Burns
Emergent Phase: Complications
Cardiovascular system --Impaired microcirculation Respiratory system --Upper airway burns ----Edema ----Mechanical airway obstruction and asphyxia --Lower airway burns ----Pneumonia ----Pulmonary edema
Thermal Burns
Caused by flame, flash, scald, or contact with hot objects Severity of injury depends on --Temperature of burning agent --Duration of contact time
Chemical Burns
Contact with acids, alkalis, and organic compounds Alkali burns are harder to manage Cause protein hydrolysis and liquefaction Damage continues after alkali is neutralized Results in injuries to Skin Eyes Respiratory system Liver and kidney
Which clinical manifestations are observed in a patient in the emergent phase of a burn injury?
During the emergent phase of a burn injury, the patient exhibits tachycardia and hypotension. Other clinical manifestations during this phase include a loss of appetite, a decreased urine output, and tachypnea.
The patient in the emergent phase of a burn injury is being treated for pain. What medication should the nurse anticipate using for this patient?
IV medications are used for burn injuries in the emergent phase to deliver relief rapidly and prevent unpredictable absorption as would occur with the IM route. Tetanus toxoid may be administered, but not for pain. The PO route is not used because gastrointestinal function is slowed or impaired because of shock or paralytic ileus, although oxycodone and acetaminophen may be used later in the patient's recovery.
Burns
Injury to tissues of the body caused by heat, chemicals, electrical current, or radiation Types of Burn Injury --Thermal burns --Chemical burns --Smoke inhalation injury --Electrical burns --Cold thermal injury
First Degree: Superficial
Involves the epidermis Causes: Sunburn, heat flash, flame Characteristics: dry, pinkish red, blanches with pressure Painful, itching during healing Healing: 3-6 days
Prehospital Care
Remove person from source of burn and stop burning process Rescuer protect self from becoming injured Electrical injuries --Remove patient from contact with source Chemical injuries --Brush solid particles off skin --Use water lavage Small thermal burns --Cover with clean, cool, tap water—dampened towel Large thermal burns --Airway, breathing, and circulation --Do not immerse in cool water or pack with ice --Remove burned clothing --Wrap in clean, dry sheet or blanket Inhalation injury --Observe for signs of respiratory distress --Treat quickly and efficiently --100% humidified oxygen if CO poisoning is suspected
Emergent Phase : Drug therapy
Analgesics and sedatives Morphine Hydromorphone (Dilaudid) Lorazepam (Ativan) Antimicrobial agents Topical agents Silver sulfadiazine (Silvadene) Mafenide acetate (Sulfamylon) VTE prophylaxis Heparin
Second Degree Burns: Deep Partial-thickness burn
Epidermis, part of dermis sweat glands intact Causes: flame, radiant injury Characteristics: dry, pale waxy, no blanching Pain: sensitive to pressure Healing: 30 days to months
Third and Fourth Degree Burns: Full-thickness burn
Involves all skin elements, nerve endings, fat, muscle, bone. All skin elements & local nerve endings are destroyed. Causes: chemical, electrical Characteristics: leathery, white, cherry red, brown, black Little pain, deep pressure Surgical: grafting
A nurse notes decreased reflexes during the physical assessment of a patient who was admitted with a burn injury. What is the likely cause for this clinical manifestation?
A decreased level of potassium, known as hypokalemia, results from the loss of potassium from the burn wounds. Clinical manifestations include muscle weakness, leg cramps, paresthesias, and decreased reflexes. Decreased levels of water and increased levels of sodium do not affect reflexes in patients with burn injuries. Increased sodium levels result in thirst, a dry and furry tongue, lethargy, and seizures.
Which type of burn injury occurs on the layers of subcutaneous fat, muscle, or deeper structures?
A full thickness burn is a burn of the layers of subcutaneous fat, muscle, or deeper structures. A superficial partial thickness burn is a burn of the epidermis layer; a sunburn is a type of superficial partial thickness burn. A deep partial thickness burn involves the dermis layer, between the epidermis and subcutaneous layers.
