BURNS

STSG, continued:

The meshing allows for coverage of a large burn area with a small piece of skin by stretching it and securing it with sutures or staples. A mesh graft is especially useful when a patient's burns are extensive, resulting in few available donor sites. Graft "take", or vascularization, is complete in about 3 to 5 days.

Two things to keep in mind when caring for a patient with a major burn are:

The most comfortable position, flexion, is the position of contracture and the burn wound will shorten until it meets an opposing force.

What kind of injury takes precedence over other injuries?

Treatment of inhalation injuries

Open Dressings

Use of a topical agent without any dressing

Synthetic Dressings

Used in the management of partial-thickness burns and donor sites. These dressings are more readily available, less costly, and easier to store than biological dressings. They are made from a variety of materials and come in many different sizes and shapes. Most of these dressings contain no antimicrobial agents.

Hyperemia Injury (epidermis)

Vascularity is maintained, no cell death, red in appearance, and blanching.

Immune Function

With skin destroyed, the body loses its first line of defense against infection. Major burns also depress immunoglobulins IgA, IgG, and IgM.

Partial Thickness (superficial) Burn

1st to 2nd degree burn. Involves epidermis and possibly papillae of dermis. Appears bright red to pink, blanches to the touch, has serum filled blisters, and is glistening and moist. Sensitivity to air, temperature, and touch. Heals in 7 to 10 days.

Partial Thickness (deep) Burn

2nd degree burn. Involves epidermis and half to 7/8 of the dermis. Blisters may be present. Appears pink to light red to white, soft and pliable, and blanching is present. Pressure may be painful due to exposed nerve endings. Heals in 14 to 21 days. May need grafting to decrease scarring.

Full Thickness Burn

3rd to 4th degree burns. Involves the epidermis, dermis, tissue, muscle, and bone. Appears snowy white, gray, or brown. Texture is firm and leathery. Inelastic. No pain because nerve endings are destroyed, unless surrounded by areas of partial thickness burns. Needs grafting to complete healing.

Cardiac Function

A burn is followed by an initial decrease in cardiac output, which is further compromised by the loss of circulating plasma volume. Severe hematologic changes resulting from tissue damage and vascular changes occur in patients with major burns. Plasma moves into the interstitial space because of increased capillary permeability. In the first 48 hours after a burn, fluid shifts lead to hypovolemia and, if untreated, hypovolemic shock. Loss of intravascular fluid causes a relative increase in hematocrit, and red blood cells are destroyed. The intense heat decreases platelet function and half-life. Leukocyte and platelet aggregation may progress to thrombosis.

Biological Dressing

A dressing that uses tissue from living or deceased humans or deceased animals, or to cellular dressings that may use animal tissue, human tissue, or synthetics. Biological dressings assist with wound healing and stimulate EPITHELIALIZATION. These dressings may be used as donor site dressings, to manage a partial-thickness burn, and to cover the clean, excised wound before autografting. Some cellular wound dressings have varied layers that form a matrix onto which the patient's own cells migrate over a few weeks to form a new dermis. A very thin layer of the person's own skin is then grafted onto this new dermis.

Gastrointestinal Problems

A few of the gastrointestinal problems that can develop with a major burn include gastric dilation, peptic ulcers, and paralytic ileus. Most of these problems occur in response to fluid shifting, dehydration, opioid analgesics, immobility, depressed gastric motility, and the stress response.

Escharotomy

A linear excision through the eschar to the superficial fat that allows for expansion of the skin and return of blood flow or chest expansion.

Renal Function

Acute renal insufficiency can occur as a result of hypovolemia and decreased cardiac output. Fluid loss and inadequate fluid replacement can lead to decreased renal blood flow and glomerular filtration rate. With an electrical burn injury, renal damage can occur from direct electrical current or the formation of myoglobin casts (because of the muscle destruction), which can cause acute renal tubular necrosis.

Factors that promote graft viability:

Adequate hemostasis, anatomical location of graft, smooth contour, nonjoint areas, graft secured well, immobilization of graft area, and good nutritional status.

ABC'S of Burns

Airway, Breathing, Circulation, Disability, Exposure, Fluid resuscitation

What is the rationale for nursing intervention; Monitory arterial blood gases and CO level.

Assess level of oxygenation. Helps guide oxygen therapy.

What is the rationale for nursing intervention; Assess respiratory status: auscultate breath sounds every 15 minutes or as needed. Note any adventitious breath sounds. Observe chest for excursion. Monitor ability to cough.

Assessment detects changes in pulmonary function for planning care.

Dressings used as temporary wound coverings over clean partial- and full-thickness injuries:

Biological and synthetic dressings. Act as skin substitutes to help maintain the wound surface until healing occurs, a donor site becomes available, or the wound is ready for autografting.

What is the rationale for nursing intervention; Administer bronchodilators and antibiotics as prescribed.

Bronchodilators decrease bronchospasms and edema. Antibiotics fight infection.

How is the severity of a burn injury determined?

