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Burns

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Title: Burns


1
Burns
  • Linda Copenhaver

2
Introduction
  • Incidence of Burns
  • 1 million seek medical care annually
  • Approximately 100K are hospitalized, 70K require
    ICU
  • stays

3
Bonus' Site - KitchenOilFire.wmv
4
Types of Burn Injury
  • Thermal
  • Chemical
  • Electrical
  • Radiation

5
Thermal Burns( Most Common)
  • Caused by flame, flash, scald, or contact burns
  • STOP DROP
  • Roll to shut off O2 supply to fire
  • Flush or immerse in cold water
  • DO NOT use ICE on deep burns, just localized,
    superficial burns

6
Thermal Burns (cont)
  • Cover patient with a clean cover
  • Do NOT pull off clothing instead cut off
    clothing if possibleWHY?
  • Keep NPO and transport

7
  • Chemical Burns
  • Remove person from contact with agent
  • Flush with water continuously
  • Remove affected clothing if possible

8
  • Electrical burns
  • Coagulation necrosis
  • Severity depends on voltage, amount of
    resistance, time,
  • and current
  • pathways.

9
  • Frequently only entry (yellow-white) and exit
    (blow out) wounds are visible
  • Extensive tissue damage is masked
  • How can we evaluate masked tissue damage???

10
Electrical Burns (cont)
  • Patient at risk for arrhythmias due to _____,
    metabolic acidosis due to _____, and acute
    tubular necrosis due to ______.
  • Current can be so strong to
  • fracture long bones and cause respiratory
    muscles to contract

11
Interventions for Electrical Burns
  • Turn off source of electricity if possible
  • Remove current with dry piece of wood
  • Initiate CPR and Transport

12
(No Transcript)
13
Depth of Burns
  • Superficial Partial Thickness Burn (1st
  • degree)
  • Epidermis involved
  • Sunburn, UV light, mild radiation,
  • Pink to red
  • Slight edema
  • Mild pain

14
Depth of Burns
  • Deep Partial Thickness (2nd)
  • Epidermis and dermis, is painful, red, blisters

15
Depth of Burns
  • Deep Partial Thickness (2nd)
  • Epidermis and Dermis
  • Very Painful, edema, pale
  • Moist or dry
  • Blisters present

16
Depth of Burns (cont)
  • Full Thickness Burns (3rd)
  • Epidermis, Dermis, and Subcutaneous tissue burned
  • Nerve endings destroyed
  • Little or no pain

17
Depth of Burns (cont)
  • Full thickness (4th degree)
  • Involves past the 3 layers down to the bone
    and/or organs

18
Extent of Burns
  • Rule of Nines
  • Easy to remember, quick method

19
  • Lund Browder
  • More accurate, more time spent
  • calculating TBSA burned

20
Burn Unit Referral Criteria
  • Deep Partial Thickness burnsgt10 TBSA
  • Burns that involve the face, hands, feet,
    genitalia, perineum, or major joints
  • Full thickness burns in any age group
  • Electrical burns, including lightning
  • Inhalation burns requiring intubation
  • Chemical burns that involve deep and extensive
    TBSA burned

21
Survival Prediction
  • Depth of Burns
  • Extent of Burns
  • Location of Burns
  • Age of Client
  • Risk Factors
  • Major vs Minor Burns

22
Medical/Nursing Management of Burns
  • I. Emergent Phase
  • Period of time from onset of burns to the
    beginning of fluid remobilization
  • Usually lasts 24-48 hours

23
Emergent Phase (cont)
  • Also called FLUID ACCUMULATION PHASE
  • The greatest initial threat to a major burn
    victim is hypovolemic shock
  • See outline for detailsthis is a DING DING!

24
Burning Question..
  • The nurse knows that in a patient who has full
    thickness burns, that the burns must involve the
  • a) Muscle
  • b) Dermis
  • c) Tendons
  • d) Bone

25
What are the Priorities in this patient???
  • Is this patient a candidate for a major burn
    center?

26
Nursing Care During Emergent Phase
  • Impaired Gas Exchange r/t tissue hypoxia
    secondary to carbon monoxide poisoning
  • Note CO poisoning is the MOST immediate cause
    of death from fire.

