Nurs202 burn injuries final

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Nurs202 burn injuries final

  1. 1. Thermal Injuries: Burns<br />NURS 225<br />Adult Nursing II<br />1<br />
  2. 2. Objectives<br />▪ Compare the manifestations of superficial, partial thickness, and full thickness burn injuries.<br />▪ Prioritize nursing care for the patient during the resuscitation phase of burn injury.<br />▪ Prioritize nursing care for the patient during the acute phase of burn injury.<br />2<br />
  3. 3. Classification of Burns<br />▪ Superficial: first degree <br />∙ epidermal layer <br /> ∙ causes: sunburn, ultraviolet light, minor flash injuries, mild radiation burns <br /> ∙ appearance: pink to bright red, slight edema <br /> ∙ mildly painful <br /> ∙ treatment: mild analgesia, <br /> water-soluble lotions <br />3<br />
  4. 4. ▪ Partial-thickness: second degree <br />∙ dermis layer: superficial partial-thickness or deep partial-thickness burn<br />∙ causes: superficial -<br />deep -<br />∙ appearance: superficial - bright red, moist deep – pale, waxy, moist or dry <br />∙ severe pain in response to air or heat <br />∙ treatment: analgesia, skin substitutes, grafting may be necessary <br />4<br />
  5. 5. ▪ Full-thickness burns: third degree <br />Deep full thickness: involves fascia and tissues, muscle, bone, and tendons<br />∙ causes: flames, steam, chemicals, high-voltage electrical current <br />∙ appearance: hard, dry, pale, waxy, yellow, brown, mottled, charred, or non-blanching red <br />∙ no sensation of pain<br /> or sensation of light touch <br />∙ treatment: <br />requires skin grafting, amputation<br />May be needed <br />5<br />
  6. 6. Types of Burns<br />Thermal<br />∙ dry heat- <br /> ∙ moist heat-<br />Chemical<br />∙ acid – <br /> ∙ alkali – <br /> ∙ organic – <br />Electrical<br />∙ severity dependent on type, duration, pathway, and resistance<br /> ∙ damage can be concealed/internal<br /> ∙ follows path of least resistance<br /> ∙ coagulation at site leads to necrosis<br /> ∙ direct current injuries have entrance and exit wounds <br />Radiation<br />∙ therapeutic radiation – <br />∙ industrial radiation – <br />6<br />
  7. 7. Rule of 9’s - determines extent of burn, percentage of body surface involved<br />7<br />
  8. 8. Location of Burn Determines Extent of Injury<br />Face, neck, chest  respiratory obstruction<br />Hands, feet, joints, and eyes  self-care <br />Ears, nose  infection<br /> <br />Circumferential burns of the extremities can cause circulatory compromise and potential compartment syndrome<br /> <br />8<br />
  9. 9. Pre-Hospital Management<br />Stop burning process<br />∙ thermal burns – <br /> ∙ chemical burns –<br />∙ electrical burns – <br />Support<br />∙ secure airway ∙ fluid replacement<br /> ∙ comfort ∙ prevent infection<br /> ∙ thermoregulation ∙ support circulation<br /> ∙ emotional support<br />Transport - burn center criteria<br />∙ 55 burn centers in continental US<br /> ∙ University of Washington Burn Center - Seattle, Washington<br />9<br />
  10. 10. Hospital Management<br />Minor Burns<br />∙ skin remains intact - <15% split thickness, <2% full thickness<br />∙ excludes face/facial structures, hands, feet, perineum<br /> ∙ treatmentincludes:<br />10<br />
  11. 11. Major Burns ~ Emergent Phase<br />Fluid Resuscitation – three common resuscitation formulas<br />Calculated *ml/kg/TBSA% (*ml/kg varies slightly among formulas)<br />∙ requires LARGE fluid loads over first 24 hours<br /> ∙ ½ of total fluid over 1st 8 hours after injury<br /> ∙ remainder of fluid given over the remaining 16 hours<br /> ∙ Goals – 30-50ml urine output/hr, SBP>90mmHg, P<120, RR 16-20<br />Fluid resuscitation formulas calculated from the time of INJURY not ARRIVAL at the hospital.<br />11<br />
  12. 12. Fluid resuscitation example<br /> 70kg person, burn injury to head, left arm, left leg<br /> time of injury 8am – time of arrival at hospital 10am<br />TBSA 36% ~ using Parkland Formula 4ml/kg/TBSA<br />4ml x 70 x 36 = 10080ml to be given over 1st 24hours<br />5040ml over 1st 8 hours = 630ml/hr<br /> (2050÷6=840ml/hr ~ 8 hours started at 8am)<br />5040ml over remaining 16 hours = 280ml/hr<br />12<br />
