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Pathophysiology of Burn Injury: * Tissue destruction = local and systemic problems
* Fluid/protein losses
* Sepsis
* Disturbances of multiple systems
* Metabolic
* Endocrine
* Respiratory
* Cardiac
* Hematologic
* Immune
* Compensatory responses
What are the Five classification of burns?: 1 - Superficial
2 - Partial-thickness Superficial
3 - Partial-thickness Deep
4 - Full thickness
5 - Deep full-thickness
What are the ABA classifications: * Mild
* Moderate
* Major
Superficial-thickness: * Least destruction
* ONLY epidermis affected
* Often result from prolonged exposure to low-intensity heat, e.g., sunburn
* May result from short exposure to high-intensity heat, e.g., flash burns
S/Sx of Superficial burn wounds: - mild edema
- pain
- heat sensitivity
Characteristics of superficial burn wounds: * Desquamation within 2-3 days
* Rapid healing within 3-5 days
* No scar
* No significant clinical problems
PARTIAL-THICKNESS: epidermis and varying depths of dermis
Partial thickness burn wounds are subdivided into what categories: - superficial partial-thickness
- deep-partial thickness
Characteristics of Superficial Partial Thickness wounds: * Increased duration/exposure to agent
* Typically erythematous/moist
* Intense pain
* Healing: 10-14 days
* blisters (vesicles)
* Intact, provides barrier
* Large numbers of blisters
Blisters occur with what type of wound?: Superficial partial thickness
Characteristics of DEEP-PARTIAL THICKNESS: * Extend deeper into dermis
* Wounds: red and waxy without vesicles
* Edema = moderate
* Pain = present (less than superficial) more nerve endings destroyed
* No vesicles
* Blood supply reduced = vasoconstriction
* May progress to deeper involvement
* Depth and involvement may increase due to infection, hypoxia, or ischemia
* Deep-partial thickness heals 3-6 wks
* Considerable scar formation
* Surgical intervention
* Skin grafts
Characteristics of FULL-THICKNESS: * Entire epidermal and dermal layers
* No epidermal tissue
* Skin grafts required (>12-16 cm2)
* Smaller sections = wound closure
* Hard,dry, leathery ESCHAR (burn crust)
* Eschar must be removed for healing
* Removal difficult
* Circumferential eschar
* Escharotomies
* Fasciotomies
Characteristics of DEEP-FULL THICKNESS: * Extend into fasica/tissues/bones/
* Flame, electrical, or chemical
* Blackened
VASCULAR CHANGES with burn wounds: * Circulatory system disruption
* Vessels occluded
* Blood flow decreases/ceases
* Tissue release chemicals
* Initially, vasoconstriction
* May lead to further injury
Fluid Shift: * Vasoconstiction then dilation
* Increased capillary hydrostatic pressure
* Increased capillary permeability
* Fluid shift: third spacing
* Plasma leaks out of CVS
* Fluid into interstitial spaces
* Loss of plasma/proteins results in decreased colloidal osmotic pressure
* Significant edema
Fluids: * Inflammatory response = 24-36 hrs
* Capillary leak diminishes
* Fluid shifts back into the circulation
* Results in increased UO
* Body weight returns to normal
* Hyponatremia develops
* Increased renal sodium excretion
* Loss of sodium from wounds
* Hypokalemia (K+ returns to ICC)
* Anemia
CVS: * Fluid shifts
* Hypovolemia
* CO decreases
* HR increases
* Fluid support may be necessary
Pulmonary Changes: * Burns may results from inhalation of smoke, toxic fumes
* MAJOR cause of morbidity/mortality
* Pulmonary comps 77% patients
* Respiratory failure
* Respiratory edema
GI: * CurlingÂ’s ulcers may form
* Fluid shifts/decreased CO = blood shifted to vital organs
* GI organs decreased perfusion
* Increased secretion of catecholamines that inhibit GI mobility
* Peristalsis decreases
* Paralytic ileus may develop
Metabolic Changes: * Hypermetabolic state results
* Increased secretion of catecholamines, ADH, aldosterone, and cortisol
* Elevated body core temp, low-grade T
