Chapter 24 Burns

Acute Phase ComplicationsL Endocrine System

-↑ Blood glucose levels (Hyperglycemia) -↑ Insulin production but effectiveness decreased due to insulin insensitivity -Treat with IV or SC insulin

Emergent Phase complications Urinary system

-↓ Blood flow to kidneys causes renal ischemia -Acute tubular necrosis (ATN) •Myoglobin (from muscle cell breakdown) and hemoglobin (from RBC breakdown) are released into the bloodstream and block renal tubules. •Adequate fluid replacement can counteract this obstruction of the renal tubules.

Emergent Phase Interprofessional management drug therapy

Analgesics and sedatives-examples: ■Morphine ■Hydromorphone (Dilaudid) ■Haloperidol (Haldol) ■Lorazepam (Ativan) ■Midazolam (Versed) IV route bestin emergent phase: 1.onset is fast 2.PO meds have slower onset of action and GI motility is slowed or impaired resulting from shock or paralytic ileus 3.IM injections not absorbed well in burned/edematous areas

Acute Phase - Nursing and Collaborative Management Wound Care cont

Appropriate coverage of graft ■Greasy gauze dressing next to graft followed by middle layer saline-moistened dressing and then outer dry dressings ■Unmeshed sheet grafts used for facial grafts-allows for better cosmetic result -Grafts are left open -Complication: Blebs (small bubble of fluid) between the graft and facial bed. Require aspiration with TB syringe by HCP.

Emergent Phase Interprofessional management Wound Care cont 5

-Allograft or homograft skin ■Usually from cadavers ■Typically used with newer biosynthetic options

Emergent Phase Interprofessional management Drug Therapy cont 3

-Antimicrobial agents ■Topical agents -Silver sulfadiazine (Silvadene) -Mafenide acetate (Sulfamylon) -Silver sulfadiazine impregnated dressings ■Systemic agents are not usually used in controlling burn flora b/c the burn eschar has little to no blood supply -Initiated when a diagnosis of invasive burn wound sepsis is made -Sepsis is a leading cause of death in those with major burns as it may lead to MODS

Emergent Phase Complications Cardiovascular System

-Arrhythmias and hypovolemic shock -Impaired circulation to extremities & if left untreated, can lead to: •Tissue ischemia •Paresthesias •Necrosis -Escharotomy to restore circulation

Acute Phase-Nursing and Collaborative Management Excision and grafting cont 4

-Artificial skin ■Used in life-threatening full-thickness or deep partial-thickness wounds where conventional autograft is not available or advisable ■Consists of both dermal and epidermal elements

Acute Phase-Nursing and Collaborative Management Excision and grafting cont 3

-Cultured epithelial autographs (CEAs) ■Grown from biopsies obtained from the patient's own skin -After approx. 18-25 days, keratinocytes have expanded up to 10,000 times to form sheets then used as skin grafts ■Used in patients with a large body surface burn area or those with limited skin for harvesting

Emergent Phase Interprofessional management Airway Management

-Early endotracheal intubation—Why early? -Escharotomies of the chest wall -Bronchoscopy -Humidified air and 100% oxygen as needed, if not intubated-those w/o extensive face & neck burn injuries -High fowler's positioning unless contraindicated (i.e. spinal injury) -TCDB q1hr, Repositioning q1-2hrs, CPT as ordered and suctioning SpO2 does not distinguish oxyhemoglobin from carboxyhemoglobin! Meaning a ptwith CO poisoning will have normal SpO2 reading!! For those with known or suspected CO poisoning, use pulse CO oximetry (SpCO) device & check ABGs.

