IN THE NAME OF GOD
#BURNS
BURNS INCIDENCE
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Approx. 140 Burn Centers in U. S.
Approx. 1.25 million people suffer a burn
injury in the U.S. each year.
About 5,500 people die from burns and
related inhalation injuries annually
Young people and elderly are high risks
Most injuries occur at home
75% of patients are victims of their own
actions
Burns
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Devastating
Heals slowly
Disfiguring
Long months of
rehabilitation
Occupational
therapy
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Nurse’s role:
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Be knowledgeable of
the pathophysiology
of burns
Help meet
biopsychosocial
needs
Carry out measures
to meet physical
needs
Phases of Burn Care
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Emergent/Resuscitative Phase (onset of injury
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Acute/intermediate Phase (beg. of diuresis to
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Rehabilitation Phase (wound closure to optimal
to completion of fluid resuscitation)
 On the scene care (ABC, initial wound care, injury)
 Management of fluid loss & shock
near completion of wound closure)
 Maintenance of resp. & circulatory status, fluid &
electrolyte balance, GI function
 Infection prevention, wound care, pain
management, nutritional support
level)
 Wound healing, restoring maximal functional
activity, alterations in self-image & lifestyle
Burns
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Emergency management
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cold wet towels, cool water, no direct ice, cover
with sterile dressing
don’t break blisters
lotion only after a burn is completely cooled
wrap loosely to avoid putting pressure on burned
skin
ABC
Prevent shock
Fluid replacement
Flush area thoroughly with water or saline
(chemical burns)
Burns
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Short term effects of burns
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fl volume deficit
hypovolemic shock
infection
Long term effects of burns
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scarring (full thickness burns)
contraction
Burns
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Minor burns
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<15% TBSA with <2% full thickness
Moderate burns
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partial thickness burns 15-25% TBSA with
2-10% full thickness
Burns
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Major Burns
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>25% TBSA or >10% full thickness
involvement of hands, feet, face or
genitalia
Survival due to refinement of fluid
resuscitation management and early
transfer to burn unit.
Burns
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Facial burns have the possibility of
airway impairment
Important to know the circumstance of
burn:greater risk of airway involvement
if burn occurred in closed space
Always suspect a head injury if a
patient had an electrical burn which
resulted from a fall
Mechanism of Burn
Injuries
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flame (thermal) 55%
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contact with fire etc.
(smoke inhalation can be as damaging as
thermal)
get pt. Supine to decrease facial burn
(STOP, DROP, ROLL)
prolonged exposure to cold considered
thermal burn
Mechanism of Burn
Injuries
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Scald 33%
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most common for children
chemical 10%
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severity depends on duration of contact, conc.
Strength of chemical, amt. Of tissue exposed
alkaline more serious than acid
irrigate area immediately (most chem labs have
high pressure showers)
powder-brush off; do not inhale
Mechanism of Burn
Injuries
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chemical con’t
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chemical burns destroy tissue through
protein coagulation rather than heat
some acids (sulfuric and muriatic) also
destroy tissue through heat production in
chemical reaction with tissue
first aid
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take of clothes (chemical on clothes)
Mechanisms of Burn
Injuries
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First aid of Chemical con’t
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if powder, dust off before irrigate
so not attempt to neutralize agent (takes valuable time)
running water will dilute the chemical
Electrical <10%
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voltage running through body can do a lot of
damage (leaves an exit wound as well as entrance
wound); evaluate internal damage along the path
of the current
Mechanisms of Burn
Injuries
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Electrical con’t
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as electrical current goes through tissue, it
produces heat causing thermal coagulation
necrosis
immediate extent of injury unknown
(electrical current pathway)
deep muscle burn-burgundy color urine
Classification of Burns
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Burn injuries are
described according
to:
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Depth of injury
Extent of body
surface area (BSA)
injured
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Depth
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Superficial Partialthickness
Deep partial-thickness
Full-thickness
BSA
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Rule of nines
Lund & Bowder method
Palm method
Classification of Burns
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First degree (superficial partialthickness)
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eg. Sunburn
involvement: usually epidermis only
symptoms: tingling, hypersthesia (inc.
