Class_%2319_-_Burns_Pp_(3)(1

Burns

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ObjectivesAt the end of the teaching session the student will be enabled to:• Discuss with understanding pathophysiological response

at tissue and organ levels in relation to burns injury.• Demonstrate knowledge of the process of wound healing,

and the three phases of burn care.• Differentiate between the three classifications of burn

injury• Discuss the significance of size and depth of injury in

relation to age, past medical history, and affected areas of the body

• Generate a comprehensive burn treatment plan using the nursing process to include education and discharge teaching.

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Types of Burn Injury

• Thermal burns – fire, contact with hot objects, scald burns – wet burn • Cold thermal injury /frostbite • Inhalation – smoke /CO2, hot chemicals • Chemical – hydrochloric acid• Electrical Burns – bare wires, Burns are described in terms of the type extent of injury and depth of the burn

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Cross Section of Skin

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Fig. 25-3. Cross section of skin indicating the depth of burn and

structures involved.

Generate a diagram for the students to complete

• The skin is divided into three layers: the epidermis,

dermis, and subcutaneous tissue (Fig. 25-3). The

epidermis, or nonvascular outer layer of the skin, is

approximately as thick as a sheet of paper. It is

composed of many layers of nonliving epithelial

cells that provide a protective barrier to the skin,

hold in fluids and electrolytes, help to regulate

body temperature, and keep harmful agents in the

external environment from injuring or invading the

body.

• The dermis, which lies below the epidermis, is

approximately 30 to 45 times thicker than the

epidermis. The dermis contains connective tissues

with blood vessels and highly specialized

structures consisting of hair follicles, nerve

endings, sweat glands, and sebaceous glands.

Under the dermis lies the subcutaneous tissue,

which contains major vascular networks, fat,

nerves, and lymphatics.

• The subcutaneous tissue acts as a heat insulator

for underlying structures, which include the

muscles, tendons, bones, and internal organs

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Classification of Burn InjuryDepth of Burn

• Burns have been defined by degrees (1st, 2nd, 3rd, 4th)• ABA advocates categorizing the burn according to depth of skin

destruction. Partial-thickness burn Full-thickness burnSkin-reproducing (re-epithelializing) cells are located throughout the dermis and along the shafts of the hair follicles and sebaceous glands. If significant damage to the dermis occurs (e.g., a full-thickness burn), remaining skin cells are insufficient to regenerate new skin. A permanent, alternative source of skin then needs to be found.

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Classification of Burn InjuryDepth of Burn

•Superficial partial-thickness burn Involves the epidermis

•Deep partial-thickness burn Involves the dermis

• Full-thickness burn Involves fat, muscle, bone


7Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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Prehospital Care

• Remove the person from the source of the burn & stop the burning process.

• Rescuer must be protected from becoming part of the incident.

The burn patient may have sustained other injuries that take priority over the burn wound. It is important for individuals involved in the prehospital phase of burn care to adequately communicate the circumstances of the injury to the hospital-based health care providers. This is especially important when the injury involves entrapment in a closed space, hazardous chemicals, electricity, or possible trauma (e.g., fall).

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Prehospital Care

• Electrical injuries Remove patient from contact with source.

• Chemical injuries Brush solid particles off the skin. Use water lavage.

•Chemical burns are best treated by quickly removing solid particles from the skin. Any clothing containing the chemical must also be removed as the burning process continues while the chemical is in contact with the skin. •The affected area should be flushed with copious amounts of water to

irrigate the skin anywhere from 20 minutes to 2 hours post exposure. Tap water is acceptable for flushing eyes exposed to chemicals. •Tissue destruction may continue for up to 72 hours after a chemical

burn.

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Prehospital Care

• Small thermal burns Cover with clean, cool, tap water– dampened towel

•Cooling of the injured area (if small) within 1 minute helps minimize the depth of the injury.•Airway: Check for patency, soot around nares/on the tongue, singed nasal hair, darkened oral or nasal membranes.•Breathing: Check for adequacy of ventilation.•Circulation: Check for presence and regularity of pulses, and elevate the burned limb(s) above the heart to decrease pain and swelling.•To prevent hypothermia, large burns should be cooled for no longer than 10 minutes.

