Created by Nicole Shafar RN, BSN Burns Created by Nicole Shafar RN, BSN

Objectives Safe and Effective are Environment Apply principles of asepsis to protect burn patients and open wounds. Manage the patient’s environment to prevent infection from auto contamination and cross contamination in patients with burn injuries.

Objectives Continued Health Promotion and Maintenance Teach everyone fire prevention strategies Instruct everyone on the correct use of placement of smoke detectors and carbon monoxide detectors.

Objectives Continued Psychosocial Integrity Support the patient and family in coping with permanent changes in appearance and function Encourage the burn patient with wound and scars to participate in burn care. Assess the patient’s and family’s use of coping strategies related to burn injury, treatment, possible changes and outcomes. Allow patients who have lost family members, homes or jobs time to grieve for their losses.

Objectives Continued Psychosocial Integrity Identify burn patients at risk for inhalation injury. Compare the manifestations of superficial, partial-thickness, and full-thickness burn injuries. Explain the expected manifestations of neural and hormonal compensation during the resuscitation/emergent phase of burn injury. Prioritize nursing care for the patient during the resuscitation/emergent phase of burn injury.

Objectives Continued Use laboratory data and clinical manifestations to determine the effectiveness of fluid resuscitation/emergent phase of burn injury. Prioritize nursing care for the patient during the acute phase of burn injury. Coordinate with the nutritionist to meet the nutritional needs for the patient during the acute phase of the burn injury. Evaluate the patient’s wound healing during the acute phase of the burn injury.

Objectives Continued Compare pain management for patients in the resuscitation/emergent and acute phases of burn injury. Describe the characteristics of infected burn wounds. Use appropriate positioning and range-of-motion interventions for prevention of mobility problems in the patient with burns Coordinate nursing care for the patient during the rehabilitation phase of burn injury.

Classifications Superficial Partial Thickness Deep Partial Thickness Full Thickness

Visualizing Burn Depth

Superficial Partial Thickness Of all burn types; this type has the least damage because the epidermis is the only part of the skin that is injured. Symptoms: redness with mild edema, pain and increased sensitivity to heat. Blisters. Desquamation (peeling of dead skin) occurs for 2 to 3 days after the burn. The area heals rapidly in 3-5days without a scar or other complication.

Deep Partial Thickness Wounds extend deeper into the skin dermis, and fewer healthy cells remain. In these patients, blisters usually do not form because the dead tissue layer is so thick and sticks to the underlying dermis that it does not readily lift off the surface. Heals in 3-6wks, but scar formation results. Symptoms: the wound surface is red and dry with white areas in deeper parts. It may blanch slowly or not at all, edema is moderate and pain is less than superficial burns.

Full Thickness Wounds occur with destruction of the entire epidermis and dermis, leaving no true skin to heal on its own. Will require grafting. Take weeks to months to heal. Symptoms: has a hard, dry leathery eschar that forms from coagulated particles of destroyed dermis. Eschar must slough off or be removed before healing can occur.

Deep Full Thickness Burn Extend beyond the skin into underlying fascia and tissues. These injuries damage muscle, bone, tendons and leave them exposed. Symptoms: the wound is blackened and depressed, and sensation is completely absent. These wounds need excision and grafting. Amputation may be needed when an extremity is involved.

Changes From Burn Injury Changes include: Cardiac Pulmonary GI (Curling’s ulcer) Metabolic Immunologic

Vascular Changes Resulting From Burn Injury Fluid shift—third spacing or capillary leak syndrome, usually occurs in the first 12 hr and can continue 24 to 36 hr Profound imbalance of fluid, electrolyte, and acid-base, hyperkalemia and hyponatremia levels, and hemoconcentration Fluid remobilization after 24 hr, diuretic stage begins 48 to 72 hr after injury, hyponatremia and hypokalemia

Cardiac Changes Heart rate increases Cardiac output decreases Heart rate increases and cardiac output decreases because of the initial fluid shifts and hypovolemia that occur after a burn injury Cardiac output may remain low until 18-36hrs after the burn injury. Proper fluid resuscitation and support oxygen prevent further complications.

