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Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chapter 57
Management of Patients With
Burn Injury
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Burn Injuries
• Approximately 1.1 million people require medical
attention of burns every year, and about 4500 persons
die from burns and associated inhalation injuries every
year.
• Most burns occur in the home.
• Young children and the elderly are at high risk for burn
injuries.
• Nurses must play an active role in the prevention of burn
injuries by teaching prevention concepts and promoting
safety legislation.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Goals Related to Burns
• Prevention
• Institution of lifesaving measures for the severely burned
person
• Prevention of disability and disfigurement through early
specialized and individualized care
• Rehabilitation through reconstructive surgery and
rehabilitation programs
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Classification of Burns
• Superficial partial-thickness
• Deep partial-thickness
• Full thickness
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Zones of Burn Injury
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Factors to Consider in Determining Burn
Depth
• How the injury occurred
• Causative agent
• Temperature of agent
• Duration of contact with the agent
• Thickness of the skin
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Classification of Burns by Extent of Injury
• Minor burn
• Moderate, uncomplicated burn
• Major burn
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Methods to Estimate Total Body Surface
Area (TBSA) Burned
• Rule of nines
• Lund and Browder method
• Palm method
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Rule of Nines
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Pathophysiology of Burns
• Burns are caused by a transfer of energy form a heat
source to the body.
• Thermal (includes electrical)
• Radiation
• Chemical
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Physiologic Changes
• Burns less than 25% TBSA produce primarily a local
response.
• Burns more than 25% may produce a local and systemic
response, and are considered major burns.
• Systemic response includes release of cytokines and
other mediators into systemic circulation.
• Fluid shifts and shock result in tissue hypoperfusion and
organ hypofunction.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Effects of Major Burn Injury
• Fluid and electrolyte shifts
• Cardiovascular effects
• Pulmonary injury
– Upper airway
– Inhalation below the glottis
– Carbon monoxide poisoning
– Restrictive defects
• Renal and GI alterations
• Immunologic alterations
• Effect upon thermoregulation
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Management of Shock—Fluid
Resuscitation
• Maintain blood pressure of greater than 100 mm Hg
systolic and urine output of 30–50 mL/hr, maintain
serum sodium at near-normal levels
• Consensus formula
• Evans formula
• Brooke Army formula
• Parkland Baxter formula
• Hypertonic saline formula
• Note: Adjust formulas to reflect initiation of fluids at the
time of injury
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Fluid and Electrotype Shifts—Emergent
Phase
• Generalized dehydration
• Reduced blood volume and hemoconcentration
• Decreased urine output
• Trauma causes release of potassium into extracellular
fluid: hyperkalemia
• Sodium traps in edema fluid and shifts into cells as
potassium is released: hyponatremia
• Metabolic acidosis
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Fluid and Electrolyte Shifts—Acute Phase
• Fluid reenters the vascular space from the interstitial
space
• Hemodilution
• Increased urinary output
• Sodium is lost with diuresis and due to dilution as fluid
enter vascular space: hyponatremia
• Potassium shifts from extracellular fluid into cells:
potential hypokalemia
• Metabolic acidosis
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Burn Wound Care
• Wound cleaning
– Hydrotherapy
• Use of topical agents
• Wound debridement
– Natural debridement
– Mechanical debridement
– Surgical debridement
• Wound dressing, dressing changes, and skin grafting
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Use of Biobrane Dressing
Refer to fig. 57-4
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
Formulas are only a guide for burn care fluid resuscitation.
How often must the patient’ s response to fluid therapy
(heart rate, blood pressure, and urine output) be
evaluated?
A.1 hour
B.2 hours
C.3 hours
D.4 hours
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
A
The patient’ s response to fluid therapy (heart rate, blood
pressure, and urine output) should be evaluated at least
hourly.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Pain Management
• Burn pain has been described as one of the most severe
forms of acute pain
• Pain accompanies care, and treatments such as wound
cleaning and dressing changes
• Types of burn pain
– Background or resting
– Procedural
– Breakthrough
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Pain Management
• Analgesics
– IV use during emergent and acute phases
– Morphine
– Fentynal
– Other
• Role of anxiety in pain
• Effect of sleep derivation on pain
• Nonpharmacologic measures
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nutritional Support
• Burn injuries produce profound metabolic abnormalities,
and patient with burns have great nutritional needs
related to stress response, hypermetabolism, and
requirement for wound healing.
