1. Sarah Bishop, Troy Davis, Laura Kiss-Illes
BURN INJURY
Sarah Bishop, Troy Davis, Laura Kiss-Illes

2. Pathophysiology
Burns are caused by a transfer of energy from a heat source to the body.
Disruption of the skin can lead to increased fluid loss, infection, hypothermia, scarring, compromised immunity, and change in function and appearance of body.
The depth of the injury depends on the temperature of the burning agent and the duration of contact with the agent.
Types
Thermal (includes electrical)
Radiation
Chemical
Sarah

3. Physiologic Changes
Burns less than 25% total body surface area (TBSA) produce primarily a local response.
Burns more than 25% may produce a local and systemic response, and are considered major burns.
Systemic response includes release of cytokines and other mediators into systemic circulation.
Fluid shifts and shock result in tissue hypoperfusion and organ hypofunction.
Fluid and electrolyte shifts
Fluid reenters the vascular space from the interstitial space
Hemodilution
Increased urinary output
Sodium is lost with diuresis and due to dilution as fluid enter vascular space: hyponatremia
Potassium shifts from extracellular fluid into cells: potential hypokalemia
Metabolic acidosis
Sarah
As class some risk factors
Talk about rule of 9s

4. Risk Factors
Men have greater than twice the chance of burn injury than women
Elderly because of reduced mobility, coordination, strength, and sensation. Vision changes also place them at high risk.
Diabetics with neuropathy because they have decreased sensation
Those with high risk jobs dealing with high heat
Young Children
Laura

5. General Goals Related to Burns
Prevention
Institution of lifesaving measures for the severely burned person
Prevention of disability and disfigurement through early specialized and individualized care
Rehabilitation through reconstructive surgery and rehabilitation programs
Laura

6. Burn Severity 6-10 Troy Symptoms:
Superficial-Partial- Tingling, hyperesthesia (supersensitivity), pain that is soothed by cooling
Deep-Partial- pain, hyperesthesia, sensitive to cold air
Full- pain free, shock, hematuria, possibly hemolysis, possible entrance and exit wounds (electrical burns)

7. Severity of Burn Injury

8. Superficial Partial

9. Deep-Partial

10. Full Thickness

11. Factors to consider How the injury occurred Causative agent
Temperature of agent
Duration of contact with the agent
Thickness of the burn
Laura 11-16

12. Phases of Burn Injury Emergent or resuscitative phase
Onset of injury to completion of fluid resuscitation
Acute or intermediate phase
From beginning of diuresis to wound closure
Rehabilitation phase
From wound closure to return to optimal physical and psychosocial adjustment

13. Emergent or Resuscitative Phase
Prevent injury to rescuer
Stop injury: extinguish flames, cool the burn, irrigate chemical burns
ABCs: Establish airway, breathing, and circulation
Start oxygen and large-bore IVs
Remove restrictive objects and cover the wound
Do assessment surveying all body systems and obtain a history of the incident and pertinent patient history
Note: treat patient with falls and electrical injuries as for potential cervical spine injury

14. Emergent or Resuscitative Phase Cont.
Patient is transported to emergency department
Fluid resuscitation is begun
Foley catheter is inserted
Patient with burns exceeding 20–25% should have an Ng inserted and placed to suction
Patient is stabilized and condition is continually monitored
Patients with electrical burns should have ECG
Address pain; only IV medication should be administered
Psychosocial consideration and emotional support should be given to patient and family
Potential Complications for this Phase:
Acute respiratory failure
Distributive shock
Acute renal failure
Compartment syndrome
Paralytic ileus
Curling’s ulcer
Nursing Diagnoses for this Phase:
Impaired gas exchange
Ineffective airway clearance
Fluid volume deficit
Hypothermia
Acute Pain
Anxiety

15. Acute of Intermediate Phase
48–72 hours post injury
Continue assessment and maintain respiratory and circulatory support
Prevention of infection, wound care, pain management, and nutritional support are priorities in this stage
Potential Complications
Heart failure and pulmonary edema
Sepsis
Acute respiratory failure
Visceral damage (electrical burns)
Other Nursing Diagnoses in this phase:
Excessive fluid volume
Risk for infection
Imbalanced nutrition
Acute pain
Impaired physical mobility
Ineffective coping
Interrupted family processes
Deficient knowledge

16. Rehabilitation Phase
Rehabilitation is begun as early as possible in the emergent phase and extend for a long period after the injury.
Focus is upon wound healing, psychosocial support, self-image, lifestyle, and restoring maximal functional abilities so the patient can have the best quality life, both personally and socially.
The patient may need reconstructive surgery to improve function and appearance.
Vocational counseling and support groups may assist the patient.

