Burns.pdf

Chapter 24 Burns Copyright © 2020 by Elsevier, Inc. All rights reserved. Burns ˜ ˜ ˜ Occur when there is injury to the skin or other tissues of the body caused by heat, chemicals, electrical current, or radiation The patient with a burn injury may have a multitude of problems Most burn accidents are...

Chapter 24 Burns Copyright © 2020 by Elsevier, Inc. All rights reserved. Burns ˜ ˜ ˜ Occur when there is injury to the skin or other tissues of the body caused by heat, chemicals, electrical current, or radiation The patient with a burn injury may have a multitude of problems Most burn accidents are preventable Copyright © 2020 by Elsevier, Inc. All rights reserved. 2 Types of Burn Injury ˜ ˜ ˜ ˜ ˜ Thermal burns Chemical burns Smoke inhalation injury Electrical burns Cold thermal injury Copyright © 2020 by Elsevier, Inc. All rights reserved. 3 Types of Burn Injury Thermal Burns ˜ ˜ ˜ Caused by flame, flash, scald, or contact with hot objects Most common type of burn injury Severity of injury depends on Ø Ø Temperature of burning agent Duration of contact time Copyright © 2020 by Elsevier, Inc. All rights reserved. 4 Partial-Thickness Burn to Hand Fig. 24-1 Copyright © 2020 by Elsevier, Inc. All rights reserved. 5 Full-Thickness Flame Burn Fig. 24-1 Copyright © 2020 by Elsevier, Inc. All rights reserved. 6 Types of Burn Injury Chemical Burns ˜ ˜ Result of contact with acids, alkalis, and organic compounds Alkali burns can be more difficult to manage because they cause protein hydrolysis and melting Ø Ø Alkalis found in cement, oven and drain cleaners, heavy metal cleaners Organic compounds include phenols and petroleum products Copyright © 2020 by Elsevier, Inc. All rights reserved. 7 Types of Burn Injury Smoke Inhalation Injuries (1 of 7) ˜ ˜ ˜ ˜ From breathing noxious chemicals or hot air Cause damage to respiratory tract Major predictor of mortality in burn victims Rapid initial and ongoing assessment is critical Ø Airway compromise and pulmonary edema can quickly develop Copyright © 2020 by Elsevier, Inc. All rights reserved. 8 Types of Burn Injury Smoke Inhalation Injuries (2 of 7) ˜ Three types Ø Ø Ø Upper airway injury Lower airway injury Metabolic asphyxiation Copyright © 2020 by Elsevier, Inc. All rights reserved. 9 Types of Burn Injury Smoke Inhalation Injuries (3 of 7) ˜ Metabolic asphyxiation Ø Ø Carbon monoxide (CO) and hydrogen cyanide inhaled Impairs oxygen delivery to tissues, resulting in Hypoxia Elevated carboxyhemoglobin levels Death when levels reach less than 20% Ø May occur in absence of burn injury Copyright © 2020 by Elsevier, Inc. All rights reserved. 10 Types of Burn Injury Smoke Inhalation Injuries (4 of 7) ˜ Upper airway injury Ø Ø Ø Ø Injury to mouth, oropharynx, and/or larynx Thermal burns Inhalation of hot air, steam, or smoke Mucosal burns of oropharynx and larynx manifested by Redness Blistering edema Copyright © 2020 by Elsevier, Inc. All rights reserved. 11 Types of Burn Injury Smoke Inhalation Injuries (5 of 7) ˜ Upper airway injury Ø Swelling may be massive and onset rapid Eschar and edema may compromise breathing Edema from facial and neck burns can be lethal Internal pressure from edema may narrow airway Ø Obstruction can occur quickly, presenting airway emergency Copyright © 2020 by Elsevier, Inc. All rights reserved. 12 Types of Burn Injury Smoke Inhalation Injuries (6 of 7) ˜ Lower airway injury Ø Ø Ø Injury to trachea, bronchioles, and alveoli Tissue damage is related to duration of exposure to toxic fumes or smoke Pulmonary edema may not appear until 12 to 48 hours after burn May manifest as acute respiratory distress syndrome (ARDS) Copyright © 2020 by Elsevier, Inc. All rights reserved. 13 Types of Burn Injury Smoke Inhalation Injuries (7 of 7) ˜ Lower airway injury Ø Assess for Facial burns Singed nasal hair Hoarseness Painful swallowing Darkened oral and nasal membranes Carbonaceous sputum History of being burned in enclosed space Clothing burns around neck and chest Copyright © 2020 by Elsevier, Inc. All rights reserved. 