Burn wounds occur when there is contact between tissue and an energy source, such as heat, chemicals

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Burn wounds occur when there is contact between
tissue and an energy source, such as heat,
chemicals, electrical current, or radiation.
Burns and Patient Management
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The resulting effects of the burn are influenced
by the

• intensity of the energy
• duration of exposure
• type of tissue injured

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Burn Statistics

• At least 50 of all burn accidents can be
  prevented
• children playing with fire account for more than
  one-third of preschool deaths by fire
• In the US, approximately 2.4 million burn
  injuries are reported each year.
• Burn injuries are second to motor vehicle
  accidents as leading cause of accidental death in
  the US

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What 2 types of clients account for 2/3 of all
burn fatalities?

• Older adults

• Children (especially preschool aged children)

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Where do most burns occur?

• Children, newborn to 4 y.o, from kitchen and then
  the bathroom
• ages 5-74, most burn injuries occur outdoors with
  next area-kitchen
• ages 75 and above, kitchen and then outdoors

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Major cause of fires in the home

• Carelessness with cigarettes!!
• Hot water from water heaters set at high levels
  above 140 degrees F (60 degrees C)
• cooking accidents
• space heaters
• combustibles - gasoline, lighter fluids, etc.
• chemicals

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Types of Burn Injury

• Thermal burns-can be caused by flame, flash,
  scald, or contact with hot objects
• Chemical burns-are the result of tissue injury
  and destruction from necrotizing substances.
• Electrical burns-results from coagulation
  necrosis that is caused by intense heat from an
  electrical current
• Smoke inhalation injury-inhaling hot air or
  noxious chemicals
• Cold thermal injury-frostbite.

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Referral Criteria

• 2nd or 3rd Degree Burns gt10 BSA
• Burns to Face, Hands , Feet, Genitailia,
  Perineum, or major Joints. ESPECIALY
  CIRCUMFRENTIAL BURNS
• Electrical Burns
• Chemical Burns
• Inhalation Injury

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Referral Criteria

• Burns with pre-existing PMHX that could
  complicate recovery
• Concomitant trauma (If Major Trauma, The Trauma
  Center , Not the Burn Center should be the
  initial stabilizing unit)
• When in doubt , consult with a burn center

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Thermal Burns

• most common type
• result from residential fires, automobile
  accidents, playing with matches, improperly
  stored gasoline, space heaters, electrical
  malfunctions, or arson
• inhaling smoke, steam, dry heat (fire), wet heat
  (steam), radiation, sun, etc...

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Chemical Burn

• 2 types of chemical burns
• acids-can be neutralized
• alkaline- adheres to tissue, causing protein
  hydrolyses and liquefaction
• examples cleaning agents, drain cleaners, and
  lyes, etc...

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Chemical Burn

• Different types of burns1 Outer skin layer2
  Middle skin layer3 Deep skin layer4 First
  degree burn5 Second degree burn6 Third degree
  burn

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Remember.

• With chemical burns, tissue destruction may
  continue for up to 72 hours afterwards.
• It is important to remove the person from the
  burning agent or vice versa.
• The latter is accomplished by lavaging the
  affected area with copious amounts of water.

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Smoke and Inhalation Injury

• Can damage the tissues of the respiratory tract
• Although damage to the respiratory mucosa can
  occur, it seldom happens because the vocal cords
  and glottis closes as a protective mechanisms.

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3 types of smoke and inhalation injuries

• 1. Carbon monoxide poisoning (CO poisoning and
  asphyxiation count for majority of deaths)
• Treatment- 100 humidified oxygen-draw
  carboxyhemoglobin level- can occur without any
  burn injury to the skin

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• 2. Inhalation injury above the glottis (caused by
  inhaling hot air, steam, or smoke.)
• Mechanical obstruction can occur quickly-True ER!
  Watch for facial burns, signed nasal hair,
  hoarseness, painful swallowing, and darkened oral
  or nasal membranes

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• 3. Inhalation injury below glottis
• (above glottis-injury is thermally produced)
• below glottis-it is usually chemically produced.
• Amount of damage related to length of exposure to
  smoke or toxic fumes
• Can appear 12-24 hours after burn

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ELECTRICAL BURNS

• Injury from electrical burns results from
  coagulation necrosis that is caused by intense
  heat generated from an electric current.

