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Integumentary: Burns

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Integumentary: Burns Marnie Quick, RN, MSN, CNRN Skin layers Types of burns Thermal Chemical Thermal Radiation Thermal burn Cool burn with cold water until pain is ... – PowerPoint PPT presentation

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Title: Integumentary: Burns


1
Integumentary Burns
  • Marnie Quick, RN, MSN, CNRN

2
Skin layers
3
Types of burns
  • Thermal
  • Chemical
  • Thermal
  • Radiation

4
Thermal burn
5
Cool burn with cold water until pain is relieved-
Do not apply to more than 20 body surface-
hypothermia may occur
6
Chemical burn from sulfuric acid
7
Electrical burns top
picture- toe Leg
bottom picture- mouth
8
Depth of burn Layers of skin and burns
9
Depth of burn First degree burn to third degree
10
First degree burns
11
Second degree burn- note blisters
12
Second degree burn
13
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14
Full thickness third degree burn
  • All layers skin

15
Full thickness
  • Involves past the 3 layers down to the bone
    and/or organs

16
Extent of Burn Rule of Nines
Lund Browder- age
17
What are the Priorities in this patient???
  • Is this patient a candidate for a major burn
    center?

18
Common manifestations/complications of

Major Burn
  • 1. Integumentary system
  • eschar formation
  • necrotic tissue
  • hard, leathery
  • must be removed for healing to take place

19
Common manifestations/complications
Major Burn
  • 2. Cardiovascular
  • Burn shock- third spacing (hypovolemic) 24-36 hrs
  • Blood vess damagedgt inc cap permeability
  • H2O, Na serum albumingt intestial space(3rd
    space)
  • HCT and blood viscosity increases
  • gt 40 burn causes dec cardiac contractibility
    CO
  • Electrical burn can cause arrhythmias/cardiac
    arrest
  • Compartment syndrome of extremities/torso as
    edema compresses blood vessels and nerves- may
    need escharotomy

20
Third spacing
21
Burn with escarotomy
22
Before the escharotomy, how would this eschar
affected his respirations?
23
Escarotomy
24
Common Manifestations Complications
Major Burn
  • 3. Respiratory
  • Direct inhalation injury/systemic response (ARDS)
  • Upper airway thermal injury- esp if burned in
    enclosed space (room) breaths in hot air. May
    be no outward sign of burn- look for soot, nasal
    hairs
  • Laryngeal spasms as edema peaks in 34-48 hrs
  • Bronchial congestion and infection
  • Intersitial pulmonary edema alveolar collapse
  • CO poisoning- 200 Xs greater affinity for
    hemoglobin- hypoxiagt headache to coma sym

25
What are your 1 priorities in this patient?
  • Patient 1 Patient 2

26
  • What do you assess for here???

27
Common Manifestations Complications
Gastrointestional
  • Paralytic ileus gt increased risk for aspiration
  • Stress ulcer (Curlings ulcer) ck pH
  • Ischemia of intestine increases intestinal
    mucosal permeabilitygt bacteria can cause systemic
    sepsis, ARDS and multiple organ failure

28
Common Manifestations/Complications
Urinary
  • Urinary-
  • Renal blood flow/GFR decrease causing release ADH
  • Myoglobinurea- dark urine may block renal tubules

29
Common Manifestations/complications
Immune system and metabolism
  • Immune system
  • Capillary leak- serum levels immunogloblin
    decreased
  • Opportunistic infections can be fatal
  • Most common source infection/septicemia- clients
    own GI track
  • Metabolism
  • BMR increases 2Xs, more if complications
  • Hypermetabolism continues until wound closure
  • Body weight and temperature drop- shivering inc
    met

30
Common Manifestations/Complications-

Pain
  • Where are nerve ending?
  • Morphine/Fentanyl
  • Give IV in acute stage due to fluid shift---No
    IMs

31
Therapeutic Interventions Major Burns
Stage one Emergent/resuscitative Stage
  • Onset injury to successful fluid resuscitation
  • Major concern- Fluid Resuscitation- prevent
    hypovolemic shock
  • 2 large bore IVs in unburned area to restore bl
    vol due to inc capillary permeabilitygt 3rd
    spacing
  • Guidelines burns gt20 TBSA- Parkland formula or
    Modified Brooke formula
  • Need Weight and TBSA burned to calculate

32
  • Lactated Ringers solution 1st 24 hrs then add 5
    Dextrose to crystalloid fluid
  • 50 of formula volume in first 8 hrs rest over
    next 16 hrs then maintain urinary output
  • Hourly output 30-50 cc/hr (foley) heart rate
    less than 120/min hemodynamic monitoring
  • Elevate edematous part escharotomy

33
Elevate arms to decrease swelling also note
escarotomy of arms and chest- assess CMS
34
Other therapeutic interventions during
Stage one emergent/resucitative stage
  • First aide treatment to limit severity of burn
  • Prevent heat loss through burn- warm envir
  • Respiratory involved-
  • intubation/ventilation with PEEP/humidified O2
  • bronchodilators
  • mucolytic agents to liquefy secretions
  • TCDB
  • HOB 30
  • GI- Pepcid NG tube when gut ready- antacids

35
Third spacing- Note edema of the
face decreasing
36
  • Summary of Emergent Phase

37
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38
Therapeutic Interventions Major Burns
Stage 2 Acute Stage
  • Start of diuresis and ends with closure of burn
  • Major concern in this stage- infection
  • Most common cause infection- pts own GI track
  • Wound management-
  • hydrotherapy, debridement of eschar
  • topical antimicrobial creams (open/closed method)
  • splints/exercise prevent contractures
  • Excision/grafting of 3rd degree (temporary cover
    2nd )

39
Hydrotherapy Hubbard Tank
40
Cleaning and debriment in Hubbard
41
Topical broad spectrum antimicrobials (p.425)
  • Silvadene
  • Silver Nitrate
  • Sulfamylon

42
Wound Care
  • Open Method
  • Apply topical chemotherapy

43
Wound Care- Closed method
  • Apply topical chemo and wrap with gauze, fluffs,
    kerlix
  • Assess for
  • constriction
  • circulation
  • checks

44
  • Elevate burned arms on pillows
  • Give pain meds 30 minutes
  • prior to treatments

45
Skin will grow together if not separated
46
Several patients utilizing closed method Who is
that nurse with white stockings cap?

47
  • Excision Grafting
  • Removal of necrotic tissue
  • Eschar is removed until viable tissue is reached

48
Acute Phase- grafting
49
Acute Phase
  • Autograft-
  • on right- donor site
  • Permanent if no infection
  • Temporary grafts
  • Homograft- cadaver
  • Heterograft- animal
  • Synthetic

50
Interventions
  • Assist with positioning
  • ROM exercises
  • Support O.T. P.T. efforts

51
Therapeutic Interventions Stage 3
Rehabilitation Stage
  • Wound closure to highest level of function- years
  • Major concern is psychosocial adjustment
  • Prevent/reduce hypertrophic scares- pressure
    garments
  • Skin care
  • Potential for repeated cosmetic surgeries

52
Keloid formation
53
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54
Rehabilitation Phase- Pressure garments
55
Pertinent Nursing Problems/interventions
  • Impaired skin integrity
  • Deficient fluid volume
  • Acute pain
  • Risk for infection
  • Impaired physical mobility
  • Imbalanced nutrition less than body req
  • Powerlessness

56
What are your assessment findings?
57
What are your nursing priorities for this patient?
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