Emergent Phase Interprofessional management Wound Care other measures cont

-Ears should be kept free of pressure ■No use of pillows ■Rolled towel is placed under the shoulders -Hands and arms should be extended and elevated on pillows or foam wedges ■May need hand splints -Perineum must be kept as clean and dry as possible ■Indwelling catheter ■Perineal care ■If frequent loose stools, consider fecal management devices -Routine laboratory tests -Early ROM exercises

Acute Phase - Nursing and Collaborative Management Excision and grafting

-Eschar is removed down to subcutaneous tissue or fascia -Graft is placed on clean, viable tissue -Wound is covered with autograft (person's own) skin -Donor skin is taken with a dermatome (surgical instrument used to remove a very thin layer of skin from unburned site) -Choice of dressings varies (ex. Silver sulfadiazine, calcium alginate, silver-impregnated dressings, transparent dressing, xenograft, hydrophilic foam)

Acute Phase - Nursing and Collaborative Management Excision and grafting cont

-Grafts are attached with ■Fibrin sealant ■Sutures or staples ■Negative pressure wound therapy dressings may be placed on top of grafts to encourage adherence of graft to wound bed. -With early excision, function is restored, scar tissue minimized

Acute Phase Lab Values Potassium

-Hyperkalemia may occur if patient has ■Renal failure ■Adrenocortical insufficiency ■Massive deep muscle injury -Large amounts of potassium is released from damaged cells -Manifestations: cardiac dysrhythmias and ventricular failure, muscle weakness, cramping, paralysis, and EKG changes.

Emergent Phase Interprofessional management Nutritional Therapy cont

-Hypermetabolic state ■Resting metabolic expenditure may be increased by 50% to 100% above normal ■Core temperature is elevated ■Caloric needs are about 5000 kcal/day ■Early, continuous enteral feeding promotes optimal conditions for wound healing ■Supplemental vitamins, zinc, and iron may be given

Acute Phase Lab Values Sodium cont

-Hypernatremia may develop following ■Successful fluid replacement if large amounts of hypertonic solutions were used ■Improper tube feedings ■Inappropriate fluid administration -Restrict sodium in IVs, oral feedings -Manistationsof hypernatremia: thirst; dried, furry tongue; lethargy; confusion; and possibly seizures

Acute Phase Lab Values Potassium cont

-Hypokalemia occurs with ■Vomiting, diarrhea ■Prolonged GI suction ■Lengthy IV therapy without potassium -Manifestations: fatigue, weakness, leg cramps, paresthesias, decreased reflexes, cardiac dysrhythmias, ECG changes

Emergent Phase Complications Cardiovascular System cont

-Impaired microcirculation and ↑ viscosity → sludging •Corrected by adequate fluid resuscitation -Increased risk of venous thromboembolism (VTE) if one or more of the following conditions are present: advanced age, morbid obesity, extensive or lower-extremity burns, concomitant lower-extremity trauma, and prolonged immobility. VTE prophylaxis should be started, unless contraindicated

Emergent Phase Interprofessional management Wound Care cont

-Infection is most serious threat to further tissue injury ■Source of infection is patient's own flora typically from the skin, respiratory and GI tracts. -Preventing cross-contamination is a priority!!!

Upper airway injury

-Injury to mouth, oropharynx, and/or larynx -Thermally produced or inhalation of hot air, steam, or smoke -Swelling may be massive and onset rapid •Eschar and edema may compromise breathing •Swelling from scald burns to face and neck can be lethal

Lower Airway injury

-Injury to trachea, bronchioles, and alveoli -Injury is related to length of exposure to smoke or toxic fumes -Pulmonary edema may not appear until 12 to 48 hours after burn ■Manifests as acute respiratory distress syndrome (ARDS)

Acute Phase Complications: Infection

-Localized inflammation, induration, and production of pus -Partial-thickness burns can change to full-thickness wounds in the presence of infection •Invasive wound infections may be treated with systemic antibiotics based on wound culture results -Watch for signs and symptoms •Hypo-or Hyperthermia, increased HR and RR, decreased BP, decreased UOP, mild confusion, chills, malaise, and loss of appetite may be observed -Obtain cultures from all possible sources of infection (burn wound, blood, sputum, urine, IV site, oropharynx & perineal regions) & Collaborate with ID specialist to ensure appropriate antibiotic coverage for patient.

