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BURN LECTURE

BURN LECTURE. M. Catherine Hough RN, Ph.D University of North Florida College of Health Department of Nursing. REVIEW OF SKIN FUNCTIONS. Functions of the Skin Protection Heat Regulation Sensory perception Excretion Vitamin D Production Expression. Cross section of Skin.

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BURN LECTURE

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  1. BURN LECTURE M. Catherine Hough RN, Ph.D University of North Florida College of Health Department of Nursing

  2. REVIEW OF SKIN FUNCTIONS • Functions of the Skin • Protection • Heat Regulation • Sensory perception • Excretion • Vitamin D Production • Expression

  3. Cross section of Skin

  4. CLASSIFIATION OF BURNS Rx of burn is R/T the severity of the burn - severity is determined by: • depth of the burn • extent o the burn (% of total body surface area (TBSA) • location of the burn • patients risk factors

  5. CLASSIFIATION OF BURNS... • Partial Thickness - characterized by varying depth from epidermis (outer layer of skin) to the dermis (middle layer of the skin) • Superficial - includes only the epidermis (First Degree) • Deep - involves entire epidermis and part of the dermis (Second Degree) • Full Thickness - includes destruction of the epidermis and • the entire dermis as well as possible damage to the SQ, muscle and bone (Third and Fourth Degree)

  6. Classification… • Clinical Appearance – Superficial – 1st degree • Erythema, blanching on pressure, pain & mild swelling, no vesicles or blisters (although after 24 hours the skin may blister and peel • Clinical Appearance – Deep – 2nd degree • Fluid-filled vesicles that are red, shiny, wet (if vesicles have ruptured), severe pain caused by nerve injury, mid-to-moderate edema • Clinical Appearance – Full-thickness – 3rd degree • Dry, waxy, leathery, or hard skin, visible thrombosed vessels, insensitivity to pain and pressure of nerve distruction, possible involvement of muscles, bone and tendons.

  7. MINOR BURNS • < 10% of BSA of Partial Thickness Burn • < 2% of BSA of a Full Thickness Burn

  8. MODERATE BURNS • 15-25 % of BSA of Partial Thickness Burn • <10% of BSA of a Full Thickness Burn

  9. MAJOR BURNS • > 25% of BSA of a partial thickness • > 10% of BSA of a full thickness • Age > 65 or < 2

  10. Lund-Bowder Chart

  11. Rule of Nines

  12. Types of Burns • Thermal Burns • Chemical • Electrical • Inhalation • Radiation

  13. PERIODS OF TREATMENT • Emergent • Acute • Rehabilitation

  14. STAGES OF BURNS Hypovolemic Stage - begins @ onset of burn and lasts for the first 48 hours • Rapid fluid shifts - from the vascular compartments into the interstitial spaces • Capillary permeability with burns increases with vasodilation fluid loss deep in wounds (initially sodium and H2O then protein loss) Hemoconcentration - Hct increases • Low blood volume, oliguria • Hyponatremia - loss of sodium and fluid • Hperkalemia - damaged cells release K+, oliguria • Metabolic acidosis

  15. STAGES OFBURNS ... Diuretic Stage - begins @ 48 - 72 hours after burn injury • Capillary membrane integrity returns • Edema fluid shifts back into vessels - blood volume increases • Increase in renal blood flow - result in diuresis (unless renal damage) • Hemodilution - low Hct, decreased potassium as it moves back into the cell or is excreted in urine with the diuresis • Fluid overload can occur due to increased intravascular volume • Metabolic acidosis - HCO3 loss in urine, increase in fatmetabolism

  16. I. EMERGENT PERIOD • First 24 - 48 hours • Maintain airway, fluids, analgesia, temperature, wound • Assessment: • Objective: how burn occurred, when, duration, type of agent • Subjective: previous medical problems, size and depth of burn, age, body part involved, mechanism of injury

  17. EMERGENT PERIOD ... Factors determining severity of burns: • size of burn • depth of burn • age • body part effected • mechanism of injury • history of cardiac, pulmonary, renal, or hepatic diseases • injuries sustained @ time of burns • duration of contact with burning agent • size & depth of burn • “Rule of Nines”

  18. NURSING DIAGNOSIS • Airway clearance • Ineffective fluid volume (deficit or excess) • Hypothermia • High risk for pain (with partial thickness burns) • Skin integrity, impaired • Anxiety • Knowledge deficit

  19. INTERVENTIONS • Maintain patent airway - watch for laryngeal edema • Escharotomy may be needed • 100% FiO2 mask • intubation for inhalation is often required • may inquire emergent tracheostomy • may require ventilatory assistance

  20. Tracheostomy to Prevent Airway Obstruction

  21. Interventions - Fluid Therapy • Start with two large bore IV’s • suture in place • Jugular or subclavian line • unburned tissue • burned tissue • Cutdown final measure

  22. Interventions - Fluid Therapy... Fluid Replacement • Crystalloid Solutions • NS • LR • D5%/NS • Collid Solutions • Albumin • Dextran

