Burn Lecture Notes ▪ Capillary permeability with burns

increases with vasodilation

BURNS: ▪ Fluid loss deep in wounds
▪ Initially Sodium and H2O
A. CLASSIFICATION OF BURNS ▪ Protein loss – hypo-
• Partial thickness - characterized by varying depth proteinemia
from epidermis (outer layer of skin) to the dermis ▪ Hemoconcentration - Hematocrit
(middle layer of skin) increases
▪ Superficial - includes only the ▪ Low blood volume, oliguria
epidermis ▪ Hyponatremia - loss of sodium with
▪ Deep - involve entire epidermis and fluid
part of the dermis ▪ Hyperkalemia - damaged cells
• Full thickness - includes destruction of the release K, oliguria
epidermis and the entire dermis as well as possible ▪ Metabolic acidosis
damage to the SQ, muscle and bone • Diuretic Stage - begins 48 - 72 hours after burn
injury:
B. REVIEW OF SKIN FUNCTIONS ▪ Capillary membrane integrity returns
• Functions of the skin ▪ Edema fluid shifts back into vessels -
▪ Protection - intact skin is the first line blood volume increases
of defense against bacterial and ▪ Increase in renal blood flow - result in
foreign-substance invasion diuresis (unless renal damage)
▪ Heat regulation ▪ Hemodilution - low Hct, decreased
▪ Sensory perception potassium as it moves back into the
▪ Excretion cell or is excreted in urine with the
▪ Vitamin D production diuresis
▪ Expression - important with body ▪ Fluid overload can occur due to
image - fear of disfigurement increased intravascular volume
▪ Metabolic acidosis - HCO3 loss in
C. STAGES OF BURNS: urine, increase in fat metabolism
• Hypovolemic state - begins at the onset of burn E. Fluid shifts resolving - pt still acutely ill
and lasts for the first 48 hours - 72 hours 2. malnutrition
▪ Rapid fluid shifts - from the vascular 3. anemia - develops from the loss of RBC
compartments into the interstitial
spaces
Three periods of treatment - Emergent, Acute, • e. Body part involved - not all are equal
Rehabilitation: Cosmetic and functional concerns Face,
eyes, ears, feet, hands, perineum Limbs,
neck and chest - burns can produce a
I. EMERGENT (first 24-48 hrs) immediate problems tourniquet effect
• Maintain airway, fluids, analgesia, temperature, • f. Mechanism of injury - identify causative agent
wound (Flame, contact, scalds, chemical, electrical)
• Assessment: • g. Nursing diagnosis:
o Objective o Airway clearance,
▪ how burn occurred, when o ineffective Fluid volume deficit Fluid volume
▪ duration excess
▪ type of agent o Hypothermia
o Subjective: o Infection,
▪ previous medical problems o high risk for Pain (with partial thickness
▪ size and depth of burn burns)
▪ age o Skin integrity, impaired
▪ body part involved o Anxiety Knowledge
▪ mechanism of injury • h. Interventions:
• Factors Determining Severity of Burns: o maintain a patent airway - watch for
o Size of Burn Depth of Burn laryngeal edema,
o Age o 100% FiO2 mask (increase in
o Body part effected carboxyhemoglobin) intubation for
o Mechanism of Injury inhalation most often required
o History of cardiac, pulmonary, renal or o maintain circulation - fluid resuscitation -
hepatic diseases crystalloids and colloids Crystalloids - may
o Injuries sustained at time of burn be isotonic or hypertonic
o Duration of contact with burning agentc. 1. Isotonic - most common are lacted
o Size & Depth of Burn - "Rule of Nines" Divide Ringers or NaCl (0.9%) - these do not
body surface into multiples of nine generate a difference in osmotic
MAJOR BURN: pressure between the intravascular
> 25% of BSA of a partial thickness and interstitial spaces - subsequently
> 10% of BSA of a full thickness LARGE amounts of fluid are required
• d. Age < 2 years old or > 60 years old, the 2. Hypertonic salt solutions create an
mortality rates increases osmotic pull of fluid from the
 interstitial space back to the sterile sheets emotional support - fear of dying,
depleted intravascular space (helps disfigurement, trauma
decrease the amount of fluid
needed during resuscitation. SIGNS OF ADEQUATE FLUID RESUSCITATION:
decreases the development of burn • Clear sensorium
tissue edema, pulmonary edema, • Pulse < 120 beats per minute
and CHF) • Urine output for adults 30 - 50 cc/hour
Colloids - replacement begins during the second 24 • Systolic blood pressure > 100 mm Hg
hours following the burn to replace intravascular volume • Blood pH within normal range 7.35 - 7.45
ONCE CAPILLARY PERMEABILITY SIGNIFICANTLY
DECREASES
II. ACUTE PERIOD -
• General Indications for Fluid Resuscitation: • end of emergent period until burns heals
▪ 1. Burns > 20% of BSA with adults • focus now shifts to care of wounds and prevention
▪ 2. Burns > 10% of BSA with children of complications.
▪ 3. Age >65 or < 2 • Actual range of this phase depends on degree
and extent of burn
"Parkland Formula" 4ml of Lacted Ringers x weight (Kg) x a. ASSESSMENT:
%BSA burned = ml of Lacted Ringers to be given during Subjective -
the first 24 hour period following the burn first 8 hours ▪ pain and anxiety
following the burn are the most crucial - need to half of Objective -
the total, the second 8 hrs give one-quarter or the ▪ complete assessment every 8 hours
remaining fluids, the last 8 hrs give the remaining one- ▪ Observe burn wound and donor sites
quarter (with severe burn it is not uncommon to give for skin grafting,
greater than 20 thousand ml in a 24 hour period) colloid ▪ dietary intake,
(protein) given after capillary integrity returns NPO - great ▪ motor ability,
thirst, ileus is common assess for adequate fluid ▪ I&O,
replacement - HR < 120, BP - systolic >100, UO > 30 cc/hr ▪ weight
pH 7.35 - 7.45, weight gain the first 72 hours during the
diuretic phase UP is not a reliable indicator look at NURSING DIAGNOSIS:
electrolytes analgesia - drug of choice is IV Morphine - ▪ Skin integrity, impaired
NO IM or SQ wound care maintain body temperature - ▪ Infection, high risk for
need to keep environment WARM, no drafts, heat lamps, ▪ Altered nutrition
 ▪ Pain, acute (with partial thickness f. Oliguria
burns)
▪ Fluid Volume deficit Ways to prevent infection:
▪ Anxiety a. Gowns, masks, gloves
▪ Hypothermia b. Sterile linen
▪ Coping, ineffective individual c. Persons with URI should not come in contact
▪ Coping, ineffective family with patient
▪ Body image disturbance
▪ Knowledge deficit WOUND CARE:
▪ Mobility, impaired 1. Burn wound is unique
▪ Self-Care deficit 2. Burn wound sepsis -
▪ gram +
INTERVENTIONS: ▪ gram- (pseudomonas),
• relieving anxiety, denial, regression, anger, ▪ viruses,
depression ▪ fungal (candida albicans)
• wounds - REFER TO WOUND CARE 3. Nutrition -
• nutrition (Nutritional assessment, pre-albumin ▪ collagen primary structure in healing
levels, large protein requirement, carbohydrates by secondary intention,
and fats for energy, mega vitamins, TPN, enteral ▪ need increased protein,
tube feedings) ileus is common ▪ may need double the normal calorie
• pain - around the clock management prevention requirements
of infection - SEE WOUND CARE 4. Inadequate blood supply
5. Burn wound disorders:
Organisms that usually infect burns are: ▪ scarring
a. Staphylococcus aureus ▪ contractures
b. Pseudomonas Infection is usually the cause of ▪ keloids
any deterioration ▪ failure to heal