* Oxygen requirements increase
* Kcal requirements increase
* May be tripled
Immunologic Changes: * Loss of protective barrier
* Increased risk for infection
* Activates inflammatory response
* Supress immune function
During vascular changes...cells begin to release ?: toxins
As the amount of circulating volume decreases, what is the effect on breathing rate, heart rate, and H & H?: - Tachypneic
- Tachycardic
- Increased H & H
COMPENSATORY RESPONSES: * Inflammatory response
* Sympathetic nervous system response
Inflammatory: * Helps healing
* Responsible for some complications
* Blood vessels leak and WBC releases chemicals
* Initially, helpful; harmful if continued
What are medications for Curlings ulcers?: H 2 Histamine blockers -
Cimetidine (Tagamet)
Ranitidine (Zantac)
Sucralfate (Carafate)
Etiology of Burn Injury Name types of burn injuries...: * Dry heat
* Moist heat
* Contact burns
* Chemical injury
* Electrical injury
* Thermal
* Flash
* True electrical
* Radiation injury
What is an example of a dry heat injury?: Flame...house fire, explosions
What is an example of a moist heat injury?: Scald...hot liquid
What is an example of a contact burn?: Grease, hot tar, heating pad
What is an example of a chemical injury burn?: Industrial settings, cleaning agents
What may occur with an electrical burn?: Amputation
With electrical burns what are two distinct characteristics?: Entrance and exit
Interventions for burn: * Emergent Phase
* 1st hour critical
* Open airway
* Adequate circulation
* Limit extent of injury
* Maintaining functions of vital organs
* Nurse: obtain HISTORY
Physical Assessment burn: * Emergent phase and later phases
* Respiratory Assessment
* Direct airway injury
* May be observed in nares, mouth, eyes
* Hoarseness
* Cough
* Drooling/difficulty swallowing
* Lung sounds, adventitious
Assessment burn: * Dyspnea
* Eschar from circumferential chest burns
* Put patient in position to facilitate breathing
* Thorough respiratory assessment
With carbon monoxide poisoning, carbon monoxide binds to what molecule?: Hemoglobin
What is the color of person's skin with carbon monoxide poisoning?: Cherry red
Minor burns: - Emergency care
- Deep partial thickness <15% TBSA
- Full thickness < 2% TBSA
- No burns of eyes, ears, face, hands, feet, perineum
- No electrical burns
- No inhalatin injury
- < 60 years of age and no chronic cardiac, pulmonary or endocrine disorder
Moderate burn: - Deep partial thickness 15%-25% TBSA
- Full thickness < 2%-10% TBSA
- No burns of eyes, ears, face, hands, feet, perineum
- No electrical burns
- No inhalatin injury
- No complicated comcomitant injury
- < 60 years of age and no chronic cardiac, pulmonary or endocrine disorder
Major burn: - Deep partial thickness >25% TBSA
- Full thickness > 10% TBSA
- Any burn involving the eyes, ears, face, hands, feet, perineum
- Electrical burns
- Inhalatin injury
- > 60 years of age
- Burn is complicated with other injuries (e.g., fracture)
- Client has cardiac, pulmonary, or other chronic metabolic disorder
Assessment CVS: * Shock, monitor for s/sx (Chapter 37)
* Initially, hypovolemia and decreased CO
* Note edema
* Assess CVS
* Pulses
* VS
* Cap refill
* Oximeter
* Ekg changes
Assessment Renal: * Changes d/t decreased perfusion
* U/O diminished (even with IV)
* Sp gr increased
* Tissue damage Â– other substances in blood
* Destroyed RBCs release Hb and Hct
* Myoglobin (muscles) may be released
* Damaged cells release protein Â– uric acid
* All of these affect kidneys
assessment
Renal function assessment: * Urine output, spec grav
* Uo decreased initially
* Maintain 30-50 cc/hr
* Monitor BUN, electrolytes
Integumentary Assessment: * Total body surfact area (TBSA)
* 40% body = 40% burn
* Calculations important (meds,kcal)
* Skin assessment
* Â“Rule of NinesÂ” Â– commonly used to determine percentage of body affected by burn injury