  23. Formulas to Calculate Fluid

  24. SIGNS OF ADEQUATE FLUID RESUSCITATION • Clear sensorium • Pulse < 100 bpm • U/O 30-50 cc/hour • SBP > 90-100 mm Hg • Blood pH within normal range 7.35 - 7.45 • Respirations 16-20

  25. II. ACUTE PERIOD • End of emergent period until burns heal • Focus shifts to care of wounds and prevention of complications • Actual range of phase depends on degree and extent of burn • Assessment: Subjective- pain and anxiety Objective- complete assessment every 8 hours, dietary intake, motor ability, I&O, weight

  26. NURSING DIAGNOSIS • Skin integrity, impaired • Infection, high risk for • altered nutrition • Pain, acute (with partial thickness burns) • Fluid Volume Deficit • Anxiety • Hypothermia

  27. Pain Control • Morphine Sulfate 5-10 mg IV every 1-3 hours • Combination therapy for painful procedures: • Diprivan • Valium • Haldol • Versed • …

  28. NURSING DIAGNOSIS ... • Impaired skin integrity R/T thermal injury • Coping, ineffective individual/family • Body Image Disturbance • Altered nutrition: less than body requirements R/T increased catabolism and metabolism • Mobility, Impaired R/T pain, impaired joint movement, scar formation • Self-care Deficit • High risk for infection R/T denuded skin, presence of pathogenic organism, & altered immune response

  29. INTERVENTIONS • Releiving anxiety, denial, regression, anger, depression • Wounds - refer to wound care • Nutrition (Nutritional assessment, pre albumin levels, large protein requirement, carbohydrates and fats for energy, mega vitamins, TPN, enteral tube feedings any follow (~5,000 kcal/day) • Pain - around the clock management • Prevention of infection - refer to wound care

  30. ORGANISMS: • Staphylococcus aureus • Pseudomonas Infection is usually the cause of any deterioration

  31. SIGNS OF SEPSIS: • Change in sensorium • Fever • Tachyapnea • Paralytic ileus • Abdominal distention • Oliguria

  32. WAYS TO PREVENT INFECTIONS: • Gowns, masks, gloves • Sterile linen • Person with URI should not come in contact with patient

  33. WOUND CARE Goals: • clean & debride the area of necrotic tissue • minimize further destruction of viable skin • promote wound re-epithelialization • promote patient comfort

  34. WOUND CARE: • Burn wound is unique • Burn wound sepsis • gram + • gram (pseudomonas) • fungal (candida albicans)

  35. WOUND CARE... • Nutrition • collagen primary structure in healing by secondary intention • need increased protein • may need up to double the normal calorie requirements • Inadequate blood supply • Burn wound disorders • scarring, contractures, keloids, failure to heal

  36. WOUND CARE ... • GOALS: • close wound ASAP • prevent infection • reduce scarring and contractures • provide for comfort

  37. WOUND CARE ... • Wound cleaning: • at bed side hyrotherapy tanks, tubbing, spray tables • Debridement: • mechanical, surgical, enzymatic • Topical antibacterial therapy - • sulfonamide

  38. WOUND CARE ... Open Technique or Exposed- more often used with burns effecting the: • face • neck • perineum • broad areas of the trunk • Partial thickness- exudate dries in 48 to 72 hours forming a hard crust that protects the wound. • Full thickness- dead skin is dehydrated and converted to black leathery escar in 48 to 72 hours. Loose escare is gradually removed with hydrotherapy &/or debridement

  39. WOUND CARE ... • Closed Technique • Wound is washed and sterile dressings changed (may be q shift, daily) • Dressing consists of gauze &/or ace wraps impregnated with topical ointments

  40. WOUND CARE ... • Semi-Open consists of covering the wound with topical antimicrobial agents and gauze ADVANTAGE: • speeds debridement • develops granulation tissues faster • makes skin grafting possible sooner

  41. WOUND CARE ... Biological Dressings: • Homeografts - same species (cadaver skin) • temporary (3 days to 2 weeks) then body rejects • Heterografts - another species (pig skin) • temporary coverage (3days to 2 weeks) • Autografts - patients own skin • can be temporary or permanent coverage • Cultured Epithelial Autographs • permanent

  42. Wound Care - GRAFTING • Indications for Grafting: • full thickness burns • priority areas (face) • wound bed pink firm, free of exudate • bacterial count < 100,000/gram of tissue • Care of Grafts - assess, assess, assess

  43. Skin Grafting

  44. Cultured Epithelial Autografts

  45. III. REHABILITATION PERIOD • Care of healing skin - wash daily, cover with cocoa butter or other barrier • Pressure garments, ace wraps - helps prevent scaring and contractures • Promote mobility - positioning, exercise, splinting, ADL • Rehab period can last for months to even years

  46. Primary Prevention Strategies Safety Education: • Wear sun-screen • Fireproof your home • Install smoke alarms – check routinely • Plan emergency exits • Have regular fire drills • Check wiring in home; safety caps on unused outlets if you have children • Teach children safety rules for matches, fires, electrical outlets, cords, etc.

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