Management of Patients with Burn Injury

Burns: Major Goals

1. Prevention 2. Institution of lifesaving measures for severely burned person. 3. Prevention of disability and disfigurement through early, individualized treatment 4. Rehabilitation through reconstructive surgery and rehabilitative programs.

Burn Classifications
Superficial
Least destruction Only epidermis injured

Partial-thickness
Epidermis destroyed Varying depths of dermis damaged/destroyed

Superficial partial-thickness
Erythematous and moist with vesicles painful

Deep partial-thickness
Red and waxy without blisters Moderate edema, lesser degree of pain Hypoxia and ischemia can cause extension of wound

Burn Classifications
Full-thickness
Entire epidermis and dermis involved No viable epithelial cells, grafts required Hard, dry leathery eschar

Deep full-thickness
Extend beyond skin into underlying fascia and tissues Muscle, bone and tendon damage with exposure to surface Blackened and depressed, little or no sensation Early excision and grafting beneficial

Illustrations of Burns
Superficial partialthickness Deep partial-thickness

Illustration of Burns
Full Thickness Deep Full Thickness

Burn Classification
Extent of Body Surface Area Injured
Rule of Nines Lund-Browder Palm method

Pathophysiology of Burn Injury

Tissue destruction can lead to:
Fluid/protein losses Sepsis Multiple system disturbances
Metabolic Endocrine Respiratory Cardiac Hematologic Immune

Pathophysiology of Burn Injury

Extent of local and systemic disruption depends on
Age General health status Extent of injury Depth of injury Area of body injured

(morbidity and mortality of burn clients is related to a lack of or delay in healing)

Vascular Changes
Fluid Shift
Period of inflammatory response Vessels adjacent to burn injury dilate capillary hydrostatic pressure and capillary permeability Continuous leak of plasma from intravascular space into interstitial space Associated imbalances of fluids, electrolytes and acid-base occur Hemoconcentration Lasts 24-36 hours

Vascular Changes
Fluid remobilization
Capillary leak ceases and fluid shifts back into the circulation Restores fluid balance and renal perfusion
Increased urine formation and diuresis

Continued electrolyte imbalances

Hyponatremia Hypokalemia

Hemodilution

Other System Changes

Cardiac Pulmonary
Decreased cardiac output Need fluid resuscitation and support with O2
Respiratory insufficiency as a secondary process Can progress to respiratory failure Aggressive pulmonary toilet and oxygenation

Gastrointestinal
Decreased or absent motility (may need NG tube) Curlings ulcer formation H2 histamine blockers, mucoprotectants and enteral nutrition

Other System Changes

Metabolic
Hypermetabolic state
Increased oxygen and calorie requirements Increase in core body temperature

Immunologic
Loss of protective barrier Increased risk of infection Suppression of humoral and cell-mediated immune responses

Compensatory Responses
Inflammatory Compensation
Initiates healing Contributes to fluid shift ( capillary permeability) Local tissue reaction due to release of chemicals by wbcs

Sympathetic Nervous System Compensation

Stress Response (Figure 71-8, p. 1625)

Phases of Burn Injury

Emergent/Resuscitative
First 48 hours

Acute
Approximately 48 hours after injury to complete wound closure

Rehabilitative
Begins with wound closure and ends when client returns to highest possible level of functioning

Emergent/Resuscitative Phase
Goals:
Maintain open airway Ensure adequate breathing/circulation Limit extent of injury Maintain function of vital organs Prevent potential complications

Transfer to Burn Center

Major burns Very young or elderly Coexisting health problems that could affect recovery Circumstances that increase risk of acute and long term complications

Acute Phase
Interventions aimed at:
Maintenance of cardiovascular/respiratory system Nutritional status Burn wound care Pain control Psychosocial interventions

Rehabilitative Phase
Emphasis:
Psychological adjustment of client Prevention of scars and contractures Resumption of pre-burn activity
Work Family Social

Clinical Manifestations of Burns

Respiratory
Direct airway injury Carbon monoxide poisoning Thermal injury Smoke poisoning Pulmonary fluid overload External factors

Cardiovascular
Hypovolemic shock and cardiac output Impaired circulation/tissue perfusion Potential for ECG changes

Clinical Manifestations
Renal/urinary
Changes R/T renal perfusion and debris Fluid shift GFR and urine output Fluid remobilization-- GFR and diuresis Tubular blockage from myoglobin and uric acid Fluid resuscitation should maintain output at 30-50 mL/hour

Integumentary
Size of injury is important to diagnosis and prognosis
Rule of Nines Lund-Browder method

Specific treatments dependent upon depth of injury

Decreased CO, Deficient Fluid Volume, & Ineffective Tissue Perfusion

Interventions: Non-surgical
IV fluid therapy Plasma exchange Drug therapy

Surgical
Escharotomy

Ineffective Breathing Pattern

Interventions Non-surgical
Airway maintenance Promotion of ventilation Monitoring gas exchange Oxygen therapy Drug therapy Positioning and deep breathing

Surgical
Tracheostomy Chest tubes escharotomy

Acute Pain
Interventions: Non-surgical
Drug therapy (opioids) (anesthetic agents) Complimentary/alternative therapies Environmental manipulation

Surgical
Early surgical excision of burn wound

Impaired Skin Integrity Wound Care Management

Non-surgical Debridement
Mechanical Enzymatic

Cleaning Stimulating granulation and revascularization Dressings

Dressings
Standard
Multiple gauze layers over topical agent or antibiotic

Biologic Homograft (allograft) from cadaver

Heterograft (xenograft) from animal (pig) Amniotic membrane Cultured skin

Artificial skin
Two-layer product which creates an artificial dermis

Synthetic dressing
Solid silicone and plastic membrane Can see through to monitor wound status

Impaired Skin Integrity Wound Care Management

Surgical management
Surgical excision
Treatment of choice for deep partial-thickness wounds

Wound coverings
Permanent skin coverage by autograft
Split thickness Successive reharvesting Meshing of split thickness graft

Risk for Infection

Non-surgical management
Drug therapy
Tetanus Toxoid and Topical Antimicrobials Organism specific drugs

Isolation Environmental manipulation Secondary prevention/early detection

Surgical management
Aggressive surgical incision of infected wound

Additional Interventions
Imbalanced Nutrition
Calculate calorie needs and provide adequate calories and nutrients Calorie requirements can exceed 5000 per day

Impaired Mobility
Interventions to maintain pre-burn ROM and prevent contractures

Disturbed Body Image

Grief counseling Encouraging independence