BURN CARE OF BURN

1. Tuesday,
May
10,
2022
MEDICARE
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OF
NURSING,
MULTAN
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2. BURN INJURIES & ITS MANAGEMENT
Tuesday,
May
10,
2022
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3. BURN
A burn is an injury caused by extremes of
temperature, electric current, or certain chemicals.
Tuesday,
May
10,
2022
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4. BURNS
Wounds caused by exposure to:
1. excessive heat
2. Chemicals
3. fire/steam
4. radiation
5. electricity
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Tuesday,
May
10,
2022
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5. 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
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Tuesday,
May
10,
2022
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6. 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
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Tuesday,
May
10,
2022
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7. CHEMICAL BURN
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8. ELECTRICAL BURN
Tuesday, May 10, 2022 8
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9. 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. partial thickness (second-degree)
3. full thickness (third and fourth degree)
9
Tuesday,
May
10,
2022
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10. Tuesday,
May
10,
2022
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11. SUPERFICIAL BURNS
(FIRST DEGREE)
 Superficial (1st degree) – involves only the upper
layers of the epidermis and dermis. It is an irritation
of the living cells in this region and results in some
pain, minor edema, and erythema
 i.e. sunburn
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Tuesday,
May
10,
2022
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12. Tuesday,
May
10,
2022
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13. Tuesday,
May
10,
2022
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14. Tuesday,
May
10,
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15. PARTIAL THICKNESS (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
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May
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16. Tuesday,
May
10,
2022
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17. Tuesday,
May
10,
2022
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18. Tuesday,
May
10,
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19. FULL THICKNESS (THIRD/FOURTH
DEGREE)
 Destruction of all skin layersThrough all dermal
layers
 SQ tissue, muscle, bone, and/or organs involved.
 Nerves have been burnt away.
 Requires immediate hospitalization
 Dry, waxy white, leathery, or hard skin, no pain
 Exposure to flames, electricity or chemicals can
cause 3rd degree burns
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Tuesday,
May
10,
2022
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20. Tuesday,
May
10,
2022
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21. Tuesday,
May
10,
2022
21
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22. CALCULATION OF BURNED BODY SURFACE
AREA
Calculation of Burned Body
Surface Area
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23. 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
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May
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24. LUND BROWDER CHART USED FOR
DETERMINING BSA
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Evans, 18.1, 2007)
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25. 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%
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26. 26
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27. Tuesday,
May
10,
2022
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28. MINOR BURNS
 <15% of BSA
 No complications or involvement of hands, face,
feet, or perineum.
 No evidence of inhalation burns, associated injury,
or severe preexisting medical problem.
Tuesday,
May
10,
2022
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29. MODERATE BURN
 15-25% of BSA
 No complications or involvement of the face, hands,
feet or perineum.
 No evidence of inhalation burns, associated injury,
or severe preexisting medical problem.
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May
10,
2022
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30. MAJOR BURN
 25% or greater of BSA burns
 A functionally significant involvement of hands,
face, feet, or perineum
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2022
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31. VASCULAR CHANGES
 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
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32. FLUID SHIFT
 Occurs after initial vasoconstriction, 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 32
Tuesday,
May
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2022
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33. 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
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May
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34. 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
34
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May
10,
2022
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35. CURLING’S 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
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May
10,
2022
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36. PHASES OF BURN INJURIES
 Emergent (24-48 hrs)
 Acute
 Rehabilitative
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May
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2022
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37. 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
37
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May
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2022
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38. EMERGENT PHASE
 Knowledge of circumstances surrounding the burn
injury
 Obtain client’s 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 client’s health history because the
physiologic stress seen with a burn can make a
latent disease process develop symptoms
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May
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39. 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
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May
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40.  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
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May
10,
2022
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41. 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 41
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42. 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
42
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43. 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
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May
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44. 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
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45. 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
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46. PARKLAND BURN FORMULA
I. Formula to calculate the volume of fluid
necessary for fluid replacement
 Adult
 4ml x (% of BSA 2nd or 3rd burns) x kg
2
 = fluid replacement for first 8 hours after insult.
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47. COMMON FLUIDS
 Protenate or 5% albumin in isotonic saline (1/2
given in first 8 hr; ½ given in next 16 hr)
 LR (Lactate Ringer) without dextrose (1/2 given in
first 8 hr; ½ given in next 16 hr)
 Crystalloid (hypertonic saline) adjust to maintain
urine output at 30 mL/hr
 Crystalloid only (lactated ringers)
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48. NURSING DIAGNOSIS IN THE
EMERGENT PHASE
 Decreased CO
 Deficient fluid volume r/t active fluid volume loss
 Ineffective Tissue perfusion
 Ineffective breathing pattern
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49. 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)
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50. CONT......
 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
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51. 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
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52. LAB VALUES
 Na – hyponatremia or Hypernatremia
 K – Hyperkalemia or Hypokalemia
 WBC – 10,000-20,000
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53. NURSING DIAGOSIS IN THE ACUTE
PHASE
 Impaired skin integrity
 Risk for infection
 Imbalanced nutrition
 Impaired physical mobility
 Disturbed body image
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54. 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
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55. 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
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56. 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
56
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57. 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
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58. 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
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59. 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
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60. SKIN GRAFTS
 Done during the acute phase
 Used for full-thickness and deep partial-thickness
wounds
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61. 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
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62. THE END
QUESTIONS
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