Burns Fluid & Electrolytes

Nursing Care BURN INJURIES 1. Identify the mechanism of burn (TYPE) injuries. 2. Describe methods for determining assessment/physiology/ classification of burns. 3. Differentiate degrees of burn (1st- 4th) versus epidermal/superficial, partial and full thickness, deep burns. 4. Determine nursing care based upon the systemic pathological changes associated with burn injury in the first 24 – 48 hours. 5. Identify assessment, nursing diagnoses and management of the burn victim’s airway, breathing and circulation and wounds. 6. Identify the Pain/Nutritional/Rehab requirements for a burns patient.

Mechanism/Burn Type Zones of Injury Thermal - burning of tissue via direct contact with a heat source hot water, flame Zones of Injury 1. Zone of coagulation – thrombosis, vasoconstriction, necrosis and cell death 2. Zone of stasis - low blood flow 3. Zone of hyperemia - inflammatory response

Mechanism/Burn Type Chemical - tissue destruction via direct contact chemical ·         oxidizing agent: sodium hypo chloride ·         reducing agent : hydrochloric acid ·         corrosives : phosphorus ·         protoplasmic poisons : formic acid ·         desiccants : sulfuric acid ·         vesicants : mustard gas ·         gasoline

Mechanism/Type: Chemical Burn

Mechanism/Type:Electrical Burn - direct contact with electrical current                 ®  entry & exit wounds

Burns Assessment/Physiology/ Classification Based on: Depth/Degree of injury, Percent of body surface areas involved, Location of the burn, Association with other injuries.

Burns Physiology/Classification Depth of Burn Assessment Epidermal : destruction epidermis only ·     reddened, ·     blanches to pressure, ·     no blisters ·     painful ·     healing 3-5 days ·     no scarring

Burns Physiology & Classification Depth/Degree of Injury First Degree: superficial, epidermal damage erythematous & painful due to intact nerve endings heal in 5-10 days pain resolves within 3 days no residual scarring Neuroendocrine responses in the first 24 hours, the brain releases ACTH and ADH (as a response to pain, hypoxia and hypovolemia) and catecholamine secretion is accelerated hypoglycemia is common in children (hyperglycemia in adults) ADH causes antidiuresis, and increased aldosterone activity results in sodium retention, edema and oliguria after 24 hours the patient begins a hypermetabolic phase with increased cardiac output, increased oxygen consumption, and increased tissue catabolism will see a 1-2 degree (C) increase in body temperature due to increased metabolism cardiac output increased due to increased oxygen demand insulin levels normalize but hyperglycemia may persist due to increased cortisol secretion

Burns Physiology & Classification Depth/Degree of Injury Second Degree: partial thickness, epidermis/ dermis superficial burns – moist, blister; deeper burns - white and dry, blanch with pressure, and have reduced pain heal in 10-14 days can develop into third degree burns with infection, edema, inflammation and ischemia treatment varies with degree of involvement - grafting is indicated for deep burns Wound care sterile technique should be observed remove clothing and cover or irrigate the wound with cool saline careful to avoid hypothermia debride dead material and ruptured vesicles; blisters should be left intact unless at flexor areas after cleansing, apply antimicrobial cream with a fine mesh absorbent dressing (no dressing to face and perineal burns) initially burn surfaces have no or reduced bacterial colonization, so treatment with antimicrobrial creams should wait until the patient is stabilized (should be undertaken within a few hours of the injury) antibiotic creams: 1% silver sulfadiazine is the preferred first-line preventative agent for eschar, not as ongoing treatment for deep burns (can cause thrombocytopenia, leukopenia, and rash) neosporin or bacitracin are excellent for facial burns (nontoxic to the eyes) but should not be used on large areas mafenide acetate penetrates eschar well but is painful during application and causes bicarbonate wasting surgical consultation for removal of eschar (eschar may interfere with neurovascular function of extremities and of ventilation when present at the thorax) attention should be placed on distal pulses - circumferential burns can cause eschar that when combined with edema can impede distal perfusion