• Goal of nutritional support is to promote a state of
nitrogen balance and match nutrient utilization.
• Nutritional support is based upon patient preburn status
and % of TBSA burned.
• Enteral route is preferred. Jejunal feedings are frequently
utilized to maintain nutritional status with lower risk of
aspiration in a patient with poor appetite, weakness, or
other problems.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Other Major Care Issues
• Pulmonary care
• Psychological support of patient and family
• Patient and family education
• Restoration of function
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Phases of Burn Injury
• Emergent or resuscitative phase
– Onset of injury to completion of fluid resuscitation
• Acute or intermediate phase
– From beginning of diuresis to wound closure
• Rehabilitation phase
– From wound closure to return to optimal physical and
psychosocial adjustment
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Emergent or Resuscitative Phase—
On-the-Scene Care
• Prevent injury to rescuer
• Stop injury: extinguish flames, cool the burn, irrigate
chemical burns
• ABCs: Establish airway, breathing, and circulation
• Start oxygen and large-bore IVs
• Remove restrictive objects and cover the wound
• Do assessment surveying all body systems and obtain a
history of the incident and pertinent patient history
• Note: treat patient with falls and electrical injuries as for
potential cervical spine injury
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Emergent or Resuscitative Phase
• Patient is transported to emergency department
• Fluid resuscitation is begun
• Foley catheter is inserted
• Patient with burns exceeding 20–25% should have an Ng
inserted and placed to suction
• Patient is stabilized and condition is continually monitored
• Patients with electrical burns should have ECG
• Address pain; only IV medication should be administered
• Psychosocial consideration and emotional support should be
given to patient and family
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Use of the Nursing Process in the Care of
the Patient in the Emergent Phase of Burn
Care—Diagnoses
• Impaired gas exchange
• Ineffective airway clearance
• Fluid volume deficit
• Hypothermia
• Acute Pain
• Anxiety
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Use of the Nursing Process in the Care of
the Patient in the Emergent Phase of Burn
Care—Potential Complications/
Collaborative Problems
• Acute respiratory failure
• Distributive shock
• Acute renal failure
• Compartment syndrome
• Paralytic ileus
• Curling’s ulcer
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Acute or Intermediate Phase:
• 48–72 hours post injury
• Continue assessment and maintain respiratory and
circulatory support
• Prevention of infection, wound care, pain management,
and nutritional support are priorities in this stage
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Use of the Nursing Process in the Care of
the Patient in the Acute Phase of Burn
Care—Diagnoses
• Excessive fluid volume
• Risk for infection
• Imbalanced nutrition
• Acute pain
• Impaired physical mobility
• Ineffective coping
• Interrupted family processes
• Deficient knowledge
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Use of the Nursing Process in the Care of
the Patient in the Acute of Burn Care—
Collaborative Problems/Potential
Complications
• Heart failure and pulmonary edema
• Sepsis
• Acute respiratory failure
• Visceral damage (electrical burns)
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Rehabilitation Phase
• Rehabilitation is begun as early as possible in the
emergent phase and extend for a long period after the
injury.
• Focus is upon wound healing, psychosocial support, self-
image, lifestyle, and restoring maximal functional abilities
so the patient can have the best quality life, both
personally and socially.
• The patient may need reconstructive surgery to improve
function and appearance.
• Vocational counseling and support groups may assist the
patient.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Home Care Instruction
• Mental health
• Skin and wound care
• Exercise and activity
• Nutrition
• Pain management
• Thermoregulation and clothing
• Sexual issues
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Elastic Pressure Garments
Refer to fig. 57-7
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
Is the following statement True or False?
Breathing must be assessed and patent airway established
immediately during the initial minutes of emergency burn
care.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
True
Breathing must be assessed and patent airway established
immediately during the initial minutes of emergency burn
care.

