4/1/2011
BURN INJURIES & ITS MANAGEMENT
Dr Ibraheem Bashayreh, RN, PhD
BURNS
Wounds caused by exposure to:
1. excessive heat
2. Chemicals
3. fire/steam
4. radiation
5. electricity
4/1/2011
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
4/1/2011
TYPES OF BURNS
Thermal
exposure to flame or a hot object
Chemical
exposure to acid, alkali or organic substances
Electrical
result from the conversion of electrical energy into heat.
Extent of injury depends on the type of current, the pathway of
flow, local tissue resistance, and duration of contact
Radiation
result from radiant energy being transferred to the body
resulting in production of cellular toxins
4/1/2011
CHEMICAL BURN
4/1/2011
ELECTRICAL BURN
4/1/2011
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 tissue
involved
1. superficial (first-degree)
2. deep (second-degree)
3. full thickness (third and fourth degree)
4/1/2011
4/1/2011
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
4/1/2011
4/1/2011
10
4/1/2011
11
4/1/2011
12
DEEP (SECOND DEGREE)
*Involves the epidermis and deep layer of the dermis
Fluid-filled vesicles red, shiny, wet, severe pain
Hospitalization required if over 25% of body surface
involved
i.e. tar burn, flame
4/1/2011
13
4/1/2011
14
4/1/2011
15
4/1/2011
16
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 can
cause 3rd degree burns
4/1/2011
17
4/1/2011
18
4/1/2011
19
CALCULATION OF BURNED BODY SURFACE
AREA
Calculation
of Burned Body
Surface Area
4/1/2011
20
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 body adequate for initial
assessment for adult burns
4/1/2011
21
LUND BROWDER CHART USED FOR
DETERMINING BSA
4/1/2011
22
Evans, 18.1, 2007)
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%
4/1/2011
23
4/1/2011
24
VASCULAR CHANGES RESULTING
FROM BURN INJURIES
Circulatory
disruption occurs at the burn
site immediately after a burn injury
Blood flow decreases or cease due to
occluded blood vessels
Damaged macrophages within the tissues
release chemicals that cause constriction of
vessel
Blood vessel thrombosis may occur
causing necrosis
Macrophage: A type of white blood that ingests (takes in) foreign material.
Macrophages are key players in the immune response to foreign invaders
such as infectious microorganisms.
4/1/2011
25
FLUID SHIFT
Occurs
after initial vasoconstriction, then
dilation
Blood vessels dilate and leak fluid into the
interstitial space
Known 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
4/1/2011
26
FLUID IMBALANCES
Occur
as a result of fluid shift and cell
damage
Hypovolemia
Metabolic acidosis
Hyperkalemia
Hyponatremia
Hemoconcentration (elevated blood
osmolarity, hematocrit/hemoglobin) due to
dehydration
4/1/2011
27
FLUID REMOBILIZATION
Occurs
after 24 hours
Capillary leak stops
See diuretic stage where edema fluid shifts
from the interstitial spaces into the vascular
space
Blood volume increases leading to
increased renal blood flow and diuresis
Body weight returns to normal
See Hypokalemia
4/1/2011
28
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
4/1/2011
29
PHASES OF BURN INJURIES
Emergent (24-48 hrs)
Acute
Rehabilitative
4/1/2011
30
EMERGENT PHASE
*Immediate problem is fluid loss, edema,
reduced blood flow (fluid and electrolyte
shifts)
Goals:
1. secure airway
2. support circulation by fluid replacement
3. keep the client comfortable with
analgesics
4. prevent infection through wound care
5. maintain body temperature
6. provide emotional support
4/1/2011
31
EMERGENT PHASE
Knowledge of circumstances surrounding the burn
injury
Obtain clients pre-burn weight (dry weight) to
calculate fluid rates
Calculations based on weight obtained after fluid
replacement is started are not accurate because of
water-induced weight gain
Height is important in determining body surface
area (BSA) which is used to calculate nutritional
needs
Know clients health history because the
physiologic stress seen with a burn can make a
latent disease process develop symptoms
4/1/2011
32
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 clients
admitted to burn centers
Assess the respiratory system by inspecting the mouth, nose, and
pharynx
Burns of the lips, face, ears, neck, eyelids, eyebrows, and
eyelashes are strong indicators that an inhalation injury may be
present
Change in respiratory pattern may indicate a pulmonary injury.