sensitivity to pain), skin reddened,blanched
with pressure, minimal or no edema
how it heals: some peeling over a week,
no scar
Types of Burns
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Second degree burn (partial-thickness)
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eg. Scalding burns
involvement:epidermis and part of dermis
symptoms: hyperesthesia, sensitivity to
cold, blistered mottled red base, broken
epidermis , weeping surface
how it heals: new epidermis grows in
1-3 weeks
Types of Burns
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Third degree (full thickness)
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eg. Fire burn, prolonged exposure to hot liquid
involvement: epidermis, entire dermis, and
sometimes subcutaneous tissue, muscle, and bone
symptoms: painless, s/s shock, hematuria,
hemolysis of blood likely,skin and fat exposed
edema, skin (dry, pale white, or charred)
how it heals: needs skin grafting unless very small
Burns
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Rules of nine (total equals 100%)
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arms 9 each (4 1/2 front, 4 1/2 back)
legs 18 each (9 front, 9 back)
trunk 36 (front 18 and back 18)
head and neck 9 (41/2 front, 4 1/2 back)
perineum 1
A superficial burn can bring on a severe
systemic reaction when it covers a large
body surface area
Burns
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Suspect inhalation injury if victim has
burns on head, neck, or anterior chest
s/s inhalation injury
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dyspnea, carbonaceous sputum, wheezing.
Hoarseness (caused by laryngeal edema),
altered mentation
Burns
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Pain
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continuous problem with second-degree
burns but not third degree because nerves
have not completely been destroyed as
with third degree
when eschar removed from third degree,
other pain mechanisms become operative
Burns
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Assessing a patient with burns
 ABCs
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history and physical, rules of
nine,pulmonary status,check peripheral
pulses on burned extremities,vital signs,
urine output, labs fluid replacement,
prevention of infection, psychological
needs
temp usually hypothermic
Physiologic Changes con’t
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Pulmonary
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carbon monoxide most common cause of
inhalation injury because it is a byproduct
of the combustion of organic materials
and therefore present in smoke (need
100% O2 due to cell hypoxia
upper airway injury, pulmonary edema, etc
Physiologic Changes in
Burn Injury
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Cardiovascular
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outpouring of catecholamines from SNS
(sympathetic nervous system) with injury
which leads to peripheral blood vessel
constriction and increase pulse rate
vessels become more permeable due to
injury and allow fluid and colloids to leak
into surrounding tissues (third spacing)
Physiologic Changes con’t
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Cardiovascular
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peripheral vascular vasoconstriction further
decreases cardiac output
with third spacing less intravascular fluid
which leads to low blood volume and low
cardiac output which contributes to
inadequate tissue perfusion
Physiologic Changes con’t
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Renal
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decreased renal blood flow which leads to
glomerular damage
GI
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hypovolemia leads to gastric dilatation and
paralytic ileus
Curling’s ulcer-stress ulcer
Physiologic Changes con’t
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Fluid and Electrolytes
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hyponatremia (first week of acute phase)
as water shifts from interstitial to the
vascular space
hyperkalemia (immediate after burn)
results from massive cell destruction
hypokalemia may occur later with fluid
shifts and inadequate potassium intake
Burns
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Pyschosocial
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self-concept
body image
There is a rapid fluid and electrolyte change
taking place
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fluid loss leads to decreased blood volume which
leads to thicker blood and decreased efficiency of
circulation. There is a inc cellular elements of
blood which leads to inc Hct
Burns
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What happens in third spacing
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burns produce a dilatation of capillaries and the
small vessels in the area of the burn leading to
increase capillary permeability. The plasma seeps
out into the surrounding tissues which produce
blisters and edema..
The capillary walls that are damaged permit
plasma proteins to move into interstitial
(extracellular) spaces
Burns
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Third spacing con’t
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the developed capillary permeability allows
plasma proteins to go through the barrier.
There is decreased osmotic pressure in
blood vessels and increased osmotic
pressure in interstitial space and fluid
accumulates at the burn sites in blister
leading to third spacing loss. Fluid shift is
from vascular compartment to third space.
Burns
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Fluid loss with burns great. Fluid loss
by evaporation 20 times greater than
normal. Loss due to evaporation called
white bleeding.
Burns
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First 24-48 hours
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large amounts of Na+ move with fluid from
intravascular (within vessels) to interstitial fluid
(Normally Na+ present approximately in same
proportions both in intravascular and interstitial
areas)
Increase in release of aldosterone and antidiuretic
hormone as a result of general stress response
(this inc amt of Na+ and H2O retained. Pt.
Becomes oliguric.
