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What are the different mechanisms of burns? Who are the most vulnerable populations?
- Heat: flames, scolding water
- Chemicals: battery acid, cleaning fluid
- Radiation: sun, equipment
- Inhalation: smoke
- Vulnerable populations include children and the elderly
What is the function of the integumentary system?
- Intact skin protects from infection
- Prevention of loss of bodily fluids
- Production of vit D
- Excretion (sweat)
- Sensation reception
What determines the severity of a thermal burn?
- Duration of contact
- Temperature of agent
- Amount of tissue exposed
- Age of patient
What is the method of injury for a chemical burn?
- Inhalation or fumes
- Ingestion or injection
- *can have both local and systemic effects and must be completely neutralized or damage continues
What determines the severity of a chemical burn? What are some basic interventions that can be done?
- Severity determined by:
- type of agents
- volume of agent
- duration of contact
- concentration of agent
- Alkaline vs. Acid
basic interventions- remove chemical (if dry, simply brush off do not wet!) and remove clothing. Call poison control asap
Describe how electrical injuries are effected by the level and type of electricity
- High voltage is >1000 wats, low voltage is <1000wats
- Alternating Current (AC): flow of electrical charge periodically reverses direction. higher probability of cardiac arrest
- Direct Current (DC): unidirectional flow of electrical charge. Damage from batteries, electric machines
What factors contribute to the severity of an electrical burn?
- Type and path of current (look for entry and exit wounds (exit is worse), always get EKG)
- Duration of contact
- Environmental factors (wet?)
- Tissue resistance
What are radiation burns and what factors contribute to the severity?
- Exposure to large amounts of radioactive material
- type of radiation
- distance from source
- duration of exposure
- absorbed dose
- depth of penetration
What is inhalation injury? What should be assessed? What is the greatest concern?
- Such as carbon monoxide, smoke, bleach fumes
- Assess for above the glottis and below the glottis injuries
- Soot in note, throat can cause obstruction
- Edema in airway can cause obstruction
What is the immediate, general emergency management for burns?
- Assess airway patency
- Administer oxygen
- Cover with blanket (prevent heat loss)
- Keep NPO
- Elevate the extremities if no fractures are obvious
- Vital signs
- Initiate 2 large bore IVs for fluid replacement
- Administer tetanus shot
- Head to toe assessment
What emergency actions should be taken for thermal burns?
- Smother the burns
- Remove smoldering clothing and all metal objects
What emergency actions should be taken for chemical burns?
- If dry chemicals are present on the skin, brush them off (do not wet them!!)
- Remove clothing
- Determine the chemical causing the burn
- Do no attempt to neutralize the chemical unless it has been positively identified and the appropriate neutralizing agent is available
What emergency actions should be taken for electric burns?
- At the scene, separate patient from the electrical current
- Smother any flames that are present
- Initiate cardiopulmonary resuscitation
- Obtain an ECG
What emergency actions should be taken for radiation burns?
- remove patient from radiation source
- If the patient has been exposed to radiation from an unsealed source, remove the patient's clothing (using tongs or lead protected gloves)
- If the patient has radioactive particles on their skin, send the patient to the nearest designated radiation decontamination center
- Assist the patient in bathing or showering
What factors should be taken into account when classifying the severity of a burn?
- Type of burn
- Burn wound characteristics
- Other injuries
- clients age
- Preexisting health status
Describe a superficial (first degree) burn
- Epidermis only
- Heals in 3-6 days without treatment
- Erythema, blanching or pressure, pain and mild swelling
- Not calculated for fluid resuscitation
Describe a Partial thickness (Second degree) burn and what are the two categories?
