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BURNS
Traumatic injury to the skin or tissue due to thermal, cold,…
BURNS
- Traumatic injury to the skin or tissue due to thermal, cold, electrical, radiation, friction, or chemical exposure
- Range from minor => life-threatening
- Possibly permanently disfiguring and incapacitating
- Depth of injury ranging from superficial to full thickness
Classification
- 1st degree / Superfcial
- 2nd Degree / Superficial/ Partial thickness
- 2nd degree / Deep partial thickness
- 3rd / 4th degree/ Full thickness burns
2nd degree/ Superficial
- Injury extends from the epidermis into the *superficial layer of the dermis.
- Thin-walled, fluid-filled blisters form.
- Nerve endings are exposed to air when blisters break, causing pain.
- Loss of the skin's barrier function occurs.
2nd degree Deep
- Injury extends from the epidermis into the deep layers of the dermis.
- Damage to hair follicles and glandular tissue occurs.
- Thicker-walled blistery areas form that usually present as red or waxy white.
- Nerve endings are exposed to air when blisters break, causing pain.
- Skin loses its barrier function.
- Grafting may be necessary.
1st degree/ Superficial:
- local epidermal injury
- non-life threatening
3rd & 4th degree/ Full thickness
- Injury affects every body system and organ.
- Injury extends into the subcutaneous tissue layer.
- Muscle, bone, and interstitial tissues suffer damage (fourth-degree).
- Interstitial fluids result in edema.
- Immediate immunologic response occurs.
- Wound sepsis may occur.
- Injuries are painless because of extensive nerve damage.
Causes
- Electrical: Contact with electrical source, faulty electrical wiring, or high-voltage power lines
- Thermal: Contact with heat, steam, or flames
Scald: Contact with hot water
- Chemical: Contact, ingestion, inhalation, or injection of acids, alkali, or vesicants
- Radiation: Exposure to sun, sun-lamps, or radiation therapy
- Friction: Contact with rough surfaces, such as roadway, carpet, or gym floors
- Cold exposure: Exposure to extreme cold (also known as frostbite)
Risk Factors
- Dementia
- Smoking
- Poor socioeconomic status
- Developmental disabilities (children)
- Adults with chronic illness with poor mobility
- Sun exposure /no sunscreen
- Occupation w/ exposure to burn source: firefighters, cooks, electricians, chemical workers
Incidence
- Burns affect 1.2 to 2 million people/ year in US.
- Most =thermal (from heat).
- Minor burns =most common type (young adults).
- 69% occur @ home.
Complications
- Anemia
- Flexion contractures (affected area)
- Scarring + disability (deformity /destruction of skin, nerves, vessels, and musculoskeletal tissue)
- Gastroduodenal ulcer (increase gastric acid secretion from stress)
- Hypovolemic shock
- Malnutrition
- Multiple organ dysfunction syndrome
- Pneumonia
- Acute respiratory distress syndrome
- Respiratory collapse
- Sepsis
Assessment
Hx
- Cause of burn revealed (most commonly open flame or hot liquid)
- Preexisting medical conditions
- Estimated severity of the burn (according to the American Burn Association):
- Minor
- < 10% of total body surface area (TBSA) in adults
- < 5% TBSA in adults over age 50
- < 2% full-thickness burn
- Moderate
- 10% to 20% TBSA burn in adults
- 5% to 10% TBSA in adults over age 50
- 2% to 5% full-thickness burn
- High-voltage injury
- Suspected inhalation injury
- Circumferential burn
- Underlying medical problem, such as diabetes
- Major
20% TBSA burn in adults
10% TBSA burn in adult over age 50
5% full-thickness burn
- High-voltage burn
- Known inhalation injury
- Any significant burn to the face, eyes, ears, genitalia, or joints
- Significant associated injuries
Other Physical Findings
- Respiratory distress and cyanosis
- Edema
- Alterations in pulse rate, strength, and regularity
- Stridor, wheezing, crackles, and rhonchi
- Hoarseness
- S3 or S4 heart sounds
- Hypotension
- Soot marks on face
- Blisters or edema of oropharynx
Full-thickness (third-degree)
- Waxy white, leathery, or charred skin that does not blanch and is nonpliable to palpation
- Destruction of all layers of skin and subcutaneous layers, resulting in an avascular burn w/o tenderness
