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BURNS 2009

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BURNS 2009 WOUND DEBRIDEMENT DEBRIDEMENT: Removal of tissue contaminated by bacteria Removal of dead tissue (burn eschar) Natural Debridement Mechanical Debridement ... – PowerPoint PPT presentation

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Title: BURNS 2009


1
BURNS 2009
2
DEPTH OF WOUND
  • Temperature of burning agent and Duration of
    contact determines depth of wound
  • Eg 1 sec of contact with hot tap water at 156
    degrees F full thickness burn
  • Eg 15 sec of contact to hot water 133 degrees F
    full thickness burn

3
DEPTH OF WOUND
  • DEGREES 1st, 2nd, 3rd degree
  • THICKNESS layers of skin burned
  • Superficial partial thickness, deep partial
    thickness, full thickness
  • RULE OF NINES system of assigning percentages in
    multiples of nine to major body surfaces
  • LUND AND BROWDNER METHOD estimating extent of
    burned area recognizing effects of body growth
  • PALM METHOD useful for scattered burns size of
    pts palm used to assess extent of burn injury

4
ASSESSMENT
  • SUPERFICIAL THICKNESS
  • Involves only the epidermis
  • Pink to Red, mild edema, painful, no blisters, no
    eschar, heals in 3-5days, no grafts
  • EXAMPLE sunburn, flash burns

5
ASSESSMENT
  • FIRST DEGREE OR SUPERFICIAL PARTIAL THICKNESS
    BURN
  • involves upper third of the dermis
  • skin is pink to red, painful, mild to moderate
    edema, yes blisters, no eschar. Complete recovery
    within 10-21 days.
  • CAUSED BY scalds, flames, brief contact with hot
    objects

6
ASSESSMENT
  • SECOND DEGREE OR DEEP PARTIAL THICKNESS
  • Caused by flames, prolonged contact with hot
    objects, tar, grease, chemicals
  • Red to white color, moderate edema, painful, rare
    to have blisters, eschar soft and dry, heals 2-6
    wk, grafts used if healing is prolonged

7
ASSESSMENT
  • THIRD DEGREE OR FULL THICKNESS
  • Caused by flame, prolonged exposure to hot
    liquids, electric current, chemicals, grease
  • Destruction of entire epidermis and dermis
  • Black, brown, yellow, white, red, severe edema,
    yes and no to pain, eschar (burn crust), heals in
    weeks to months requiring grafts

8
ASSESSMENT
  • DEEP FULL THICKNESS
  • Extends beyond the skin into the underlying
    fascia and tissues, damages muscle, bone, tendons
  • Black, no edema, no pain, no blisters, eschar,
    takes weeks to months to heal, requires grafts,
    may need amputation
  • Caused by flames, electricity, grease, tar,
    chemicals

9
WHO ARE AT HIGHEST RISK FOR BURNS?
  • Age of victim

10
Primary survey on the scene
  • FIRST PRIORITY prevent injury to rescuer then
    ABCS
  • Airway, C-spine immobilization
  • Breathing
  • Circulation
  • Deficits (neurological)
  • Expose
  • STOP THE BURNING PROCESS

11
SURVEY CONTINUED
  • Secondary survey
  • Head to toe assessment
  • Pertinent history
  • Mechanism of injury
  • Medical history AMPLE

12
EMERGENT PHASE OF BURN INJURY
  • EMERGENT PHASE first phase begins at onset of
    injury and goes to 48 hours
  • GOALS
  • Secure airway
  • Support circulation by fluid replacemnt
  • Provide comfort with analgesics
  • Prevent infection through wound care
  • Maintain body temperature
  • Provide emotional support

13
AIRWAY MANAGEMENT
  • POTENTIALLY SERIOUS INJURY
  • Mouth burn
  • Singed nasal hairs
  • SMOKE INHALATION
  • Burns of the lips, face, ears, neck, eyelids,
    eyebrow, eyelashes
  • Carbonaceous particles in the nose, mouth, sputum
  • Edema of the nasal septum
  • Smoky smell to clients breath

14
ASSESSMENT OF RESPIRATORY PATTERN INDICATES A
PULMONARY INJURY
  • Change in resp pattern means pulmonary injury
  • increased hoarsenes
  • Brassy cough
  • drooling or difficulty swallowing
  • Indicates oropharyngeal edema
  • Can proceed to pulmonary failure may NEED
    INTUBATION
  • Audible wheezing, crowing, stridor
  • Wheezing means obstruction
  • Sounds disappear
  • IMPENDING AIRWAY OBSTRUCTION NEEDING INTUBATION

