Burn Injury Care and 7 Phases of Burn Management

• The main goals for major burn injury care involve restoring form, function, and feeling through 7 phases of burn management.

Phases of Burn Management:

• Rescue: Remove the individual from the source of injury and provide first aid.
• Resuscitate: Immediate support must be provided for any failing organ system.
• Retrieve: Patients with serious burns may need transfer to a specialist burns unit after initial evacuation to an accident and ER for further care.
• Resurface: Repair skin and tissues that have been damaged by the burn.
• Rehabilitative: Begins on the day a patient enters the hospital and continues for years after being discharged.
• Reconstruct: Address scarring from burns that leads to functional impairment.
• Review: Regular review is required for burn patients, especially children, for many years to identify problems early and provide solutions.

Body fluids and Electrolytes:

• Body fluids consist of a solution of solvent and solutes.
• Our body is made up of fluids and solids.
• Fluids are necessary for chemical reactions and transport.
• Water makes up about 50-60% of body weight.
• A 70 kg adult male has 40-42 liters of water (60% X 70).
• Note that 1 kg of body weight is equal to 1 liter of water.
• Intracellular and extracellular are the body's two major compartments.
• Intracellular fluid is found inside the cell surrounded by a membrane.
• Highest percentage of water in adults is in the intracellular compartment.
• Extracellular fluid is found outside the cells.
• Interstitial fluid is a type of extracellular fluid found between the cells.
• Intravascular fluid is a type of extracellular fluid found inside the blood vessels and lymphatic vessels.
• Transcellular fluid is a type of extracellular fluid that is found inside body cavities like the pleura, peritoneum, and CSF.

Fluid Input Sources:

• Exogenous sources include fluid intake like water from foodstuffs, IVF, medications, and blood products.
• Endogenous sources include byproducts of metabolism and secretions.

Fluid Dynamics : Movement of Fluids (Solutes and Solvents)

• Osmosis involves the force that draws water/solvent from a less concentrated solution into a more concentrated solution through a semipermeable membrane.
• Osmotic pressure draws water inside the vessel that is more concentrated.
• Oncotic pressure is a type of osmotic pressure exerted by proteins in plasma.
• Diffusion refers to the movement of solutes or particles in a solution from a higher concentration to a lower concentration.
• If a sugar is placed in plain water, the glucose molecules will dissolve and distribute in the solution.
• Filtration involves the movement of both solute and solvent by hydrostatic pressure from an area of higher pressure to an area of lower pressure.
• Urine formation is an example of this process.
• Increased hydrostatic pressure is one mechanism producing edema.
• Active transport involves movement of solutes across a membrane from a lower to a higher concentration, utilizing energy.
• The sodium-potassium pump is a primarily active transport process.

Fluid Loss Routes:

• Urine and Fecal losses
• Sweat and Vomitus
• Insensible losses through the skin and lungs as water vapor.

Tonicity Defined:

• Tonicity refers to the concentration of solutes in a solution.
• A solution with a high solute concentration is hypertonic, causing cells to shrink as fluid exits.
• A solution with a low solute concentration is hypotonic, causing cells to swell as fluid enters.
• A solution with the same tonicity as body fluid/plasma is isotonic, resulting in equal fluid tonicity.

Regulation of Body Fluid Balance:

• The kidney regulates fluid output by urine formation, sodium and water balance, also it releases renin.
• The gastrointestinal tract digests food and absorbs water, excreting only about 200 ml of water in fecal material daily.
• Endocrine regulation regulates fluid intake via the thirst mechanism.
• ADH increases water reabsorption, aldosterone increases sodium retention, and ANP promotes sodium excretion and inhibits thirst.