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Prehospital Care• Large thermal burns

ABCs Do not immerse in cool water or pack with ice. Remove burned clothing. Wrap in clean, dry sheet or blanket.

•Do not immerse the burned body part in cool water because doing so might lead to extensive heat loss. Never cover a burn with ice, as this can cause hypothermia and vasoconstriction of blood vessels, further reducing blood flow to the injury. •Gently remove as much burned clothing as possible to prevent further tissue

damage. Adherent clothing should be left in place until the patient is transferred to a hospital. •The patient should then be wrapped in a dry, clean sheet or blanket to

prevent further contamination of the wound and to provide warmth.

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Prehospital Phase• Inhalation injury

Observe for signs of respiratory distress or compromise. Treat quickly.

•Patients with inhalation injuries must be observed closely for signs of respiratory distress or compromise. •They need to be treated quickly and efficiently at the scene if they are to survive. If CO intoxication is suspected, the patient should be treated with 100% humidified O2. Patients with both body burns and inhalation injury must be transferred to the nearest burn center.

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Partial-Thickness Burn to the Hand


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Partial-Thickness Burns Due to Immersion in Hot Water



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Types of Burn InjurySmoke Inhalation Injuries

• Inhalation injury above the glottisReliable clues to this injury: Presence of facial burns Singed nasal hair Hoarseness, painful swallowing Darkened oral and nasal membranes Carbonaceous sputum History of being burned in enclosed space Clothing burns around chest and neck

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Rule of Nines Chart


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Electrical Burn: Back

Does the external

extent of the

injury show if you

look at the

external injury?

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Electrical Burn: Leg


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Conditions Leading to Burn Shock•At the time of major burn

injury, capillary permeability

is increased. All fluid

components of the blood

begin to leak into the

interstitium, causing edema

and a decreased blood

volume. The red blood cells

and white blood cells do not

leak. Hematocrit increases,

and the blood becomes more

viscous. The combination of

decreased blood volume and

increased viscosity produces

increased peripheral

resistance. Burn shock, a

type of hypovolemic shock,

rapidly ensues, and if it is not

corrected, death can result.


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Emergent PhasePathophysiology

• Fluid & Electrolyte shifts (cont’d)Normal insensible loss: 30 to 50 mL/hrSeverely burned patient: 200 to

400 mL/hr Fluids given—observe urine o/pThe period time required to resolve the life threatening problems resulting from the burn This last up to 72 hours from the time of the burn. Primary concerns being the onset of hypovolemic shock and edema formation. The phase ends when fluid mobilization and diuresis begin.

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Fluid Resuscitation-Parkland Baxter

• 1st 24 (Crystalloids)4ml/kg/%Total Body Surface Area burned

1/2 total volume 1st 8 hrs ¼ next 8 hrs ¼ last 8 hrs

• 2nd 24(Colloids-Albumin)0.3-0.5 ml/kg %TBSA burnedGlucose/Water –to replace evaporated

losses

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Fluid Resuscitation-Parkland Baxter

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Emergent PhasePathophysiology• Fluid & Electrolyte shifts (cont’d)

RBCs are hemolyzed by a circulating factor released at the time of the burn.

Thrombosis of burnt tissue causes additional loss of circulating RBCs Elevated hematocrit caused by hemoconcentration resulting form fluid

loss•The circulatory status is also impaired because of hemolysis of RBCs. •The RBCs are hemolyzed by circulating factors (e.g., oxygen free radicals)

released at the time of the burn, as well as by the direct insult of the burn injury.

•Thrombosis in the capillaries of burned tissue causes an additional loss of circulating RBCs.

•An elevated hematocrit is commonly caused by hemoconcentrationresulting from fluid loss. After fluid balance has been restored, lowered hematocrit levels are found secondary to dilution.

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Effects of Burn Shock


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Emergent PhasePathophysiology

• Fluid & Electrolyte shifts (cont’d)Na+ shifts to the interstitial spaces &

remains until edema formation ceases.K+ shift develops because injured cells &

hemolyzed RBCs release K+ into extracellular spaces.