Burns
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First 24-48 hours con’t
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K+ elevated in blood since tissue destruction and
oliguria (hyperkalemia)
Patients’ feet cold due to inc. BMR (body’s
reaction to try to replace heat lost from
evaporation)
Burns
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48-72 hours
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Na+ shifts back to intravascular space (capillaries
begin to regain their integrity)
Diuresis leads to low K+ (hypokalemia)
RBC loss from a microangiopathic anemia
(severeness depends on extent of burn)
RBC destruction initially caused by heat of the
burn and later by hemolysis of heat damaged cells
(result not only anemia but possible
Burns
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48-72 hours con’t
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kidney damage. Damaged RBC’s release Hgb
which is filtered by kidneys.
Myoglobin is released by damaged muscle tissue.
Both are filtered by kidneys and kidney tubules.
They may get plugged which leads to acute tubule
necrosis.
Diuresis phase lasts 3-5 days after burns.
Vascular leakage recovery complete.
Burns
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Parkland/Baxter Formula
4 ml RL/kg body wt X % TBSA=ml RL for
24 hours
 eg. Pt. wt=75 kg and burned 25%
4/75/25=7500 ml/24 hours
50% 1st 8 hours=3750ml
25% 2nd 8 hours=1875 ml
25% 3rd 8 hours=1875
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Burns
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Parkland/Baxter Formula
eg. Pt. Wt 82kg body wt and burned 58%
4/82/58=19024 ml/24 hours
50% 1st 8 hours=9512 ml
25% 2nd 8 hours=4756 ml
25% 3rd 8 hours=4756 ml
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Usually D5 1/2 NS with KCL when pt in
diuretic phase
Burns
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Goal: perfuse vital organs as fully as
possible without overload
Nutrition
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greater protein requirement due to
negative nitrogen balance
2 times calories
2 times protein
Burns
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Full thickness burns result in death of
skin and subcutaneous tissue
Compartment syndrome
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pain, pallor, decreased capillary refill,
decreased peripheral pulses, decreased
sensation, impaired movement (Poor
peripheral tissue perfusion)
Burns
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IV best route for pain relief (peripheral
vasoconstriction limits absorption of drug
given IM or SQ route)
Open wound-use bed cradle
Circumferential burns usually involve an
extremity
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edema may shut off circulation and an
escharotomy or fasciotomy may be necessary to
Burns
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relieve the constriction and return normal
blood flow
Infection remains a threat until all
second degree burns have healed and
third degree burns have been closed by
grafting (second degree could become
third degree if infection goes deeper)
Burns (Grafts)
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Graft-a piece of tissue separated
completely from its normal and original
position and transferred by one or more
stages to correct a distant defect
Free graft: completely separated from
their donor site (blood supply
completely interrupted)
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survival of graft depends on vascular bed
from recipient site
Burns (Grafts)
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Free flap graft (free-tissue transfer)
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cover a variety of wounds, cover exposed
tendons, bones, major blood vessels.
Completely severed from the body and
transferred to another site
Pedicle graft
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a segment of tissue that has been left
attached at one end (pedicle) while other
end has been
Burns (grafts)
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Pedicle graft (con’t)
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moved to recipient area
used when thick pieces of skin that could
not survive an interruption of blood supply
are transplanted
usually about 3-4 weeks for sufficient blood
supply to be established
Burns (grafts)
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Split thickness graft
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varies from thin to nearly full thickness of
skin
Full thickness graft
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composed of a full depth of skin(epidermis
and dermis)
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gives best cosmetic appearance so used for face,
neck, hands
Burns (grafts)
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Pre-op skin grafts
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hgb and clotting time noted since their
levels can affect healing process
tissues need to be free from infection
pt in optimum physical condition
pt teaching
Burns (grafts)
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Necessary for a graft to take
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recipient bed must be adequately
vascularized
graft must be in complete contact with the
bed
immobilization must be assured
area must be free from infection
Burns (grafts)
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Types of grafts
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allografts (cadaver) temporary
xenografts animal (pigskin)
autografts (self)
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split thickness-epidermis 8-12 thousandth of an
inch thick
full thickness-full depth of skin
sheet grafts are put on joint areas (areas that
stress) and secured with staples or sutures
Bone (grafts)
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Autografts (con’t)
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mesh grafts-donor skin expand to cover large area
expands graft 1 1/2 -9 times its original surface
culture epithelial growth medium-grows 50-70 times
initial sample (donor site heals in 1-2 weeks)
Debridement
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Surgical (excise)
Mechanical or enzymatic (commercial preparation)
natural (body and bacterial enzymes dissolve
eschar
“Cultured Skin” ref UCSD 2001
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Growing cultured skin from samples
taken from patients
Copyrighted materials have been deleted from this slide
Burns (medications)
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Silver nitrate 0.5% (rarely used)
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con’t wet dressing effectively prevents cross
infection
>0.5% injures the tissue and not effective<0.5%
danger of electrolyte imbalance (especially Na and
K) since the electrolytes are withdrawn from the
body fluids and also from the dressing.
