Burn Injuries Nursing Role and Intervention

Burn Injuries
Burn Injuries

Categories :
1.  Thermal  (Flame and electrical)
2.   Radiation
3.   Chemical
Skin and mucosa of upper airways are sites of tissue destruction, deep tissues can be damaged by electrical burns or through long contact
Depth of injury depends on temperature of burning agent and duration of contact
  Classified according to :
      1.  Depth of tissue destruction
2.  Extent of body surface area injured (BSA)

Classification of Burns

First Degree (superficial partial-thickness)
     –  Epidermis, possibly part of dermis
–  Symptoms: tingling, super sensitivity, pain soothed by    cooling
–   Appearance: reddened, blanches with pressure,  dry,  no  edema,  possible blisters
–   Complete recovering within a week,  no scarring
Second Degree (deep partial-thickness)
      –   Epidermis, upper dermis and part of lower dermis
–   Pain,  hyperesthesia,  sensitive to cold air
–   Blistered,  mottled red base,  broken epidermis,  weeping,  edema
–   Recovery in  2 – 4  weeks,  some scarring
   Third Degree  (full thickness)

–  Epidermis, entire dermis, may involve subcutaneous tissue, connective tissue, muscle and bone
–  Pain-free, signs of shock, hematuria,
–  Wound is dry, pale white, leathery or charred, broken skin with fat exposed, edema
–  Grafting is necessary, scarring and loss of function, contractures, loss of extremities possible

Rule of Nines

– Quick way to calculate the extent of burns
– Assigns percentages in multiples of nine to major body surfaces

Systemic Effects

– Burns that exceed 25% of BSA  produce systemic effects  proportional to extent of burn injury, maximum systemic response seen in burns covering 60% or more of  BSA
Cardiovascular instability resulting from loss of capillary integrity
    –  Shift of fluid, Na, protein from intravascular space to interstitial spaces.
–  Greatest volume of fluid leak in first  24 – 36 hrs
–  Decreased cardiac output and BP – Burn Shock
–  Capillaries begin to regain integrity and fluid returns to vascular system – blood volume increases,  urine output increases for up to 2 weeks.

Pulmonary System

– Inhalation injury is leading cause of Death,  1/3  of patients have pulmonary problems :
1.  Upper airway injury from direct heat or edema, obstruction in pharynx and larynx, requiring intubation
2.  Inhalation injuries below glottis from inhaling noxious gases (C.O., nitrogen oxide, cyanide, ammonia, chlorine, benzene, etc.)  Direct chemical irritation of pulmonary tissue at alveoli causes:
–  Loss of ciliary action, hyper secretion, severe mucosal damage, bronchospasm, atelectasis
– C.O. most common cause – byproduct of combustion of organic material
–  C.O. combines with HBG to form carboxyhemoglobin, competes with O2 for HGB binding sites – hypoxia
– 50% with pulmonary involvement show no  S&S initially – must be closely monitored for 24 hrs
– Airway obstruction can occur very rapidly or slowly
– Decreased lung compliance, decreased O2, respiratory acidosis can be gradual over 5 days
Indications of pulmonary damage:
– Burn in enclosed area, burn of face/neck, singed nasal hair, hoarse voice, dry cough, stridor, sooty sputum, bloody sputum, labored breathing, tachypnea, erythema or blistering or oral mucosa
– Pulmonary complications – ARDS, ARF

  Renal
– Destruction of RBC’s  and muscle cells  cause free HGB and myoglobin to occlude renal tubules if inadequate blood flow – acute tubular necrosis and renal failure

Immune System
     – Loss of  skin integrity, decreased lymphocytes cause immunosuppression – high risk for sepsis
   GI System
     – Paralytic ileus leads to gastric distention and N/V
– Gastric bleeding secondary to massive physiological stress – coffee ground vomit, occult blood in stool – signs of ulcer

