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Burns Caring for the Burn Patient Victoria Siegel, RN, CNS, MSN Margarett Alexandre, RN,MS,CNA * Also determine if other injuries. Allergies Height Weight to be able ... – PowerPoint PPT presentation

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Title: Burns

  • Caring for the Burn Patient
  • Victoria Siegel, RN, CNS, MSN
  • Margarett Alexandre, RN,MS,CNA

Burn Injury Statistics
  • Over 2 million burn injuries and 7,000-9,000
    deaths as a result of fire and burns each yr. in
    the U.S.
  • The home is frequently where burn injuries occur.
  • The very young and the elderly are at greatest
    risk for burn injuries.
  • Infants and toddlers are especially prone to
    scald injuries.http//www.ameriburn.org/

Burn Injury Statistics
  • School age children may incur injury as a result
    of playing with matches.
  • Teenage boys have a high incidence of electrical
  • Males are more common than females to be injured
    by burns.
  • 6 of burn center admissions do not survive.

Anatomy- Normal Skin Functions
  • Maintain fluid and electrolyte balance
  • Protective barrier
  • Regulation of temperature
  • Sensory functions
  • Immunologic functions

Anatomy of the burn wound
  • Superficial Thickness
  • Epidermis only portion affected
  • Erythema, mild edema, pain
  • Peeling dead skin 2-3 days after burn

Partial thickness
  • Partial Thickness epidermis partial dermis
  • - sparing of significant portion of hair
    follicles, sebaceous and sweat glands
    significant portion of dermis.
  • Blister formation

Deep partial thickness
  • Second degree- Deep- destruction of large
    portions of hair follicles, sebaceous and
    substantial portion of dermis. No blisters

Full thickness burns
  • Full ThicknessThird degree burns- entire
    epidermal layers. Skin grafts required.
  • Escharotomies to relieve pressure
  • Healing takes weeks to many months.

Deep full thickness
  • Fourth degree burns- underlying fascia
  • Damage to muscle and bones, tendons- exposed.
  • Sensation absent.
  • Wound blackened and depressed.

Severity of burn related to
  • Depth
  • Extent
  • Age
  • Parts of body burned
  • Past Medical History
  • Concomitant injuries and illness
  • Presence of inhalation injury

Initial management
  • Goal Limit extent of injury
  • Stop the burning process
  • Assess type of burn
  • Assure adequacy of ventilation and oxygenation.
  • Initiate restoration of hemodynamic stability.
  • Look for other traumatic injuries
  • Burn wound last priority.

Primary Survey
  • Methodology of ABCDEF
  • A- Airway/C- spine immobilization
  • B- Breathing
  • C- Circulation, cardiac status.
  • D- disability, neurologic deficit
  • E- Expose and examine
  • F- Fluid resuscitation

Secondary Survey
  • A- allergies?
  • M- Medications/alcohol/drugs used?
  • P- Previous illness PMH, last tetanus?
  • L- Last meal or drink
  • E- Events preceding injury (cause of burn?,
    injury occur in a closed space?, chemicals
    involved? Related trauma?

Respiratory tract injury
  • Carbonaceous sputum
  • Facial burns, singed nasal hairs
  • Agitation, tachypnea, anxiety, stupor, cyanosis,
    other signs hypoxemia.
  • Rapid resp. rate, flaring nostrils, intercostal
  • Hoarse voice, brassy cough, grunting or guttural
    respiratory sounds.
  • Rales, rhonchi or distant breath sounds

Airway management
  • Administer O2- Give 100 oxygen to all patients
    with burns of 20 or more TBSA.
  • Give 100 O2 by mask to any patient suspected of
    CO /or inhalation injury.
  • Endotracheal Intubation- Transnasal intubation if
    possible, transorally if necessary.
  • Obtain blood gases and carboxyhemoglobin levels

  • Smoke inhalation
  • Carbon monoxide poisoning
  • Assess blood gas, chest x-ray.
  • Listen for hoarseness and crackles
  • Prepare for bronchoscopy and/or possible
    intubation or tracheostomy for facial burns

Airway Management
  • Carbon Monoxide Poisoniong- 100 O2 until
    carboxyhemoglobin lt15
  • Transfer to a Burn Unit.
  • Inhalation injury above or below glottis-
    intubate immediately, suctioning, relieve
  • Circumferential burns of chest may require

  • Necrotic tissue resulting from a burn wound.
  • Separates slowly from underlying viable tissue.
  • Good medium for microorganisms.
  • Failure to treat can lead to infection
  • Escharotomies are commonly performed.

