ch 51 burns

Medications

In addition to pain management, patients with burn injuries are given a variety of other pharmacological therapies. Medications are given to treat common concerns or potential complications facing the burn patient, including anticoagulation therapy, nutritional support, gastrointestinal motility, anxiety, and depression. See Table 51.6 for a listing of medications commonly used in patients with burn injuries.

Rehabilitative Phase-Medical Management

The last phase in the burn process is the rehabilitation phase. This stage begins from the time the patient is admitted to the burn center and may last for several years, even extending well beyond discharge. All members of the interprofessional team are essential during this phase; however, rehabilitative and psychological support are of primary importance.

During every dressing change, it is essential that both the

nurse and physician assess the burn wound for progression of healing and evidence of infection. -->The dressing change is also the ideal time for the physical and occupational therapists to assess the wound, as well as to observe the patient's function and range of motion.

An escharotomy (surgical incision through eschar) is performed to

relieve the pressure and should extend only through the eschar and into the immediate subcutaneous fat. This procedure may be performed at the bedside using a scalpel or an electrocautery device. -->In circumferential burns to the chest, pulmonary function may be restricted because of the inability of the chest wall to expand with ventilation.

• Wounds for signs of healing and clinical manifestations of infection-intermediate

If the burn wound is not showing any evidence of healing, surgery may be indicated, or a change in the wound-care regimen may be warranted. -->With the loss of the skin as a protective barrier, the patient remains at constant risk for infection resulting from the invasion of microorganisms.

Because of the protective response of the respiratory tract, the majority of heat absorption and tissue damage occurs

above the glottis and vocal cords. -->These above-the-glottis burns are associated with injury to the nose, throat, and mouth, and because swelling can occur within minutes to hours of injury, emergent intubation may be required to maintain the airway. -->Inhalation injury below the glottis is almost always chemical in nature and is rarely caused by heated air alone. --->This type of severe inhalation injury is most common in patients with prolonged exposure to smoke, such as those rendered unconscious by fire. --->Wheezing and tracheobronchitis may be seen in the first minutes to several hours post-injury.

A serum carboxyhemoglobin level is obtained on

all patients with suspected inhalation injuries, and bronchoscopy is indicated for a definitive diagnosis.

To determine the patient's baseline condition and identify pre-existing illnesses,

basic laboratory studies and radiographical examinations are necessary for all patients with burn injuries.

Most fatalities that occur at the scene of a fire are due to

carbon monoxide poisoning. -->Because carbon monoxide binds to the hemoglobin molecule with an affinity 200 times greater than that of oxygen, tissue hypoxia results when carbon monoxide levels are above normal. -->In cases of suspected carbon monoxide poisoning, oxygen measurement by pulse oximeter is useless because the determination between the oxygen and carbon monoxide molecules saturating the hemoglobin is not possible.

Chemical Injuries-Early recognition and immediate initiation of continuous irrigation to the affected area is crucial when dealing with

chemical burns -The three most common classes of chemicals that cause burn injuries are acids, alkalis, and organic compounds. -->It is important to note that alkali burns tend to penetrate deeper, causing liquefaction necrosis of the underlying tissue requiring a lengthy irrigation period. -->Organic compounds, such as gasoline, are also of importance because of their ability to systemically absorb into the body, causing renal and hepatic damage. -->Tar and asphalt burns are also common injuries but are thermal and not chemical in nature and require immediate cooling rather than removal.

Wound Care

Typically, the burn wound is not the first priority during the emergent resuscitative phase because more life-threatening issues often take precedence. -->Although the burn wound is covered with clean, dry blankets to prevent hypothermia, the initiation of wound care may be delayed for several hours until the patient is stabilized because there are more life-threatening concerns for the patient at this point.

• Explain all procedures to the patient and family in clear and simple terms.

Understanding helps alleviate fear and anxiety in the patient, which may result in tachycardia and hypertension.

In extensive burns where there is not enough unburned tissue to harvest, allograft

(cadaver skin) is often utilized. -->With the placement of allograft as a temporary covering, there is decreased evaporative loss of heat and better pain control for the patient, and it provides a barrier against bacterial growth. ----> is only a temporary covering and is eventually rejected by the body and is replaced by the patient's own skin. -->When allograft is not available, xenograft (pig skin) may also be considered. -->In some developing countries where allograft and xenograft are not readily available, things such as fish skin are being sterilized and used for temporary burn wound coverage.

Skin grafts are meshed

(have holes placed in them that allow for expansion) when unburned skin is in short supply in order to provide maximal wound coverage and closure. -->A mesh expansion ratio of 1:2 upward to 1:4 is commonly utilized. -->In some instances, the burn surgeon may choose to apply a small full-thickness skin graft to allow for the best function in certain anatomical areas, such as the eyelids.

Specific diagnostic studies include

-complete blood count (CBC) -serum glucose -creatinine -blood urea nitrogen (BUN) -prothrombin time/activated partial thromboplastin time (PT/aPTT) -international normalized ratio (INR) -complete metabolic panel (CMP) -arterial blood gases (ABGs) -ECG -chest x-ray -toxicology screen.

• Roughly estimate the %TBSA burned and patient weight in kilograms.

A quick estimation of the %TBSA burned and patient weight guides the determination of fluid to be administered in the first 24 hours on the basis of the resuscitation formula.

Evidence-Based Practice-Infection and Sepsis in Patients With Burns-A panel of experts in burn care came together in 2007 to develop a consensus for definitions concerning infection and sepsis among burn patients. This definition is still relevant today. The panel defined sepsis in patients with burns as "a change in the burn patient that triggers the concern for infection."-The triggers include at least three of the following clinical manifestations:

A. Temperature greater than 102.2°F (39°C) B. Progressive tachycardia and tachypnea C. Thrombocytopenia, low platelet count (does not apply until 3 days after resuscitation) D. Hyperglycemia E. Insulin resistance F. Enteral tube feed intolerance characterized by large amounts of residual tube feeding-In addition to these indicators, documented incidence of an infection or clinical response to antimicrobials is also required to make a definitive diagnosis of sepsis in the patient with burns.

Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis

Although both Stevens-Johnson syndrome and toxic epidermal necrolysis (TEN) have been related to multiple etiologies, the most common causes are an adverse medication reaction, viral infection, or reaction to the staphylococcal toxin. -->In both disorders, the epidermis separates from the dermal layer and sloughs. Stevens-Johnson syndrome (SJS) may involve less than 30% TBSA, whereas TEN may involve greater than 30% TBSA. -->In both conditions, slough to the oral mucosa, conjunctiva, vaginal canal, gastrointestinal tract, and urethral lining may also occur. -->The mortality rate associated with TEN ranges from 25% to 80% and is usually due to septicemia, which leads to multiple organ failure. The lesions associated with SJS and TEN are extremely painful and hypersensitive. -->Immediate concerns focus on protection of the airway because of the oral lesions and inability to control oral sloughing and bleeding. Endotracheal intubation may be required. -->A definitive diagnosis is confirmed through biopsy. Because of the complexity of this type of condition, in which treatment often includes electrolyte replacement, nutritional support, expert wound care, strong infection control practices, and extensive rehabilitation, these patients are often best managed at a burn center.

• Vital signs-intermediate

An elevated heart rate may be secondary to sustained hypovolemia, as well as pain and anxiety. Respiratory rate and blood pressure may also be elevated secondary to pain and anxiety. Temperature may be elevated with an infection. -->The patient also needs to be assessed for hypothermia, particularly with large burns that can lead to increased loss of heat through the open wounds.

Escharotomies and Fasciotomies

Any circumferential burn to an extremity is at risk for developing compartment syndrome. As fluid seeps from the intravascular spaces into the interstitium, pressure within the tissues continues to rise and confines swelling inside muscle compartments, resulting in compartment syndrome. Involved extremities are elevated, and pulses in both burned and unburned extremities are assessed and compared on an hourly basis. -->Clinical manifestations of compartment syndrome include progressive diminishing of the pulse, numbness, tingling, and complaint of pain with flexion and/or extension.

• Total protein and albumin levels-intermediate

Assessment of nutritional status includes monitoring total protein and albumin levels. Normal serum total protein is 6 to 8 g/dL, and serum albumin is 3.4 to 5.1 g/dL. Adequate albumin also supports oncotic pressure that promotes fluid remaining in the intravascular space.