The client may: become progressively hoarse, develop a brassy
cough, drool or have difficulty swallowing, produce expiratory
sounds that include audible wheezes, crowing, and stridor
Upper airway edema and inhalation injury are most common in
the trachea and mainstem bronchi
Auscultate these areas for wheezes
If wheezes disappear, this indicates impending airway obstruction
and demands immediate intubation
4/1/2011
33
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
4/1/2011
34
CLINICAL MANIFESTATIONS
Changes
in renal function are related to
decreased renal blood flow
Urine is usually highly concentrated and has
a high specific gravity
Urine output is decreased during the first 24
hours of the emergent phase
Fluid resuscitation is provided at the rate
needed to maintain adult urine output at 30
to 50- mL/hr.
Measure BUN, creat and NA levels
4/1/2011
35
CLINICAL MANIFESTATIONS
Sympathetic
stimulation during the
emergent phase causes reduced GI motility
and paralytic ileus
Auscultate the abdomen to assess bowel
sounds which may be reduced
Monitor for n/v and abdominal distention
Clients with burns of 25% TBSA or who are
intubated generally require a NG tube
inserted to prevent aspiration and removal
of gastric secretions
4/1/2011
36
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 their
heights
4/1/2011
37
IV FLUID THERAPY
Infusion of IV fluids is needed to maintain sufficient blood
volume 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 decrease
circulating volume and CO by pulling fluid from the
circulating blood volume to enhance diuresis
4/1/2011
38
COMMON FLUIDS
Protenate or 5% albumin in isotonic saline (1/2
given in first 8 hr; given in next 16 hr)
LR (Lactate Ringer) without dextrose (1/2 given in
first 8 hr; given in next 16 hr)
Crystalloid (hypertonic saline) adjust to maintain
urine output at 30 mL/hr
Crystalloid only (lactated ringers)
4/1/2011
39
NURSING DIAGNOSIS IN THE
EMERGENT PHASE
Decreased CO
Deficient fluid volume r/t active fluid volume loss
Ineffective Tissue perfusion
Ineffective breathing pattern
4/1/2011
40
ACUTE PHASE OF BURN INJURY
Lasts until wound closure is complete
Care is directed toward continued assessment and
maintenance of the cardiovascular and respiratory system
Pneumonia is a concern which can result in respiratory
failure requiring mechanical ventilation
Infection (Topical antibiotics Silvadene)
Tetanus toxoid
Weight daily without dressings or splints and compare to
pre-burn weight
A 2% loss of body weight indicates a mild deficit
A 10% or greater weight loss requires modification of
calorie intake
Monitor for signs of infection
4/1/2011
41
LOCAL AND SYSTEMIC SIGNS OF
INFECTION- GRAM NEGATIVE
BACTERIA
Pseudomonas, Proteus
May led to septic shock
Conversion of a partial-thickness injury to a full-thickness
injury
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
4/1/2011
42
LAB VALUES
Na hyponatremia or Hypernatremia
K Hyperkalemia or Hypokalemia
WBC 10,000-20,000
4/1/2011
43
NURSING DIAGOSIS IN THE ACUTE
PHASE
Impaired skin integrity
Risk for infection
Imbalanced nutrition
Impaired physical mobility
Disturbed body image
4/1/2011
44
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
4/1/2011
45
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
4/1/2011
46
REHABILITATIVE PHASE OF BURN
INJURY
Started
at the time of admission
Technically begins with wound closure and
ends when the client returns to the highest
possible level of functioning
Provide psychosocial support
Assess home environment, financial
resources, medical equipment, prosthetic
rehab
Health teaching should include symptoms of
infection, drugs regimens, f/u appointments,
comfort measures to reduce pruritus
4/1/2011
47
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
4/1/2011
48
GOALS
Prevent
complications (contractures)
Vital signs hourly
Assess respiratory function
Tetanus booster
Anti-infective
Analgesics
No aspirin
Strict surgical asepsis
Turn q2h to prevent contractures
Emotional support
4/1/2011
49
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
4/1/2011
50
SKIN GRAFTS
Done during the acute phase
Used for full-thickness and deep partial-thickness
wounds
4/1/2011
51
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
4/1/2011
52
4/1/2011
THE END
QUESTIONS
53
