BURNS Burn injury and the number of deaths - dropped in the past 10 years -decrease is from: -use of...
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BURNS
BURNS Burn injury and the number of deaths - dropped in the past 10 years -decrease is from: -use of smoke detectors -creation of regional burn centers
BURNS Burn injury and the number of deaths - dropped in the
past 10 years -decrease is from: -use of smoke detectors -creation
of regional burn centers -national focus on safety -occupational
safety mandates
Slide 3
Causes -Thermal or nonthermal causes. -Thermal burns -most
common type of burn injury -caused from heat -flames, scalds,
thermal energy -Nonthermal burns -electricity, chemicals, and
radiation.
Slide 4
Causes Skin destruction -depends on the burning agent
-condition of the skin before injury -duration of the persons
contact with the agent
Slide 5
Severity of burns The factors that determine the severity of a
burn are: -Percentage of the body surface area burned. - Age
-Specific location of the burn. -Cause -Other diseases -Depth of
the burn. -Injuries
Slide 6
THERMAL BURNS
Slide 7
NONTHERMAL BURNS
Slide 8
Depth of burns/Classification Superficial thickness injuries
Partial-thickness injuries Full-thickness injuries - graphically
describe the burn -depth and severity of the tissue injury See AHN
p. 95, Table 3-3 for descriptions of the burn classifications. -If
you use only the visual characteristics of the burn wound, it would
not provide an accurate assessment of how much damage might have
been caused.
Slide 9
First Degree Burns
Slide 10
Second Degree Burns
Slide 11
Third Degree Burns
Slide 12
Percentage Estimates The RULE OF NINES - determines the total
body surface area (BSA) burned. See p. 106, FIGURE 3-22. The rule
of nines divides the body into multiples of nine. -Head to neck 18%
-Arm (shoulder to fingertips) 9% each -Anterior trunk 18%
-Posterior trunk 18% -Leg (groin to toe) 14% each
Slide 13
Age considerations Percentage of body area burned in infants
and children -the surface area of the childs head is larger
Increased risk to develop circulatory -adults with cardiac disease
-the very old -the very young overload.
Slide 14
Burns Dramatic changes -first few minutes to the first 12-24
hours
Slide 15
Extent of the burns? -greater the 20% -cause massive
evaporative of water -fluid losses into the interstitial space
-capillaries dilate (hypermeablitiy) for 24 hours -fluid shifts
from the capillaries to the interstitial spaces -causes edema and
blistering (third spacing) -cells become dehydrated -hypovolemic
shock starts - hypotension and decreased renal flow
Slide 16
Three stages of medical treatment 1. Emergent Phase (Stage 1)
Decreased volume and shock -occur up to 48 hours after being
burned.
Slide 17
Three stages of medical treatment 2. Acute Phase (Stage 2)
-48-72 hours after a burn -circulatory overload - secondary to
fluid shifting back from the interstitial spaces to the capillaries
- increased urine output -diuretic stage
Slide 18
3. Rehabilitation Phase (Stage 3) -wound treatment begins
-slowly returns to as normal status as possible
Slide 19
Complications Carbon Monoxide (CO) poisoning -Person in an
enclosed area during a fire -CO displaces O2 from hemoglobin -Dont
rely on oximeters - cant distinguish from oxyhemoglobin and
carboxyhemoglobin -Early signs- -headache -nausea -vomiting -
unsteady gait -Treatment- 100% oxygen
Slide 20
Smoke Inhalation Inhaling chemicals produced by the fire
Damages- -celia and mucous membranes of the respiratory tract
Symptoms- -several hours after the initial burn High risk for
patients -upper chest, neck and face burns
Smoke Inhalation Treatment -establish airway -initiate oxygen
-may need intubation
Slide 23
Shock Emergent phase -fluid shifting from the capillaries to
the interstitial spaces. Requires fluid resuscitation (IV fluids)
-Adults-greater then 20% of their body surface -Children-10 %
-Older then 55 -Younger then 14 years -Cardiac, pulmonary disease
or diabetic -Electric burns
Slide 24
IV fluid therapy -central line of Lactate Ringers -amount of
fluid given -body weight -percentage of body surface burned. Foley
catheter -monitors urine output. -30-50 cc/hour urine output
-maintain adequate renal function Airway -continue to maintain
-vital signs monitored
Slide 25
Infection Most common cause of death in the first 72 hours in
burn victims Nursing implications -erythema, odor, green or yellow
exudate -wound culture and sensitivity -topical bacteriostatics
-capillaries are coagulated by the burns
Slide 26
Protective Isolation -gown, mask, cap and glove -dressing
changes require strict surgical aseptic techniques.
