Description

An alteration in skin integrity resulting in tissue loss or injury caused by heat, chemicals, electricity or radiation Types of burn injury

Etiology

a. Thermal: results from dry heat (flames) or moist heat (steam or hot liquids); it is the most common type; it causes cellular destruction that results in vascular, bony, muscle, or nerve complications; thermal burns can also lead to inhalation injury if the head and neck area is affected b. Chemical burns are caused by direct contact with either acidic or alkaline agents; they alter tissue perfusion leading to necrosis c. Electrical burns; severity depends on type and duration of current and amount of voltage; it follows the path of least resistance(muscles, bone, blood vessels and nerves); sources of electrical injury include direct current, alternating current and lightning d. Radiation burns: are usually associated with sunburn or radiation treatment for cancer; are usually superficial; extensive exposure to radiation may lead to tissue damage Pathophysiology It depends on the cause and classification of the burn; the injuring agents denatures cellular proteins; some cells die because of traumatic or ischemic necrosis; loss of collagen cross-linking also occurs with denaturation, creating abnormal osmotic and hydrostatic pressure gradients that cause intravascular fluid to move into interstitial spaces; Cellular injury triggers the release of mediators of inflammation, contributing to local and in the case of major burns , systemic increases in capillary permeability Localized pain and erythema, usually without blisters in the first 24 hours (first degree burn) Chills, headache, localized edema, nausea and vomiting (most severe first degree burn) Thin-walled, fluid filled blisters appearing within minutes of the injury, with mild to moderate edema and pain (second degree superficial partial thickness burn) White, waxy appearance to damaged area(second degree partial-thickness burn)

Clinical Manifestations

White, brown or black leathery tissue and visible thrombosed vessels due to destruction of skin elasticity(dorsum of hand, most common site of thrombosed veins), without blisters (thirddegree burn) Silver-colored, raised or charred area, usually at the site of electrical contact

Diagnostics

*Rule of Nines chart determines the percentage of body surface area (BSA)covered by the burn ABG levels may be normal in the early stages but may reveal hypoxemia and metabolic acidosis Carboxyhemoglobin level may reveal the extent of smoke inhalation due to the presence of carbon monoxide Complete blood count may reveal a decrease hemoglobin due to hemolysis, increased hematocrit and leukocytosis Electrolyte levels show hyponatremia and hyperkalemia,other laboratory tests reveals elevated BUN,decreased total protein and albumin Creatinine kinase (CK) and myoglobin levels may be elevated Presence of myoglobin in urine may lead to acute tubular necrosis Risk for Deficient Fluid Volume Risk for Infection Impaired Physical Mobility Imbalanced Nutrition: Less than Body Requirements Ineffective Breathing Pattern Impaired Tissue Perfusion Risk for Impaired Gas Exchange Anxiety Risk for Ineffective Thermoregulation Pain

Nursing Diagnoses -

Nursing Management -

Impaired Skin Integrity Assess patients ABCs; monitor arterial oxygen saturation and serial ABG values and anticipate the need for ET intubation and mechanical ventilation Auscultate breath sounds Administered supplemental humidified oxygen as ordered Perform oropharyngeal or tracheal suctioning as indicated by the patients inability to clear his airway Monitor the patients cardiac and respiratory status Assess LOC for changes such as confusion, restlessness or decreased responsiveness Irrigate the wound with amounts of water or normal saline solution for chemical burns Place the patient in semi-Fowlers position to maximize chest expansion; keep patient as quiet and comfortable to minimize oxygen demand Prepare the patient for an emergency escharotomy of the chest and neck for deep burns Administer rapid fluid replacement therapy as ordered

*For burn patient in shock Monitor VS and hemodynamic parameters Assess patients intake and output every hour, insert an indwelling cathether Assess the patients level of pain, including nonverbal indicators and administer analgesics such as Morphine Sulfate IV as ordered Keep the patient calm, provide periods of uninterrupted rest between procedures and use nonpharmacologic pain relief measures as appropriate Obtain daily weights and monitor intake, including daily calorie counts; provide high calorie, high protein diet Administer histamine 2 receptor antagonists as ordered to

reduce risk of ulcer formation Assess the patients sign and symptoms of infection; may obtain wound culture and administer antimicrobials an antipyretics as ordered Administer tetanus prophylaxis if indicated Perform burn wound care as ordered; prepare patient for grafting as indicated Assess the neurovascular status of the injured area, including pulses, reflexes, paresthesia, color and temperature of the injured area at least 2 to 4 hours or more frequently as indicated Assist with splinting, positioning, compression therapy and exercise to the burned area as indicated; maintain the burned area in a neutral position to prevent contractures and minimize deformity Explain all procedures to the patient before performing them Antibiotic prophylaxis will eradicate bacterial component Pain therapy Tetanus prophylaxis Topical antimicrobial Enzymatic debriding agents such as collagenase, fibrinolysindesoxyribonuclease, papin or sutilins are used with a moisture barrier to protect surrounding tissue Recommended dressings include polyurethane films(Op-site, Tegaderm), absorbent hydrocolloid dressings (Duoderm) Environmental safety: use low temperature setting for hot water heater, ensure access to and adequate number of electrical cords/outlets, isolate household chemicals, avoid smoking inbed Use of household smoke detectors with emphasis on maintenance Proper storage and use of flammable substances Evacuation plan for family Care of burn at home

Pharmacotherapy -

Client Education

Signs and symptoms of infection How to identify risk of skin changes Use of sunscreen to protect healing tissue and other protective skin care