• Instruct patient to cough and deep breathe every hour.

Assists in clearing airway and mobilizing secretions

• Give pain medication on a scheduled basis instead of on an as-needed (prn) basis.-intermediate

Assists in effectively managing pain and allows a steady state to develop within the body; also ideally provides the patient with more consistent pain relief

Evaluating Care Outcomes

At the end of the emergent phase, the anticipated outcomes include the absence of respiratory distress, appropriate fluid resuscitation manifested by stable vital signs and adequate urine output, temperature regulation, and effective pain management. In the event of inhalation injuries, stabilization of the airway and sufficient oxygenation are positive outcomes during this emergent phase. The nurse anticipates adequate urine output with an expected outcome of 0.5 mL/kg/hr, with the recognition that any decrease in urine output below the recommended level must be immediately reported to the provider. Because patients with burns lose the ability to effectively manage their temperature, the nurse anticipates normothermia with appropriate interventions. Adequate pain management and lessened anxiety are also expected outcomes of management during the emergent phase.

• Risk factors that increase chances of infection

Because of loss of skin integrity, the patient is at increased risk of infection, so family members must follow instructions regarding gloves, gowns, and hand washing.

Renal

Because of the initial decrease in circulating blood volume, renal function may also be impaired secondary to decreased renal perfusion. -->Destruction of red blood cells results in free hemoglobin being released into the body following a major burn injury. ---->If the patient has sustained muscle damage as a result of the burn injury, myoglobin may also be present in the bloodstream. -->When fluid resuscitation and resulting blood flow are inadequate, myoglobin and hemoglobin have the potential to occlude renal tubules, causing acute tubular necrosis. This is most commonly seen with electrical injuries.

OTHER CONDITIONS TREATED IN A BURN CENTER

Burn center referrals are not always limited to treating typical burn injuries, and patients with various disease processes that involve the integumentary system, underlying soft tissue, and/or muscle are treated and managed at burn centers. -->Some of the conditions and disease processes treated at burn centers include Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), erythema multiforme, purpura fulminans, staphylococcal scalded skin syndrome, bullous pemphigoid, necrotizing fasciitis, calciphylaxis, scleroderma, and frostbite.

Pain Management - intermediate burn phase

Burn pain continues to be managed aggressively throughout the emergent phase and well into the intermediate and even rehabilitative phases. -->The multifaceted pain experienced by the burn patient includes background, procedural, and breakthrough pain. -->Background pain is the underlying pain from the primary injury that is continuous and ongoing. -->Breakthrough pain is pain related to specific episodes associated with activities of daily living (ADLs), such as walking.

MANAGEMENT OF BURN INJURIES

Burn treatment is based on an interprofessional team approach including physicians, registered nurses, advanced practice registered nurses, physician assistants, wound-care technicians, intensivists, clergy, environmental services, physical therapists, occupational therapists, clinical nutritionists, social workers, case management, psychologists, psychiatrists, respiratory therapists, research coordinators, community outreach educators, child life specialists, and outpatient management services.

Burn Depth

Burns are classified according to the depth of tissue damage: superficial, partial-thickness, or full-thickness injuries. -->burn wounds frequently evolve or "declare themselves" within the first 24 to 72 hours, and it is essential to frequently reassess the burn injury to ensure appropriate resuscitation and treatment. The traditional classification terms of first-, second-, and third-degree are not used in the burn community because they do not give an accurate or descriptive representation as to the true extent of injury.

Classifications

Burns are generally classified in terms of etiology, depth of tissue damage, total body surface area (TBSA) involved, and severity.

Chemical

Chemical burns account for approximately 3% of all burn center admissions and occur in both the industrial and household settings. -->The three subclasses of chemical burns include acids, alkalines, and organic compounds. ---->Some examples of chemical burns include those caused by cement, gasoline, lime, hydrofluoric acid, and bleach.

• Monitor mechanically ventilated patients closely for signs of respiratory compromise.

Close monitoring of mechanically ventilated patients allows for early detection of respiratory distress.

• Upper airway

Damage and irritation caused by the heat and chemical irritants in smoke may cause the airway to appear red and edematous. The mouth and/or airway may also appear black because of soot.

• Changes in voice, hoarseness, and swallowing difficulty

Damage for the heat and chemical irritants in smoke may cause edema and irritation, resulting in changes in the voice, hoarseness, and/or difficulty swallowing.

• Importance of maintaining a warm environment

Decreases risk of heat loss and development of hypothermia

Surgical Debridement and Wound Closure

Early excision and grafting of burns decrease the length of hospital stay and greatly increases the survival rates of these patients. -->Burn excision is considered as soon as the patient is hemodynamically stable and able to tolerate the procedure. -->It is not uncommon for the patient with a large full-thickness burn to be taken to the operating room for excision and grafting within 24 to 48 hours of admission.

• Assist with ADLs and compliance with rehabilitation exercises.-intermediate

Even though the patient's injury location may present a challenge, encouragement of self-performance of ADLs and rehabilitation exercises is essential for rehabilitation therapy.

Lund and Browder Classification

In the hospital setting and in the majority of burn centers, the most widely accepted and accurate method of determining the percentage of TBSA burned is the Lund and Browder classification. -->Measurements, which take into account surface area related to age, are assigned to each body part. The Lund and Browder classification chart has come into question because it does not account for the altered body mass distribution in obese patients, and future revisions are currently being considered by burn experts. -->Only partial- and full-thickness burns are recorded on the Lund and Browder chart because superficial burns are not taken into account during resuscitation. The Lund and Browder chart is not completed until a full and thorough debridement (removal of damaged tissue) of the burn wound has been completed because this TBSA percentage provides the basis for determining the amount of fluid resuscitation.

• Daily weight-intermediate

Increased metabolic rate may result in weight loss.

• Daily caloric intake-intermediate

Increased metabolic rate results in an increased caloric need to assist in wound healing.

• Trend ABG values and carboxyhemoglobin levels.

Increasing PaCO2 and decreasing PaO2 and oxygen saturation may indicate the need for intubation. -->As carboxyhemoglobin levels lower, weaning of oxygen support (FiO2) to a minimal level to sustain oxygenation is indicated.

• Urine output

Indicators of inadequate resuscitation and development of hypovolemia may be evidenced by urine output less than 0.5 mL/kg/hr.

• Participation in plan of care and ADLs-intermediate

It is important for the patient to be actively involved in the plan of care and to understand the rationales for all interventions.

Clean Technique and Infection Control

It is important to note that burn wound care is a clean, not a sterile, procedure. Sterile technique involves employing techniques to reduce exposure to microorganisms, such as using a sterile field and sterile instruments and gloves. Clean technique involves using techniques to reduce the overall number of microorganisms, such as preparing a clean field and using clean gloves and instruments. -->Burn wound care is extensive, physically exhausting, and time-consuming, with some dressing changes lasting up to 2 to 4 hours. -->Often, these dressing changes occur in patient rooms where the temperature is usually set as high as 90°F (32.2°C) to prevent the risk of hypothermia.

• White blood cell counts-intermediate

Loss of the protective mechanisms due to burn injuries increases the risk of infection, and an elevated white blood count may indicate a wound infection.

• Education on the importance of nutrition and provision of a diet plan-intermediate

Maintenance of caloric needs is essential for wound healing, performance of daily activities, and the rehabilitation regimen.

Geriatric/Gerontological Considerations-Burn Care in Older Adults

Managing the care of older adults with burn injuries can present many challenges for the burn team. -->Common age-related changes in this population put them at a much higher risk of burn injury. These changes include reduced mobility, decreased vision, decreased sense of smell, reduced coordination and strength, and decreased sensation. -->These normal changes can place older adults at a much higher risk of a severe burn injury because they may have difficulty escaping the fire or removing the source of heat.

• Cover wounds with a clean, dry sheet.

Minimizes evaporative heat loss and decreases the risk of hypothermia

• Institute warming measures in the form of blankets or other external heat sources.

Minimizes evaporative heat loss and prevents the development of hypothermia

• Explore the effectiveness of nonpharmacological pain relief techniques, such as music therapy and guided imagery.-intermediate

Nonpharmacological techniques have been shown to assist in the reduction of procedural burn pain and anxiety.

