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BURNINJURIES& ITSMANAGEMENT
Dr I braheem Bashayreh, RN, PhD
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BURNS
Wounds caused by exposure to:
1. excessive heat
2. Chemicals
3. fire/steam4. radiation
5. electricity
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BURNS
Results in 10-20 thousand deaths annually
Survival best at ages 15-45
Children, elderly, and diabetics
Survival best burns cover less than 20% of TBA
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TYPES OF BURNS
Thermal
exposure to flame or a hot object
Chemical
exposure to acid, alkali or organic substancesElectrical
result from the conversion of electrical energy into heat.Extent of injury depends on the type of current, the pathway offlow, local tissue resistance, and duration of contact
Radiation
result from radiant energy being transferred to the bodyresulting in production of cellular toxins
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CHEMICALBURN
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ELECTRICAL BURN
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BURN WOUND ASSESSMENT
Classified according to depth of injury and
extent of body surface area involved
Burn wounds differentiated depending on
the level of dermis and subcutaneous tissueinvolved
1. superficial (first-degree)
2. deep (second-degree)3. full thickness (third and fourth degree)
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SUPERFICIAL BURNS
(FIRST DEGREE)
Epidermal tissue only affected
Erythema, blanching on pressure, mild swelling
no vesicles or blister initially
Not serious unless large areas involved i.e. sunburn
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DEEP (SECOND DEGREE)
*Involves the epidermis and deep layer of the dermis
Fluid-filled vesiclesred, shiny, wet, severe pain
Hospitalization required if over 25% of body surface
involvedi.e. tar burn, flame
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FULL THICKNESS (THIRD/FOURTH
DEGREE)
Destruction of all skin layers
Requires immediate hospitalization
Dry, waxy white, leathery, or hard skin, no pain
Exposure to flames, electricity or chemicals cancause 3rddegree burns
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TOTAL BODY SURFACE AREA (TBSA)
Superficial burns are not involved in the calculation
Lund and Browder Chart is the most accurate
because it adjusts for age
Rule of nines divides the bodyadequate for initialassessment for adult burns
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LUND BROWDER CHART USED FOR
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LUNDBROWDERCHARTUSEDFOR
DETERMININGBSA
4/1/2011 22Evans, 18.1, 2007)
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RULES OF NINES
Head & Neck = 9%
Each upper extremity (Arms) = 9%
Each lower extremity (Legs) = 18%
Anterior trunk= 18% Posterior trunk = 18%
Genitalia (perineum) = 1%
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VASCULAR CHANGES RESULTING
FROM BURN INJURIES
Circulatory disruption occurs at the burnsite immediately after a burn injury
Blood flow decreases or cease due tooccluded blood vessels
Damaged macrophages within the tissuesrelease chemicals that cause constriction ofvessel
Blood vessel thrombosis may occurcausing necrosis Macrophage:A type of white blood that ingests (takes in) foreign material.
Macrophages are key players in the immune responseto foreign invaderssuch as infectious microorganisms.
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FLUID SHIFT
Occurs after initial vasoconstriction, then
dilation
Blood vessels dilate and leak fluid into the
interstitial spaceKnown as third spacing or capillary leak
syndrome
Causes decreased blood volume and blood
pressure
Occurs within the first 12 hours after the
burn and can continue to up to 36 hours
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FLUID IMBALANCES
Occur as a result of fluid shift and cell
damage
Hypovolemia
Metabolic acidosisHyperkalemia
Hyponatremia
Hemoconcentration (elevated bloodosmolarity, hematocrit/hemoglobin) due to
dehydration
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CURLINGS ULCER
Acute ulcerative gastro duodenal disease
Occur within 24 hours after burn
Due to reduced GI blood flow and mucosal damage
Treat clients with H2 blockers, mucoprotectants,
and early enteral nutrition
Watch for sudden drop in hemoglobin
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EMERGENT PHASE
*Immediate problem is fluid loss, edema,reduced blood flow (fluid and electrolyteshifts)
Goals:
1. secure airway2. support circulation by fluid replacement3. keep the client comfortable withanalgesics
4. prevent infection through wound care5. maintain body temperature6. provide emotional support
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EMERGENT PHASE
Knowledge of circumstances surrounding the burninjury
Obtain clients pre-burn weight (dry weight) tocalculate fluid rates
Calculations based on weight obtained after fluidreplacement is started are not accurate because ofwater-induced weight gain
Height is important in determining body surfacearea (BSA) which is used to calculate nutritionalneeds
Know clients health history because thephysiologic stress seen with a burn can make alatent disease process develop symptoms
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CLINICAL MANIFESTATIONS IN THE
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CLINICAL MANIFESTATIONS IN THE
EMERGENT PHASE Clients with major burn injuries and with inhalation injury are at
risk for respiratory problems
Inhalation injuries are present in 20% to 50% of the clientsadmitted to burn centers
Assess the respiratory system by inspecting the mouth, nose, andpharynx
Burns of the lips, face, ears, neck, eyelids, eyebrows, and
eyelashes are strong indicators that an inhalation injury may bepresent
Change in respiratory pattern may indicate a pulmonary injury.
