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What are the different mechanisms of burns?
- heat: flame, scalding water
- Chemicals: battery acid, cleaning fluids
- Electrical: equipment
- Radiation: sun, equipment
- Inhalation: smoke
What population is highest risk for burns? Can most burn injuries be prevented?
- Elderly and children are most at risk;
- Yes, most can be prevented
What is the skin composed of?
- Epidermis; dermis
- Subcutaneous fat tissue
What functions does the integumentary system serve?
- Protects from infection (when skin is intact)
- prevents loss of body fluids
- production of vitamin D
- Sensation reception
What factors determine the severity of injuries for a thermal burn?
- duration of contact
- temperature of agent
- amount of tissue exposed
- age of patient
What are the methods of injury for a chemical burn?
- inhalation of fumes
- ingestion or injection
In chemical burns what 2 broad effects can occur? how can you halt damage? What do you use for instructions when there is a chemical burn?
- they can be systemic or local effects
- The chemical must be completely removed or neutralized or damage continues
- The MSDS Material Safety Data Sheets have instructions for every chemical in a facility
What determines the level of severity of chemical burns? What are the two types of chemical burns?
- Severity of injuries: type of agent, volume of agent, duration of contact, concentration of agent
- Types: Alkalis-base
What is the difference between high and low voltage electrical injuries? What is the energy level converted into? What is alternation current? What is direct current?
- High voltage: High is greater than 100 watts
- Low: less than 1000 watts
- Energy level is converted into heat
- Alternating current: flow of electrical charge periodically reverses direction. Higher probability of producing cardiac arrest
- Direct Current: unidirectional flow of electrical charge. Batteries, electric machines
Who invented alternating current? Who invented direct current?
- Nikola tesla: AC
- Thomas Edison: DC
What factors determine severity of injuries for electrical injuries?
- type and path of injury
- duration of contact
- tissue resistance
What is radiation injury? What determines the severity of injury
- Radioactive injury: exposure to large amount of radioactive material
- Severity: type of radiation, distance from source, duration of exposure, absorbed dose, depth of penetration
What is an example of inhalation injury? How are they classified?
- Carbon monoxide poisoning;
- class: above or below the glottis
What is the emergency management of burns?
- assess airway patency
- administer oxygen
- cover with blanket
- keep NPO
- elevate the extremities if no fracture is obvious
- vital signs
- initiate IV line for fluid replacement
- administer tetanus
- head-to-toe assessment
What is the (specific to burn types) emergency management of burns?
- Flame burns: smother the flames, remove smoldering clothing and all metal objects
- Chemical: if dry chemical are present o the skin do not wet them, brush off any dry chemicals present on the skin or clothing, remove clothing, determine the chemical causing the burn, do not attempt to neutralize the chemical unless it has been positively identified and the appropriate neutralizing agent is available
- Electric burns: At the scene, separate patient from electrical current, smother any flames that are present, initiate cardiopulmonary resuscitation, obtain EKG
- Radiation: 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 protective gloves, if the patient has radioactive particles on the skin send them to nearest designated radiation decontamination center, help the patient to bathe or shower
What factors determine severity of burns?
- type of burn
- burn wound characteristics (depth, extent, body part burned)
- Any other injuries
- patient age
- preexisting health status
What are the different depths of injury?
- superficial (first degree): epidermis only; heals in 3-5 days without tx; erythema ( blanching on pressure, pain and mild swelling
- Not calculated for fluid resuscitation
- partial thickness (second degree): epidermis and most of dermis
- full thickness: divided into 2 sub classifications- superficial partial thickness and deep partial thickness
What is superficial partial thickness? Deep partial thickness?
- superficial: epidermis and limited portion of the dermis; heals in 10-21 days; moist pink or mottled red, very painful; blister formation
- Deep partial thickness: epidermis and most of the dermis; heals in 3-6 weeks; pale, mottled, pearly red/white; less painful
What is full thickness?