14 Types of Burn Injury Electrical Burns (1 of 5) ˜ ˜ Result from intense heat generated from an electric current May result in direct damage to nerves and vessels, causing tissue anoxia and death Copyright © 2020 by Elsevier, Inc. All rights reserved. 15 Electrical Burn: Back Fig. 24-2 Copyright © 2020 by Elsevier, Inc. All rights reserved. 16 Electrical Burn: Leg Fig. 24-2 Copyright © 2020 by Elsevier, Inc. All rights reserved. 17 Types of Burn Injury Electrical Burns (2 of 5) ˜ Severity of injury depends on Ø Ø Ø Ø Ø Amount of voltage Tissue resistance Current pathways Surface area Length of time current flow was sustained Copyright © 2020 by Elsevier, Inc. All rights reserved. 18 Types of Burn Injury Electrical Burns (3 of 5) ˜ ˜ Current that passes through vital organs produces more life-threatening sequelae than current that passes through other tissues Electric sparks may also ignite patient’s clothing, causing a thermal flash injury Copyright © 2020 by Elsevier, Inc. All rights reserved. 19 Types of Burn Injury Electrical Burns (4 of 5) ˜ ˜ Severity of injury can be difficult to determine since most damage occurs below the skin Electrical current can cause muscle spasms strong enough to fracture long bones and vertebrae Copyright © 2020 by Elsevier, Inc. All rights reserved. 20 Types of Burn Injury Electrical Burns (4 of 5) ˜ ˜ Patients at risk for dysrhythmias or cardiac arrest, severe metabolic acidosis, and myoglobinuria Myoglobin from injured muscle and hemoglobin from damaged RBCs travel to kidneys Ø Ø Acute tubular necrosis (ATN) Acute kidney injury Copyright © 2020 by Elsevier, Inc. All rights reserved. 21 Case Study (1 of 13) ˜ ˜ ˜ ˜ M.K., a 25-year-old male, fell from a ladder while repairing the roof and struck a hot charcoal grill. He is a cigarette smoker and drinks beer three times a week. He works as a carpenter. He lacerated his left leg and his clothes caught fire. Copyright © 2020 by Elsevier, Inc. All rights reserved. 22 Classification of Burn Injury ˜ Severity of injury is determined by Ø Ø Ø Ø Depth of burn Extent of burn in percent of TBSA Location of burn Age of patient, pre-burn medical history, and circumstances or complicating factors Copyright © 2020 by Elsevier, Inc. All rights reserved. 23 Cross Section of Skin Fig. 24-3 Copyright © 2020 by Elsevier, Inc. All rights reserved. 24 Case Study (2 of 13) ˜ ˜ M.K. was brought to the ED. His burns were estimated to be partial and full thickness over his face, neck, trunk, right upper arm, and left leg. Copyright © 2020 by Elsevier, Inc. All rights reserved. 25 Classification of Burn Injury Depth of Burn (1 of 2) ˜ ˜ Burns are defined by degrees (first, second, third, and fourth) ABA classifies burns according to depth of skin destruction Ø Ø Partial-thickness burn Full-thickness burn Copyright © 2020 by Elsevier, Inc. All rights reserved. 26 Classification of Burn Injury Depth of Burn (2 of 2) ˜ Superficial partial-thickness burn Ø Ø ˜ Deep partial-thickness burn Ø Ø ˜ Involves epidermis First degree Involves dermis Second degree Full-thickness burn Ø Ø Involves all skin elements, nerve endings, fat, muscle, bone Thirds and fourth degree Copyright © 2020 by Elsevier, Inc. All rights reserved. 27 Classification of Burn Injury Extent of Burn ˜ Two common tools for determining the total body surface area Ø Lund-Browder chart Considered more accurate Ø Rule of Nines Used for initial assessment Ø Sage Burn Diagram (www.sagediagram.com) Copyright © 2020 by Elsevier, Inc. All rights reserved. 28 Lund-Browder Chart Fig. 24-4 Copyright © 2020 by Elsevier, Inc. All rights reserved. 29 Rule of Nines Chart Fig. 24-4 Copyright © 2020 by Elsevier, Inc. All rights reserved. 30 Classification of Burn Injury Location of Burn (1 of 2) ˜ Severity of burn injury is determined by location of burn wound Ø Face, neck, chest Respiratory obstruction from edema, eschar Ø Hands, feet, joints, eyes Self-care difficult Ø Ears, nose, buttocks, perineum High risk for infection Copyright © 2020 by Elsevier, Inc. All rights reserved. 