Acute Phase-Nursing and Collaborative Management Nutrition Therapy

-Meeting daily caloric requirements is crucial -Caloric needs should be calculated by dietitian -High-protein, high-carbohydrate foods & supplemental vitamins, minerals -Monitor laboratory values (i.e. albumin, prealbumin, total protein, transferrin) -Weigh patient at least weekly to evaluate progress

Three Types of Smoke and Inhalation Burn

-Metabolic asphyxiation -Upper airway injury -Lower airway injury

Emergent Phase Interprofessional management Nutritional Therapy

-Once fluid replacement needs have been addressed, nutrition is a priority -Early and aggressive nutritional support within hours of burn injury ■Decreases complications and mortality ■Optimizes burn wound healing ■Minimizes negative effects

Emergent Phase Interprofessional management Wound Care cont 3

-Open method ■Burn is covered with topical antibiotic with no dressing over wound ■Usually limited to the care of facial burns -Multiple dressing changes or closed method ■Sterile gauze dressings are laid over topical antibiotic ■Dressings may be changed from every 12 to 24 hours to once every 14 days

Acute Phase-Nursing and Collaborative Management Pain Management

-Patients experience two kinds of pain ■Continuous background pain -IV infusion of an opioid -Or slow-release, twice-a-day oral opioid ■Treatment-induced pain -Analgesic and an anxiolytic -Nonpharmacologic strategies: relaxation breathing, guided imagery, music therapy, hypnosis, etc..

metabolic asphyxiation

-Primary carbon monoxide (CO) poisoning -Majority of deaths at fire scene are result of inhalation metabolic asphyxiation -CO is produced by the incomplete combustion of burning materials -Inhaled CO displaces oxygen •Hypoxia •Death when Carboxyhemoglobinemia(hemoglobin + CO) levels >20% -Treat with 100% humidified oxygen -CO poisoning may occur in absence of burn injury to the skin

Emergent Phase Interprofessional management Wound Care

-Should be delayed until a patent airway, adequate circulatio an extensive full-thickness burn to prepare for skin grafting)n, and adequate fluid replacement have been achieved -Cleansing ■Can be done on a shower cart, in a shower, or on a bed. (Fig. 24-9 shows picture of a hydrotherapy shower cart) -Debridement ■May need to be done in the OR ■Loose necrotic skin is removed (Fig. 24-11 shows surgical debridement of

Emergent Phase Interprofessional management Drug Therapy cont

-Tetanus immunization ■Given routinely to all burn patients -VTE prophylaxis ■Low-molecular-weight heparin or low-dose unfractionated heparin is started ■Those with high bleeding risk, VTE prophylaxis with sequential compression devices, or compression stockings recommended

Emergent Phase Interprofessional management Wound Care cont 4

-The room must be kept warm (approximately 85°F) to prevent shivering. -When open burns wounds are exposed, staff should wear ■Disposable hats ■Masks ■Gowns ■Gloves Sterile gloves used when applying ointments and sterile dressings

Emergent Phase Interprofessional management FLuid Therapy

-Two large-bore IV lines for >15% TBSA -Central line >30% TBSA -Arterial line for frequent ABGs or invasive monitoring -Fluid replacement: crystalloids (LR), colloids (albumin), or combo of both -Parkland (Baxter) formula for fluid replacement. Refer to Table 24-11 •4ml Lactated Ringer's solution per body weight in (kg) per % TBSA=Total fluid requirements in first 24hrs after burn—ex. 4ml x 70kg x 50 TBSA burned=14,000ml in 24hrs •Formula is an estimate. Fluids are titrated based on the patient's response (hourly UOP, vital signs) •Electrical injuries require greater than normal fluid needs.

Emergent Phase complications Respiratory System

-Upper airway burns ■Edema formation ■Mechanical airway obstruction and asphyxia -Lower airway injury ■Pneumonia ■Pulmonary edema •Examine sputum •Bronchoscopy and carboxyhemoglobin blood levels used to confirm a suspected inhalation injury •Watch for signs of impending respiratory distress (increased agitation, anxiety, restlessness, or a change in the rate or character of the patient's breathing as symptoms may not be present immediately). ABGs and CXR may be initially normal but changes occur within next 24-48hrs.