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Emergent

•Airway-maintainCO poisoning—100%-Non-Rebreather

•Pain- IV opioids•Asepsis• Fluids (hypovolemic shock)(edema)•Body temp-maintain•Paralytic Ileus – Check for bowel

sounds •Curlings Ulcer-H2 blockers

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Emergent PhaseNursing and Collaborative Management

•Wound care (cont’d)Open method Burn is covered with a topical antibiotic with

no dressing over the wound.

Two approaches to burn wound treatment are the open method and the use of multiple dressing changes.

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• Wound care (cont’d) When open burns wounds are exposed, staff should wear

Disposable hats Masks Gowns Gloves

•When the patient’s open burn wounds are exposed, you must wear personal protective equipment (PPE) (e.g., disposable hat, masks, gown, gloves).

•When removing contaminated dressings and washing the dirty wound, you may use nonsterile, disposable gloves.

•Sterile gloves are used when applying ointments and sterile dressings. • In addition, the room must be kept warm (approximately 85° F [29.4° C]). •All PPE is removed and new applied before you treat another patient. This is necessary to avoid

transmitting organisms from one patient to another—a significant risk, especially when there is more than one patient to a room.

•Careful hand washing and the use of alcohol hand gel, both inside and outside each patient room, are required to prevent cross-contamination.

•After the dressing change is completed, the equipment and immediate environment are thoroughly cleaned and disinfected. The use of plastic liners on equipment is helpful in reducing potential contamination of equipment and facilitates cleaning.

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• Wound care (cont’d) Multiple dressing changes or closed method

Sterilized gauze dressings are laid over a topical antibiotic.

Dressings may be changed from every 12 to 24 hours to once every 14 days.

These dressings are changed anywhere from every 12 to 24 hours to once every 14 days, depending upon the product. Most burn centers support the concept of moist wound healing and use dressings to cover burned areas, with the exception of the burned face.

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• Other care measures Facial care

Performed by the open method Eye care for corneal burns

Antibiotic ointment is used. Periorbital edema may frighten patient.

Emergent ends with diuresis

•The face is highly vascular and is subject to a great amount of edema. It often is covered with ointments and gauze but is not wrapped, to limit pressure on delicate facial structures.

•Eye care for corneal burns or edema includes antibiotic ointments. An ophthalmology examination should occur soon after admission for all patients with facial burns.

•Periorbital edema can prevent opening of the eyes and can be frightening to the patient. You must provide assurance that the swelling is not permanent.

•Instillation of methylcellulose drops or artificial tears into the eyes for moisture provides additional comfort.

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Hydrotherapy Cart Shower


Showering presents an opportunity for physical therapy, as well as wound care.

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Acute PhaseClinical Manifestations

• Partial-thickness wounds form eschar. Once eschar is removed,

re-epithelialization begins.• Full-thickness wounds require debridement

medicate prior-opioids

•Partial-thickness wounds form eschar, which begins separating fairly soon after injury. Once the eschar is removed, re-epithelialization begins at the wound margins and appears as red or pink scar tissue.

•Epithelial buds from the dermal bed eventually close in the wound, which then heals spontaneously without surgical intervention, usually within 10 to 21 days.

•Margins of full-thickness eschar take longer to separate. As a result, full-thickness wounds require surgical debridement and skin grafting for healing.

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Acute PhaseNursing and Collaborative Management• Excision and grafting

Eschar is removed down to the subcutaneous tissue or fascia. Graft is placed on clean, viable tissue. Wound is covered with autograft. Donor skin is taken with a dermatome. Choice of dressings varies.

•Current therapeutic management of full-thickness burn wounds involves early removal of the necrotic tissue followed by application of split-thickness autograft skin.

•This therapy has changed the management and mortality rate of burn patients. In the past, patients with major burns had low rates of survival because healing and wound coverage took so long that the patient usually died of sepsis or malnutrition. Because of current earlier intervention, mortality and morbidity rates have been greatly reduced.

•Many patients, especially those with major burns, are taken to the OR for wound excision on day 1 or 2 (resuscitation phase). The wounds are covered with a biological dressing or allograft for temporary coverage until permanent grafting can occur.

•Devitalized tissue (eschar) is excised down to the subcutaneous tissue or fascia, depending on the degree of injury. Surgical excision can result in massive blood loss, and blood conservation techniques are used to limit this complication. Topical application of epinephrine or thrombin, application of extremity tourniquets, and application of a new fibrin sealant (Artiss) all work to decrease surgical blood loss.

