Ch. 26 Care of Patients with Burns

Respiratory Assessment: Direct Airway Injury

-A change in respiratory pattern may indicate a pulmonary injury. The patient may: ~Become progressively hoarse ~Develop a brassy cough ~Drool or have difficulty swallowing ~Produce sounds on exhalation that include audible wheezes, crowing, and stridor - Immediately apply O2 and call rapid response team

Metabolic Changes Resulting from Burn Injury:

- Bad burns increase secretions of catecholamines, ADH, Aldosterone, and Cortisol. - With hypermetabolism oxyegn needs and calorie needs are high - Catecholamines activate the stress response - Increased production (and loss) of heat breaks down protein and fat (catabolism), rapidly uses glucose and calories, and increases urine nitrogen loss. - Heat and water loss also increase metabolic rate and calorie needs - Pt. will need increased caloric needs - Rates will peak 4-12 days after the burn and can remain elevated for months - Hypermetabolic state causes the body to lose heat and results in a low temp to adjust

Etiology of Burn Injury:

- Burns are cause by dry heat (flame), moist heat (scald), contact with hot or rough surfaces, chemicals, electricity, and ionizing radiation

Moist Heat (Scald) Injuries:

- Caused by contact with hot water - More common in older adults - Hot liquid usually burn upper front of body - Immersion affects lower body

Dry Heat Injuries:

- Caused by open flame - Explosions usually result in flash burns because they are brief

Table 26-7 Needs to Address Before Discharge of the Patient with Burns:

- Early patient assessment - Financial assessment - Evaluation of family resources - Weekly discharge planning - Psychological referral - Designation of principal learners (family who will help with care) - Development of teaching plan - Training for wound care - Rehab referral - Home assessment - Medical equipment - Public health nursing referral - Visit to referral agency - Re-entry programs for school or work - Long-term care placement - Environmental interventions - Auditory testing - Speech therapy - Prosthetic rehab

Surgical Management of Burns in Emergent Phase:

- Escharotomy - Fasciotomy

The nurse is caring for a patient who is admitted to the ED with burns to the lower legs and hands. During the initial management, what is the priority nursing care? - Assess and treat pain. - Evaluate airway and circulation. - Place two IV catheters and initiate fluid resuscitation. - Use the rule of nines to estimate percent of body surface area burned.

- Evaluate airway and circulation. Rationale: Initial management of a burn-injured patient focuses on assessing the patient's airway, breathing, and circulation. Other priorities include keeping the patient warm, elevating extremities to reduce edema, preparing for fluid resuscitation, estimating the total body percent of burn injury, and administering tetanus toxoid prophylaxis.

Resuscitation/Early:

- Events within the first hour after injury can make the difference between life and death for the patient with a burn injury. - Immediate care focuses on maintaining an open airway, ensuring adequate breathing and circulation, limiting the extent of injury, and maintaining the function of vital organs. - Assess the burn patient's airway and adequacy of breathing before assessing any other body system. Keep an endotracheal kit or tracheostomy kit at the bedside of any patient with facial burns, burns inside the mouth, singed nasal hairs, or a "smoky" smell to the breath. - Check ventilator alarms hourly for patients who are receiving paralytic drugs during mechanical ventilation, - Give analgesics, sedatives, and anti-anxiety drugs to patients receiving paralytic drugs during mechanical ventilation. - Notify the physician immediately if the patient with an inhalation injury becomes more breathless or audible wheezes disappear. - When signs of pulmonary edema are present, elevate the head of the bed to at least 45 degrees, apply oxygen and facilitate immediate intubation. - Use strict aseptic technique when caring for patients who have open burn wounds. - Nonsurgical interventions include airway maintenance, promotion of ventilation, monitoring gas exchange, oxygen therapy, drug therapy, positioning, and deep breathing. * Continues for about 24 to 48 hours * Goals of management: - Secure airway - Support circulation—fluid replacement - Prevent infection - Maintain body temperature - Provide emotional support

GI Changes Resulting from Burn Injury:

- Fluid shifts and decreased CO decreased BF to GI tract causing gastric mucosal tissue and motility to become impaired - Increased secretion or epinephrine and norepinephrine inhibit GI motility and further reduce BF - Secretions and gases collect in GI tract causing abdominal distention - Curling's Ulcer: Acute gastroduodenal ulcer that occurs with the stress of severe injury may develop in 24h due too reduced GI BF - Ulcers develop from decreased mucus and increased hydrogen ion production - Pt. is given H2 histamine blockers, Proton-Pump Inhibitors, and early enteral feeding to prevent such complications