Nutritional Support (intermediate)

Nutrition plays a significant role in the outcomes of the patient with major burn injuries. Large burn injuries place the patient in a prolonged hypermetabolic and catabolic state, resulting in an increased caloric need to assist in wound healing. Early enteral nutrition is associated with a reduction in ileus and stress ulcers because it reduces the inflammatory mediators released by the body. --->Once a person has sustained a burn of approximately 20% or greater, it is difficult to consume the amount of calories and protein needed for wound healing, and nutritional supplementation is often required because of the fact that his or her metabolic rate is greatly increased as a result of the burn injury. Nutritional supplementation is most often achieved through the placement of a nasogastric tube, where feedings can be given continuously or intermittently in the form of a bolus. -->In large burn injuries, longer nutritional support is required, and the placement of a duodenal feeding tube is often recommended to help prevent aspiration and allow for feeding up to and during procedures. -->Supplemental vitamins and minerals are also often administered to promote wound healing. -->Total parenteral nutrition is not often utilized among patients with burns because of its complication rates, including an increased risk for infection and hyperglycemia.

• Pain and anxiety-intermediate

Pain associated with daily dressing changes places the patient at risk for tachycardia and hypertension.

• Anxiety

Patient anxiety levels may be high because of the appearance of the burn wound and exposure to trauma.

■• Time medication administration so that the patient receives the full benefit during wound-care procedures.-intermediate

Procedural pain is often the most intense pain associated with a burn injury, and medication must be timed to allow for maximum absorption, as well as to time the most painful procedures during the peak effectiveness times of medications.

• Provision of a rehabilitation plan and discussion of the importance of doing ADLs and rehabilitation therapy-intermediate

Providing a rehabilitation plan and encouragement of self-performance of ADLs helps prevent complications associated with decreased mobility and provides a sense of self-control.

• Provide information to patient and family about the natural progression of burn wounds, grafts, and/or donor sites.-intermediate

Providing information can help to reduce misconceptions and anxiety related to surgery and recovery.

• Immediately report difficulty breathing and/or swallowing.

Respiratory distress may develop quickly or may be delayed in patients with an inhalation injury.

Intermediate Phase-Medical Management

The burn patient enters into the intermediate phase after resuscitation and stabilization have been achieved. This phase usually begins 48 to 72 hours after the initial burn injury. -->Within the intermediate phase, the management priorities shift to wound healing and closure, pain management, ensuring optimal nutrition, and continued prevention of infection. --->Although the focus moves away from the life-threatening priorities of the emergent phase, continued assessment and management of respiratory and circulatory status are essential during the intermediate phase.

Mechanical and Enzymatic Debridement

The preferred method of wound cleansing involves the use of a mild soap or chlorhexidine and water along with gentle debridement of the burn wound -->The three kinds of debridement are mechanical, enzymatic, and surgical. -->While cleansing, removal of the loose tissue is important to allow for proper visualization of the burn wound and is accomplished through the use of tweezers and scissors and is often aided by the removal of gauze dressings and hydrotherapy. --> Enzymatic debridement involves the application of a proteolytic ointment that hastens eschar separation and wound healing. --->often reserved for patients with deep partial-thickness wounds where signs of healing are evident. This type of debridement is also considered in patients with full-thickness burns who may not be candidates for surgery. -->If mechanical and enzymatic debridement are not effective, surgical debridement is necessary.

Topical Medicines and Wound Dressings

There are numerous variations of topical medications and wound dressings that are used on burn wounds. The choice of the agent and dressing depends on wound depth, location of the injury, presence of infection, and provider preference. -->Special care is taken when wrapping fingers and toes because they must be dressed individually to prevent webbing (the growing together of the skin between the fingers and toes) and maintain full range of motion

Wound Care-Hydrotherapy

Wound-healing practices vary greatly among facilities and burn centers. -->Hydrotherapy is the favored cleansing method within most burn centers because it allows for thorough wound cleansing and uses water during dressing changes to assist in the removal of residual topical agents and necrotic tissue. -->In the past, hydrotherapy involved total immersion into a tank or tub of water. More recently, burn centers have begun using portable shower trolleys covered with disposable plastic liners to help prevent the spread of infection and cross-contamination. For patients who cannot tolerate extensive hydrotherapy, burn wound care may be done at the bedside.

However, in patients with large burns,

any site on the body may be utilized, including the scalp and scrotum if necessary. -->Once healed, donor sites may be re-harvested numerous times. -->These split-thickness skin grafts are then applied to the excised wound in the form of a sheet or meshed graft. -->Sheet grafts are often utilized on exposed areas of the body, such as the face and hands, because they give a more seamless and cosmetic appearance due to the fact that the grafts are not meshed.

The ideal replacement for lost skin is

autograft because it is the patient's own skin and will not be rejected by the body. -->The epidermis and a partial layer of the dermis (split-thickness skin grafts) are harvested from an unburned area, known as the donor site. -->The most common donor site is the thigh because of the ability to obtain a continuous donor sheet of skin.

Rehabilitative Phase-Complications-One of the most devastating sequelae associated with burn injuries is the development of

contractures. There are several contributing factors to the development of contractures, including the extent, depth, and location of the burn.

Another alternative to consider with massive burns is the use of

cultured epithelial autograft (CEA). -->This technique is considered only in the most severely burned patients where there is no other alternative because the patient remains very vulnerable to infection, and the CEA skin is extremely fragile. -->Cultured epithelial autograft involves a biopsy taken from an area of unburned skin and then sent to a laboratory where, over a 2-week period, epithelial cells are grown in the laboratory and attached to petroleum-impregnated gauze. -->Excision of the burn wound is not delayed while waiting for the CEA, and ideally, the wound is excised, and an allograft is placed as a temporary covering. Cultured epithelial autograft is extremely delicate because it involves the growth of only the epidermal layer. -->After the placement of the CEA, the patient is often placed in traction, which allows elevation of extremities and pressure relief. These patients then require extensive one-on-one nursing care that focuses on time-consuming wound healing and infection control.

Rehabilitative Phase-Although survival rates for patients with major burn injuries are

increasing, it is essential to return the patient to his or her highest level of function and mobility. Physical and occupational therapists are important members of the interprofessional team and begin working with the burn patient immediately upon admission. -->Modalities including range of motion, positioning, splinting, ambulation, and ADLs are implemented as soon as the patient is physiologically stable. -->Once the patient is discharged, physical and occupational services continue in the home, at a rehabilitation facility, or in an outpatient setting. In some cases, these patients require rehabilitation therapy for several hours a day up to 5 days a week for many months after their injury.

Rehabilitative Phase-Scarring is another

major concern when dealing with a burn injury. Any area that has been grafted will have some element and degree of scarring. -->As burn wounds mature over the course of months to years, hypertrophic scarring can result. -->Burns to the face and hands that have caused scarring are particularly traumatic to the patient and may result in appearance changes and disfigurement. -->As patients progress to discharge, they are measured and fitted for specialty pressure garments -->The purpose of these garments is to apply continuous and uniform pressure over the area of burn to prevent hypertrophic scarring. These garments are to be worn 23 hours a day for up to a year or more after injury in some patients. Specialty face masks may also be utilized to help prevent scarring.

Rehabilitative Phase-Not only is a burn injury physically painful, but dealing with the long-term emotional consequences is also

often difficult. -->The patient with a burn injury may endure many psychological and emotional challenges throughout his or her lengthy course of treatment and recovery. The patient may experience posttraumatic stress disorder (PTSD), body image disorder, anxiety, and/or depression. -->Psychologists, psychiatrists, and advanced practice mental health nurse practitioners and clinical specialists are often involved, and many patients may require both emotional and pharmacological interventions for mental health issues. -->Although the patient may suffer emotional consequences as a result of the burn injury, the family members and loved ones are also often affected by this traumatic experience. -->Nurses often have the most contact with the patient and his or her family and play a key role in the provision of support. Many burn centers have specialty support groups for survivors of burn injuries and their families.

Rehabilitative Phase-Contractures are characterized as

permanent tightening of the skin that may involve underlying muscles and tendons and result in limited mobility. -->The patient's personal motivation and compliance with therapy regimens play important roles in the development of contractures. -->Contractures are especially devastating in the pediatric population because burned or grafted skin is unable to expand as the child grows. -->Splinting is the most common method used to help prevent the formation of contractures ---->Splints are placed by rehabilitation therapists to maintain range of motion and function of the involved joints. It is especially important to employ the use of splints when a burn injury crosses over a major joint, such as the elbow or knee.