Acute Phase Complications: Cardiovascular and Respiratory

Cardiovascular and respiratory systems -Same complications can be present in emergent phase and may continue into acute phase -In addition, new problems might arise, requiring timely intervention

Thermal Burns

Caused by flame, flash, scald or contact with hot objects Most common type of burn

Depth of Burn

Epidermic Dermis Subcutaneous Tissue

Acute Phase Lab Values Sodium

Hyponatremiacan develop from ■Excessive GI suction ■Diarrhea ■Excess water intake leading to water intoxication (dilutional hyponatremia) -Avoid with offering juices, nutritional supplements instead of water -Manifestations of hyponatremia: weakness, dizziness, muscle cramps, fatigue, headache, tachycardia, and confusion

Acute Phase Complications Musculoskeletal and GI

Musculoskeletal system -Decreased ROM -Contractures ■Gastrointestinal system -Paralytic ileus -Diarrhea -Constipation -Curling's ulcer •Medication prophylaxis with H2 antagonists and/or proton pump inhibitors & start feedings early

Burns (ATI Ch 75)

Occur when there is injury to the tissues of the body caused by heat, chemicals, electric current, or radiation ■Effects are influenced by: -Temperature of the burning agent -Duration of the contact time -Type of tissue injured ■Most burn incidents are preventable. ■Nearly 11 million people need medical attention annually around the world for burn injuries and about 265,000 die!! Highest fatality rate-children under 4yo and older adults >65. ■You can advocate for and teach about burn risk reduction strategies in the home and at work. Familiarize yourself with TABLE 24-2 (strategies to reduce burn injury)

A patient who is admitted to a burn unit is hypovolemic. A new nurse asks an experienced nurse about the patient's condition. Which response if made by the experienced nurse is most appropriate? a."Blood loss from burned tissue is the most likely cause of hypovolemia." b."Third spacing of fluid into fluid-filled vesicles is usually the cause of hypovolemia." c."The usual cause of hypovolemia is evaporation of fluid from denuded body surfaces." d."Increased capillary permeability causes fluid shifts out of blood vessels and results in hypovolemia."

d."Increased capillary permeability causes fluid shifts out of blood vessels and results in hypovolemia."

Depth of Burn Injury

• Three skin layers: the epidermis, dermis, and subcutaneous tissue • Epidermis • Nonvascular outer layer of the skin • Comprises many layers of nonliving epithelial cells • Protection, holds in fluids and electrolytes, helps to regulate body temperature, and keeps harmful agents in the external environment from injuring or invading the body • Dermis • Contains connective tissues with blood vessels and hair follicles, nerve endings, sweat glands, and sebaceous glands • Subcutaneous tissue • Contains major vascular networks, fat, nerves, and lymphatics • Acts as a heat insulator for underlying structures

Burn to Burn Shock Patho

•Burn shock, a type of hypovolemic shock, rapidly ensues, and if it is not corrected, death can result. Hgb and Hematocrit would be high because blood will be thicker and will have a higher risk of clots and PEs

Acute Phase - Nursing and Collaborative Management Wound Care

•Goals: (1) prevent infection by cleansing and debriding the area of necrotic tissue that would promote bacterial growth & (2) promote wound re-epithelialization and/or successful skin grafting -Daily observation -Assessment -Cleansing Soap & water or saline soaked gauze removing old cream & loose necrotic tissue, then covered in antimicrobial cream or antimicrobial impregnated dressing -Debridement Enzymatic debridement: Speeds up removal of dead tissue from healthy wound bed -Dressing reapplication Typically a protective, coarse or fine-meshed, grease-based (paraffin or petroleum) gauze dressing

Acute Phase Complications: Neurological System

•No physical symptoms unless severe hypoxia from respiratory injuries or complications from electrical injuries occur -Disorientation -Combative -Hallucinations -Delirium •Probable causes of neurologic complications: electrolyte imbalance, stress, cerebral edema, sepsis, sleep disturbances, and the use of analgesics and antianxiety drugs

Case Study Cont 3

•What places M.K. at risk for an inhalation injury? Face and neck •What are your nursing goals for his care initially in the emergent phase? Hypovolemic shock prevention Airway management Pain management Check for CO posioning

Escharotomy chest and arm

•a scalpel or electrocautery incision through the full-thickness eschar •frequently done after transfer to a burn center to restore circulation

Emergent Phase Interprofessional management cont.