ABA Referral Criteria
  • Refer patients to a Burn Center
  • Partial thickness burns greater than 10 total
    body surface area (TBSA).
  • Burns that involve face, hands, feet, genitalia,
    perineum, or major joints.
  • Third degree burns in any age group.
  • Patients with pre-existing medical disorders or
  • Patients requiring special social, emotional,
    rehab intervention

Initial treatment in ER
  • Establish airway
  • Initiate IV therapy, weigh pt.
  • Insert foley hourly assessment of u/o
  • Insert NG tube to remove contents.
  • Insert CVP hemodynamics
  • Baseline mental status
  • Initiate treatment of burn wounds
  • Initiate tetanus prophylaxis.
  • Perform a head to toe assessment

Specific Management
  • Flame Burns
  • Smother the flames
  • Remove smoldering clothing and all metal objects
  • Chemical Burns
  • Brush off all chemicals present on the skin or
  • Remove the clients clothing
  • Ascertain the type of chemical causing the burn
    (acid or alkalai)

  • Electrical Burn
  • At the scene, separate the client from the
    electrical current
  • Smother any flames that are present
  • Initiate cardiopulmonary resuscitation
  • Obtain an electrocardiogram
  • Radiation Burns
  • Remove the client form the radiation source
  • If the client has been exposed to radiation from
    an unsealed source, remove clothing (using lead
    protective gloves)

  • Determine extent of body surface burned.
  • Rule of nines body divided into groups equal to
    about 9 of BSA.
  • Palm method- rough estimate adult palm is equal
    to 0.5 to 1 of BSA.
  • Lund- Browder classification- each section of
    body has own according to age of pt.
  • Computerized mechanism in some burn units.

(No Transcript)
Fluid Resuscitation
  • Systemic Response
  • Marked increase in peripheral vascular resistance
  • Reduced cardiac output- edema forms in burn
    injury area blood volume decreases.
  • Cellular response Full thickness burn protein
    coagulation causes cell death with thrombosis of
    small vessels and nerve necrosis.
  • Goal is to maintain vital organ function and
    avoid complications of inadequate or excessive

Parkland (Baxter) Fluid Resuscitation
  • Calculation of fluids for 1st 24 hrs
  • Adults Ringers Lactate 4ml/kg body weight x
  • TBSA burn.
  • Children Ringers Lactate 4 ml/kg body weight x
  • Infusion rate is regulated so 50 of estimated
    volume is administered in the first 8 hours post
  • Remaining 50 administered over next 16 hrs.

Fluid Resuscitation Response
  • Monitoring of Response- Hourly urine output.
  • Adults 0.5 1.0 mL/kg/hr
  • Children 1.0 mL/kg/hr.
  • Fluid and electrolytes
  • Weigh patient daily
  • Monitor vital signs, assess lung sounds.

  • Impaired gas exchange decreased cardiac output
  • Inadequate tissue perfusion
  • Fluid volume deficit or fluid volume overload
  • Impaired skin integrity.
  • Risk for infection

  • 1. Emergent period 24-48 hours, vascular changes,
    shock, respiratory failure
  • 2. Acute phase- until all wounds heal (up to
    several months). Risk- infection.
  • 3. Rehabilitation phase- regain or compensate for
    loss- many years.

Initial management of burn wound
  • Cool the wound within 30 minutes to limit tissue
    damage and reduce edema but avoid excessive
  • Maintain blisters intact
  • Cover wound with clean, dry, occlusive dressing
    (sterile if possible).
  • Apply topical antimicrobial ointment if transfer
    to burn unit is to be delayed.

  • Cleanse wounds daily
  • Debride eschar, dress wounds,
  • Fine mesh gauze on granulating, healing wounds.
  • Promote healing to donor sites- open to air 24
    hrs. post-op.

  • Desire normal body temp- do not expose wounds
  • Warm ambient temp.
  • Warm dressing and solution to body temp.
  • Administer antipyretics as needed.

  • Avoid infection
  • Monitor for sepsis
  • Hand hygiene
  • Sterile dressing changes
  • Use barrier garments
  • Administer antibiotics

Treatment methods for burns
  • Method open exposure
  • Burned area cleansed and exposed to air, no
    clothing or bedclothes over area.
  • Cradle over bed.
  • Isolation technique
  • Sterile linen
  • Room temp. 85 degrees, humidity- 40-50

Treatment methods for burns
  • Method- closed
  • Burned area cleansed
  • Dressings applied and changed one to five times a
  • Standard dressing- topical antibiotics on wound,
    then sterile multiple gauze layers.

Treatment method for burns
  • Method hydrotherapy
  • Place pt. in hydrotherapy tub for 20-30 min, 2X
    per day.
  • Attendants wear gowns, gloves until wounds are
  • Tub room kept 80-90 to prevent chilling.