•Once hemostasis has been achieved, a graft is then placed on clean, viable tissue to achieve good adherence.

•Whenever possible, the freshly excised wound is covered with autograft (person’s own) skin.

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Debriding Full–Thickness Burn

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Circumferential burns

•Assess pulses•Assess breathing•Escharotomy-relieves pressure

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Escharotomies of the Chest and Arm

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Acute PhaseLaboratory Values

• Sodium Hyponatremia can develop from

Excessive GI suction Diarrhea

Water intoxication may also develop which is a dilutionalhyponatremia So patient should drink fluids other than water with additional nutritional supplements

Manifestations of hyponatremia include weakness, dizziness, muscle cramps, fatigue, headache, tachycardia, and confusion. The burn patient may also develop a dilutional hyponatremia called water intoxication. To avoid this condition, the patient should drink fluids other than water, such as juice, soft drinks, or nutritional supplements.

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• Sodium (cont’d) Hypernatremia may develop following

Successful fluid replacement Improper tube feedings Inappropriate fluid administration

Patient will present with thirst; dried, furry tongue; lethargy; confusion; and possibly seizures.

•Hypernatremia may be seen following successful fluid resuscitation if copious amounts of hypertonic solutions were required. •Manifestations of hypernatremia include thirst; dried, furry tongue; lethargy; confusion; and possibly seizures.

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•Potassium (cont’d)Hyperkalemia can cause Cardiac dysrhythmias & ventricular failure Muscle weakness ECG changes

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•PotassiumHyperkalemia noted if patient has Renal failure Adrenocortical insufficiency Massive deep muscle injury

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•Potassium (cont’d)Hypokalemia can be caused by Lengthy IV therapy without potassium Vomiting, diarrhea Prolonged gastrointestinal suction

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Split-Thickness Sheet Skin Graft to Hand

Fig. 25-11 ACopyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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Donor Site Being Harvested


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Covering Donor Site With Hydrophilic Foam Dressing

Fig. 25-11 CCopyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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Healed Donor Site

Fig. 25-11 D


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Acute phase

•Nutrition—↑calories & ↑protein•Acute phase ends w/ wound closure—

graft/skinLess chance of infection with intact skin

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Acute PhaseNursing and Collaborative Management

• Excision and grafting (cont’d) Cultured epithelial autographs (CEAs)

Grown from biopsies obtained from the patient’s own skin Used in patients with a large body surface burn area or those with limited skin for

harvesting• In the patient with large body surface area burns, only a limited amount of unburned skin may be

available as donor sites for grafting, and some of that skin may be unsuitable for harvesting. •Cultured epithelial autograft (CEA) is a method of obtaining permanent skin from a person with

limited available skin for harvesting. CEA is grown from biopsy specimens obtained from the patient’s own unburned skin.

•This procedure is performed in some burn centers as soon as possible after admission on suitable patients.

•The specimens are sent to a commercial laboratory, where the biopsied keratinocytes are grown in a culture medium containing epidermal growth factor. After approximately 18 to 25 days, the keratinocytes have expanded up to 10,000 times and form confluent sheets that can be used as skin grafts.

•The cultured skin is returned to the burn center, where it is placed on the patient’s excised burn wounds.

•Because CEA grafts are made only of epidermal cells, meticulous care is required to prevent shearing injury or infection. CEA grafts generally form a seamless, smooth replacement skin tissue. Problems related to CEA include a poor graft take due to thin epidermal skin graft loss during healing, infection, and contracture development.

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Application of Cultured Epithelial Autograft

Fig. 25-12 ACopyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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Healed Cultured Epithelial Autograft

Fig. 25-12 B


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Rehabilitation PhasePathophysiologic Changes

• In approximately 4 to 6 weeks, the area becomes raised and hyperemic.• Mature healing is reached in

6 months to 2 years. • Skin never completely regains its original color.

• In approximately 4 to 6 weeks, the area becomes raised and hyperemic. If adequate ROM is not instituted, the new tissue will shorten, causing a contracture.

•Mature healing is reached in about 12 months, when suppleness has returned and the pink or red color has faded to a slightly lighter hue than the surrounding unburned tissue. It takes longer for more heavily pigmented skin to regain its dark color because many of the melanocytes have been destroyed.

