Burns

Burn Inhalation Injury

#1 cause of death, normally related to inhaling carbon monoxide or hydrogen cyanide. CM- hypoxia, give 100% oxygen. HC- airway/breathing, 100% oxygen on scene, antidote in hospital, incubate prophylactically

Considerations to Prevent Burns in the Home

-turn pot handles toward the wall when cooking -curling irons, flat irons, irons can cause burns -Drop-in stoves should be attached to the wall -do not put hot items on a tablecloth -set hot water heater no higher than 120 F or 49 C -keep electrical sockets covered

0.9% NS vs Albumin

0.9% NS-isotonic, stays where you put it, increases vascular volume Both- BP, CO Albumin- hypertonic, pulls from the tissues, increases vascular volume

The nurse is taking care of a client with major partial thickness burns. Tobramycin 125 mg IVPB has been ordered. What is the priority lab assessment prior to administering this medication? 1. Creatinine 2. Potassium 3. Magnesium 4. Blood urea nitrogen

1. Creatinine-Right away we worry about ototoxicity and nephrotoxicity because a mycin antibiotic is prescribed. None of the answer options have anything to do with hearing so think about kidneys. Only options 1 and 4 have to do with the kidney. Creatinine is the most specific indicator of renal function and is always the best answer if you have to choose between the two.

Burn Classification

1. Extent- most common method to determine the % of the body that is burned is the rule of nines: head and neck=9%, trunk-front=18%, back=18%, Arm=9% each, genitalia=1%, leg=18% each 2. Depth- partial thickness burns, also called first and second degree burns, and full thickness burns are also known as third and fourth degree burns. 3. Burn location- how does the burn location help to determine severity? If the burn is located on the face, neck, or chest it could interfere with breathing. Hands, feet, joints, and eyes can also be serious.

Burn Fluid Replacement

2 large bore IVs, LR and albumin used to replace fluid Know time burn occurred-fluid replacement in 1st 24 hours based on time injury occurred, not when treatment was started. Rule: calculate total amount needed for 1st 24 hours and then give half of the amount during first 8 hours. I calculate fluid replacement- (2-4 mL LR) x (body weight in Kg) x (% of TBSA burned)= total fluid replacement for 1st 24 hours. 1st 8 hours= 1/2 of total volume, 2nd 8 hours=1/4 of total volume, 3rd 8 hours=1/4 of total volume. Nursing diagnosis- inadequate fluid replacement, pain, hypoxia (priority), urinary output- 30-59 mL hr. 75-100 mL hr for electrical injuries, and children require urinalysis output if 1 mL/kg/hr.

A client weighing 220 lbs received full-thickness burns to 40% of the clients total body surface area this morning at 7:30 am. Using the consensus Formula (Parkland Formula), calculate fluid replacement for the first 24 hours.

4 mL x 100 (kg) x 40= 16,000 mL 24 hr fluid: 16,000 mL. First 8 hrs: 16,000/2=8,000 mL Burn time: 7:30 am Current time: 10:30 am Completion time: 3:30 pm 8 hrs begins at the time of the burn which was 7:30 Residual time for infusion: 5 hrs 8,000 mL/5 hrs= 1,600 mL/hr

parkland formula for burns (consensus Formula)

4mL of LR x (body weight in kg) x (% of TBSA burned)

The body makes antibodies with what type of immunity?

Active immunity

What type of immunity takes 2-4 weeks to develop?

Active immunity

What assessment findings would indicate fluid volume replacement is adequate in a client with severe burns?

Adequate urinary output, slow continual rise in the CVP

Pathophysiology of Burns

After a burn, many different pathophysiological changes occur. 1. Plasma seeps out into the tissue (increased capillary permeability, leaking) 2. Majority occurs first 24 hours (worry about shock, FVD) 3. Pulse increase (anytime someone is in FVD, the pulse will increase) 4. Cardiac output decreases (less volume to pump out) 5. Urinary output decreases (kidneys are either trying to hold on to fluid or they aren't being perfumed adequately). 6. Epinephrine secreted- initially BP drops (epinephrine and norepinephrine secretion makes you peripherally vasoconstrict, blood is shunted to the vital organs, BP goes back up, with a normal BP of 120/80, anytime the systolic BP drops below 90, the client will not have adequate organ perfusion. This can be very dangerous. 7. ADH and aldosterone secreted (retain sodium + water with aldosterone and retain water with ADH—>therefore, the blood volume will increase, GOOD THING!)