■Airway management ■Fluid therapy ■Wound care ■Drug therapy ■Nutrition therapy ■PT/OT therapy -proper positioning & splinting begin on day of admission ■Psychosocial care and Education

Acute Phase

■Begins with mobilization of extracellular fluid and subsequent diuresis ■Concludes when -Partial thickness wounds are healed and/or -Full thickness burns are covered by skin grafts

Rehabilitation Phase Patho

■Burn wound heals either by spontaneous re-epithelialization or by skin grafting. New skin appears flat and pink ■Layers of keratinocytes begin to rebuild the tissue structure ■Collagen fibers add strength to weakened areas ■In approximately 4 to 6 weeks, area becomes raised and hyperemic ■Mature healing is reached about 12 months ■Skin never completely regains its original color

Depth of Burn cont.

■Burns have been defined by degrees (first, second, third, and fourth) ■ABA advocates categorizing burn according to depth of skin destruction -Superficial Partial-thickness burn (first-degree) -Deep Partial-thickness burn (second-degree) -Full-thickness burn (third & fourth-degree) •Not enough remaining skin cells to regenerate new skin in full thickness burns. A permanent, alternative source of skin then needs to be found

Electrical Burns cont.

■Current that passes through vital organs will produce more life-threatening sequelae than current that passes through other tissue ■Electrical sparks may ignite patient's clothing, causing a combination of thermal flash injury ■As with inhalation injury, a rapid assessment of the patient with electrical injury must be performed. Transfer to a burn center is indicated. ■Severity of injury can be difficult to assess, as most damage occurs beneath skin -"Iceberg effect"

Rehabilitation Phase Patho cont

■Discoloration of scar fades with time ■Scar contour elevates and enlarges. Gentle pressure can help to keep scar flat with custom fitted garments but should not be worn on unhealed wounds. ■Typically experience discomfort from itching where healing is occurring ■Newly healed areas can be hypersensitive or hyposensitive to cold, heat, and touch ■Healed areas must be protected from direct sunlight for about 3 months to prevent hyperpigmentation and sunburn injury

Acute Phase Patho

■Diuresis from fluid mobilization occurs, and patient is less edematous ■Bowel sounds return ■Healing begins as WBCs surround burn wound and phagocytosis occurs ■Necrotic tissue begins to slough ■Granulation tissue forms ■Partial-thickness burn wounds heal from edges and from dermal bed ■Full-thickness burns must have eschar removed and skin grafts applied

Electrical burns pt 2

■Electrical current may cause muscle spasms strong enough to fracture bones. Another reason to suspect fractures is if a fall occurred resulting from the electrical injury. All patients with electrical burns you should consider at risk for cervical spine injury. Use immobilization during transport until radiologic testing can r/o fracture ■Patients are at risk for dysrhythmias or cardiac arrest, severe metabolic acidosis, and myoglobinuria ■Myoglobin and hemoglobin from damaged RBCs travel to kidneys blocking the renal tubules leading to: -Acute tubular necrosis (ATN) -Eventual acute kidney injury

Phases of Burn

■Emergent (resuscitative) ■Acute (wound healing) ■Rehabilitative (restorative) -These phases often overlap in care. (Ex. Wound care is primary focus of acute phase but it also takes place in both the emergent and rehabilitative phases.)

