Nursing Care of Patients with Burns Dr. Karim Shaarawy, MD

Types and Causative Agents of Burns Thermal: open flame, steam, hot liquids Chemical: acids, strong alkalis, organic compounds Electrical: direct current, alternating current, lightening Radiation: solar, x-rays, radioactive agents Dr.Karim Shaarawy, MD

Factors Affecting Burn Classification Characteristics of Burns by Depth Superficial (epidermis): skin may pink to red and dry, painful Partial thickness (epidermis and dermis): skin bright pink and blisters, painful Full thickness (epidermis, dermis, underlying tissues): skin appears waxy, dry, leathery, charred, no pain Dr.Karim Shaarawy, MD

Classification by Burn Depth Dr. K. Shaarawy Dr. K. Shaarawy Figure 17–1 Burn injury classification according to the depth of the burn. Dr.Karim Shaarawy, MD

Zones of Injury Dr. K. Shaarawy Dr.Karim Shaarawy, MD Figure 17–8 The zones of injury. Dr.Karim Shaarawy, MD

Extent of Burn - TBSA Dr.Karim Shaarawy, MD Figure 17–5 The “rule of nines” is one method for quickly estimating the percentage of TBSA affected by a burn injury. Although useful in emergency care situations, the rule of nines is not accurate for estimating TBSA for adults who are short, obese, or very thin. Dr.Karim Shaarawy, MD

Lund & Browder Burn Chart Figure 17–6 The Lund and Browder burn assessment chart. This method of estimating TBSA affected by a burn injury is more accurate than the “rule of nines” because it accounts for changes in body surface area across the life span. Dr.Karim Shaarawy, MD

Minor Burns Sunburn Scald burn Superficial burns less than 15% of TBSA Exposure to ultraviolet light More commonly seen in light skinned clients Redness, pain, nausea/vomiting, chills Scald burn Exposure to moist heat Involves superficial and partial thickness Superficial burns less than 15% of TBSA Dr.Karim Shaarawy, MD

Classification – Minor Burns Classification of Burn Injuries Minor Burn Injuries Excludes electrical, inhalation, and complicated injures such as trauma Partial thickness burn of less than 15% of total body surface area Full thickness burn of less than 2% of total body surface Dr.Karim Shaarawy, MD

Classification - Moderate Moderate Burn Injuries Excludes electrical, inhalation, and complicated injures such as trauma Partial thickness burns of 15-25% of the total body surface Full thickness burns of less than 10% of total body surface Dr.Karim Shaarawy, MD

Partial Thickness Burn Figure 17–2 Partial-thickness burn injury. Dr.Karim Shaarawy, MD

Major Burn Event Dr.Karim Shaarawy, MD Figure 17–7 Effects of a severe burn on major body systems and metabolism. Dr.Karim Shaarawy, MD

Cardiovascular System Hypovolemic shock (Burn shock) – massive fluid shift from intracellular & intravascular into the interstitium 24 to 36 hours of injury Direct loss of cell wall integrity BP falls as cardiac output diminishes Proteins and sodium escape into interstitium Potassium increases then will decrease as burn shock resolves Dr.Karim Shaarawy, MD

Cardiovascular System Myocardial dysfunction – ventricular fibrillation, cardiac arrest, & vascular compromise Peripheral vascular compromise – edema, compartment syndrome Dr.Karim Shaarawy, MD

Classification - Major Major Burn Injuries Includes all burns of the hands, face, eyes, ears, feet, and perineum, all electrical injuries, multiple traumas, and all clients that are considered high risk Partial thickness burns of greater than 25% of the total body surface Full thickness burns of 10% or greater of the total body surface area Dr.Karim Shaarawy, MD

Burn Injuries Dr.Karim Shaarawy, MD Figure 17–4 Full-thickness burn injury. Dr.Karim Shaarawy, MD

Pathophysiologic Effects of a Major Burn Can involve all body systems Extensive loss of skin can result in massive infection, fluid and electrolyte imbalances, and hypothermia Cardiac dysrhythmias and circulatory failure Profound catabolic state & dehydration Alteration in gastrointestinal motility – Curling’s ulcer Overall body metabolism is profoundly altered Dr.Karim Shaarawy, MD

Pathophysiologic Effects of a Major Burn Burn wound healing Inflammation, Proliferation, Remodeling Burn wound infection Increased sloughing of burn tissue Increased edema around wound edges Partial-thickness wound converting to full- thickness wound Black or brown areas of discoloration Dr.Karim Shaarawy, MD

Stages of Progression Dr. K. Shaarawy Dr.Karim Shaarawy, MD Figure 17–9 The client’s progression through the healthcare system during the emergent, acute, and rehabilitative stages of burn injury. Dr. K. Shaarawy Dr.Karim Shaarawy, MD

Burn Stages Emergent/Resuscitative Stage From onset of injury through successful fluid resuscitation Estimate extent of burn injury Institute first aid measures Client may be intubated Nursing diagnosis – Impaired Skin Integrity, Deficient Fluid Volume, Acute Pain, Powerlessness, Risk for Infection Dr.Karim Shaarawy, MD

Burn Stages Acute Stage Rehabilitative Stage Begins with start of diuresis and ends with closure of the wound, either by natural healing or by using skin grafts Rehabilitative Stage Begins with wound closure and ends when client returns to highest level of health restoration, which may take years Dr.Karim Shaarawy, MD

Fluid Resuscition Necessary in all burns >20%TBSA Warmed Ringer’s lactate using Parkland formula 4mLxkgx&TBSA through two large bore (14 to 16 gauge) catheters for 1st 24 hours Hourly urine 30 to 50 mL/hr HR <120 beats/min Changed to 5% dextrose to maintain urine output Dr.Karim Shaarawy, MD

Respiratory Management Maintain head of bed 30 degrees TCDB every 2 hours Maintain adequate tissue oxygenation with least amount of inspired oxygen necessary Arterial line for continuous assessment of ABGS Pulmonary artery pressure catheter Dr.Karim Shaarawy, MD

Medications Morphine 3 to 5mg every 5 to 10 minutes Anxiolytic agents – midazolan (Versed)andlorazepan (Ativan) Antiulcer meds – dec.intestinal motility Topical antimicrobial therapy Mafenide acetate (Sulfamylon) cream – face and neck edema Silver nitrate 0.5% soaks – blackens skin Sulfadiazine(Silvadene) cream- leukopenia Dr.Karim Shaarawy, MD

Closed Dressing Method Figure 17–14 Closed method of dressing a burn. Dr.Karim Shaarawy, MD

Surgery Escharotomy - prevent circumferential constriction, removal of eschar facilitates healing Surgical Debridement – remove burn wound to level of viable tissue, should bleed briskly before coagulation Autografting – permanent skin coverage Homograft/allograft – human skin Heterograft/xenograft – animal usually pig Biologic dressings – Biobrane, Intregra Dr.Karim Shaarawy, MD

Escharotomy Dr.Karim Shaarawy, MD Figure 17–10 Escharotomy. The surgical procedure consists of removing the eschar formed on the skin and underlying tissue following severe burns. The procedure is particularly helpful in restoring circulation to the extremities of clients when scar tissue forms a tight, constrictive band around the circumference of a limb. Dr.Karim Shaarawy, MD

Autograft Dr.Karim Shaarawy, MD Figure 17–12 Skin graft for burn injury (autograft). Dr.Karim Shaarawy, MD

Skin Grafting Dr.Karim Shaarawy, MD Figure 17–11 Skin grafting procedure. Dr.Karim Shaarawy, MD

Burn Contracture Figure 17–3 Burn contracture. Dr.Karim Shaarawy, MD