Emergent Phase Nursing Management
Airway management --Early endotracheal intubation --Escharotomies of the chest wall --Fiberoptic bronchoscopy --Humidified air and 100% oxygen Fluid therapy --Two large-bore IV lines for >15% TBSA --Fluid replacement based on size/depth of burn, age, and individual considerations --Parkland (Baxter) formula for fluid replacement ----4 mL Lactated Ringers per Kg of bodyweight per percent of total body surface area (%TBSA) = total fluid requirements for first 24 hours. ----½ of total in first 8 hours ----¼ of total in second 8 hours ----¼ of total in third 8 hours Wound care --Delayed until a patent airway, adequate circulation, and fluid replacement have been established --Monitor for infection Cleansing --Done in a cart shower, shower, or bed Debridement --May need to be done in the OR --Loose necrotic skin is removed Open method --Burn is covered with topical antibiotic with no dressing over wound Closed method --Multiple dressing changes --Sterilized gauze dressings are laid over topical antibiotic --Dressings may be changed from every 12 to 24 hours to once every 14 days
Acute Phase
Begins with the mobilization of extracellular fluid and subsequent diuresis Concludes when --Superficial partial-thickness, deep-partial thickness wounds are healed and/or --Full thickness burns are covered by skin grafts Acute Phase Pathophysiology Diuresis: fluid mobilization --> patient is less edematous Bowel sounds return WBCs surround wound and phagocytosis occurs Necrotic tissue begins to slough Granulation tissue forms Superficial partial-thickness burn wounds heal from edges and from dermal bed Full-thickness burns must have eschar removed and skin grafts applied
Location of Burn
Burn severity is determined by location of burn --Face, neck, chest → respiratory obstruction --Hands, feet, joints, eyes → self-care --Ears, nose, buttocks, perineum → infection Circumferential burns of extremities can cause circulation problems distal to burn Patients may also develop compartment syndrome
Rehabilitation Phase Pathophysiologic Changes
Burn wound heals either by spontaneous re-epithelialization or by skin grafting Keratinocytes begin to rebuild the tissue structure Collagen fibers add strength to weakened areas 4 to 6 weeks, the area becomes raised and hyperemic Mature healing is reached about 12 months Skin never completely regains its original color Discoloration of scar fades with time Pressure can help keep scar flat Newly healed areas can be hypersensitive or hyposensitive to cold, heat, and touch Healed areas must be protected from direct sunlight for 3 months Skin and joint contractures Positioning, splinting, and exercise should be used to minimize contracture.
Depth of Burn
Burns are defined by degrees --First, second, third, and fourth ABA: categorizing burn according to depth of skin destruction --Superficial burn --Superficial partial-thickness burn --Deep partial-thickness burn --Full-thickness burn
A patient arrives in the burn unit with erythema, pain, and mild swelling following a burn injury while cooking. Based on the wound observation and patient symptoms, the nurse should document the depth of the burn as what?
Burns which are painful, erythematous, and associated with mild swelling are first-degree burns. Second-degree burns are associated with vesicles and appear shiny. Third- and fourth-degree burns are white, waxy, and are insensitive to pain due to nerve destruction.
Which complication is caused by an electric burn?
Electric burns often cause the release of myoglobin from injured muscle tissues into circulation, causing myoglobinuria. Systemic toxicity and protein hydrolysis results from chemical injury. Smoke and inhalation injury results in metabolic asphyxiation.
Which burn injury results in tissue anoxia?
Electrical injury causes tissue anoxia due to nerve damage and nerve death. The injury sustained by a thermal burn is dependent on the temperature of the burning agent and the length of exposure. Chemical burns can cause tissue damage and eyes can be injured if a splash occurs. Smoke and inhalation injury result in hypoxia
Phases of Burn Management: Emergent Phase
Emergent (resuscitative) phase --Time required to resolve immediate problems resulting from injury --Up to 72 hours --Primary concerns ----Hypovolemic shock ----Edema
Rehabilitation Phase Nursing Management
Encourage both patient and caregiver to participate in care --Skills for dressing changes --Wound care Use water-based creams Reconstructive surgery may be needed following major burns Exercise Constant encouragement and reassurance Emotional and psychological needs Assess the circumstances of the burn Burn survivors often experience guilt, concern, frustrations New fears arise during recovery Self-esteem may be adversely affected Address spiritual and cultural needs Family and patient support groups
Second Degree Burns: Superficial partial-thickness burn
Epidermis, superficial dermis Causes: flash, scald, hot liquids, contact burns Characteristics: moist, pinkish or mottled red, blisters Pain Healing: 10-14 days
Emergent Phase Pathophysiology
Fluid and electrolyte shifts --Caused by a massive shift of fluids out of blood vessels R/T increased capillary permeability --Fluid shifts out of the vascular space into interstitial spaces ----Edema: secondthird spacing ----Decreased BP and increased pulse --Na+: moves to interstitial spaces and remains until edema formation ceases --K+: shift develops because injured cells and hemolyzed RBCs release K+ into extracellular spaces Inflammation and healing --Neutrophils and monocytes accumulate at the site of injury --Fibroblasts and collagen fibrils begin wound repair within the first 6 to 12 hours after injury Immune system is challenged --Skin barrier is destroyed --Bone marrow is depressed --Circulating levels of immune globulins are decreased --WBCs develop defects
A nurse is caring for a patient with second- and third-degree burns to 50% of the body. The nurse prepares fluid resuscitation based on knowledge of the Parkland (Baxter) formula that includes which recommendation?