Integumentary Changes: * Lund-Browder (Berkow) Methods
* Very important to continually assess affected areas
* Areas may change
* Impact medications, supplies, kcal, etc
Assessment GI: * NG tube usually inserted
* Assessment: decreased bowel sounds
* Nausea, vomiting, and abdominal distention
* Ulcer formation
* Full abdominal assessment
* Stool specimen (RBC particles)
* Occult blood
Laboratory Assessment - Serum: * Hg 1.7-15.5 g/dl; 13.2 -17.3
* Hct 25-45; 40-60%
* Electrolytes
* ABGs
* Other
* Total protein
* albumin
Emergency Management - General: * Assess for airway patency
* Oxygen
* Cover client with blanket
* NPO
* Elevate affected part if no fx
* VS
* IV
* History/assessment
* Tetanus, prophylactically
Decreased CO, Tissue Perfusion & FVD Planning: Expected Outcomes: * Emergency phase: restore CO
* Maintain oxygenation/perfusion
Interventions for decreased cardiac output, tissue persuion, and fluid volume deficit: * Aimed at increasing fluid volume
* Supporting compensatory mechanisms
* Preventing complications
Fluid Monitoring: * Monitor serum electrolytes/UA
* Monitor VS
* Monitor changes in cardiac status
* Ekgs
* Monitor weight
* Accurate I&O
* Note any vertigo/syncope
* Specific gravity, quality of urine output
Nursing Interventions for fluid monitoring: * Aimed at increasing fluid volume, supporting compensatory mechanisms, and preventing complications
* Nonsurgical management Â–
* Intravenous Fluid Therapy
* 15-20% burns typically require IV therapy
* Many different formulas for IV therapy
* Be familiar with different type names
* IV therapy used to prevent ? * Severe burn Â– large fluid loads quickly * Boluses are avoided, why? * Usually, calculated based on time of injury * Known as Â“resuscitationÂ” therapy: - shock
- increases cap hydrostatic pressure and exacerbates edema
Plasma Exchange Therapy: * Shock/persistent shock (eti unknown)
* Used in burn centers for patients with massive burns who fail to respond
* Remove plasma/add FFP Â“plasmapheresisÂ”
* Remove blood/add blood
Monitoring: * Clinical criteria
* Monitor all systems
* Urine output is the most common and most sensitive noninvasive assessment parameter for CO and T perfusion
* IV rate must sustain 30ml/hr
* Titration of IV to perfuse adequately
* >35% burns, uo and VS inadequate
* Invasive cardiac monitoring necessary
Hypovolemic shock: * Extensive cardiac monitoring
* CVP (central venous pressure), PAP (pulmonary artery pressure), and CO
* Nurse monitors EKG/ECG
* Atrial fib and other abnormalities may be seen
Drug Therapy: *common mistake Â– administer diuretics which can reduce perfusion to other organs (diuretics do not increase CO; they decrease volume and thus CO by pulling fluid from circulating volume to enhance diuresis)
* Exception: electrical burns
* Mannitol may be given AFTER u/o est
* Problems: CHF or MI
Surgical Management: * Escharotomy = incision through burn eschar
* Relieves pressure
* If not relieved, arterial compression with irreversible damage
* Compromised perfusion
* Ischemia
* Necrosis
* If insufficient, may need fasciotomy (deeper)
* Performed at bedside
* No anesthesia
* Sedation/analgesia, « anxiety
* Dressings
* Topical antimicrobial agents
* Carefully monitored for bleeding, infection, inflammation, changes
Ineffective Breathing Pattern: * Outcome: airway patency
* Interventions
* Nonsurgical
* Promote airway clearance
* Promote ventilation
* Promote gas exchange
* O2 therapy
* Drug therapy
* Positioning
* Deep breathing
Airway Maintenance: * Chin lift/repositioning head of unconscious victim at scene
* Upper airway edema Â– intubation
* Bronchoscopy to view structures
* Endotracheal tube
* Monitor secretions/sloughed off tissue from lungs which can obstruct airway
* Rigorous Suctioning necessary but painful (sedation required beforehand)
Promotion of Ventilation: * Depends on pertinent muscles, etc.