Emergent Phase

■Emergent (resuscitative) phase is time required to resolve immediate problems resulting from injury ■Up to 72 hours ■Primary concerns -Hypovolemic shock (very probable to happen) -Edema

Rehabilitation Phase-Nursing & Collaborative Management

■Encourage both patient and caregiver to participate in care -Skills for dressing changes -Wound care ■Use water-based creams to keep skin moisturized, supple, and aiding in decreased itching. Oral antihistamines may be used if itching persists. ■Reconstructive surgery is frequently required after a major burns ■The role of exercise cannot be overemphasized ■Constant encouragement and reassurance

Emergent Phase Patho

■Fluid and electrolyte shifts -As the capillary walls become more permeable, water, sodium, and later plasma proteins (especially albumin) move into interstitial spaces and other surrounding tissue. The colloidal osmotic pressure decreases with progressive loss of protein from the vascular space. This results in more fluid shifting out of the vascular space into the interstitial spaces. -Net result of fluid shift is intravascular volume depletion ■Edema ■↓ Blood pressure ■↑ Pulse Third spacing!

Emergent Phase cont

■Fluid and electrolyte shifts -Greatest threat is hypovolemic shock ■Caused by a massive shift of fluids out of blood vessels as a result of increased capillary permeability (third spacing) ■Can begin as early as 20min after burn

Emergent Phase Patho cont

■Fluid and electrolyte shifts -Normal insensible loss: 30 to 50 mL/hr -Severely burned patient: 200 to 400 mL/hr -Net result of the fluid shifts and losses is termed intravascular volume depletion

Emergent Phase Patho cont 3

■Fluid and electrolyte shifts -RBCs are hemolyzed by a circulating factor released at time of burn as well as from direct injury from the actual burn •Thrombosis •Elevated hematocrit -K+ shift develops first because injured cells and hemolyzed RBCs release K+into extracellular spaces -Na+rapidly moves to interstitial spaces and remains until edema formation ends

Emergent Phase Patho cont 4

■Fluid and electrolyte shifts •Toward the end of emergent phase: -Capillary membrane permeability is restored if adequate fluid replacement -Fluid loss and edema formation ends -Interstitial fluid gradually returns to the vascular space -Diuresis occurs

Smoke and Inhalation Injury

■From inhalation of hot air or noxious chemicals causing damage to the respiratory tract ■Major predictor of mortality in burn victims ■Need to be treated quickly! ■Assess for signs and symptoms of airway compromise and pulmonary edema that can develop over the first 12-48 hours.

Emergent Phase Patho cont 5

■Inflammation and healing -Neutrophils and monocytes accumulate at site of injury -Fibroblasts and collagen fibrils begin wound repair within first 6 to 12 hours after injury ■Immunologic changes -Immune system is challenged when burn injury occurs ■Skin barrier is destroyed ■Bone marrow is depressed ■Circulating levels of immune globulins are decreased ■WBCs develop defects

Prehospital care cont 3

■Large thermal burns -Cool burns for no more than 10 minutes to prevent hypothermia -Do not immerse in cool water or pack with ice -Remove burned clothing -Wrap in clean, dry sheet or blanket to prevent further contamination of wound and to provide warmth ■Inhalation injury -Watch for signs of respiratory distress -Treat quickly and efficiently -100% humidified oxygen if CO poisoning is suspected

Prehospital Care cont.

■Large thermal burns (>10% TBSA), electrical or inhalation burn suspected. -If responsive ABCs. If unresponsive, CAB order is priority. (meaning compressions first) -Airway •Check for patency, soot around nares or on the tongue, singed nasal hair, darkened oral and/or nasal membranes -Breathing •Check for adequacy of ventilation -Circulation •Check for presence of pulses and elevate the burned limb(s) above the heart

Case Study cont

■M.K. was brought to the ED. ■His burns were estimated to be partial and full thickness over his face, neck, trunk, right upper arm, and left leg. What degree burns has he suffered from? 2nd and 3rd degree What TBSA has been burned? 36% (rule of nines) Let's discuss severity of the burns in relation to their location...What may he be at risk for with these burns? Dehydration, hypothermia, infection, impaired airway What actual and potential risk factors might affect M.K. and his recovery? His smoking history could cause him dependence on a ventilator or pneumonia risk Drinking history can cause him to possibly have difficulty controlling his pain or keeping him sedated