31 Classification of Burn Injury Location of Burn (2 of 2) ˜ ˜ Circumferential burns of extremities can cause circulation problems distal to burn Possible nerve damage to affected extremity Ø Patients may also develop compartment syndrome Copyright © 2020 by Elsevier, Inc. All rights reserved. 32 Classification of Burn Injury Patient Risk Factors (1 of 2) ˜ ˜ Preexisting heart, lung, or kidney disease contribute to poorer prognosis Diabetes and peripheral vascular disease put patient at high risk for delayed healing Copyright © 2020 by Elsevier, Inc. All rights reserved. 33 Classification of Burn Injury Patient Risk Factors (2 of 2) ˜ Physical weakness make it challenging for patient to recover Ø Ø ˜ Alcohol or drug use Malnutrition Concurrent fractures, head injuries, or other trauma leads to a more difficult time recovering Copyright © 2020 by Elsevier, Inc. All rights reserved. 34 Case Study (3 of 13) ˜ What actual and potential risk factors might affect M.K. and his recovery? Copyright © 2020 by Elsevier, Inc. All rights reserved. 35 Prehospital Care (1 of 3) ˜ ˜ ˜ Remove person from source of burn and stop burning process Rescuer must protect themselves from being injured Electrical and chemical injuries Ø Remove patient from contact with source Copyright © 2020 by Elsevier, Inc. All rights reserved. 36 Prehospital Care (2 of 3) ˜ Small thermal burns Ø Ø ˜ Cover with clean, cool, tap water-dampened towel Cooling within 1 minute helps minimize depth of injury Large thermal burns Ø Ø If unresponsive—circulation, airway, breathing If responsive—Airway, breathing, circulation Copyright © 2020 by Elsevier, Inc. All rights reserved. 37 Prehospital Care (3 of 3) ˜ Large thermal burns Ø Ø Ø Ø Cool burns for no more than 10 minutes Do not immerse in cool water or cover with ice Remove burned clothing Wrap in dry, clean sheet or blanket Copyright © 2020 by Elsevier, Inc. All rights reserved. 38 Prehospital Phase ˜ Chemical burns Ø Ø ˜ Remove chemical particles or powder Flush area with water Inhalation injury Ø Ø Ø Watch for signs of respiratory distress Treat quickly and efficiently 100% humidified oxygen if CO poisoning is suspected Copyright © 2020 by Elsevier, Inc. All rights reserved. 39 Phases of Burn Management ˜ ˜ ˜ Emergent (resuscitative) Acute (wound healing) Rehabilitative (restorative) Copyright © 2020 by Elsevier, Inc. All rights reserved. 40 Case Study (4 of 13) ˜ ˜ ˜ Two large-bore IVs are started. An indwelling urinary catheter is inserted into the bladder. By using the Lund-Browder chart, M.K.’s total body surface area affected is 46%. Copyright © 2020 by Elsevier, Inc. All rights reserved. 41 Emergent Phase ˜ ˜ ˜ Emergent (resuscitative) phase is time required to resolve immediate problems resulting from injury Up to 72 hours Main concerns Ø Ø ˜ Hypovolemic shock Edema Ends when fluid mobilization and diuresis begins Copyright © 2020 by Elsevier, Inc. All rights reserved. 42 Emergent Phase Pathophysiology ˜ Fluid and electrolyte shifts Ø Greatest threat is hypovolemic shock Caused by a massive shift of fluids out of blood vessels because of increased capillary permeability Can begin as early as 20 minutes postburn Copyright © 2020 by Elsevier, Inc. All rights reserved. 43 Conditions Leading to Burn Shock Fig. 24-5 Copyright © 2020 by Elsevier, Inc. All rights reserved. 44 Emergent Phase Pathophysiology ˜ Fluid and electrolyte shifts Ø Ø Ø Colloidal osmotic pressure decreases More fluid shifting out of vascular space into interstitial spaces Third spacing Exudate and blisters Edema in unburned areas Copyright © 2020 by Elsevier, Inc. All rights reserved. 45 Facial Edema Before and After Fluid Resuscitation Fig. 24-6 Copyright © 2020 by Elsevier, Inc. All rights reserved. 46 Emergent Phase Pathophysiology (1 of 3) ˜ Fluid and electrolyte shifts Ø Ø Ø Normal insensible loss: 30 to 50 mL/hr Increased insensible losses in the severely burned patient Net result of fluid shift is intravascular volume depletion Edema Decreased blood pressure Increased pulse Copyright © 2020 by Elsevier, Inc. All rights reserved. 