17. Treatments and Nursing Management
Management of shock
Fluid resuscitation
Maintain blood pressure of greater than 100 mm Hg systolic and urine output of 30–50 mL/hr, maintain serum sodium at near-normal level
Burn wound care
Wound cleaning
Hydrotherapy
Use of topical agents
Wound debridement
Natural debridement
Mechanical debridement
Surgical debridement
Wound dressing, dressing changes, and skin grafting
Sarah 17-27

18. Treatments and Nursing Management
Burn wound care
Wound cleaning
Hydrotherapy
Use of topical agents
Wound debridement
Natural debridement
Mechanical debridement
Surgical debridement
Wound dressing, dressing changes, and skin grafting

19. Treatments and Nursing Management
Pain Management
Burn pain has been described as one of the most severe forms of acute pain
Pain accompanies care, and treatments such as wound cleaning and dressing changes
Types of burn pain
Background or resting
Procedural
Breakthrough
Analgesics
Role of anxiety in pain
Effect of sleep derivation on pain
Nonpharmacologic measures

20. Treatment and Nursing Management
Nutritional Support
Burn injuries produce profound metabolic abnormalities, and patient with burns have great nutritional needs related to stress response, hypermetabolism, and requirement for wound healing.
Goal of nutritional support is to promote a state of nitrogen balance and match nutrient utilization.
Nutritional support is based upon patient preburn status and % of TBSA burned.
Enteral route is preferred. Jejunal feedings are frequently utilized to maintain nutritional status with lower risk of aspiration in a patient with poor appetite, weakness, or other problems.

21. Treatment and Nursing Management
Other care to consider
Pulmonary care
Psychological support of patient and family
Patient and family education
Restoration of function

22. Medications Analgesics Fluids IV use during emergent and acute phases
Morphine
Fentynal
Other
Fluids

23. Lab/Diagnostic Tests Labs Diagnostics
Potassium (will be high initially, then will be low)
Sodium (will be low)
Blood pH (metabolic acidosis)
Hematocrit (will be high)
Diagnostics
Determine what percentage of your total body surface area (TBSA) is involved.
Rule of nines, Lund and Browder method, Palm method
Depending on the severity of the burn and the circumstances that caused it, you may need lab tests, X-rays or other diagnostic procedures.

24. Nursing Diagnosis
Impaired gas exchange r/t carbon monoxide poisoning, smoke inhalation, and upper airway obstruction AEB labored breathing, hoarseness and dry cough
Goal
Maintenance of adequate tissue oxygenation
Interventions
Provide humidified oxygen
Assess breath sounds/respiratory rate/rhythm/depth/symmetry. Monitor patient for signs of hypoxia
Monitor ABGs, pulse oximetry
Prepare to assist with intubation

25. Nursing Diagnosis
Ineffective airway clearance r/t edema and effects of smoke inhalation AEB bloody sputum and difficulty getting rid of secretions, O2 <90%
Goal
Maintain patent airway and adequate airway clearance
Interventions
Maintain patent airway through proper positioning, removal of secretions, and artificial airway if needed.
Provide humidified oxygen
Encourage patient to turn, cough, deep breathe. Encourage patient to use incentive spirometry
Suction as needed

26. Nursing Diagnosis
Fluid volume deficit r/t increased capillary permeability and evaporative losses from burn wound AEB decreased urine output
Goal
Restoration of optimal fluid and electrolyte balance and perfusion of vital organs
Interventions
Observe vital signs, urine output, and be alert for s/s of hypovolemia or fluid overload.
Monitor urine output hourly, daily weights
Maintain IV lines
Observe for symptoms of deficiency or excess of serum electrolytes (sodium, potassium, calcium, phosphorus, and bicarbonate)

27. Patient/Family Teaching
Teach about the injury, treatment, complications and planned follow-up care to reduce anxiety of family and patient
Assess psychological reactions to burns and address patient’s fears and concerns (providing them with support and available health care teams that can help. Also journal keeping may be helpful)
Available support groups (usually located at burn facility)
Home/self-care. Prepare patient and family for the care that will continue at home, which include: measures and procedures they will need to perform (wash small areas of clean, open wounds that are healing slowly with mild soap and water and apply topical agent/dressing), written/verbal instructions about pain management, nutrition, and prevention of complications; information about exercises and use of pressure garments and splints. How to recognize abnormal signs and to report them to physician

28. Case Study
Bill is a 54-year-old Asian male who sustained a full-thickness burn to 20% of his body while at work 3 days ago. He was exposed to a hot liquid at temperatures exceeding 180°F.
The burn occurred primarily on his right arm, hand, and right side of his chest.
He is currently hospitalized in a burn unit and is in stable condition.
Troy

29. How do thermal burns reduce irreversible cellular injury?

30. What is the impact of this degree and extent of burn on Bill’s cardiovascular system

31. What is the role of escar formation in a full thickness burn?

32. How are full thickness burns different than partial thickness burns with regard to clinical manifestations?

33. What complications are likely given the severity

34. Would the burn Bill sustained be classified as minor, moderate, or major given the American Burn Association Classification?