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Electrical Burns

• Can cause tissue anoxia and death
• The severity depends on amount of voltage, tissue
  resistance, current pathways, and surface area in
  contact with the current and length of time the
  current flow was sustained.

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Electrical injury can cause

• Fractures of long bones and vertebra
• Cardiac arrest or arrhythmias--can be delayed
  24-48 hours after injury
• Severe metabolic acidosis--can develop in minutes
• Myoglobinuria--acute renal tubular necrosis-
  myoglobin released from muscle tissue whenever
  massive muscle damage occurs--goes to
  kidneys--and can mechanically block the renal
  tubules due to the large size!

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Electrical injury can cause

• Fractures of long bones and vertebra
• Cardiac arrest or arrhythmias--can be delayed
  24-48 hours after injury
• Severe metabolic acidosis--can develop in minutes
• Myoglobinuria--acute renal tubular necrosis-
  myoglobin released from muscle tissue whenever
  massive muscle damage occurs--goes to
  kidneys--and can mechanically block the renal
  tubules due to the large size!

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Electrical injury can cause

• Fractures of long bones and vertebra
• Cardiac arrest or arrhythmias--can be delayed
  24-48 hours after injury
• Severe metabolic acidosis--can develop in minutes
• Myoglobinuria--acute renal tubular necrosis-
  myoglobin released from muscle tissue whenever
  massive muscle damage occurs--goes to
  kidneys--and can mechanically block the renal
  tubules due to the large size!

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Treatment of electrical burns

• Fluids--Ringers lactate or other fluids-flushes
  out kidneys--you want 75-100 cc/hr until urine
  sample clear
• an osmotic diuretic (Mannitol) may be given to
  maintain urine output

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Cold Thermal Injury (Frostbite)

• Can be localized such as frostbite
• systemic (hypothermia)

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Classification of Burn Injury

• Treatment of burns is directly related to the
  severity of injury!
• Severity is determined by
• depth of burn
• external of burn calculated in percent of total
  body surface (TBSA)
• location of burn
• patient risk factors

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DEPTH OF BURNS

• Burn injury involves the destruction of the
  integumentary system.
• What is the function of the integumentary system?
• Protective
• holds in fluids and electrolyes
• regulates heat
• keeps harmful agents from injuring or invading
  the body

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Burns are defined by...

• Were defined by degrees in the past! First,
  second, and third degree
• 2 common guidelines now used are the
• Lund-Browder Chart
• Rule of Nines

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Rule of Nines

• In the adult, most areas of the body can be
  divided roughly into portions of 9, or multiples
  of 9. This division, called the rule of nines, is
  useful in estimating the percentage of body
  surface damage an individual has sustained in
  burn.

• In small children, relatively more area is taken
  up by the head and less by the lower extremities.
  Accordingly, the rule of nines is modified. In
  each case, the rule gives a useful approximation
  of body surface.

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Rules of Nines
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Location of Burns

• Has a direct relationship to the severity of the
  burn.
• Face, neck chest burns may inhibit respiratory
  illness RT mechanical obstruction secondary to
  edema or eschar formation

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Complicating or Co-Morbid Factors

• Associated Trauma
• Inhalation Injuries
• Circumferential Burns
• Electricity
• Age (Young or Old)
• Pre-Existing Disease
• Abuse

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3 Phases of Burn Management

• emergent (resuscitative)
• acute
• rehabilitative

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Pre-hospital Care

• Remove from area! Stop the burn!
• If thermal burn is large--FOCUS on the ABCs
• Aairway-check for patency, soot around nares, or
  signed nasal hair
• Bbreathing- check for adequacy of ventilation
• Ccirculation-check for presence and regularity
  of pulses

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Other precautions...

