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1. Burns can be classified as partial thickness or full thickness and involve varying depths of skin damage.
2. After a burn, the body experiences fluid shifts between vascular compartments and interstitial spaces that can lead to hypovolemia, hemoconcentration, and electrolyte imbalances in the initial days.
3. Treatment involves three periods: emergent, acute, and rehabilitation. The emergent period focuses on airway, circulation, and wound care in the first 24-48 hours post-burn.
1. Burns can be classified as partial thickness or full thickness and involve varying depths of skin damage.
2. After a burn, the body experiences fluid shifts between vascular compartments and interstitial spaces that can lead to hypovolemia, hemoconcentration, and electrolyte imbalances in the initial days.
3. Treatment involves three periods: emergent, acute, and rehabilitation. The emergent period focuses on airway, circulation, and wound care in the first 24-48 hours post-burn.
1. Burns can be classified as partial thickness or full thickness and involve varying depths of skin damage.
2. After a burn, the body experiences fluid shifts between vascular compartments and interstitial spaces that can lead to hypovolemia, hemoconcentration, and electrolyte imbalances in the initial days.
3. Treatment involves three periods: emergent, acute, and rehabilitation. The emergent period focuses on airway, circulation, and wound care in the first 24-48 hours post-burn.
Burn Lecture Notes ▪ Capillary permeability with burns
increases with vasodilation
BURNS: ▪ Fluid loss deep in wounds ▪ Initially Sodium and H2O A. CLASSIFICATION OF BURNS ▪ Protein loss – hypo- • Partial thickness - characterized by varying depth proteinemia from epidermis (outer layer of skin) to the dermis ▪ Hemoconcentration - Hematocrit (middle layer of skin) increases ▪ Superficial - includes only the ▪ Low blood volume, oliguria epidermis ▪ Hyponatremia - loss of sodium with ▪ Deep - involve entire epidermis and fluid part of the dermis ▪ Hyperkalemia - damaged cells • Full thickness - includes destruction of the release K, oliguria epidermis and the entire dermis as well as possible ▪ Metabolic acidosis damage to the SQ, muscle and bone • Diuretic Stage - begins 48 - 72 hours after burn injury: B. REVIEW OF SKIN FUNCTIONS ▪ Capillary membrane integrity returns • Functions of the skin ▪ Edema fluid shifts back into vessels - ▪ Protection - intact skin is the first line blood volume increases of defense against bacterial and ▪ Increase in renal blood flow - result in foreign-substance invasion diuresis (unless renal damage) ▪ Heat regulation ▪ Hemodilution - low Hct, decreased ▪ Sensory perception potassium as it moves back into the ▪ Excretion cell or is excreted in urine with the ▪ Vitamin D production diuresis ▪ Expression - important with body ▪ Fluid overload can occur due to image - fear of disfigurement increased intravascular volume ▪ Metabolic acidosis - HCO3 loss in C. STAGES OF BURNS: urine, increase in fat metabolism • Hypovolemic state - begins at the onset of burn E. Fluid shifts resolving - pt still acutely ill and lasts for the first 48 hours - 72 hours 2. malnutrition ▪ Rapid fluid shifts - from the vascular 3. anemia - develops from the loss of RBC compartments into the interstitial spaces Three periods of treatment - Emergent, Acute, • e. Body part involved - not all are equal Rehabilitation: Cosmetic and functional concerns Face, eyes, ears, feet, hands, perineum Limbs, neck and chest - burns can produce a I. EMERGENT (first 24-48 hrs) immediate problems tourniquet effect • Maintain airway, fluids, analgesia, temperature, • f. Mechanism of injury - identify causative agent wound (Flame, contact, scalds, chemical, electrical) • Assessment: • g. Nursing diagnosis: o Objective o Airway clearance, ▪ how burn occurred, when o ineffective Fluid volume deficit Fluid volume ▪ duration excess ▪ type of agent o Hypothermia o Subjective: o Infection, ▪ previous medical problems o high risk for Pain (with partial thickness ▪ size and depth of burn burns) ▪ age o Skin integrity, impaired ▪ body part involved o Anxiety Knowledge ▪ mechanism of injury • h. Interventions: • Factors Determining Severity of Burns: o maintain a patent airway - watch for o Size of Burn Depth of Burn laryngeal edema, o Age o 100% FiO2 mask (increase in o Body part effected carboxyhemoglobin) intubation for o Mechanism of Injury inhalation most often required o History of cardiac, pulmonary, renal or o maintain circulation - fluid resuscitation - hepatic diseases crystalloids and colloids Crystalloids - may o Injuries sustained at time of burn be isotonic or hypertonic o Duration of contact with burning agentc. 