Burn Injuries Cell destruction of the layers of the skin and the resultant depletion of fluid and electrolytes

s Mortality rates are higher for children less than 4 years of age, particularly in the birth to 1-year age group and for clients over the age of 65 years Debilitating disorders, such as cardiac, respiratory, endocrine and renal disorders negatively influence the clients response to injury and treatment Mortality rate is higher when the client has preexisting disorder at the time of burn injury Burn Size: 1. Small burns 2. Large or extensive burns Burn Depth 1. Superficial thickness burn 2. Partial thickness superficial burn 3. Full thickness burn 4. Deep full thickness burn Estimating the extent of injury

Lund-Browder Classification

Types of Burns: 1. Thermal Burns - Caused by exposure to flames, hot liquids, steam or hot objects 2. Chemical Burns - caused by tissue contact with strong acids, alkalis or organic compounds 3. Electrical burns - caused by heat generated by an electrical energy as it passes through the body 4. Radiation burns - caused by exposure to ultraviolet light, x-rays or radioactive source Pathophysiology : Burn Injury Release of vasoactive substances Increase in capillary permeability Plasma seeps to the surrounding tissues Generalized edema Decrease in circulating intravascular blood volume Decrease in organ perfusion Increased heart rate, decrease CO, decreased BP Hyponatremia , Hyperkalemia Initial Increase in hematocrit level then falls to below normal Red blood cell damage and loss

 Oliguria Reabsorption of fluid Diuresis Signs and symptoms : A. Smoke inhalation injury Facial burns Erythema Swelling of the oropharynx and nasopharynx Singed nasal hairs Flaring nostrils Stridor, wheezing and dyspnea Hoarse voice Sooty (carbonaceous) sputum and cough Agitation and anxiety Tachycardia B. Thermal Heat injury Erythema and edema of the upper airways Mucosal blisters and ulcerations Management : A. Emergent Phase Begins at the time of injury and ends with the restoration of the capillary permeability (Fluid resuscitation) usually at 48 to 72 hours following the injury. I. Prehospital care Remove victim from the source of the burn Remove the source of heat Assess ABC Assess for associated trauma. Conserve body heat. Cover burns with sterile of clean cloths. Remove constricting jewelry or clothing. Assess the need for intravenous fluids Transport. II. Emergency room care Major Burns : 1. Evaluate the degree and extent of the burn and treat life-threatening conditions. 2. Ensure patent airway and administer 100% oxygen as prescribed if the burn occured in an enclosed area. 3. Monitor for respiratory distress and assess the need for intubation 4. Assess oropharynx for blisters and erythema 5. Initiate peripheral IV access to non-burned skin proximal to any extremity burn. 6. Prepare for a central venous line if prescribed. 7. Assess for hypovolemia and prepare to administer fluids intravenously. 8. Monitor VS closely. 9. Insert foley catheter as prescribed and maintain a normal urine output per hour. 10. Insert a nasogastric tube as prescribed 11. Administer tetanus prophylaxis as prescribed.

12. Administer pain medication as prescribed by IV route. 13. Prepare the patient for escharotomy or fasciotomy as prescribed. B. Resuscitative Phase - begins with the initiation of fluids and ends when capillary integrity returns to near- normal levels and the large fluid shifts have decreased. I. Fluid resuscitation *The amount of fluid administered depends on how much IV fluid per hour is required to maintain a urinary output of 30 to 50 ml per hour. -This is given at 15-20% TBSA Interventions: a. Monitor for tracheal and laryngeal edema and administer respiratory treatments as prescribed. b. Monitor pulse oximetry and prepare for arterial blood gases and carboxyhemoglobin levels if inhalation injury is suspected. c. Elevate head of bed to 30 degrees or more for burns of the face and head. d. Initiate protective isolation techniques. e. Shave or cut body hair around wound margins. f. Monitor daily weights. g. Monitor for the presence of stress ulcer. Administer antacids as prescribed. h. Auscultate bowel sounds and monitor abdominal distention and GI dysfunction. i. Monitor IV fluids and hourly intake and output. j. Elevate circumferential burns of the extremities on pillows above the level of the heart if no obvious fractures are present. k. Monitor pulses and capillary refill of the affected extremities II. Pain management: 1. Administer Morphine SO4 or meperidine (Demerol) as prescribed by IV route III. Nutrition: 1. Maintain NPO status until the bowel sounds are heard and then advance to clear liquids as prescribed. 2. Nutrition may be provided via enteral tube feeding, peripheral parenteral nutrition or total parenteral nutrition 3. Provide a diet high in protein, carbohydrates, fats and vitamins. IV. Surgery: 1. Escharotomy 2. Fasciotomy C. Acute Phase - Begins when the client is hemodynamically stable, capillary permeability is restored and diuresis has begun. - Usually begins 48 to 72 hours at the time of injury. - Emphasis is placed on restorative therapy and the phase continues until wound closure is achieved. Interventions: 1. Continue with protective isolation techniques. 2. Provide wound care as prescribed and prepare for wound closure. 3. Provide pain management. 4. Provide adequate nutrition as prescribed.

5. Prepare client for rehabilitation. Wound care Hydrotherapy -Wounds are cleansed by immersion, showering or spraying - Occurs for 30 minutes or less - Client should be premedicated before the procedure. - It is generally not used for clients who are hemodynamically unstable or for those who have new skin drafts. Debridment - removal of eschar to prevent bacterial proliferation under the eschar and to promote wound healing. - may be mechanical, enzymatic or surgical.

Wound closure A. Temporary wound coverings: 1. Amnion 2. Allograft homograft 3. xenograft heterograft 4. Biosynthetic and synthetic B. Autografting - surgical removal of a thin layer of the clients own unburned skin, which then is applied to the excised burn. Autografts are immobilized following surgery for 3-7 days. Position patient for immobilization and elevation of the graft site to prevent movement and shearing of the graft. Physical Therapy Individualized program of splinting, positioning, exercising, ambulation and activities of daily living is implemented early during the acute phase of recovery to maximize functional and cosmetic outcomes D. Rehabilitative Phase Rehabilitation is the final phase of burn care Goals of this phase are designed so that the client can gain independence and achieve maximum function. Goals: 1. Promote wound healing. 2. Minimize deformities. 3. Increase strength and function. 4. Provide emotional support.