Case Study

■M.K., a 25-year-old male, fell from a ladder while repairing the roof and struck a hot charcoal grill. ■He is a cigarette smoker and drinks beer three times a week. ■He works as a carpenter. ■He lacerated his left leg and his clothes caught fire. What type of burns does M.K. most likely have? Thermal Smoke and Inhalation

Emotional/Psychosocial Needs of Patients and Caregivers

■Many emotional and psychologic needs ■Assess circumstances of burn injury ■Burn survivors often experience anxiety, guilt, and depression ■New fears arise during recovery

Gerontologic Considerations

■Normal aging puts the patient at risk for injury because of the possibility of -Unsteady gait -Limited eyesight -Diminished hearing -The fact that wounds take longer to heal

Emergent Phase Interprofessional management Wound Care other measures

■Other care measures -Facial care ■Performed by open method as face is highly vascular and sensitive to edema with pressure from dressing wraps -Eye care for corneal burns ■Antibiotic ointment is used ■Periorbital edema may frighten patient -Provide reassurance that it is not permanent. -Check that the eyelashes are not turned inward toward the eyeball.

Acute Phase Clinical Manifestations

■Partial-thickness wounds form eschar -Once eschar is removed, reepithelialization begins ■Full-thickness wounds require debridement and grafting

Acute Phase-Nursing and Collaborative Management: Physical and occupational therapy

■Physical and occupational therapy -Good time for exercise is during wound cleaning -Passive and active ROM -Splints should be custom-fitted

Patient Risk Factors

■Preexisting heart, lung, and kidney diseases contribute to poorer prognosis ■Diabetes mellitus and peripheral vascular disease contribute to poor healing and gangrene ■Physical weakness from any chronic disease renders patient less able to recover, including alcoholism, drug abuse, malnutrition. ■Concurrent fractures, head injuries, or other trauma leads to a more difficult recovery.

Clues to smoke and inhalation injury

■Presence of facial burns ■Mucosal blisters, redness, edema ■Singed nasal hair ■Hoarseness, painful swallowing ■Darkened oral and nasal membranes ■Carbonaceous sputum (burned saliva) ■History of being exposed to fire in an enclosed space or clothing caught fire ■Clothing burns around neck and chest

Emergent Phase Interprofessional management

■Rapid and thorough assessment ■Inpatient vs outpatient care ■Hospital vs transfer to burn center

Prehospital Care

■Remove person from source of burn and stop burning process ■Rescuer must be protected from becoming part of incident ■Electrical injuries -Remove patient from contact with source ■Chemical injuries -Brush solid particles off skin--Any clothing containing the chemical must also be removed as the burning process continues while the chemical is in contact with the skin. -Use water lavage copious amounts of water to irrigate anywhere from 20min to 2hrs based on extent of injury ■Small thermal burns (10% or less TBSA) -Cover with clean, cool, tap water—dampened towel. Cooling of injured area within 1 min helps to minimize depth of injury if small burn.

Electrical Burns

■Result from intense heat generated from an electric current ■May result from direct damage to nerves and vessels, causing tissue anoxia and death (Stabilize spine until x rays come) ■Severity of injury depends on -Amount of voltage -Tissue resistance -Current pathways -Surface area -Duration of the flow

Chemical Burns

■Result of contact with acids (found in many household cleaners), alkalis (cement, oven & drain cleaners, heavy industrial cleaners), and organic compounds (chemical disinfectants, petroleum products) ■Alkali burns are harder to manage since alkali adhere to tissue causing protein hydrolysis and liquefaction. The damage continues after the alkali is neutralized. On the other hand, acids cause precipitation of proteins which creates a barrier, therefore, prevents further damage in the majority of cases. ■In addition to tissue damage, chemical burns can occur to the eyes if splashed. ■Chemical should be quickly removed from the skin. ■Clothing containing the chemical should be removed. ■Tissue destruction may continue up to 72 hours after chemical injury.