Lab Tests Indicating Fluid Balance:

• The normal range for urine specific gravity is 1.010-1.020.
• Increased fluid volume in the blood leads to more dilute urine, decreasing specific gravity (below 1.010).
• Decreased fluid volume in the blood (dehydration) leads to more concentrated urine, increasing specific gravity (above 1.020).
• Hematocrit indirectly indicates fluid volume, measuring the number of blood cells per volume of blood.
• Increased fluid in the blood dilutes blood cells and decreases the hematocrit level.
• Normal hematocrit ranges for men is 39-49%, and for women is 35-45%.
• Too little fluid in the blood causes hemoconcentration and a high hematocrit level.
• Serum osmolality measures the concentration of particles dissolved in blood.
• Sodium contributes to osmolality in extracellular fluid.
• Serum osmolality generally ranges from 285 to 295 mOsm/kg of H2O or mmol/kg (SI units).
• Decreased fluid volume, as in dehydration, increases serum osmolality, while fluid overload decreases it.
• Urine osmolality measures the concentration of particles in urine, showing how well kidneys clear waste, electrolytes and concentrate urine.
• The normal range for urine osmolality in a random sample is 50-1200 mOsm/kg H2O or mmol/kg.

Fluid Volume Deficit (Hypovolemia):

• Hypovolemia occurs when loss of ECF volume exceeds the intake of fluid ratio of serum electrolytes to water remains the same.

Causes Fluid Volume Deficit:

• Vomiting and Diarrhea
• GI suctioning, Sweating
• Third-space fluid shifts- movement of fluid from the vascular system to other body spaces
• Ascites with liver dysfunction
• Diabetes insipidus
• Adrenal insufficiency
• Osmotic diuresis
• Hemorrhage

Clinical Manifestations of Fluid Volume Deficit:

• Acute weight loss, decreased skin turgor and Oliguria
• Concentrated urine, Orthostatic hypotension (due to volume depletion)
• Weak, rapid heart rate
• Flattened neck veins
• Increased temperature
• Thirst
• Decreased or delayed capillary refill
• Decreased central venous pressure
• Cool, clammy, pale skin (related to peripheral vasoconstriction)
• Anorexia and Nausea
• Lassitude
• Muscle weakness
• Cramps

Diagnostic Findings of Fluid Volume Deficit:

• Elevated BUN out of proportion to serum creatinine
• Urine specific gravity is increased.
• Decreased urinary sodium and chloride.
• Urine osmolality can be greater than 450 mOsm/kg.

Nursing Management of Fluid Volume Deficit:

• Fluid replacement. PLR (Plasma-Lyte R) or PNSS (Physiologic Normal Saline Solution)
• Solutions used to treat the hypotensive patient because they expand plasma volume
• Monitor intake and output.
• Observe for a weak, rapid pulse and orthostatic hypotension.

Fluid Volume Excess (Hypervolemia)

• Refers to an isotonic expansion of the ECF caused by the abnormal retention of water and sodium in approximately the same proportions in which they normally exist in the ECF.

Causes of Fluid Volume Excess:

• Renal failure
• Heart failure
• Liver Cirrhosis

Clinical Manifestations of Fluid Volume Excess:

• Edema
• Distended neck veins and Crackles (abnormal lung sounds)
• Tachycardia
• Increased blood pressure, pulse pressure, and central venous pressure
• Increased weight
• Increased urine output
• Shortness of breath and wheezing.

Diagnostic Findings of Fluid Volume Excess:

• BUN (blood urea nitrogen) and hematocrit are decreased because of plasma dilution.
• The urine sodium level is increased if the kidneys attempt to excrete excess volume.
• Chest x-ray may reveal pulmonary congestion.

Nursing Management of Fluid Volume Excess:

• Discontinuing the infusion may be needed.
• Diuretics are prescribed to reduce edema by inhibiting the reabsorption of sodium and water by the kidneys.
• Hemodialysis/peritoneal dialysis removes nitrogenous wastes, controls potassium/acid-base balance, and removes sodium and fluid.
• Implement dietary restriction of sodium.
• Low-sodium diets range from mild restriction to as little as 250 mg of sodium per day
• Weigh Daily

Electrolytes:

• Electrolytes are charged ions capable of conducting electricity and are solutes in all compartments.
• Anions are negatively charged ions: Bicarbonate, chloride, and PO4-.
• Cations are positively charged ions: Sodium, Potassium, magnesium, and calcium.
• Helpful mnemonics include: PI-SO
  • Potassium is inside
  • Phosphate is inside
  • Sodium is outside
  • Chloride is outside

Regulation of Electrolyte Balance

• Renal regulation occurs via glomerular filtration, tubular reabsorption, and secretion.
• Endocrine regulation involves hormones that play a role in electrolyte regulation.
• Aldosterone promotes Sodium retention and Potassium excretion.
• ANP promotes Sodium excretion.
• Parathormone promotes Calcium retention and Phosphate excretion.
• Calcitonin promotes Calcium excretion and Phosphate excretion.

Sodium

• The Major Extracellular Cation
• Normal range: 135-145 mEq/L.
• Contributes to plasma osmolarity.

Sodium functions:

• Participates in the Na-K pump.
• Assists in maintaining blood volume.
• Assists in nerve transmission and muscle contraction.
• Aldosterone - increases sodium retention
• ANP increases sodium excretion

Hyponatremia

• Less than 135 mEq/L level
• Possible causes: Prolonged diuretic therapy, Excessive burns/sweating, SIADH, and Plain water consumption.
• Signs and symptoms : Nausea, Vomiting and Seizures.

Hypernatremia

• More than 145 mEq/L level
• Possible Causes: Sodium intake, IVF, water loss in excess of water, and Diarrhea.
• Signs and Symptoms include a dry, sticky tongue and thirst.

Calcium

• The majority of calcium is in the bones and teeth.
• Normal serum range: 8.6-10 mg/dL.

Calcium Functions:

• Formation and mineralization of bones/teeth.
• Muscular contraction and relaxation.
• Cardiac function.
• Blood clotting.
• Enzyme activation

Regulation of Calcium:

• GIT- absorbs Ca+ in the intestine with the help of Vitamin D.
• Kidney- Ca+ is filtered in the glomerulus and reabsorbed in the tubules
• PTH- increases Ca+ by bone resorption, Ca+ retention and activation of Vitamin D.
• Calcitonin- released when Ca+ is high, it decreases Ca+ by excretion in the kidney.

Hypocalcemia

• Less than 8.6 mg/dL Level.
• Decreased parathyroid gland function, decreased dietary intake of calcium, decreased levels of vitamin D.
• Magnesium deficiency.
• Elevated phosphorus
• Acute inflammation of the pancreas
• Chronic renal failure
• Calcium ions becoming bound to protein (alkalosis)
• Bone disease, malnutrition & alcoholism
• Nervousness, excitability, cramps, Trousseau's sign (carpopedal spasm)
• Chvostek's sign, laryngospasm & tetany.
• Prolonged ST interval, prolonged QT interval on ECG.

Hypercalcemia

• More than 10 mg/dL Level.
• Hyperthyroidism, Bone breakage with inactivity, Sarcoidosis, Tuberculosis
• Vitamin D excess & Kidney transplant.
• Anorexia, Nausea, Vomiting, Muscle weakness
• Somnolence, Coma
• Shortened ST segment, widened T wave on ECG.

Potassium

• Major Intracellular Cation
• Normal range is 3.5-5.0 mEq/L
• Major electrolyte maintaining ICVF balance.

Potassium Function:

• Maintains ICF Osmolality
• Nerve conduction and muscle contraction
• Metabolism of carbohydrates, fats and proteins.
• Aldosterone promotes renal excretion of K+.
• Acidosis promotes exchange of K+ for H+ in the cell.

Hypokalemia

• Level: less than 3.5 mEq/L
• Possible Causes: Diuretic, Diet and Hyperglycemia.
• Signs and Symptoms: Muscle weakness, Paralysis
• ECG: Flattened T waves, presence of "U" waves.

