Acute wk 8 - Burns practice/PP

Goal of care of burns

1. Prevent infection, restore fluid balance, maintain body heat, control pain, restore skin integrity, provide adequate nutrition, provide emotional support

Silver nitrate

: Similar to Silvadene, helps remove and debride hyper-granulation tissue, effective agent to cauterize bleeding Chemical burns may result from inappropriate use of product. May stain

Smoke and inhalation injury

: from breathing hot air or noxious chemicals can cause damage to the respiratory tract. • Three types of smoke and inhalation injuries : metabolic asphyxiation, upper airway injury, and lower airway injury.

Renal/Urinary Care

Anticipate increase urinary output After 36 to 48 hours, capillary integrity returns to normal in non-burned areas and reabsorption of edema fluid occurs over the next 1 to 2 weeks.

Fourth degree

As above Tendons/muscles/bone affected full-thickness destruction of the skin and subcutaneous tissue, with involvement of the underlying fascia, muscle, bone, or other structures. Require extensive debridement and reconstruction and usually result in prolonged disability.

Nursing Priorities Acute Phase

Acute or intermediate phase begins 48 to 72 hours after the burn injury. Focus on hemodynamic alterations, wound healing, pain and psychosocial responses, and early detection of complications. Measure vital signs frequently. Respiratory and fluid status remains highest priority. Assess peripheral pulses frequently for first few days after the burn for restricted blood flow. Closely observe hourly I & O, as well as blood pressure and cardiac rhythm; changes should be reported immediately. For patient with inhalation injury, regularly monitor level of consciousness, pulmonary function, and ability to ventilate; if patient is intubated and placed on a ventilator, frequent suctioning and assessment of the airway are priorities. As patients become more alert during this phase they are more aware of the physical and psychological impact of their injuries.​ May demonstrate depression and anxiety.

Monitoring and Managing Potential Complications

Acute respiratory failure: Assess for increasing dyspnea, stridor, changes in respiratory patterns; and assist as needed with intubation or escharotomy. Distributive shock: Monitor for early signs of shock or progressive edema. Administer fluid resuscitation as ordered in response to physical findings; continue monitoring fluid status. Acute renal failure: Monitor and report abnormal urine output and quality, blood urea nitrogen (BUN) and creatinine levels; assess for urine hemoglobin or myoglobin; administer increased fluids as prescribed. Compartment syndrome: Assess peripheral pulses hourly with Doppler; assess neurovascular status of extremities hourly; elevate burned extremities; report any extremity pain, loss of peripheral pulses or sensation; prepare to assist with escharotomies. Paralytic ileus: Maintain nasogastric tube on low intermittent suction until bowel sounds resume; auscultate abdomen regularly for distention and bowel sounds. Curling's ulcer: Assess gastric aspirate for blood and pH; assess stools for occult blood; administer antacids and histamine blockers (eg, ranitidine [Zantac]) as prescribed. ...An escharotomy is a surgical procedure used to treat full-thickness (third-degree) circumferential burns. In full-thickness burns, both the epidermis and the dermis are destroyed along with sensory nerves in the dermis. The tough leathery tissue remaining after a full-thickness burn has been termed eschar Curling's ulcer (stress ulcer) or a Curling ulcer is an acute gastric erosion resulting as a complication from severe burns when reduced plasma volume leads to ischemia and cell necrosis (sloughing) of the gastric mucosa. ... A similar condition involving elevated intracranial pressure is known as Cushing's ulcer

A burn is...

An injury to the tissues of the body caused by heat, chemicals, electric current, or radiation. The resulting effects are influenced by the temperature of the burning agent, duration of contact time, and type of tissue that is injured.

Promoting Skin Integrity

Assess wound status. Support patient during distressing and painful wound care. Coordinate complex aspects of wound care and dressing changes. Assess burn for size, color, odor, eschar, exudate, epithelial buds (small pearl-like clusters of cells on the wound surface), bleeding, granulation tissue, the status of graft take, healing of the donor site, and the condition of the surrounding skin; report any significant changes to the physician. Inform all members of the health care team of latest wound care procedures in use for the patient. Assist, instruct, support, and encourage patient and family to take part in dressing changes and wound care. Early on, assess strengths of patient and family in preparing for discharge and home care.

Strengthening Coping Strategies

Assist patient to develop effective coping strategies: Set specific expectations for behavior, promote truthful communication to build trust, and give positive reinforcement when appropriate. Demonstrate acceptance of patient. Enlist a non involved person for patient to vent feelings without fear of retaliation. Include patient in decisions regarding care. Encourage patient to assert individuality and preferences. Set realistic expectations for self care.