Contact Burns:

- From hot metal, tar, or grease contacts often leading to full-thickness burn - Tar and asphalt temperatures are usually hotter than 400 degrees F - Deep injuries occur within seconds

Cardiac Changes Resulting From Burn Injuries:

- HR increases and CO decreases because of initial fluid shifts and hypovolemia - CO may remain low for up to 18-36 hours - Proper fluid resuscitation and support with oxygen prevent further complications

Chart 26-4 Fluid Resuscitation of the Burn Patient:

- Initiate and maintain at least one large-bore IV in an area of intact skin - Coordinate with physician for appropriate fluid type & volume to be infused during first 24h - Adminsiter at least 1/2 of total 24-hour prescribed volume within the first 8 hours & the remaining over the next 16 hours - Assess IV site, infusion rate, and volume hourly Monitor these vitals hourly: - BP - Pulse - RR - Breath sounds - Voice Quality - O2 Saturation - End-Tidal CO2 levels Assess Urine Output: - Volume - Color - Specific Gravity - Character - Presence of Protein Assess for Fluid Overload: - Formation dependent edema - Engorged neck veins - Rapid, thready pulse - Presence of lung crackles or wheezes on auscultation - Measure any additional body fluid output hourly

Immunologic Changes Resulting from Burn Injury:

- Injury activates inflammatory response and often suppresses all immune functions

Electrical Burns:

- Known as "grand masquerader" because the injury looks smalls but causes an array of internal injuries - Extent of injury depends on type of current, the pathway of flow, the local tissue resistance, and duration - Longer the electricity is in contact the greater the damage - Classified as either thermal burns, flash burns, or true electrical injury Thermal Burn: - Clothes ignite heat or flames by electrical sparks - Injury is severe and deep True Electrical Injury: - Occurs when direct contact is made with an electrical source - Damage starts on inside and goes out - Organs in the pathway may become ischemic and necrotic

It has been 12 hours since a patient has been admitted for burns to the face and neck with associated inhalation injuries. The patient had been wheezing audibly and the wheezing has now stopped. What nursing action is appropriate? - Check the patient's Spo2 level. - Notify the physician immediately. - Re-assess breathing in 1 hour. - Document improvement in patient's condition.

- Notify the physician immediately. Rationale: Notify the physician immediately if the patient with an inhalation injury becomes more breathless or audible wheezes disappear. This could indicate a worsening of the patient's respiratory injuries, including possible loss of the patient's airway.

Chemical Burns:

- Occur in home or industrial accidents - Occurs when chemical comes into direct contact with skin - Severity depends on the duration of contact, the concentration of the chemical, the amount of tissue exposed, and the action of it. - Alkalis is often found in oven cleaners, fertilizers, drain cleaners, and heavy industrial cleaners damage tissue by causing the skin and its proteins to liquefy - Acids found in pool cleaners, bathroom cleaners, rust removers, and industrial drain cleaners damage by coagulating cells and skin proteins which can limit the depth of tissue damage - Easily absorbed through skin and cause kidney damage

Radiation Injuries:

- Occur when people are exposed to large doses of radioactive material - Most common type of tissue injury is from therapeutic radiation - Minor and rarely causes problems - More serious in indistrial settings - Injury severity depends on the type of radiation, distance from the source, absorbed dose, and depth of penetration

A patient has been receiving dressing changes with silver sulfadiazine (Silvadene) for burn injuries over both lower arms. The nurse notices that the patient's white blood cell count has dropped significantly over the past 4 days. How does the nurse interpret this finding? - Electrolyte imbalance - Infection is improving - Impending kidney disease - Possible allergic reaction to silver sulfadiazine (Silvadene)

- Possible allergic reaction to silver sulfadiazine (Silvadene) Rationale: During therapy with silver sulfadiazine (Silvadene), a drop in the patient's white blood cell count indicates an allergic reaction. Silvadene does not cause kidney disease or electrolyte imbalance.

