Thermal Injuries: Burns

NURS 225

Adult Nursing II1

Objectives

▪ Compare the manifestations of superficial, partial thickness, and full thickness burn injuries.

▪ Prioritize nursing care for the patient during the resuscitation phase of burn injury.

▪ Prioritize nursing care for the patient during the acute phase of burn injury.

2

∙ epidermal layer

∙ causes: sunburn, ultraviolet light, minor flash injuries, mild radiation burns

∙ appearance: pink to bright red, slight edema

∙ mildly painful

∙ treatment: mild analgesia, water-soluble lotions

▪ Superficial: first degree Classification of Burns

3

∙ dermis layer: superficial partial-thickness or deep partial-thickness burn

∙ causes: superficial - deep -

∙ appearance: superficial - bright red, moist deep – pale, waxy, moist or dry

∙ severe pain in response to air or heat

∙ treatment: analgesia, skin substitutes, grafting may be necessary

▪ Partial-thickness: second degree

4

Deep full thickness: involves fascia and tissues, muscle, bone, and tendons

∙ causes: flames, steam, chemicals, high-voltage electrical current

∙ appearance: hard, dry, pale, waxy, yellow, brown, mottled, charred, or non-blanching red

∙ no sensation of pain or sensation of light touch

∙ treatment: requires skin grafting, amputationMay be needed

▪ Full-thickness burns: third degree

5

Types of Burns

Thermal∙ dry heat- ∙ moist heat-

Chemical∙ acid – ∙ alkali – ∙ organic –

Electrical∙ severity dependent on type, duration, pathway, and resistance∙ damage can be concealed/internal∙ follows path of least resistance∙ coagulation at site leads to necrosis∙ direct current injuries have entrance and exit wounds

Radiation∙ therapeutic radiation – ∙ industrial radiation – 6

Rule of 9’s - determines extent of burn, percentage of body surface involved

7

Location of Burn Determines Extent of Injury

Face, neck, chest respiratory obstructionHands, feet, joints, and eyes self-care Ears, nose infection Circumferential burns of the extremities can cause circulatory compromise and potential compartment syndrome 

8

Pre-Hospital Management

Stop burning process∙ thermal burns – ∙ chemical burns –∙ electrical burns –

Support∙ secure airway ∙ fluid replacement∙ comfort ∙ prevent infection

∙ thermoregulation ∙ support circulation∙ emotional support

Transport - burn center criteria∙ 55 burn centers in continental US∙ University of Washington Burn Center - Seattle, Washington

9

Hospital ManagementMinor Burns

∙ skin remains intact - <15% split thickness, <2% full thickness

∙ excludes face/facial structures, hands, feet, perineum

∙ treatment includes:

10

Major Burns ~ Emergent Phase

Fluid Resuscitation – three common resuscitation formulasCalculated *ml/kg/TBSA% (*ml/kg varies slightly among formulas)

∙ requires LARGE fluid loads over first 24 hours∙ ½ of total fluid over 1st 8 hours after injury∙ remainder of fluid given over the remaining 16 hours∙ Goals – 30-50ml urine output/hr, SBP>90mmHg, P<120, RR 16-20

Fluid resuscitation formulas calculated from the time of INJURY not ARRIVAL at the hospital.

11

12

Fluid resuscitation example

70kg person, burn injury to head, left arm, left leg

time of injury 8am – time of arrival at hospital 10am

TBSA 36% ~ using Parkland Formula 4ml/kg/TBSA

4ml x 70 x 36 = 10080ml to be given over 1st 24hours

5040ml over 1st 8 hours = 630ml/hr

(2050÷6=840ml/hr ~ 8 hours started at 8am)

5040ml over remaining 16 hours = 280ml/hr

Pathophysiology∙ Integumentary ∙massive fluid loss through evaporation

∙heat loss∙dependent on depth and severity of injury

∙no blood flow through damaged vessels∙Bull’s eye appearanceGoal = relieve pressure, restore blood flow, salvage