15
AIRWAY INJURYCARBON MONOXIDE POISONING
  • Carbon Monoxide (CO) found in smoke
  • CO causes tissue hypoxia when CO combines with
    Hgb forming carboxyhemoglobin which competes with
    oxygen. Hgb likes CO better than O2
  • vasodilating action of CO cherry red color
  • TREATMENT 100 O2

16
SMOKE POISONING
  • Smoke poisoning or chemical injury from the
    inhalation of combustion by-products

17
CIRCULATORY MANAGEMENT
  • Circulatory management
  • shock due to fluid loss
  • infuse with LR via large bore IV
  • weigh pt ASAP to determine fluid replacement needs

18
FLUID SHIFT DURING THE EMERGENT PHASE
  • Initial vasoconstriction of blood vessels
  • leak fluid third spacing
  • Loss of plasma fluids and proteins blood
    volume BP extensive edema
  • wgt gain
  • Protein in the interstitial space the
    movement of fluids out from the vascular space

19
FLUID SHIFT CONTINUES
  • IMBALANCES OF FE
  • Hypovolemia
  • Metabolic acidosis
  • Hyperkalemia
  • Hyponatremia
  • Hemoconcentration blood viscosity
    tissue hypoxia

20
GUIDELINES/FORMULAS FOR FLUID REPLACEMENT IN BURN
PATIENTS
  • See page 1634
  • Modified Brooke Formula
  • Parkland/Baxter Formula
  • Modified Parkland
  • Winski
  • Calculated from time of inijury and not from the
    time of arrival at the hospital

21
FLUID REPLACEMENT Parkland/Baxter Formula
  • 4 ml LR x body wgt (kg) x BSA burned fluid
    replacement
  • Give 1/2 calculated amt. in 1st 8hr.
  • Give 1/4 in 2nd 8 hr. period
  • Give 1/4 in 3rd 8 hr. period

22
FLUID REPLACEMENT
  • EXAMPLE Pt weighs 70 kg (about 168 lbs)
  • Burned 50 BSA
  • FORMULA Using lactated Ringers solution
  • 2-4ml/kg/TBSA
  • 2 X 70kg X 50 7000 ml/24 hours
  • Plan to administer first 8 hours 3500 ml or 437
    ml/hour
  • Next 16 hours 3500 ml or 219 ml/hour

23
SKIN ASSESSMENT
  • CALCULATING TBSA or total body surface area is
    the first step in determining what amount of
    fluid will be given using the formula
  • RULE OF NINES (see p 1630)
  • Most rapid
  • Can overestimate TBSA with this method
  • LUND-BROWDER AND BERKOW method (see page
    1630-31) better at identifying differences from
    birth through adulthood
  • BURN CENTER REFERRAL CRITERIA
  • See page 1620
  • Helps determine where a client is best serviced
    medically

24
PULMONARY FLUID OVERLOAD
  • Pulmonary edema can result from fluid
    resuscitation

25
CARDIOVASCULAR ASSESSMENT
  • Immediately after the burn SHOCK can develop
  • Most common cause of death in emergent phase
  • Invasive monitoring may be needed for BP
    measurement, cannot put on BP cuff
  • ASSESSMENT tachycardia, hypotension, decreased
    peripheral pulses, slow peripheral cap refill

26
RENAL/URINARY ASSESSMENT
  • RENAL BLOOD FLOW during the fluid shift of
  • the emergent period urine
    output
  • HOW DOES THIS EFFECT
  • URINE SPECIFIC GRAVITY?
  • increased concentration leads to increased urine
    specific gravity

27
GATROINTESTINAL ASSESSMENT
  • During fluid shift
  • blood flow to vital organs
  • and sympathetic stimulation during emergent phase
    GI motility and paralytic ileus
  • COMMON CHANGES WITH SEVERE BURNS
  • bowel sounds or absent
  • N V, abdominal distention
  • Usually intubated burn pts have NGT to prevent
    aspiration and to remove gastric secretions
  • CURLINGS ULCER may develop within 24 hours
    because of reduced GI blood flow