Burns Medical Management

Albumin- administered after first 24 hours (capillary permeability normal), ho,do onto fluid in vascular space, vascular volume increases, kidney perfusion increases, BP increases, Cardiac output increases, workload of heart increases- more volume to pump. ALBUMIN ALERT: if you stress the heart too much, the client could go into FVE, CO will decrease, lung sounds will be wet/crackles, monitor CVP hourly to ensure infusion not overloading the client.

Burn Complications: Renal

Client will have in dwelling catheter that needs to be monitored to measure urinary output every hour, the kidneys are trying to hold onto or retain what little fluid remains or the kidneys not being perfused adequately, mannitol might be ordered to flush out the kidneys, urine should be clear, no urine kr less than 30 mL—> worry about renal failure, after 48 hours, the client will begin to diurese because fluid is going back into the vascular space—> now worry about FVE, urine output will increase.

Burn: Nutrition

Clients will need more or less calories- hypermetabolic state, meeting daily caloric requirements is critical and should start within 1-2 days postpartum, caloric needs should be regularly calculated by a dietitian and readjusted as the clients condition changes, protein and vitamin C are needed in the diet to promote healing, check pre-albumin levels to ensure proper nutrition and a positive nitrogen balance.

Whirlpool Treatment-what are we scared of? What meds? Purpose.?

Cross-contamination and infection. They will need pain meds and antibiotics. Pain meds about 30 minutes before debriding treatment because it is very painful. Antibiotics before treatment to prevent further infection (cross-contamination) Purpose- to debride the wounds

Burn: Wound Care

Debridement- enzymatic drugs—> suitilains, collagenase- eat dead tissue hydrotherapy- pain management before therapy Grafting- autograft uses the clients own skin , donor site now open wound (dressing to stop bleeding, then leave open to air)m can reharvest from the same donor site ever 12-14 days, if skin graft becomes blue or cool it could mean poor circulation- primary healthcare provider may take a tuberculin syringe and aspirate blood or exudate from under the graft. If air, blood, or exudate is accumulating under the graft, the new graft will not adhere leading to total or partial loss of the graft.

24 hours after a burn-CVP?

Decreased because FVD

24 hours after burn-Urinary Output?

Decreased-because they are in FVD. All their fluid is third spaced out into the tissues where it does them no good.

24 hours after major burn-BP?

Decreased-less volume less pressure.

What assesment finding would you expect 24 hours after a burn?

FVD- the fluid has shifted to the tissues from the vascular space. The client is third spacing—>going to a place that does the client no good

Burn Complications: Electrolyte Imbalance

Hyperkalemia-why?

Active immunity, Passive immunity

If the proceeds requires the clients body to work to develop the immunity, then the body is actively involved-active immunity. If the immunity just comes as a gift with no work out of the body then the body is a recipient-passive immunity

24 hours after a burn-pulse?

Increased-the heart is working hard to pump what little fluid is left within the vascular space

What type of solution would you use for the 24 hours after a burn client?

Isotonic solution (0.9% NS)- we need a solution that will go into the vascular space and stay there

24 hours after burn-edema?

Massive edema because they are third spacing

Burn Complications: GI

Magnesium carbonate, pantoprazole, famotidine prescribed to prevent stress ulcer (Curling's), possible paralytic ileus because decreased vascular volume, decreased GI motility, hyperkalemia (muscle weakness)—> primary healthcare provider will order the client NPO with an NG tube to be hooked to suction—> if now bowel sounds, abdominal girth increase, NG removed when Bowen sounds heard. Need to measure gastric residuals and hold feeding in residual greater than 150 mLs- return residual back to client.

