Casey Stevens

04/09/13

ObjectivesDiscuss the pathophysiology of burnsDiscuss the difference of 1st, 2nd, and 3rd degree burns

Discuss the different causes of burnsDiscuss risk factors for burns Describe signs and symptoms of burnsDiscuss the prevalence of burns in our societyDescribe a patient case scenario Discuss medical and nursing interventions, treatments and outcomes for a hospitalized patient with burns.

PathophysiologyBurn injury results in dramatic changes in most physiologic functions of the body within the first few minutes after the event.

The effect of burns depends on two parameters:The extent of the body surfaceThe depth of the cutaneous injury

Burn injuries result in both local and systemic responses.

Pathophysiology: Systemic Response

First degree burnSuperficial burn Mildest type of burnOften caused by ultraviolet light, or very short (“flash") flame exposure

Affects only the outer layer of the skin Normally does not cause scarringTakes about 3-6 days to heal

Second degree burn Superficial partial-thickness burnOften caused by a scald (spill or splash) or short (“flash”) flame exposure

Affects the outer layer of the skin more deeply, usually causing blistering

May or may not cause scarring, but often does cause long-term skin color changes

Takes about 1-3 weeks to heal

Third degree burn Full-thickness burn Very seriousMay involve flame, steam, oil, grease, chemicals, or high-voltage electricity

Damages all layers of the skin, and may involve the tissues underneath (muscle and bone)

Causes scarringWill heal only at the wound edges by scarring, unless skin grafting is done

Causes of burns Heat or flame (thermal burns)

Hot foods or drinks such as boiling water, tea, or coffee

Hot oil or grease Hot tap water Direct heat such as stoves,

heaters, or curling irons Direct flame Flammable liquids such as

gasoline Fireworks

• Chemicals—strong acids or strong bases such as:• Cleaning products• Battery fluid• Pool chemicals• Drain cleaners

• Radiation (radiation burn)• Nuclear radiation• X-rays

• Sunlight • Tanning beds

• Electricity (electrical burn)• Damaged electrical cords• Electrical outlets• High-voltage wires• Lightning

Risk Factors Age: less than four yearsSex: MaleLow socioeconomic statusSmokingAlcohol use Illegal drug useAbsent or non-functioning smoke detectorsSubstandard or older housingUnsupervised or improperly supervised childrenUsing tap water hotter than 120° F

Signs & Symptoms Burned area turns red and is painfulThe area blanches (turns white) when you press on it

The area may swellBlistersThe area is moist, red, and weepingPainful to air and temperature

InterventionsIV fluids to replace those lost from the burnSplints—placed on joints to help maintain mobility

Physical therapy, in the case of large burnsOxygen to help with breathing Intubation Skin graft

Skin grafts

Skin bank Skin banks are similar to blood banks. They test for communicable diseases and store skin

from individuals who agreed to be organ donors before dying.

The donor skin (called an allograft) is preserved in a solution or frozen.

Grafts from skin banks are used as a temporary covering to protect against infection, reduce pain, reduce fluid loss, and allow the tissues underneath to heal. However, because the body’s immune system recognizes an allograft as being foreign, it rejects the graft in 1 to 3 weeks. It is then removed.

Burn Incidence and Treatment in the United States

Burn Injuries Receiving Medical Treatment: 450,000Fire and Burn Deaths Per Year: 3,400Hospitalizations Related to Burn Injury: 40,000, including 30,000

at hospital burn centersSurvival Rate:  96.1%  Gender:  69% male, 31% femaleEthnicity:  59% Caucasian, 19% African-American, 15%

Hispanic, 7% Other Admission Cause:  44% fire/flame, 33% scald, 9% contact, 4%

electrical, 3% chemical, 7% other Place of Occurrence:  69% home, 9% occupational, 7%

street/highway, 5% Recreational/Sport, 10% Other

Source: American Burn Association National Burn Repository (2012 report)

Case Scenario The patient is a 51-year-old male presenting with sulfuric acid burns to

the right ear, scalp, neck, and face. The patient was first day post op, with a skin graft to his right ear and

neck. The affected areas are all wrapped up along with donor site, which is located on his right upper thigh.

The patient stated that the pain he is currently in is a constant, sharp, throbbing pain that will go away for the most part after being administered his pain medication. The patient stated that when he takes his pain medication on time that the pain is manageable.