28
FLUID REMOBILIZATION
  • At about 24 hrs after injury capillary leak stops
  • Pt moves into DIURETIC STAGE begins 48 hrs to 72
    hrs after burn injury
  • Edema fluid shifts from interstitial space into
    vascular space
  • blood volume renal blood flow
    and diuresis
  • specific gravity urinary output
  • Body weight returns to normal
  • Hyponatremia from renal sodium excretion and
    loss of sodium from wound
  • Hypokalemia from K moving back to cells
    potassium excreted in urine
  • Anemia from hemodilution
  • protein lost from the wounds
  • Metabolic acidosis from loss of sodium bicarb in
    urine and increased
  • fat metabolism resulting from decreased
    carbohydrate intake

29
HANDLING LARGE PARTS OF THE BODY BEING BURNED
  • Leads to massive systemic edema
  • Leads to compartment syndrome
  • Treated with escharotomy (surgical incision into
    the eschar to relieve the constricting effect of
    the burned tissue

30
NURSING CARE CONTINUED
  • Insert NG tube
  • Foley catheter IO, sp gr, urine glucose
  • Pain relief
  • opiods - morphine sulfate, hydromorphone
    (Dilaudid), fentanyl
  • Anesthetic agents ketamine (Ketalar),
    pentobarbital sodium (Nembutal), nitrous oxide
    OBSERVING STRICT PROTOCOLS
  • Continuous assessment of
  • extremity pulses and
  • ventilatory limitation
  • Emotional support

31
ACUTE PHASE OF BURN INJURY
  • Begins about 36-48 hrs after burn injury and
    lasts until wound closure is complete
  • Multidisciplinary approach
  • Maintenance of all systems
  • Burn wound care
  • Pain control
  • Psychosocial

32
WOUND CARE
  • Hydrotherapy
  • Topical antibacterial therapy
  • Silvadene
  • Sulfamylon
  • Silver nitrate

33
WOUND DRESSING
  • EXPOSURE METHOD exposed to air, topical agent,
    no dressing
  • OCCLUSIVE METHOD topical agent followed by
    occlusive dressing on wounds and used to protect
    new skin grafts

34
WOUND DEBRIDEMENT
  • DEBRIDEMENT
  • Removal of tissue contaminated by bacteria
  • Removal of dead tissue (burn eschar)
  • Natural Debridement
  • Mechanical Debridement
  • Scissors/forceps/drsgs,debriding agents
  • Surgical Debridement
  • In OR, removing tissue, covering with graft

35
PURPOSE OF GRAFTING
  • To cover the wound
  • To decrease the risk of infection
  • To prevent further loss of protein, fluid and
    electrolytes
  • To decrease heat loss
  • To promote earlier function
  • To reduce contractures

36
GRAFTING BURN WOUND
  • Autografts graft of the patients own skin
  • Homografts graft of skin obtained from living or
    recently deceased humans
  • Heterografts graft of skin taken from animals
    (usually pigs)
  • Biosynthetic synthetic dressing composed of
    nylon combined with collagen derivative
  • (eg) Biobrane, Opsite, Integra

37
NURSING CARE OF PT WITH AUTOGRAFT
  • Occlusive dressing
  • OT makes splint
  • Observe for infection
  • If graft dislodged sterile saline dressing
  • Keep pressure off site, elevate
  • Exercises begin 5-7 days after grafting
  • Donor site very painful

38
DISORDERS OF WOUND HEALING
  • Hypertrophic scarring and keloid formation form
    from excessive abnormal healing or inadequate
    tissue formation
  • TX Compression, ace/jobst
  • Wound contractures
  • Tx splints, traction, ROM

39
PAIN
  • Pain associated with burns is SEVERE
  • Nurses and caregivers need to anticipate when
    pain will be worsened by dressing changes,
    debridement, hydrotherapy, physical therapy
  • PCA with morphine help burn victims

40
EMOTIONAL SUPPORT
  • ACUTE PHASE
  • Facing reality of burn trauma
  • Grieving over obvious losses
  • Depression, regression, manipulative behavior,
    withdrawal, anger

41
EMOTIONAL RESPONSE
  • REHAB PHASE
  • Include the patient in the decision making
  • Help patient set realistic self goals

42
NURSING DIAGNOSIS
  • IDENTIFY PRIORITY NURSING DIAGNOSIS

43
PREVENTION
  • Who is at risk?
  • Who needs to be taught?
  • What changes should be made in the home?
  • What kind of legislation should be promoted?
  • What education can be done in schools?
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