burns 2009 depth of wound temperature of burning agent and duration of contact determines depth of...
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DEPTH OF WOUND
Temperature of burning agent and Duration of contact determines depth of wound:
• Eg: 1 sec of contact with hot tap water at 156 degrees F : full thickness burn
• Eg: 15 sec of contact to hot water 133 degrees F: full thickness burn
DEPTH OF WOUNDDEGREES: 1st, 2nd, 3rd degreeTHICKNESS: layers of skin burned• Superficial partial thickness, deep partial thickness, full thicknessRULE OF NINES: system of assigning percentages in multiples of nine to major
body surfacesLUND AND BROWDNER METHOD: estimating extent of burned area recognizing
effects of body growthPALM METHOD: useful for scattered burns; size of pt’s palm used to assess extent
of burn injury
ASSESSMENT
• SUPERFICIAL THICKNESS: – Involves only the epidermis– Pink to Red, mild edema, painful, no blisters, no
eschar, heals in 3-5days, no grafts– EXAMPLE: sunburn, flash burns
ASSESSMENT
• FIRST DEGREE OR SUPERFICIAL PARTIAL THICKNESS BURN– involves upper third of the dermis; – skin is pink to red, painful, mild to moderate
edema, yes blisters, no eschar. Complete recovery within 10-21 days.
– CAUSED BY: scalds, flames, brief contact with hot objects
ASSESSMENT– SECOND DEGREE OR DEEP PARTIAL THICKNESS:– Caused by: flames, prolonged contact with hot
objects, tar, grease, chemicals – Red to white color, moderate edema, painful, rare
to have blisters, eschar soft and dry, heals 2-6 wk, grafts used if healing is prolonged
ASSESSMENT
• THIRD DEGREE OR FULL THICKNESS;• Caused by: flame, prolonged exposure to hot
liquids, electric current, chemicals, grease• Destruction of entire epidermis and dermis• Black, brown, yellow, white, red, severe
edema, yes and no to pain, eschar (burn crust), heals in weeks to months requiring grafts
ASSESSMENT:
DEEP FULL THICKNESS• Extends beyond the skin into the underlying
fascia and tissues, damages muscle, bone, tendons
• Black, no edema, no pain, no blisters, eschar, takes weeks to months to heal, requires grafts, may need amputation
• Caused by: flames, electricity, grease, tar, chemicals
Primary survey on the sceneFIRST PRIORITY: prevent injury to rescuer then
ABC’S:– Airway, C-spine immobilization– Breathing– Circulation– Deficits (neurological)– ExposeSTOP THE BURNING PROCESS
SURVEY CONTINUED
• Secondary survey– Head to toe assessment
• Pertinent history– Mechanism of injury– Medical history: AMPLE
EMERGENT PHASE OF BURN INJURY
• EMERGENT PHASE: first phase begins at onset of injury and goes to 48 hours
• GOALS: – Secure airway– Support circulation by fluid replacemnt– Provide comfort with analgesics– Prevent infection through wound care– Maintain body temperature– Provide emotional support
AIRWAY MANAGEMENT
• POTENTIALLY SERIOUS INJURY:– Mouth burn– Singed nasal hairs
• SMOKE INHALATION– Burns of the lips, face, ears, neck, eyelids,
eyebrow, eyelashes– Carbonaceous particles in the nose, mouth,
sputum– Edema of the nasal septum– Smoky smell to client’s breath
ASSESSMENT OF RESPIRATORY PATTERN INDICATES A PULMONARY INJURY
Change in resp pattern means pulmonary injury• increased hoarsenes• Brassy cough• ****drooling or difficulty swallowing
– Indicates oropharyngeal edema– Can proceed to pulmonary failure; may NEED INTUBATION
• Audible wheezing, crowing, stridor– Wheezing means obstruction– Sounds disappear– IMPENDING AIRWAY OBSTRUCTION NEEDING INTUBATION
AIRWAY INJURY:CARBON MONOXIDE POISONING
• Carbon Monoxide (CO) found in smoke• CO causes tissue hypoxia when CO combines
with Hgb forming carboxyhemoglobin which competes with oxygen. Hgb likes CO better than O2
• vasodilating action of CO “cherry red color”
• TREATMENT: 100% O2
CIRCULATORY MANAGEMENT
• Circulatory management– shock due to fluid loss– infuse with LR via large bore IV– weigh pt ASAP to determine fluid
replacement needs
FLUID SHIFT DURING THE EMERGENT PHASE
• Initial vasoconstriction of blood vesselsleak fluid third spacing
• Loss of plasma fluids and proteins blood volume BP extensive edema
wgt gain• Protein in the interstitial space the
movement of fluids out from the vascular space
FLUID SHIFT CONTINUES
• IMBALANCES OF F&E– Hypovolemia– Metabolic acidosis– ****Hyperkalemia– Hyponatremia– Hemoconcentration blood viscosity tissue
hypoxia
GUIDELINES/FORMULAS FOR FLUID REPLACEMENT IN BURN PATIENTS
See page 1634• Modified Brooke Formula• Parkland/Baxter Formula• Modified Parkland• Winski
• Calculated from time of inijury and not from the time of arrival at the hospital
FLUID REPLACEMENT: Parkland/Baxter Formula
• 4 ml LR x body wgt (kg) x % BSA burned = fluid replacement
• Give 1/2 calculated amt. in 1st 8hr.• Give 1/4 in 2nd 8 hr. period• Give 1/4 in 3rd 8 hr. period
FLUID REPLACEMENT
EXAMPLE: Pt weighs 70 kg (about 168 lbs)Burned 50% BSA
FORMULA: Using lactated Ringer’s solution: 2-4ml/kg/%TBSA • 2 X 70kg X 50% = 7000 ml/24 hours• Plan to administer first 8 hours 3500 ml or 437 ml/hour• Next 16 hours = 3500 ml or 219 ml/hour
SKIN ASSESSMENT• CALCULATING TBSA or total body surface area is the first step
in determining what amount of fluid will be given using the formula
• RULE OF NINES (see p 1630)– Most rapid– Can overestimate TBSA with this method
• LUND-BROWDER AND BERKOW method: (see page 1630-31) better at identifying differences from birth through adulthood
• BURN CENTER REFERRAL CRITERIA: – See page 1620– Helps determine where a client is best serviced medically
CARDIOVASCULAR ASSESSMENT
• Immediately after the burn: SHOCK can develop
• ****Most common cause of death in emergent phase
• Invasive monitoring may be needed for BP measurement, cannot put on BP cuff
• ASSESSMENT: tachycardia, hypotension, decreased peripheral pulses, slow peripheral cap refill
RENAL/URINARY ASSESSMENT
• RENAL BLOOD FLOW during the fluid shift of the emergent period urine output
HOW DOES THIS EFFECT URINE SPECIFIC GRAVITY?