Prevent Infection

Provide a clean and safe environment; Protect patient from sources of cross contamination (e.g., visitors, other patients, staff, equipment). Closely scrutinize wound to detect early signs of infection. Monitor culture results and white blood cell counts. Practice clean technique for wound care procedures and aseptic technique for any invasive procedures. Use meticulous hand hygiene before and after contact with patient. Caution patient to avoid touching wounds or dressings; wash unburned areas and change linens regularly.

Nurse Care For A Patient With Burn Injury

Burn care is a delicate task and being knowledgeable in the proper sequencing of the interventions is very essential. Nurse must be knowledgeable about the physiologic changes that occur after a burn. Nurse must have astute assessment skills to detect subtle changes in the patient's condition.

question 2

ans C SEE PP FOR MORE QUESTIONS

Chemical Burns

Chemical burns. All clothing and jewelry are removed and burns should be flushed.

Chemical

Chemical burns occur when the skin comes in contact with strong acids, alkalis and other corrosive materials. Chemicals continue to burn until the chemical is removed through flushing or is neutralized; are the result of contact with acids, alkalis, and organic compounds.

Third degree Full Thickness

Dry Waxy white Heathery/hard Thrombosed vessels Insensitive to pain Full-thickness burns that destroy both epidermis and dermis, white or leathery appearance with underlying clotted vessels, don't feel pain to the area. Unless a third-degree burn is small (< 1 cm), skin grafting always is necessary to resurface the injured area

Other Risk Factors Increasing Burn Classification

Elderly people are at higher risk for burn injury because may have: Predisposing existing health conditions. Pulmonary function. May have a history of smoking. Decreased cardiac function and coronary artery disease. Malnutrition and presence of diabetes mellitus or other endocrine disorders. Varying degrees of orientation may present themselves The skin is thinner and less elastic; affects the depth of injury and ability to heal.

Electrical

Electrical burns occur when an electric current enters the body. As the current travels through the body, it follows the path of least resistance, traveling through nerve bundles and blood vessels. You will normally see an entry wound and an exit wound. However, the most serious damage may occur along the path of the current. Electricity may also cause the heart to develop a fatal arrhythmia (irregular beat); damage to the eye from the electrical arc; and thermal burns if the victim's clothing ignites

Quantifying Burn Severity: Continued

Higher mortality of older patients with burn injuries is attributed to their preexisting medical conditions, including cardiac, pulmonary, renal, and hepatic dysfunction. Moderate burn injury: This category excludes high-voltage electrical injury, all burns complicated by inhalation injury or other trauma, and burns sustained by high-risk patients. Patients with moderate burn injuries should be hospitalized for their initial care but not necessarily at a burn center. Minor burn injury: These burns do not present a serious threat of functional or cosmetic risk to eyes, ears, face, hands, feet, or perineum. These burns usually can be managed safely in the outpatient setting.

Mechanical

Mechanical burns are caused by friction, such as from ropes, carpet or sports activities

Promoting Gas Exchange and Airway Clearance

Provide humidified oxygen, and monitor arterial blood gases (ABGs), pulse oximetry, and carboxyhemoglobin levels. Assess breath sounds and respiratory rate, rhythm, depth, and symmetry; monitor for hypoxia. Observe for signs of inhalation injury: blistering of lips or buccal mucosa; singed nostrils; burns of face, neck, or chest; increasing hoarseness or soot in sputum or respiratory secretions. Report labored respirations, decreased depth of respirations, or signs of hypoxia to physician immediately; prepare to assist with intubation and escharotomies. Monitor mechanically ventilated patient closely. Institute aggressive pulmonary care measures: turning, coughing, deep breathing, periodic forceful inspiration using spirometry, and tracheal suctioning. Maintain proper positioning to promote removal of secretions and patent airway and to promote optimal chest expansion; use artificial airway as needed.

Maintaining Normal Body Temperature

Provide warm environment: use heat shield, space blanket, heat lights, or blankets. Assess core body temperature frequently. Work quickly when wounds must be exposed to minimize heat loss from the wound.

Rehabilitative

The last stage in caring for a client with burn injury is the rehabilitative stage. Technically, this stage begins with closure of the burn and ends when the client has reached the optimal level of functioning. In the emergent and intermediate phases, the focus is on establishing and maintaining physiological equilibrium In the rehabilitative phase, the focus is on helping the client return to preinjury life. Rehabilitation begins the day the client enters the hospital and can continue for a lifetime. The focus is on helping the client adjust to the changes the injury has imposed

Sources of burns: Identify the sources of burns and what causes them: Thermal

Thermal burns are caused by exposure to heat sources, such as flame, hot liquids or hot objects. Thermal burns continue to burn until the heat source is removed, and the skin is cooled; Caused by flame, flash, scald, or contact with hot objects, most common type of burn injury

Chlorhexidine gluconate

disinfectants are often employed to clean burn wounds, their use is discouraged because these agents can actually inhibit the healing process

What determines the severity of burns

1. The burned section of skin and how many layers of skin are affected. There are several levels of severity for burns: first-, second- and third-degree burns. One of the most significant identifiers for burn severity is the overall size of the burn.