27
Signs Symptoms of Carbon Monoxide Poisoning
  • Edema of Airway
  • Hoarseness
  • Dysphagia
  • Stridor
  • Copius Secretions usually black tinged
  • Substernal Retractions

28
Interventions for CO Poisoning
  • Assess for SS CO poisoning (mild to severe)
  • Humidified O2 100 via face mask
  • High Fowlers Position
  • TCDB q 1 hour
  • Intubation Ventilation
  • Bronchodilators for bronchospasm
  • One other thing..does anyone know???

29
Nursing Care during Emergent Phase (cont)
  • Impaired Gas Exchange r/t mucosal edema
    throughout respiratory tract secondary to smoke
    inhalation, hot air, chemical gases

30
Interventions
  • Early intubation to prevent trach placement
  • Ventilation
  • Humidified O2 100
  • ABGs (respiratory acidosis or alkalosis?)
  • Bronchodilators
  • Serial CXRs and fiberoptic bronchoscopy

31
  • What do you assess for here???

32
Question
  • A client has sustained deep partial thickness
    burns to the anterior trunk and the anterior
    aspect of both arms. The nurse should expect the
    clients immediate care would be conducted
  • a) on an outpatient basis
  • b) in a home health setting
  • c) on an inpatient surgical unit
  • d) in a burn unit

33
Questions to Ask Burn Victims
  • Were you in an enclosed space?
  • Were you standing up?
  • Was it a flame and chemical fire?
  • Are you having difficulty breathing?

34
What are your 1 priorities in this patient?
  • Patient 1 Patient 2

35
Emergent Phase (cont)
  • Ineffective Breathing pattern r/t constriction of
    chest/trachea secondary to the effects of full
    thickness burns.
  • Assess for signs of constriction
  • Escharotomies with circumferential burns of chest

36
Escharotomy of chest and arm
  • What is the pathophysiology here?

37
Emergent Phase (cont)
  • Fluid Volume Deficit (intravascular) r/t massive
    fluid shift to interstitial spaces
  • Assess fluid needs
  • Brooke Formula
  • Evans Formula

38
  • Parkland Baxter Formula
  • Most widely used
  • Formula
  • LR 4ml X Kg body weight X TBSA burned
  • ½ that total amt. given 1st 8 hours
  • ¼ that total amt. given each next 8 hours

39
Okay Nurses Lets Calculate
  • What would the fluid replacement be for patient
    who weighed 60kg and had 30 TBSA burned???
  • 1st 8 hours _____or ____cc/hr
  • 2nd 8 hours _____or ____cc/hr
  • 3rd 8 hours _____or ____cc/hr

40
  • Crystalloids used such as LR, 0.9NS, D5NS
  • Colloids (albumin, dextran, FFP) used to expand
    plasma.
  • Colloids not given until after capillary
    permeability decreases and returns to
    normal..WHY?

41
  • Insert foley catheter to monitor output. What
    should urine output be in an adult???
  • Frequent vital signs
  • SBPgt100
  • Pulselt100
  • RR 16-20

42
Emergent Phase (cont)
  • Assess Neuro status
  • Neuro vital signs, WHY???
  • Monitor Electrolytes and Hematocrit tells you
    about fluid shift.
  • What should Hct be doing as time progresses???

43
Emergent Phase (cont)
  • Potential for Infection r/t loss of skin and
    micro invasion
  • Meticulous hand washing
  • Sterile technique during dressing changes wound
    care
  • Hair near burned areas shaved

44
  • Potential for Infection r/t loss of skin and
    micro invasion (cont)
  • Blisters popped or not???
  • Tetanus Toxoid I.M. given to all major burn
    victims to fight
  • anaerobic contamination of burn wound

45
  • Hydrotherapy in cart (water is heated to
    approximately 104 degrees)
  • lt 30 minutes to prevent _____

46
(No Transcript)
47
Hubbard Tank (old method)
48
Hydrotherapy Cart
  • What does hydrotherapy accomplish?