- (third degree)
- Destruction of all layers down to or past fat, fascia, muscle or bone
- thick dry leathery appearance;dry, white, cherry-red, or brown-black
- insensate (no pain)
- does not heal; requires skin grafting
How is the extent of injury expressed? What are the methods of measuring extent?
- expressed as total body surface area percent (%TBSA)
- methods: rule of nines, patient's palm method, (differences between adults and children)
- Lund-Browder chart
describe the rule of nines
- Head: anterior 4.5; posterior 4.5
- Chest: anterior 18; posterior 18
- Right arm: anterior 4.5 posterior 4.5
- left arm: anterior 4.5 posterior 4.5
- pipi: 1
- Right leg: anterior 9% posterior 9%
- Left leg: anterior 9% posterior 9%
Burns of the face, neck, chest can lead to what what Nursing diagnosis? Burns to the hands, feet, joints can lead to what Nursing diagnosis? Ears/nose? Circumferential burns of the extremities can cause what? circulatory compromise;
- Face/neck/chest: R/F respiratory obstruction
- hands/feet/joints: R/F self care
- Ears/nose: R/F infection
- Circumferential burns can cause circulatory compromise
- (may develop compartment syndrome)
What are risk factors make burns worse?
- older adults heal more slowly
- preexisting cardiovascular, respiratory, renal disease
- drug abuse
- concurrent fractures, head injuries or other trauma
What are the local responses to burns?
- acute inflammation
- intravascular coagulation
- altered vascular permeability (fluid shifts)
Describe fluid shifts
- fluid shifts to the extravascular space; burns greater than 20% total body surface areas; maximum edema 24-48 hours post burn
- burn shock (combination of distributive and hypovolemic shock
What are the systemic responses to Burns (6)
- Cardiovascular: loss of intravascular volume; decreased cardiac output, tachycardia and vasoconstriction
- Host defense mechs: increased risk for infection
- Pulmonary: pulmonary HTN effect of direct injury
- Metabolic: hyper state, lasts up to 8 to 12 months after burn
- Gastrointestinal: ischemia due to redistribution of blood to brain and heart; paralytic ileus, curlings ulcers from stress
- Renal: sensitive to decreased cardiac output, initial decrease in urine output related to decreased GFR, followed by diuresis as fluid shifts
What is prehospital care for burns?
- remove the person from the source of the burn and stop the burning process
- the caregiver must be protected from becoming part of the incident
What is the emergent phase/care of burns?
- from burn onset to 5 or more days
- usually the fist 48 hours
- Fluid management to prevent shock
- Phase begins with fluid loss and edema formation and continues until fluid mobilization and diuresis begins
- Emergent phase is the period of time required to resolve the immediate problems resulting from the burn injury
What is the pathophys of the emergent phase, what are the clinical manifestations?
What are the complications?
- Fluid and electrolyte shifts; inflammation and healing; immunologic changes
- Manifestations: shock from pain and hypovolemia, blisters, adynamic ileus, shivering, altered
- Complications: cardiovascular system; respiratory system, urinary system
What is the nursing and collaborative care of emergent phase?
- Airway management: intubation, oxygen-humidified/100%/O2; escharotomies
- Fluid therapy: Twp large bore IV (18 gauge); Parkland (baxter) formula for fluid replacement (2-4mL LR/kg/%TBSA=first 24 hours of fluid replacement half given in first 8 hours)
- colloidal therapy
Describe wound care during the emergent phase
- delayed until patient has patent airway
- immersion tank
- infection is the most serious threat to further tissue injury
- open method, multiple dressing changes, allograft or homograft skin
- other care measures
- facial care, ears-pressure free, peri-care, routine lab tests, early ROM exercises
What drug therapy is used for the emergent phase? nutritional therapy?