Hyperkalemia

• Level: more than 5.0 mEq/L
• Possible Causes: Renal failure, Acidosis and Blood transfusion
• Signs and Symptoms: Tingling in the extremities, Weakness and Constipation
• ECG: Peaked T waves and wide QRS

Magnesium

• 2nd to K+ in the ICF.
• Normal range is 1.6-2.6 mg/dL.

Magnesium Function:

• Intracellular production and utilization of ATP
• Protein and DNA synthesis
• Neuromuscular irritability.

Hypomagnesemia

• less than 1.6 mg/dL
• Possible Cause: Use of too much diuretics
• Signs and Symptoms: Tachycardia, Hypertension & Shallow respirations
• ECG: Tall T waves, depressed ST segments

Hypermagnesemia

• more than 2.6 mg/dL
• Possible Causes: Use of Mg antacids, Renal failure & Mg medications
• Signs and Symptoms: Depressed tendon reflexes, Oliguria & Increase RR
• ECG: Prolonged PR interval, widened QRS complex

Chloride

• The MAJOR Anion in the ECF
• Normal range is 95-108 mEq/L

Chloride Function:

• Major component of gastric juice aside from H
• Together with Na+, regulates plasma osmolality
• Participates in the chloride shift
• Acts as chemical buffer

Hypochloremia

• less than 95 mEq/L
• Possible Causes: Gastric suctioning, Severe vomiting & Diarrhea
• Signs and Symptoms: hyperactive DTR, Weakness & Twitching Cramps & Cardiac dysrhythmias associated with hypokalemia.

Hyperchloremia

• more than 108 mg/dL
• Possible Causes: Metabolic acidosis, Loss of HCO3-ions & Dec. GFR
• Signs and Symptoms: Tachypnea, Weakness, Lethargy & Deep, rapid respirationsDec. cognitive ability

Phosphates Characteristics

• Normal range is 2.7-4.5 mg/L
• Inverse relationship with Calcium’

Phosphates Functions:

• Component of bones
• Needed to generate ATP
• Components of DNA and RNA.
• PTH - decreases PO4 in blood by renal excretion
• Calcitonin - increases renal excretion of PO4

Hypophosphatemia

• Level less than 2.7 mg/dL
• Possible Causes: Hyperparathyroidism, Malignancy & Use of Mg-based or Al(OH)3-based antacids
• Hyperglycemia, Alkalosis & Shallow respirations
• Signs and Symptoms: Weakness & Dec. DTR Dec. bone density & Irritability.

Hyperphosphatemia

• more than 4.5 mg/dL Level.
• Possible Causes: Dec. renal excretion, Tumor lysis syndrome & Hypoparathyroidism
• Signs and Symptoms: Dec HR and BP & Tetany. , Camps

Bicarbonates:

• Present both in ICF and ECF
• Normal range- 22-26 mEq/L

Bicarbonates Function:

• Regulates acid-base balance
• Component of the bicarbonate-carbonic acid buffer system

Acid-Base Concepts

• Acid: a substance that can donate or release hydrogen ions
  • Examples include Carbonic acid and Hydrochloric acid
• Base: a substance that can accept hydrogen ions
  • Example includes Bicarbonate
• Buffer: a substance that can accept or donate hydrogen
  • Example includes Hemoglobin buffer
• Bicarbonate- carbonic acid buffer
• Phosphate buffer

How to determine acid base balance/ imbalances (Helpful hints:)

• Determine the normal values pH: 7.35-7.45
  • PaCO2: 35-45mmHg
  • PaO2: 80-100mmHg
  • HCO3: 22-26mEq/L
  • 02 Saturation: 95-100%=
• Look at the pH, if it is Increased that means it's acidosis or Decrease means alkalosis.
• Look at PaCO2 (Respiratory Indicator) if it is, Increased meaning Respiratory acidosis & Decrease meaning Respiratory alkalosis.
• Look at HCОЗ, if Increased meaning Metabolic Alkalosis and Decrease meaning Metabolic Acidosis.
• Determine primary acid base imbalance.
• pH, pCO2 and HCO3 in Respiratory Acidosis shows (DEC., INC., N). pH, pCO2 and HCO3 in Respiratory Alkalosis shows (INC, DEC, N).
• pH, pCO2 and HCO3 in Metabolic Acidosis shows (INC, N, INC).
• pH, pCO2 and HCO3 in Metabolic Alkalosis shows (DEC, N, DEC). If 2 arrows (CO2 and HCO3) follow the same direction it is COMPENSATED
• Compensated with abnormal pH is PARTIAL COMPENSATED
• Compensated with normal pH is COMPLETE COMPENSATED

Dynamics of Acid and Bases:

• Acids and bases are constantly produced in the body
• They must be constantly regulated
• CO2 and HCO3 are crucial in the balance
• A ratio of 20:1 is maintained (HCO3:H2CO3)
• Respiratory and renal system are active in regulation

Ways to balance the acids and bases:

• Excretion
  • Acid can be excreted, and Hydrogen can be excreted in ACIDOTIC condition
  • Bicarbonate can be excreted in ALKALOTIC condition
• Production
  • Bicarbonate can be produced in ACIDOTIC condition
  • Hydrogen can be produced in ALKALOTIC condition
• ROME:
• The respiratory system compensates for metabolic problems
  • CO2 (acid) can be exhaled from the body to normalize the pH in ACIDOSIS
  • CO2 (acid) can be retained in the body to normalize the pH in ALKALOSIS
• The kidney can compensate for problems in the respiratory system
  • The Kidney reabsorbs and generates Bicarbonate (alkaline) in ACIDOSIS
  • The Kidney can excrete H+ excess (Acidosis) to normalize the pH in ACIDOSIS
  • The kidney can excrete bicarbonate (alkali) in conditions of ALKALOSIS
  • The kidney can retain H+ (acid) in conditions of ALKALOSIS

Respiratory Acidosis

• The pH is less than 7.35 and the PaCO2 is greater than 45 mm Hg
• Possible causes: Aspiration of a foreign object, Atelectasis & Pneumothorax Overdose of sedatives, Sleep apnea & Acute respiratory distress syndrome
• Muscular dystrophy, Myasthenia gravis & Guillain- Barre syndrome

Respiratory Alkalosis

• Increased pulse and respiratory rate & Feeling of fullness in the head.
• Hyperkalemia may result because the hydrogen concentration overwhelms the compensatory mechanisms and H moves into cells, causing a shift of potassium out of the cell. Treatment is directed at improving ventilation & Adequate hydration (2 to 3 L/day)
• The pH is greater than 7.45 and the PaCO2 is less than 35 mm Hg
• Respiratory alkalosis is always caused by hyperventilation, which causes excessive "blowing off" of CO2 and, hence, a decrease in the plasma carbonic acid concentration
• Extreme anxiety/Gram-negative bacteremia Lightheadedness due to vasoconstriction and decreased cerebral blood flow.
• Instruct to breathe more slowly to allow CO2 to accumulate or to breathe into a closed system.

Metabolic Acidosis

• Include a low pH (less than 7.35) and a low bicarbonate level (less than 22 mEq/L)
• Possible Causes: overproduction of hydrogen ions, Deficient elimination and production of hydrogen ions Excess elimination of bicarbonate ions (diarrhea)
• Lethargy leads to increasing hydrogen ion concentration in blood Rapid, deep breathing (hyperventilation) as body attempts to compensate
• Administer Bicarbonate (if levels are low), Correct the underlying condition that causing the imbalance, and Administer Insulin and fluids to diabetic ketoacidosis & Hemodialysis if necessary.

Metabolic Alkalosis

• The pH more than7.45 and serum bicarbonate concentration greater than 26 mEq/L Excess intake of antacids and long-term parenteral nutrition
• Prolonged vomiting and nasogastric suctioning due to electrolyte changes Hypokalemia & Chloride low needs to be considered while replacement.
• Muscle weakness and Muscle cramping as Electrolyte disturbances
• Monitor arterial blood gases & Administer electrolyte as indicated also Administer supplement.