• Burn too large--dont immerse in water due to
  extensive heat loss
• Never pack in ice
• Pt. should be wrapped in dry clean material to
  decrease contamination of wound and increase
  warmth

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Emergent Phase (Resuscitative Phase)

• Lasts from onset to 5 or more days but usually
  lasts 24-48 hours
• begins with fluid loss and edema formation and
  continues until fluid motorization and diuresis
  begins
• Greatest initial threat is hypovolemic shock to a
  major burn patient!

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Complications during emergent phase of burn
injury are 3 major organ systems...

• Cardiovascular
• Respiratory
• Renal systems

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Cardiovascular Systems

• Arrhythmias, hypovolemic shock which may lead to
  irreversible shock
• circulation to limbs can be impaired by
  circumferential burns and then the edema
  formation
• Causes occluded blood supply thus causing
  ischemia, necrosis, and eventually gangrene.
• Escharotomies (incisions through eschar) done to
  restore circulation to compromised extremities.

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Respiratory System

• Vulnerable to 2 types of injury
• 1. Upper airway burns that cause edema formation
  obstruction of the airway
• 2. Inhalation injury can show up 24 hrs
  later-watch for resp. distress such as increased
  agitation or change in rate or character of resp.
• preexisting problem (ex. COPD) more prone to get
  resp. infection
• Pneumonia is common complication of major burns
• Is possible to overload with fluids--leading to
  pulmonary edema

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Renal System

• Most common renal complication of burns in the
  emergent phase is ATN. Because of hypovolemic
  state, blood flow decreases, causing renal
  ischemia. If it continues, acute renal failure
  may develop.

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Nursing management in the emergent phase is...

• Airway management-early nasotracheal or
  endotracheal intubation before airway is actually
  compromised (usually 1-2 hours after burn)
• ventilator? ABGs? Escharotomies?
• 6-12 hours later-Bronchoscopy to assess lower
  resp. tact
• high fowlers position-cough deep breathe every
  hour, turn q 1-2 hrs, chest physiotherapy,
  suction prn

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Fluid Shifts

• Massive fluid shifts out of blood vessels as a
  result of increased capillary permeability. When
  capillary walls become more permeable, water,
  sodium, and later plasma protein (esp. albumin)
  moves into interstitial spaces other tissues.
  The colloidal osmotic pressure decreases with
  loss of protein from the vascular space. This
  called second spacing.

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Third Spacing

• Fluids goes into areas with no fluids and this is
  called third spacing. Examples of third spacing
  are exudate and blister formation.
• Net result is decreased volume, depletion due to
  fluid shifts edema, decreased blood pressure,
  and increased pulse

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Hypovolemic Shock

• Occurs when there is a loss of intravascular
  fluid volume. The volume is inadequate to fill
  vascular space and is unavailable for
  circulation.
• Also, burns have a direct loss of fluid due to
  evaporation.

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Inflammation Healing

• Burn injuries casue coagulation necrosis whereby
  tissues and vessels are damaged or destroyed
• Wound repair begins within the first 6-12 hours
  after injury.

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Immunologic Changes

• Are caused by burns.
• Skin barrier destroyed and all changes make the
  burn patient more susceptible to infection
• Pt may be in shock from pain and hypovolemia.

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Other factors to consider...

• Full-thickness burns and deep partial thickness
  burns are initially anesthetic because nerve
  endings are destroyed.
• Superficial to moderate partial thickness burns
  are very painful. Why?

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Still more factors to consider...

