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BURN

y Cell destruction of the layers of the skin and the resultant depletion of fluid and electrolytes/

Review of anatomy and physiology

Largest organ in the body Serves as protective barrier against harmful external agents Insulates and cushions deeper body organs Acts as a mini excretory system Storage of vit D precursor Contains cutaneous receptors that serves as sensors for touch, pressure, temperature and 3 pain

Layers of the skin

Epidermis Dermis Hypodermis

Can be classified as

First degree burn Second degree burn Third degree burn Fourth degree burn

First Degree Burn

Depth: Epidermis only Causes: Sunburn, splashes of hot liquid Sensation: Painful Characteristics
Erythema Blanching on pressure No vesicles, No blisters Skin grafts are not required Discomfort lasts about 48 hrs Healing occurs in about 3 to 7 days
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Second Degree Burn

Depth: Epidermis and Dermis Causes: Flash, scalding or flame burn Sensation: Very painful Characteristics:
Fluid filled vesicles Red, shiny, wet after vesicles ruptures Grafts may be used if the healing process is prolonged Heals in 2 to 3 weeks
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Third Degree Burn

Depth: all skin layers and nerve endings Causes: flame, chemicals, scalding, electric current Sensation: Little or no pain Characteristics:
Wound is dry, white, leathery, or hard Scarring and wound contractures are likely to develop without preventive measures Healing takes weeks to months
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Fourth Degree Burn

Depth: involves injury to the muscles and bone Causes: flame, high voltage electric current Sensation: pain is absent Characteristics:
Injured area appears black Edema is usually absent Grafts are required Healing takes weeks to months
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TYPES OF BURNS
Thermal burns
Caused by exposure to flames, hot liquids, steams, or hot objects

Chemical burns
Caused by tissue contact with strong acids, alkali or organic compounds Systemic toxicity from cutaneous absorption can occur

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TYPES OF BURNS
Electrical burns Caused by heat generated by electrical energy as it passes through the body Results in internal tissue damage Cutaneous burns cause muscle and soft tissue damage that may be extensive Radiation burns Caused by exposure to ultraviolet light, x-rays, or a radioactive source
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Extent of the Burn

The extent of the burn injury is expressed as a percentage of the total body surface area (TBSA) The rule of nines is a rapid method of estimation used during the prehospital and emergency care phases.
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Rule of Nines
The body is divided into 5 surface areas. Head ( 9% ), anterior and posterior head and neck Arms ( 18% ), anterior and posterior upper Trunk ( 36% ), anterior and posterior trunk limbs Legs ( 36% ), anterior and posterior lower limbs Perineum ( 1% )`
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Major Burns >30% TBSA Possible inhalation Injury Lost of skin barrier

Cell Lysis Capillary permeability Hemolysis Hyperkalemia Sodium, H2O and Protein shift from Intravascular to Interstitial spaces Hemoglobin/ Myoglobin in urine

ThermoRegulation problem

Inflammatory response

Circulating Blood Volume (up to 50%) Concentration of RBC Massive stress Response, Sympathetic nervous System activation

Impaired Immune response Hyponatrimia

Hypoxemia

Blood viscosity

Burn shock Myocardial Depressant factor Blood Pressure

Adrenal corticoid Hormone and catecholamine release

Peripheral vasoconstriction Afterload Cardiac output

Tachycardia

Hyperglycemia

Catabolism

Risk of Curlings ulcer

Metabolism (after burn Shock resolves)