Emotional/Psychosocial Needs of Patients and Caregivers cont

■Self-esteem may be adversely affected ■Address spiritual and cultural needs ■Issues related to sexuality must be met with honesty ■Family and patient support groups

Location of Burn

■Severity of burn injury is determined by location of burn wound -Face, neck, circumferential burns to chest and/or back→ respiratory obstruction -Hands, feet, joints, eyes → self-care deficit risk -Ears, nose, buttocks, perineum → infection risk (will require foleys or fecal management system to prevent infection) -Circumferential burns of extremities → circulation problems distal to burn and possible nerve damage •May develop compartment syndrome: swelling and increased pressure within a limited space press on and compromise the function of blood vessels, nerves, and/or tendons (access circulatory system of those pulses)

Classification of Burn Injury

■Severity of burn injury is determined by: •Depth of burn •Extent of burn calculated in percent of total body surface area (TBSA) •Location of burn •Patient risk factors (past medical hx) ■American Burn Association uses referral criteria to determine which burns should require transfer and treatment in a burn center. Refer to TABLE 24-2 for this criteria

Emergent Phase Clinical Manifestations

■Shock from hypovolemia ■Blisters ■Paralytic ileus (should not be eating) ■Shivering ■Altered mental status or unconsciousness •Typically secondary to hypoxia associated with smoke inhalation but may be related to other associated factors with injury (i.e. substance abuse, opioid/sedative use, head trauma) (check for CO monoxide poisoning or suspect it) ■Pain •Superficial to moderate partial-thickness burns -Areas of full-thickness and deep partial-thickness burns are initially without pain due to the nerve endings being destroyed in burn injury

Rehab Phase Complication

■Skin and joint contractures -Most common complications during rehab phase. -Positioning, splinting, and exercise should be used to minimize contracture. (Contracture of neck)

Depth of Burn injury 2

■Superficial partial-thickness burn (1st degree) -Involves epidermis -Erythema, blanching on pressure, pain and mild swelling, no vesicles or blisters (although after 24hrs skin may blister and then peel) ■Deep partial-thickness burn ( 2nd degree) -Involves dermis -Fluid-filled vesicles red, shiny, wet (if ruptured). Severe pain caused by nerve injury. Mild to moderate edema ■Full-thickness burn (3rd and 4th degree (bone exposure 4th) -Involves all skin elements, nerve endings, fat, muscle, bone -Dry, waxy white, leathery, or hard skin (eschar). Visible thrombosed vessels. Insensitivity to pain due to nerve destruction.

Rehabilitation Phase

■The rehabilitation phase begins when -Wounds have healed -Patient is engaging in some level of self-care ■Goals: (1) work toward resuming a functional role in society (2) rehabilitate from any functional and cosmetic postburn reconstructive Rehabilitation phase can occur as early as 2 weeks or as long as 7-8 months after a major burn injury.

Types of Burns

■Thermal burns ■Chemical burns ■Smoke and inhalation injury ■Electrical burns ■Cold thermal injury (frostbite) discussed in Ch. 68

Extent of Burn

■Two commonly used guides for determining the total body surface area -Lund-Browder chart ■Considered more accurate because the patient's age, in proportion to relative body-area size, is taken into account -Rule of Nines ■Used for initial assessment because it is easy to remember ■The extent of a burn is often revised after edema has subsided and a demarcation of the zones of injury has occurred.

Acute Phase - Nursing and Collaborative Management

■Wound care ■Excision and grafting ■Pain management ■Physical and occupational therapy ■Nutritional therapy

Special Needs of the Nursing Staff

■You may find it difficult to cope with burn injuries (odors, unpleasant sight of the wound, reality of the pain that comes with the burn & its treatment) ■Know you provide care that makes a critical difference ■Practice good self-care to maintain positive attitude and a healthy work-life balance Trusting, warm, and gratifying relationships develop frequently between burn patients and staff during the hospitalization and long term rehab phase. At times, the bond is so strong that patients have difficulty separating from the hospital and nursing staff.