Burn Complications: Integumentary System

Main complications are contractures and infections- remove eschar for new tissue to regenerate

Burn Emergency treatment

More death in upper body burns because if airway Stop the burning process- wrap in blanket, cool water soak (10 mins), remove jewelry and non-adherent clothing, cover burned area with clean dry cloth

Occurrence and Safety Considerations

Most burns occur at home. Safety considerations- keep electrical sockets covered and keep matches and lighters out kf reach, smoke alarm- having a smoke detector in the home doubkes the chance if a family surviving a fire, change the batteries every 6-12 minths, heating elements are related to 1 out of every 6 ho,e fires. Keep anything flammable at least 3 feet from heat sources, dryers are the cullprit of 9 out of 10 appliance fires- clean the lint screen with each use, have and practice your escape plan, do not let pot handles stick out while cooking, drop-in tyoe stoves should be attached to the wall, if toddlers ljve in home, do not use tablecloths, small appliances like an iron or hair appliance can cause serious burns, if children or e,ederly family in home, set the water heater no higher than 120 F (48.9 C). Use an antiscald device.

Complications of Burns

Myoglobin a byproduct of all the burned muscles and tissues in burns can cause renal failure because the kidneys cannot filter it out. It clogs the ureters. The urine will be brown or red—> the primary healthcare provider is going to want to flush out the kidneys so the myoglobin will not collect in the tubules so we give fluid and then a diuretic (mannitol) to help the kidneys rid themselves of the myoglobin.

IGg provides what type of immunity?

Passive- provides temporary protection

Osmotic Diuretics (Mannitol)

Pulls fluid from the intracellular compartment, unlike loop diuretic that pulls fluid from the blood

Electrical Burns

Remember that they are entrance and exit, and do not forget about internal damage Require continuous heart monitoring for 24 hours- at risk for V-fib, myoglobin and hemoglobin build up and can cause kidney damage Electrical injuries occur in high places—> may have spine board or C-collar, muscle contractures can cause fractures, and the force of electricity can throw the victim forcefully, amputations are common because the circulatory system gets destroyed. Other Complications: cataracts, gait problems, and neurological deficits

Chemical Burns

Remove the client from the chemical and begin flushing from skin, flush for 15 to 30 minutes with cool water or sterile saline, brush powder chemicals off first

What precautions do you place severe burn clients on?

Reverse Isolation/Protective Precautions- no fruit, flowers, wash hands, wear goggles mask gloves. No loose clothing. Anyone who has a low white blood cell count would also be placed in reverse isolation-neutropenic clients, chemotherapy, leukemia, aplastic anemia, transplant clients. Anyone with impaired immunity!!!!

Burn Risk Factors

Risk Factors: anyone with heart, lung, or kidney disease. If your client had pre-existing Diabetes, or peripheral vascular disease they may not heal as well with burn, other injuries while client was burned, increased mortality in very young and very old because old people have thin skin and young people have less BSA (Body surface area).

Burn: Infection Control

Systemic antibiotic therapy- broad spectrum antibiotics avoided because usage could lead to super infection or secondary infections/sepsis. Always make sure that wound cultures have been collected before you start the antibiotics. When giving mucin drugs, worry when the clients BUN or creatinine increase or if the client reports any hearing loss. Mycin drugs can lead to ototoxicity and nephrotoxicity. Topical medications: silver impregnated dressings provide broad antimicrobial effects to the burn by delivering a uniform amount if silver to the wound, dressings can be left in place 3-14 days-mafenide acetate. Silver nitrate antimicrobial ointments, antibiotics should be alternated because bacteria will build resistance or tolerance, apply a thin layer of the medication using sterile gloves (High risk for infection), aseptic technique is used, a light gauze dressing may or may not be applied to cover the burn area.

Burn immunization

Tetanus toxoid (active immunity)- takes 2-4 weeks to develop, immune globulin (passive immunity)- provide immediate protection

Aminoglycosides-how to identify?

They end in mycin- gentamicin, neomycin, anamycin, streptomycin

Burns: Pain Management

When giving IV narcotic, monitor respiration count, IV pain meds prescribed over IM because IV act faster. drug of choice: opioids.

Burn: Complications circulation

With burns especially circumferential always be checking for circulation, elevate to help improve circulation,action by reducing edema, if a clients vascular check in and tre its is decreased—> escharotomy and fasciotomy fo help relieve pressure and restore circulation.