47 Emergent Phase Pathophysiology (2 of 3) ˜ Fluid and electrolyte shifts Ø Ø Ø RBCs are hemolyzed by circulating factors released at time of burn, as well as direct result of insult of burn injury Thrombosis in capillaries of burned tissue High hematocrit caused by hemoconcentration Copyright © 2020 by Elsevier, Inc. All rights reserved. 48 Emergent Phase Pathophysiology (3 of 3) ˜ Fluid and electrolyte shifts Ø Ø K+ shift develops first because injured cells and hemolyzed RBCs release K+ into circulation Na+ rapidly moves to interstitial spaces and stays there until edema formation ends Copyright © 2020 by Elsevier, Inc. All rights reserved. 49 Effects of Burn Shock Fig. 24-7 Copyright © 2020 by Elsevier, Inc. All rights reserved. 50 Audience Response Question (1 of 2) A patient who is admitted to a burn unit is hypovolemic. A new nurse asks an experienced nurse about the patient’s condition. Which response if made by the experienced nurse is most appropriate? a. “Blood loss from burned tissue is the most likely cause of hypovolemia.” b. “Third spacing of fluid into fluid-filled vesicles is usually the cause of hypovolemia.” c. “The usual cause of hypovolemia is evaporation of fluid from denuded body surfaces.” d. “Increased capillary permeability causes fluid shifts out of blood vessels and results in hypovolemia.” Copyright © 2020 by Elsevier, Inc. All rights reserved. 51 Audience Response Question (2 of 2) Answer: D “Increased capillary permeability causes fluid shifts out of blood vessels and results in hypovolemia.” Copyright © 2020 by Elsevier, Inc. All rights reserved. 52 Emergent Phase Pathophysiology (1 of 2) ˜ Inflammation and healing Ø Ø Neutrophils and monocytes accumulate at site of injury Fibroblasts and newly formed collagen fibrils begin wound repair within first 6 to 12 hours after injury Copyright © 2020 by Elsevier, Inc. All rights reserved. 53 Emergent Phase Pathophysiology (2 of 2) ˜ Immunologic changes Ø Immune system is challenged when burn injury occurs Skin barrier is destroyed Bone marrow depression occurs Circulating levels of immune globulins are decreased Defects occur in function of WBCs † Patient at greater risk for infection Copyright © 2020 by Elsevier, Inc. All rights reserved. 54 Emergent Phase Clinical Manifestations ˜ ˜ ˜ ˜ ˜ ˜ Shock from hypovolemia Pain Blisters Paralytic ileus Shivering Altered mental status Copyright © 2020 by Elsevier, Inc. All rights reserved. 55 Emergent Phase Complications (1 of 6) ˜ Cardiovascular system Ø Ø Dysrhythmias and hypovolemic shock Impaired circulation to extremities with circumferential burns- if untreated can lead to Tissue ischemia Paresthesia Necrosis Copyright © 2020 by Elsevier, Inc. All rights reserved. 56 Escharotomies of Chest and Arm Fig. 24-8 Copyright © 2020 by Elsevier, Inc. All rights reserved. 57 Emergent Phase Complications (2 of 6) ˜ Cardiovascular system Ø Impaired microcirculation and increased viscosity results in sludging Corrected by adequate fluid replacement Ø Venous thromboembolism (VTE) Prophylaxis with anticoagulants Copyright © 2020 by Elsevier, Inc. All rights reserved. 58 Emergent Phase Complications (3 of 6) ˜ Respiratory system Ø Upper airway burns May occur with or without smoke inhalation Ø Lower airway injury Copyright © 2020 by Elsevier, Inc. All rights reserved. 59 Emergent Phase Complications (4 of 6) ˜ Respiratory system Ø Ø Ø Need fiberoptic bronchoscopy and carboxyhemoglobin blood levels Watch for signs of respiratory distress Chest x-ray may appear normal on admission; changes can occur over next 24 to 48 hours ABGs may be within normal range on admission and change over time Copyright © 2020 by Elsevier, Inc. All rights reserved. 60 Case Study (5 of 13) ˜ What places M.K. at risk for an inhalation injury? ˜ What are your nursing goals for his care? Copyright © 2020 by Elsevier, Inc. All rights reserved. 61 Emergent Phase Complications (5 of 6) ˜ Other cardiopulmonary problems Ø Patients with preexisting heart or lung disease are at increased risk Heart failure Pulmonary edema Pneumonia Copyright © 2020 by Elsevier, Inc. All rights reserved. 62 Emergent Phase Complications (6 of 6) ˜ Urinary system Ø Ø Acute tubular necrosis (ATN) Decreases blood flow to kidneys causes renal ischemia Copyright © 2020 by Elsevier, Inc. All rights reserved. 