* Many burn dressings restrictive
* Monitoring Gas Exchange
* Laboratory tests
* Physical assessment
* Chest x-ray
* Cardiac monitoring
Oxygen Therapy for airway maintenance: * Administering humidfied O2 by face mask, cannula, or hood
* Arterial oxygenation <60PaO2, intubation and mechanical ventilation
* Airway equipment at bedside
Drug Therapy for airway maintenance: * Antibiotics may be prescribed
* Paralytic drugs
Positioning and Deep Breathing for airway maintenance: * Turned, repositioned, OOB
Surgical management for airway maintenance: * Tracheostomy Â–long term intubation
* Chest tubes Â– to reexpand lungs
Acute/Chronic Pain: * From burns and treatments
* Pain assessment scales
* Medications
* Diversional/alternative pain modalities
* Important to alleviate/monitor pain
* One of the MAJOR issues!
Drug Therapy for acute/chronic pain: * Opioid and nonopioid analgesics (morphine)
* Problem: respiratory depression
* Diminished GI motility
* Emergent phase: IV pain medications preferred (give GI tract rest)
* IM Â– remain in skin, are not absorbed
* Edema - fluid impairs absorption
* Strict protocols for all medications
Complementary and Alternative Tx for acute/chronic pain: * Relaxation
* Focused breathing
* Guided visual imagery
* Music
* Massage/therapeutic touch
Environmental Manipulation for acute/chronic pain: * Quiet, restful, calm environment
* Increase patientÂ’s control
* Sleep deprivation
* Plan care to provide rest/sleep
* Tactile stimulation, may reduce pain
* Changing position
* Warm room temperatures
* Patient involvement
Pulmonary Edema * Outcome * Interventions: * May affect even young patients
* Digoxin or another inotropic medication to improve left ventricular function
* Diuretics, may/may Not be used depending on renal function
ARDS: * Outcome: ABGs wnl
* Interventions aimed at increasing lung compliance
* Improving ABGs
* PEEP to augment decreasing lung volume by providing continuous PP in the airways to alveoli
* Maximizes gas exchange
* Monitor respiratory status
Phases of Burn Injury: - Emergency
- Acute phase
- Rehabilitative phase
Emergency Phase: * First 48 hours
* Maintain an open airway, ensure adequate breathing/circulation
* Limit extent of injury/maintain function of vital organs
* Prevent potential complications
Acute phase: * First 48 hours to complete wound closure
* Maintenance of cardiovascular/respiratory systems
* Nutritional status
* Burn wound care
* Pain control
* Psychosocial interventions
Interventions for Burn Wound Management - nonsurgical: - Debridement
- Dressings
Types of Debridement: - Mechanical
- Enzymatic
Types of Dressings: - Standard wound dressings
- Biologic dressings
- Synthetic dressing/artificial skin
Interventions - surgical: - Surgical excision
- Wound coverings
Body Image Distrubance: * Serious problem
* Nonsurgical management
* NurseÂ–stages of grief understanding and intervention to assist patient
* Patient often confused
* Patient may be angry, anxious, etc.
* Nurse must be strong and able to interpret patientÂ’s feelings without internalizing
* Assurance to patient feelings are normal
ConÂ’t
* May need to provide referral
* Nurse must accept patientÂ’s physical appearance
* Work with family/groups
SURGICAL MANAGEMENT for body image: - reconstructive surgery
* Cosmetic surgery
* May be performed for many years
* Restoration of function/appearance
* Increases patientÂ’s feelings of self-worth
* Patients may have unrealistic expectations, education critical
Immune: * Infection = LEADING CAUSE OF MORTALITY/MORBIDITY acute phase
* Nurse Â– continually assess patient for s/sx infection
* Gram+, gram -, fungal infections
* METICULOUS HAND WASHING
* Local and systemic s/sx infection
Burns-Nursing Diagnosis: * Decreased cardiac output
* Deficient fluid volume
* Ineffective tissue perfusion (multiple)
* Ineffective breathing pattern
* Pain
* Excess fluid volume
* Risk for ineffective thermoregulation
* Sensory/perceptual alterations
Vesicles...which type of wound?: Superficial partial thickness
Red and waxy without vesicles...what type of wound?: Deep partial thickness
Black eschar?: Deep full thickness
Sunburn, example of?: Superficial wound
Nerve endings exposed?: Deep superficial partial thickness

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