- Second degree burns involve both the epidermis and the dermis and blistering is common
- Superficial partial thickness
- Deep partial thickness
Compare and contrast Superficial partial thickness burns with deep partial thickness burns
- Superficial partial thickness is the epidermis and a portion of the dermis
- Heals in 10-21 days
- Moist, pink or mottled red, very painful due to exposed nerve ends blisters form
- Deep partial thickness burns involve the epidermis and most of the dermis
- Heal in 3-8 weeks
- Pale, mottled, pearly red/white, less painful due to more nerve destruction
- Scars form and grafts may aid in healing
- BOTH may have blisters
- BOTH are candidates for fluid resus
Describe full thickness (3rd degree) burns
- Destruction of all layers down to or past fat, fascia, muscle or bone (no hair or nerves)
- Dry, thick leathery, black/brown, cherry red or white
- No pain due to nerve destruction
- Does not heal due to dermis destruction, requires grafting
What are the different ways to determine the extent of injury? Describe the rule of 9s
- Total body surface area perfect (TBSA%)
- Patient's palm method
- Lund-Brower chart
- Rule of nines (different for adults and children)
What are some assessments/interventions that should be taken depending on the location of the burn (head to toe)?
- face, neck, chest: risk for resp obstruction
- Hands, feet, joint: risk for self care deficits
- ears, nose: risk for infection
- Circumferential burns can cause compartment syndrome and need to be released with an escarotomy to prevent damage to vessels and nervses
- * always assess CMS distal to burn site
What are some pt risk factors that put a person at risk for a more severe burn/delayed healing/complicated healing?
- Older adults heal slowly
- Preexisting cardiovascular, respiratory, renal disease
- alcohol and drug abuse
- Concurrent fractures, head injuries or other trauma
Describe the local response to a burn
- Acute inflammation
- Intravascular coagulation (hemoconcentration)
- Altered vascular permeability (capillary leak syndrome)
- *direct cell injury leads to release of potassium leads to immediate hyperkalemia, followed by hypokalemia, anemia (hemodilution) and hyponatremia during capillary leak
What is a fluid shift? When does it occur? What E/F imbalances will be seen? What are s/s of burn shock?
- Fluid shifts within 24 hours due to capilarry leak syndrome
- Edema occurs in both burned and unburned areas for TBSA 20% or more
- Maximum third spacing occurs 24-48 hours followed by diuretic phase
- Burn shock- combination of distributive and hypovolemic shock (mixed shock with increased HR, decreased BP)
- During fluid shift, hyponatremia, hypokalemia, and anemia (hemodilution) occurs
What is the Parkland (Baxter) fluid resuscitation equation? what factors need to be considered?
- Uses LR (crytalloid only solutions)
- Fluid resus used for the first 24 hours AFTER burn (need to calculate from time of burn, not from time of arrival to ED)
- Use the tule of 9's to get TBSA%
- Fluid given by 2 large bore IVs or Central line
- 1/2 of total fluid given during first 8 hrs, remainder given over 16 hrs
- (for Gordon, round to 10th from the beginning of the equation!!)
What is the cardiovascular response to burns? what about Pulmonary?
- -loss of intravascular volume
- -decreased cardiac output
- -tachycardia and vasoconstriction
- -pulmonary hypertension
- -effect of direct injury, such as pulmonary edema and obstruction (may lead to ARDS)
What is the metabolic response to burns?
- Hypermetabolic state may lead to a low grade fever
- Increased caloric intake up to 5000 kcal/day, increased protein intake to aid in healing
- Hypermetabolic state can last 9-12 months after burn
Describe the GI response to burns
- ischemia due to redistribution of blood to brain and heart
- May result in a paralytic ileus
- May result in a Curling's ulcer within 24hrs due to decreased blood flow to GI tract
Describe the Renal response to burns
- Sensitive to decreased cardiac output
- Initial decrease in urine output related to decreased GFR and third spacing
- Followed by diuresis as fluid shifts
What are the 4 phases of burn management? describe prehospital care
- Prehospital care, emergent (resuscitative), acute, rehabilitative
- Prehospital care:
- -remove the person from the source of the burn and stop the burning process
- -caregiver needs to protect from becoming part of the incident (Safety assessment)
What is the emergent phase? Describe the pathophys, s/s and possible complications
- Emergent phase is the period of time required to resolve the immediate problems resulting from the burn injury
- From the time of burn until 5+ days, but usually first 48 hrs
- Phase begins with fluid loss and edema formation and continues until fluid mobilization and diuresis begins
- Pathophys includes F/E shifts, inflammation and healing, and immunologic changes
- S/S include hypovolemic shock, shock from pain, blisters, adynamic ileus, shivering, altered mental status
- Complications include cardiovascular, respiratory, urinary
What nursing care should be done during the emergent phase?