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Chapter057

  • 1. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 57 Management of Patients With Burn Injury
  • 2. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Burn Injuries • Approximately 1.1 million people require medical attention of burns every year, and about 4500 persons die from burns and associated inhalation injuries every year. • Most burns occur in the home. • Young children and the elderly are at high risk for burn injuries. • Nurses must play an active role in the prevention of burn injuries by teaching prevention concepts and promoting safety legislation.
  • 3. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Goals Related to Burns • Prevention • Institution of lifesaving measures for the severely burned person • Prevention of disability and disfigurement through early specialized and individualized care • Rehabilitation through reconstructive surgery and rehabilitation programs
  • 4. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Classification of Burns • Superficial partial-thickness • Deep partial-thickness • Full thickness
  • 5. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Zones of Burn Injury
  • 6. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Factors to Consider in Determining Burn Depth • How the injury occurred • Causative agent • Temperature of agent • Duration of contact with the agent • Thickness of the skin
  • 7. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Classification of Burns by Extent of Injury • Minor burn • Moderate, uncomplicated burn • Major burn
  • 8. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Methods to Estimate Total Body Surface Area (TBSA) Burned • Rule of nines • Lund and Browder method • Palm method
  • 9. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Rule of Nines
  • 10. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Pathophysiology of Burns • Burns are caused by a transfer of energy form a heat source to the body. • Thermal (includes electrical) • Radiation • Chemical
  • 11. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Physiologic Changes • Burns less than 25% TBSA produce primarily a local response. • Burns more than 25% may produce a local and systemic response, and are considered major burns. • Systemic response includes release of cytokines and other mediators into systemic circulation. • Fluid shifts and shock result in tissue hypoperfusion and organ hypofunction.
  • 12. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Effects of Major Burn Injury • Fluid and electrolyte shifts • Cardiovascular effects • Pulmonary injury – Upper airway – Inhalation below the glottis – Carbon monoxide poisoning – Restrictive defects • Renal and GI alterations • Immunologic alterations • Effect upon thermoregulation
  • 13. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Management of Shock—Fluid Resuscitation • Maintain blood pressure of greater than 100 mm Hg systolic and urine output of 30–50 mL/hr, maintain serum sodium at near-normal levels • Consensus formula • Evans formula • Brooke Army formula • Parkland Baxter formula • Hypertonic saline formula • Note: Adjust formulas to reflect initiation of fluids at the time of injury
  • 14. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Fluid and Electrotype Shifts—Emergent Phase • Generalized dehydration • Reduced blood volume and hemoconcentration • Decreased urine output • Trauma causes release of potassium into extracellular fluid: hyperkalemia • Sodium traps in edema fluid and shifts into cells as potassium is released: hyponatremia • Metabolic acidosis
  • 15. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Fluid and Electrolyte Shifts—Acute Phase • Fluid reenters the vascular space from the interstitial space • Hemodilution • Increased urinary output • Sodium is lost with diuresis and due to dilution as fluid enter vascular space: hyponatremia • Potassium shifts from extracellular fluid into cells: potential hypokalemia • Metabolic acidosis
  • 16. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Burn Wound Care • Wound cleaning – Hydrotherapy • Use of topical agents • Wound debridement – Natural debridement – Mechanical debridement – Surgical debridement • Wound dressing, dressing changes, and skin grafting
  • 17. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Use of Biobrane Dressing Refer to fig. 57-4
  • 18. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Formulas are only a guide for burn care fluid resuscitation. How often must the patient’ s response to fluid therapy (heart rate, blood pressure, and urine output) be evaluated? A.1 hour B.2 hours C.3 hours D.4 hours
  • 19. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer A The patient’ s response to fluid therapy (heart rate, blood pressure, and urine output) should be evaluated at least hourly.
