2. Burns Fluid & Electrolytes

3. 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.

4. 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

5. 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

6. Mechanism/Type: Chemical Burn

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

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

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

10. 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

11. 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 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

12. Superficial Burn

13. 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 days , no scarring

14. 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

15. 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

16. Deep Burn

17. 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

18. 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

19. 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

20. Burn Assessment Lund & Browder Chart

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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?

31. 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

32. 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

33. 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

34. 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