49
Wound Care
  • Open Method
  • Apply topical chemotherapy

50
  • Advantages of Open Method
  • No painful dressing changes
  • Is visible for assessing wound for signs of
    infections
  • Less equipment which means
  • less ______

51
  • Disadvantages of Open Method
  • Not suitable for burns of hands and feet
  • More difficult to control body temperature
  • Difficulty when transferring patient

52
Topical Meds/Chemo
  • Silvadene
  • Silver Nitrate
  • Sulfamylon

53
Wound Care (cont)
  • Closed Method
  • Apply topical chemo and wrap with gauze, fluffs,
    kerlix
  • Assess for
  • constriction
  • circulation
  • checks

54
Emergent Phase (cont)
  • Anxiety r/t loss of skin and pain
  • Allow verbalization of loss
  • Explain all procedures
  • Edema will subside in 2-4 days
  • IV analgesics NOT I.M.s,
  • why???

55
Emergent Phase (cont)
  • Elevate burned arms on pillows
  • Give pain meds 30 minutes
  • prior to treatments

56
Emergent Phase (cont)
  • Alteration in body temp (hypothermia) r/t loss of
    skin
  • Set thermostats at warm temp in room
  • Avoid drafts
  • Heat lamp or warming lights placed over bed prn
    as ordered

57
Emergent Phase (cont)
  • Potential for injury r/t effects of stress
    response
  • Stress diabetes What is the patho here???
  • Curlings ulcer (associated with burn trauma
    patients)
  • Gastroduodenal ulcer caused by increased gastric
    acid secretion

58
Emergent Phase (cont)
  • Potential for injury r/t effects of stress
    response
  • Paralytic ileus (stress related)
  • NPO, NG tube to suction
  • Delirium (psychological stress)

59
Emergent Phase (cont)
  • Compartment syndrome r/t the effects
    circumferential burns
  • Circulation is impaired
  • Edema formation
  • Occluded blood supply
  • Ischemia
  • Necrosis
  • Gangrene

60
Emergent Phase (cont)
  • What is the treatment?
  • Escharotomy

61
Emergent Phase (cont)
  • Renal Failure
  • Hypovolemia (Why?)
  • blood flow to kidneys
  • Renal ischemia
  • ARF may develop

62
Emergent Phase (cont)
  • Renal Failure
  • Full thickness electrical burns
  • Myoglobin from muscle cells released
  • Hgb (from RBCs breakdown) released into
    bloodstream
  • Blocks renal tubules

63
Emergent Phase (cont)
  • What is the treatment for these 2 renal
    problems????

64
Emergent Phase (cont)
  • Cardiac Function
  • Arrhythmias due to electrolyte imbalance or
    electrical burns
  • Hypovolemic shock due vascular bed depletion

65
  • Summary of Emergent Phase

66
II. Acute Phase (weeks to months)
  • Begins after 48-72 hours
  • Fluid begins to shift interstitial spaces back
    into bloodstream or intravascular space
  • Diuresis occurs
  • Ends when TBSA burned is lt20 by grafting or
    wound healing

67
Nursing Care During Acute Phase
  • Skin/systemic infection r/t
  • Loss of normal skin
  • Formation of eschar
  • Suppression of immune system
  • Metabolic/hormonal alterations

68
Acute Phase
  • Interventions for Skin/Systemic Infection
  • Hydrotherapy cart shower to debride
  • Open/Closed dressing changes
  • Topical chemotherapy
  • Weekly cultures
  • Systemic antibiotics

69
Acute Phase (cont)
  • Rules for Treating Infection in Burn Patients
  • Rule 1 Burn trauma patients will be exposed to
    microorganisms no matter how germ free the
    environment

70
  • Rule 2 No single antibiotic or combo of
    antibiotics will fight all organisms
  • Rule 3 First the bug, then the drug