Rehab Phase

Begin immediately after the burn has occurred Healing, psychosocial support, and restoring maximum functional activity remain priorities. Maintaining fluid and electrolyte balance and improving nutrition status. Perform ongoing assessments goals, range of motion of affected joints, ADLs, skin breakdown/neuropathies activity tolerance, and quality of healing skin. Protect skin from sunburn. Wear custom fit pressure garments only over healed wounds. Leave on 23/hrs. a day for 12-24 months Assess for early detection of complications ...Rehabilitation Phase Rehabilitation should begin immediately after the burn has occurred. Wound healing, psychosocial support, and restoring maximum functional activity remain priorities. Maintaining fluid and electrolyte balance and improving nutrition status continue to be important. In early assessment, obtain information about patient's educational level, occupation, leisure activities, cultural background, religion, and family interactions. Assess self concept, mental status, emotional response to the injury and hospitalization, level of intellectual functioning, previous hospitalizations, response to pain and pain relief measures, and sleep pattern. Perform ongoing assessments relative to rehabilitation goals, including range of motion of affected joints, functional abilities in ADLs, early signs of skin breakdown from splints or positioning devices, evidence of neuropathies (neurologic damage), activity tolerance, and quality or condition of healing skin. Document participation and self care abilities in ambulation, eating, wound cleaning, and applying pressure wraps. Maintain comprehensive and continuous assessment for early detection of complications, with specific assessments as needed for specific treatments, such as postoperative assessment of patient undergoing primary excision.

Nursing Management

Focus on the major priorities of any trauma patient. the burn wound is a secondary consideration Monitor vital signs frequently and evaluate apical, carotid, and femoral pulses particularly in areas of burn injury to an extremity. Check peripheral pulses on burned extremities hourly; use Doppler as needed. Start cardiac monitoring if indicated. If patient has history of cardiac or respiratory problems, electrical injury. Monitor I & O hourly. Note amount of urine obtained when catheter is inserted (indicates pre-burn renal function and fluid status). Obtain history, pre-burn weight, allergies, tetanus immunization, past medical surgical problems, current illnesses, and use of medications. Arrange for patients with facial burns to be assessed for corneal injury. Continue to assess the extent of the burn; assess depth of wound, and identify areas of full and partial thickness injury. Assess neurologic status: consciousness, psychological status, pain and anxiety levels, and behavior.

Relieving Pain and Discomfort

Frequently assess pain and discomfort Administer analgesic agents and anxiolytic medications, before the pain becomes severe. Assess and document the patient's response to medication and any other interventions. Teach patient relaxation techniques. Give some control over wound care and analgesia. Use guided imagery and distraction to alter patient's perceptions and responses to pain; hypnosis, music therapy, and virtual reality are also useful. Work quickly to complete treatments and dressing changes. Encourage patient to use analgesic medications before painful procedures. Promote comfort during healing phase with the following: oral antipruritic agents, a cool environment, frequent lubrication of the skin with water or a silica-based lotion, exercise and splinting to prevent skin contracture, and diversional activities.

Monitoring and Managing Potential Complications

Heart failure: Assess for fluid overload, decreased cardiac output, oliguria, jugular vein distention, edema, or onset of S3 or S4 heart sounds. Pulmonary edema: Assess for increasing CVP, pulmonary artery and wedge pressures, and crackles. Position comfortably with head elevated unless contraindicated. Administer medications and oxygen as prescribed and assess response. Sepsis: Assess for increased temperature, increased pulse, widened pulse pressure, and flushed, dry skin in unburned areas (early signs), and note trends in the data. Perform wound and blood cultures as prescribed. Give scheduled antibiotics on time. Acute respiratory failure and acute respiratory distress syndrome (ARDS): Monitor respiratory status for changes in respiratory pattern. Assess for decrease in tidal volume and lung compliance in patients on mechanical ventilation. Visceral damage (from electrical burns): Monitor ECG; pay attention to pain related to deep muscle ischemia. Early detection may minimize severity of complication. Fasciotomies may be necessary to relieve swelling and ischemia in the muscles and fascia. Contractures: Provide early and aggressive PT and OT; support patient if surgery is needed to achieve full range of motion. Obtain psychological or psychiatric referral as soon as evidence of major coping problems appears. ...The hallmark of onset of ARDS is hypoxemia on 100% oxygen, decreased lung compliance, and significant shunting.

Ice/cold water

Never use ice or cold water because it will restrict peripheral circulation locally, increasing the depth of the burn, and it may decrease body temperature. It is imperative to prevent hypothermia in burn patients, as body temperatures below 97.7° F (36.5° C) in the first 24 hours are associated with increased mortality. Cover the patient with a clean, dry covering such as a sheet or blanket to prevent evaporative heat loss.

