Metropolitan Community College Fall 2013 Jane Miller, RN
MSN
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Objectives Identify clinical manifestations of depth of burn
injuries: superficial, partial thickness, and full thickness and
treatment modalities. Define importance of assessment skills and
gathering of important data in determining treatment in the
emergent phase of burns. Identify burn etiology and significance in
treatment Identify vascular changes resulting from burn injuries
including fluid shifts, electrolyte changes, gastrointestinal
involvement, cardiac, pulmonary, skin, metabolic changes, and
immunologic changes. Identify prioritization of treatment of burns
from emergent phase, acute phase, and rehabilitative phase of burn
injury. Compare and contrast the Browder-Lund chart and Rule of
Nines chart in calculating total body surface area(TBSA) in a burn
injury. Apply the Parkland Formula together with the TBSA in
establishing correct fluid replacement in the emergent phase
Identify airway management in burn injury
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Identify compensatory responses to burn injury Evaluate
laboratory profiles during the emergent phase of burn injury.
Identify the role of burn centers. Identify surgical management of
burn injury. Identify pain management in burn injury and
treatments. Define prevention of infection interventions. Identify
would care management to include debridement, dressings, and types
of grafts. Compare and contrast types of grafts available. Identify
nutrition requirements in burn injury. Identify nursing
interventions for prevention of complications such as patient
position, range of motion, ambulation, pressure dressings, and
post-op cares utilized to prevent complications of burns. Identify
research in the burn realm that may affect future burn
interventions. Identify current/future therapies in the treatment
of burn patients.
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Burns are Traumatic Painful Dehumanizing Embarrassing Holistic
Disfiguring Incapacitating Fatal
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Burn Statistics 450,000 people received treatment for burn
injuries in 2011 55% of the 450,000 injuries were admitted to one
of the 125 burn centers in the United States 70% of burn center
admissions were male The survival rate of those admitted to a burn
center was 96% There were 3,500 fire/burn related deaths Burn
Survivor Resource Center, 2013
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Burns and Children 85% of fires that injure or kill children
occur in a residence 2/3 of residential fires that result in the
death of a child occur in homes without a working smoke detector
Fires kill more than 600 children per year and 47,000 are injured
but survive. Scald and contact burns are the most common cause o f
burn-related injuries in children 4 years old and under Burn
Survivor Resource Center, 2013
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Burn Etiology Burn injuries occur when there is direct or
indirect contact with a heat source o Electrical wiring, hot
liquid, lightning, sun, caustic chemicals, fire No matter the
cause, the burn injury results in loss of skin integrity Inhaling
smoke causes injury to the lung known as an inhalation injury
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Types of Burns Thermal o Most often from fire o Extent depends
on the length of exposure and temperature of the heat source Scald
o Type of thermal burn caused by hot food or liquid o Extent
depends on the length of exposure and temperature of the heat
source Electrical o Tend to be deeper than other burns o Extent
depends of amount of voltage, length of exposure, type of current,
pathway of flow, and local tissue resistance o Difficult to assess
damage
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Radiation o Result from overexposure to the sun, radiation
treatment, industrial accidents o Extent depends on how close the
individual was to the source and length of exposure Chemical o
Occur when the skin contacts a caustic agent o Extent depends on
length of exposure Inhalation Injury o Result from inhaled smoke
and heated air o The majority of deaths from burn injuries are due
to smoke inhalation o Signs include: burns to the face and neck,
singed nasal hair, dry cough, bloody/sooty sputum, labored
respiration
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Burn Prevention Keep matches and lighters out of childrens
reach Set water heater no higher than 120 o F Lock up chemicals
Limit exposure to the sun and wear sunscreen Have a working smoke
detector in the home Dont overload electrical circuits Properly
extinguish cigarettes and never smoke in bed Have an escape plan
Community education
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Pathophysiology When damage occurs there are 3 distinct zones
of injury o Zone of coagulation o Zone of stasis o Zone
hyperemia
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Pathophysiology Immediately after the injury third spacing
begins Edema develops in unburned tissue and organs away from the
site of injury This process starts at the time of injury, peaks in
12 to 24 hours, and continues for 49 to 72 hours
Cardiac o Heart failure o Dysrhythmias and cardiac arrest from
the release of potassium Pulmonary o Pulmonary edema
Gastrointestinal o Decreased motility and nutrient absorption due
to shunting of blood o Paralytic ileus o Stress gastritis and
ulcerations
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Renal o Decreased urine output o Renal failure from blocked
renal tubules Immune o Impaired immune function o Increased risk of
developing opportunistic infection and death Integumentary o
Fingerprints may be lost o Permanent loss of hair growth,
perspiration, and sensory abilities o Impaired temperature control
and protection from infection
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Emergency Phase Begins with the injury and last 2 to 3 days
Goals o Maintain an airway o Treatment of concurrent injuries o
Correcting fluid imbalances o Preventing infection o Conserving
body heat o Relieving pain o Emotional support
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Burn Centers in NE Acute care o The Nebraska Medical Center o
Saint Elizabeth Community Health Center Rehabilitation o Madonna