Slide 27
Immediate Medical Management 1. Establish an airway -Oxygen
-intubated to ensure a patent airway 2. Initiate fluid therapy
-Insert a central IV line -Ringers Lactate IV immediately -the
amount depends on: -body weight and the -percentage of the body
surface area burned
Slide 28
3. Renal function and urine output -insert a foley catheter
-maintain a 30-50cc/hour urine output to perfuse the kidneys
-adjust the IV fluid to maintain adequate urine output 4. Pain
control -Morphine IV -small doses given frequently
Slide 29
-3-5mg IV every 5-10 minutes until pain relived -Children-
0.1-0.2 mg/kg every 2-4 hours PRN -Hypovolemic -effects of
analgesic may increase -Monitor for respiratory depression
-Fentanyl may be an alternative if the client is allergic to
Morphine
Slide 30
6. Body temperature -chilling -secondary to the skin being left
open to the air for wound healing. -keep room at 85 degrees and
humidity at 40-50% -light and heat lamps (use caution) 7. Infection
control -Tetanus immunization if client is not up to date, -Wound
infections-topical bacteriostatics -Systematic infections
(pneumonia) -IV antibiotics.
Slide 31
Recovery Phase - 10 days to several months depending on
severity of the burns -72 hours after a burn injury -increased
metabolism -decreased urine output -decreased edema -Goals -treat
burn wounds -prevent and manage complications
Wound Debridement Debridement -removes the damaged
tissue/debris from a wound or burned tissue -prevents infection
-promotes healing Partial thickness wounds -debrided twice a day
-topical antibiotic -dressing applied
Slide 34
Eschar removal Black leathery crust -forms over burned tissue
-holds in micro-organisms -causes infection Escharectomy- -cutting
down to the healthy tissue -chest expansion is restricted -burns
around the chest, arms or legs
Slide 35
Slide 36
Debridement -Helps with regeneration of the tissues -Enzymes
-applied topically -chemically debride the eschar -Hydrotherapy
-softens the eschar with water -makes debridement less painful
-promotes range of motion the extremities - preventing
contractures
Slide 37
Debridement Failure to debride -increased the chance for
infection -delays healing -increases scarring
Slide 38
WOUND CARE -Severity of the burn -Open (exposure) method -burns
of the face, neck, ears, and perineum -cleaned and exposed to air
-hard crust forms -regeneration of tissue occurs -advantages :
-wound can be observed -body part is not restricted -circulation is
not compromised -exercises can be performed more easily
Slide 39
Pain Control Changing the dressing will be PAINFUL!!!!!