Maintain Adequate Nutrition

Initiate oral fluids slowly when bowel sounds resume. Report if vomiting and distention occur. Increase diet gradually and advanced to a normal diet if possible. Collaborate with dietitian to plan a protein and calorie-rich diet Provide nutritional and vitamin and mineral supplements if prescribed. Document caloric intake. Insert feeding tube if caloric goals cannot be met by oral feeding (for continuous or bolus feedings); note residual volumes. Weigh patient daily and graph weights. ...Encourage family to bring nutritious and patient's favorite foods.

Burn Care Goals

It's important to recognize that the first priority for burn patients is not the treatment of the wound. This can be a difficult concept to understand because burn injuries may be visually distracting and extremely painful for the patient. Rather, the priority is to implement the ABCDE approach, a methodical response that ensures life-threatening complications of burn emergencies are addressed rapidly and effectively. (See The ABCDEs of emergency burn care.)

Methods to determine the TBSA affected by burns.

Rule of Nines. A common method, the rule of nines is a quick way to estimate the extent of burns in adults through dividing the body into multiples of nine and the sum total of these parts is equal to the total body surface area injured. Lund and Browder Method. This method recognizes the percentage of surface area of various anatomic parts, especially the head and the legs, as it relates to the age of the patient. Palmer Method. The size of the patient's palm, not including the surface area of the digits, is approximately 1% of the TBSA, and the patient's palm without the fingers is equivalent to 0.5% TBSA and serves as a general measurement for all age groups.

Mafenide acetate (Sulfaylon)

Mafenide acetate is an antimicrobial agent that is commonly used for significant full thickness burns; burns over cartilage; burns with eschar; and postexcision, meshed autografts. The topical solution or cream can be used as prophylaxis or an adjunctive therapeutic agent for burn wound infections. Sulfamylon soaks were shown to be effective for debridement, granulation tissue protection and preparation, and bacterial control. Expensive

Nursing Priorities

Maintain patent airway/respiratory function. Restore hemodynamic stability/circulating volume. Alleviate pain. Prevent complications. Provide emotional support for patient/significant other (SO). Provide information about condition, prognosis, and treatment. Clients with severe burns caused in an enclosed area: car fires, house fires Should be monitored for signs of respiratory distress.

Restoring Normal fluid Balance

Monitor IV and oral fluid intake; use IV infusion pumps. Measure intake and output and daily weight. Report changes (e.g., blood pressure, pulse rate) to physician.

Restoring Fluid and Electrolyte Balance Nurse Priorities

Monitor vital signs and urinary output (hourly), central venous pressure (CVP), pulmonary artery pressure, and cardiac output. Note and report signs of hypovolemia or fluid overload. Maintain IV lines and regular fluids at appropriate rates, as prescribed. Elevate the head of bed and burned extremities. Monitor serum electrolyte levels (eg, sodium, potassium, calcium, phosphorus, bicarbonate); recognize developing electrolyte imbalances. Notify physician immediately of decreased urine output; blood pressure; central venous, pulmonary artery, or pulmonary artery wedge pressures; or increased pulse rate.

Superficial First degree Partial Thickness

Pink to red Blanches with pressure Painful Mild swelling No blisters (tho may after 24 hrs) Sunburn Quick flash Minor skin damage, redness, tenderness and pain. Heals without scarring

For each of the topical antibiotic medications listed, state the indication for use, advantages, and disadvantages: Silver sulfadiazine (Silvadene)

Prevent and treat serious burns, stops the growth of bacteria and spread to surrounding area, blodd. Cannot be used on babies under 2 months of age

Promote Physical Mobility

Prevent complications of immobility (atelectasis, pneumonia, edema, pressure ulcers, and contractures) by deep breathing, turning, and proper repositioning. Modify interventions to meet patient's needs. Encourage early sitting and ambulation. When legs are involved, apply elastic pressure bandages before assisting patient to upright position. Make aggressive efforts to prevent contractures and hypertrophic scarring of the wound area after wound closure for a year or more. Initiate passive and active range-of-motion exercises from admission until after grafting, within prescribed limitations. Apply splints or functional devices to extremities for contracture control; monitor for signs of vascular insufficiency, nerve compression, and skin breakdown.

Deep Second degree

Red Swelling Shiny Blisters Wet Pain in severe Superficial partial-thickness and deep partial-thickness burns, appear pink, moist, and soft and are exquisitely tender, may have thin-walled, fluid-filled blisters. May leave scars.