63 Emergent Phase (1 of 19) Nursing/Interprofessional Management ˜ Airway management Ø Ø Ø Ø Ø Ø Ø Early endotracheal intubation Escharotomies of the chest Fiberoptic bronchoscopy Humidified air and 100% oxygen High fowler’s position Suctioning, chest PT Bronchodilators Copyright © 2020 by Elsevier, Inc. All rights reserved. 64 Emergent Phase (2 of 19) Nursing/Interprofessional Management ˜ Fluid therapy Ø Ø Ø Ø 2 large-bore IV lines for greater than 15% TBSA For burns greater than 20% TBSA central line may be considered Arterial line placed if frequent ABGs or invasive BP monitoring needed Parkland (Baxter) formula for fluid replacement Copyright © 2020 by Elsevier, Inc. All rights reserved. 65 Emergent Phase (3 of 19) Nursing/Interprofessional Management ˜ Wound care Ø Cleansing and gentle debridement Can be done on a shower cart, in a shower, or on a bed or stretcher Ø Surgical debridement May need to be done in the OR Necrotic skin is removed Releasing escharotomies and fasciotomies may be done Copyright © 2020 by Elsevier, Inc. All rights reserved. 66 Hydrotherapy Cart Shower Fig. 24-9 Copyright © 2020 by Elsevier, Inc. All rights reserved. 67 Debriding Full–Thickness Burn Fig. 24-10 Copyright © 2020 by Elsevier, Inc. All rights reserved. 68 Case Study (6 of 13) ˜ ˜ M.K.’s breathing is stable on 100% humidified oxygen. He is taken to OR for debridement of burns of his trunk and arm. Copyright © 2020 by Elsevier, Inc. All rights reserved. 69 Emergent Phase (4 of 19) Nursing/Interprofessional Management ˜ Wound care Ø Shower Once-daily shower Dressing change in morning and evening Ø Newer antimicrobial dressings can be left in place from 3 to 14 days Copyright © 2020 by Elsevier, Inc. All rights reserved. 70 Emergent Phase (5 of 19) Nursing/Interprofessional Management ˜ Wound care Ø Infection can cause further tissue injury and possible sepsis Source of infection is patient’s own flora Skin, respiratory, GI Copyright © 2020 by Elsevier, Inc. All rights reserved. 71 Emergent Phase (6 of 19) Nursing/Interprofessional Management ˜ Wound care Ø Open method Burn is covered with topical antimicrobial No dressing over wound Usually limited to the care of facial burns Copyright © 2020 by Elsevier, Inc. All rights reserved. 72 Emergent Phase (7 of 19) Nursing/Interprofessional Management ˜ Wound care Ø Multiple dressing changes or closed method Sterile gauze dressings are laid over topical antimicrobial Dressings may be changed from every 12 hours to once every 14 days Copyright © 2020 by Elsevier, Inc. All rights reserved. 73 Application of Silver Sulfadiazine to Moistened Gauze Fig. 24-11 Copyright © 2020 by Elsevier, Inc. All rights reserved. 74 Emergent Phase (8 of 19) Nursing/Interprofessional Management ˜ Wound care Ø When open burns wounds are exposed, staff should wear PPE Ø Disposable hats Masks Gowns Gloves Use sterile gloves to apply antimicrobial ointment and sterile dressings Copyright © 2020 by Elsevier, Inc. All rights reserved. 75 Emergent Phase (9 of 19) Nursing/Interprofessional Management ˜ Wound care Ø Ø Allograft Homograft skin From skin donor cadavers Used with newer biosynthetic options Copyright © 2020 by Elsevier, Inc. All rights reserved. 76 Emergent Phase (10 0f 19) Nursing/Interprofessional Management ˜ Other care measures Ø Facial care Covered with ointment and gauze Not wrapped to limit pressure Ø Eye care for corneal burns Antibiotic ointment is used Artificial tears for moisture, comfort Periorbital edema may frighten patient Copyright © 2020 by Elsevier, Inc. All rights reserved. 77 Emergent Phase (11 of 19) Nursing/Interprofessional Management ˜ Other care measures Ø Keep ears free of pressure No use of pillows Raise patient’s head with rolled towel Ø Hands and arms should be extended and elevated on pillows or foam wedges Splints may be used on hands and feet Wraps may reduce edema Copyright © 2020 by Elsevier, Inc. All rights reserved. 