Superficial Burn

Burns Physiology / Classification Depth of Burn Assessment Partial Thickness Superficial destruction epidermis to upper dermis · bright red to pale ivory, blistered or weeping, blanches to pressure ·  sensitive to pain, pressure temperature ·  healing 14-21 days , no scarring

Burns Physiology/Classification Depth of Burn Assessment Partial Thickness deep destruction epidermis to deep dermis ·   mottled ·   white & waxy ·   blistering ·   diminished sensation to light pressure ·   healing months-weeks/usually scarring  

Burns Physiology & Classification Depth/Degree of Injury Third Degree: full-thickness, most severe of burns results in necrosis and avascular areas tough, waxy, brownish leathery surface with eschar, numb to touch grafting required usually have permanent impairment

Deep Burn

Burns Physiology & Classification Depth/Degree of Injury Fourth Degree: full-thickness as well as adjacent structures such as fat, fascia, muscle or bone reconstructive surgery is indicated severe disfigurement is common

Burns Physiology & Classification Depth/Degree of Injury Full - destruction to epidermis, dermis, subcutaneous ·    dry, ·    pearly/yellow-charred, ·    does not blanch, ·    leathery, inelastic ·    minimal to no sensation of pain, healing via secondary granulation/graft

Burn Assessment Body Surface Area Rule of Nines adult: 9% head; 9 % arms; 18 % legs ; 18 % chest; 18% back; 1 % perineum child: 18% head; 9% arms; 14 % legs; 18 % chest; 18 % back

Burn Assessment Lund & Browder Chart

Burn Assessment Location: Important for assessing potential disability greatest risk with face, eyes, ears, feet, perineum and hands Upper extremities involved in 71% of burns, head and neck 52% Associated Injuries: Smoke inhalation hoarseness, cough, singed nasal hairs, oral burns, wheezing Carbon monoxide poisoning Fractures Trauma ABC: Airway, Breathing and Circulation oxygen to all patients, intubate if there is airway, respiratory or neurological compromise pulmonary disease is progressive and may have a delayed onset of 24 hours laryngeal edema increases during the first 24 hours common to have burns of the upper airway - usually the subglottic area is protected from burns intubation is indicated with deep facial burns, inhalation injury documented by bronchoscopy or laryngoscopy, and with massive thoracic burns which interfere with adequate respiratory movement (due to decreased compliance of the chest wall) avoid early tracheostomy IV fluid resuscitation with large bore catheters (*LR or NS) avoid placing PIV through burned tissue because of increased risk of infection until fluid/electrolyte needs are calculated, can start at 20 ml/kg/hr shock is common when the burn exceeds 12% BSA cardiac output decreases almost immediately due to hypovolemia remember-hypotension is a late event and needs to be treated aggressively

Hospitalization in Major Burns ·    >10% surface area in children, elderly ·    >15% surface area in adults ·    specific regions - respiratory tract, face, neck, circumferential burns, hands, feet, major joints, genitalia, electrical burns, lightening burns ·    3rd degree burns >3% children, >5% adults  

Mortality in Burns · >65% body surface area (BSA) ·         associated smoke inhalation ·         infection >20% BSA with shock and other complications/related sequelae ABC: Airway, Breathing and Circulation oxygen to all patients, intubate if there is airway, respiratory or neurological compromise pulmonary disease is progressive and may have a delayed onset of 24 hours laryngeal edema increases during the first 24 hours common to have burns of the upper airway - usually the subglottic area is protected from burns intubation is indicated with deep facial burns, inhalation injury documented by bronchoscopy or laryngoscopy, and with massive thoracic burns which interfere with adequate respiratory movement (due to decreased compliance of the chest wall) avoid early tracheostomy IV fluid resuscitation with large bore catheters (*LR or NS) avoid placing PIV through burned tissue because of increased risk of infection until fluid/electrolyte needs are calculated, can start at 20 ml/kg/hr shock is common when the burn exceeds 12% BSA cardiac output decreases almost immediately due to hypovolemia remember-hypotension is a late event and needs to be treated aggressively