The pain management plan of care is individualized and includes both (intermediate phase / anxiety)

pharmacological and nonpharmacological methods of pain management. Recommended IV narcotics, usually used during dressing changes, include morphine sulfate (morphine), fentanyl (Sublimaze), ketamine, and/or hydromorphone (Dilaudid). Intravenous narcotics are continued while the pain is severe and unrelenting; however, all efforts are made to transition to oral pain medications as soon as tolerated. -->It is important to differentiate between pain and anxiety because they are treated differently. In addition to pain management, patients are often given anxiolytics for anxiety related to wound-care procedures, appearance changes, and fear. -->However, these medications are indicated only once the pain is under control. In addition, pain medication is given on a scheduled basis instead of on an as-needed (prn) basis because this helps to better manage the pain over time and hopefully prevents it from becoming intolerable.

When giving large doses of IV pain medication, especially during dressing changes, ensure that

proper ventilatory support and emergency equipment are immediately available.

Nursing Diagnoses pt 2

pt 2 • Risk for infection related to impaired immune response and loss of skin integrity • Altered nutrition less than body requirements related to hypermetabolism and burn injury • Acute pain related to exposure of nerve endings in wound bed and wound-care procedures • Anxiety related to painful wound-care procedures • Self-care deficit related to impaired mobility due to the burn injury • Powerlessness related to hospitalization and inability to care for self

Evaluating Care Outcomes The focus during the rehabilitative phase is to

return the patient to the highest functioning level, and expected outcomes include pain management, prevention of complications, improvements in mood, and increasing independence with activities of daily living. The nurse plays an integral role in assisting and encouraging the patient during physical and occupational therapy treatment regimens. -->It is important for the patient and family to verbalize and demonstrate an understanding of therapy routines because noncompliance can quickly lead to contractures and loss of function. -->The nurse also works closely with the patient and the psychologist to effectively manage and deal with the possible psychological sequelae, which may include body image disorder, nightmares, and PTSD.

Evaluating Care Outcomes-During the intermediate phase, there are

several additional priorities for the nurse to focus on, including outcomes related to adequate nutrition, pain management, wound healing, and infection control. -->Stable body weight and normal albumin and total protein levels are indicative of improving nutritional status. -->Effective pain management is supported by stable vital signs, as well as the patient reporting adequate comfort. -->Additionally, the patient is comfortable enough to participate in ADLs and understands the importance of asking for pain medications prior to pain becoming intolerable. The effectiveness of wound management is determined by evidence of the healing of burn injuries as well as no signs of infection. -->Stable vital signs, including normal heart rate and blood pressure, are consistent with adequate fluid volume status and pain management. Normal temperature and normal white blood cell counts support a lack of infection.

Nursing Management-Assessment and Analysis-The rehabilitative phase is

the longest and may last several years depending on the TBSA affected, the severity of the burns, and the complexity of the treatments.

Procedural pain is associated with

therapeutic activities such as wound care and physical therapy. Inadequate and inconsistent management of pain is well documented in the burn literature, and pain is whatever the burn patient says it is. -->Although the pain is aggressively managed and patient comfort is a priority, the patient needs to actively participate in the plan of care and particularly in the rehabilitation process. -->Because of the large doses of pain medication that are administered, the patient is optimally treated at a burn center, where his or her pain can be effectively managed by the interprofessional team.

In full-thickness burns, eschar acts as a

tourniquet, and as fluid resuscitation continues, vascular compromise may result. -->Pulses are monitored on an hourly basis in all affected extremities. --->In some patients, if it is difficult to palpate pulses, a Doppler may be required to assess peripheral circulation. ->Other assessments include skin color, temperature, sensation, and capillary refill. -->It is imperative that the nurse monitor for progressive diminution of pulses and report these data to the healthcare provider rather than waiting until pulses are completely absent.

Nursing Diagnosesrehab

• Activity intolerance related to pain when exercising because of the burn injury • Impaired physical mobility related to pain on movement and potential scar and contracture development • Disturbed body image related to altered physical appearance • Moral distress related to anticipation of discharge to home and/or a rehabilitation center

Burn Prevention Outside the Home

• Always store flammable liquids outside the home in clearly labeled, airtight containers in well-ventilated areas (such as a garage or shed). • Never refill a hot engine (i.e., lawnmower or weed whacker). Wait until thoroughly cooled before refilling with gasoline. • Never use flammable liquids to start a campfire or grill. • Never throw flammable liquids onto an already burning fire. • Use caution with campfires, and do not leave children unattended around the fire. • Fireworks should be used only by adults and with extreme caution. • Be careful of overhead and underground electrical wires while working outside. • If downed electrical wires are found, do not touch! Call the local electric company to report immediately. • Caution children never to play near or on electrical boxes or climb trees with electrical wires passing through the branches. • Always use sunscreen with an SPF of at least 30 when outdoors, and be sure to reapply often. Consider a wide-brimmed hat and sunglasses.SPF, Sun protection factor.

Secondary Survey Assessment Includes:

• Circumstances of the injury • Cause of burn injury? • Exact time of burn injury? • Enclosed space? • Associated trauma (electrical)? • Length of time before rescue? • Chemicals involved? • Use of accelerant? • Medical history, current medications, allergies, and vaccinations • Last food and fluid intake documentation • Complete "head-to-toe" physical examination• Determine the extent and depth of burn injury (calculate TBSA percentage) • Cover the wounds with a clean, dry sheet • Maintain core body temperature • Pain medication, IV narcotics preferred • Tetanus status (considered current if received within the previous 5 years) • Initial laboratory values/tests: CBC, CMP, PT/aPTT, urinalysis, surveillance cultures • ABG and carboxyhemoglobin level for suspected inhalation injury • 12-Lead ECG and CK-MB/troponin for electrical injury • Fluid resuscitation calculation and IV fluid rate adjustment

Superficial tx

• Do not apply ice or submerge in ice water. • May apply a cool compress or run under cool water. • A dressing should not be required because there are no open blisters. • Lotion should be applied liberally once or twice per day. • Choose lotion that is aloe based and/or fragrance-free. • Ibuprofen, acetaminophen, or aspirin may be taken as necessary for pain and discomfort. • Drink plenty of fluids to rehydrate • Rest.

Nursing Management-Assessment and Analysis-During the emergent phase, the priority assessments focus on immediate life-threatening injuries, including airway management, particularly with suspected inhalation injury; fluid volume status; temperature control; and pain management. Clinical manifestations during this phase may include:

• Facial burns • Naso- or oropharynx erythema • Hoarseness, grunting • Carbonaceous (soot) sputum • Dyspnea • Wheezing • Tachypnea • Intercoastal retractions and flaring nostrils • Elevated carboxyhemoglobin levels • Tachycardia • Hypotension • Confusion, agitation, changes in level of consciousness • Decreased urine output • Hypothermia • Headache • Complaints of pain

Box 51.5 Physical and Clinical Manifestations of an Inhalation Injury

• Facial burns • Singed nasal and facial hairs • Carbonaceous sputum (soot), hypersecretion • Naso- or oropharynx erythema • Excessive agitation/anxiety (hypoxia) • Tachypnea, intercostal retractions, flaring nostrils • Inability to swallow • Hoarseness, grunting, brassy voice • Rales, rhonchi, diminished breath sounds

Partial Thickness tx

• If one to three quarter-sized or smaller blisters appear, try not to open (pop) the blisters. This allows for a moist healing environment, decreased risk of infection, and less discomfort for the patient. • If the blister or blisters are broken, wash the area with a mild antiseptic soap and warm water.• Apply a thin layer of bacitracin ointment and cover with a nonadherent bandage. • The wound should be thoroughly cleansed and the dressing changed at least once per day.• The patient may continue with his or her usual activities of daily living; however, dependent extremities should be elevated to prevent edema and encourage venous return. • The patient should be aware of any clinical manifestations of infection, such as fever, increased pain, redness or swelling, purulent drainage, or red streaks radiating from the wound. --->If noted, the patient should see his or her primary care provider right away. • It is encouraged that the patient follow up with his or her primary care provider.