-Analgesics-given at least 30 minutes before dressing changes -IV
Morphine -Remove dressings after hydrotherapy
Slide 40
Rehabilitation -Less the 20% BSA remains burned -Physical and
Occupational Therapy work -improve endurance, strengthening and
independence in ADLs Nursing Implications -realistic short term
goals-keep the client motivated -encourage to verbalize feelings
about his changed body image
Slide 41
Surgical Options Skin Grafts- -Prevents the scar tissue
-disfigurement -and loss of mobility -Required for burns -disrupted
the epidermis -most of the dermis
Slide 42
Surgical Options -Promotes healing -Prevents infection -First 3
weeks after a burn -4 types of grafts -auto graft -homograft
-heterograft -synthetic graft
Slide 43
Auto graft Surgical transplantation of tissue from one part of
the body from the same person
Slide 44
Homograft Surgical transfer of tissue from two genetically
different individuals of the same species -a temporary graft can be
from a cadaver
Slide 45
Heterograft Tissue from another species -Temporary graft
Slide 46
Synthetic Graft Made from a variety of materials such as
neonatal human fibroblast cells TransCyte developed in 1997
-applied only once -temporary covering -protect against fluid loss
-decreases the chance of infection
Slide 47
Methods of application of grafts Pedicule method -partially
attached to the donor site and the other portion is attached to the
burn site Free standing method -tissue is completely removed from
the donor site and attached to the burn site
Slide 48
Slide 49
Client education 1. Do not to remove the dressing until the
physician orders the removal. 2. Report bruising or fluid
collection under the graft to the physician. 3. Protect the skin
graft from sunlight/use sunscreen to the graft site for 6 months
after the surgery. 4. Use lotion to the skin graft site for 6-12
months. 5. Wear elastic stocking when having skin grafts to the
lower extremities for 4-6 months
Pharmacology Antibiotics- -Cultured wound infections -Periods
before and after surgical procedures -Maintains a therapeutic blood
level -gives equal doses -evenly spaced over 24 hours.
Slide 52
Narcotics -narcotic analgesics given for pain control -Morphine
-Fentanyl can be substituted if the client has a allergy Topical
Agents- -Scarlet Red- -drying agent applied to dressings on donor
sites -no antiseptic effects -stains and irritates the skin
-monitor infection under the dyed gauze
Slide 53
Xerophorm- -promotes epitheliazation -debrides -protects donor
and graft sites -can adhere to the site -not antiseptic Dakins
Solution- -chlorine bactericidal solution -debrides the wound
-cleans large amounts of drainage -inhibit clotting/dissolves blood
clots -can irritate the skin
Slide 54
Travase- -topical enzyme -dissolves necrotic tissue -removes
eschar/purulent drainage -mild pain on application -numbness,
bleeding and dermatitis -dressings must be kept moist at all
times
Slide 55
NUTRITIONAL NEEDS OF THE BURN PT. -should eat by mouth as soon
as possible -intake needs must meet the demands of the healing body
-increased requirements for protein and calories. -Normal protein
needs are 0.8 g per kg. of body weight -Burned pt. needs 1.5-3.2 g
per kg. of body weight per day
Slide 56
NUTRITION -Calories -2000-6000 per day -foods need to be
concentrated -high in calories -more vitamins- A,B, and C -promote
digestion, absorption, and repair of tissue -Vitamin B complex
helps in the metabolism of the extra proteins and carbohydrates.
-increased amounts of calcium, zinc, magnesium, iron.
Slide 57
-Most burn victims have poor appetites -frequent, small
feedings are offered. -Curlings ulcer 8-14 days after the burn
injury. - Prophylactic treatment -Tagamet (IV/oral), Zantac, or
Prilosec.
Slide 58
Enteral Feedings - Nasal gastric (N/G) tube -burn client is
unable to eat -secondary to facial or throat burns -unable to take
in adequate calories to meet his needs. -Low rate continuous
solution ( 2 Cal, Jevity, etc.) -administered over 24 hours/day via
pump. -2-3L of solution -weighed daily -urine output is measured
-BUN, creatine, glucose and electrolytes - drawn and monitored
daily.
Slide 59
Lower incidence of abnormalities, sepsis and mortality -enteral
feedings started in the first 24 hours after the client is
hospitalized
Slide 60
Total Parental Nutrition (TPN) IV nutrition -usually administer
along with enteral nutrition -administered alone -disturbances with
GI motility -N/G intolerance -inability to absorb enough calories
or protein
Slide 61
Total Parental Nutrition (TPN) IV solution -composed of
concentrated glucose, electrolytes, amino acids, insulin, vitamins,
trace minerals. -lipid solution -piggybacked with the solution.
-central IV line (PICC, PAC, Groshong)
Slide 62
Monitor CBG every 6 hours Signs of fluid overload or infection
Daily labs- -electrolytes -liver function tests -BUN/Creatine
-albumin levels -weekly
Slide 63
ASSESSMENT SUBJECTIVE DATA: -causative agent -other diseases
present -temperature of the fire -duration of contact -patients
age. -level of pain -scale of 0-10.