Rehabilitation Hospital
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Initial Treatment Remove the source of injury if possible
ABCDEF Apply clean saline soaked towels Copious irrigation of
chemical burns Apply a clean blanket Do not use oils or salves Give
a tetanus shot
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ER Airway assessment and possible intubation ABGs, CBC, BMP,
BUN, BS, Coags 12-lead ECG Carotid and peripheral pulses VS Place 2
large bore IVs NG tube Assess concurrent injuries Maintain body
temperature Prevent infection Provide emotional support Assess the
burn
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Treatment Plan Based on five factors o Size of the injury o
Depth of the injury o Age of the patient o Past medical history o
Part of the body burned
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Rule of Nines Size is expressed as a percent of the total body
surface area o Head and neck = 9% o Each arm = 9% o Each leg = 18%
o Trunk = 36% o Perineum = 1% = 100%
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Lund-Browder Formula Also assess burn size Divides the body
into smaller percentage areas Considered more accurate, especially
for children
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Question
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Burn Depth Partial thickness o 1 st and 2 nd degree o Partial
destruction of skin layers o Enough epithelial cells, hair
follicles, and sweat glands remain to provide a new dermis o Heal
spontaneously in 2 weeks to 21 days o Little to no scar or
contracture formation o Characterized by: Pink or white, pain,
blanchable, thick walled blisters, firm texture
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Burn Depth Full thickness o 3 rd degree, involves all skin
layers, subcutaneous tissue, muscles, and bone o 4 th degree, some
say burns that involve muscle and bone are actually 4 th degree o
Requires grafting o Characterized by: White or charred black, waxy,
not blanchable, charred vessel visible, no pain, no blisters, dry
and leather like
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Age The very young and the elderly have the highest mortality
rates due to burn injuries Under 2 yrs of age o Immature immune
system o High body surface area per body mass. Elderly o Burns
exacerbate previous medical problems o Less physiological
reserves
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Past Medical History Cardiac Respiratory Renal Endocrine
Substance abuse All decrease the rate of survival
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Area Burned Burns to the head, neck, and chest are more serious
due to pulmonary complications Burns in the perineum and upper
thigh are more prone to infection Burns to the hands, face, and
neck require special care for both physical and psychological
reasons
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A general rule of prognosis If the age of the patient + the
percent of the body burned = more than 100 there is little chance
for survival 65 yr old + 50% burned = 115 This patient has little
chance of survival
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Medical Management Fluid resuscitation o 0.9% NaCl or Lactated
Ringers o Once stabilized begin colloids o Parkland formula 4ml/kg
x % TBSA of burn = replacement volume given in first 8 hours, in
second 8 hours, and in the third 8 hours Example: 100kg male burned
over 25% of his body 4 x 100 x 25 = 10000 ml
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Fluid Resuscitation Assessment Monitor o Mental status o Skin
color and temperature o Heart rate o Blood pressure o Urine output
o Specific gravity o CVP o H & H o GI function
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Pain Management Opioids such as morphine, fentanyl, and codeine
are given on a non-pain-contingent schedule Additional narcotics
are given before dressing changes IM needs to be avoided due to
poor absorption Anti-anxiety meds need to be given as well Start on
stool softeners Proper pain management is essential for improved
healing
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Acute Phase Begins when the patient is hemodynamically stable
and ends with wound closure Goals o Wound cleansing and healing o
Pain relief o Maintaining body temperature o Preventing infection o
Promoting nutrition o Splinting o ROM
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Wound Care Clean the burn with chlorhexidine gluconate and
gauze pads to remove dead tissue and debris Wound debridement
removes further loose tissue and eschar Fasciotomy may need to be
performed in order to restore blood flow to a limb Apply temporary
dressing o Xenograft (pigskin) o Allograft (cadaver skin) o
Biosynthetic dressings o Synthetic Dressings
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Skin Grafting Full thickness skin graft o Entire thickness of
skin down to the subcutaneous tissue is excised o Use for areas
that need thicker covering to prevent breakdown or improved
cosmetic result Palm of hand, bottom of foot, joints, face o Less
common Split-thickness skin graft o Partial layer of skin is
harvested with a dermatome o Is either used as a sheet or meshed o
Most common skin graft
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Maintaining Mobility Splinting and a ROM exercise plan is
essential to maintaining function and motility Exercise begins on
admission and goes until the scars are matured PT and OT are
essential members of the care team
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Nutrition Burn patient experience extreme metabolic stress
Their resting energy expenditure can increase by as much as 150%
Oral route is preferred Enteral and parental nutrition may be
required
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Rehabilitative Phase Begins when less than 20% of the wound is
open Emphasis is on physical and psychological restorative therapy
Treatments include: o PT/OT o ROM exercises o Increased strength
and endurance o Pain management o Nutrition o Cosmetic
reconstruction o Psychological care
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Resources Osborn, Wraa & Watson chapter 68 Burn Survivor
Resource Center o http://www.burnsurvivor.com/ Split thickness skin
graft video o http://www.youtube.com/watch?v=pvbxmm9 inoo