By the depth of tissue destruction, percentage of body surface area injured, cause of the burn, age of the patient, additional injuries, medical history, and location of the burn wound.

FTSG

Can be sheet grafts or pedicle flaps. They are used over areas of muscle mass, soft tissue loss, hands, feet, and eyelids. They are not used for extensive wounds because the donor sites usually require an STSG for closure, or closure from the wound edges. A pedicle graft or flap is a skin flap and subcutaneous tissue that is still attached at one corner by a "pedicle" to a blood supply; it is then attached to an adjacent area in need of grafting. Once the distal part of the graft takes, it remains in place and the flap is divided, with the remainder returning to the original site. They require more than one surgery and take longer for the graft site and donor site to heal.

Mechanical Debridement

Can involve the use of scissors and forceps to manually excise loose non-viable tissue, or the use of wet-to-moist or wet-to-dry fine-mesh gauze dressings.

What is the rationale for nursing intervention; Suction frequently as needed. Obtain sputum cultures. Note amount, color, and consistency or pulmonary secretions.

Carbonaceous sputum is diagnostic for smoke inhalation injury. Infection changes color, amount, and consistency of sputum. Culture and sensitivity assists in selection of appropriate antibiotic.

Common laboratory tests done with burns include:

Complete blood count and differential, blood urea nitrogen, serum glucose and electrolytes, serum protein and albumin levels, urinalysis, urine cultures, and clotting studies. If an inhalation injury is suspected, arterial blood gases, bronchoscopy, and carboxyhemoglobin levels are done. X-rays, electrocardiogram, and wound cultures are completed if indicated.

Neurovascular Compromise

Complication of a major burn

Eschar Formation

Creates pressure and contributes to decreasing blood flow to areas distal to the burned area.

Acute Stage, continued:

Debridement, or the removal of nonviable tissue, also called eschar, can be mechanical, chemical, surgical, or a combination of these methods. If the patient has a circumferential burn an increase in tissue pressure secondary to tissue edema occurs. The burn then acts like a tourniquet, imepeding arterial and venous flow. An ESCHAROTOMY may be immediately needed to relieve pressure.

What is the rationale for nursing intervention; Elevate head of bed if no cervical spine injuries or no history of multiple trauma.

Decreases swelling of face and neck. Increases ability to expand lungs.

The Rule of Nines

Divides the body into segments whose areas are either 9% or multiples of 9% of the total body surface, with the perineum being counted as 1%.

Treatment in the Emergent Stage

Emergency rescuers at the scene will stabilize the victim by establishing an airway, ensuring oxygenation, inserting an IV line, and stabilizing fractures, hemorrhage, spine immobilization, and other injuries. IV fluids are given to treat hypovolemic shock. The patient is treated for pain with appropriate IV opioid analgesics. An accurate history of the injury is obtained to determine severity, probable complications, and any associated trauma.

Three Overlapping Stages of Burn Treatment

Emergent Stage, Acute Stage, and Rehabilitation Phase

Most common causes of burn injuries...

Flames, contact burns, scalding, and chemical, electrical, and radiation burns.

Fluid Balance

Following a major burn, increased capillary permeability leads to the leakage of plasma and proteins into the tissue, resulting in the formation of edema and loss of intravascular volume. There is also water loss by evaporation through the burned tissue that can be 4 to 15 times normal. Increased metabolism leads to further water loss through the respiratory system.

Scarring

Hypertrophic scarring, or a proliferation of scar tissue, can be minimized or prevented through the use of a pressure garment.

What is the greatest cause of death with burns?

Infection

Factors that inhibit graft viability:

Infection, necrotic skin, anatomic location of graft: Perineum, axillae, buttocks. Poor quality donor skin, poor nutritional status, bleeding, mechanical trauma, and shock.

What is a major complication that can occur with a flame burn in an enclosed space?

Inhalation injury. An inhalation injury is a major cause of morbidity and mortality associated with burn injuries.

Pulmonary Effects

Pulmonary effects are mostly related to smoke inhalation. However, hyperventilation may occur with any moderate to major burn injury, usually proportional to the severity of the burn. Oxygen consumption increases because of the hypermetabolic state, fear, anxiety, and pain.

Chemical Debridement

Involves the use of a proteolytic enzymatic debriding agent that digests necrotic tissue.

Closed Dressing

Involves the use of an occlusive dressing over the wound.

Coagulation Injury (subcutaneous)

Irreversible cell death, white or gray in appearance, no blanching.

Contractures

It is important to implement a specific exercise program 24 to 48 hours after injury to avoid contractures. Splinting devices are used to maintain proper positioning and stretching.

Itching

Itching must be controlled. Itching may be intense as the burn heals and scratching can impair healing and increase risk of infection.

Care of graft site includes:

Keep graft site immobilized until after the graft takes to prevent movement or slippage of the grafted skin. Dressings may be bulky to assist in immobilization. These dressings must not be disturbed. The involved area requires frequent circulatory checks, including assessment of color, warmth, sensation, pulses, and capillary refill. Any involved extremities must be elevated to maintain circulation. A graft has been successful if there is good adherence of the graft to the wound with no evidence of necrosis of infection.

