OSTE
NSG 255
Kim Nelson, Nikki Moor, Jen Moser,
Brittany Orr, Steph Nadeau
“Each year, more than 2 million Americans suffer burn
injuries. Only about 1% of these people require
hospitalization for severe burns. But for these
unfortunate people, the nursing care provided in the first
few hours after injury is crucial. Your interventions can
help determine a patient's ability to survive a serious burn
and make a functional recovery.”
(Wiebelhaus & Hansen, 2001)
Case Study
Patient with Burns
Patient Profile:
Sylvia, a 44-year-old woman from a nearby farm,
was brought to the emergency department with
extensive full-thickness burns to her upper body.
Her stove exploded while she was manually
lighting the oven with firewood and kerosene. Her
10 children remain at home and her husband is in
the field, unable to be reached.
Classifications of Burns
Superficial Burns
• “1st Degree”
• Only epidermal damage
• Dry and painful to touch
• Presented as red or pink
• Does not blister, but
swelling can occur
• No residual scarring
• Causes: Sunburn,
ultraviolet light, flame
exposure
• Heals 3-6 days
(Mendez-Eastman, 2005)
Partial Thickness Burn
• “2nd Degree”
• Superficial burn, moist and
blistered
• Deeper burns are white and dry
and blanche with pressure and
have reduced pain
• Treatment varies with degrees
of involvement
• Intense pain and edema is
common
• Painful to air and temperature
• Residual scarring can vary
depending on depth on injury
(pigment change to risk of
contracture)
• Causes: Scalds – flame, oil,
grease & Flame exposure
• Heals in 7- 20+ days
Full Thickness Burn
• “3rd Degree”
• Completely destroys
epidermis and dermis
• Skin is tough, waxy,
brown, leathery and firm,
numb to touch
• Edema may be massive
• Residual scarring is
severe – grafting usually
required
• Burn never heals to
original state
(Mendez-Eastman, 2005)
Full thickness and Injury
• “4th Degree”
• most severe of them all
• Involves subcutaneous
fat, fascia, muscle or
bone
• Burn frequently has a
charred appearance
• Reconstructive surgery is
indicated
• Severe disfigurement is
common
• Causes: Scalds from
flame, steam, oil, grease,
chemical, 7 high voltage
electricity
(Mendez-Eastman, 2005)
Rule of Nines
• Quick way to calculate the extent of burns
• The system assigns percentages in multiples of nine to major body
surfaces
(Mendez-Eastman, 2005)
Types of Burns
• Thermal burn: Burning of tissue via direct contact with a
heat source
• Hot water/steam
• Flame
• Chemical Burn: tissue destruction via direct contact with
chemical
•
•
•
•
Gasoline
Desiccants: sulfuric acid
Reducing agent: Hydrochloric acid
Vesicants: mustard gas
• Electrical Burn: direct contact with electrical current
• Entry and exit wounds
(Day, Paul, Williams, Smeltzer, Bare, 2007)
Zones of Burn Injury
• Zone of Coagulation: The inner zone - where cellular death
occurs. Treatment will not influence the tissue as it is already
dead. This sustains the most damage.
• Zone of Stasis: The middle area - has a compromised blood
supply, inflammation, and tissue injury. Given the appropriate
assessment and treatment, tissue can survive.
• Zone of Hyperemia: The outer zone - sustains the least
damage and is most likely to heal regardless of treatment.
(Mendez-Eastman, 2005)
Associated Injuries to
all Burns
•
Smoke inhalation
• Hoarseness, cough, singed nasal hairs,
oral burns, wheezing
• Carbon monoxide poisoning
• Fractures
• Trauma
Pre-Hospital Priorities
• First priority is to prevent injury to the rescuer
• Call 911
• Extinguish the flames: “stop-drop-roll”
• Cool the burn with cold water. DO NOT apply a cold soak for no
longer than several minutes. DO NOT apply ice directly. These all
halt the burning process
• Assess ABC’s (Airway, breathing, circulation)
• Remove restrictive objects: If possible remove clothing/jewelry
immediately. Adherent clothing may be left in place once cooled.
• Cover the wound: Burns should be covered as quickly as
possible to minimize bacterial contamination and decrease pain by
preventing air from coming in contact with the injured surface. DO
NOT use ointments or other medications on wound.
Full Thickness Burns
•Circumferential burns to the extremities:
•Risk of compression of structures underneath the
wound – edema
•A combination of increased extravascular fluid in the
wound, and underlying tissues can cause lack of
elasticity in the wound
•Blood flow is then compromised to viable tissue
•Interventions:
•All extremities should be elevated to minimize
edema formation
•Extremities should be elevated hourly for signs of
vascular compromise
(Norton, Randall-Bollinger, 2001)
Full thickness burn to face – patient intubated
Airway Management
• First assess breathing & ensure a patent airway by:
• Proper positioning
• Removal of any obstructions
• Artificial airway if needed – endotrcheal tube (by
qualified personnel only)
• Administer oxygen therapy – 100% humidified
• After securing airway, turn attention to patients breathing
• Assess/Auscultate for respiratory rate, pattern, depth, and
breath sounds
(Cancio, 2005)
Circulation
• Hypovolemic shock – serious burn complication resulting
from:
• Changes in capillary & interstitial hydrostatic
pressures
• Causes fluid to leave the intravascular space and
migrate to the interstitial space
• Results in rapid edema formation and a loss of
circulating vascular volume
• Fluid resuscitation is needed to maintain cardiac output
and organ perfusion
(Osborn, 2003)
Fluid Resuscitation
• A critical part of treatment during emergency stage due
to loss of volume from the vascular space after the injury
• During this period it is critical to administer enough fluid
to maintain organ perfusion and cardiac output but to not
overload the patient
• Guidelines:
• Consider the size of the wound
• Patients weight
• Medical history
• Indicators of adequate fluid volume replacement:
•
•
•
•
Heart rate of less than 120 bpm
Systolic blood pressure of >100 mmHg
Strong peripheral pulses
Urine output of approx, 0.5ml/kg/hr
(Osborn, 2003)
• Effects on electrolytes:
• Hyponatremia (sodium depletion in blood) – water
shifts from interstitial to the vascualr space
• Hyperkalemia (excessive potassium in blood) – results
from massive cell destruction
• Hypokalemia (potassium depletion) – may occur later
with fluid shifts and inadequate potassium replacement
• Not unusual to administer 400ml – 800ml/ hour for a
major burn patient
• A variety of fluids have been recommended for use,
such as colloids (whole blood, plasma, and plasma
expanders)
• The most common fluid replacement formula is
Ringers Lactate (contains small amounts of potassium
chloride, calcium chloride, sodium lactate & large
amounts of sodium chloride in water. This solution is an
excellent extracellular replacement.
• Should titrate fluid resuscitation to urine output on a hr
to hr bases
(Osborn, 2003)
Inhalation Injury
Inhalation can be classified as 4 types of injuries:
1) Asphyxiation – injury that occurs as oxygen transport
is interfered with or obstructed
2) Direct topical injury – results from direct contact with
heat or chemical irritants
3) Systemic destruction – occurs when toxins cross
alveolar capillary membranes, and damage to other
organs
4) Stress & Inflammatory response – the body’s own
defense mechanism, which constricts the airway
(Hansen, Weibelhaus & Hill, 2001)
Inhalation Injury
Signs:
•Singed nasal hairs, eyebrows, eyelashes
• Soot on face, mouth, and nares
• Depressed/changed mental status
• Wheezing or rails on auscultation
Interventions:
•Airway management
•100% humidified oxygen
•Edema control
(Hansen, Weibelhaus & Hill (2001)
Pain
• Often painless because the nerves are destroyed
• May feel pain on other burn areas that are less damaged
•Interventions:
• Administer oxygen or increase fluid administration (narcotics
& analgesics may mask signs of hypoxemia or hypovolemia)
• Intravenous narcotic analgesics and sedatives may be
administered in small, frequent doses
•Medications:
• Antibiotics: help prevent an infection
• Analgesics - given once vital signs have stabilized
• Tetanus shot: given if you had not had one in the past 5-10
yrs
(Day, Paul, Williams, Smeltzer, Bare, 2007)
Hypothermia
Risk for hypothermia R/T skin microcirculation and open
wounds:
Interventions:
•Provide a warm environment (heat shield, space
blanket, heat lights, or blankets)
•Work quickly when wounds are exposed
•Assess core body temperature frequently
(Day, Paul, Williams, Smeltzer, Bare, 2007)
Support
Patients psychological status:
•Assess patients emotional state and allow them to verbalize
thoughts and feelings
•Provide recommendations to support psychological recovery –
counselors, psychologists, social workers
Family’s psychological status:
•Provide psychological assessment, support, therapy and
education
•Provide resources and references to assist the patients
psychological recovery
“This is an on-going process that begins when the patient is
able to communicate and extends well beyond their
discharge from the hospital”
(Klein, 2009)
References
Cancio. L. (2005). Current concepts in the pathophysiology and treatment of inhalation
injury. Trauma, 7 (1), 19-35. Retrieved from CINAHL Plus Full Text database.
Day, R.A., Paul, P., Williams, B., Smeltzer, S.C., & Bare. B. (2008). Brunner & Suddarth’s textbook of
medical-surgical nursing (1st ed.). Toronto: Lippincott Williams & Wilkins.
Klein, J. (2009). The Psychiatric Nurse in the Burn Unit. Perspectives in Psychiatric Care, 45(1), 7174. Retrieved from ProQuest Nursing & Allied Heath Source database.
Norton, J.A., Randall-Bollinger, R. (2001). Surgery: Basic Science and Clinical Evidence. New York:
Springer.
Osborn, K. (2003). Nursing burn injuries. Nursing Management 34(5), 49-56. Retreived from
ABI/INFORM Global database.
Weibelhaus, P., Hansen, S., & Hill, H. (2001). Helping patients survive inhalation injuries. RN, 64(10),
28-32. Retrieved from CINAHL Plus with Full Text database.
Wiebelhaus, P, Hansen, L. (2001). Managing burn emergencies. Dimensions of Critical Care Nursing,
20(4), 2-8. Retrieved from CINAHL Plus Full Text database.
Can you
name and
describe
these burns?