Nursing Interventions rehab-■ Assessments

• Pain levelIf the patient is in pain, participation in physical activities may be impaired, further complicating recovery. • Range of motionIn the patient with extensive scarring and/or contracture development, the mobility of joints may be limited, requiring specific strengthening and flexibility exercises. • Compliance with treatment and the rehabilitation regimen -->Helps to prevent tightening of the skin and the development of contractures and scarring • Assess readiness for integration into society. -->Many patients have anxiety about pending discharge and perceive difficulties with returning to society.

Just as in the two previous phases, the patient must be monitored for infection, nutritional status, and pain during this phase. Additionally, the priorities expand to promoting greater mobility, flexibility, comfort, and psychosocial health. During this phase, the nurse observes for the following clinical manifestations:

• Pain/discomfort • Contractures • Scarring • Disfigurement • Limited mobility • Altered/depressed mood • Flat affect • Fear • Anxiety

Hospital may tx?

• Partial-thickness burns equal to or greater than 10% of the total body surface area • Burns that involve the face, hands, feet, genitalia, perineum, or major joints • Full-thickness burns in any age group • Electrical injury, including lightning injury • Chemical injury • Inhalation injury • Burn injury in patients with pre-existing medical conditions that may complicate management, prolong recovery, or affect mortality • Any patients with burns and concomitant trauma (e.g., fractures) in which the burn injury poses the greatest risk of morbidity or mortality. • Burned children in hospitals without qualified personnel or equipment for the care of children • Burn injury in patients who require special social, emotional, or rehabilitative intervention

■ Actions-rehab

• Splinting and encouragement of rehabilitation exercises and ADLs -->Essential to help prevent development of contractures and maintain joint function • Include psychology in patient treatment decisions --->Burn patients may deal with multiple associated sequelae, including PTSD, nightmares, and body image disorder. • Provide community resources for support upon discharge, including psychological support. --->Community resources for burn survivors may be difficult to find but can provide essential social and psychological support.

■ Teaching rehab

• Teach patient and family the importance of and how to apply pressure garments and/or face masks. -->Prevent hypertrophic scarring • Teach patient and family about burn prevention, sun protection, and prevention of hyperthermia. --->Patients with burns may be lacking sweat glands, and new skin and/or grafted skin is sensitive to sunlight.

Nursing Management-Assessment and Analysis-The nurse monitors for the following additional clinical manifestations during the intermediate phase:

• Wound color and consistency • Wound drainage • Eschar • Responses to therapeutic interventions • Graft sites • Pain • Weight • Serum total protein and albumin • Infection

Box 51.2 Burn Prevention Strategies-Burn Prevention Inside the Home

• Install and maintain working smoke alarms on each level of the home and inside each sleeping area. Each month, check that they are working, and change the batteries every 6 months unless the alarm is hardwired into the home or has a 10-year lithium battery. • Install and maintain working carbon monoxide detectors on each level of your home. • Develop and practice a home fire escape plan. Make sure everyone in the home knows the meeting place and knows never to return into a burning home for any reason. • Keep all windows and doorways free of clutter in case of the need to escape quickly. • Keep a flashlight and telephone near the bedside. • Keep a working fire extinguisher on each level of the home and know how to use it properly. • Never set the water heater above 120°F (48.9°C).• Teach children how to stop, drop, and roll.• Keep matches and lighters out of the reach of children. • Never leave a child unattended in a bathtub or near a fire/fireplace.• Never smoke in bed or while drowsy. • Never smoke while receiving oxygen therapy. • Never leave burning candles unattended, and try not to burn candles on low surfaces for risk of being knocked or bumped. • Always exercise caution while cooking, and do not leave anything unattended on the stove. • Avoid wearing long sleeves or flowing clothing while cooking. • Never let a child play near the stove/oven while cooking. Always turn pot handles inward and use the rear burners when possible. • Never use the kitchen oven as a means to heat the home. • Avoid running electrical cords under carpets.• Avoid using space heaters in the bedroom or while asleep. • While a space heater is in use, there should be a minimum of 3 feet of clearance around the heater in all directions. • Avoid falling asleep while using a heating pad. • Be sure to use proper protection and ventilation while working with chemicals in the home, including cleaning products. Read all product labels carefully before use. • Never store flammable liquids inside the home or near a source of heat.

If myoglobin is present in the urine, output should be maintained at

1 mL/kg/hr until clearing of the urine occurs to prevent the development of acute renal failure. -->Diuretics are not indicated during the emergent phase, and if urine output drops, the rate of fluid administration is increased. -->Other parameters that are monitored during fluid resuscitation include heart rate, blood pressure, central venous pressure, serum chemistries, hemoglobin, and hematocrit.

The common household electric circuit carries a charge of

120 volts. High-voltage injuries occur when a person comes into contact with 1,000 volts or greater. These types of injuries are often work related and are more common in men. -->Patients who sustain high-voltage injuries often present with very deep burns and sequela from associated trauma. -->Flash injuries and/or flame burns may also occur as a result of possible ignition of clothing. The hands and mouth are the most frequently injured sites for low-voltage electrical injuries in children as they may have oral contact with electrical cords or sockets.

The majority of fire-related fatalities and injuries occur in people between the ages of

20 to 69 years. -->Although the exact reasons for this are unknown, possibilities include the greater likelihood of men participating in risk-taking behavior and the more high-risk occupations of men. -->Men also suffer more injuries trying to extinguish fires and rescuing people. -->Approximately 30% of all fire deaths in females occurs in women 70 years old and older, and this may be due to the fact that women have a longer life expectancy than men and are often performing the majority of the cooking. -->By contrast, male fire deaths are higher in the age range of 40 to 59. -->Notably, older adult females have twice the number of fire injuries when compared with older males.

In the post-burn shock phase, which begins approximately

24 to 48 hours after injury, the capillaries begin to regain integrity. -->Burn shock slowly begins to resolve, and the fluid gradually returns to the intravascular space. Urinary output continues to increase secondary to patient diuresis, and blood pressure and cardiac output begin to normalize.

Continuous cardiac monitoring is recommended for at least

24 to 48 hours for patients presenting with a documented cardiac arrest or dysrhythmia and/or extremes in burn size and age. -->It is important to obtain a baseline ECG to track any cardiac abnormalities that may arise.

Scald injuries are most prevalent in children under the age of

5, whereas fire/flame dominates all other age groups. The leading cause of both residential and non-residential structure fires is cooking (80.2%), with fires caused by heating being the second-leading cause (9.6%). -->The two leading causes that result in fatalities and/or injuries for residential fires are cooking- and smoking-related incidents. Some examples include grease burns, scald injuries, flame burns, and falling asleep while smoking.

Generally, fluid leakage occurs during the first

8 to 36 hours after the injury, with maximum shifting peaking at approximately 24 hours post-burn. If fluid resuscitation is not adequate, the burn patient begins to demonstrate clinical manifestations of shock, including hypotension, tachycardia, reduced urinary output, and altered mental status. -->If the state of shock continues to progress without proper fluid resuscitation and management, the patient will begin to decompensate, resulting in multisystem organ failure and potentially death.

Metabolic

A burn injury causes an array of physiological alterations within the body, placing the patient in a constant hypermetabolic state for up to 1 to 3 years post-injury. -->Burn injuries often double the normal resting energy expenditure and greatly increase the patient's caloric needs. -->Factors affecting the metabolic rate in patients with burns include age, gender, infection, concomitant trauma, pain, surgery, sleep, and ambient temperature. -->Without additional nutritional support in patients with large burn injuries, particularly those with a burn greater than 20% TBSA, wound healing is impaired. -->Nutrition is so important that many burn centers continue to enterally feed patients up to and throughout their entire operative procedures

Burn Etiology

A burn injury results when the tissues of the body are damaged by a heat source. The heat source may be thermal, electrical, chemical, or the result of radiation.

Pain Management for burns

A burn is one of the most painful injuries an individual can sustain. Intravenous narcotics, such as morphine sulfate (morphine), are used for the initial management of pain. -->The intramuscular route of administration is avoided because there may be impaired medication absorption due to an edema formation and decreased peripheral perfusion. -->Pain medication is administered intravenously in doses no larger than those needed to manage pain. The nurse monitors closely for signs of respiratory depression when giving large doses of pain medication. --->Although morphine sulfate (morphine) is commonly used, other types of narcotics may also be used, including fentanyl (Sublimaze) and hydromorphone (Dilaudid).