The medication that he is on is Percocet and his order allows him to take it every 4 hours.

When asked about his pain on a 0-10 scale that patient stated his pain is a 5 with the use of pain medication but without it is easily a 10.

Nursing diagnosis Impaired skin integrity related to epithelial skin loss.

Risk for infection related to loss of skin integrity and impaired nonspecific and specific immunity.

Acute pain related to chemical burn as evidence by patient verbalizing his pain as a 10 on a 0-10 scale.

Deficient fluid volume related to increased capillary permeability, increased intravascular hydrostatic pressure, and increased evaporative loss.

Medical Interventions What was done while the patient was in the hospital:

Ordered IV fluids: Lactated Ringers Skin graft was done on 2/19/13Donor site was his right upper thigh

Oxygen was ordered PRN Prescribed pain medication (Percocet) Prescribed topical Sulfonamide (Silvadene) Prescribed topical anti-infective (Bacitracin) Prescribed a multivitamin Ordered daily dressing changeOrdered a CBC and BMP daily

Nursing Interventions Prevent infection Diet: Regular diet Apply dry gauze dressing over affected area (daily) Bed rest with bathroom privileges Follow PACU protocol including pulse ox and O2 sat to maintain O2sat

above 90% Head of bed at 30 degrees or higher Neurovascular checks: every 4 hours Monitor temperature POCT glucose: 4 times daily before meals and bedtime Skin assessment Vital signs Dressing change at donor site (right upper thigh) Keep skin free from pressure Maintain wound covering as indicated

Outcomes Patients head of bed remained 30 degrees or higher Blood glucose was 113 Preformed a dressing change on the donor site

Had some drainage but not much All medications were given on time Temperature remained within normal limits Patient remained alert and oriented to person, time, and place Patients labs came back and all were within normal limits Patient ate majority of all meals during my shift Vital signs were all within normal ranges Patient ambulated with physical therapy Patient was not discharged during my shift

NCLEX Question 1On the third post-burn day, the nurse finds that the client’s

hourly urine output is 26 ml. The nurse should continue to assess the client and notify the doctor for an order to:

A. Decrease the rate of the intravenous infusion.B. Change the type of intravenous fluid being

administered.C. Change the urinary catheter.D. Increase the rate of the intravenous infusion.

NCLEX Question 1On the third post-burn day, the nurse finds that the

client’s hourly urine output is 26 ml. The nurse should continue to assess the client and notify the doctor for an order to:

A. Decrease the rate of the intravenous infusion.B. Change the type of intravenous fluid being

administered.C. Change the urinary catheter.D. Increase the rate of the intravenous infusion.

NCLEX Question 2A male client comes to the physician’s office for treatment

of severe sunburn. The nurse takes this opportunity to discuss the importance of protecting the skin from the sun’s damaging rays. Which instruction would best prevent skin damage?

A. “Minimize sun exposure from 1 to 4 p.m. when the sun is strongest.”B. “Use a sunscreen with a sun protection factor of 6 or higher.”C. “Apply sunscreen even on overcast days.”D. “When at the beach, sit in the shade to prevent sunburn.”

NCLEX Question 2A male client comes to the physician’s office for

treatment of severe sunburn. The nurse takes this opportunity to discuss the importance of protecting the skin from the sun’s damaging rays. Which instruction would best prevent skin damage?

A. “Minimize sun exposure from 1 to 4 p.m. when the sun is strongest.”B. “Use a sunscreen with a sun protection factor of 6 or higher.”C. “Apply sunscreen even on overcast days.”D. “When at the beach, sit in the shade to prevent sunburn.”

References Osborne, K.S., Wraa, C.E. &Watson, A.B. (2010). Medical –Surgical

Nursing: Preparation for Practice. Upper Saddle River, NJ: Pearson.

Huether, S.E., & McCance, K.L. (2012). Understand Pathophysiology (5th ed.). St. Louis, MO: Mosby.

Nursing, C (2011, April 28). Burns. Retrieved from

http://nursing.unboundmedicine.com/nursingcentral/ub/view/Diseases-and-Disorders/73542/all/burns

Lucas , P. (2012, September 30). Burns. Retrieved from http://web.ebscohost.com.ezproxy.hsc.usf.edu/dynamed

Coll, J. A. (2012, August 24). Full-thickness burns . Retrieved from http://web.ebscohost.com.ezproxy.hsc.usf.edu/dynamed