Pulmonary Changes Resulting From Burn Injury:

- Respiratory problems are caused by super-heated air, steam,toxic fumes, or smoke. - These are a major cause of death in patients with burns and are most likely to occur when the burn takes place indoors - Resp. failure from burn can be from airway edema during fluid resuscitation, pulmonary capillary leak, chest burns that restrict movement, and carbon monoxide poisoning - Upper airway is affected when inhaled smoke or irritants cause edema and obstruct the trachea. - Ciliated membranes trap foreign materials and smoke and gases slow this activity, allowing particles to enter the bronchi. - Lung tissue injuries result from toxic irritant damage to the alveoli and capillaries.

Health Promotion and Maintenance:

- Teach all people to use home smoke detectors and carbon monoxide detectors, and to ensure that the detectors are in good working order. - Teach people to reduce the risk for house fires by never smoking in bed, avoiding smoking when drinking alcohol or taking drugs that induce sleep, and keeping matches or lighters out of the reach of children or anyone who is cognitively impaired. - Teach all people to assess how hot the water is before bathing, showering, or immersing a body part in it. - Instruct patients who have reduced sensation in hands or feet to use a bath thermometer to check water temperature before bathing. - Teach patients to avoid exposing burned skin to the sun or to temperature extremes. - If space heaters must be used, stress the importance of keeping clothing, bedding, and other flammable objects away from them. - Remind people to keep the screens and doors closed on the fronts of fireplaces and to have chimneys swept each year to prevent creosote buildup.

Silver Sulfadiazine (Silvadine, Thermazene):

Action: Adheres to bacterial cell membranes inhibiting DNA synthesis and bacterial replication Interventions: Watch for allergic reaction causing drop in WBCs; Do not use if reaction to sulfonamides has occurred; Use on deep partial-thickness or full-thickness wounds; Monitor wound for infection

Table 26-1 Classification of Burn Depth: p. 466

Characteristic: Superficial: Color: Pink-Red Edema: Mild Pain: Yes Blisters: No Eschar: No Healing: 3-6 Days Graft Required: No Example: Sunburn, Flash Burn Superficial Partial-Thickness: Color: Pink-Red Edema: Mild-Moderate Pain: Yes Blisters: Yes Eschar: No Healing: 2 Weeks Graft Required: No Example: Scalds, Flames, Brief Contact with hot objects Deep Partial-Thickness: Color: Red-White Edema: Moderate Pain: Yes Blisters: Rare Eschar: Yes, Soft & Dry Healing: 2-6 Weeks Graft Required: Can be used if healing is prolonged Example: Scalds, Flames, Prolonged Contact with hot objects, tar, grease, chemicals Full-Thickness: Color: Black, Brown, Yellow, White, Red. Edema: Severe Pain: Yes and No Blisters: No Eschar: Yes, Hard & Inelastic Healing: Weeks to Months Graft Required: Yes Example: Scalds, Flames, Prolonged contact with hot objects, tar, grease, chemicals, electricity Deep Full-Thickness: Color: Black Edema: Absent Pain: Absent Blisters: No Eschar: Yes, Hard & Inelastic Healing: Weeks to Months Graft Required: Yes Example: Flames, Electricity, Grease, Tar, Chemicals

Deep Full-Thickness Wounds:

Extend beyond the skin and damage muscle, bone, and tendons Causes: - Flame - Electrical - Chemical - Wound is blackened and depressed, and sensation is absent - Need early excision and grafting - Amputation may be needed

Rule of Nines:

Head- 4.5% front/back Arms- 4.5% front/back Chest/ Abdomen- 18% front/back Legs- 9% front/back

Minimizing Infection:

Indicators of infection: - Foul-smelling discharge - Fever - Blood Culture colonization - Wound culture colonization - WBCs elevated Interventions- Nonsurgical management: - Drug Therapy - Isolation - Environmental management Drug Therapy for Infection Prevention: - Tetanus toxoid o.5mL given IM because i enhances immunity to C. tetani which is common in burn victims - Topical antimicrobials can also be done - Usually need to be applied twice daily Drug Therapy for Treatment of Infection: - Broad-spectrum used unti culture and sensitivty come back - Peak and trough must be drawn to ensure that antibiotic doesn't reach toxic levels Use of Asepsis: - Washing hands - Changing gloves Examine all wounds for these manifestations: - Pervasive Odor - Color changes (Focal, Dark, Red, Brown) - Change in texture - Purulent Drainage - Exudate - Sloughing Grafts - Redness of wound edges

Minimizing Weight Loss:

Indicators that the patient should have mild or no deviations from normal ranges for: - Weight/Height Ratio - Food intake - Serum Albumin and Pre-albumin - Blood Glucose Interventions: - Coordinate with dietitian - Calculate patient's caloric needs - Caloric need for pt. with large burn area exceed 5000 kcal//day - High calories and protein is needed for healing - Oral diet therapy may be delayed and nasoduodenal tube feedings are often started after admission

Table 26-2 Classification of Burn Injury and Burn Center Referral Criteria:

Minor Burns: - Partial-Thickness less than 10% TBSA (Total Body Surface Area) - Full-thickness burns less than 2% TBSA - No burns on eyes, ears, face, hands, feet, or perineum - No electrical burn - No inhalation injury - No complicated additional injury - Patient is younger than 60 with no chronic cardiac, pulmonary, or endocrine disorder (Patients in this category should receive care at the scene and be taken to regular hospital. A special burn unit is not necessary.) Moderate Burns: - Partial-Thickness burns 15-25% TBSA - Full-Thickness burns 2-10% TBSA - No burns on eyes, ears, face, hands, feet, or perineum - No electrical burn - No inhalation injury - No complicated additional injury - Patient is younger than 60 with no chronic cardiac, pulmonary, or endocrine disorder (Patients in this category should receive care at the scene and be transferred to a special expertise or designated burn center) Major Burns: - Partial-Thickness burns greater than 25% TBSA - Full-Thickness burns greater than 10% TBSA - Any burn involving eyes, ears, face, hands, feet, perineum - Electrical injury - Inhalation injury - Patient older than 60 - Burn complicated - Patient has cardiac, pulmonary, or other endocrine disorders (Patients who meet any one of the criteria should receive emergency care at nearest ER and then be transferred to designated burn center ASAP)

Compensatory Responses to Burn Injury:

Two compensatory Responses that benefit during burn injury: 1. Inflammatory Compensation: • Triggers healing and responsible for problems during fluid shift • Causes blood vessels to leak fluid into the interstitial space and WBCs release chemicals that trigger local reactions • Causes massive fluid shift, edema, and hypovolemia seen in the resuscitation phase 2. Sympathetic Nervous System Compensation: • Changes caused by sympathetic compensation are most evident in CV, Resp, and GI systems

Acute Phase of Burn Injury:

• Begins about 36 to 48 hr after injury; lasts until wound closure is completed • Care directed toward: - Continued assessment and maintenance of CV, respiratory systems - Continued assessment and maintenance of GI and nutritional status - Burn wound care - Pain control - Psychosocial interventions - The size of the burn is estimated with the total body surface area to calculate drug doses, fluid replacement volumes, and caloric needs. fluid volume and tissue blood flow (perfusion) are restored with IV fluids and drug therapy. - The rule of nines is the most rapid method for calculating the size of a burn injury in adult patients whose weights are in normal proportion to their heights. With this method, the body is divided into areas that are multiples of 9%. - The rule of nines is useful at the site of injury, but more accurate evaluations using other methods are made in the burn unit. - Give half of the fluid volume calculated for the first 24 hours after burn injury in the first 8 hours post-burn. - Monitoring patient responses is critical to determine adequacy of hydration and blood perfusion to vital organs. - Escharotomy is a surgical intervention for the treatment of a circumferential burn that causes inadequate tissue perfusion. - Use strict aseptic technique when caring for patients who have open burn wounds. - Explain all procedures to the patient. - Reassure patients that pain will be managed effectively. - Drug therapy for pain usually requires opioid analgesics and non-opioid analgesics. - Although these drugs may provide adequate pain relief when no procedures are being performed, they rarely offer more than moderate relief during painful procedures and can depress respiratory function and reduce intestinal motility. - Encourage the patient to actively participate in pain control measures, including nonpharmacologic interventions. - Give prescribed opioid analgesics by the IV route during the emergent phase of burn recovery. - Notify the Rapid Response Team immediately if the patient with an inhalation injury becomes more breathless or audible wheezes disappear. - Patients with a burn injury are at risk for musculoskeletal and mobility problems as a result of other injuries, immobility, healing processes, and treatment. - Coordinate with a registered dietitian to provide a high-calorie, high-protein diet to support the nutritional needs of the patient with a burn. - Protein supplements, enteral tube feedings, and/or parenteral nutrition may be used to meet the patient's nutrition needs if the patient's caloric needs cannot be met otherwise.