  Fluid and Electrolytes
   – Blood volume decreases rapidly
– Evaporative losses through wound 3-5  L/24 hrs
–  Hyponatremia
–  Hyerkalemia (massive cell destruction)
–  Hypokalemia later with fluid shifts
–  Anemia – RBC’s damaged and destroyed, and blood loss during surgeries and wound care
–  Abnormal coagulation – decreased platelets, prolonged clotting times
   Temperature
    – In early hours, decreased body temperature due to loss of skin
–  Later hypermetabolism causes increased temperature
Local Effects
– Burns that cover less than  25%  BSA
– Loss of capillary integrity and fluid shifts are localized to burn itself – blister and edema
Compartment Syndrome:
– If edema in extremities causes pressure on blood vessels and nerves can obstruct blood flow and cause ischemia
–  Treated with Escharotomy – surgical incision into eschar (scar) to relieve constriction
–  Full thickness burns to neck and thorax can cause edema that constricts trachea and chest wall
Nursing Management – Emergent Phase
– ABC’s
    – Establish airway, 100% humidified O2, intubate
– Prevent Shock
   At Scene:
    – Extinguish Flames
–  Cool Water to halt burning process, pain relief and decrease edema  (NOT ice or cold water)
–  Remove restrictive objects (clothes, jewelry)
– Cover wound  ASAP with clean cloth
> Decreases bacterial contamination and pain
> No ointments or medicines on wound
–  Irrigate chemical wound with water, flush eyes
  History
–   Time of injury,  mechanism of burn, closed space, inhalation of noxious chemicals, related trauma, pre-burn weight, allergies, tetanus immunization
– Baseline  ABG’s blood work, X-rays, urinalysis
– Assess and clean wound
– Insert NG  tube if nauseated or greater than  25%  BSA
– Urinary catheter
– Large Bore  lV – 16, 18G
– Frequent VS, respiratory status, peripheral pulses
– Elevate burned extremities
Fluid replacement to prevent shock
    – Fluid requirements calculated based on extent of burn injury, weight of patient, time of injury
– Combination of colloids (blood, plasma) and crystolloids (NS, lactated Ringers)
– Monitor response carefully (HR, BP, U/O)
– Goal: HR less than 110/min,  SBP greater than 100, U/O  30-50 ml/hr
– Monitor HCT, HBG, Na, urinalysis

Nursing Care – Intermediate phase

– Begins  48 – 72 hrs after injury
– Monitor respiratory status
– Airway obstruction related to edema can take 48 hrs to develop
– Monitor Cardiac status
– capillaries regain integrity after  48 hrs – fluid moves into intravascular compartment – diuresis begins
– If cardiac or renal function is inadequate – fluid overload – symptoms of  CHF ( treat with vasoactive drugs, diuretics, fluid restriction)
– Maintain body temperature at  37.2 – 38.3 Cent.
– Fever is common (treat with Tylenol, hypothermic blankets to reduce metabolic stress)
– Prevent Infection
    – Major cause of Death
– Burn is excellent medium for bacterial growth
– Wear cap, gowns, gloves, mask
– Use aseptic technique for wound care
– Monitor WBC’s, culture wounds regularly
– Screen visitors, no flowers or fruits in room
– Maintain Fluid Balance
     – Monitor carefully – l & O, daily weights
– Assess for edema, JVD, crackles
– Use Infusion pump for fluid administration
– Nutrition
    – Hyper metabolism causes increased basal metabolic needs by 100%
– Formulas used for estimating caloric requirements
– Start oral fluids slowly when bowel sounds resume
– Protein-rich, calorie-rich diet, supplements as needed
– TPN if weight loss greater than  10%
– Pain Management
– Morphine IV before wound care, possible conscious sedation, antianxiety meds. (Ativan, Versed)
– Frequent assessment of pain, give meds. before pain is severe to increase effectiveness
   Promote skin integrity
    –  Assess wound carefully, monitor progress of healing
–  Analgesics prior to care
–  Dressings soaked if adhered to wound
–  Hydrotherapy – cleansed well and patted dry
–  Exudate and dead skin removed
–  Topical antibacterial creams applied
–  Covered with several layers of dressing
–  Assess discharge planning needs for wound care at home
– Debridement
   – Natural – Dead tissue separates from underlying viable tissue spontaneously
– Mechanical
> using scissors and forceps to separate and remove eschar
> Dressing can be a good debriding agent – applied dry or wet – dry will slowly debride the wound or exudate or eschar when it is removed
> Topical enzymatic debridement agents
– Surgical
> excision of full thickness skin down to viable tissue
> skin graft applied
> High risk for blood loss
  Grafts
– In full thickness wounds, spontaneous wound healing is not possible.
– Wounds are covered to prevent infection, prevent loss of protein, fluids and electrolytes and to minimize heat loss through evaporation, until grafting is possible.
– Main areas for skin grafting are face, hand, feet and joints (increases function, reduces contractures)
– Biological or synthetic dressings are used until autografting is possible
– Autografts applied in sheets, covered with occlusive dressing.
– If blood, serum, fat, air or necrotic tissue lies under graft, it may not take.
– Donor site – moist dressing, heals in 1-2 weeks.
Promote physical mobility
– Deep breathing, turning to prevent pneumonia and atelectasis.
– Control edema.
– Prevent pressure ulcers.
– Range of motion exercises and splints to prevent contractures.
Monitor and manage potential complications
– CHF and pulmonary edema
– Sepsis
– Acute respiratory failure and ARDS
Calculation of fluid requirement
4ml x wt in kg x TBSA burned
Calculation of caloric requirement
(25 x wt in kg) + (40 x TBSA burned)

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