Slide 64
ASSESSMENT OBJECTIVE DATA: -depth of the burn -skin thickness
involved -percentage of body surface (BSA) area burned -other
injuries sustained -specific location of burns -Other disease
processes that have an effect on the outcome of the burn.
Slide 65
ASSESSMENT -Burn that involves the face, neck, or chest
-observe him for any respiratory complications. -If the pt. has had
a tetanus booster in the past 5 years. -The severity of the burn
depends on several factors.
Slide 66
NURSING DIAGNOSES -Emergent phase of burns Ineffective airway
clearance, related to edema of the respiratory passages Deficient
fluid volume (dehydration), related to shift of body fluids
Deficient fluid volume, related to capillary hyper permeability
with fluid moving out of the cells into the interstitial area Acute
anxiety, related to injury Acute pain, related to loss of skin
Slide 67
NURSING DIAGNOSES Risk for infection, related to impairment of
skin integrity Impaired skin integrity, related to damage by the
burns Decreased cardiac output, related to hypovolemia Risk for
aspiration, related to decreased peristalsis Impaired swallowing,
related to mucosal edema
Slide 68
NURSING DIAGNOSES Impaired verbal communication, related to
breathing difficulties Disturbed sleep pattern, related to hospital
environment
Slide 69
Nursing Diagnosis -Acute phase -Acute anxiety, related to
change in body image -Fear, related to chronic illness -Chronic
pain, related to procedures performed -Risk for infection, related
to open skin wounds -Imbalanced nutrition, less than body
requirements, related to increased metabolic demands -Social
isolation, related to perceived change in body image -Impaired
physical mobility, related to burns
Slide 70
NURSING DIAGNOSES Self-care deficit, in activities of daily
living, related to area of burn involved Deficient knowledge, all
areas, related to expected care Interrupted family processes,
related to long-term hospitalization Disturbed body image, related
to disfigurement from burns
Slide 71
NURSING DIAGNOSES Deficient diversional activity, related to
confinement during care Ineffective coping, related to seriousness
of injury and perceived role changes Powerlessness, related to
prolonged recovery, loss of income, loss of physical
attractiveness
Slide 72
NURSING DIAGNOSES - Rehabilitation Phase Ineffective airway
clearance, related to edema of the respiratory passages Impaired
physical mobility, related to splinting, dressings, or pain
Activity intolerance, related to prolonged bed rest Anxiety, acute
to moderate, related to role change Disturbed body image, related
to scarring
Slide 73
NURSING DIAGNOSES Deficient knowledge, related to impaired home
maintenance management Self-care deficit, related to pain or
fatigue Fear, related to impending surgery Risk for disuse
syndrome, related to noncompliance Post-trauma syndrome, related to
the cause of the burn
Slide 74
NURSING DIAGNOSES Impaired adjustment, related to lack of
ability to limited expectations of self Ineffective coping. Related
to long-term rehabilitation Disturbed personal identity, related to
inability to return to previous lifestyle for prolonged period
Care-giver role strain, related to prolonged recovery period
Slide 75
NURSING DIAGNOSES Ineffective management of therapeutic
regimen, related to complexity and chronicity of rehabilitation
Anticipatory grieving, related to loss of wellness
Slide 76
HOME HEALTH TEACHING -Bathe twice a day with a mild soap -Avoid
extremes of water temperature -Only enter a very clean tub or
shower. -Take a lukewarm bath - Alpha Keri lotion relieves itching.
-Avoid lotions with alcohol or lanolin -they cause blisters
Slide 77
TEACHING -Avoid direct sunlight. -Scarring is part of the
healing process -Scars are red - then become softer and lose their
color. -Report these signs to the PCP: -fever (temp. >101
degrees F) -s/s of infection -feeling of inability to cope.
Slide 78
PROGNOSIS -Depends on many factors: - size and depth of the
burn -body part that was burned -burning agent -other pre-existing
diseases/conditions. -Burn care is very extensive -Many times the
patient must change his vocation, his job. It affects
relationships, social situations, self-esteem, etc.