1. Isotonic - most common are lacted o Size & Depth of Burn - "Rule of Nines" Divide Ringers or NaCl (0.9%) - these do not body surface into multiples of nine generate a difference in osmotic MAJOR BURN: pressure between the intravascular > 25% of BSA of a partial thickness and interstitial spaces - subsequently > 10% of BSA of a full thickness LARGE amounts of fluid are required • d. Age < 2 years old or > 60 years old, the 2. Hypertonic salt solutions create an mortality rates increases osmotic pull of fluid from the interstitial space back to the sterile sheets emotional support - fear of dying, depleted intravascular space (helps disfigurement, trauma decrease the amount of fluid needed during resuscitation. SIGNS OF ADEQUATE FLUID RESUSCITATION: decreases the development of burn • Clear sensorium tissue edema, pulmonary edema, • Pulse < 120 beats per minute and CHF) • Urine output for adults 30 - 50 cc/hour Colloids - replacement begins during the second 24 • Systolic blood pressure > 100 mm Hg hours following the burn to replace intravascular volume • Blood pH within normal range 7.35 - 7.45 ONCE CAPILLARY PERMEABILITY SIGNIFICANTLY DECREASES II. ACUTE PERIOD - • General Indications for Fluid Resuscitation: • end of emergent period until burns heals ▪ 1. Burns > 20% of BSA with adults • focus now shifts to care of wounds and prevention ▪ 2. Burns > 10% of BSA with children of complications. ▪ 3. Age >65 or < 2 • Actual range of this phase depends on degree and extent of burn "Parkland Formula" 4ml of Lacted Ringers x weight (Kg) x a. ASSESSMENT: %BSA burned = ml of Lacted Ringers to be given during Subjective - the first 24 hour period following the burn first 8 hours ▪ pain and anxiety following the burn are the most crucial - need to half of Objective - the total, the second 8 hrs give one-quarter or the ▪ complete assessment every 8 hours remaining fluids, the last 8 hrs give the remaining one- ▪ Observe burn wound and donor sites quarter (with severe burn it is not uncommon to give for skin grafting, greater than 20 thousand ml in a 24 hour period) colloid ▪ dietary intake, (protein) given after capillary integrity returns NPO - great ▪ motor ability, thirst, ileus is common assess for adequate fluid ▪ I&O, replacement - HR < 120, BP - systolic >100, UO > 30 cc/hr ▪ weight pH 7.35 - 7.45, weight gain the first 72 hours during the diuretic phase UP is not a reliable indicator look at NURSING DIAGNOSIS: electrolytes analgesia - drug of choice is IV Morphine - ▪ Skin integrity, impaired NO IM or SQ wound care maintain body temperature - ▪ Infection, high risk for need to keep environment WARM, no drafts, heat lamps, ▪ Altered nutrition ▪ Pain, acute (with partial thickness f. Oliguria burns) ▪ Fluid Volume deficit Ways to prevent infection: ▪ Anxiety a. Gowns, masks, gloves ▪ Hypothermia b. Sterile linen ▪ Coping, ineffective individual c. Persons with URI should not come in contact ▪ Coping, ineffective family with patient ▪ Body image disturbance ▪ Knowledge deficit WOUND CARE: ▪ Mobility, impaired 1. Burn wound is unique ▪ Self-Care deficit 2. Burn wound sepsis - ▪ gram + INTERVENTIONS: ▪ gram- (pseudomonas), • relieving anxiety, denial, regression, anger, ▪ viruses, depression ▪ fungal (candida albicans) • wounds - REFER TO WOUND CARE 3. Nutrition - • nutrition (Nutritional assessment, pre-albumin ▪ collagen primary structure in healing levels, large protein requirement, carbohydrates by secondary intention, and fats for energy, mega vitamins, TPN, enteral ▪ need increased protein, tube feedings) ileus is common ▪ may need double the normal calorie • pain - around the clock management prevention requirements of infection - SEE WOUND CARE 4. Inadequate blood supply 5. Burn wound disorders: Organisms that usually infect burns are: ▪ scarring a. Staphylococcus aureus ▪ contractures b. Pseudomonas Infection is usually the cause of ▪ keloids any deterioration ▪ failure to heal
Signs of sepsis: WOUND CARE PRINCIPLES:
a. Change in sensorium 1. GOALS b. Fever ▪ close wound asap c. Tachypnea ▪ prevent infection d. Paralytic ileus ▪ reduce scarring and contractures e. Abdominal distention ▪ provide for comfort 2. Wound cleaning bed side hydrotherapy tanks ▪ speeds debridement, tubbing spray table ▪ develops granulation tissues faster, 3. Debridement mechanical surgical enzymatic ▪ and makes skin grafting possible 4. Topical antibacterial therapy mafenide sooner. (sulfonamide) sulfadiazine 4. Biological dressings ▪ homografts - same species (cadaver WOUND CARE - DRESSING THE BURN skin) - 1. Open technique or exposed - more often used ▪ temporary coverage heterografts - with burns effecting the: another species (pig skin) - ▪ face, ▪ temporary coverage autografts - ▪ neck patients own skin - permanent ▪ perineum and coverage ▪ broad areas of the trunk Partial thickness - exudate dries in 48 to 72 WOUND CARE - GRAFTING hours forming a hard crust that protects the 1. Indications for grafting wound. ▪ full thickness ▪ Epithelialization occurs beneath the ▪ priority areas crust and may take 14 to 21 days to ▪ wound bed pink, firm, free of heal. exudate ▪ Crust then falls off spontaneously - ▪ bacterial count < 100,000/gram of leaving healed unscared surface tissue Full thickness - dead skin is dehydrated and 2. Care of grafts - assess converted to black leathery eschar in 48 to 72 hours. Loose eschar is gradually removed with hydrotherapy &/or debridement III. REHABILITATION PERIOD 2. Closed technique 1. Care of healing skin - wash daily, cover with Wound is washed, and sterile dressings cocoa butter changed (may be q shift, daily). 2. Pressure garments, ace wraps - prevent scaring Dressing consists of gauze &/or ace wraps and contractures impregnated with topical ointments. 3. Promote mobility - positioning, exercise, 3. Semi-open - splinting, ADL consists of covering the wound with topical Antimicrobial agents and gauze. Advantage: