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1 Nursing Care & Interventions in the Client with Burn Injury Keith Rischer RN, MA, CEN.

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Presentation on theme: "1 Nursing Care & Interventions in the Client with Burn Injury Keith Rischer RN, MA, CEN."— Presentation transcript:

1 1 Nursing Care & Interventions in the Client with Burn Injury Keith Rischer RN, MA, CEN

2 2 Todays Objectives… Compare and contrast the clinical manifestations of superficial, partial-thickness, and full-thickness burn injuries. Prioritize nursing care for the client during the emergent, acute, and rehabilitation phase of burn injury. Analyze assessment data to determine nursing diagnoses and formulate a plan of care for clients with burn injuries. Use laboratory data and clinical manifestations to determine the effectiveness of fluid resuscitation. Describe nursing management wound care and nutritional needs for the burn client. Evaluate assessment data to determine wound healing in the burn client. Identify pain management strategies for burn clients. Explain the positioning and range-of-motion interventions for the prevention of mobility problems in the client with burns. Discuss the potential psychosocial problems associated with burn injury.

3 3 Burn Injury: Patho Skin Epidermis Dermis Purposes Skin destruction Fluid/protein loss Sepsis Multi-system changes Dependant on age Health Depth of injury Body area involved

4 Depth of Burn Injury 4 Superficial-thickness Epidermis only Partial-thickness Epidermis + partial Dermis Full-thickness Epidermis + all dermis + underlying tissue/muscle/bone

5 5 Assessment: Superficial-thickness Pain Redness Heals in 3-5 days

6 6 Assessment: Partial-thickness Red-blanch No blanch with deeper burn Blister and broken epidermis Painful Heal in days

7 7 Assessment: Full-thickness Pale, white to red, yellow Charred eschar Leathery skin, dry surface Painless Edema present Signs of systemic shock may be present Needs grafting

8 8 Burns: Vascular Changes Fluid shift Capillary leakage First 12 hours Lasts hours Lyte & acid base imbalance Hypovolemia Hyperkalemia, hyponatremia Fluid remobilization Diuretic stage (48-72 hours) Hyponatremia hypokalemia

9 9 Burns: Body System Assessment Cardiac HR increase CO decreased initially Respiratory Airway edema pulmonary cap. leakage GI Paralytic ileus Metabolic Increased due to catecholamines, cortisol and SNS Caloric needs double or triple Immune Diminished response Increased risk of infection

10 10 Burns: Emergency Management Primary Survey Airway Breathing Circulation C-Spine immobilization (when indicated) Secondary Survey Complete head to toe exam % of TBSA Depth of burn Part(s) of body burned Rule out other serious or life threatening injuries

11 11 Inhalation Injury: Assessment Facial burns Singed nasal hairs Stridor CO Poisoning HA Nausea Alterered LOC Confusion Coma Severe cough Hoarseness Shortness of breath Anxiety Wheezing Dyspnea Disorientation Obtunded Coma Symptoms Signs

12 Burn Classification 12 Minor <15% partial thickness Moderate 15-25% partial thickness <10% full thickness Severe >25% partial thickness >10% full thickness

13 ABA Burn Referral Guidelines 13 2° Burns > 10% TBSA Burns involving the face, hands, feet, genitalia, perineum, & major joints 3° Burns in any age group Electrical Burns lightning injuries Chemical Burns

14 14 Laboratory Findings: First 48 hours Hgb/Hct Glucose Sodium Potassium BUN/creatinine Albumin ABGs pO2 pCO2 pH CO

15 15 Nursing Diagnostic Priorities: First 48 Hours Decreased cardiac output r/t… Deficient fluid volume r/t… Ineffective tissue perfusion r/t… Ineffective breathing pattern r/t… Acute pain r/t…

16 16 Fluid Resuscitation Nursing interventions Large bore IV/central IV access Lactated ringers Nursing Assessment I&O Urine output Daily weight Oxygenation needs Fluid overload VS Labs Creatinine Albumin lytes

17 17 Nursing Diagnostic Priorities: First 48 Hours Ineffective breathing pattern r/t… Respiration pattern Oxygenation ABGs –pH: 7.41….7.29 –p02: 73….55 –pCO2: 44….60 Acute pain r/t… Opiods IV Fentanyl... Onset___ Peak___ Duration___ Morphine… Onset___ Peak___ Duration___ Dilaudid…Onset___ Peak___ Duration___

18 18 Assessment Priorities: After 48 Hours Cardiopulmonary Pneumonia Neuroendocrine Increased metabolic demands Immune (risk of infection) Local Systemic VS Altered LOC u/o

19 19 Nursing Diagnostic Priorities: After 48 Hours Impaired skin integrity r/t… Risk of infection r/t… Imbalanced nutrition-less than body requirements r/t… Impaired physical mobility r/t… ROM Early ambulation Disturbed body image r/t…

20 Impaired Skin Integrity-Wound Care 20 Debridement Hydrotherapy Wound dressings Antibiotic ointment Biologic Synthetic Skin grafts Autograft Artificial

21 21 Dressings: Topical Antibiotics Silver Sulfadiazine Most frequently used topical Gram negative/positive organisms Penetrates eschar well Applied with a gloved hand, tongue depressor or impregnated in gauze Bacitracin Acceptable for use with superficial burns Least expensive antimicrobial agent

22 Dressings 22 Decrease pain Absorb drainage Preserve joint mobility and allow ROM Provide protection and isolation of wound from environment

23 23 Nutrition Metabolic changes Hormone mediated > Catecholamines > Glucocorticoids and glucose to insulin ratios Metabolic alterations > Gluconeogenesis > Proteolysis > Ureagenesis < Lipolysis & Ketone utilization Net Results of Changes > Nitrogen losses > Energy Expenditures and nutrition metabolism Results Hypermetabolic - catabolic state

24 24 Enteral Feedings Preferred route Safety Better utilization of nutrients Gut integrity Lower cost Parenteral (TPN) Nonfunctional guts High risk for sepsis Objectives

25 25 Psychological Issues & Follow Up Inpatient PTSD Disfigurement Sexual issues CD Outpatient Ongoing therapy Support groups Burn Camp

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