Beruflich Dokumente
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BURNS
Wounds caused by exposure to:
1. excessive heat
2. Chemicals
3. fire/steam
4. radiation
5. electricity
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BURNS
Results in 10-20 thousand deaths annually
Survival best at ages 15-45
Children, elderly, and diabetics-increase risk
Survival best burns cover less than 20% of TBA
(total body surface area)
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TYPES OF BURNS
Thermal
Chemical
Electrical
Radiation
CHEMICAL BURN
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ELECTRICAL BURN
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SUPERFICIAL BURNS
(FIRST DEGREE)
Epidermal tissue only affected
Erythema, blanching on pressure, mild swelling
no vesicles or blister initially
Not serious unless large areas involved
i.e. sunburn
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FULL THICKNESS
(THIRD/FOURTH DEGREE)
Destruction of all skin layers
Requires immediate hospitalization
Dry, waxy white, leathery, or hard skin, no pain
Exposure to flames, electricity or chemicals can
cause 3rd degree burns
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Calculation
of Burned
Body Surface Area
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Evans, 18.1, 2007)
RULES OF NINES
Head & Neck = 9%
Each upper extremity (Arms) = 9%
Each lower extremity (Legs) = 18%
Anterior trunk= 18%
Posterior trunk = 18%
Genitalia (perineum) = 1%
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VASCULAR CHANGES
RESULTING FROM BURN
INJURIES
Circulatory
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FLUID SHIFT
Occurs
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FLUID IMBALANCES
Occur
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FLUID REMOBILIZATION
Occurs
after 24 hours
Capillary leak stops
See diuretic stage where edema fluid
shifts from the interstitial spaces into the
vascular space
Blood volume increases leading to
increased renal blood flow and diuresis
Body weight returns to normal
See Hypokalemia
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CURLINGS ULCER
Acute ulcerative gastro duodenal disease
Occur within 24 hours after burn
Due to reduced GI blood flow and mucosal
damage
Treat clients with H2 blockers, mucoprotectants,
and early enteral nutrition
Watch for sudden drop in hemoglobin
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EMERGENT PHASE
*Immediate problem is fluid loss, edema,
reduced blood flow (fluid and electrolyte
shifts)
Goals:
1. secure airway
2. support circulation by fluid
replacement
3. keep the client comfortable with
analgesics
4. prevent infection through wound care
5. maintain body temperature
6. provide emotional support
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EMERGENT PHASE
Knowledge of circumstances surrounding the
burn injury
Obtain clients pre-burn weight (dry weight) to
calculate fluid rates
Calculations based on weight obtained after fluid
replacement is started are not accurate because
of water-induced weight gain
Height is important in determining body surface
area (BSA) which is used to calculate nutritional
needs
Know clients health history because the
physiologic stress seen with a burn can make a
latent disease process develop symptoms
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CLINICAL MANIFESTATIONS
Cardiovascular
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CLINICAL MANIFESTATIONS
Changes
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CLINICAL MANIFESTATIONS
Sympathetic
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SKIN ASSESSMENT
Assess
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IV FLUID THERAPY
Infusion of IV fluids is needed to maintain sufficient
blood volume for normal CO
Clients with burns involving 15% to 20% of the TBSA
require IV fluid
Purpose is to prevent shock by maintaining adequate
circulating blood fluid volume
Severe burn requires large fluid loads in a short time
to maintain blood flow to vital organs
Fluid replacement formulas are calculated from the
time of injury and not from the time of arrival at the
hospital
Diuretics should not be given to increase urine output.
Change the amount and rate of fluid administration.
Diuretics do not increase CO; they actually decrease
circulating volume and CO by pulling fluid from the
circulating blood volume to enhance diuresis
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COMMON FLUIDS
Protenate or 5% albumin in isotonic saline (1/2
given in first 8 hr; given in next 16 hr)
LR (Lactate Ringer) without dextrose (1/2 given
in first 8 hr; given in next 16 hr)
Crystalloid (hypertonic saline) adjust to maintain
urine output at 30 mL/hr
Crystalloid only (lactated ringers)
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Pseudomonas, Proteus
May led to septic shock
Conversion of a partial-thickness injury to a full-thickness
injury
Ulceration of health skin at the burn site
Erythematous, nodular lesions in uninvolved skin
Excessive burn wound drainage
Odor
Sloughing of grafts
Altered level of consciousness
Changes in vital signs
Oliguria
GI dysfunction such as diarrhea, vomiting
Metabolic acidosis
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LAB VALUES
Na hyponatremia or Hypernatremia
K Hyperkalemia or Hypokalemia
WBC 10,000-20,000
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PLANNING AND
IMPLEMENTATION
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REHABILITATIVE PHASE OF
BURN INJURY
Started
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DIET
Initially NPO
Begin oral fluids after bowel sounds return
Do not give ice chips or free water lead to
electrolyte imbalance
High protein, high calorie
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GOALS
Prevent
complications (contractures)
Vital signs hourly
Assess respiratory function
Tetanus booster
Anti-infective
Analgesics
No aspirin
Strict surgical asepsis
Turn q2h to prevent contractures
Emotional support
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DEBRIDEMENT
Done with forceps and curved scissor or through
hydrotherapy (application of water for treatment)
Only loose eschar removed
Blisters are left alone to serve as a protector
controversial
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SKIN GRAFTS
Done during the acute phase
Used for full-thickness and deep partialthickness wounds
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