Burns

1. Burns Linda Copenhaver

2. Introduction • Incidence of Burns • ½ million seek medical care annually • Approximately 40K are hospitalized • Where do most burn trauma injuries occur? • Bonus' Site - KitchenOilFire.wmv

3. Types of Burn Injury • Thermal • Chemical • Electrical • Radiation

4. Thermal Burns( Most Common) • Caused by flame, flash, scald, or contact burns • STOP & DROP • Roll to shut off O2 supply to fire • Flush or immerse in cold water • DO NOT use ICE on deep burns, just localized, superficial burns

5. Thermal Burns (cont) • Cover patient with a clean cover • Do NOT pull off clothing; instead cut off clothing if possible…WHY? • Keep NPO and transport

6. Chemical Burns • Remove person from contact with agent • Flush with water continuously • Remove affected clothing if possible

7. Electrical burns • Coagulation necrosis • Severity depends on voltage, amount of resistance, time, and current pathways.

8. Electrical Burn–Back Fig. 25-2 B

9. Frequently only entry (yellow-white) and exit (blow out) wounds are visible • Extensive tissue damage is masked • How can we evaluate “masked tissue damage”???

10. Electrical Burns (cont) • Patient at risk for arrhythmias due to _____, metabolic acidosis due to _____, and acute tubular necrosis due to ______. • Current can be so strong to fracture long bones and cause respiratory muscles to contract

11. Interventions for Electrical Burns • Turn off source of electricity if possible • Remove current with dry piece of wood • Initiate CPR and Transport

12. Cross Section of Skin Fig. 25-3

13. Depth of Burns Superficial Partial Thickness Burn (1st degree) Epidermis involved Sunburn, UV light, mild radiation, Pink to red Slight edema Mild pain

14. Depth of Burns • Deep Partial Thickness (2nd) • Epidermis and some of dermis, is painful, red, blisters

15. Depth of Burns • Deep Partial Thickness (2nd) • Epidermis and Dermis • Very Painful, edema, pale • Moist or dry • Blisters

16. Depth of Burns (cont) • Full Thickness Burns (3rd) • Epidermis, Dermis, and Subcutaneous tissue burned • Nerve endings destroyed • Little or no pain

17. Depth of Burns (cont) • Full thickness (4th degree) • Involves past the 3 layers down to the bone and/or organs

19. Rule of Nines Chart; quick & easy Fig. 25-4 B

20. Lund-Browder Chart; More accurate Fig. 25-4 A

21. Burn Unit Referral Criteria • Deep Partial Thickness burns > 10% TBSA • Burns that involve the face, hands, feet, genitalia, perineum, or major joints • Full thickness burns in any age group • Electrical burns, including lighting • Inhalation burns requiring intubation • Chemical burns that involve deep and extensive TBSA burned

22. Survival Prediction • Depth of Burns • Extent of Burns • Location of Burns • Age of Client • Risk Factors • Major vs Minor Burns

23. Medical/Nursing Management of Burns • I. Emergent Phase • Period of time from onset of burns to the beginning of fluid remobilization • Usually lasts 24-48 hours

24. Emergent Phase (cont) • Also called FLUID ACCUMULATION PHASE • The greatest initial threat to a major burn victim is hypovolemic shock • Let’s do the Patho on p. 479 Lewis…this is a DING DING!

26. Some Questions….. • The nurse knows that in a patient who has full thickness burns, that the burns must involve the: a) Muscle b) Dermis c) Tendons d) Bone

27. A 40 year old male sustains burns to his anterior torso following an explosion of a fuel tank. The burned area is brown and leather like. The client does not c/o pain. The nurse should conclude that the client has burns that are: • a) superficial partial thickness • b) moderate partial thickness • c) deep partial thickness • d) full thickness

28. What are the Priorities in this patient??? • Is this patient a candidate for a major burn center?

29. Nursing Care During Emergent Phase • Impaired Gas Exchange r/t tissue hypoxia secondary to carbon monoxide poisoning • Note: CO poisoning is the MOST immediate cause of death from fire.

30. Signs & Symptoms of Carbon Monoxide Poisoning • Edema of Airway • Hoarseness • Dysphagia • Stridor • Copius Secretions usually black tinged • Skin will appear cherry red

32. Cherry red skin appearance

33. Interventions for CO Poisoning: • Assess for S&S CO poisoning (mild to severe) • Humidified O2 100% via face mask • High Fowler’s Position • TCDB q 1 hour • Intubation & Ventilation • Bronchodilators for bronchospasm • One other thing…..does anyone know???

34. Nursing Care during Emergent Phase (cont) • Impaired Gas Exchange r/t mucosal edema throughout respiratory tract secondary to smoke inhalation, hot air, chemical gases

35. Interventions: • Early intubation to prevent trach placement • Ventilation • Humidified O2 100% • ABG’s • Bronchodilators • CXR’s

36. What do you assess for here???

37. Question: • A client has sustained deep partial thickness burns to the anterior trunk and the anterior aspect of both arms. The nurse should expect the client’s immediate care would be conducted: • a) on an outpatient basis • b) in a home health setting • c) on an inpatient surgical unit • d) in a burn unit

38. Questions to Ask Burn Victims • Were you in an enclosed space? • Were you standing up? • Was it a flame and chemical fire? • Are you having difficulty breathing?

39. What are your #1 priorities in this patient? Patient #1 Patient #2

40. Emergent Phase (cont) • Ineffective Breathing pattern r/t constriction of chest/trachea secondary to the effects of full thickness burns. • Assess for signs of constriction • Escharotomies with circumferential burns of chest

41. Escharotomy of chest and arm • What is the pathophysiology here?

42. Emergent Phase (cont) • Fluid Volume Deficit (intravascular) r/t massive fluid shift to interstitial spaces • Assess fluid needs: • Brooke Formula • Evans Formula

43. Parkland Baxter Formula • Most widely used • Formula • LR 4ml X kg body weight X TBSA % burned • ½ total amount given 1st 8 hours • ¼ total amount given next 8 hours • ¼ total amount given next 8 hours

44. Okay Nurses Let’s Calculate • What would the fluid replacement be for a patient who weighed 60kg and had 30% TBSA burned??? • 1st 8 hours= _____ or ____ml/hr • 2nd 8 hours= _____ or _____ml/hr • 3rd 8 hours= ______ or _____ml/hr

45. Crystalloids used such as LR, 0.9NS, D5NS • Colloids (albumin, dextran, FFP) used to expand plasma. • Colloids not given until after capillary permeability decreases and returns to normal…..WHY?

46. Insert foley catheter to monitor output. What should urine output be in an adult??? • Frequent vital signs • SBP>100 • Pulse<100 • RR 16-20

47. Emergent Phase (cont) • Monitor Electrolytes and Hematocrit; tells you about fluid shift. • What should Hct be doing as time progresses???

48. Using the Parkland formula, a client who has full and deep partial thickness burns to 30% of his body is to receive 6000ml of fluid over the next 24 hours. You would administer: • 1/3, 1/3 and 1/3 during each 8 hour period • 1/2, 1/4, and 1/4 during each 8 hour period • 1/4, 1/4, 1/4 and 1/4 during each 6 hour period • 1/8, 1/8, 1/4, and 1/2 during each 6 hour period

49. Emergent Phase (cont) • Potential for Infection r/t loss of skin and micro invasion • Meticulous hand washing • Sterile technique during dressing changes & wound care • Hair near burned areas shaved

50. Potential for Infection r/t loss of skin and micro invasion (cont) • Blisters popped or not??? • Tetanus Toxoid I.M. given to all major burn victims to fight anaerobic contamination of burn wound