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  1. Rule of Nine
    • Head- 9% (posterior and anterior)
    • Arms- 9% (each arm)
    • Anterior Torso- 18%
    • Posterior Torso- 18%
    • Legs- 18% (each leg)
    • Perineum- 1%
  2. 1st degree burn
    Superficial partial thickness

    Cause: sunburn, low-intensity flash

    Skin involved: epidermis

    Symptoms: tingling, hyperesthesia (super sensitive), pain that is soothed by cooling

    Wound appearance: reddened; blanches with pressure, dry, minimal or no edema, no blisters, pink to red

    Recuperative course: complete recovery within a week, no scarring, peeling
  3. 2nd degree burn
    Deep Partial Thickness

    Cause: scalds, flash flame

    • Skin Involved: *Epidermis, upper dermis
    • ** Portion of deeper dermis

    • Symptoms: *Intense pain, hyperersthesia, sensitive to cold air
    • ** Deep- not intense pain due to destruction of some nerve endings

    Wound appearance: blistered, mottled red, pearly, broken epidermis, weeping surface, edema

    Recuperative Course: recovery in 2 to 4 weeks, some scaring and depigmentation, contractures, infection may convert in to full thickness
  4. 3rd and 4th degree burns
    Full Thickness

    Cause: Flame (thermal), prolonged exposure to hot liquid, electric current, chemical

    • Skin involved: epidermis, entire dermis, and sometimes subcutaneous tissue.
    • May involve connective tissue muscle and bone (4th)

    Symptoms: pain free, shock, hematuria and hemolysis, possible entrance and exit wounds (electrical)

    Wound Appearance: dry, pale white, tan, leathery, or charred, edema, broken skin with fat exposure
  5. Minor
    • 2nd degree burn <15% BSA burn
    • 3rd degree burn <2% BSA not involving special areas (eyes, ears, face, hands, feet, perineum, joints)

    Excludes electrical injury, inhalation injury, concurrent trauma, all poor-risk pts (extremes of age, current disease)
  6. Moderate
    • 2nd degree burns 15-20% BSA
    • 3rd degree burns <10% BSA not involving special areas (eyes, ears, face, hands, feet, perineum, joints)

    Excludes electrical injury, inhalation injury, concurrent trauma, all poor-risk pts (extremes of age, current disease)
  7. Major
    • 2nd degree burns >25% BSA
    • all 3rd degree burns >10% BSA

    all burns involving eyes, ears, face, hands, feet, perineum, joints

    all inhalation injuries, electrical injuries, concurrent trauma, all poor risk pts (extremes of age, current disease)

    Need to go to major burn center
  8. Local Response to Burns
    • <25% TBSA
    • Blister formation and edema at the site of injury
  9. Systemic response to burns
    • >25% TBSA
    • Hemodynamic instability due to loss of capillary intergrity → shift of fluid, sodium and protein from intravascular space to interstitial space

    *Inflammatory response

    Systemic response involves: cardiovascular: fluid, electrolytes and blood volume; pulmonary response
  10. Emergency Phase
    • Duration:
    • *onset of burn to end of fluid resuscitation
    • *1st 48 hours after burn

    • Priorities:
    • *prevent respiratory distress
    • -ABCs

    • *prevent burn shock
    • -assess extent of burn
    • -fluid resusciation

    • *transfer to burn center
    • -assess criteria

    *initial wound care
  11. Acute Phase
    • Duration:
    • *Beginning of diuresis (48-72 hrs after burn)
    • Completion of wound closure

    • Priorities:
    • *Prevent infection
    • *prevent complications
    • *pain management
    • *wound care/closure
    • *nutritional support
  12. Rehabilitation phase
    • Duration:
    • *from wound closure to return to optimal level of physical and psychosocial adjustment
    • *months to years

    • Priorities:
    • *prevent scars
    • *prevent contractures
    • * PT, OT, Rehab
    • *functional/cosmetic reconstruction
    • *Psychosocial counseling
  13. Parkland/Baxter Formula
    • *Guideline for fluid replacement
    • *estimates fluid loss

    LR Solution: 4mL x kg body weight x %TBSA burned

    • Day1: half to be given in first 8 hours from time of burn
    • Half to be given over next 16 hours

    Day 2: Colloid is added

    • *Volume and rate gauged by pt response and adjusted hourly
    • *Clinical Parameters
    • -systolic >100 mmHg
    • -HR < 110
    • -Urine output 30-50mLs
    • Urinary output most important 30-50mL goal (adult)

Card Set Information

2014-11-29 21:31:50
Burns Nursing

Burns Nursing
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