• Severe dehydration is possible even though the
  patient maybe edematous--Why?
• May have an dynamic ileus RT bodys response to
  massive trauma and potassium shifts--Why?
• Shivering due to chilling caused by heat loss,
  anxiety, and pain
• unable to recall events RT hypoxia associated
  with smoke inhalation, or head trauma or overdose
  of sedatives or pain meds

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Fluid Therapy

• 1 or 2 large bore IV replacement lines (may need
  jugular or subclavian)
• Cutdown rare RT increased risk of infection
  sepsis
• Fluid replacement based on size/depth of burn,
  age of pt., individualized considerations--ex.
  Dehydration in preburn state, chronic illness
• options- RL, D5NS, dextam, albumin, etc.
• there are formulas for replacement Parkland
  formula and Brooke formula

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Assessment of adequacy of fluid replacement

• Urinary output is most commonly used parameter
• urine OP-30-50 cc/hr in an adult
• cardiopulmonary factors- BP (systolic 90-100
  mmHg, pulse less than 100, resp 16-20 breaths per
  min. (BP more accurate with arterial line)
• sensoruim-alert, oriented to time, place, person

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Wound Care for Burns

• Can wait until patent airway, adequate
  circulation, fluid replacement is in place!

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Full-thickness burns are

• Will be dry and waxy white to dark brown
• will have little to no sensation because nerve
  endings have been destroyed

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Partial thickness burns

• Are pink to cherry red, wet, shiny with serous
  exudate
• May or may not have intact blisters and are very
  painful when touched or exposed to air

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Cleansing and Debridement

• Can be done in tank, shower, or bed
• Debridement may be done in surgery. (Loose
  necrotic skin is removed)
• bath given with with surgical detergent,
  disinfectant, or cleansing agent to reduce
  pathogenic organisms

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Infection is the most serious threat to further
tissue injury and possible sepsis.

• SURVIVAL is related to prevention of wound
  contamination.
• Source of infection is pts own flora,
  predominantly from the skin, resp. tract, and GI
  tract.
• Prevention of cross contamination from other
  patients is the priority for nurses!

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2 methods used to control infections in burn
wounds...

• Open method- pts burn is covered wit ha topical
  antibiotic and has no dressing
• Closed method-uses sterile gauze impregnated with
  or laid over a topical antibiotic. Dressings
  changed 2-3 times q 24 hrs.

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Wound Care continued...

• Staff should wear disposable hats, gowns, gloves,
  masks when wounds are exposed
• appropriate use of sterile vs. nonsterile
  techniques
• keep room warm
• careful handwashing
• any bathing areas disinfected before and after
  bathing

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• Coverage is the primary goal for burn wounds.
  Since usually not enough unburned skin for
  immediate skin grafting, other temporary wound
  closure methods are used
• Allograph or homograft (same species which is
  usually from cadavers) is used for wound
  closure-- temporary--3 days to 2 wks
• Porcine skin-heterograft or xenograft (different
  species)--temporary--3 days to 2 wks
• autograft or cultured epithelial autograft- (pts
  own skin and cell culture)- permanent

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Surgeons use a dermatome (left) to remove donor
skin and a mesher (right) to put holes in it.
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• Surgeons agree that no single product or
  technique is right for every burn situation. And
  so far, there's no true replacement for healthy,
  intact skin, which is the body's largest organ,
  and one of the most complex. It's the first line
  of defense against infection and dehydration, but
  it's more than just a physical barrier. Skin also
  helps control temperature, through adjustments of
  blood flow and evaporation of sweat. It's an
  important sensory organ, too.

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Other care measures include

• Face is vascular and subject to increased edema-
  use open method if possible to decrease confusion
  and disorientation
• eye care-use saline rinses, artificial tears
• hands arms-extended and elevated on pillows or
  in slings to minimize edema, may need splints to
  keep them in functional positions

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• Ears- keep free of pressure. Ear burns-no
  pillows! Neck burns should not use pillows in
  order to decrease wound contraction.
• Perineum-must be kept clean dry. Indwelling
  foley will help in this also to provide hourly
  outputs.
• Lab tests prn to monitor electrolyte imbalance
  and ABGs
• Physical therapy stared immediately

