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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.
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∙ 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
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∙ 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
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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
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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
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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
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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
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Hospital ManagementMinor Burns
∙ skin remains intact - <15% split thickness, <2% full thickness
∙ excludes face/facial structures, hands, feet, perineum
∙ treatment includes:
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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.
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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
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∙ 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
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∙ direct inhalation or systemic response∙ inflammation ~∙ interstitial pulmonary edema ~∙ upper airway ~ ∙ smoke poisoning ~ ∙ CO poisoning ~
∙ Respiratory
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∙ 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
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∙ 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
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∙ 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%
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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
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∙ 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
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∙ 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
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