BURN LECTURE
M. Catherine Hough RN, Ph.D
University of North Florida
College of Health
Department of Nursing
REVIEW OF SKIN FUNCTIONS
• Functions of the Skin
– Protection
– Heat Regulation
– Sensory perception
– Excretion
– Vitamin D Production
– Expression
Cross section of Skin
CLASSIFIATION OF BURNS
Rx of burn is R/T the severity of the burn severity is determined by:
• depth of the burn
• extent o the burn (% of total body surface
area (TBSA)
• location of the burn
• patients risk factors
CLASSIFIATION OF BURNS...
• Partial Thickness - characterized by varying depth from
epidermis (outer layer of skin) to the dermis (middle
layer of the skin)
–
–
Superficial - includes only the epidermis (First Degree)
Deep - involves entire epidermis and part of the dermis (Second
Degree)
• Full Thickness - includes destruction of the epidermis
and
– the entire dermis as well as possible damage to the SQ, muscle and bone
(Third and Fourth Degree)
Classification…
• Clinical Appearance – Superficial – 1st degree
– Erythema, blanching on pressure, pain & mild swelling, no vesicles or
blisters (although after 24 hours the skin may blister and peel
• Clinical Appearance – Deep – 2nd degree
– Fluid-filled vesicles that are red, shiny, wet (if vesicles have ruptured),
severe pain caused by nerve injury, mid-to-moderate edema
• Clinical Appearance – Full-thickness – 3rd degree
– Dry, waxy, leathery, or hard skin, visible thrombosed vessels,
insensitivity to pain and pressure of nerve distruction, possible
involvement of muscles, bone and tendons.
MINOR BURNS
• < 10% of BSA of Partial Thickness Burn
• < 2% of BSA of a Full Thickness Burn
MODERATE BURNS
• 15-25 % of BSA of Partial Thickness Burn
• <10% of BSA of a Full Thickness Burn
MAJOR BURNS
• > 25% of BSA of a partial thickness
• > 10% of BSA of a full thickness
• Age > 65 or < 2
Lund-Bowder Chart
Rule of Nines
Types of Burns
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•
•
•
•
Thermal Burns
Chemical
Electrical
Inhalation
Radiation
PERIODS OF TREATMENT
• Emergent
• Acute
• Rehabilitation
STAGES OF BURNS
Hypovolemic Stage - begins @ onset of burn and lasts
for the first 48 hours
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–
–
–
–
–
Rapid fluid shifts - from the vascular compartments into the
interstitial spaces
Capillary permeability with burns increases with vasodilation
fluid loss deep in wounds (initially sodium and H2O then
protein loss) Hemoconcentration - Hct increases
Low blood volume, oliguria
Hyponatremia - loss of sodium and fluid
Hperkalemia - damaged cells release K+, oliguria
Metabolic acidosis
STAGES OF BURNS ...
Diuretic Stage - begins @ 48 - 72 hours after burn injury
•
•
•
•
Capillary membrane integrity returns
Edema fluid shifts back into vessels - blood volume increases
Increase in renal blood flow - result in diuresis (unless renal damage)
Hemodilution - low Hct, decreased potassium as it moves back into
the cell or is excreted in urine with the diuresis
• Fluid overload can occur due to increased intravascular volume
• Metabolic acidosis - HCO3 loss in urine, increase in fat metabolism
I. EMERGENT PERIOD
• First 24 - 48 hours
• Maintain airway, fluids, analgesia, temperature,
wound
• Assessment:
– Objective: how burn occurred, when, duration,
type of agent
– Subjective: previous medical problems, size
and
depth of burn, age, body part involved, mechanism
of injury
EMERGENT PERIOD ...
Factors determining severity of burns:
• size of burn
• depth of burn
• age
• body part effected
• mechanism of injury
• history of cardiac, pulmonary, renal, or hepatic diseases
• injuries sustained @ time of burns
• duration of contact with burning agent
• size & depth of burn
• “Rule of Nines”
NURSING DIAGNOSIS
•
•
•
•
•
•
•
Airway clearance
Ineffective fluid volume (deficit or excess)
Hypothermia
High risk for pain (with partial thickness burns)
Skin integrity, impaired
Anxiety
Knowledge deficit
INTERVENTIONS
• Maintain patent airway - watch for laryngeal edema
– Escharotomy may be needed
– 100% FiO2 mask
– intubation for inhalation is often required
– may inquire emergent tracheostomy
– may require ventilatory assistance
Tracheostomy to Prevent Airway Obstruction
Interventions - Fluid Therapy
• Start with two large bore IV’s
– suture in place
• Jugular or subclavian line
– unburned tissue
– burned tissue
• Cutdown final measure
Interventions - Fluid Therapy...