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Drug Therapy

• Analgesics and Sedatives
• given for pt comfort
• IV pain meds initialy due to
• GI function is slowed or impaired because of
  shock or paralytic ileus
• IM injections will not be absorbed well

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Drug Therapy

• Tetanus immunization- given routinely to all burn
  patients because of the likelihood of anaerobic
  burn-wound contamination
• Antimicrobial agents-usually topical due to
  little or no blood supply to the burn eschar so
  little delivery of the antibiotic to wound
• Drug of choice is Silver sulfadiazine

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Nutritional Therapy

• Fluid replacement takes priority over nutritional
  needs in the initial emergent phase. Why?
• NG tube is inserted and connected to low
  intermittent suction for decompression. When
  bowel sounds return (48-72 hrs) after injury,
  start with clear liquids and progress up to a
  diet high in proteins and calories

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• Burn patients need more calories failure to
  provide will lead to delayed wound healing and
  malnutrition.
• Give calorie containing liquids instead of water
  due to need for calories and potential for water
  intoxication
• Enteral feedings into the duodenum (recommended)
  can reduce nv, more continuous feedings, and
  increase wd healing!

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Acute Phase

• Begins with mobilization of extracellular fluid
  and subsequent diuresis.
• Is concluded when the burned area is completely
  covered or when wounds are healed. May take weeks
  or months.
• Pt is no longer grossly edematous due to fluid
  mobilization, full partial thickness burns more
  evident, bowel sounds return, pt more aware of
  pain and condition.

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• Healing begins when WBCs have surrounded the burn
  and phagocytosis begins, necrotic tissue begins
  to slough, fibroblasts lay down matrices of
  collagen precursors to form granulation tissue.
• Partial-thickness burns (if kept free from
  infections) will heal from edges and from below.
  (10-14 days)
• Full-thickness burns must be covered by skin
  grafts.

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Laboratory Values

• Sodium- Hyponatremia can occur due to silver
  nitrate topical oints as a result of sodium loss
  through eshcar, hydrotherapy, excessive GI
  drainage, diarrhea, excessive water intake
• S/S of hyponatremia weakness, dizziness, muscle
  cramps, fatigue, HA, tachycardia, confusion
• Hypernatremia can occur too much hypertonic
  fluids, improper tube feedings, inappropriate
  fluid administration
• S/S of hypernatremia thirst dried furry tongue
  lethargy confusion and possible seizures

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• Potassium- hyperkalemia is note if pt is in renal
  failure, adrenocortical insufficiency, or massive
  deep muscle injury with lg. amts. of potassium
  released from damaged cells. Cardiac arrhythmias
  and ventricular failure can occur if K level
  greater gt7mEq/L. muscle weakness EKG changes
  are noted.
• Hypokalemia is noted with silver nitrate therapy
  and long hydrotherapy. Other causes vomiting,
  diarrhea, prolonged GI suction, prolonged IV
  therapy without K supplementation. Constant K
  losses occur through the burn wound.

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Complications of Acute Phase

• Infection- due to destruction of bodys 1st line
  of defense. Partial thickness wds can convert to
  full-thickness wds with infection present. Pt may
  get sepsis from wound infections. Signs of sepsis
  are high temp., increased pulse resp.,
  decreased BP, and decreased urinary output, mild
  confusion, chills, malaise, and loss of appetite.
  WBC bet. 10,000 and 20,000. Infections usually
  gram neg. bacteria (pseudomonas, proteus)
• Obtain cultures from all possible sources IV,
  foley, wound, oropharynx, and sputum

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• Cardiovascular- same as in emergent phase
• Neurologic-possible from electrical injuries
• Musculoskeletal-has the most potential for
  complications during acute phase due to healing
  and scar formation making skin less supple and
  pliant. ROM limited, contractures can occur
• Gastrointestinal-adynamic ileus results from
  sepsis, diarrhea or constipation (RT narcotics
  decreased mobility), gastric ulcers RT stress,
  occult blood in stools possible
• Endocrine-stress DM might occur-assess glucose prn