Emergent

The emergent phase begins with the onset of burn injury and lasts until the completion of fluid resuscitation or a period of about the first 24 hours. Resuscitive care Resolve immedirtaely life threatingn probleems Lasts 48-72 hours Goal to secure the airway, prevent hypovolemic shock Airway . Breathing . Circulation Important steps in treating a burn client include . Treat airway and breathing—Traces of carbon around the mouth or nose, blisters in the roof of the mouth, or the presence of respiratory stridor indicate the client has respiratory damage. Endotracheal intubation with assisted ventilation might be required to achieve adequate oxygenation. . Ensure proper circulation—Compromised circulation is evident by slowed capillary refill, a drop in normal blood pressure, and decreased urinary output. These symptoms signal impending burn shock. Diagnostic Tests: CBC . Complete metabolic panel . Urinalysis . Chest x-ray Fluid replacement Parkland Formula Administering a tetanus booster . Inserting a urinary catheter for determining hourly output . Inserting a nasogastric tube attached to low suction to minimize aspiration Elevating burned extremities to lessen edema formation

Discharge and Home Care Guidelines

The focus of rehabilitative interventions is directed towards outpatient care, home care, or care in a rehabilitation center. Wound care. The patient and the family are instructed in wound care. Education. The patient and the family require careful written and verbal instructions about pain management, nutrition, prevention of complications, specific exercises, and the use of pressure garments and splints. Follow up care. Patients who receive care in a burn center usually return to the burn clinic periodically for evaluation, modification of burn care instructions, and planning for reconstructive surgery. Referral. Patients who return home after a severe burn injury, those who cannot manage their own burn care, and those with inadequate support systems need referral for home care.

Acute

The intermediate phase of burn care begins about 48-72 hours following the burn injury. Changes in capillary permeability and a return of osmotic pressure bring about diuresis or increased urinary output. If renal and cardiac functions do not return to normal, the added fluid volume, which prevented hypovolemic shock, might now produce symptoms of congestive heart failure. Assessment of central venous pressure provides information regarding the client's fluid status. Infections represent a major threat to the post-burn client. Bacterial infections (staphylococcus, proteus, pseudomonas, escherichia coli, and klebsiella) are common due to optimal growth conditions posed by the burn wound; however, the primary source of infection appears to be the client's own intestinal tract. As a rule, systemic antibiotics are avoided unless an actual infection exists. Additional complications found during the intermediate phase include infections, the development of Curling's ulcer, paralytic ileus, anemia, disseminated intravascular coagul During the intermediate phase, attention is given to removing the eschar and other cellular debris from the burned area. Debridement, the process of removing eschar, can be done placing the client in a tub or shower and gently washing the burned tissue away with mild soap and water or by the use of enzymes, substances that digest the burned tissue. Santyl (collagenase) is an important debriding agent for burn wounds. The central venous pressure (CVP) is read with the client in a supine position Following debridement, the wound is treated with a topical antibiotic and a dressing is applied (more on dressings is covered in the next section).

Pathophysiology

Tissue destruction results from coagulation, protein denaturation, or ionization of cellular components. Local response. Burns that do not exceed 20% of TBSA according to the Rule of Nines produces a local response. Systemic response. Burns that exceeds 20% of TBSA according to the Rule of Nines produces a systemic response. The systemic response is caused by the release of cytokines and other mediators into the systemic circulation. The release of local mediators and changes in blood flow, tissue edema, and infection, can cause progression of the burn injury.

burns among different ages

Toddler Scalds are the greatest risk for infants and toddlers. Promote safety in the environment, educate parents about safety measures that help promote burns Preschool common in young children, and over 80% do not seek medical attention Most frequent burns include electrical, chemical matches are greatest risk factor for a preschooler. Promote safety in the environment, educate parents about safety measures that help promote burns. Teach children about the dangers of hot surfaces, keep matches out of reach. Working smoke alarms School Age Electrical burns are greatest risk for adolescents. Promote safety in the environment, educate parents about safety measures that help promote burns. Teach children about the dangers of hot surfaces, keep matches out of reach. Working smoke alarms Adolescent Hair treatment (curlers, straighteners), cooking, space heaters Burns are more significant. Promote safety and education with grooming tools, environmental modifications, and legislation. Adults flame and scald burns, or scalds alone. mortality in adults is related to incidences at work or related to activities outside of the household.Cigarettes are greatest risk for adults. Promote safety and education with grooming tools, environmental modifications, and legislation. Elderly flame and scald burns, or scalds alone Higher risk for burn injury, mortality rate, as well as severity of complications. Promote safety and education with grooming tools, environmental modifications, and legislation.