Pulmonary Changes Respiratory failure Inhalation injury Sloughing Pulmonary insufficiency and infection Direct injury to the lung from contact with flames rarely occurs. Rather, respiratory problems are caused by super heated air, steam, toxic fumes, or smoke. Such problems are a major cause of death in patients with burns and most likely occur when the burn takes place indoors. The upper airway is affected when inhaled smoke or irritants cause edema and obstruct the trachea. This often causes a reflex closure of the vocal cords. The ciliated membranes lining the trachea normally trap bacteria and foreign materials. Smoke and combustion products slow this activity, allowing these foreign particles to enter the bronchi. The lining of the trachea and bronchi may slough 48-72hrs after injury, enter the airway, narrow the trachea lumen, and obstruct lower airways. Leaking capillaries cause alveolar edema that can occur immediately or as late as one week after injury.

Gastrointestinal Changes Decreased blood flow Mucosa is impaired Peristalsis is affected Curling’s ulcer

Metabolic Changes Increases metabolism Caloric needs double or triple depending on the extend of injury. Increased core body temperature

Immunologic Changes Protective barrier destroyed Inflammatory response activated Suppressed immune function

Compensatory Responses to Burn Injury Inflammatory compensation can trigger healing. Sympathetic nervous system compensation occurs when any physical or psychological stressors are present.

Etiology of a burn Injury Dry heat Moist heat Contact burns Chemical injury Electrical injury Radiation injury

Resuscitation/Emergent Phase Is the first phase of a burn injury. The primary goals for this period are to: secure the airway support circulation by fluid replacement keep the patient comfortable with analgesics prevent infection through careful wound care maintain body temperature provide emotional support

Respiratory Manifestations Direct airway injury Carbon monoxide poisoning Thermal injury Smoke poisoning Pulmonary fluid overload External factors

Cardiovascular Assessment Hypovolemic shock is a common cause of death in the emergent phase in patients with serious injuries. Monitor vital signs. Monitor cardiac status, especially in cases of electrical burn injuries.

Renal/Urinary Assessment Changes are related to cellular debris and decreased renal blood flow. Myoglobin is released from damaged muscle and circulates to the kidney. Assess renal function, blood urea nitrogen, serum creatinine, and serum sodium levels. Examine urine for color, odor, and presence of particles or foam.

Skin Assessment Determine size and depth of injury. Determine percentage of total body surface area affected. Use "rule of nines," using multiples of 9% of total body surface area.

Rule of Nines

Nonsurgical Management IV fluids Monitoring patient response to fluid therapy Drug therapy

Surgical Management Escharotomy Fasciotomy

Acute Phase of Burn Injury Begins about 36 to 48 hr after injury and lasts until wound closure is completed Care directed toward continued assessment and maintenance of the cardiovascular and respiratory systems, as well as toward GI and nutritional status, burn wound care, pain control, and psychosocial interventions Begins about 36 to 48 hr after injury and lasts until wound closure is completed Care directed toward continued assessment and maintenance of the cardiovascular and respiratory systems, as well as toward GI and nutritional status, burn wound care, pain control, and psychosocial interventions

Assessment Assessments include those of: Cardiopulmonary Neuroendocrine Immune Musculoskeletal

Nonsurgical Management Mechanical débridement: Hydrotherapy Enzymatic débridement: Autolysis Collagenase

Positioning to Prevent Contractures See Chart page 544 Head Neck Hip

Dressing the Burn Wound Standard wound dressings Biologic dressings: Homograft—human skin Heterograft—skin from other species Amniotic membrane Cultured skin Artificial skin Biosynthetic dressings Synthetic dressings

Surgical Management Surgical excision Wound covering: Skin graft

Nonsurgical Management Drug therapy Isolation therapy Environmental management Safe environment (p541): Isolation therapy: Is used in some burn centers with the belief that it prevents cross contamination. All isolation methods use proper and consistent hand washing as the most effective technique for preventing infection transmission. Use of Asepsis: requires all health care personnel to wear gloves during all contact with open wounds. The use of sterile vs. clean gloves for routine wound care varies by agency. Change gloves when handling wounds on different areas of the body and between old and new dressings.

Rehabilitative Phase Rehabilitation begins with wound closure and ends when the patient returns to the highest possible level of functioning. Emphasis during this phase is on psychosocial adjustment, prevention of scars and contractures, and resumption of preburn activity. This phase may last years or even a lifetime if patient needs to adjust to permanent limitations.