- increased risk of infection and sepsis
Superficial (first-degree)
- erythema of tissue
- skin blanching with pressure
- possible tenderness (resembles sunburn)
Partial-thickness:
Superficial partial-thickness
- red, blistered, highly tender skin
- blanching with pressure
- no scarring
- Deep partial-thickness
- Possibly red or waxy white (mottled appearance from patchy, cheesy white to red)
- No blanching with pressure
- significantly delayed or absent capillary refill time
- impaired sensation
- painful to pressure
- blistering
Physical Findings
- Depth / Size of burn
- Estimated burn severity
- Respiratory distress and cyanosis
- Edema
- Alterations in pulse rate, strength, and regularity
- Stridor, wheezing, crackles, and rhonchi
- Hoarseness
- S3 or S4 heart sounds
- Hypotension
- Soot marks on face
- Blisters or edema of oropharynx
Monitoring
- Vital signs
- Pain level + effectiveness of interventions
- Respiratory status
- Cardiac status
- Burn areas, including evidence of healing
- S&S of infection + shock
- I&O
- Daily weight
- Fluid balance
- Nutritional status
- emotional status /coping mechanisms
Nursing Interventions
- Imediate, aggressive burn treatment.
- Strict sterile technique.
- Remove pt's clothing; cover all burned areas with dry sheets.
- Remove constrictive items, (rings/ watches) to prevent tourniquet effect.
- Administer 100% O2 for all major burns; maintain saturation between 94%-98%; anticipate need for endotracheal intubation + mechanical ventilation.
- Perform appropriate wound care
- Whirlpool hydrotherapy
- daily or twice-daily wound cleaning w/ dressing changes.
- Administer fluid replacement therapy as ordered
- Insert Foley catheter (evaluate hourly urine output)
- Give analgesics as ordered.
- if administering morphine I.V. give small freq doses+ be alert for respiratory depression
- Ensure patent I.V. access.
- Pre-medicate pt w/ analgesics before:
- dressing changes
- wound care
- hydrotherapy
- In pt w/electrical burns +evidence of myoglobulinuria increase fluids to decrease risk of kidney failure.
- mannitol (Osmitrol-alkalization agent) if fluid boluses don't increase urine output / decrease urinary pigmentation
Institute continuous cardiac monitoring for the 1st 24 h post electrical burn.
- Auscultate heart /lung sounds for changes.
- Institute hemodynamic monitoring as appropriate.
- Daily patient weight.
- Reposition pt min q two hours,
- Assess skin integrity + perform skin care.
- Provide NG tube feedings if ordered + indicated, or
- TPN if the patient is expected to be on NPO status for > 5 days.
- Provide a high-calorie/ high-protein diet once bowel function returns.
- Administer histamine-2 blockers (ulcer prophylaxis)
- Obtain specimens for laboratory testing, including CBC, BUN / creatinine + ABG's.
- Prepare the patient +family for possible surgery (escharotomy or skin grafting)
- Apply antiembolism stockings /sequential compression stockings (prevent VTE)
- Encourage verbalization +provide support.
- Allow the patient & family to verbalize fears /concerns
- Provide honest explanations /answers
- Assist with positive coping strategies
Patient Teaching
General
- injury, diagnostic testing, + treatment, including the use of analgesics for pain relief
appropriate wound-care methods, including dressing changes, topical applications, and types of dressings
- pain-relief measures, including the use of analgesics
- prescribed medications, including drugs, dosages, schedule of administration, rationale for use, and possible adverse reactions
- appropriate nutritional plan, including ways to increase calories and protein in the diet
- signs and symptoms of infection
- signs and symptoms of complications
- infection-control measures
- activity and exercise program as indicated
- care of the donor and skin graft sites if appropriate
- burn-prevention measures, if indicated
- long-term nature of the care required if surgery or skin grafting is indicated.
Discharge Planning
- coordinate discharge planning efforts w/ care team including bedside nurse, social worker, care manager, psychiatrist, burn specialist, physical therapist, and surgeon.
- Determine the appropriate post-hospital setting to be discharged to.