Rehabilitative Phase of Burn Injury:

• Begins with wound closure, ends when patient returns to highest possible level of functioning • Emphasis on psychosocial adjustment, prevention of scars and contractures, resumption of preburn activity • This phase may last years or even a lifetime if patient needs to adjust to permanent limitations - Encourage the patient to look at and touch burned areas. - Allow patients time to grieve over a change in body image. Position patients to prevent contractures and promote joint function. - Assist patients to ambulate several times each day as soon as the fluid shifts have resolved to maintain mobility. - Encourage patients to use the prescribed splints and pressure garments to prevent joint immobility. - Worn 23 hours a day, compression dressings are applied to help prevent contractures and hypertrophic scars, and to inhibit venous stasis and edema in the burn area, but can inhibit mobility. - Teach patients to avoid exposing the burned skin areas to the sun or to temperature extremes.

Burn Categorization:

• Categorized as: - Superficial - Superficial partial-thickness - Deep partial-thickness - Full-Thickness - Deep Full-Thickness

Gastrointestinal Assessment:

• Changes in GI function expected • Decreased blood flow and sympathetic stimulation during early phase cause reduced GI motility, paralytic ileus • GI bleeding • Curling's ulcer

Kidney/Urinary Assessment:

• Changes related to cellular debris, decreased kidney blood flow • Myoglobin released from damaged muscle, circulates to kidney • Kidney function, BUN, serum creatinine, serum sodium levels • Urine color, odor, presence of particles/foam - During fluid shift, BF to the kidney may not be adequate for filtrating - Urine output is decreased and is very concentrated with a high specific gravity - Myoglobin is released in urine if muscle damage occurs - Sludge may form that blocks kidney blood and urine flow and may cause kidney failure - Fluid resuscitation is provided at the rate needed to maintain urine output at 30-50mL per hour or 0.5mL/kg/hr

Phase of Burn Injury:

• Continues for about 24 to 48 hours - until diuresis occurs • Assessment of body systems • Goals of management: - Secure airway - Support circulation - fluid replacement - Prevent infection - Maintain body temperature - Provide emotional support

Superficial Burn:

• Damage only the top layer of the skin- the epidermis • Healing occurs in 3-6 days Caused by: Prolonged exposure to low-intensity heat - Sunburn - Short flash of exposure to high-intensity heat S&S: - Redness & mild edema - Pain - Increased sensitivity to heat - Desquamation or peeling of dead skin occurs within 2-3 days after - Heals rapidly without a scar

Full Thickness:

• Destruction of entire epidermis and dermis and sometimes even into the subcutaneous fat • Skin does NOT regrow/ heal on its own & doesn;t close by wound contraction - Burn has a hard, dry, and leathery eschar - Eschar is dead tissue that must slough off or be removed from the wound before healing can occur - Edema is severe under eschar - When the wound is circumferential- (completely surrounds an extremity or the chest) blood flow and chest movements for breathing may be reduced by tight eschar - Escharotomies (incisions through eschar) or fasciotomies (Incisions through eschar and fascia) may be needed to relieve pressure - Coloring may be waxy white, deep red, yellow, brown, or black

Injuries to the Respiratory System:

• Direct airway injury • Carbon monoxide poisoning • Thermal injury • Smoke poisoning • Pulmonary fluid overload • External factors • Facial edema

Nonsurgical Management:

• Drug therapy - Opioid analgesics - Non-opioid analgesics (Be careful with giving opioids as the fluid shifting makes the body absorb the meds all at once which can leads to lethal levels) - To avoid lethal blood levels only give opioids during the resuscitation phase to prevent delayed rapid absorption • Complementary and alternative medicine (CAM) therapies - Hypnosis - Acupuncture - Therapeutic touch • Environmental changes - Tactile stimulation - Position change Q2h - Apply heat - Maintain warm room

Deep Partial-Thickness Burn:

• Extend into the deeper layers of the dermis. • Healing occurs within 2-6 weeks - Blisters usually do not form because the dead tissue layer is thick - When pressure is applied, it blanches slowly or not at all - Edema is moderate and pain is less than with superficial burns - Blood flow to area is reduced, and progression to deeper injury can occur from hypoxia and ischemia. - Need lots of hydration, nutrients, and oxygen for regrowth - Scar formation occurs due to long healing process

Vascular Changes Resulting from Burn Injuries:

• Fluid shift: Third spacing or capillary leak syndrome, usually occurs in first 12 hr, can continue 24 to 36 hr - Fluid shift occurs after initial vasoconstriction as a result of blood vessels near near the burn dilating and leaking - Impaired F&E lead to loss of plasma and proteins, which decrease blood volume and BP • Fluid shift with excessive weight gain occurs in first 12 hr, can continue 24 to 36 hr - Edema develops as plasma and electrolytes escape into the interstitial space • Profound imbalance of fluid, electrolyte, acid-base; hyperkalemia and hyponatremia levels; hemoconcentration - Hyperkalemia occurs as a result of direct cell injry that releases large amounts of K+ - NA+ is retained by the body, but aldosterone increases, leading to sodium re-absorption by the kidneys - However, this NA+ quickly passes the interstitial space and most is trapped there so a NA+ deficit occurs - Hemoconcentration (Elevated blood osmolarity, H&H) develops from vascular dehydration which increases blood viscosity reducing BF and increases tissue hypoxia • Fluid re-mobilization starts after 24 hr once capillary leak stops; - Diuretic stage begins 48 to 72 hr after injury as capillary membrane integrity returns and edema fluid shifts from interstitial to intravascular; Blood volume increases and increased kidney blood flow and diuresis and body weight returns to normal; - During this phase, hyponatremia occur because of increased kidney NA+ excretion and then hypokalemia occurs as well from K+ moving back into cells - Metabolic acidosis is possible because of the loss of bicarb & increased rate of metabolism

Cardiovascular Assessment:

• Hypovolemic shock - Common cause of death in early phase in patients with serious injuries • Vital signs • Cardiac rhythm, especially in cases of electrical burn injuries • Pt. first has tachycardia, decreased BP, and decreased peripheral pulses; Cap refill is slow or absent as BF decreases -ECG can indicate problems as a result of electrical burn or stress that induces a myocardial infarction

Metabolic Assessment:

• Increased secretions of catecholamines, anti-diuretic hormone, aldosterone, cortisol • Increased core body temperature as response to temperature regulation by hypothalamus Nonsurgical Management of Burns: • IV fluids • Monitoring patient response to fluid therapy • Drug therapy

Compensatory Responses to Burn Injury:

• Inflammatory compensation can trigger healing • SNS compensation occurs when any physical or psychological stressors are present

Nonsurgical Management: Acute Phase

• Mechanical débridement - Hydrotherapy • Enzymatic débridement - Autolysis - Collagenase

Pulmonary Fluid Overload:

• Occurs even when lung tissues have not been damaged directly • Histamine, other inflammatory mediators cause capillaries to leak fluid into pulmonary tissue space • Elevate HOB to 45 degrees, apply O2, and notify burn team and rapid response team

Depth of Burn Injury:

• Severity determined by how much body surface is involved, as well as depth • Differences in skin thickness in various parts of the body also a factor Superficial Thickness • Least damage; epidermis is only part of skin that is injured • Desquamation (peeling of dead skin) occurs 2 to 3 days after burn

Skin Assessment:

• Size and depth of injury • Percentage of total TBSA affected -Accurate burn depth is performed using thermography, vital dyes, indocyanine green (ICG) video angiography, and laser Doppler imaging. • "Rule of nines" using multiples of 9% of total BSA

Pathophysiology of Burn Injury:

• Skin changes resulting from burn injury • Anatomic changes • Functional changes • Temperature - Burns are complex injuries with loss of tissue integrity that cause patients to develop many physiologic, metabolic, and psychological changes. - Burn injuries can range from sunburn to major injuries involving all layers of the skin. - The burn patient needs comprehensive care by a multidisciplinary team of health care providers for weeks to months in order to survive the injury, reduce complications, and return to his or her best functional status. - The tissue destruction caused by a burn injury affects fluid and electrolyte balance, and leads to local and systemic problems, including fluid and protein losses, sepsis, and changes in metabolic, endocrine, respiratory, cardiac, hematologic, and immune functioning. - The extent of problems is related to age, general health, extent of injury, depth of injury, and the specific body area injured. - Patient care priorities are the prevention of infection and closure of the burn wound. - The skin has many protective functions when tissue integrity is intact. With injury, inflammation and fluid loss affect the function of most body systems, greatly increasing the risk of infection. - Nurses coordinate the activities of the many professionals involved in providing the best care to burn patients. - The severity of a burn is determined by how much of the body surface area is involved and the depth of the burn. - The degree of tissue damage is related to the agent causing the burn and to the temperature of the heat source as well as length of exposure. - Differences in skin thickness of various parts of the body also affect burn depth. - Burn wounds are classified as superficial-thickness wounds, partial-thickness wounds, full-thickness wounds, and deep full-thickness wounds. - Of all burn types, superficial-thickness wounds result in the least damage because the epidermis is the only part of the skin that is injured. - A partial-thickness wound involves the entire epidermis and varying depths of the dermis. - Depending on the amount of dermal tissue damaged, partial-thickness wounds are further subdivided into superficial partial-thickness and deep partial-thickness injuries. - A full-thickness wound involves destruction of the entire epidermis and dermis, leaving no true skin cells to repopulate; therefore, skin will not regrow. - Areas of the wound not closed by wound contraction will require grafting. - The American Burn Association describes burns as minor, moderate, or major depending on the depth, extent, and location of injury, and describes the criteria for referral to a burn center - Circulatory disruption occurs at the burn site immediately after a burn injury. - Blood vessels to the burned skin are occluded, and blood flow is reduced or stopped. - Damaged macrophages within the tissues release chemical mediators that cause blood vessel constriction. - Blood vessel thrombosis may occur, causing necrosis. - After a burn injury, there is a massive fluid loss through evaporation. - A fluid shift occurs after initial vasoconstriction as a result of blood vessels near the burn dilating and leaking fluids into the interstitial space. - This impaired fluid and electrolyte balance leads to a continuous leak of plasma fluids and proteins from the vascular space into the interstitial space, which decreases blood volume and blood pressure. - Profound disruptions of fluid and electrolyte balance and acid-base balance occur as a result of the fluid shift and cell damage. - These imbalances include hypovolemia, metabolic acidosis, hyperkalemia, and hyponatremia. - Fluid remobilization starts about 24 hours after injury, when the capillary leak stops and capillary integrity is restored. - The diuretic stage begins at about 48 to 72 hours after the burn injury as capillary membrane integrity returns. - Heart rate increases and cardiac output decreases because of the initial fluid shifts and hypovolemia that occur after a burn injury. - Cardiac output may remain low until 18 to 36 hours after the burn injury. - Cardiac output increases with fluid resuscitation and reaches normal levels before plasma volume is restored completely. - Proper fluid resuscitation and support with oxygen prevent further complications. - Direct injury to the lung from contact with flames rarely occurs. - Respiratory problems are caused by superheated air, steam, toxic fumes, or smoke, often resulting in death. - Other organs, including the GI tract, have decreased blood flow. - Gastric mucosal integrity and motility are impaired. - Curling's ulcer, an acute gastroduodenal ulcer that occurs with the stress of severe injury, may develop within 24 hours after a severe burn injury because of reduced GI blood flow and mucosal damage. - Any tissue injury is a stressor and can disrupt homeostasis. - Two compensatory (adaptive) responses that have immediate benefit are the inflammatory response and the sympathetic nervous system stress response. - Fires and burns are the fifth most common cause of unintentional injury deaths in the United States and the third leading cause of fatal home injury. - Although the number of fatalities and injuries caused by residential fires has declined gradually over the past several decades, many residential fire-related deaths remain preventable. - Burn injuries are caused by dry heat or flame, moist heat or scald, contact with hot surfaces, chemicals, electricity, and ionizing radiation. - The cause of the injury affects both the prognosis and the treatment.

Dressing the Burn Wound:

• Standard wound dressings • Biologic dressings - Homograft - Human skin - Heterograft - Skin from other species - Amniotic membrane - Cultured skin - Artificial skin • Biosynthetic dressings • Synthetic dressings

Surgical Management:

• Surgical excision • Wound covering - Skin graft (mesh autograph pictured)

Superficial Partial-Thickness Burn:

• Those in which the entire epidermis and variable portions of the dermis layer of skin are destroyed • Uncomplicated healing occurs in 10-21 days Causes: - Injury to the upper third of the dermis, leaving good blood supply S&S: - Wound pink but doesn't blanch when pressure applied - Small vessels are injured, resulting in leakage of plasma which lifts heat-destroyed epidermis causing blisters - Blisters continue to increase in size after burn as cell and protein breakdown occur - Nerve endings are exposed, and any stimulation cause intense pain