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Nursing management-acute phase

• Predominant therapeutic interventions are
• fluid replacement, physical therapy, wd care,
  early excision and grafting, and pain management
• Fluid replacement continues from emergent phase
  to acute phases--given for fluid losses,
  administer medications, for transfusions.
• Physical therapy- to maintain optimal joint
  function
• Pain management- most critical functions as a
  nurse.
• Nutritional therapy-provide adequate proteins
  calories

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• Wound Care- the goals are cleanse and debride the
  area of necrotic tissue debris, minimize further
  damage to viable skin, promote patient comfort,
  reepithelialization or success with skin
  grafting.
• Care for donor site and other grafts necessary
• Excision and grafting-eschar removed to
  subcutaneous tissue or fascia, graft applied to
  tissue
• Cultured epithelial autograft (CEA)uses patients
  own cells to grow skin-permanent
• artificial skin is the latest trend. Examples
  Alloderm, Life-Skin, etc.

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Rehabilitation Phase

• Defined as beginning when the patients burn
  wound is covered with skin or healed and patient
  is capable of assuming some self-care activity.
• Can occur as early as 2 weeks to as long as 2-3
  months after the burn injury
• Goals for this time is to assist patient in
  resuming functional role in society accomplish
  functional and cosmetic reconstruction.

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Clinical Manifestations

• Burn wd either heals by primary intention or by
  grafting.
• Scars may form contractures.
• Mature healing is reached in 6 months to 2 years
  
• Avoid direct sunlight for 1 year on burn
• new skin sensitive to trauma

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Complications

• Most common complications of burn injury are skin
  and joint contractures and hypertrophic scarring
• Because of pain, pts will assume flexed position.
  It predisposes wds to contracture formation
• Use of physical therapy, pressure garments,
  splints, etc. are used

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Nursing management during rehabilitation phase

• Must be directed to returning patient to society,
  address emotional concerns, spiritual and
  cultural needs, self-esteem, teaching of wound
  care management, nutrition, role of exercises and
  physical therapy explained. A common emotional
  response seen is regression.

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Special needs of the nursing staff

• The staff of burn units are prone to higher rates
  of burn-out. The care of a burn patient is a long
  journey that the patient, nurse, and significant
  others must travel. The road to recovery is full
  of potential threats to the patient. Support
  services are necessary for the medical team of
  any long-term burn patients.

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Care of B U R N S

• B - breathing
• body image
• U - urine output
• R - rule of nines
• resuscitation of fluid
• N - nutrition
• S - shock
• silvadene

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• B- Breathing- keep airway open. Facial burns,
  singed nasal hair, hoarseness, sooty sputum,
  bloody sputum and labored respiration indicate
  TROUBLE!
• Body Image- assist Bernie in coping by
  encouraging expression of thoughts and feelings.

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• U- URINE OUTPUT- in an adult, urine output should
  be 30-70 cc per hour, in the child 20-50 cc per
  hour, and in the infant, 10-20 cc per hour. Watch
  the K to keep it between 3.5-5.0 mEq/L. Keep the
  CVP around 12 cm water pressure!

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• R- RESUSCITATION OF FLUID- Salt electrolyte
  solutions are essential over the 1st 24 hours.
  Maintain B/P at 90-100 systolic. ½ of the fluid
  for the first 24 hrs should be administered over
  the first 8 hour period, then the remainder is
  administered over the next 16 hours. First 24
  hour calculation starts at the time of injury.
• RULE OF NINES- used for adults to determine burn
  surface area!

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• N-NUTRITION- protein calories are components of
  the diet! Supplemental gastric tube feedings or
  hyperalimentation may be used in pts with large
  burned areas. Daily weights will assist in
  evaluating the nutritional needs!

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• S-SHOCK- Watch the B/P, CVP, and renal function.
• Silvadene-for infection.
• REMEMBER THESE PEOPLE ARE AFRAID AND NEED
  SUPPORT!!!!!