  • 20. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Pain Management • Burn pain has been described as one of the most severe forms of acute pain • Pain accompanies care, and treatments such as wound cleaning and dressing changes • Types of burn pain – Background or resting – Procedural – Breakthrough
  • 21. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Pain Management • Analgesics – IV use during emergent and acute phases – Morphine – Fentynal – Other • Role of anxiety in pain • Effect of sleep derivation on pain • Nonpharmacologic measures
  • 22. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Nutritional Support • Burn injuries produce profound metabolic abnormalities, and patient with burns have great nutritional needs related to stress response, hypermetabolism, and requirement for wound healing. • Goal of nutritional support is to promote a state of nitrogen balance and match nutrient utilization. • Nutritional support is based upon patient preburn status and % of TBSA burned. • Enteral route is preferred. Jejunal feedings are frequently utilized to maintain nutritional status with lower risk of aspiration in a patient with poor appetite, weakness, or other problems.
  • 23. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Other Major Care Issues • Pulmonary care • Psychological support of patient and family • Patient and family education • Restoration of function
  • 24. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Phases of Burn Injury • Emergent or resuscitative phase – Onset of injury to completion of fluid resuscitation • Acute or intermediate phase – From beginning of diuresis to wound closure • Rehabilitation phase – From wound closure to return to optimal physical and psychosocial adjustment
  • 25. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Emergent or Resuscitative Phase— On-the-Scene Care • Prevent injury to rescuer • Stop injury: extinguish flames, cool the burn, irrigate chemical burns • ABCs: Establish airway, breathing, and circulation • Start oxygen and large-bore IVs • Remove restrictive objects and cover the wound • Do assessment surveying all body systems and obtain a history of the incident and pertinent patient history • Note: treat patient with falls and electrical injuries as for potential cervical spine injury
  • 26. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Emergent or Resuscitative Phase • Patient is transported to emergency department • Fluid resuscitation is begun • Foley catheter is inserted • Patient with burns exceeding 20–25% should have an Ng inserted and placed to suction • Patient is stabilized and condition is continually monitored • Patients with electrical burns should have ECG • Address pain; only IV medication should be administered • Psychosocial consideration and emotional support should be given to patient and family
  • 27. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Use of the Nursing Process in the Care of the Patient in the Emergent Phase of Burn Care—Diagnoses • Impaired gas exchange • Ineffective airway clearance • Fluid volume deficit • Hypothermia • Acute Pain • Anxiety
  • 28. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Use of the Nursing Process in the Care of the Patient in the Emergent Phase of Burn Care—Potential Complications/ Collaborative Problems • Acute respiratory failure • Distributive shock • Acute renal failure • Compartment syndrome • Paralytic ileus • Curling’s ulcer
  • 29. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Acute or Intermediate Phase: • 48–72 hours post injury • Continue assessment and maintain respiratory and circulatory support • Prevention of infection, wound care, pain management, and nutritional support are priorities in this stage
  • 30. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Use of the Nursing Process in the Care of the Patient in the Acute Phase of Burn Care—Diagnoses • Excessive fluid volume • Risk for infection • Imbalanced nutrition • Acute pain • Impaired physical mobility • Ineffective coping • Interrupted family processes • Deficient knowledge
  • 31. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Use of the Nursing Process in the Care of the Patient in the Acute of Burn Care— Collaborative Problems/Potential Complications • Heart failure and pulmonary edema • Sepsis • Acute respiratory failure • Visceral damage (electrical burns)
  • 32. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Rehabilitation Phase • Rehabilitation is begun as early as possible in the emergent phase and extend for a long period after the injury. • Focus is upon wound healing, psychosocial support, self- image, lifestyle, and restoring maximal functional abilities so the patient can have the best quality life, both personally and socially. • The patient may need reconstructive surgery to improve function and appearance. • Vocational counseling and support groups may assist the patient.
  • 33. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Home Care Instruction • Mental health • Skin and wound care • Exercise and activity • Nutrition • Pain management • Thermoregulation and clothing • Sexual issues
  • 34. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Elastic Pressure Garments Refer to fig. 57-7
  • 35. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement True or False? Breathing must be assessed and patent airway established immediately during the initial minutes of emergency burn care.
  • 36. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer True Breathing must be assessed and patent airway established immediately during the initial minutes of emergency burn care.