78 Emergent Phase (12 of 19) Nursing/Interprofessional Management ˜ Other care measures Ø Keep patient’s perineum clean and dry as possible Indwelling catheter Perineal care Fecal diversion device if loose stools Ø Ø Ø Laboratory tests to monitor fluids and electrolytes ABGs to assess oxygenation PT for ROM exercises Copyright © 2020 by Elsevier, Inc. All rights reserved. 79 Emergent Phase (13 of 19) Nursing/Interprofessional Management ˜ Drug therapy Ø Analgesics and sedatives Ø Morphine Hydromorphone (Dilaudid) Haloperidol (Haldol) Lorazepam (Ativan) Midazolam IV pain medication for fastest onset of action Copyright © 2020 by Elsevier, Inc. All rights reserved. 80 Case Study (7 of 13) ˜ ˜ M.K. reports severe pain (9 on a 0-to-10 scale) over his face and leg. He appears very anxious and expresses fear regarding his healing and future. Copyright © 2020 by Elsevier, Inc. All rights reserved. 81 Emergent Phase (14 of 19) Nursing/Interprofessional Management ˜ Drug therapy Ø Tetanus immunization Given routinely to all burn patients Copyright © 2020 by Elsevier, Inc. All rights reserved. 82 Emergent Phase (15 of 19) Nursing/Interprofessional Management ˜ Drug therapy Ø Antimicrobial agents Topical agents † † Silver sulfadiazine Mafenide acetate Systemic antibiotics are not usually used in controlling burn wound flora † Started when diagnosis of sepsis is made Copyright © 2020 by Elsevier, Inc. All rights reserved. 83 Emergent Phase (16 of 19) Nursing/Interprofessional Management ˜ Drug therapy Ø VTE prophylaxis Low-molecular-weight heparin or low-dose unfractionated heparin is started Those with high bleeding risk, VTE prophylaxis with intermittent pneumatic compression devices, or graduated compression stockings recommended Copyright © 2020 by Elsevier, Inc. All rights reserved. 84 Emergent Phase (17 of 19) Nursing/Interprofessional Management ˜ Nutritional therapy Ø Ø Nutrition takes priority once fluid replacement needs addressed Early and aggressive nutritional support within hours of burn injury Decreases complications and mortality Optimizes burn wound healing Minimizes negative effects of hypermetabolism and catabolism Copyright © 2020 by Elsevier, Inc. All rights reserved. 85 Case Study (8 of 13) ˜ ˜ M.K. reports slight difficulty swallowing and his voice is hoarse. He is able to swallow ice chips without difficulty. Copyright © 2020 by Elsevier, Inc. All rights reserved. 86 Emergent Phase (18 of 19) Nursing/Interprofessional Management ˜ Nutritional therapy Ø Hypermetabolic state Resting metabolic expenditure may be increased by 50% to 100% above normal Core temperature is increased Catecholamines increased, stimulate catabolism Copyright © 2020 by Elsevier, Inc. All rights reserved. 87 Emergent Phase (19 of 19) Nursing/Interprofessional Management ˜ Nutritional therapy Ø Hypermetabolic state Early, continuous enteral feeding promotes optimal conditions for wound healing Adequate calories and protein needed Supplemental vitamins and iron may be given Copyright © 2020 by Elsevier, Inc. All rights reserved. 88 Audience Response Question (1 of 2) When monitoring initial fluid replacement for the patient with 40% TBSA deep partial-thickness and full-thickness burns, which finding is of most concern to the nurse? a. Serum K+ of 4.5 mEq/L b. Urine output of 35 mL/hr c. Decreased bowel sounds d. Blood pressure of 86/72 mm Hg Copyright © 2020 by Elsevier, Inc. All rights reserved. 89 Audience Response Question (2 of 2) Answer: D Blood pressure of 86/72 mm Hg Copyright © 2020 by Elsevier, Inc. All rights reserved. 90 Audience Response Question (1 of 2) During the emergent phase of burn injury, the nurse assesses for the presence of hypovolemia. In burn patients, hypovolemia occurs primarily as a result of a. Blood loss from injured tissue. b. Third spacing of fluid into fluid-filled vesicles. c. Evaporation of fluid from denuded body surfaces. d. Capillary permeability with fluid shift to the interstitium. Copyright © 2020 by Elsevier, Inc. All rights reserved. 91 Audience Response Question (2 of 2) Answer: D Capillary permeability with fluid shift to the interstitium. Copyright © 2020 by Elsevier, Inc. All rights reserved. 