Collaborative Nursing & Medical Management Pathology of the First 24 hours: ·     Temperature loss ® hypothermia ·     Plasma & Protein Loss ·     Hypovolemia/hemoglobin concentration ·     Tissue/blood destruction hypoxia ·     Release hemoglobin pigment/myoglobin ® ¯ GFR & UO ·     Tissue hypoxia and reduced renal function ® metabolic acidosis ·     Platelet destruction & of activation clotting cascade via intrinsic/extrinsic pathway ® DIC   Temperature loss hypothermia Plasma Loss protein and plasma into interstitial peak movement 4-6 hours post injury resulting in reduced intravascular colloid pressure ·     Temperature loss ® hypothermia ·     Plasma & Protein Loss ·     Hypovolemia/hemoglobin concentration ·     Tissue/blood destruction hypoxia ·     Release hemoglobin pigment/myoglobin ® ¯ GFR & UO ·     Tissue hypoxia and reduced renal function ® metabolic acidosis ·     Platelet destruction & of activation clotting cascade via intrinsic/extrinsic pathway ® DIC Neuroendocrine responses in the first 24 hours, the brain releases ACTH and ADH (as a response to pain, hypoxia and hypovolemia) and catecholamine secretion is accelerated hypoglycemia is common in children (hyperglycemia in adults) ADH causes antidiuresis, and increased aldosterone activity results in sodium retention, edema and oliguria after 24 hours the patient begins a hypermetabolic phase with increased cardiac output, increased oxygen consumption, and increased tissue catabolism will see a 1-2 degree (C) increase in body temperature due to increased metabolism cardiac output increased due to increased oxygen demand insulin levels normalize but hyperglycemia may persist due to increased cortisol secretion

Collaborative Nursing & Medical Management Pathology of the Second 48 hours: temperature ­ 2. fluid mobilization to intravascular space 3. renal loss K+ 4 Fluid resuscitation ® ­ Serum Na+ ®  dilutional coagulopathy   Temperature loss hypothermia Plasma Loss protein and plasma into interstitial peak movement 4-6 hours post injury resulting in reduced intravascular colloid pressure ·     Temperature loss ® hypothermia ·     Plasma & Protein Loss ·     Hypovolemia/hemoglobin concentration ·     Tissue/blood destruction hypoxia ·     Release hemoglobin pigment/myoglobin ® ¯ GFR & UO ·     Tissue hypoxia and reduced renal function ® metabolic acidosis ·     Platelet destruction & of activation clotting cascade via intrinsic/extrinsic pathway ® DIC

Collaborative Nursing & Medical Management Wound Care      ·   tetanus toxoid > 50% BSA burn ·   and/or tetanus immunization ·   chemical burns irrigate all burns, cover until initial resuscitation complete   ·   electrical burns AC current ® Tetany & risk Vent Fib High energy ® check # volts & blunt injuries

Collaborative Burn Management Primary Assessment & Resuscitation Airway check risks – event in an enclosed area, singed eyebrows/nasal hair, hoarse voice, stridor, wheeze, air entry/edema Breathing check risks – event in an enclosed area® evaluate for CO2 poisoning high PaO2 low SataO2 Airway check risks – event in an enclosed area, singed eyebrows/nasal hair, hoarse voice, stridor, wheeze, air entry   Breathing check risks – event in an enclosed area ® evaluate for CO poisoning, high PaO2 – low SataO2

Collaborative Burn Management Circulation :Assessment & Resuscitation Parkland Formula – one of the most commonly used:First 24 hours an isotonic solution (Ringers Lactate)4mL/kg x TBSA% divide into 8 hour periods - first 50% in 8 hours - next 25% in 8 hours - final 25% in 8 hours urinary output should be 50-70mL/hr (1mL/kg) in the first 24 hours   Airway check risks – event in an enclosed area, singed eyebrows/nasal hair, hoarse voice, stridor, wheeze, air entry   Breathing check risks – event in an enclosed area ® evaluate for CO poisoning, high PaO2 – low SataO2