Prehospital

Transport. Alert ED en route so that life-saving measures can be initiated immediately Priorities. airway, breathing, and circulation Airway. 100% humidified oxygen encourage cough so that secretions can be removed IV access: 16 or 18 gauge IV is inserted in the non-burned area. GI access. If the burn exceeds 20% to 25% TBSA, a nasogastric tube is inserted and connected to low intermittent suction Emergency care of burns at the site of injury includes . Extinguishing the burn source . Soaking the burn with cool water to relieve pain and to limit local tissue edema . Removing jewelry and nonadherent clothing . Covering the wound with a sterile (or at least clean) dressing to minimize bacterial contamination . Brushing off chemical contaminants, removing contaminated clothing, and flushing the area with running water Rapid assessment of the burn severity, airway management, preventing hypothermia and fluid resuscitation are key goals for EMS providers treating and transporting burn patients. Airway. 100% humidified oxygen encourage cough so that secretions can be removed IV access: 16 or 18 gauge IV is inserted in the non-burned area. GI access. If the burn exceeds 20% to 25% TBSA, a nasogastric tube is inserted and connected to low intermittent suction

Pre-Hospital Care

Transport. Alerted ED en route so that life-saving measures can be initiated immediately. Rapid assessment of the burn severity, airway management, preventing hypothermia and fluid resuscitation are key goals for EMS providers treating and transporting burn patients. Priorities. airway, breathing, and circulation. Airway. 100% humidified oxygen encourage cough so that secretions can be removed IV access: 16 or 18 gauge IV is inserted in the non-burned area. GI access. If the burn exceeds 20% to 25% TBSA, a nasogastric tube is inserted and connected to low intermittent suction Clean sheets are placed over and under the patient to protect the burn wound from contamination, maintain body temperature, and reduce pain caused by air currents.

Minimizing Pain and Anxiety

Use a pain scale to assess pain level (ie, 1 to 10); differentiate between restlessness due to pain and restlessness due to hypoxia. Administer IV opioid analgesics as prescribed, and assess response to medication; observe for respiratory depression in patient who is not mechanically ventilated. Provide emotional support, reassurance, and simple explanations about procedures. Assess patient and family understanding of burn injury, coping strategies, family dynamics, and anxiety levels; explain all procedures in clear, simple terms. Provide pain relief, and give antianxiety medications if patient remains highly anxious and agitated after psychological interventions.

Radiation

burns are caused by ultraviolet and ionizing rays. Some sources of Radiation burns • ultraviolet light from the sun. • heat from a stove burner. • x-rays from an x-ray machine. • alpha particles emitted from the radioactive decay of uranium. microwaves from a microwave oven.

Prevention: Promote Safety And Avoid Burns

vAdvise that matches and lighters be kept out of reach of children. vEmphasize the importance of never leaving children unattended around fire or in bathroom/bathtub. vCaution against smoking in bed, while using home oxygen, or against falling asleep while smoking. vTo prevent burns, hot water heaters should be set no higher than 120° Fahrenheit vCaution against throwing flammable liquids onto an already burning fire. vCaution against using flammable liquids to start fires. vRecommend avoidance of overhead electrical wires and underground wires when working outside. vAdvise that hot irons and curling irons be kept out of reach of children. vCaution against running an electrical cord under carpets or rugs. vAdvocate caution when cooking, being aware of loose clothing hanging over the stove top and remove pot handles from reach of small children. vRecommend having a working fire extinguisher in the home and knowing how to use it.

A&P of Skin

§It is the largest organ §It provides the first defense against trauma §It shields the body against infection, dehydration, and temperature changes; provides sensory information about the environment; §Manufactures vitamin D and excretes salts and small amounts of urea. §Is able to regenerate itself §Is important for the sense of personal identity

A&P of Burn Injury continued

§Myoglobin and K released from cell damage §High risk for kidney damage, high K §Inflammatory response, destroyed skin •Immunosuppression, risk of infection/sepsis, loss of ability to sweat § Increase demand on the metabolic system §Massive catabolism and increase need for calories, increase body temp increase O2 demand §RBC's hemolyzing causing hemo-concentration High HCT, Hgb and increase blood viscosity

Burn Statistics and Epidemiology

ØA burn injury can affect people of all age groups, in all socioeconomic groups. ØAn estimated 500, 000 people are treated for minor burn injury annually. Account for about 2,000,000 injuries each year in the United States. ØThe number of patients who are hospitalized every year with burn injuries is more than 40,000 v47% of injuries occurred at home, 27% on the road, 8% are occupational, 5% are recreational, and the remaining 13% from other sources. v40% of injuries are flame related, 30% scald injuries, 4% electrical, 3% chemical, and the remaining unspecified. ØBurns are the third leading cause of death in children under age 14 and are in the top 10 of causes of death for all age groups. ØMales have greater than twice the chance of burn injury than women. ØThe most frequent age group for contact burns is between 20 to 40 years of age. ØThe National Fire Protection Association reports 4,000 fire and burn deaths each year. ØOf the 4,000, 3,500 deaths occur from residential fires and the remaining 500 from other sources such as motor vehicle crashes, scalds, or electrical and chemical sources. A burn: an injury to the tissues of the body caused by heat, chemicals, electric current, or radiation. The resulting effects are influenced by the temperature of the burning agent, duration of contact time, and type of tissue that is injured.

