males 60% (60 years and older) -Complications- Pneumonia, UTI, Resp failure -↓ kidney and hepatic function -Malnutrition prior to injury -Dementia

Emergent/Resuscitative Phase

-Patient is transported to emergency department -ABC's -Fluid resuscitation is begun in burns > 20% TBSA -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- may be abuse, neglect, suicide attempt

Mobility, Coping, Support

-Prevent complications-contractures -Strengthen coping strategies -Support pt. and family

Burn Goals

-Prevention (Chart 62-1) -Life saving measures for severely burned clients -Prevention of disability and disfigurement -Rehabilitation

Major Burns= One Third of TBSA

-Produce Local and Systemic response -Characterized by burn wound edema, generalized edema in good tissue, c/v function alteration, impaired organ perfusion

Rehabilitation Phase

-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 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. -May be complications.

Emergent or Resuscitative Phase— On-the-Scene Care

-Remove pt from source of injury and Prevent injury to rescuer -Stop injury: extinguish flames, soak clothing, cool the burn -Rescue workers-ABCs: Establish airway, breathing, and circulation -Start oxygen and large-bore IVs -Remove restrictive objects and cover the wound -Irrigate chemical burns -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.

Prevention

-Signs of child abuse induced burns -Our most defenseless children are the most likely to be burned intentionally. Child abuse burn victims are almost always under the age of 10 with the majority under the age of 2.

Emergent Phase

-The burn patient has a number of complex injuries that must be taken care of: in addition, the patient's condition changes substantially during the burn disease's evolution. -The initial post-burn period is characterized by cardiopulmonary instability (caused by- significant fluid shifts between compartments) and in many cases by direct injuries to the airways. -With the onset of wound inflammation. immunosuppression, and infection the physiological and metabolic parameters change from those seen initially.

Pulmonary Injury

-Upper airway/Inhalation below the glottis -Lower airway -Carbon monoxide poisoning -Restrictive deficits Smoke may contain 400 toxic Compounds!

Chemical burns

-caused by industrial or household chemicals that are corrosive and abrasive to the skin. -may occur from chemicals in solid, liquid, or gas form. -caused by direct contact with a strong acid or base.

Electrical Burns

-occur rapidly as electricity passes through the body. -typically more severe, causing more damage to tissue layers beneath the skin. -the severity of electrical burns are underestimated and underdiagnosed. -Severe electrical burns may cause shock or strain to internal organs, including the brain or heart.

Thermal

Flame, Scald (from steam, hot or molten liquid), Contact (from a hot object, such as a hot cooking pan)

Moderate burn-

3rd degree burns covering 2% to 10% BSA, EXCLUDING face, hands, feet, genitalia, or respiratory tract. 2nd degree burns of 15% to 30% BSA 1st degree burns of greater than 50% BSA

Minor burn-

3rd degree burns involving less than 2% BSA 2nd degree burns involving less than 15% BSA

Acute or intermediate phase=

From beginning of diuresis to wound closure

Rehabilitation phase=

From wound closure to return to optimal physical and psychosocial adjustment

Potential Complications and Collaborative Problems

Acute respiratory failure Distributive shock Acute renal failure Compartment syndrome Paralytic ileus Curling's ulcer

Burn Mortality

Age + %TBSA = Mortality 25 + 25% = 50 % Survival Rate

Topical Antibacterial Therapy

Alteration of therapy is necessary : refer to Table 62-4 General -Antimicrobial ointment Specific -Silver Sulfadiazine -Mafenide Acetate (severe side effects if impaired renal function)) -Silver nitrate -Silver impregnated dressings

Infection Prevention

At risk for: -Health care associated infections d/t Barrier loss -Necrotic tissue in burn eschar + serum proteins = environment for bacterial growth -Burns Compromise local and systemic immunity

Managing Pain

Burn pain - 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 -Background or resting -Procedural -Breakthrough

Pathophysiologic Changes with Severe Burns

CV Pulmonary GI Kidney

Wound Debridement

Goal: -Removal of devitalized tissue or eschar -Removal of contaminated tissue -Natural debridement -Mechanical debridement -Chemical debridement -Surgical debridement

Systemic Effects

Immediate systemic event= hemodynamic instability r/t loss of capillary integrity resulting in fluid shift, sodium, and protein from intravascular space to interstitial space= hypovolemic shock

e of the Nursing Process in the Care of the Patient in the Emergent Phase of Burn Care—Diagnoses

Impaired gas exchange Ineffective airway clearance Fluid volume deficit Hypothermia Acute pain Anxiety

ABA (American Burn Association)

Lactated Ringers -Dosage Form: IV solution 2ml - 4ml LR x pts wt in kg x %TBSA 2nd, 3rd, 4th- degree burns ½ of total in 1st 8 hrs 2nd half next 16 hours Titrate to u/o

Lund and Browder method

More precise % of surface area r/t age of pt

Rule of Nines

Most commonly used for adults Divides anatomic regions

Emergent or resuscitative phase=

Onset of injury to completion of fluid resuscitation

Common signs of significant smoke inhalation injury and the potential need for intubation include

Persistent cough, stridor, or wheezing -Hoarseness -Deep facial or circumferential neck burns -Nares with inflammation or singed hair -Carbonaceous sputum or burnt matter in the mouth or nose -Blistering or edema of the oropharynx -Depressed mental status, including evidence of drug or alcohol use -Respiratory distress -Hypoxia or hypercapnia -Elevated carbon monoxide and/or cyanide levels -Renal Alterations -GI alterations -Immunologic alterations -Effect on thermoregulation

Management/Fluid Resuscitation-Acute Phase

Restore normal fluid balance -Fluid re-enters the vascular space from the interstitial space -Hemo-dilution- increase in the volume of plasma in relation to red blood cells; reduced concentration of red blood cells in the circulation. -Diuresis begins -Sodium is lost with diuresis and dilution as fluid enters vascular space: hyponatremia -Potassium shifts from extracellular fluid into cells: potential hypokalemia -Metabolic acidosis

Palmer method

Used with scattered burns Size of pts hand including fingers is approximately 1%

Wound Care/Dressing

Wound cleaning -Hydrotherapy - the use of warm water, both during immersion in a tub, and in showers with running water, provided these procedures contribute to the healing process of burn injury. -Encourage pt. participation -Use of topical agents -Appropriate dressings as ordered -Documentation

Additional risk factors

are low-socioeconomic status, low educational level of the primary care giver, home crowding (as estimated by number of household rooms) and psychosocial family stress.

Flexor sparing-patterns

are seen when the victim's joints are held in flexion from fear, pain or by others in forced immersion. Commonly involve the hips anteriorly and popliteal fossa posteriorly. The lower abdomen may also be spared when the trunk is in flexion when adopting a typical defensive position.

Contact thermal burns-

may result from irons, ovens and fire grills with upper limbs mostly effected.

Splash

occur when the scalding agent is thrown on to the victim. These are difficult to distinguish from accidental splash burns.

Scald induced-porcelain contact sparing/immersions-

that are deliberate incur burns of uniform depth with distinct borders with skin-fold sparing