Collaborative Burn Management Circulation Con’t: :Assessment & Resuscitation Second 24 hours Colloid/plasma is delivered 0.5mL/kg x TBSA for the next 8 hours.  At 32 hours: 5% Dextrose + nutritional replacement require serial measurement serum electrolytes, urea, hematocit, blood albumin, urinary N+. Airway check risks – event in an enclosed area, singed eyebrows/nasal hair, hoarse voice, stridor, wheeze, air entry Circulation Parkland Formula – one of the most commonly used:   First 24 hours an isotonic solution (Hartmannn's/Ringers Lactate) 4mL/kg x TBSA% divide into 8 hour periods - first 50% in 8 hours - next 25% in 8 hours - final 25% in 8 hours urinary output should be 50-70mL/hr (1mL/kg) in the first 24 hours Second 24 hours Colloid/plasma is delivered 0.5mL/kg x TBSA for the next 8 hours. At 32 hours 5% Dextrose + nutritional replacement require serial measurement serum electrolytes, urea, hematocrit, blood albumin, urinary nitrogen. Breathing check risks – event in an enclosed area ® evaluate for CO poisoning, high PaO2 – low SataO2

Nursing Diagnoses Altered Tissue Perfusion Fluid & Electrolyte Imbalance Risk for Infection Altered Comfort: Pain Altered Nutritional: Less than Body Requirements (more Calories needed) Body Image Change : Loss?: Role?

Nursing Care IV access (Multiple) Manage perfusion needs by parameters of CVP, Urinary Output Pain management once vital signs have stabilized, pain medication should be used (ie morphine, or meperidine, fentanyl, benzodiazepines as indicated ) Morphine or Fentanyl Drip silver sulfadiazine (Silvadine) – (broad spectrum risk leukopenia) mafenide acetate (Sulfamylon) - use on deep burns (complication electrolyte disturbances

Nursing Care of Ulcer/Pain/Tetanus Curlings ulcer prophylaxis (Peptic Ulcer) An H2 blocker (cimetidine, ranitidine,famotidine) start first 6 hours antacids are no longer recommended - the patient should be kept NPO with burns > 15% of BSA, an NG (OG) tube and bladder catheter should be placed Tetanus immunization if out of date

Nursing Care of Burn Wounds Wound Care (Sterile Technique) Debridement Anti-microbial Application silver sulfadiazine (Silvadine) mafenide acetate (Sulfamylon) Closed dressing except face & perineum Wound cover synthetic,biosynthetic, biological Graft Wound Allograft Split thickness skin graft full thickness graft silver sulfadiazine (Silvadine) – (broad spectrum risk leukopenia) mafenide acetate (Sulfamylon) - use on deep burns (complication electrolyte disturbancesWound care sterile technique should be observed remove clothing and cover or irrigate the wound with cool saline careful to avoid hypothermia debride dead material and ruptured vesicles; blisters should be left intact unless at flexor areas after cleansing, apply antimicrobial cream with a fine mesh absorbent dressing (no dressing to face and perineal burns) initially burn surfaces have no or reduced bacterial colonization, so treatment with antimicrobrial creams should wait until the patient is stabilized (should be undertaken within a few hours of the injury) antibiotic creams: 1% silver sulfadiazine is the preferred first-line preventative agent for eschar, not as ongoing treatment for deep burns (can cause thrombocytopenia, leukopenia, and rash) neosporin or bacitracin are excellent for facial burns (nontoxic to the eyes) but should not be used on large areas mafenide acetate penetrates eschar well but is painful during application and causes bicarbonate wasting surgical consultation for removal of eschar (eschar may interfere with neurovascular function of extremities and of ventilation when present at the thorax) attention should be placed on distal pulses - circumferential burns can cause eschar that when combined with edema can impede distal perfusion

Evaluation of Nursing Care ABC’s Airway – stridor Breathing – use of accessory muscles, lung sounds Circulation – CVP’s, BP, Pulse-Ox Fluids & Electrolytes/Renal Urinary output, labs, specific gravity, osmalarity, myoglobin Pain Infection (Gram Negative Sepsis) Nutrition Weight, ulcer Management silver sulfadiazine (Silvadine) – (broad spectrum risk leukopenia) mafenide acetate (Sulfamylon) - use on deep burns (complication electrolyte disturbances