Burn lecture.ppt

8/10/2019 Burn lecture.ppt

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BURNINJURIES& ITSMANAGEMENT

Dr I braheem Bashayreh, RN, PhD

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BURNS

Wounds caused by exposure to:

1. excessive heat

2. Chemicals

3. fire/steam4. radiation

5. electricity

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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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TYPES OF BURNS

Thermal

exposure to flame or a hot object

Chemical

exposure to acid, alkali or organic substancesElectrical

result from the conversion of electrical energy into heat.Extent of injury depends on the type of current, the pathway offlow, local tissue resistance, and duration of contact

Radiation

result from radiant energy being transferred to the bodyresulting in production of cellular toxins

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CHEMICALBURN

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ELECTRICAL BURN

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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 tissueinvolved

1. superficial (first-degree)

2. deep (second-degree)3. full thickness (third and fourth degree)

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SUPERFICIAL BURNS

(FIRST DEGREE)

Epidermal tissue only affected

Erythema, blanching on pressure, mild swelling

no vesicles or blister initially

Not serious unless large areas involved i.e. sunburn

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DEEP (SECOND DEGREE)

*Involves the epidermis and deep layer of the dermis

Fluid-filled vesiclesred, shiny, wet, severe pain

Hospitalization required if over 25% of body surface

involvedi.e. tar burn, flame

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FULL THICKNESS (THIRD/FOURTH

DEGREE)

Destruction of all skin layers

Requires immediate hospitalization

Dry, waxy white, leathery, or hard skin, no pain

Exposure to flames, electricity or chemicals cancause 3rddegree burns

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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 bodyadequate for initialassessment for adult burns

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LUND BROWDER CHART USED FOR


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LUNDBROWDERCHARTUSEDFOR

DETERMININGBSA

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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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VASCULAR CHANGES RESULTING

FROM BURN INJURIES

Circulatory disruption occurs at the burnsite immediately after a burn injury

Blood flow decreases or cease due tooccluded blood vessels

Damaged macrophages within the tissuesrelease chemicals that cause constriction ofvessel

Blood vessel thrombosis may occurcausing necrosis Macrophage:A type of white blood that ingests (takes in) foreign material.

Macrophages are key players in the immune responseto foreign invaderssuch as infectious microorganisms.

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FLUID SHIFT

Occurs after initial vasoconstriction, then

dilation

Blood vessels dilate and leak fluid into the

interstitial spaceKnown 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

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FLUID IMBALANCES

Occur as a result of fluid shift and cell

damage

Hypovolemia

Metabolic acidosisHyperkalemia

Hyponatremia

Hemoconcentration (elevated bloodosmolarity, hematocrit/hemoglobin) due to

dehydration

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CURLINGS 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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EMERGENT PHASE

*Immediate problem is fluid loss, edema,reduced blood flow (fluid and electrolyteshifts)

Goals:

1. secure airway2. support circulation by fluid replacement3. keep the client comfortable withanalgesics

4. prevent infection through wound care5. maintain body temperature6. provide emotional support

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EMERGENT PHASE

Knowledge of circumstances surrounding the burninjury

Obtain clients pre-burn weight (dry weight) tocalculate fluid rates

Calculations based on weight obtained after fluidreplacement is started are not accurate because ofwater-induced weight gain

Height is important in determining body surfacearea (BSA) which is used to calculate nutritionalneeds

Know clients health history because thephysiologic stress seen with a burn can make alatent disease process develop symptoms

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CLINICAL MANIFESTATIONS IN THE


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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 clientsadmitted to burn centers

Assess the respiratory system by inspecting the mouth, nose, andpharynx

Burns of the lips, face, ears, neck, eyelids, eyebrows, and

eyelashes are strong indicators that an inhalation injury may bepresent

Change in respiratory pattern may indicate a pulmonary injury.

The client may: become progressively hoarse, develop a brassycough, drool or have difficulty swallowing, produce expiratorysounds that include audible wheezes, crowing, and stridor

Upper airway edema and inhalation injury are most common inthe trachea and mainstem bronchi

Auscultate these areas for wheezes

If wheezes disappear, this indicates impending airway obstructionand demands immediate intubation

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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

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Changes in renal function are related todecreased renal blood flow

Urine is usually highly concentrated and hasa high specific gravity

Urine output is decreased during the first 24hours of the emergent phase

Fluid resuscitation is provided at the rate

needed to maintain adult urine output at 30to 50- mL/hr.

Measure BUN, creat and NA levels

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Sympathetic stimulation during theemergent phase causes reduced GI motilityand paralytic ileus

Auscultate the abdomen to assess bowel

sounds which may be reducedMonitor for n/v and abdominal distentionClients with burns of 25% TBSA or who are

intubated generally require a NG tube

inserted to prevent aspiration and removalof gastric secretions

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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 theirheights

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IV FLUID THERAPY

Infusion of IV fluids is needed to maintain sufficient bloodvolume 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 Diuretics should not be given to increase urine output.

Change the amount and rate of fluid administration.Diuretics do not increase CO; they actually decreasecirculating volume and CO by pulling fluid from thecirculating blood volume to enhance diuresis

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COMMON FLUIDS

Protenate or 5% albumin in isotonic saline (1/2given in first 8 hr; given in next 16 hr)

LR (Lactate Ringer) without dextrose (1/2 given infirst 8 hr; given in next 16 hr)

Crystalloid (hypertonic saline) adjust to maintainurine output at 30 mL/hr

Crystalloid only (lactated ringers)

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ACUTE PHASE OF BURN INJURY

Lasts until wound closure is complete

Care is directed toward continued assessment andmaintenance of the cardiovascular and respiratory system

Pneumonia is a concern which can result in respiratoryfailure requiring mechanical ventilation

Infection (Topical antibioticsSilvadene) Tetanus toxoid

Weight daily without dressings or splints and compare topre-burn weight

A 2% loss of body weight indicates a mild deficit

A 10% or greater weight loss requires modification ofcalorie intake

Monitor for signs of infection

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LOCAL AND SYSTEMIC SIGNS OF


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LOCAL AND SYSTEMIC SIGNS OFINFECTION- GRAM NEGATIVE

BACTERIA

Pseudomonas, Proteus May led to septic shock

Conversion of a partial-thickness injury to a full-thicknessinjury

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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LAB VALUES

Nahyponatremia or Hypernatremia

KHyperkalemia or Hypokalemia

WBC10,000-20,000

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NURSING DIAGOSIS IN THE ACUTE

PHASE

Impaired skin integrity

Risk for infection

Imbalanced nutrition

Impaired physical mobility Disturbed body image

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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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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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REHABILITATIVE PHASE OF BURN

INJURY

Started at the time of admissionTechnically begins with wound closure and

ends when the client returns to the highestpossible level of functioning

Provide psychosocial supportAssess home environment, financial

resources, medical equipment, prostheticrehab

Health teaching should include symptoms ofinfection, drugs regimens, f/u appointments,comfort measures to reduce pruritus

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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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GOALS

Prevent complications (contractures)Vital signs hourly

Assess respiratory functionTetanus boosterAnti-infective

AnalgesicsNo aspirinStrict surgical asepsisTurn q2h to prevent contractures

Emotional support

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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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SKIN GRAFTS

Done during the acute phase

Used for full-thickness and deep partial-thickness

wounds

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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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THE END

QUESTIONS

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Documents

Burn lecture.ppt