- Drug: analgesics and sedatives, tetanus immunization, antimicrobial
- Nutritional: fluid replacement takes priority
- oral intake after bowel sounds return (usually at 48-72 hours)
- Hypermetabolic state (caloric needs- 500 kcal/day)
What is the acute phase?
- the acute phase begins with the mobilization of extracellular fluid and subsequent diuresis
- The acute phase is concluded when the burned area is completely covered by skin grafts or when the wounds are healed
What is the pathophys of the acute phase?
- Diuresis from fluid mobilization occurs
- bowel sounds return
- healing begins, necrotic tissue begins to slough
- formation of granular tissue
- Partial thickness: heal from the edges
- Full thickness: covered by skin grafts
What are the clinical manifestations of the acute phase?
- Partial-thickness wounds from eschar
- eschar removed- epithealization begins
- expected to occur in 10-14 days
- Full thickness wounds require debridement
What lab values will you see with acute phase?
- Sodium: hyponatremia
- Potassium: hyperkalemia/Hypokalemia
What are the complications of acute phase?
- cardiovascular and respiratory systems
- neurologic system
- musculoskeletal system
- gastrointestinal system
- endocrine system
What wound care do nurses do during acute phase?
- Daily observations, assessment, cleansing, debridement
- excision and grafting: graft dressings, eschar removal, cultured epithelial autografts (CEA)
- Artificial skin
What pain management is needed for acute phase? physical/occupational? Nutritional? Psychosocial?
- pain: pharmacologic, non pharm
- Physical/occupational: Exercise during/after hydrotherapy, passive or active ROM
- Nutritional therapy: High protein;high carb foods, diet supplements daily weights
- Psychosocial: social work, nursing staff, pastoral care
What is the rehab phase?
the rehabilitation phase is defined as beginning wen the patients burn wounds are covered with skin or healed and the patient is able to resume a level of self care activity
What is the pathophys and clinical manifestations of the rehab phase?
- burn wound heals either by primary intention or by grafting
- Layers of epitheliazation begin rebuilding tissue structure
- Collagen fibers add strength to weakened areas
- 4-6 weeks- area becomes raised
- Mature healing: 6 months to 2 years
- Skin never completely regains its orginal color
- discoloration of scar fades with time; pressure can keep the scar flat (avoid Keloids)
- Newly healed areas: hyper/hypo-sensitive; protect from direct sunlight for 1 year
What are the complications of rehab phase?
- Skin and joint contractures (most common complication)
- Hypertrophic scarring
What is the nursing/collab care for the rehab phase?
- Patient and family actively learn to care for healing wounds
- emollient water-based cream should be used
- cosmetic surgery
- role of exercise cannot be overemphasized
- continuous encouragement/reassurance
- address spiritual cultural needs
- high calorie, high protein diet
- occupational therapy
What things must be done before discharge?
- early patient assessment
- financial assessment
- evaluation of family resources
- weekly discharge planning meeting
- psychologic referral
- patient and family teaching (home care)
- designation of principal learners (specific family members of s/o who will help with care)
- development of a teaching plan
- training for wound care
- rehab referral
- home assessment/ environmental interventions
- medical equipment/ prosthetic rehab
- public health nursing referral
- evaluation of community resources
- visit to referral agency
- re-entry programs for school or work environment
- nursing home placement
- auditory testing/speech therapy
What are the emotional needs of burn patients?
- Family members need to understand the importance of reestablishing the patient's independence
- Encourage family to participate as team member
- Early psychiatric intervention
- Assess psycho-emotional cues
- common emotional response: regress
- Issues of sexuality must be met with honesty
- Family and patient support groups
What are the Expected outcomes for burn patients?
- Cardiac output restored or normal
- Pain alleviated or reduced
- No further skin integrity lost and skin integrity restored
- no infection
- adequate nutritional intake
- acceptable perception of body
What issues with staffing do nurses experiencing?
- nurse cares for patients who at times may be unpleasant, hostile, apprehensive, and frustrated
- Nurses new to burn nursing often find it difficult to cope