- Airway management: intubation, humidified/100% O2, escharotomy
- Fluid Therapy: two large bore IVs or central line, Parkland (Baxter) formula for fluid replacement
- Colloidal Therapy: D5W, Albumin
- Wound care:: delayed until airway is secure, cleaning and debridement, may use immersion tank or shower, risk for infection is a serious threat. Open or closed method. May use allograft/homograft or xenograft
- Other: manage self care deficits, routine lab tests, early ROM exercises
What drug and nutritional therapy should be done during the emergent phase?
- Analgesics and sedatives
- Tetanus immunization
- Antimicrobial Agents
- Fluid replacement takes priority, oral intake not until bowel sounds return usually 48-72 hrs after injury
- 5000 kcal/day
What is the acute phase of a burn? Describe the pathophys, the s/s, and lab values
- Acute phase begins with the mobilization of extracellular fluid and subsequent diuresis
- Concluded when the burned area is completely covered by skin grafts r when the wounds are healed
- Pathophys includes diuresis from fluid mobilization, return of BS, formation of granulation tissue and necrotic tissues sloughs
- Partial thickness heals from the edges while full thickness is covered by skin grafts
- S/S include necessary removal of eschar from partial thickness wounds (epithelization then occurs, 10-14 days) which full thickness burns will require debridement
- Lab values to monitor include sodium (hyponatremia due to fluid shift) and potassium (hyperkalemia immediately followed by hypokalemia during cap leak)
- Complications include infection, cardiovascular, respiratory, neuro, musculoskeletal, GI, and endocrine
What nursing care should be done during the acute phase of a burn?
- Wound care: daily assessments, cleansing, debridement
- Excision and grafting: graft dressings, eschar removal, cultured epithelial autograft, artificial skin
- Pain management: pharm and nonpharm
- PT and OT: passive and active ROM, exercise during, after hydrotherapy. Prevents contractures
- Nutritional: high calorie, supplements, daily weights
- Psychosocial: social work, nursing staff, partoral care
What is the rehabilitation phase of a burn? What is the pathophys and possible complications?
- Begins when the patient's burn wounds are covered with skin or healed and the pt is able to resume a level of self-care activity
- Pathophys includes wound healing wither by primary intention or grafting, layers of epithelization begin to rebuilding tissue structures, collagen fibers add strength to weakened areas, 4-6 areas are rained and mature healing occurs 6mo-2yr. Skin never completely returns to orig color, pressure can prevent keloid scarring, newly healed areas can be hypo/hypersensitive, protect from direct sunlight for 1 yr
- Complications include skin and joint contractures (PT and OT) and hypertrophic scaring
What nursing care should be done during the rehabilitation phase of a burn?
- Patient and family education on woundcare
- Emollient based creams should not be used
- Plastic surgery may be an option
- Education on the importance of exercise
- Continuous encouragement/reassurance
- Address spiritual/cultural needs
- High calorie, high protein diet
- OT and PT
What needs to be done for a burn patient prior to discharge?
- Patient assessment
- Financial assessment
- Evaluation of family resources
- Weekly meetings/followups
- Psych referral
- Patient and family learning (home care needs)
- Development of a teaching plan for patient and family
- Educating client and family on wound care
- Rehab referrals
- Home assessments for home care/accessibility needs
- Medical equip/prosthetic needs
- Evaluation of community resources
- Re-entry programs for school or work
- Auditory and speech therapy
What emotional needs exists during a burn injury?
- Family members need to understand the importance of reestablishing the pt's independence
- Encourage family to participate as team members
- Early psych intervention
- Assess psycho-emotional cues
- Common emotional response is regression
- Issues of sexuality should be met with honesty
- Family and patient support groups
What are some expected patient outcomes for burn patients?
- Cardiac output restored to normal
- Pain alleviated or reduced
- No further skin integrity lost and skin integrity restored
- No infection
- Adequate nutritional intake
- Acceptable perception of body
Describe some special nursing needs for burn unit nurses
- Nurse cares for patients and family members who at times may be unpleasant, hostile, apprehensive and frustrated
- Nurses new to burn unit often find it difficult to cope and need new coping skills