2. BURN LECTURE M. Catherine Hough RN, Ph.D University of North Florida College of Health Department of Nursing

3. REVIEW OF SKIN FUNCTIONS Functions of the Skin – Protection – Heat Regulation – Sensory perception – Excretion – Vitamin D Production – Expression

4. Cross section of Skin

5. CLASSIFIATION OF BURNS Rx of burn is R/T the severity of the burn - severity is determined by: depth of the burn extent o the burn (% of total body surface area (TBSA) location of the burn patients risk factors

6. CLASSIFIATION OF BURNS... Partial Thickness - characterized by varying depth from epidermis (outer layer of skin) to the dermis (middle layer of the skin) – Superficial - includes only the epidermis (First Degree) – Deep - involves entire epidermis and part of the dermis (Second Degree) Full Thickness - includes destruction of the epidermis and – the entire dermis as well as possible damage to the SQ, muscle and bone (Third and Fourth Degree)

7. Classification… Clinical Appearance – Superficial – 1 st degree Clinical Appearance – Superficial – 1 st degree – Erythema, blanching on pressure, pain & mild swelling, no vesicles or blisters (although after 24 hours the skin may blister and peel Clinical Appearance – Deep – 2 nd degree Clinical Appearance – Deep – 2 nd degree – Fluid-filled vesicles that are red, shiny, wet (if vesicles have ruptured), severe pain caused by nerve injury, mid-to-moderate edema Clinical Appearance – Full-thickness – 3 rd degree Clinical Appearance – Full-thickness – 3 rd degree – Dry, waxy, leathery, or hard skin, visible thrombosed vessels, insensitivity to pain and pressure of nerve distruction, possible involvement of muscles, bone and tendons.

8. MINOR BURNS < 10% of BSA of Partial Thickness Burn < 2% of BSA of a Full Thickness Burn

9. MODERATE BURNS 15-25 % of BSA of Partial Thickness Burn <10% of BSA of a Full Thickness Burn

10. MAJOR BURNS > 25% of BSA of a partial thickness > 10% of BSA of a full thickness Age > 65 or < 2

11. Lund-Bowder Chart

12. Rule of Nines

13. Types of Burns Thermal Burns Thermal Burns Chemical Chemical Electrical Electrical Inhalation Inhalation Radiation Radiation

14. PERIODS OF TREATMENT Emergent Acute Rehabilitation

15. STAGES OF BURNS Hypovolemic Stage - begins @ onset of burn and lasts for the first 48 hours – Rapid fluid shifts - from the vascular compartments into the interstitial spaces – Capillary permeability with burns increases with vasodilation fluid loss deep in wounds (initially sodium and H2O then protein loss) Hemoconcentration - Hct increases – Low blood volume, oliguria – Hyponatremia - loss of sodium and fluid – Hperkalemia - damaged cells release K+, oliguria – Metabolic acidosis

16. STAGES OF BURNS... Diuretic Stage - begins @ 48 - 72 hours after burn injury Capillary membrane integrity returns Edema fluid shifts back into vessels - blood volume increases Increase in renal blood flow - result in diuresis (unless renal damage) Hemodilution - low Hct, decreased potassium as it moves back into the cell or is excreted in urine with the diuresis Fluid overload can occur due to increased intravascular volume Metabolic acidosis - HCO3 loss in urine, increase in fat metabolism

17. I. EMERGENT PERIOD First 24 - 48 hours Maintain airway, fluids, analgesia, temperature, wound Assessment: – Objective: how burn occurred, when, duration, type of agent – Subjective: previous medical problems, size and depth of burn, age, body part involved, mechanism of injury

18. EMERGENT PERIOD... Factors determining severity of burns: size of burn depth of burn age body part effected mechanism of injury history of cardiac, pulmonary, renal, or hepatic diseases injuries sustained @ time of burns duration of contact with burning agent size & depth of burn “Rule of Nines”

19. NURSING DIAGNOSIS Airway clearance Ineffective fluid volume (deficit or excess) Hypothermia High risk for pain (with partial thickness burns) Skin integrity, impaired Anxiety Knowledge deficit

20. INTERVENTIONS Maintain patent airway Maintain patent airway - watch for laryngeal edema – Escharotomy may be needed – 100% FiO2 mask – intubation for inhalation is often required – may inquire emergent tracheostomy – may require ventilatory assistance

21. Tracheostomy to Prevent Airway Obstruction

23. Interventions - Fluid Therapy Start with two large bore IV’s – suture in place Jugular or subclavian line – unburned tissue – burned tissue Cutdown final measure

24. Interventions - Fluid Therapy... Fluid Replacement Crystalloid Solutions NS LR D5%/NS Collid Solutions Albumin Dextran