•Frequently, the skin does not regain its original color. Paramedical cosmetic camouflage, the implantation of pigment within the skin, can help even out unequal skin tones and improve the patient’s overall appearance and self-image.

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Rehabilitation Phase Pathophysiologic Changes• Discoloration of scar fades with time.• Pressure can help keep scar flat.• Newly healed areas can be hypersensitive or hyposensitive to cold, heat, and touch.• Healed areas must be protected from direct sunlight for 1 year.

•Scarring has two components: discoloration and contour. The discoloration of scars will fade somewhat with time. However, scar tissue tends to develop altered contours, that is, it is no longer flat or slightly raised but becomes elevated and enlarged above the original burned area.

• It is believed that pressure can help keep a scar flat. Gentle pressure can be maintained on the healed burn with custom-fitted pressure garments (e.g., Jobst garments). They should never be worn over unhealed wounds and are removed only for short periods while bathing.

•These garments are worn up to 24 hours a day for as long as 12 to 18 months. The patient typically experiences discomfort from itching where healing is occurring. Application of water-based moisturizers and use of oral antihistamines (e.g., diphenhydramine [Benadryl]) help reduce the itching. Massage oil, silicone gel sheeting (e.g., Biodermis), gabapentin (Neurontin), and injectable steroids also may be helpful.

•As “old” epithelium is replaced by new cells, flaking will occur. The newly formed skin is extremely sensitive to trauma. Blisters and skin tears are likely to develop from slight pressure or friction.

•Additionally, these newly healed areas can be hypersensitive or hyposensitive to cold, heat, and touch. Grafted areas are more likely to be hyposensitive until peripheral nerve regeneration occurs. Healed burn areas must be protected from direct sunlight for about 3 months to prevent hyperpigmentation and sunburn injury.

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Contracture of the Foot

Fig. 25-13


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Contracture of the Neck


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Gerontologic Considerations• Normal aging puts the patient at risk for injury because of:

Unsteady gait Failing eyesight Diminished hearing The fact that wounds take longer to heal

As people age, skin becomes more dry, wrinkled, and loose. The dermal layer thins, and loss of elastic fibers, a reduction in subcutaneous adipose tissue, and a decrease in vascularity occur. As a result, the thinner dermis, with reduced blood flow, sustains deeper burns with poorer rates of healing.Once injured, the older adult has more complications in the emergent and acute phases of burn resuscitation because of preexisting medical conditions. For example, older patients with diabetes, heart failure, or chronic obstructive pulmonary disease will have morbidity and mortality rates exceeding those of healthy, younger patients. In older patients, pneumonia is a frequent complication, burn wounds and donor sites take longer to heal, and surgical procedures are less well tolerated. Weaning from a ventilator can be a challenge, and delirium from medication/anesthesia may be a distressing, although usually self-limiting, outcome. It usually takes longer for these patients to rehabilitate to the point where they can safely return home. For some, a return home to independent living may not be possible. As the population ages, development of strategies to prevent burn injuries in this population is a priority.

Case Study

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Case Study

• 25-year-old man fell from ladder while repairing the roof and struck a hot charcoal grill.

•He lacerated his left leg and his clothes caught fire.


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Case Study

•Once brought to the ED, his burns were estimated to be partial and full thickness over his face, neck, trunk, right arm, and right leg.


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Case Study

•He is alert and his voice slightly hoarse.

•His left leg is splinted; the lacerated wound is cleaned and dressed, and bleeding is under control.


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Case Study

•Two large-bore IVs are started, and an indwelling urinary catheter is inserted into the bladder.

•Using the Lund-Browder chart, his total body surface area affected is 63%.


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Discussion Questions

1. In what phase of a burn injury would he be classified? Because the burn occurred in the last 24 hours, he is classified in the emergent phase.2. What are the priorities of care for him?Priorities: #1 airway, #2 fluids, #3 wound care

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Discussion Questions

3. What places him at risk for an inhalation injury?

The burns on his face and neck

4. What are your nursing goals for his care?Primary nursing concerns during the emergent phase are

• Monitoring for hypovolemic shock • Monitoring for edema formation

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