Wound debridement
  • 1. Mechanical- hydrotherapy, tub, shower, forceps
    to remove loose, nonviable tissues
  • 2. Enzymatic- naturally- by autolysis,
    spontaneous disintegration of tissues (own
    cellular enzymes.
  • Travase (sutilains)- proteolytic agent applied
  • 3. Surgical (within first 5 days after injury)
  • excise burn wound, then cover with skin graft or
    temporary covering- reduces hydrotherapy
    treatments, risk- massive blood loss.

Topical medications
  • Silvadene-broad antimicrobial activity, no
    electrolyte imbalances, can cause leukopenia.
  • Sulfamylon- broad, used partial and full
    thickness, side effects- met acidosis, causes
    severe pain when applied.
  • Silver nitrate solution- broad, applied with wet,
    bulky dsg., restricts mobility, causes elec.
    imbalances, stings when applied.

Agents used in burns
  • Dakins- dress wounds that are soupy, aids in
    debridement, may inhibit clotting, causes elec.
  • Betadine- may control candida, may cause elec
  • Furacin- antimicrobial- effective staph aureus,
    may cause contact dermatitis, renal problems if
    burns are extensive.

Skin grafts
  • Biologic- viable tissue on once living tissue
  • To promote re-epithelialization of deep second
    degree burns.
  • To cover a wound temporarily after wound
  • To protect granulation tissue between autografts.
  • Heterograft- xenograft, skin from another species
  • Rejection after 24-72 hours.

Skin grafts
  • Homograft (allograft)-
  • From another human (cadaver usually)
  • Rejection after 24 hours.
  • Amniotic membrane- disintegrates 48 hrs.
  • Artificial skin- gradually dissolves.
  • Autograft- first debride, then transplant
  • Transcyte grown in lab from foreskins.

Pressure dressings
  • After graft heals
  • Prevents formation of contractures and tight
    hypertrophic scars
  • Uniform pressure over burned surfaces.
  • Worn 23 hrs. a day.

Burns- body positions
  • Encourage prone and supine positions for a
    definite interval each day.
  • Frequent position changes
  • Burns on neck and chin- encourage position of
    neck hyperextension for part of the day.
  • Burns on hand- consult M.D. for specifics.

Burns- preventing mobility limitations
  • Contractions serious complication.
  • Help to maintain range of joint motion
  • Exercises to prevent and correct contractures are
    begun ASAP- stable
  • PT/OT, Hubbard tank
  • Chewing gum and blowing up balloon prevent
    facial contractures.

Burns- Pain Management
  • Provide analgesic medication 30 minutes prior to
    painful treatments.
  • Provide clear explanations to gain patients
  • Handle burned parts gently.
  • Use careful sterile technique (infection causes
    more pain).

Burns Pain Management
  • PCA, imagery , breathing techniques, enhance
    coping strategies.
  • Pt. and family education and support
  • Patient may need years of PT and OT.
  • Psych support for trauma suffered and body image
    changes endured.

Burns emotional responses
  • Patient response- aggression
  • Nursing approach
  • Acknowledge ability to cope.
  • Provide structure allow pt. choices when
    possible. Pt. needs some control.
  • Burn team must be sensitive to emotional and
    psychological needs of patient and family.

Emotional responses
  • Depression-
  • Nursing approach- support patient, listen.
  • Encourage verbalization of frustrations.
  • Paranoia-
  • Nursing approach- acknowledge c/o fear.
  • Investigate all complaints.
  • Support pt.
  • Provide reality orientation.

Teaching and Discharge Instructions
  • Care of the healed burn wound
  • Nutritional needs
  • Prevention of injury
  • Recognition of SS of complications.
  • Methods of re-socialization.
  • Evaluation- Any signs of infection?, Diet being
    followed?, Pt. involved? Pt. understand D/C

NCLEX TIMEBlisters are a classic sign of which
classification of burn?
  • 1. Superficial
  • 2. Superficial partial thickness
  • 3. Deep partial thickness
  • 4. Full thickness

Which is your first priority when caring for a
burn victim at the scene?
  • 1. Assess for additional injuries.
  • 2. Apply cool compresses to the affected areas.
  • 3. Stop the fire on the victims clothing.
  • 4. Use ice packs for swelling.

Patients with which conditions should be
transferred to a burn center?
  • 1. Burns that involve the face, hands, feet,
    genitalia, perineum or major joints.
  • 2. Second degree burns covering less than 10
    total BSA.
  • 3. Life threatening traumatic injuries.
  • 4. Electrical burns, excluding lightning.

During the primary survey of a burn victim, you
first assess
  • 1. Airway.
  • 2. Circulation.
  • 3. Burn size.
  • 4. Fractures of limbs.
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