Deep Partial Thickness

A deep partial-thickness burn involves the epidermis and extends into the deeper portions or bottom layers of the dermis -->The patient often reports varying areas of pain and decreased sensation. -->Deep partial-thickness burns appear waxy and do not have the characteristic weeping blisters that are seen in superficial partial-thickness injuries. This is due to the fact that the entire epidermis and the majority of the dermis have been damaged. -->The burn may appear light pink or cherry red in color, and capillary refill is decreased or absent. -->The challenge with a deep partial-thickness burn is determining the true extent of the injury and whether it will heal without requiring surgical intervention. -->It is essential to engage in close observation of the burn wound to monitor for potential progression from a deep partial-thickness to a full-thickness burn injury. -->The majority of these types of burns take more than 2 weeks to heal, during which time the risk of infection is paramount because patients with burn injuries are immune-compromised without the skin as a barrier to infection. -->Unfortunately, burns are not an exact science, and the burn surgeon decides whether to operate or to try to let the burn heal on its own.

Full Thickness

A full-thickness burn involves destruction of the epidermis, the dermis, and portions of the subcutaneous tissue --> All epidermal and dermal structures are destroyed, including hair follicles, sweat glands, and nerve endings. Full-thickness burns do not heal spontaneously. --> As a result of the extensive damage to the nerve endings, full-thickness burns are often insensate. This absence of pain is often misleading for patients, and many do not comprehend the severity of their injury. -->Full-thickness burns generally have no blister formation. -->Although full-thickness burns may take on a variety of colors, they are always very dry and feel like leather to the touch. ----->This full-thickness burn tissue is often referred to as eschar. -The charred appearance associated with full-thickness injuries is not common. -->Because all epithelial elements and structures are destroyed, full-thickness burns do not heal spontaneously and require skin grafting. -->Burns that extend beyond the subcutaneous layer into muscle and/or bone are also considered full thickness

Superficial Partial Thickness

A superficial partial-thickness burn involves the epidermis and the superficial or minimal layers of the dermis (Fig. 51.3). Because of the exposed nerve endings located within the dermal layer of the skin, these burns are often very painful. -->The patient is extremely sensitive to touch and even to air currents when the wound dressing is removed and the burn is exposed. -->Superficial partial-thickness burns often have wet, weeping blisters and are pink in color. The capillary refill time on areas of open blisters remains normal. -->Despite the destruction of the entire epidermis, superficial partial-thickness burns usually heal in 1 to 2 weeks with minimal to no scarring.

• Place two large-bore IV catheters and begin fluid resuscitation with lactated Ringer's.

Adequate fluids are necessary to prevent hypovolemic shock from developing as a result of massive fluid loss and fluid shifts. Lactated Ringer's is an isotonic fluid that supports intravascular volume.

Box 51.6 Primary and Secondary Survey of the Burn Patient in the Emergent Phase-Primary Survey Assessment Includes:

Airway and C-spine stabilization • Maintain a patent airway (may require intubation). • Consider cervical spine immobilization if warranted.- Breathing • Provide high-flow 100% oxygen by mask. -Circulation • Elevate extremities (no pillow under head). • Remove tight jewelry or clothing • Neurovascular checks with circumferential burns and electrical burns to extremities -Disability • Neurological examination -Expose and examine • Extent and depth of burn wounds and possible associated trauma Fluid resuscitation • Insert a minimum of two large-bore peripheral IV lines and start Lactated Ringer's.

SPECIAL CONSIDERATIONS IN THE PATIENT WITH BURNS-Inhalation Injuries

An inhalation injury can exist in the presence or absence of a cutaneous burn --> Regardless of the TBSA percentage burned, an inhalation injury increases the overall mortality rate because the patient often develops pneumonia or hypoxemia and requires lengthy ventilatory support. Although inhalation injuries can significantly increase morbidity and mortality, there are few standards for diagnosis, treatment, and the measurement of outcomes. -->Chest x-rays performed on admission are often normal in patients with an inhalation injury, and as a result, a fiberoptic bronchoscopy examination is recommended for definite diagnosis because this study can reveal damage to the respiratory tract and lungs that is not evident on chest x-ray. ---> It is important that patients are observed closely for approximately 24 hours post-burn injury because of the insidious onset of inhalation injuries.

• Face and neck for burns, singed nasal and/or facial hair, and singed eyebrows/eyelashes

Edema and irritation of the airway may develop secondary to damage caused by heat and chemical irritants as evidenced by hypoxemia, rhonchi, stridor, change in voice (hoarseness), and/or dyspnea.

• Breath sounds, respiratory rate, and indicators of inhalation injury

Edema and irritation of the airway may develop secondary to damage caused by heat and chemical irritants as evidenced by hypoxemia, rhonchi, stridor, change in voice (hoarseness), and/or dyspnea. Inhalation injuries may impair respiratory function, leading to decreased ventilation and changes in rate and effort, resulting in lower oxygenation.

Electrical

Electricity has many devastating effects on the body and may result in a wide spectrum of injuries, ranging from mild to lethal. -->Electrical injuries are associated with an overall increase in the length of hospital stay, morbidities, and number of required surgeries. ---->This is due to the fact that electrical injuries often are linked to other types of ensuing trauma due to subsequent falls and the potential cardiac injury. ---->In addition, as electricity passes through the body, it has the potential to cause damage to multiple organs, which then must also be addressed and treated in conjunction with any burns that have occurred. -->Patients may present with cardiac and/or neurological problems as well as associated trauma and/or flame burns.

Total Body Surface Area Percentage

Expressed as a percentage, total body surface area (TBSA) determination is essential to guiding adequate fluid resuscitation and treatment. -->Both over- and underestimation of the size of the burn can have significant effects on outcome. Underestimation can result in inadequate resuscitation, which may cause shock and organ failure. -->Overestimation can put the patient at risk for complications such as pulmonary edema due to the excess fluid given during resuscitation. --> The three most common methods for determining TBSA are the rule of palm, the rule of nines, and the Lund and Browder classification.

Fluid Resuscitation

Fluid resuscitation is crucial to the survival of the patient who has suffered a burn of 20% TBSA or greater. The overall objective is to maintain tissue perfusion and organ function while at the same time avoiding potential complications of inadequate or excessive fluid resuscitation. -->It is important to note that insufficient fluid resuscitation can lead to organ failure and death, and excessive amounts of fluid can also cause morbidity and mortality. -->Intravenous resuscitation is initiated in adults at 20% TBSA, and if possible, it is recommended to consult with a burn center prior to the initiation of resuscitation.

Prevention of Hypothermia

Hypothermia is commonly seen in patients with burns because the skin, their primary insulation, is no longer intact. --->It is imperative to keep the patient covered at all times and to closely monitor his or her temperature, especially in the emergency department, where patients are typically exposed for assessments. --->The ambient room temperature is usually increased to decrease heat loss in patients with significant burn injuries.

• Ensure securement of the endotracheal tube if the patient is intubated.

If the tube is dislodged, it may be impossible to reinsert due to the edema. In addition, the securement device will require adjustment (e.g., twill) as the edema continues to worsen/decrease.

• Place patient on 100% humidified oxygen or assist with intubation if necessary.

Immediate intervention is necessary for respiratory distress and to provide humidified oxygen and assist in the clearing of carbon monoxide. -->The half-life of carbon monoxide while on 100% oxygen is 30 minutes to 1 hour compared with 4 hours breathing room air.

• Maintain emergency airway (intubation and tracheostomy) trays at the bedside.

Inflammation and edema secondary to airway injury may make endotracheal intubation difficult or impossible. -->In patients with an endotracheal tube in place, a tracheostomy tray should be maintained at the bedside in the event of an unplanned extubation.

Respiratory

Inhalation injuries, defined as the toxic effects of heat and the chemical products of combustion on the lungs and in the airways, are present in 10% to 20% of patients admitted to burn centers and significantly increase morbidity and mortality. In order to minimize complications and decrease the overall mortality rate, rapid diagnosis and management of inhalation injuries are critical -->Recognizing an inhalation injury is particularly important because it has been recognized as the third most important factor, after extent/depth of burn and patient age, in determining mortality. Inhalation injuries should always be considered when the patient was injured or trapped within an enclosed space, such as in a house or car, or there are burn injuries of the face, neck, or chest.