71
Acute Phase (cont)
  • Excision Grafting
  • Removal of necrotic tissue
  • Eschar is removed until viable tissue is reached

72
Acute Phase (cont)
  • Significant amount of blood loss
  • when excision occurs
  • Hemostasis can occur
  • clots may form between the
  • graft and the
  • wound

73
Operative Debridement
74
Acute Phase (cont)
  • Clotting problem may be managed by excising wound
    one day and grafting the next day.
  • Excised areas should be soaked with antibiotic
    solution

75
Acute Phase (cont)
  • Reasons for Grafting (priorities)
  • Survival
  • Function
  • Cosmetic
  • Synthetic Grafts
  • BIOBRANE

76
Types of Grafts
  • Autograft or Autologous
  • self
  • Heterograft
  • Different species
  • Pig, bovine
  • Homograft
  • Cadaver
  • Which are temporary vs permanent?

77
Latest in Skin grafting
  • Integra- Bovine collagen which is permanent
  • Alloderm- derived from donated human skin
  • CEA (cultured epithelial autograft)-
  • unburned skin biopsied and sent to lab to
    grow with epithelial growth factor added.

78
Graft Survival depends on
  • Recipient bed must have adequate blood supply
  • Graft must be in close contact with recipient bed
  • Graft must be immobilized
  • Free from infection

79
Acute Phase (cont)
  • GRAFTING

80
Acute Phase (cont)
  • GRAFTING

81
Dermatome-harvesting donor skin from thigh
82
Acute Phase (cont)
  • For graft to SURVIVE and be effective
  • Recipient bed must have adequate blood supply
  • Graft must be in close contact with recipient bed
  • Graft must be firmly fixed or immobile
  • Free from infection

83
Acute Phase (cont)
  • Can you describe this???

84
Acute Phase (cont)
  • Potential for fluid volume excess r/t fluid shift
    from interstitial back to intravascular space
  • Daily weights
  • Monitor lab values-Which ones?
  • Auscultate lungs
  • Fluids as ordered
  • Avoid free water-dilutional hyponatremia

85
Acute Phase (cont)
  • Alteration in Nutrition r/t hypermetabolism
  • Goals are to minimize energy demands and to..
  • Provide adequate calories to promote wound healing

86
Acute Phase (cont)
  • Interventions for altered nutrition
  • Monitor bowel sounds
  • High Protein High CHO
  • Assess food preferences
  • TPN as ordered

87
Acute Phase (cont)
  • Ineffective Coping r/t long rehab process with
    multiple surgeries and change in lifestyle/social
    isolation
  • Include family in plan of care
  • Assess clients readiness to talk
  • Allow client to work through grief process
  • Give honest, accurate information

88
Acute Phase (cont)
  • Self-care Deficit r/t restricted
    movement/contractures/muscle atrophy

89
Interventions
  • Assist with positioning
  • ROM exercises
  • Support O.T. P.T. efforts
  • Always maintain eye contact with client

90
III. Rehabilitation Phase
  • From wound closure to optimal level of physical
    and psychosocial adjustment
  • Potential for impaired home maintenance
  • Discuss grief process, self-concept,
    resocialization process

91
Rehabilitation Phase
  • Instruct client on skin care
  • Skin will itch, be dry, have a tight feeling
  • Use Vaseline Intensive Care ES lotion, mild soaps
  • Avoid direct sunlight (will cause
    hyperpigmentation)

92
Rehabilitation Phase
  • Instruct client on skin care
  • Skin may be hypo or hyper sensitive to
    cold/heat/touch
  • Diet (high protein, vitamins)
  • Exercise to prevent contractures
  • Instruct client on S S of infection

93
Rehabilitation Phase
  • Instruct client to wear JoBST pressure garment up
    to 1 year

94
Rehabilitation Phase
  • Instruct client on skin care
  • Need to wear Jobst to prevent keloid formation

95
What are your assessment findings?
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