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BURNS Reynel Dan L. Galicinao Angelia T. Galinato Maria Lourdes R. Balucan

Burns : 

Burns Cell destruction of the layers of the skin and the resultant depletion of fluids and electrolytes Burns can be fatal, permanently disfiguring, and incapacitating, both emotionally and physically.


INCIDENCE Most accidents occur at home. The 2nd most frequent place of injury is at work. Flame injury is the leading cause of accidents for adults Scalding is the leading cause of accidents for children. Teenage boys have a high incidence of electrical injuries. The very young and the elderly are at greatest risk for burn injuries. Smoking, usually combined with alcohol intake, is associated with at least half of major fire injuries and deaths. Males are more commonly injured by burns than are females.

Types of Burns : 

Types of Burns Thermal burns most common type Caused by exposure to flames hot liquids, steam, or hot objects Chemical burns Caused by tissue contact with strong acids, alkali, or organic compounds Systemic toxicity from cutaneous absorption can occur

Types of Burns : 

Types of Burns Electrical burns Caused by heat generated by an electrical energy as it passes through the body Result in internal tissue damage Radiation burns Caused by exposure to UV light, x-rays, or radioactive source

Burn Size : 

Burn Size Small burns Localized response to the injured area Large burns ≥25% TBSA Systemic response Affect all the major systems of the body

Depth of Burns : 

Depth of Burns

Depth of Burns : 

Depth of Burns

Estimating the extent of injury : 

Estimating the extent of injury Palm Method Rule of Nines Lund-Browder Method

Slide 13: 

Rule of Nines for estimating burn percentage

Slide 14: 

Lund-Browder Chart

Severity Classification for Burn Injuries : 

Severity Classification for Burn Injuries Minor 2° burns of <15% TBSA in adults or <10% in children 3° burns of <2% TBSA not involving special care areas Major 2° burns >25% TBSA in adults or >20% in children All 3° burns >10% TBSA All burns involving eyes, ears, face, hands, feet, perineum, joints All inhalation injury, electrical injury, concurrent trauma, poor risk patients Moderate 2° burns of 15-25% TBSA in adults or 10-20% in children 3° burns of <10% TBSA not involving special care areas

Slide 16: 

Inflicted Burns

Slide 17: 

Burns of any type may occur in cases of child or elder neglect or abuse.

Burn Location : 

Burn Location Head, neck, chest Assoc w/ pulmonary complications Face Assoc w/ corneal abrasions Ear Assoc w/ auricular chondritis Hands, joints Require intensive therapy to prevent disability

Burn Location : 

Burn Location Perineal area Prone to autocontamination by urine & feces Circumferential burns of extremities Produce tourniquet-like effect and lead to vascular compromise (compartment syndrome) Circumferential thorax Lead to inadequate chest wall expansion and pulmonary insufficiency

Inhalation injuries : 

Inhalation injuries Assessment: Facial burns Erythema Swelling of oropharynx & nasopharynx Singed nasal hairs Flaring nostrils Stridor, wheezing, dyspnea Hoarse voice Sooty (carbonaceous) sputum & cough Agitation & anxiety Tachycardia Injury results when the victim is trapped in an enclosed, hot, smoke-filled space.

Slide 21: 

In the nursing history, determine whether the victim was in a closed area during the fire and whether he or she lost consciousness. Assess for the clues of inhalation injury.

Stages of Burns : 

Stages of Burns 1st Stage: Shock/Fluid Accumulation Phase 1st 48 hrs Generalized dhn 2nd Stage: Diuretic/Fluid Remobilization Phase After 48 hrs 3rd Stage: Recovery 5th day onwards Hypocalcemia Negative nitrogen balance Hypokalemia

Stages of Burns : 

Stages of Burns

Complications : 

Complications respiratory complications and sepsis most common complications and leading causes of death in burn patients Other possible complications hypovolemic shock anemia malnutrition multisystem organ dysfunction

Managements : 

Managements Medical, Surgical, Nursing

Assessment : 

Assessment As with all trauma victims, a primary and secondary trauma survey, including assessment of airway, breathing, and circulation as well as vital signs, is done. Other assessment parameters specific to the burn injury focus on the extent and severity of burn injury and inhalation injury.