- Assess pt /family understanding of the diagnosis, treatment, prognosis, follow-up, +warning signs for which to seek medical attention.
- Assess the pt's cognitive status.
- Assess the pt's level of independence prior to admission + how the p's current illness will impact his independence.
- Identify the pt's formal /informal supports.
- Identify the pt's and family's goals, preferences, comprehension, and concerns about discharge.
- Confirm arrangements for transportation to initial follow-ups.
- Assess/confirm the pt's + family's understanding of prescribed medication, including dosage, administration, expected results, duration, and possible adverse effects.
- Assess/confirm the patient's ability to obtain medications+ identify the party responsible for obtaining medications.
- Ensure that the patient +caregivers have been given medical contact information.
- Provide contact information for local support groups/ services.
- Document the discharge planning evaluation in the patient's clinical record, including who was present/involved in discharge planning and teaching.
- Document the pt's understanding of the teaching provided and if follow-up teaching is needed.
Diagnostics
Laboratory
- Arterial blood gases:
- levels may show evidence of smoke inhalation, decreased alveolar function, and hypoxia.
*CBC
- may show decreased Hemoglobin / hematocrit from blood loss
- CMP: Complete metabolic Panel
- fluid losses and shifts=> abnormal electrolyte levels.
- BUN
- UA:
- myoglobinuria +hemoglobinuria.
- Carboxyhemoglobin:
- inhalation burns /exposure to enclosed fires =>level increases
Procedures
- Electrocardiography
- myocardial ischemia/ injury / arrhythmias ( especially in electrical burns or carbon monoxide poisoning)
- Fiber-optic bronchoscopy
- shows airway edema from inhalation burns /steam injuries.
Fluid Replacement post burn injury
To replace fluid in an adult with a burn, use the Parkland formula:
- 4 mL × patient's weight (kg) × % TBSA burn (lactated Ringer solution)
- Give one-half of volume in the first 8 hours, and then infuse the remainder over 16 hours.
Surgery
- Debridement
- Fasciotomy / escharotomy
- Skin grafting
Medications
- Tetanus toxoid booster
- Analgesics,
- I.V. morphine sulfate
- methadone hydrochloride (Dolophine) severe pain
- codeine phosphate-acetaminophen (Tylenol w/ Codeine)
- oxycodone hydrochloride-acetaminophen (Percocet)
- hydrocodone bitartrate-acetaminophen (Norco) moderate pain
- Mannitol (Osmitrol) (oliguria in electrical burns)
- Silver sulfadiazine (topically)
:forbidden: Avoid applying silver sulfadiazine to the face (prevent permanent facial discoloration)
- bacitracin ointment (superficial partial-thickness burns)
- Mafenide (severe infected burns + no response 2 silver sulfadiazine)
- Histamine-2 blockers (stress ulcer prophylaxis for severe burns)
- cimetidine (Tagamet)
- ranitidine (Zantac)
- famotidine (Pepcid)
- Insulin therapy (glycemic control for severe burns)
- Oxygen therapy
General Treatment
- Eliminate burn source; cessation of the burning process
- Decontaminate chemical burns
- Remove constrictive clothing / jewelry
- Assess + Secure Airway, breathing, and circulation
- Intubate for inhalation injury
- Administer Oxygen /maintain SpO2 94%–98%
- ECG monitoring x 1st 24 h
- Prevent hypoxia
- I.V. fluids through large-bore line: urine output
- 0.5 to 1 mL/kg/hour
- electrical injuries /rhabdomyolysis / myoglobulinuria present= urine output at 1 to 2 mL/kg/hour
- Urine Output qh =Foley Cath
- NG tube for decompression + aspiration prevention
- Wound care
- Physical / Occupational therapy
- VTE prophylaxis if hospitalized
- Prepare patient 4 transport to burn center, if appropriate
Diet
*NPO until burn severity established => high-protein, high-calorie BS return
- Increased hydration w/high-calorie/protein drinks
*no free water
*Enteral feedings if unable to take food orally
- TPN if unable to take food by mouth
- Control of Blood Glucose levels (hypermetabolic stress response / receiving TPN)
Activity
- Limitations based on extent + location of burn and treatment
- PT