The client may: become progressively hoarse, develop a brassycough, drool or have difficulty swallowing, produce expiratorysounds that include audible wheezes, crowing, and stridor
Upper airway edema and inhalation injury are most common inthe trachea and mainstem bronchi
Auscultate these areas for wheezes
If wheezes disappear, this indicates impending airway obstructionand demands immediate intubation
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CLINICAL MANIFESTATIONS
Cardiovascular will begin immediately
which can include shock (Shock is a
common cause of death in the emergent
phase in clients with serious injuries)Obtain a baseline EKG
Monitor for edema, measure central and
peripheral pulses, blood pressure, capillary
refill and pulse oximetry
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CLINICAL MANIFESTATIONS
Changes in renal function are related todecreased renal blood flow
Urine is usually highly concentrated and hasa high specific gravity
Urine output is decreased during the first 24hours of the emergent phase
Fluid resuscitation is provided at the rate
needed to maintain adult urine output at 30to 50- mL/hr.
Measure BUN, creat and NA levels
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CLINICAL MANIFESTATIONS
Sympathetic stimulation during theemergent phase causes reduced GI motilityand paralytic ileus
Auscultate the abdomen to assess bowel
sounds which may be reducedMonitor for n/v and abdominal distentionClients with burns of 25% TBSA or who are
intubated generally require a NG tube
inserted to prevent aspiration and removalof gastric secretions
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SKIN ASSESSMENT
Assess the skin to determine the size and
depth of burn injury
The size of the injury is first estimated in
comparison to the total body surface area(TBSA). For example, a burn that involves
40% of the TBSA is a 40% burn
Use the rule of nines for clients whose
weights are in normal proportion to theirheights
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IV FLUID THERAPY
Infusion of IV fluids is needed to maintain sufficient bloodvolume for normal CO Clients with burns involving 15% to 20% of the TBSA
require IV fluid Purpose is to prevent shock by maintaining adequate
circulating blood fluid volume Severe burn requires large fluid loads in a short time to
maintain blood flow to vital organs Fluid replacement formulas are calculated from the time
of injury and not from the time of arrival at the hospital Diuretics should not be given to increase urine output.
Change the amount and rate of fluid administration.Diuretics do not increase CO; they actually decreasecirculating volume and CO by pulling fluid from thecirculating blood volume to enhance diuresis
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COMMON FLUIDS
Protenate or 5% albumin in isotonic saline (1/2given in first 8 hr; given in next 16 hr)
LR (Lactate Ringer) without dextrose (1/2 given infirst 8 hr; given in next 16 hr)
Crystalloid (hypertonic saline) adjust to maintainurine output at 30 mL/hr
Crystalloid only (lactated ringers)
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ACUTE PHASE OF BURN INJURY
Lasts until wound closure is complete
Care is directed toward continued assessment andmaintenance of the cardiovascular and respiratory system
Pneumonia is a concern which can result in respiratoryfailure requiring mechanical ventilation
Infection (Topical antibioticsSilvadene) Tetanus toxoid
Weight daily without dressings or splints and compare topre-burn weight
A 2% loss of body weight indicates a mild deficit
A 10% or greater weight loss requires modification ofcalorie intake
Monitor for signs of infection
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LOCAL AND SYSTEMIC SIGNS OF
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LOCAL AND SYSTEMIC SIGNS OFINFECTION- GRAM NEGATIVE
BACTERIA
Pseudomonas, Proteus May led to septic shock
Conversion of a partial-thickness injury to a full-thicknessinjury
Ulceration of health skin at the burn site
Erythematous, nodular lesions in uninvolved skin Excessive burn wound drainage
Odor
Sloughing of grafts
Altered level of consciousness
Changes in vital signs Oliguria
GI dysfunction such as diarrhea, vomiting
Metabolic acidosis
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LAB VALUES
Nahyponatremia or Hypernatremia
KHyperkalemia or Hypokalemia
WBC10,000-20,000
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NURSING DIAGOSIS IN THE ACUTE
PHASE
Impaired skin integrity
Risk for infection
Imbalanced nutrition
Impaired physical mobility Disturbed body image
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PLANNING AND IMPLEMENTATION
Nonsurgical management: removal of exudates and
necrotic tissue, cleaning the area, stimulating
granulation and revascularization and applying
dressings. Debridement may be needed
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DRESSING THE BURN WOUND
After burn wounds are cleaned and debrided,
topical antibiotics are reapplied to prevent infection
Standard wound dressings are multiple layers of
gauze applied over the topical agents on the burn
wound
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REHABILITATIVE PHASE OF BURN
INJURY
Started at the time of admissionTechnically begins with wound closure and
ends when the client returns to the highestpossible level of functioning
Provide psychosocial supportAssess home environment, financial
resources, medical equipment, prostheticrehab
Health teaching should include symptoms ofinfection, drugs regimens, f/u appointments,comfort measures to reduce pruritus
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DIET
Initially NPO
Begin oral fluids after bowel sounds return
Do not give ice chips or free water lead to
electrolyte imbalance
High protein, high calorie
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GOALS
Prevent complications (contractures)Vital signs hourly
Assess respiratory functionTetanus boosterAnti-infective
AnalgesicsNo aspirinStrict surgical asepsisTurn q2h to prevent contractures
Emotional support
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DEBRIDEMENT
Done with forceps and curved scissor or through
hydrotherapy (application of water for treatment)
Only loose eschar removed
Blisters are left alone to serve as a protector
controversial
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SKIN GRAFTS
Done during the acute phase
Used for full-thickness and deep partial-thickness
wounds
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POST CARE OF SKIN GRAFTS
Maintain dressing
Use aseptic technique
Graft should look pink if it has taken after 5 days
Skeletal traction may be used to prevent
contractures Elastic bandages may be applied for 6 mo to 1 year
to prevent hypertrophic scarring
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THE END
QUESTIONS
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