Integumentary: Burns Marnie Quick, RN, MSN, CNRN

Skin layers, hair follicle, nerves, sweat glands

Types of burns Thermal Chemical Smoke and inhalation Electrical 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

Smoke & Inhalation: Which is this?- CO; injury above glottis; below glottis

Electrical burns

Depth of Burn

Depth of burn: Superficial partial (old 1st) Deep partial-thickness (old 2 nd ) Full-thickness (old 3/4 th )

Deep partial-thickness burn- note blisters

Partial-thickness (Second degree burn)

Full-thickness

Extent of Burn: *To calculate total burn with rule of 9’s-- ½ of anterior trunk=9% and ¼ of right arm burn=3% **TOTAL area burn=12%TBS Rule of Nines chart Lund & Browder chart- age

Location of Burn Location of the burn is related to the severity of the injury: Face, neck, chest → respiratory obstruction Hands, feet, joints, eyes → self-care Ears, nose → infection Circumferential burns of the extremities can cause circulatory compromise Patients may also develop compartment syndrome

Phases of Burn Management Prehospital care Emergent (resuscitative- fluid) Acute (wound healing) Rehabilitative (restorative)

Emergent/resuscitative 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> 3 rd spacing Guidelines burns >20% TBSA- Parkland formula or Modified Brooke formula Need Weight and % TBSA burned to calculate

Lactated Ringers solution 1 st 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 cc/hr (foley); heart rate less than 120/min; SBP> 90;hemodynamic monitoring Elevate edematous part; escharotomy

Effects of Burn Shock

Third spacing

Burn with escarotomy

Escarotomy

Elevate arms to decrease swelling also note escarotomy of arms and chest- assess CMS (circulation/motor/sensory)

Before the escharotomy, how would this eschar affected his respirations?

What are the Priorities in this patient??? Meet criteria for Burn Unit Referral?

What do you assess for here???

Complications in emergent phase Cardiovascular Respiratory Upper/inhalation/lower Urinary Renal blood flow/GFR decrease causing release ADH Myoglobinurea- dark urine may block renal tubules

Summary:

Acute Phase 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 3 rd degree (temporary cover 2 nd )

Decreasing of third spacing- Note edema of the face decreasing

Hydrotherapy: Hubbard Tank

Clean/debridement Rt tank or Lt surgery

Topical broad spectrum antimicrobials Open method

Separate skin; use of splints Closed method

Skin will grow together if not separated

Several patients utilizing closed method Who is that nurse with white stockings& cap?

Removal of necrotic tissue Eschar removed until viable tissue

Donor sites: after harvesting healed donor site

Grafting (Lewis 498 Table 25-13) Permanent- if no infection Autograft CEA Integra/AlloDerm Temporary grafts Homograft- cadaver Heterograft- animal Synthetic

Grafting

Application of Cultured Epithelial Autograft Cultured epithelial autografts Grown from biopsies obtained from the patient’s own skin Used in patients with a large body surface burn area or those with limited skin for harvesting

Pressure garments

What are your assessment findings?

What are your nursing priorities for this patient?