Integumentary: Burns
Marnie Quick, RN, MSN, CNRN
Skin layers
Types of burns Thermal Chemical Thermal Radiation
Thermal burn
Cool burn with cold water until pain is relieved- Do not apply to more than 20% body surface- hypothermia may occur
Chemical burn from sulfuric acid
Electrical burns: top picture- toe Leg bottom picture- mouth
Depth of burn: Layers of skin and burns
Depth of burn: First degree burn to third degree
First degree burns
Second degree burn- note blisters
Second degree burn
Full thickness third degree burn All layers skin
Full thickness
Involves past the 3 layers down to the bone and/or organs
Extent of Burn: Rule of Nines Lund & Browder- age
What are the Priorities in this patient??? Is this patient a candidate for a
major burn center?
Common manifestations/complications of Major Burn
1. Integumentary system eschar formation necrotic tissue hard, leathery must be removed for
healing to take place
Common manifestations/complications Major Burn 2. Cardiovascular
Burn shock- third spacing (hypovolemic) 24-36 hrs Blood vess damaged> inc cap permeability H2O, Na & serum albumin> intestial space(3rd space) HCT and blood viscosity increases > 40% burn causes dec cardiac contractibility & CO Electrical burn can cause arrhythmias/cardiac arrest Compartment syndrome of extremities/torso as edema
compresses blood vessels and nerves- may need escharotomy
Third spacing
Burn with escarotomy
Before the escharotomy, how would this eschar affected his respirations?
Escarotomy
Common Manifestations Complications Major Burn
3. Respiratory Direct inhalation injury/systemic response (ARDS) Upper airway thermal injury- esp if burned in
enclosed space (room) & breaths in hot air. May be no outward sign of burn- look for soot, nasal hairs
Laryngeal spasms as edema peaks in 34-48 hrs Bronchial congestion and infection Intersitial pulmonary edema; alveolar collapse CO poisoning- 200 X’s greater affinity for
hemoglobin- hypoxia> headache to coma sym
What are your #1 priorities in this patient?
Patient #1 Patient #2
What do you assess for here???
Common Manifestations Complications Gastrointestional
Paralytic ileus > increased risk for aspiration Stress ulcer (Curling’s ulcer) ck pH Ischemia of intestine increases intestinal mucosal
permeability> bacteria can cause systemic sepsis, ARDS and multiple organ failure
Common Manifestations/Complications Urinary Urinary-
Renal blood flow/GFR decrease causing release ADH
Myoglobinurea- dark urine may block renal tubules
Common Manifestations/complications Immune system and metabolism Immune system
Capillary leak- serum levels immunogloblin decreased
Opportunistic infections can be fatal Most common source infection/septicemia- clients
own GI track Metabolism
BMR increases 2X’s, more if complications Hypermetabolism continues until wound closure Body weight and temperature drop- shivering inc met
Common Manifestations/Complications- Pain
Where are nerve ending?
Morphine/Fentanyl Give IV in acute
stage due to fluid shift---No IM’s
Therapeutic Interventions Major Burns Stage one: Emergent/resuscitative Stage
Onset injury to successful fluid resuscitation Major concern- Fluid Resuscitation- prevent
hypovolemic shock 2 large bore IV’s in unburned area to restore bl
vol due to inc capillary permeability> 3rd spacing Guidelines burns >20% TBSA- Parkland formula
or Modified Brooke formula Need Weight and % TBSA burned to calculate
Lactated Ringers solution 1st 24 hrs then add 5% Dextrose to crystalloid fluid
50% of formula volume in first 8 hrs; rest over next 16 hrs; then maintain urinary output
Hourly output 30-50 cc/hr (foley); heart rate less than 120/min; hemodynamic monitoring
Elevate edematous part; escharotomy
Elevate arms to decrease swelling also note escarotomy of arms and chest- assess CMS
Other therapeutic interventions during Stage one: emergent/resucitative stage First aide treatment to limit severity of burn Prevent heat loss through burn- warm envir Respiratory involved-
intubation/ventilation with PEEP/humidified O2 bronchodilators mucolytic agents to liquefy secretions TCDB HOB 30
GI- Pepcid; NG tube when gut ready- antacids
Third spacing- Note edema of the face decreasing
Summary of Emergent Phase:
Therapeutic Interventions Major Burns Stage 2: Acute Stage
Start of diuresis and ends with closure of burn Major concern in this stage- infection Most common cause infection- pts own GI track Wound management-
hydrotherapy, debridement of eschar topical antimicrobial creams (open/closed method) splints/exercise prevent contractures; Excision/grafting of 3rd degree (temporary cover 2nd )
Hydrotherapy: Hubbard Tank
Cleaning and debriment in Hubbard
Topical broad spectrum antimicrobials (p.425)
Silvadene
Silver Nitrate Sulfamylon
Wound Care Open Method Apply topical chemotherapy
Wound Care- Closed method
Apply topical chemo and wrap with gauze, fluffs, kerlix
Assess for constriction; circulation checks
Elevate burned arms on pillows Give pain meds 30 minutes
prior to treatments
Skin will grow together if not separated
Several patients utilizing closed method Who is that nurse with white stockings& cap?
Excision & Grafting Removal of necrotic tissue Eschar is removed until viable
tissue is reached
Acute Phase- grafting
Acute Phase Autograft-
on right- donor site Permanent if no
infection
Temporary grafts Homograft- cadaver Heterograft- animal Synthetic
Interventions Assist with positioning ROM exercises Support O.T. & P.T. efforts
Therapeutic Interventions: Stage 3: Rehabilitation Stage
Wound closure to highest level of function- years Major concern is psychosocial adjustment Prevent/reduce hypertrophic scares- pressure
garments Skin care Potential for repeated cosmetic surgeries
Keloid formation
Rehabilitation Phase- Pressure garments
Pertinent Nursing Problems/interventions
Impaired skin integrity Deficient fluid volume Acute pain Risk for infection Impaired physical mobility Imbalanced nutrition: less than body req Powerlessness
What are your assessment findings?
What are your nursing priorities for this patient?