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

2. Skin layers

3. Types of burns Thermal Chemical Thermal 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. Electrical burns: top picture- toe Leg bottom picture- mouth

8. Depth of burn: Layers of skin and burns

9. Depth of burn: First degree burn to third degree

10. First degree burns

11. Second degree burn- note blisters

12. Second degree burn

14. Full thickness third degree burn All layers skin

15. Full thickness Involves past the 3 layers down to the bone and/or organs

16. Extent of Burn: Rule of Nines Lund & Browder- age

17. What are the Priorities in this patient??? Is this patient a candidate for a major burn center?

18. Common manifestations/complications of Major Burn 1. Integumentary system eschar formation necrotic tissue hard, leathery must be removed for healing to take place

19. Common manifestations/complications Major Burn 2. Cardiovascular Burn shock- third spacing (hypovolemic) 24-36 hrs Blood vess damaged> inc cap permeability H2O, Na & serum albumin> intestial space(3 rd space) HCT and blood viscosity increases > 40% burn causes dec cardiac contractibility & CO Electrical burn can cause arrhythmias/cardiac arrest Compartment syndrome of extremities/torso as edema compresses blood vessels and nerves- may need escharotomy

20. Third spacing

21. Burn with escarotomy

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

23. Escarotomy

24. Common Manifestations Complications Major Burn 3. Respiratory Direct inhalation injury/systemic response (ARDS) Upper airway thermal injury- esp if burned in enclosed space (room) & breaths in hot air. May be no outward sign of burn- look for soot, nasal hairs Laryngeal spasms as edema peaks in 34-48 hrs Bronchial congestion and infection Intersitial pulmonary edema; alveolar collapse CO poisoning- 200 X’s greater affinity for hemoglobin- hypoxia> headache to coma sym

25. What are your #1 priorities in this patient? Patient #1Patient #2

26. What do you assess for here???

27. Common Manifestations Complications Gastrointestional Paralytic ileus > increased risk for aspiration Stress ulcer (Curling’s ulcer) ck pH Ischemia of intestine increases intestinal mucosal permeability> bacteria can cause systemic sepsis, ARDS and multiple organ failure

28. Common Manifestations/Complications Urinary Urinary- Renal blood flow/GFR decrease causing release ADH Myoglobinurea- dark urine may block renal tubules

29. Common Manifestations/complications Immune system and metabolism Immune system Capillary leak- serum levels immunogloblin decreased Opportunistic infections can be fatal Most common source infection/septicemia- clients own GI track Metabolism BMR increases 2X’s, more if complications Hypermetabolism continues until wound closure Body weight and temperature drop- shivering inc met

30. Common Manifestations/Complications- Pain Where are nerve ending? Morphine/Fentanyl Give IV in acute stage due to fluid shift---No IM’s

31. Therapeutic Interventions Major Burns Stage one: Emergent/resuscitative Stage 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

32. 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; hemodynamic monitoring Elevate edematous part; escharotomy

33. Elevate arms to decrease swelling also note escarotomy of arms and chest- assess CMS

34. Other therapeutic interventions during Stage one: emergent/resucitative stage First aide treatment to limit severity of burn Prevent heat loss through burn- warm envir Respiratory involved- intubation/ventilation with PEEP/humidified O2 bronchodilators mucolytic agents to liquefy secretions TCDB HOB 30 GI- Pepcid; NG tube when gut ready- antacids

35. Third spacing- Note edema of the face decreasing

36. Summary of Emergent Phase:

38. Therapeutic Interventions Major Burns Stage 2: Acute Stage 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 )

39. Hydrotherapy: Hubbard Tank

40. Cleaning and debriment in Hubbard

41. Topical broad spectrum antimicrobials (p.425) Silvadene Silver Nitrate Sulfamylon

42. Wound Care Open Method Apply topical chemotherapy

43. Wound Care- Closed method Apply topical chemo and wrap with gauze, fluffs, kerlix Assess for constriction; circulation checks

44. Elevate burned arms on pillows Give pain meds 30 minutes prior to treatments

45. Skin will grow together if not separated

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

47. Excision & Grafting Removal of necrotic tissue Eschar is removed until viable tissue is reached

48. Acute Phase- grafting

49. Acute Phase Autograft- on right- donor site Permanent if no infection Temporary grafts Homograft- cadaver Heterograft- animal Synthetic

50. Interventions Assist with positioning ROM exercises Support O.T. & P.T. efforts

51. Therapeutic Interventions: Stage 3: Rehabilitation Stage Wound closure to highest level of function- years Major concern is psychosocial adjustment Prevent/reduce hypertrophic scares- pressure garments Skin care Potential for repeated cosmetic surgeries

52. Keloid formation

54. Rehabilitation Phase- Pressure garments

55. Pertinent Nursing Problems/interventions Impaired skin integrity Deficient fluid volume Acute pain Risk for infection Impaired physical mobility Imbalanced nutrition: less than body req Powerlessness

56. What are your assessment findings?

57. What are your nursing priorities for this patient?