92 Acute Phase ˜ ˜ Begins with mobilization of extracellular fluid and subsequent diuresis Ends when Ø Ø Partial thickness wounds are healed or Full thickness burns are covered by skin grafts Copyright © 2020 by Elsevier, Inc. All rights reserved. 93 Acute Phase Pathophysiology (1 of 2) ˜ ˜ ˜ Diuresis from fluid mobilization occurs, and patient is less edematous Bowel sounds return Healing begins as WBCs surround burn wound and phagocytosis occurs Copyright © 2020 by Elsevier, Inc. All rights reserved. 94 Acute Phase Pathophysiology (2 of 2) ˜ ˜ ˜ ˜ Necrotic tissue begins to slough Granulation tissue forms Partial-thickness burns heal from wound edges and dermal bed Full-thickness burns must have eschar removed and skin grafts applied Copyright © 2020 by Elsevier, Inc. All rights reserved. 95 Acute Phase Clinical Manifestations ˜ Partial-thickness wounds form eschar Ø ˜ Once eschar is removed, re-epithelialization begins Full-thickness burn wounds require Ø Ø Surgical debridement Skin grafting Copyright © 2020 by Elsevier, Inc. All rights reserved. 96 Case Study (9 of 13) ˜ ˜ M.K. begins to diurese and his facial and body edema subside. He is taken to OR again for further debridement and skin grafting. Copyright © 2020 by Elsevier, Inc. All rights reserved. 97 Acute Phase Laboratory Values (1 of 4) ˜ Sodium Ø Hyponatremia can develop from Excessive GI suction Diarrhea Ø Water intoxication From excess water intake Offer juices, nutritional supplements Copyright © 2020 by Elsevier, Inc. All rights reserved. 98 Acute Phase Laboratory Values (2 of 4) ˜ Sodium Ø Hypernatremia may occur after Successful fluid resuscitation Improper tube feedings Inappropriate fluid administration Ø Restrict sodium in IVs, enteral or oral feedings Copyright © 2020 by Elsevier, Inc. All rights reserved. 99 Acute Phase Laboratory Values (3 of 4) ˜ Potassium Ø Hyperkalemia may occur if patient has Renal failure Adrenocortical insufficiency Massive deep muscle injury Ø Ø Large amounts of potassium are released from damaged cells Assess for manifestations of hyperkalemia Copyright © 2020 by Elsevier, Inc. All rights reserved. 100 Acute Phase Laboratory Values (4 of 4) ˜ Potassium Ø Hypokalemia occurs with Ø Vomiting, diarrhea Prolonged GI suction IV therapy without potassium supplementation Through burn wounds Assess for manifestations of hypokalemia Copyright © 2020 by Elsevier, Inc. All rights reserved. 101 Acute Phase Complications (1 of 7) ˜ Infection Ø Ø Ø Burn wound colonized by patient’s own flora WBCs have functional deficit and patient is immunosuppressed Partial-thickness burns can convert to full-thickness wounds in the presence of infection Copyright © 2020 by Elsevier, Inc. All rights reserved. 102 Acute Phase Complications (2 of 7) ˜ Infection Ø Watch for signs and symptoms Ø Hypothermia or hyperthermia Increased heart and respiratory rate Decreased BP Decreased urine output Causative organism of sepsis usually gram-negative bacteria Obtain cultures Lactate level Copyright © 2020 by Elsevier, Inc. All rights reserved. 103 Case Study (10 of 13) ˜ ˜ ˜ At week 4, M.K. develops a temperature of 102° F, pulse is 98, and respirations are 22. He has increased redness over his neck region burns and some puslike drainage. He is started on a broad-spectrum antibiotic IV. Copyright © 2020 by Elsevier, Inc. All rights reserved. 104 Acute Phase Complications (3 of 7) ˜ Cardiovascular and respiratory systems Ø Ø Same complications can be present in emergent phase and may continue into acute phase In addition, new problems might arise, requiring timely intervention Copyright © 2020 by Elsevier, Inc. All rights reserved. 105 Acute Phase Complications (4 of 7) ˜ Neurologic system Ø Ø Ø Ø Ø No physical symptoms unless severe hypoxia from respiratory injuries or complications from electrical injuries occur Disorientation Combative Hallucinations Frequent nightmare-like episodes Copyright © 2020 by Elsevier, Inc. All rights reserved. 106 Acute Phase Complications (5 of 7) ˜ Neurologic system Ø Delirium More acute at night Occurs more often in older adults Usually transient Complications and sequelae can last for years Copyright © 2020 by Elsevier, Inc. All rights reserved. 