∙ Eschar – hard crust like, forms over necrotic skin

13

∙ Cardiovascular

∙ hypovolemic shock ~ burn shock∙ Fluid shift (3rd spacing) immediately after injury-24hours =intracellular → intravascular → interstitial

∙ ↑ permeability - ↑ intracellular edema - ↑ osmosis=profound weight gain, edema

– Fluid remobilization→ diuresis 48-72 hours after injury ∙ normal loss - 30 to 50ml/hour~ severely burned patient - 200 to 400ml/hour

∙ arrhythmia's

∙ TBSA >40% increased risk for arrhythmia'selectrolyte shifts and cellular damage∙ peripheral vascular alteration ~ compartment syndrome

14

∙ direct inhalation or systemic response∙ inflammation ~∙ interstitial pulmonary edema ~∙ upper airway ~ ∙ smoke poisoning ~ ∙ CO poisoning ~

∙ Respiratory

15

∙ paralytic ileus-∙ stress (curling’s) ulcers ~∙ ischemic bowel → bacterial translocation → sepsis →

multiple organ dysfunction

∙ Urinary

∙ early stages ~ ↓renal blood flow → ↓ GFR ∙ myoglobinuria∙ progresses to renal failure

∙ Gastrointestinal ~ dysfunction related to size of burn wound

16

∙ Immune System ~ open wounds and decreased immune function, infection and sepsis leading cause of death in acute phase

local changes∙ partial thickness → full thickness∙ ulceration of healthy tissue∙ erythematous nodular lesions → in uninvolved tissue∙ vesicular lesions in healed tissue∙ edematous tissue surrounding wound∙ excessive drainage, odor∙ pale, dry, crusted granulated tissue∙ graft rejection∙ dehiscence

systemic changes∙ changes in LOC∙ subtle changes in VS (hemodynamic instability, hypoxemia)∙ ↑ fluids to maintain adequate urine output ~ oliguria∙ GI dysfunction ~ diarrhea, vomiting, ileus, distention∙ hyperglycemia∙ thrombocytopenia∙ ↑ or ↓ WBC ∙ metabolic acidosis

Monitor for organism related infection sepsis

17

∙ increased secretion ~

∙ activated stress response ~

∙ extent of injury dictates caloric needs

∙ increase in core body temperature

∙ Metabolism ~ heat and water loss increases metabolic and catabolic rates → increase caloric needs → resting metabolic rate ↑ 50% to 100%

18

Treatment ~ three stages of treatment

∙ 1. Emergent – Resuscitative Stage ~ from injury through successful fluid resuscitation – 24 to 28 hours up to 5 days

∙ priority – detect/prevent ~ hypovolemic shock∙ airway management - intubation∙ limit extent of burn∙ restore circulating volume ~ ↓ risk of burn shock, replace electrolytes, maintain adequate urine output

∙ large bore IV access∙ cut down

∙ transfer to burn center if indicated and applicable

19

∙ 2. Acute Phase ~ begins with diuresis (fluid shift) and ends with wound closure – wound are healed

∙ wound management ~∙ nutritional support – enteral/parenteral∙ monitor for signs and symptoms of infection/prevent sepsis∙ pain management∙ monitor electrolytes ~

∙ Na hyponatremia – hydrotherapy, GI drainagehypernatremia – hypertonic IV fluids, incorrect tube feeding

∙ K+ hypokalemia – hydrotherapy, vomiting, diarrhea, GI suctioning, IV w/out replacement hyperkalemia – secondary to renal failure, adrenocorticoid insufficiency, massive deep tissue injury

20

∙ prevention of contractures and scars ∙ client returns to work, family, and social roles ∙ may include vocational, occupational, physical and psychosocial rehabilitation

3. Rehabilitative stage ~ begins with wound closure up to and including restoration of optimal health status and function – may take years

21