Fluid Replacement
• Crystalloid Solutions
• NS
• LR
• D5%/NS
• Collid Solutions
• Albumin
• Dextran
Formulas to Calculate Fluid
Parkland Crystalloids
Brooke
Colloids
D5% in Water
LR: 4ml/kg/% 20-60% of
burn; ½ given calculated
1st 8hrs; ¼
plasma volume
given each next
8 hrs
Amount to
replace estimated
evaporative
losses
Crystalloids
Colloids
D5% in Water
LR: 2ml/kg/%
burn; ½ given
1st 8 hrs; ½
given during
next 16 hrs
0.3 to 0.5
ml/kg/% burn
Amount to
replace estimated
evaporative
losses
SIGNS OF ADEQUATE FLUID RESUSCITATION
•
•
•
•
•
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Clear sensorium
Pulse < 100 bpm
U/O 30-50 cc/hour
SBP > 90-100 mm Hg
Blood pH within normal range 7.35 - 7.45
Respirations 16-20
II. ACUTE PERIOD
• End of emergent period until burns heal
• Focus shifts to care of wounds and prevention of
complications
• Actual range of phase depends on degree and extent
of burn
• Assessment:
Subjective - pain and anxiety
Objective - complete assessment every 8 hours,
dietary intake, motor ability, I&O, weight
NURSING DIAGNOSIS
•
•
•
•
•
•
•
Skin integrity, impaired
Infection, high risk for
altered nutrition
Pain, acute (with partial thickness burns)
Fluid Volume Deficit
Anxiety
Hypothermia
Pain Control
• Morphine Sulfate 5-10 mg IV every 1-3
hours
• Combination therapy for painful
procedures:
– Diprivan
– Valium
– Haldol
– Versed
–…
NURSING DIAGNOSIS ...
•
•
•
•
Impaired skin integrity R/T thermal injury
Coping, ineffective individual/family
Body Image Disturbance
Altered nutrition: less than body requirements R/T increased
catabolism and metabolism
• Mobility, Impaired R/T pain, impaired joint movement, scar
formation
• Self-care Deficit
• High risk for infection R/T denuded skin, presence of pathogenic
organism, & altered immune response
INTERVENTIONS
• Releiving anxiety, denial, regression, anger,
depression
• Wounds - refer to wound care
• Nutrition (Nutritional assessment, pre albumin
levels, large protein requirement, carbohydrates
and fats for energy, mega vitamins, TPN, enteral tube
feedings any follow (~5,000 kcal/day)
• Pain - around the clock management
• Prevention of infection - refer to wound care
ORGANISMS:
• Staphylococcus aureus
• Pseudomonas
Infection is usually the cause of any
deterioration
SIGNS OF SEPSIS:
• Change in sensorium
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•
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•
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Fever
Tachyapnea
Paralytic ileus
Abdominal distention
Oliguria
WAYS TO PREVENT INFECTIONS:
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•
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Gowns, masks, gloves
Sterile linen
Person with URI should not come in
contact with patient
WOUND CARE
Goals:
•
•
•
•
clean & debride the area of necrotic tissue
minimize further destruction of viable skin
promote wound re-epithelialization
promote patient comfort
WOUND CARE:
• Burn wound is unique
• Burn wound sepsis
– gram +
– gram (pseudomonas)
– fungal (candida albicans)
WOUND CARE...
• Nutrition
– collagen primary structure in healing by secondary
intention
– need increased protein
– may need up to double the normal calorie requirements
• Inadequate blood supply
• Burn wound disorders
– scarring, contractures, keloids, failure to heal
WOUND CARE ...
• GOALS:
• close wound ASAP
• prevent infection
• reduce scarring and contractures
• provide for comfort
WOUND CARE ...
• Wound cleaning:
• at bed side hyrotherapy tanks, tubbing,
tables
• Debridement:
• mechanical, surgical, enzymatic
• Topical antibacterial therapy • sulfonamide
spray
WOUND CARE ...
Open Technique or Exposed - more often used with burns
effecting the:
–
–
–
–
face
neck
perineum
broad areas of the trunk
• Partial thickness - exudate dries in 48 to 72 hours forming a hard crust
that protects the wound.
• Full thickness - dead skin is dehydrated and converted to black leathery
escar in 48 to 72 hours. Loose escare is gradually removed with
hydrotherapy &/or debridement
WOUND CARE ...
• Closed Technique
• Wound is washed and sterile dressings
changed (may be q shift, daily)
• Dressing consists of gauze &/or ace wraps
impregnated with topical ointments
WOUND CARE ...
• Semi-Open
consists of covering the wound with topical
antimicrobial agents and gauze
ADVANTAGE:
– speeds debridement
– develops granulation tissues faster
– makes skin grafting possible sooner
WOUND CARE ...
Biological Dressings:
• Homeografts - same species (cadaver skin)
• temporary (3 days to 2 weeks) then body rejects
• Heterografts - another species (pig skin)
• temporary coverage (3days to 2 weeks)
• Autografts - patients own skin
• can be temporary or permanent coverage
• Cultured Epithelial Autographs
• permanent
Wound Care - GRAFTING
• Indications for Grafting:
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–
–
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full thickness burns
priority areas (face)
wound bed pink firm, free of exudate
bacterial count < 100,000/gram of tissue
• Care of Grafts - assess, assess, assess
Skin Grafting
Cultured Epithelial Autografts
III. REHABILITATION PERIOD
• Care of healing skin - wash daily, cover with cocoa butter or
other barrier
• Pressure garments, ace wraps - helps prevent scaring and
contractures
• Promote mobility - positioning, exercise, splinting, ADL
• Rehab period can last for months to even years
Primary Prevention Strategies
Safety Education:
• Wear sun-screen
• Fireproof your home
– Install smoke alarms – check routinely
– Plan emergency exits
– Have regular fire drills
• Check wiring in home; safety caps on unused outlets if you
have children
• Teach children safety rules for matches, fires, electrical outlets,
cords, etc.