Cardiovascular

Initially, the greatest threat to a patient with a major burn injury is burn shock, which is a combination of distributive and hypovolemic shock. -->This type of shock results secondary to a massive fluid shift. Electrolytes, water, plasma, and proteins leak out of the intravascular space and into the interstitial space because of the increase in capillary permeability, which results from the body's initial inflammatory protective mechanism. --->The large fluid loss within the intravascular space increases the viscosity of the blood, which results in sluggish blood flow, decreased oxygen delivery, and overall decreased cardiac output. -->Because of the increased viscosity of the blood, the patient initially presents with an elevated hematocrit.

Immunological

Patients with burn injuries are at high risk for infection and sepsis because of loss of the protective function of the skin, altered immunological defenses, and the presence of open burn wounds. --->The loss of skin integrity is compounded by the release of abnormal inflammatory factors, which alter the patient's underlying metabolic profile. -->As a result of these alterations, patients with extensive burns develop systemic inflammatory response syndrome (SIRS). -->The term SIRS relates to the exaggerated inflammatory response that occurs in the body after injury and may precede the development of sepsis. All patients with extensive burns exhibit some form of SIRS regardless of whether or not sepsis ensues.

Radiation

Radiation burns are the least common type of burn injury, and the severity of complications is dependent on the type, dose, and length of exposure. --->These injuries are often associated with the industrial use of ionizing radiation, nuclear accidents, and therapeutic radiation treatment. --->Sunburn is also considered a radiation burn because it is caused by ultraviolet radiation and is the most common type of radiation burn seen in healthcare settings. -->Localized radiation injuries often appear similar in nature to thermal burns because they are characterized by erythema, edema, blisters, and pain. -->Prolonged full-body exposure to ionizing radiation often causes nausea, vomiting, diarrhea, fatigue, headache, and fever.

• Elevate the head of the bed to allow for better oxygenation.

Raising the head of the bed decreases the work of breathing by lowering the diaphragm.

Superficial burns

Superficial burns affect only the epidermal layer of the skin and are characterized by mild erythema and hypersensitivity, which typically resolve in 24 to 72 hours. Sunburn is the most common type of superficial burn injury -->These types of burns heal quickly, typically do not require medical intervention or admission to a burn center, and do not usually result in scarring.

Box 51.7 Fluid-Resuscitation Example-Patient weight: 70 kg

TBSA burned: 50% flame burn-The patient is a young healthy adult with no pertinent past medical history. -->Resuscitation Calculation:2 mL × 70 × 50 = 7,000 mL of lactated Ringer's in the first 24 hoursFirst 8 hours: 3,500 mL, rate = 438 mL/hrCalculate from time of injury.Next 16 hours: 3,500 mL, rate = 218 mL/hrTBSA, Total body surface area.

Rule of Nines

The "rule of nines" is the most commonly used method in pre-hospital settings for making a determination of the percentage of TBSA burned. -->With this method, the adult body surface areas are broken down into 9% or multiples thereof. This division is modified in infants and children because of the large surface area of the child's head and the smaller surface area of the lower extremities.

Airway Maintenance

The assessment of the patient's airway takes top priority. A nonrebreather mask is placed on all patients with burn injuries, and 100% oxygen is administered. -->Patients at risk for intubation include those with facial burns, changes in voice (such as hoarseness), carbon noted in the sputum, and with injury associated with a fire in an enclosed space. -->If intubation is warranted, the most experienced person performs the procedure, and special care is taken to secure the endotracheal tube, especially if facial burns are present. --->It is essential to secure the patient's endotracheal tube with umbilical twill or commercially prepared endotracheal tube holders and not adhesive tape because tape does not stick to the burned face and does not allow for swelling.

• Oxygen saturation, ABGs, and carboxyhemoglobin levels

The oxygen molecules may be saturated by carbon monoxide instead of oxygen, which is evident only through measurement of carboxyhemoglobin levels. Carbon monoxide binds to the hemoglobin molecule with an affinity 200 times greater than that of oxygen; tissue hypoxia results when carbon monoxide levels are above normal. Results of ABGs also provide information related to the acid-base status of the patient.

Gastrointestinal

The patient with a burn injury often has complications of the gastrointestinal system secondary to a decrease in both nutrient absorption and gastrointestinal motility. --->Paralytic ileus is not seen as frequently in the burn population because of the increased use of prokinetic agents and early initiation of enteral nutritional support. -->A nasogastric tube is placed in patients with large burns for both long-term feeding access and to relieve initial gastric distention, nausea, and vomiting. Patients with burns who have suffered a significant injury and require massive fluid resuscitation are at risk for developing abdominal compartment syndrome secondary to massive resuscitation volumes.

Rule of Palm

The size of the patient's hand, including the fingers, accounts for approximately 1% TBSA. -->This quick method of determining burn size is particularly useful in pre-hospital settings for very small and/or very large burns, scattered burns, and in mass-casualty situations where time is of the essence.

Sepsis

The skin is the body's largest protection barrier, and once it is breached, the patient is continuously at risk for infection. If the patient survives the first 24 hours after the initial burn injury, sepsis is usually the leading cause of death

Fluid and Electrolytes

The two electrolytes of most concern during the burn shock phase are potassium and sodium -->Initially, hyperkalemia may result because of the release of potassium from damaged cells into the vascular space. -->As fluid shifts continue, potassium and sodium begin to leak out of the intravascular spaces, and hypokalemia and hyponatremia may result. Although potassium and sodium are of utmost importance, all electrolytes are closely monitored, and replacement therapy is initiated as warranted. -->It is extremely important to account for evaporative fluid loss that may occur through the burn wound, as this amount may be as great as 5 L per day and continues until all wounds are closed.

Thermal

Thermal burns can be the result of a flash, scald, or contact with hot objects or flames, and common causes include house fires, car fires, cooking accidents, or injuries as a result of careless smoking. -->Associated accelerant use (e.g., gasoline, kerosene, or propane) may increase the severity of the burn and associated inhalation injury because this adds a chemical insult in addition to the thermal injury. -->Contact burns are also thermal in nature and are often associated with cooking or heating incidents. -->Scald injuries are most prevalent among the young and may be associated with accidents or even abuse.

Infection control is

a high priority when dealing with the patient who has suffered a burn injury. -->The majority of burn centers employ multiple infection control strategies and techniques, including contact precautions for all patient interactions; disposable equipment, including blood pressure cuffs, stethoscopes, electrocardiogram (ECG) leads; and antibiotic-coated urinary and central line catheters.

Neurological assessments are completed on

a regular basis to monitor for any changes in level of consciousness. -->Fluid resuscitation is calculated based on the TBSA of the burns. --->However, it is important to remember that this calculation is just a starting point for fluid resuscitation because there may be extensive damage to internal structures underneath the skin's surface that are not obvious with external assessment.

Electrical injury may occur by

direct contact with the source, by an arc between two objects, or as a result of a flame injury caused by ignition of the surroundings. -->The effects of electricity on the body depend on certain factors, including the type and strength of the current, the duration of contact, the pathway of flow through the body, and local tissue resistance. -->The epidermis is the body's best insulation, but once breached, the body acts as a volume conductor. -->Bone is more resistant to the flow of electricity, and the electricity tends to flow along the top of the bone, often damaging the overlying muscles, nerves, and vessels. -->Consequently, deep muscle injury may be present even when skin and superficial muscle may appear uninjured.

As a result of upper airway edema, an

endotracheal tube that becomes dislodged may be almost impossible to replace. -->It is essential to secure the patient's endotracheal tube with umbilical twill or commercially prepared endotracheal tube holders and not adhesive tape because tape does not stick to the burned face and does not allow for swelling. -->An emergency tracheostomy tray is maintained at these patients' bedsides in the event of unplanned extubation.

Patients with an inhalation injury may present with

facial burns, singed nasal and facial hairs, carbon in their sputum, redness of the oral pharynx, inability to swallow, and tachypnea. -->The respiratory epithelium may be damaged as a result of inhaled gases and particulate matter. Mucus production and impaired ciliary function may result, which ultimately may lead to cell death and sloughing of the respiratory tract. -->Anxiety and agitation may ensue if the patient begins to experience respiratory distress.