T issue Perfusion

Renal Blood flow Risk of acute renal failure

GI blood flow

Anaerobic Metabolism

Tissue damage Potential tissue necrosis

Cellular dysfunction Cell swelling

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Risk of ileus

Metabolic acidosis

Nursing Management of the Burn injury

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EMERGENT PHASE
Begins at the time of injury and ends with the restoration of capillary permeability, usually at 48 to 72 hours after the injury The primary goal is to prevent hypovolemic shock and preserve vital organ functioning. Remove person from source of burn THERMAL BURN Smother burn beginning with the head CHEMICAL BURN Remove clothing that contains chemical
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EMERGENT PHASE
Lavage area with copious amount of water ELECTRICAL BURN
Note victim position Identify entry/ exist routes Maintain airway Lasts from the onset of injury through successful fluid resuscitation. Wrap in dry, clean sheet or blanket to prevent further contamination of wound and provide warmth Assess how and when burn occurred. Provide lV route if possible
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Fluid Resuscitation
The administration of intravenous fluids to restore the circulating blood volume during the period if increasing capillary permeability. To counteract the effects of burn shock, fluid resuscitation guidelines are used to replace the extensive fluid and electrolyte losses associated with major burn injuries. Fluid replacements necessary in all burn wounds that involve greater than or equal to 20% TBSA Crystalloid fluids are administered through two large- bore catheters, preferably inserted through unburned skin. 24

Fluid Resuscitation
Warmed Ringers lactate solution during the 24 hours after the burn injury. As it most closely approximately the bodys extracellular fluid composition. The amount of fluid administered depends on how much intravenous fluid per hour is required to maintain a urinary output of 30 to 50 mL per hour. Successful fluid resuscitation is evidenced by stable vital signs, an adequate urine output, palpable peripheral pulses, and a clear sensorium. URINARY OUTPUT is the most common and most sensitive assessment parameter for cardiac output and tissue perfusion.
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RESUSCITATIVE PHASE
Begins with the initiation of fluids and ends when capillary integrity returns to near normal levels and the large fluid shifts have decreased The amount of fluid administered is based on the clients weight and the extent of injury Most fluid replacement formulas are calculated from the time of injury and not from the time of arrival at the hospital The goal is to prevent shock by maintaining vital organ perfusion Fluid resuscitation
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PARKLAND FORMULA

y4mL X wt (kg) % TBSA

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MODIFIED BROOKE FORMULA

y2mL X wt (kg) X % TBSA

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y The formulas specify the volume of fluid to be infused in the first 24 hours after the injury y 50% of the fluid to be infused during the first 8 hours y remaining 50% over the next 16 hours (25% per 8 hours)
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IMPLEMENTATION
Monitor pulse oximetry and prepare for ABGs and carboxyhemoglobin (COHB) levels if inhalation injury is suspected. Elevate the head of the bed to 30 degrees or more for burns of the face and head. Monitor temperature and assess for infection Initiate protective isolation techniques; maintain strict handwashing, use sterile sheets and linens when caring for the client, and use gloves, cap, masks, shoe covers scrub clothes and plastic spoons.
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IMPLEMENTATION
Monitor gastric output and pH levels for gastric comfort and bleeding. Administer antacids, H2 receptor antagonists as prescribed. Auscultate bowel sounds for ileus and monitor for abdominal distention and Gi dysfunction Monitor iv fluids and hourly intake and output. Prepare for fluids and hourly intake and output. Prepare for chest and other X-rays to rule out fractures or associated trauma.
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ACUTE PHASE
Begins when the client is hemodynamically stable, capillary permeability is restorted, and diuresis has begun Usually begins 48 to 72 hours after the time of injury Emphasis during this phase is placed on restorative therapy, and the phase continues until wound closure is achieved The focus is on infection control, wound care, wound closure, nutritional support, pain management, and physical therapy
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IMPLEMENTATION
Continue with protective isolation techniques Provide wound care as prescribed and prepare for wound closure Provide pain management Provide adequate nutrition as prescribed Prepare patient for rehabilitation
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PAIN MANAGEMENT
Administer morphine sulphate or meperidine (Demerol) as prescribed. Avoid IM or SC routes because absorption through the soft tissue is unreliable when hypovolemia and large volume fluids shifts are occurring. Avoid administering medication by the oral route, because the possibility of GI dysfunction Medicate the client prior to painful procedures.
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CONVALESCENT PHASE (REHABILITATIVE)

Final phase of burn care Overlaps the acute care phase and goes well beyond hospitalization Goals of this phase are designed so that the client can gain independence and gain maximal function. GOALS
Promote wound healing Minimize deformities Increase strength and function Provide emotional support
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