Turns black in sunlight and stains clothes and
hands black
Burns (medications)
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Silvadene
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wide-spectrum antimicrobial that is
nonstaining and relatively painless
no systemic metabolic abnormalities
however is contraindicated in pregnant
women near term and premature infants
does not penetrate the eschar as well as
sulfamylon
Burns (medications)
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Sulfamyalon acetate
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interferes with bacterial cellular metabolism
diffuses rapidly through burned skin and eschar
used for gram-negative organism
burning sensation after applied topically
may cause metabolic acidosis and is a carbonic
andryrase inhibitor
may cause a rash
Burns (medications)
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Furacin-nitrofurazone (gauze or cream)
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a synthetic broad-spectrum antibacterial
inhibits enzymes required for carbohydrate
metabolism in bacteria
Xeroform-a fine mesh gauze with
antimicrobial action
Case Study
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A 42-year old patient is brought to the ED
after being rescued from a house fire, where
firefigthers found her unconscious in a
bedroom closet. She has sustained burns to
her right arm, right chest, and both lower
extremities. On admission, she arouses to
painful stimuli only. Her VS are BP 140/74,
HR 112, RR 30/min and labored. She is
afebrile. She has facial edema and visible
soot in the oral pharynx and nares. Crackles
are heard on auscultation, with decreased
resp. excursion. Stridor is audible. The
affected skin areas are white and inelastic,
surrounded by heperemic, moist-looking
tissue. She has pain on pinprick in the
Case Study cont.
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Lab results reveal a mildly elevated
glucose level, elevated Hg and Hct.
Urine specific gravity of 1.030. Low
PaO2 and an elevated
carboxyhemoglobin level, at 37%.
What is your treatment plan? Nursing
Diagnosis?
What to do about the
pain during PT
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U of W Harborview Burn Center is using VR
(virtual reality)
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a non-pharmacological analgesic (distraction)
used in addition to traditional levels of opioids
during wound care and physical therapy
found VR worked much better than Nintendo64
pilot study showed dramatic drops in pain during
treatments
Why VR works for pain
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Pain perception is largely psychological
pain requires conscious attention
VR draws pt into another world (this drains a
lot of attentional resources leaving less
attention available to process pain signals)
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in snow world for example the patient fly through
icy canyons etc (pts experience burning sensation
during wound care so this game is designed to put
out the fire)
NY Hospital-Cornell Medical Center
Burn Center (1998 data)
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5,000 outpatients seen/yr (>1,000
children)
1,300 inpatients seen/yr
team approach(surgeons,nurses,
therapists, nutritionists, social workers)
mission
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develop an increasing effective teaching
and
NY Hospital-Cornell Medical Center
Burn Center (1998 data)
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NY’s mission con’t
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public awareness methods
having the highest standards of clinical and
therapeutic excellence
continued expansion of research in all phases
of thermal injury
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an optimum environment in which patients may
recover with the help and expertise of NY’s
hospital-wide administrative, medical and
paramedical specialists
UW Burn Center
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Approach to deep burn wounds
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remove wound surgically within 1st post burn
week
immediate grafts after wound removed to
provide best functional and cosmetic results
Treatment for (TEN) Toxic Epidermal
Necrolysis disease resulting from a
drug reaction whereby the body’s entire
epidermis sloughs
UW Burn Center
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treatment of TEN con’
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use of pig skin and immaculate supportive
care
mortality has been reduced from 70% to
15%
hospital stay has been reduced from
months to average of 3 weeks
UCSD Burn Center
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450 admits/year
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Brave Heart Kids Program
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Activities
Work on promoting self-esteem
Baltimore Regional Burn Center
(John Hopkins)
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1800/year outpatients
Michael D. Hendrix Research Center
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Died from burn and ARDS in 1995 Delta plane crash in
Georgia
Family donated large amount of money to research
Research
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Infection prevention
Wound healing
New ways to culture skin
Treatment of ARDS
Immunologic response to burns
Prevention of Burn
Injuries
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Proper education and supervision
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childproof items in electrical sockets
keep dangerous items (matches) out of
reach
Safety measures for the elderly
teach small children 911
smoke detectors in house
STOP, DROP, AND ROLL