  13. 13. Pathophysiology<br />∙ Integumentary <br />∙massive fluid loss through evaporation<br /> ∙heat loss<br />∙dependent on depth and severity of injury<br /> ∙no blood flow through damaged vessels<br />∙Bull’s eye appearance<br />Goal = relieve pressure, restore blood flow, salvage<br /> ∙ Eschar – hard crust like, forms over necrotic skin <br />13<br />
  14. 14. ∙ Cardiovascular<br />∙ hypovolemic shock ~ burn shock<br />∙ Fluid shift (3rd spacing) immediately after injury-24hours<br /> =intracellular -> intravascular -> interstitial<br /> ∙ ↑ permeability - ↑ intracellular edema - ↑ osmosis<br /> =profound weight gain, edema<br /> – Fluid remobilization-> diuresis 48-72 hours after injury <br /> ∙ normal loss - 30 to 50ml/hour<br /> ~ severely burned patient - 200 to 400ml/hour <br /> ∙ arrhythmia's<br /> ∙ TBSA >40% increased risk for arrhythmia's<br /> electrolyte shifts and cellular damage<br /> ∙ peripheral vascular alteration ~ compartment syndrome<br />14<br />
  15. 15. ∙ Respiratory<br />∙ direct inhalation or systemic response<br /> ∙ inflammation ~<br /> ∙ interstitial pulmonary edema ~<br /> ∙ upper airway ~ <br /> ∙ smoke poisoning ~ <br /> ∙ CO poisoning ~ <br />15<br />
  16. 16. ∙ Gastrointestinal ~dysfunction related to size of burn wound <br /> ∙ paralytic ileus-<br /> ∙ stress (curling’s) ulcers ~<br /> ∙ ischemic bowel -> bacterial translocation -> sepsis -> multiple organ dysfunction <br />∙ Urinary <br /> ∙ early stages ~ ↓renal blood flow ->↓ GFR<br /> ∙ myoglobinuria<br /> ∙ progresses to renal failure <br />16<br />
  17. 17. ∙ Immune System ~ open wounds and decreased immune function, infection and sepsis leading cause of death in acute phase<br />local changes<br />∙ partial thickness -> full thickness<br />∙ ulceration of healthy tissue<br />∙ erythematous nodular lesions -> in uninvolved tissue<br />∙ vesicular lesions in healed tissue<br />∙ edematous tissue surrounding wound<br />∙ excessive drainage, odor<br />∙ pale, dry, crusted granulated tissue<br />∙ graft rejection<br />∙ dehiscence <br />systemic changes<br />∙ changes in LOC<br />∙ subtle changes in VS (hemodynamic instability, hypoxemia)<br />∙ ↑ fluids to maintain adequate urine output ~ oliguria<br />∙ GI dysfunction ~ diarrhea, vomiting, ileus, distention<br />∙ hyperglycemia<br />∙ thrombocytopenia<br />∙ ↑ or ↓ WBC<br />∙ metabolic acidosis<br />Monitor for organism related infection sepsis<br />17<br />
  18. 18. ∙ Metabolism ~ heat and water loss increases metabolic and catabolic rates -> increase caloric needs -> resting metabolic rate ↑ 50% to 100%<br />∙ increased secretion ~<br />∙ activated stress response ~<br />∙ extent of injury dictates caloric needs<br />∙ increase in core body temperature<br />18<br />
  19. 19. Treatment ~ three stages of treatment<br />∙ 1. Emergent – Resuscitative Stage ~ from injury through successful fluid resuscitation – 24 to 28 hours up to 5 days<br /> ∙ priority – detect/prevent ~ hypovolemic shock<br /> ∙ airway management - intubation<br /> ∙ limit extent of burn<br /> ∙ restore circulating volume ~ ↓ risk of burn shock, replace electrolytes, maintain adequate urine output<br /> ∙ large bore IV access<br /> ∙ cut down<br /> ∙ transfer to burn center if indicated and applicable<br />19<br />
  20. 20. ∙ 2. Acute Phase ~ begins with diuresis (fluid shift) and ends with wound closure – wound are healed<br /> ∙ wound management ~<br /> ∙ nutritional support – enteral/parenteral<br /> ∙ monitor for signs and symptoms of infection/prevent sepsis<br /> ∙ pain management<br /> ∙ monitor electrolytes ~<br /> ∙ Na hyponatremia – hydrotherapy, GI drainage<br />hypernatremia – hypertonic IV fluids, incorrect tube feeding<br /> ∙ K+hypokalemia – hydrotherapy, vomiting, diarrhea, GI suctioning, IV w/out replacement <br />hyperkalemia – secondary to renal failure, adrenocorticoid insufficiency, massive deep tissue injury <br />20<br />
  21. 21. 3. Rehabilitative stage ~ begins with wound closure up to and including restoration of optimal health status and function – may take years<br />∙ prevention of contractures and scars <br />∙ client returns to work, family, and social roles <br />∙ may include vocational, occupational, physical and psychosocial rehabilitation <br />21<br />

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