Radiation Burns

•A radiation burn is damage to the skin or other biological tissue caused by exposure to radiation. The radiation types of greatest concern are thermal radiation, radio frequency energy, ultraviolet light and ionizing radiation. The most common type of radiation burn is a sunburn caused by UV radiation. Radiation burns are common complication with CA patient undergoing radiation treatments.

The ABCDES of Emergency Burn Care

•Airway maintenance with cervical spine protection •Breathing and ventilation •Circulation and cardiac status with hemorrhage control •Disability, neurological deficit, and gross deformity •Exposure to Examine for major associated injuries and maintain warm Environment

Burn Overview

•Burns disrupt the skin, which leads to increased fluid loss; infection; hypothermia; scarring; compromised immunity; and changes in function, appearance, and body image. •The severity of each burn is determined by multiple factors that, when assessed, help the burn team estimate the likelihood that a patient will survive and plan for the care for each patient. •Young children and the elderly continue to have increased morbidity and mortality when compared to other age groups with similar injuries. Inhalation injuries in addition to cutaneous burns worsen the prognosis. The first hours after a burn injury occurs are a critical time. Decisions made and treatments rendered during this time can mean the difference between life and death. Burns generally occur from one of three major sources: . Thermal injuries (hot liquid, open flame) . Electrical injuries (household current, lightning) . Chemical injuries (alkaline or acid liquids or powders) Most burns are thermal injuries that occur in the home. Cooking accidents from hot grease or stove fires result in a significant number of injuries, as do scalds from bath water that is too hot.

Electrical Burns

•Electrical current produces heat causing extensive tissue damage to nerves and vessels. •Look for entry and exit points/surface burns from sparks/fires. •Electrical current can cause muscle contractions so strong that bones can break and falls call occur. •Most damage is below the skin (iceberg effect) •Cardiac and renal problems can occur; ØNeed EKG/Cardiac monitoring ASAP ØHeart can be affected up to 24 hours after incident ØAll electrical burns should be seen by medical personal Rhabdomyolysis (RML) after electrical burns is a well-known clinical entity, Do not approach the client with electrical burns until you assure that the area is safe.

layers of the skin

•Epidermis- Outer layer (nonvascular) üProvides protection üVaries in thickness •Dermis- Second layer üHas collagen, capillaries, nerve endings, sweat/oil glands, hair follicles •Subcutaneous tissue - third layer üAttached to the dermis by collagen fibers üContains fat, nerves, lymphatics; üand cushions muscles, tendons, bones , internal organs

A&P of Burn Injury

•Immediate release of catecholamine and other mediators vIncrease BP and HR, vasoconstriction, disrupted blood flow • •Increase capillary permeability vEdema anywhere, including lungs, third spacing, low NA, hypovolemia, massive fluid shifts HR high and CO low • •Decrease perfusion to GI system vParalytic ileus, abd distension vCurling's ulcer ØA peptic ulcer that sometimes occurs following severe burns to the body; a form of stress ulcer, Øcaused by a generalized stress response to decreased blood flow to the GI tract. Severity of burn injury is related to the rate at which heat is transferred from the heating agent to the skin. Tolerable temperature to human skin is 40°C (104°F)for a brief period Tolerable temperature to human skin can vary due to age, skin condition and medical conditions. A burn is damage to your skin caused by a temperature as low as 44 degrees Celsius (109.4 Fahrenheit) for a long time. A high temperature (more than 80 degrees Celsius) can cause more severe burns in a very short period of time (less than a second).

Reconstruction Goals

•Once the burn patient has been resuscitated and stabilized, restoring anatomy, preserving function, and rehabilitating the patient is the next priority. • •To accomplish this, the surgeon must evaluate the extent to which tissue is missing and identify potential donor sites or other solutions to best manage skin and soft tissue defects. • •The aim is to reconstruct like tissue with like tissue, restoring function first, which supersedes immediate concerns over cosmetics. • •Appropriate measures are taken to limit scarring in the postoperative period; •however, once the patient has progressed through the acute phase of the injury, reassessment of the wounds may necessitate wound revisions to achieve an optimal cosmetic outcome.

Burn Center Referral Criteria

•Partial thickness burns comprising greater than 10% of total body surface area. •Burns involving face, hands, feet, genitalia, perineum, or major joints. •Any third degree burn. •Electrical burns, including lightning injuries. •Chemical burns. •Inhalation injury. •Burn injury with preexisting medical conditions. •Burns in conjunction with traumatic injuries. •Burned children in geographic areas without resources dedicated to pediatric patients. •Burn injuries in people with special social, emotional, or rehabilitation needs.