Fluid resuscitation with the Parkland (Baxter) formula recommends that one half of the total fluid requirement should be administered in the first eight hours, one quarter of total fluid requirement should be administered in the second eight hours, and one quarter of total fluid requirement should be administered in the third eight hours.
Smoke Inhalation Injuries
From inhalation of hot air or noxious chemicals Cause damage to respiratory tract Prompt treated Three types --Metabolic asphyxiation --Upper airway injury --Lower airway injury Metabolic asphyxiation Carbon monoxide (CO) poisoning CO is produced by the incomplete combustion of burning materials Inhaled CO displaces oxygen --Hypoxia --Carboxyhemoglobinemia --Death Upper airway injury Injury to mouth, oropharynx, and/or larynx Thermally produced: hot air, steam, or smoke Swelling may be massive and onset rapid --Eschar and edema may compromise breathing --Swelling from scald burns can be lethal Clinical Manifestations: Upper airway injury --Facial burns --Singed nasal hair --Hoarseness, painful swallowing --Darkened oral and nasal membranes --Clothing burns around chest and neck 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 24 hours after burn ----Manifests as acute respiratory distress syndrome (ARDS) Clinical Manifestations --Dyspnea, wheezing, altered mental status --Carbonaceous sputum --History of being burned in enclosed space
Emergent Phase Nutritional therapy
Hypermetabolic state Resting metabolic rate may be increased Core temperature is elevated Caloric needs are about 5000 kcal/day Enteral feeding: promotes optimal conditions for wound healing Supplemental vitamins and iron
Acute Phase Laboratory Values
Hypernatremia --Successful fluid replacement --Improper tube feedings --Inappropriate fluid administration --Restrict sodium in IVs, oral feedings Hyponatremia ----Excessive GI suction, diarrhea ----Water intoxication ------Juices and nutritional supplements Hyperkalemia --Large amounts of potassium is released from damaged cells --May occur if patient has renal failure, adrenocortical insufficiency, or massive deep muscle injury --Dysrhythmias and ventricular failure Hypokalemia --IV therapy without potassium --Vomiting, diarrhea --Prolonged gastrointestinal suction
Emergent Phase Clinical Manifestations
Hypovolemic Shock Blisters Paralytic ileus Shivering Altered mental status
A nurse is providing care to a patient admitted to the burn unit. Which pathophysiologic changes does the nurse anticipate in this patient?
In a burn injury, the viscosity of body fluids is increased, the blood volume is reduced, and vascular permeability is increased. Hematocrit and peripheral resistance are increased in burn injuries.
A patient sustains a second-degree (partial-thickness) burn. Which layer(s) of skin does the nurse inspect for damage?
In a second-degree, or partial-thickness, burn, both the epidermis and dermis are damaged. A first-degree superficial burn, such as sunburn, involves only the epidermis. A third- or fourth-degree full-thickness burn may involve muscle and bone. A third-degree deep partial- to full-thickness burn may include the epidermis, dermis, and subcutaneous tissue.
When assessing a patient suffering from inhalation burns on the face and chest, what findings should a nurse anticipate? Select all that apply.
In inhalation burns, either the respiratory tract is exposed to intense fumes or heat, or the patient inhales noxious chemicals or smoke. Increasing hoarseness is seen due to irritation of the upper airway during inhalation and the laryngeal edema caused by inhalation injury. Some other signs include darkened oral or nasal membranes and productive cough with black sputum, which are evident due to charring of the membranes of the respiratory tract. Location of contact points is done in case of electrical burns. In this case, the skin may appear leathery white and charred.
Acute Phase Complications
Infection -Localized inflammation, induration, and suppuration -Superficial partial-thickness and deep-partial burns can become full-thickness wounds in the presence of infection -Watch for signs and symptoms --Hypothermia or hyperthermia --Increased heart and respiratory rate --Decreased BP --Decreased urine output Cardiovascular and respiratory systems --Complications are the same as in emergent phase Neurologic system --Severe hypoxia: respiratory injuries or complications from electrical injuries --Disorientated and combative --Hallucinations --Delirium Musculoskeletal system --Decreased ROM and contractures Gastrointestinal system --Paralytic ileus --Diarrhea, constipation --Curling's ulcer (peptic ulcer) Endocrine system --Hyperglycemia --Increased insulin production
A patient is admitted to the burn center with burns of the face, upper chest, and hands after fireworks exploded in the patient's garage, catching the patient's shirt on fire. On assessment, the nurse notes that the patient is coughing up black sputum, has singed nasal hair, darkened oral and nasal membranes, and smoky breath with increasing shortness of breath and hoarseness. Which of these actions would be the most appropriate for the nurse to take next?