25. Formulas to Calculate Fluid

26. SIGNS OF ADEQUATE FLUID RESUSCITATION Clear sensorium Pulse < 100 bpm U/O 30-50 cc/hour SBP > 90-100 mm Hg Blood pH within normal range 7.35 - 7.45 Respirations 16-20

27. II. ACUTE PERIOD End of emergent period until burns heal Focus shifts to care of wounds and prevention of complications Actual range of phase depends on degree and extent of burn Assessment: Subjective - pain and anxiety Objective - complete assessment every 8 hours, dietary intake, motor ability, I&O, weight

28. NURSING DIAGNOSIS Skin integrity, impaired Infection, high risk for altered nutrition Pain, acute (with partial thickness burns) Fluid Volume Deficit Anxiety Hypothermia

29. Pain Control Morphine Sulfate 5-10 mg IV every 1-3 hours Combination therapy for painful procedures: – Diprivan – Valium – Haldol – Versed – …

30. NURSING DIAGNOSIS... Impaired skin integrity R/T thermal injury Coping, ineffective individual/family Body Image Disturbance Altered nutrition: less than body requirements R/T increased catabolism and metabolism Mobility, Impaired R/T pain, impaired joint movement, scar formation Self-care Deficit High risk for infection R/T denuded skin, presence of pathogenic organism, & altered immune response

31. INTERVENTIONS Releiving anxiety, denial, regression, anger, depression Wounds - refer to wound care Nutrition (Nutritional assessment, pre albumin levels, large protein requirement, carbohydrates and fats for energy, mega vitamins, TPN, enteral tube feedings any follow (~5,000 kcal/day) Pain - around the clock management Prevention of infection - refer to wound care

32. ORGANISMS: Staphylococcus aureus Pseudomonas Infection is usually the cause of any deterioration

33. SIGNS OF SEPSIS: Change in sensorium Fever Tachyapnea Paralytic ileus Abdominal distention Oliguria

34. WAYS TO PREVENT INFECTIONS: Gowns, masks, gloves Sterile linen Person with URI should not come in contact with patient

35. WOUND CARE Goals: clean & debride the area of necrotic tissue minimize further destruction of viable skin promote wound re-epithelialization promote patient comfort

36. WOUND CARE: Burn wound is unique Burn wound sepsis – gram + – gram (pseudomonas) – fungal (candida albicans)

37. WOUND CARE... Nutrition – collagen primary structure in healing by secondary intention – need increased protein – may need up to double the normal calorie requirements Inadequate blood supply Burn wound disorders – scarring, contractures, keloids, failure to heal

38. WOUND CARE... GOALS: close wound ASAP prevent infection reduce scarring and contractures provide for comfort

39. WOUND CARE... Wound cleaning: at bed side hyrotherapy tanks, tubbing, spray tables Debridement: mechanical, surgical, enzymatic Topical antibacterial therapy - sulfonamide

40. WOUND CARE... Open Technique or Exposed - more often used with burns effecting the: – face – neck – perineum – broad areas of the trunk Partial thickness Partial thickness - exudate dries in 48 to 72 hours forming a hard crust that protects the wound. Full thickness Full thickness - dead skin is dehydrated and converted to black leathery escar in 48 to 72 hours. Loose escare is gradually removed with hydrotherapy &/or debridement

41. WOUND CARE... Closed Technique Wound is washed and sterile dressings changed (may be q shift, daily) Dressing consists of gauze &/or ace wraps impregnated with topical ointments

42. WOUND CARE... Semi-Open consists of covering the wound with topical antimicrobial agents and gauze ADVANTAGE: – speeds debridement – develops granulation tissues faster – makes skin grafting possible sooner

43. WOUND CARE... Biological Dressings: Homeografts - same species (cadaver skin) temporary (3 days to 2 weeks) then body rejects Heterografts - another species (pig skin) temporary coverage (3days to 2 weeks) Autografts - patients own skin can be temporary or permanent coverage Cultured Epithelial Autographs permanent

44. Wound Care - GRAFTING Indications for Grafting: – full thickness burns – priority areas (face) – wound bed pink firm, free of exudate – bacterial count < 100,000/gram of tissue Care of Grafts - assess, assess, assess

45. Skin Grafting

46. Cultured Epithelial Autografts

47. III. REHABILITATION PERIOD Care of healing skin - wash daily, cover with cocoa butter or other barrier Pressure garments, ace wraps - helps prevent scaring and contractures Promote mobility - positioning, exercise, splinting, ADL Rehab period can last for months to even years

48. Primary Prevention Strategies Safety Education: Wear sun-screen Fireproof your home – Install smoke alarms – check routinely – Plan emergency exits – Have regular fire drills Check wiring in home; safety caps on unused outlets if you have children Teach children safety rules for matches, fires, electrical outlets, cords, etc.