General principles for dressings:

Limit the bulk of the dressing to facilitate range of motion. Never wrap skin-to-skin surfaces. Base dressings on the size of wounds, absorption, protection, and type of debridement. Wrap extremities from distal to proximal to promote venous return. Do not wrap dressings too tightly and check peripheral pulses often. Elevate affected extremities.

What are some alterations in normal skin functions resulting from a major burn injury?

Loss of protective functions, impaired ability to regulate temperature, increased risk of infection, changes in sensory function, loss of fluids, impaired skin regeneration, and impaired secretory and excretory functions.

STSG

May be applied as a sheet graft or a meshed graft. A sheet graft is used for cosmetic effect, such as for a face, neck, upper chest, breast, or hand burn. It is placed on the area as a full sheet. A meshed graft is passed through a mesher that produces tiny slits in the skin, similar to fishnet, with openings in the shape of diamonds to permit the skin to expand one and a half to nine times its original size.

Metabolic Changes

Metabolic demands are very high in patients with burns. A high metabolic rate proportional to the severity of the burn is usually maintained until wound closure. This hypermetabolism is further compromised by associated injuries, surgical interventions, and the stress response. Severe catabolism also begins early and is associated with a negative nitrogen balance, weight loss, and decreased wound healing. Elevated catecholamine (epinephrine, norepineprine) levels are triggered by the stress response. This, along with elevated glucagon levels, can stimulate hyperglycemia.

What is the rationale for nursing intervention; Provide appropriate pulmonary care:turn, cough, deep breathe ever 2 to 4 hours. Provide incentive spirometer every 2 to 4 hours.

Mobilizes secretions and promotes lung expansion.

Acute Stage

Multi-disciplinary care from a burn team is provided. Management goals include wound closure with no infection, minimum scarring, maximum function, maintenance of comfort as much as possible, adequate nutritional support, and maintenance of fluid, electrolyte, and acid-base balance. PCA is very effective in helping to control pain. NG tube may be required to meet nutritional requirements.

Acute Stage, 2nd continued:

Once the area is cleaned, the burn dressing and topical treatment are prescribed. The type of dressing and topical agent chosen depend on the area involved, the extent and depth of injury, and physician preference.

Types of Dressings

Open, closed, biological, synthetic, or a combination.

What kind of wound is a donor site?

Partial-thickness wounds. They usually heal in 10 to 14 days, but this depends on the thickness and method of grafting and the general health of the patient. Use of semiocclusive, transparent dressings, such as Op-Site, Biobrane, or Tegaderm, allows for a moist healing environment and is associated with reduced risk of infection.

What is the rationale for nursing intervention; Administer 100% oxygen by tight-fitting face mask for the breathing patient.

Provides oxygen for adequate gas exchange.

Autograft

Skin graft from the patient's unburned skin that is placed on the clean excised burn.

What are the two common types of autograft?

Split-Thickness Skin Graft (STSG) and Full-Thickness Skin Graft (FTSG)

What is the rationale for nursing intervention; Monitor for nasal flaring, retractions, wheezing, and stridor.

Stridor may signal upper airway involvement. Nasal flaring, retractions, and wheezing may indicate lower airway involvement.

Stasis Injury (dermis)

Temporary increase in tissue edema, vasoconstriction, sludging of blood cells, red in appearance, no blanching.

Emergent Stage

The burning process must be stopped. The clothes are removed, and the wound is cooled with tepid water and covered with clean sheets to decrease shivering and contamination. The burn wound itself is a lower priority than the ABCs of trauma resuscitation. Inhalation injury is suspected if the patient sustained a burn from a fire in an enclosed space or was exposed to smoldering materials, if the face and neck were burned, if there are vocal changes, or if the patient is coughing up carbon particles.

Stage 1 - EMERGENT

The duration is from the onset of injury to completion of fluid resuscitation.

Stage 2 - ACUTE

The duration is from the start of diuresis to near completion of wound closure.

Stage 3 - REHABILITATION

The duration is from wound closure to the return of optimal level of physical and psychosocial function.

Surgical Debridement

The excision of full-thickness and deep partial-thickness burns. This method is followed by application of a skin graft.

Common sites for a circumferential burn:

The extremities, trunk, and chest. Respiratory insufficiency can occur as a result of restricted chest expansion if the burn occurs on the chest or trunk.

What 5 elements determine the amount of skin damage from burns?

The temperature of the burning agent, the burning agent itself, the duration of exposure, the conductivity of tissue, and the thickness of the involved dermal structures.

Rehabilitation Phase

The therapy started during the acute phase continues in the rehabilitation phase. There is wound closure, and the goal is to return the patient to an optimum level of physical and psychosocial function. The may take months to years to accomplish, depending on the extent of the injury. Reconstructive surgeries may be ongoing for many years.