Rehabilitation Nurse Priorities

•Rehabilitation should begin immediately after the burn has occurred. • •Support wound healing, psychosocial support, and restoring maximum functional activities. • •Maintaining fluid and electrolyte balance and improving nutrition status • •Assess self concept, mental status, emotional response to the injury. • •Assess response to pain and pain relief measures, and sleep pattern. • •Continue assessments relative to rehabilitation goals, • range of motion of affected joints, functional abilities in ADLs, early signs of skin breakdown, evidence of neuropathies (neurologic damage), activity tolerance, and quality or condition of healing skin. • •Document participation and self care. • •Assess for early detection of complications. ...In early assessment, obtain information about patient's educational level, occupation, leisure activities, cultural background, religion, and family interactions.

Parkland Formula

•The Parkland Formula is a validated and effective approach to initial fluid resuscitation in the acutely burned patient. •When to use: Patients with acute burns. •Why it is used: •The Parkland Formula has been endorsed by the American Burn Association. •It has been shown to appropriately restore intravascular volume and limit the development of hypovolemic shock. • •CAUTION! Patients frequently receive fluid excess of predicted requirements. Up to 48% more=FLUID CREEP! •Overly aggressive fluid resuscitation, termed "fluid creep", can cause compartment syndrome, ARDS/pulmonary edema, cerebral edema, multiple organ failure. •Patients with inhalational and electrical burns, as well as children and the elderly, may require more or less fluid resuscitation than is predicted by the formula. •DO NOT allow unrestricted access for plain water, especially in children Not all burn patients require IV fluid resuscitation, only about 10-15% will. If the pt is cooperative, no nausea or vomiting, may not need IV fluids. Factors that may lead to fluid creep include lack of physician observation of endpoints (i.e. urine output), increased opioid use and the emergency nature of goal-directed resuscitation.

Systemic response

•The release of inflammatory mediators at the site of injury has a systemic effect once the burn reaches 30% of total body surface area. •Cardiovascular changes—Increased capillary permeability, loss of intravascular proteins and fluids into the interstitial compartment. Peripheral and splanchnic vasoconstriction occurs. Myocardial contractility is decreased. These changes, coupled with fluid loss from the burn wound, result in systemic hypotension and end organ hypo-perfusion. •Respiratory changes—Inflammatory mediators cause bronchoconstriction, and in severe burns adult respiratory distress syndrome can occur. •Metabolic changes—The basal metabolic rate increases up to three times its original rate. This, coupled with splanchnic hypo-perfusion, necessitates early and aggressive enteral feeding to decrease catabolism and maintain gut integrity. •Immunological changes—Non-specific down regulation of the immune response occurs, affecting the immune system 80-85% of fatalities are due to severe burn damage aggravated by the development of sepsis Splanchnic; relating to the viscera or internal organs, especially those of the abdomen. Cell-mediated immunity is an immune response that does not involve antibodies, but rather involves the activation of phagocytes, antigen-specific cytotoxic T-lymphocytes, and the release of various cytokines in response to an anti

TYPES OF BURN INJURY

•Thermal Burns: caused by flame, flash, scald, or contact with hot objects, most common type of burn injury •Electrical Burns: result from intense heat generated from an electric current. •Chemical Burns: are the result of contact with acids, alkalis, and organic compounds. •Radiation Burns: caused by sun, tanning X-rays radiotherapy •Smoke and Inhalation Injury: from breathing hot air or noxious chemicals can cause damage to the respiratory tract. •Three types of smoke and inhalation injuries : metabolic asphyxiation, upper airway injury, and lower airway injury. Because smoke inhalation injuries are a major predictor of mortality in burn patients, rapid assessment is critical

Parkland Formula for Burns

•culates fluid requirements for burn patients in a 24-hour period. •Calculate from the time of the injury/incident. Not when the patient arrives or begins to receive care. •Use in adult patients with burns. Children have larger TBSA relative to weight and may require larger fluid volumes. •The Parkland formula is mathematically expressed as: V = 4 x m x (A x 100) Where mass is in kilograms (kg), area as a percentage of total body surface area, and volume is in milliliters (mL). For example, a person weighing 75 kg with burns to 20% of his or her body surface area would require 4 x 75 x 20 = 6,000 mL of fluid replacement within 24 hours. The first half of this amount is delivered within 8 hours from the burn incident, and the remaining fluid is delivered in the next 16 hours Parkland Formula for Burns It was developed by Dr Charles Baxter at Parkland Memorial Hospital in Dallas, Texas. (Sometimes call the Baxter Formula) Calculates fluid requirements for burn patients in a 24-hour period. It is important to remember that all resuscitation formulas be used as a guide. Patients should be assessed frequently, with individual adjustments made to maintain adequate organ perfusion. Fluid Requirements = TBSA burned (%) x Weight (kg) x4 mL (RL)/ 1 kg