1. Integumentary: Burns Marnie Quick, RN, MSN, CNRN

2. Skin layers, hair follicle, nerves, sweat glands

3. Types of burns Thermal Chemical Smoke and inhalation Electrical Radiation

4. Thermal burn

5. Cool burn with cold water until pain is relieved- Do not apply to more than 20% body surface- hypothermia may occur

6. Chemical burn from sulfuric acid

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

8. Electrical burns

9. Depth of Burn

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

11. Deep partial-thickness burn- note blisters

12. Partial-thickness (Second degree burn)

14. Full-thickness

15. 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

16. 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

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

18. 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

19. 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 30-50 cc/hr (foley); heart rate less than 120/min; SBP> 90;hemodynamic monitoring Elevate edematous part; escharotomy

21. Effects of Burn Shock

22. Third spacing

23. Burn with escarotomy

24. Escarotomy

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

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

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

28. What do you assess for here???

29. 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

30. Summary:

31. 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 )

32. Decreasing of third spacing- Note edema of the face decreasing

33. Hydrotherapy: Hubbard Tank

34. Clean/debridement Rt tank or Lt surgery

35. Topical broad spectrum antimicrobials Open method

36. Separate skin; use of splints Closed method

37. Skin will grow together if not separated

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

39. Removal of necrotic tissue Eschar removed until viable tissue

40. Donor sites: after harvesting healed donor site

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

42. Grafting

43. 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

44. Pressure garments

45. What are your assessment findings?

46. What are your nursing priorities for this patient?