Although carbon monoxide may cause a cherry red discoloration of the skin in patients with carbon monoxide levels at 40% or higher, this manifestation is seen only in approximately 50% of cases. More common clinical manifestations observed in patients with carbon monoxide poisoning include

headache, confusion, nausea, dizziness, vomiting, and dyspnea. These clinical manifestations are usually seen when carbon monoxide levels reach approximately 30%.

Because of the risk of carbon monoxide poisoning associated with

inhalation injuries, treatment requires immediate application of 100% oxygen by mask, which is maintained until carboxyhemoglobin levels are below 10%. -->The half-life of carbon monoxide in the blood is approximately 30 minutes to 1 hour on 100% oxygen as opposed to 4 hours on room air. -->Because the majority of patients with burns are placed on 100% oxygen at the scene, it is important to note that measurement of carbon monoxide levels may be a poor indicator of injury because the majority of the carbon monoxide may have been dissipated by the time the patient arrives at the hospital.

There are three main types of airway inhalation injuries:

inhalation injury above the glottis, inhalation injury below the glottis, and carbon monoxide poisoning. -->Inhalation burns are most commonly limited to the upper airway above the glottis (nasopharynx, oropharynx, and larynx) and are usually thermal or chemical in nature.

The fluid of choice for resuscitation is

lactated Ringer's. -->Intravenous access is essential and should be obtained as soon as possible. -->Ideally, two large-bore, preferably No. 20 gauge or larger, peripheral IV catheters are placed through unburned skin. ---->However, if no such areas exist, the IV lines can be inserted through burned tissue but must be well secured. -->If obtaining a peripheral IV catheter is extremely difficult, an intraosseous line is also acceptable. -->Major burn injuries often require the placement of a central venous catheter because of the large volumes of fluid that need to be administered during the emergent phase.

Normal carboxyhemoglobin levels are

less than 2% but may be as high as 5% to 10% in heavy smokers.

The chest wall escharotomy is considered a

medical emergency and in rare instances may be performed by scene first responders after consultation with a burn center. See Figure 51.18 for common escharotomy sites.

Urine output is closely monitored for signs of

myoglobinuria, which indicates muscle damage and manifests as red or tea-colored urine. --> If myoglobin is suspected, a urinalysis is performed. Myoglobin can occlude renal tubules and cause acute tubular necrosis; thus, it is important to maintain a urine output of 1 mL/kg/hr for patients with electrical injuries.

For electrical injuries, it is important to

obtain a baseline ECG and troponin and creatine kinase-MB (CK-MB) levels. -->Patients with concomitant trauma require additional diagnostic and radiographical examinations.

Massive amounts of body heat may be lost through

open wounds as a result of impaired thermoregulatory function. -->Once the patient loses skin, it is impossible for the body to successfully regulate temperature. Because of this, it is essential to maintain a high ambient temperature within the patient's room and within the operating room. This is particularly essential when the wounds are exposed. --->This equipment may include heat shields located in the ceiling above the patient's bed that may be lowered, as well as additional space heaters that are often placed in the room. -->Many of the newer or newly remodeled burn centers now have radiant heat under the flooring and behind the walls in each patient room.

The use of

personal protective equipment by all healthcare team members is crucial when managing suspected chemical injuries to ensure that no one else is injured or affected by the chemical. -Initial treatment of chemical burns involves the removal of saturated clothing, brushing off the skin if the agent is in powder form, and continuous irrigation with copious amounts of water. -->The use of a neutralizing agent is usually not recommended because of the exothermic (heat-producing) reaction that occurs. -->Irrigation continues until the patient reports a decrease in pain, the patient's temperature can no longer tolerate further irrigation, or the patient is transferred to a burn center. -->Chemical injuries to the eyes are flushed continuously until an ophthalmologist can complete a full examination.

In addition to burn wound management, there are additional priorities to consider when caring for patients with electrical injuries. In 15% of patients experiencing electrical injuries, there is also associated

physical trauma secondary to the patient falling or being thrown. -->Patients with electrical burns should be placed in a cervical collar until cervical spine films are cleared for possible injury. -->Other priorities when managing patients with electrical injuries include cardiac monitoring, fluid resuscitation, neurological assessment, renal management, and maintenance of peripheral circulation.

• Vital signs pt 1

pt 1 Blood pressure may be low and pulse elevated secondary to potential hypovolemia due to significant fluid losses and shifts. -->The pulse may also be elevated secondary to increased work of breathing with inhalation injuries, pain, and fear/anxiety. -->Because of impaired skin integrity, temperature may be decreased. Patient shivering further accelerates the patient's metabolic rate and may exacerbate tachycardia.

Nursing Diagnoses pt 1

pt 1 • Ineffective airway clearance related to airway edema secondary to injury from heat and/or chemicals • Impaired gas exchange related to carbon monoxide poisoning, smoke inhalation, and upper or lower airway obstruction • Risk for fluid volume deficit related to hypovolemia due to third spacing of fluids and inadequate fluid resuscitation • Altered tissue perfusion related to decreased cardiac output • Risk for hypothermia due to altered skin integrity • Risk for infection due to loss of skin's protection and the burn injury • Acute pain secondary to the burn injury • Anxiety related to fear surrounding the burn injury

Patients with burns rarely exhibit immediate signs of

respiratory distress; therefore, it is essential to monitor for less obvious indicators of an inhalation injury, including a change in voice (such as hoarseness), anxiety, and/or confusion. -->It is also important to note whether the burn injury occurred outside or inside because confinement in a burning environment increases the risk of sustaining an inhalation injury. -->At any time that airway patency is questionable, early intubation is recommended. Delay may result in severe airway obstruction, at which time intubation may become extremely challenging and may require an emergent tracheostomy.

Clinical manifestations of respiratory distress may include

stridor, progressive hoarseness, rales, rhonchi, and/or retractions of the lower rib cage. -->Endotracheal intubation should be considered if the patient presents with any of these clinical manifestations.

During fluid resuscitation, an indwelling urinary drainage catheter is placed in

the bladder to closely monitor urine output because this is the most reliable indicator of adequate fluid resuscitation. Urine output should be maintained at 0.5 mL/kg/hr.

A fasciotomy is performed when

the burn extends into the muscle and is more commonly seen in patients who have sustained an electrical injury and have developed compartment syndrome. -->A fasciotomy is an incision that extends through the subcutaneous fat and muscle fascia, allowing for expansion of the muscle compartment. -->Fasciotomies are done by the provider under sterile conditions in the operating room.

It is important to note that burn wound care does not begin until

the patient is stabilized. -->The immediate concern is for airway, breathing, and circulation, followed by fluid resuscitation and prevention of hypothermia.

Severity-There are several other factors that play an important role in determining the severity of a burn and directly impact overall patient outcome. These factors include

the presence of an inhalation injury, patient age, past medical history, and presence of concomitant injury, as well as the anatomical location of the burn injury. -->Of these factors, the two that are of greatest significance in the determination of survival and that warrant further discussion include age and past medical history.

The calculated fluid volume is

the starting point in the fluctuating fluid-resuscitation process. Patients with inhalation injuries, electrical injuries, associated trauma, and/or alcohol and drug dependencies may require higher volumes of fluids related to pre-existing medical conditions or poor health. -->If there is a delay in starting fluid resuscitation, patients usually require higher volumes of fluid. --->It is also important to note that some patient populations, such as older adults, children, and those with pre-existing cardiac disease, may be very sensitive to fluid and should be closely monitored for signs of fluid volume overload. -->Inadequate fluid resuscitation, which results in inadequate blood flow, may also result in conversion of the burn wound within the first 24 to 72 hours

The skin of the older adult patient is also much

thinner and less elastic, which can affect the depth of the injury and the ability of the burn wound to heal. -->In fact, eschar separation in a full-thickness burn wound is normally delayed in the older adult patient, and many patients are simply not candidates for the operating room because of pre-existing medical conditions. -->For this reason, older adult patients often have prolonged and complicated hospitalizations and recoveries. --->Early wound excision and grafting are recommended if they can be tolerated by the patient. The goal is prompt closure of wounds and prevention of infection by decreasing the hospital stay as much as possible.

During the emergent phase, the primary goal is

to resolve immediate life-threatening issues resulting from the burn injury. These priorities include baseline diagnostic evaluation, airway management, fluid resuscitation, pain management, prevention of hypothermia, and initiation of wound care.