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8/3/2019 Management of Patients With Burn Injury WEB
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8/3/2019 Management of Patients With Burn Injury WEB
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Burns: Major Goals
1. Prevention2. Institution of lifesaving measures for
severely burned person.3. Prevention of disability and disfigurement
through early, individualized treatment
4. Rehabilitation through reconstructivesurgery and rehabilitative programs.
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Burn Classifications Superficial
Least destruction Only epidermis injured
Partial-thickness Epidermis destroyed Varying depths of dermis damaged/destroyed
Superficial partial-thickness Erythematous and moist with vesicles painful
Deep partial-thickness Red and waxy without blisters Moderate edema, lesser degree of pain Hypoxia and ischemia can cause extension of wound
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Burn Classifications
Full-thickness Entire epidermis and dermis involved No viable epithelial cells, grafts required
Hard, dry leathery eschar Deep full-thickness
Extend beyond skin into underlying fascia and tissues Muscle, bone and tendon damage with exposure to
surface Blackened and depressed, little or no sensation Early excision and grafting beneficial
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Illustrations of Burns
Superficial partial-thickness
Deep partial-thickness
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Illustration of Burns
Full Thickness Deep Full Thickness
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Burn Classification
Extent of Body Surface Area Injured Rule of Nines Lund-Browder Palm method
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Pathophysiology of Burn Injury
Tissue destruction can lead to: Fluid/protein losses Sepsis Multiple system disturbances
Metabolic Endocrine Respiratory Cardiac Hematologic Immune
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Pathophysiology of Burn Injury
Extent of local and systemic disruption dependson Age
General health status Extent of injury Depth of injury Area of body injured
(morbidity and mortality of burn clients is related to alack of or delay in healing)
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Vascular Changes
Fluid Shift Period of inflammatory response Vessels adjacent to burn injury dilate capillary
hydrostatic pressure and capillary permeability Continuous leak of plasma from intravascular space
into interstitial space Associated imbalances of fluids, electrolytes and
acid-base occur Hemoconcentration Lasts 24-36 hours
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Vascular Changes
Fluid remobilization Capillary leak ceases and fluid shifts back into
the circulation Restores fluid balance and renal perfusion
Increased urine formation and diuresis
Continued electrolyte imbalances
Hyponatremia Hypokalemia
Hemodilution
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Other System Changes Cardiac
Decreased cardiac output Need fluid resuscitation and support with O 2
Pulmonary Respiratory insufficiency as a secondary process Can progress to respiratory failure Aggressive pulmonary toilet and oxygenation
Gastrointestinal Decreased or absent motility (may need NG tube) Curlings ulcer formation H2 histamine blockers, mucoprotectants and enteral
nutrition
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Other System Changes
Metabolic Hypermetabolic state
Increased oxygen and calorie requirements Increase in core body temperature
Immunologic Loss of protective barrier
Increased risk of infection Suppression of humoral and cell-mediated
immune responses
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Compensatory Responses
Inflammatory Compensation Initiates healing Contributes to fluid shift ( capillary
permeability) Local tissue reaction due to release of
chemicals by wbcs Sympathetic Nervous System
Compensation Stress Response (Figure 71-8, p. 1625)
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Phases of Burn Injury
Emergent/Resuscitative First 48 hours
Acute Approximately 48 hours after injury to
complete wound closure Rehabilitative
Begins with wound closure and ends whenclient returns to highest possible level offunctioning
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Emergent/Resuscitative Phase
Goals: Maintain open airway Ensure adequate
breathing/circulation Limit extent of injury Maintain function of
vital organs
Prevent potentialcomplications
Transfer to BurnCenter Major burns
Very young or elderly Coexisting health
problems that couldaffect recovery
Circumstances thatincrease risk of acuteand long termcomplications
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Acute Phase
Interventions aimed at: Maintenance of cardiovascular/respiratory
system Nutritional status Burn wound care Pain control
Psychosocial interventions
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Rehabilitative Phase
Emphasis: Psychological adjustment of client Prevention of scars and contractures Resumption of pre-burn activity
Work Family
Social
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Clinical Manifestations of Burns
Respiratory Direct airway injury Carbon monoxide poisoning Thermal injury Smoke poisoning Pulmonary fluid overload External factors
Cardiovascular Hypovolemic shock and cardiac output Impaired circulation/tissue perfusion Potential for ECG changes
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Clinical Manifestations Renal/urinary
Changes R/T renal perfusion and debris Fluid shift GFR and urine output Fluid remobilization-- GFR and diuresis Tubular blockage from myoglobin and uric acid Fluid resuscitation should maintain output at 30-50
mL/hour Integumentary
Size of injury is important to diagnosis and prognosis Rule of Nines Lund-Browder method
Specific treatments dependent upon depth of injury
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Decreased CO, Deficient Fluid Volume,& Ineffective Tissue Perfusion
Interventions: Non-surgical
IV fluid therapy Plasma exchange Drug therapy
Surgical Escharotomy
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Ineffective Breathing PatternInterventions Non-surgical
Airway maintenance Promotion of ventilation Monitoring gas exchange Oxygen therapy Drug therapy Positioning and deep breathing
Surgical Tracheostomy Chest tubes escharotomy
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Acute Pain
Interventions: Non-surgical
Drug therapy (opioids) (anesthetic agents) Complimentary/alternative therapies Environmental manipulation
Surgical Early surgical excision of burn wound
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Impaired Skin IntegrityWound Care Management
Non-surgical Debridement
Mechanical Enzymatic
Cleaning
Stimulating granulation andrevascularization Dressings
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Dressings Standard
Multiple gauze layers over topical agent or antibiotic
Biologic Homograft (allograft) from cadaver
Heterograft (xenograft) from animal (pig) Amniotic membrane Cultured skin
Artificial skin Two-layer product which creates an artificial dermis
Synthetic dressing Solid silicone and plastic membrane Can see through to monitor wound status
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Impaired Skin IntegrityWound Care Management
Surgical management Surgical excision
Treatment of choice for deep partial-thicknesswounds
Wound coverings Permanent skin coverage by autograft
Split thickness Successive reharvesting Meshing of split thickness graft
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Risk for Infection
Non-surgical management Drug therapy
Tetanus Toxoid and Topical Antimicrobials
Organism specific drugs Isolation Environmental manipulation Secondary prevention/early detection
Surgical management Aggressive surgical incision of infected wound
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Additional Interventions
Imbalanced Nutrition Calculate calorie needs and provide adequate
calories and nutrients
Calorie requirements can exceed 5000 per day Impaired Mobility
Interventions to maintain pre-burn ROM and preventcontractures
Disturbed Body Image Grief counseling Encouraging independence