Inhalation injury results from exposure of the respiratory tract to intense heat or flames with inhalation of noxious chemicals, smoke, or carbon monoxide. The nurse should anticipate the need for endotracheal intubation and mechanical ventilation, because this patient is demonstrating signs of severe respiratory distress. The nurse should also obtain vital signs and ABGs and insert a Foley, but these interventions are not a priority at this time. A sputum sample is not necessary at this time.
Electrical Burns
Intense heat generated from an electric current Direct damage to nerves and vessels, causing tissue anoxia and death Severity of injury depends on --Amount of voltage --Tissue resistance --Current pathways --Surface area --Duration of the flow Current that passes through vital organs is more life-threatening Electrical sparks: ignite patient's clothing, causing a thermal flash injury Most damage occurs beneath skin "Iceberg effect" Electrical current may cause muscle spasms strong enough to fracture bones Patients are at risk -Dysrhythmias: V-fib, cardiac arrest -Severe metabolic acidosis, and myoglobinuria -Myoglobin and hemoglobin from damaged RBCs travel to kidneys --Acute tubular necrosis (ATN) --Eventual acute kidney injury
Extent of Burn
Two commonly used guides for determining the total body surface area Lund-Browder chart Considered more accurate Rule of Nines Used for initial assessment
Which complications occur in a patient with metabolic asphyxiation?
Metabolic asphyxiation is a type of smoke and inhalation injury that occurs due to inhalation of carbon monoxide or hydrogen cyanide. In this condition, the oxygen delivery or consumption is impaired, resulting in hypoxia. Hydrogen cyanide poisoning also occurs in metabolic asphyxiation in the absence of burn injury to the skin. Cardiac standstill occurs in an electrical injury. Protein hydrolysis occurs in a chemical injury. Acute respiratory distress syndrome occurs in a lower airway injury.
Classification of Burn Injury
Severity of injury is determined by --Depth of burn --Extent of burn in percent of TBSA-total body surface area --Location of burn --Patient risk factors
According to the Rule of Nines for calculating the percentage of burns, the nurse should assign what percentage to a burn in the genitalia?
The Rule of Nines is a formula used for calculating the percentage of burns during initial assessment of a burn patient. The genitals are assigned 1%. Burns in the head and arms are assigned 9% each. Burns on the lower extremities are assigned 18% each. Burns in the chest and back are assigned 18% for each side.
The ambulance reports that it is transporting a patient to the emergency department who has experienced a full-thickness thermal burn from a grill. What manifestations should the nurse expect?
With full-thickness burns, the nerves and vasculature in the dermis are destroyed so there is no pain; the tissue is dry and waxy looking or may be charred, and there is no blanching with pressure. Severe pain, blisters, and blanching occur with partial-thickness (deep, second-degree) burns. Pain, minimal edema, blanching, and redness occur with partial-thickness (superficial, first-degree) burns
Acute Phase: Nursing Management
Wound care Assessment and cleansing Debridement: enzymatic debridement Removal of dead tissue from healthy wound Dressing reapplication Appropriate coverage of the graft Gauze next to graft followed by middle and outer dressings Unmeshed sheet grafts used for facial grafts Excision and grafting --Eschar is removed down to subcutaneous tissue or fascia --Graft is placed on clean, viable tissue --Wound covered with autograft --Donor skin is taken with a dermatome --Choice of dressings varies --Grafts are attached with ----Fibrin sealant, sutures or staples ----Early excision-->function is restored, scar tissue minimized Types of Grafts Allograft or homograft skin -From cadavers Autograph -Cultured epithelial autographs (CEAs) -Artificial skin: biosynthetic Artificial/ Temporary (Integra) -Porcine -Biobrane Pain management --Continuous background pain --IV infusion of an opioid --Or slow-release, twice-a-day oral opioid Treatment-induced pain --Analgesic --Anxiolytic (sedative and hypnotic) Nonpharmacologic strategies --Relaxation breathing --Visualization, guided imagery Physical and occupational therapy --Best time for exercise is during wound cleaning --Passive and active ROM --Splints should be custom-fitted Nutritional therapy --Meet daily caloric requirements --Caloric needs should be calculated by dietitian --High-protein, high-carbohydrate foods --Favorite foods from home --Patients should be weighed regularly