increased concentration leads to increased urine specific gravity
GATROINTESTINAL ASSESSMENT• During fluid shift • blood flow to vital organs • and sympathetic stimulation during emergent phase
GI motility and paralytic ileus• COMMON CHANGES WITH SEVERE BURNS: – bowel sounds or absent– N &V, abdominal distention– Usually intubated burn pts have NGT to prevent
aspiration and to remove gastric secretions– CURLINGS ULCER may develop within 24 hours
because of reduced GI blood flow
FLUID REMOBILIZATION• At about 24 hrs after injury capillary leak stops• Pt moves into DIURETIC STAGE: begins 48 hrs to 72 hrs after burn injury
– Edema fluid shifts from interstitial space into vascular space– blood volume renal blood flow and diuresis
specific gravity + urinary output– Body weight returns to normal – Hyponatremia from renal sodium excretion and loss of sodium from wound– Hypokalemia from K moving back to cells & potassium excreted in urine– Anemia: from hemodilution– protein lost from the wounds– Metabolic acidosis from loss of sodium bicarb in urine and increased
fat metabolism resulting from decreased carbohydrate intake
HANDLING LARGE PARTS OF THE BODY BEING BURNED
• Leads to massive systemic edema• Leads to compartment syndrome• Treated with escharotomy (surgical incision
into the eschar to relieve the constricting effect of the burned tissue
NURSING CARE CONTINUED• Insert NG tube: • Foley catheter: I&O, sp gr, urine glucose• Pain relief:
– opiods - morphine sulfate, hydromorphone (Dilaudid), fentanyl– Anesthetic agents: ketamine (Ketalar), pentobarbital sodium
(Nembutal), nitrous oxide OBSERVING STRICT PROTOCOLS• Continuous assessment of:
– extremity pulses and – ventilatory limitation
• Emotional support
ACUTE PHASE OF BURN INJURY
• Begins about 36-48 hrs after burn injury and lasts until wound closure is complete– Multidisciplinary approach– Maintenance of all systems– Burn wound care– Pain control – Psychosocial
WOUND DRESSING
• EXPOSURE METHOD: exposed to air, topical agent, no dressing
• OCCLUSIVE METHOD: topical agent followed by occlusive dressing on wounds and used to protect new skin grafts
WOUND DEBRIDEMENT
• DEBRIDEMENT: – Removal of tissue contaminated by bacteria– Removal of dead tissue (burn eschar)
• Natural Debridement• Mechanical Debridement
– Scissors/forceps/drsgs,debriding agents
• Surgical Debridement:– In OR, removing tissue, covering with graft
PURPOSE OF GRAFTING
• To cover the wound• To decrease the risk of infection• To prevent further loss of protein, fluid and
electrolytes• To decrease heat loss • To promote earlier function• To reduce contractures
GRAFTING BURN WOUND
• Autografts: graft of the patient’s own skin• Homografts: graft of skin obtained from living or recently
deceased humans• Heterografts: graft of skin taken from animals (usually pigs)• Biosynthetic: synthetic dressing composed of nylon combined
with collagen derivative• (eg) Biobrane, Opsite, Integra
NURSING CARE OF PT WITH AUTOGRAFT
• Occlusive dressing• OT makes splint• Observe for infection• If graft dislodged: sterile saline dressing• Keep pressure off site, elevate• Exercises begin 5-7 days after grafting• Donor site very painful
DISORDERS OF WOUND HEALING
• Hypertrophic scarring and keloid formation: form from excessive abnormal healing or inadequate tissue formation– TX: Compression, ace/jobst
• Wound contractures– Tx: splints, traction, ROM
PAIN
• Pain associated with burns is SEVERE• Nurses and caregivers need to anticipate
when pain will be worsened by dressing changes, debridement, hydrotherapy, physical therapy
• PCA with morphine help burn victims
EMOTIONAL SUPPORT
• ACUTE PHASE: – Facing reality of burn trauma– Grieving over obvious losses– Depression, regression, manipulative behavior,
withdrawal, anger
EMOTIONAL RESPONSE
• REHAB PHASE:– Include the patient in the decision making– Help patient set realistic self goals