Nursing Assessment : 

Nursing Assessment Obtain a thorough history, including: Causative agent hot water, chemical, gasoline, flame, tar, radiation PUVA light, etc. Duration of exposure. Circumstances of injury whether in closed or open space, accidental or intentional, or self-inflicted. Age. Initial treatment first aid, prehospital emergency care (including fluids, intubation, etc.) care rendered in another facility (emergency department, etc.). Pre-existing medical problems heart disease human immunodeficiency virus drug abuse diabetes, ulcers

Nursing Assessment : 

Nursing Assessment Alcoholism chronic obstructive pulmonary disease (COPD) Epilepsy Psychosis hepatitis B, C, or D. Current medications. Concomitant injuries (e.g., from fall, explosions, assaults). Evidence of inhalation injury. Allergies. Tetanus immunization status. Height and weight. Perform ongoing assessment of hemodynamic and respiratory status, condition of wounds, and signs of infection.

Nursing Diagnoses : 

Nursing Diagnoses 1. Impaired Gas Exchange related to inhalation injury 2. Ineffective Breathing Pattern related to circumferential chest burn, upper airway obstruction, or ARDS 3. Decreased Cardiac Output related to fluid shifts and hypovolemic shock 4. Ineffective Tissue Perfusion: Peripheral related to edema and circumferential burns 5. Risk for Excess Fluid Volume related to fluid resuscitation and subsequent mobilization 3 to 5 days postburn

Nursing Diagnoses : 

Nursing Diagnoses 6. Impaired Skin Integrity related to burn injury and surgical interventions (donor sites) 7. Impaired Urinary Elimination related to indwelling catheter 8. Ineffective Thermoregulation related to loss of skin microcirculatory regulation and hypothalamic response 9. Risk for Infection related to loss of skin barrier and altered immune response 10. Impaired Physical Mobility related to edema, pain, skin and joint contractures

Nursing Diagnoses : 

Nursing Diagnoses 11. Impaired Nutrition: Less Than Body Requirements related to hypermetabolic response to burn injury 12. , Risk for Injury related to decreased gastric motility and stress response 13. Acute Pain related to injured nerves in burn wound and skin tightness 14. Ineffective Coping related to fear and anxiety 15. Disturbed Body Image related to cosmetic and functional sequelae of burn wound

Emergent Phase : 

Emergent Phase Prehospital Care Begins at scene of accident and ends when emergency care is obtained Remove victim from source of burn Remove source of heat Assess ABC Assess for assoc trauma Conserve body heat Cover burns w/ sterile/clean cloths Remove constricting jewelry and clothing Assess the need for IVF Transport

Emergent Phase : 

Emergent Phase Emergency Care Continuation of care administered at the scene of injury

Emergency Care for Major Burns : 

Emergency Care for Major Burns Evaluate degree and extent of the burn and treat life-threatening conditions Ensure patent airway and administer 100% O2 as prescribed Monitor for respi distress and assess need for intubation Assess oropharynx for blisters and erythema Monitor ABG and carboxyhemoglobin levels Inhalation injury: Administer 100% O2 via tight-fitting non-rebreather mask as prescribed until carboxyhemoglobin levels fall below 15%

Emergency Care for Major Burns : 

Emergency Care for Major Burns Initiate peripheral IV access to nonburned skin proximal to any extremity burn, or prepare for insertion of central venous pressure line as prescribed Assess hypovolemia and administer IVFs to maintain fluid balance Monitor VS closely Insert Foley catheter as prescribed and maintain urine output @ 30-50mL/hr Maintain NPO status