Signs of sepsis: WOUND CARE PRINCIPLES:

a. Change in sensorium 1. GOALS
b. Fever ▪ close wound asap
c. Tachypnea ▪ prevent infection
d. Paralytic ileus ▪ reduce scarring and contractures
e. Abdominal distention ▪ provide for comfort
 2. Wound cleaning bed side hydrotherapy tanks ▪ speeds debridement,
tubbing spray table ▪ develops granulation tissues faster,
3. Debridement mechanical surgical enzymatic ▪ and makes skin grafting possible
4. Topical antibacterial therapy mafenide sooner.
(sulfonamide) sulfadiazine 4. Biological dressings
▪ homografts - same species (cadaver
WOUND CARE - DRESSING THE BURN skin) -
1. Open technique or exposed - more often used ▪ temporary coverage heterografts -
with burns effecting the: another species (pig skin) -
▪ face, ▪ temporary coverage autografts -
▪ neck patients own skin - permanent
▪ perineum and coverage
▪ broad areas of the trunk
Partial thickness - exudate dries in 48 to 72 WOUND CARE - GRAFTING
hours forming a hard crust that protects the 1. Indications for grafting
wound. ▪ full thickness
▪ Epithelialization occurs beneath the ▪ priority areas
crust and may take 14 to 21 days to ▪ wound bed pink, firm, free of
heal. exudate
▪ Crust then falls off spontaneously - ▪ bacterial count < 100,000/gram of
leaving healed unscared surface tissue
Full thickness - dead skin is dehydrated and 2. Care of grafts - assess
converted to black leathery eschar in 48 to
72 hours. Loose eschar is gradually removed
with hydrotherapy &/or debridement III. REHABILITATION PERIOD
2. Closed technique 1. Care of healing skin - wash daily, cover with
Wound is washed, and sterile dressings cocoa butter
changed (may be q shift, daily). 2. Pressure garments, ace wraps - prevent scaring
Dressing consists of gauze &/or ace wraps and contractures
impregnated with topical ointments. 3. Promote mobility - positioning, exercise,
3. Semi-open - splinting, ADL
consists of covering the wound with topical
Antimicrobial agents and gauze.
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