Emergency Care for Major Burns : 

Emergency Care for Major Burns Insert NGT as prescribed to remove gastric secretions and prevent aspiration Administer tetanus prophylaxis as prescribed Administer pain meds as prescribed via IV route Prepare pt for escharotomy or fasciotomy as prescribed

Slide 40: 

Consensus Formula 2-4 mL LR x kg body wt x % TBSA burned ½ given in first 8 hrs ½ given over next 16 hrs

Emergency Care for Minor Burns : 

Emergency Care for Minor Burns Administer pain meds w/ small doses of morphine sulfate or Meperidine (Demerol) as prescribed Instruct pt in use of oral analgesics as prescribed Administer tetanus prophylaxis as prescribed Wound care Cleansing Debriding loose tissue Removing damaging agents Application of topical antimicrobial cream and sterile dressing Instruct pt on follow-up care, active ROM exercises, wound care treatments

Resuscitative Phase : 

Resuscitative Phase Monitor O2 sat ABG Carboxyhemoglobin ECG Temp Daily wt – expect wt gain 15-20lbs in first 72 hrs Gastric output, pH – discomfort, bleeding, stress ulcer Stool – occult blood Hourly I&O – notify physician UO <30mL/hr or >50mL/hr Bowel sounds – ilues, distention Pulse, CRT – for circumferential burn Fluid resuscitation Elevate HOB 30°

Resuscitative Phase : 

Resuscitative Phase Protective isolation techniques Shave/cut body hair around wound margins Antacids (H2-receptor antagonist) Use bed cradle Pain Morphine sulfate or mepiridine (Demerol) IV Nutrition BMR 40-100x greater than normal NPO until present bowel sounds, then clear liquid Enteral tube, PPN, TPN Diet: high protein, carbohydrates, fats, vitamins

Escharotomy : 

Escharotomy Lengthwise incision through burn eschar to relieve constriction and pressure to improve circulation For circumferential burns Performed @ bedside w/o anesthesia Post procedure: assess pulse, color, movement, sensation of affected extremity Control bleeding w/ pressure Pack incision gently w/ fine mesh gauze for 24hrs post escharotomy Topical antimicrobial agents

Fasciotomy : 

Fasciotomy Incision extending through SQ tissue and fascia Performed if adequate tissue perfusion doesn’t return post escharotomy Performed in OR w/ GA Post-op care: Assess pulse, color, movement, sensation Control bleeding Topical antimicrobial agents & dressings

Acute Phase : 

Acute Phase Protective isolation Wound care Pain mngmnt Adequate nutrition Prepare for rehabilitation

Antimicrobial Agents : 

Antimicrobial Agents Silver NO3 0.5% Silver Sulfadiazine (Silvadene) Mafenide acetate 10% (Sulfamylon) DOC because it can penetrate eschar Administer analgesic 15-30 min before application; it is irritating Gentamycin SO4 0.1% (Geramycin) Povidone Iodine (Betadine)

Wound Care : 

Wound Care Hydrotherapy Removes debris, improves circulation, promotes healing Immersion, showering, spraying 30min or less Pt should be premedicated Not for hemodynamically unstable, w/ new skin grafts Minimize bleeding Maintain body temp

Wound Care : 

Wound Care Debridement Removal of eschar to prevent bacterial proliferation under the eschar and to promote wound healing Mechanical – use scissors, forceps; wet-to-dry dressing Enzymatic – proteolytic and fibrinolytic topical enzymes Surgical – excision of eschar and coverage of wounds Deep partial- or full-thickness burns: Cleanse and debride Topical antimicrobial agents 1-2x daily

Skin Grafting : 

Skin Grafting

Rehabilitative Phase : 

Rehabilitative Phase Physical, psychosocial, spiritual aspects Promoting activity tolerance Improving body image and self-concept Supporting client and family process

That’s All Folks : 

That’s All Folks - Dan, Angie, Lourdes

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