107 Acute Phase Complications (6 of 7) ˜ Musculoskeletal system Ø Ø ˜ Limited ROM Skin and joint contractures Gastrointestinal system Ø Ø Ø Ø Paralytic ileus Diarrhea Constipation Curling’s ulcer Copyright © 2020 by Elsevier, Inc. All rights reserved. 108 Acute Phase Complications (7 of 7) ˜ Endocrine system Ø Increased blood glucose levels Increased mobilization of glycogen stores gluconeogenesis Ø Increased insulin production Insulin effectiveness decreased due to insulin insensitivity Ø Hyperglycemia may also be caused by high caloric intake needed Copyright © 2020 by Elsevier, Inc. All rights reserved. 109 Acute Phase (1 of 12) Nursing/Interprofessional Management ˜ ˜ ˜ ˜ ˜ Wound care Excision and grafting Pain management Physical and occupational therapy Nutritional therapy Copyright © 2020 by Elsevier, Inc. All rights reserved. 110 Acute Phase (2 of 12) Nursing/Interprofessional Management ˜ Wound care Ø Ø Ø Ø Ø Ongoing observation Assessment Cleansing Debridement Dressing reapplication Copyright © 2020 by Elsevier, Inc. All rights reserved. 111 Acute Phase (3 of 12) Nursing/Interprofessional Management ˜ Wound care Ø Enzymatic debridement Speeds up removal of dead tissue from healthy wound bed Ø Ø Ø Cleanse with soap and water or normal saline Cover with antimicrobial creams When fully debrided, cover with protective, greasybased gauze Copyright © 2020 by Elsevier, Inc. All rights reserved. 112 Acute Phase (4 of 12) Nursing/Interprofessional Management ˜ Wound care Ø Appropriate coverage of graft Greasy gauze next to graft followed by saline moistened middle and dry outer dressings Unmeshed sheet graft used for facial grafts † † Grafts are left open Complication: Blebs Copyright © 2020 by Elsevier, Inc. All rights reserved. 113 Acute Phase (5 of 12) Nursing/Interprofessional Management ˜ Excision and grafting Ø Ø Ø Ø Ø Eschar is excised down to subcutaneous tissue or fascia Hemostasis is achieved Autograft is placed on clean, viable tissue Donor skin is taken with a dermatome Choice of dressings varies Copyright © 2020 by Elsevier, Inc. All rights reserved. 114 Acute Phase (6 of 12) Nursing/Interprofessional Management ˜ Excision and grafting Ø Grafts are attached with Fibrin sealant Sutures or staples Negative pressure wound therapy Ø With early excision, function is restored, scar tissue minimized Copyright © 2020 by Elsevier, Inc. All rights reserved. 115 Split-Thickness Sheet Skin Graft to Hand Fig. 24-12 Copyright © 2020 by Elsevier, Inc. All rights reserved. 116 Donor Site Being Harvested Fig. 24-12 Copyright © 2020 by Elsevier, Inc. All rights reserved. 117 Covering Donor Site With Hydrophilic Foam Dressing Fig. 24-12 Copyright © 2020 by Elsevier, Inc. All rights reserved. 118 Healed Donor Site Fig. 24-12 Copyright © 2020 by Elsevier, Inc. All rights reserved. 119 Acute Phase (7 of 12) Nursing/Interprofessional Management ˜ Excision and grafting Ø Cultured epithelial autographs (CEAs) Grown from biopsies obtained from the patient’s unburned skin Used in patients with a large body surface burn area or those with limited skin for harvesting Copyright © 2020 by Elsevier, Inc. All rights reserved. 120 Application of Cultured Epithelial Autograft Fig. 24-13 Copyright © 2020 by Elsevier, Inc. All rights reserved. 121 Healed Cultured Epithelial Autograft Fig. 24-13 Copyright © 2020 by Elsevier, Inc. All rights reserved. 122 Audience Response Question (1 of 2) A patient is to undergo skin grafting with the use of cultured epithelial autografts for full-thickness burns. The nurse explains to the patient that this treatment involves a. Shaving a split-thickness layer of the patient’s skin to cover the burn wound. b. Using epidermal growth factor to cultivate cadaver skin for temporary wound coverage. c. Growing small specimens of the patient’s skin into sheets to use as permanent skin coverage. d. Exposing animal skin to growth factors to decrease antigenicity so it can be used for permanent wound coverage. Copyright © 2020 by Elsevier, Inc. All rights reserved. 123 Audience Response Question (2 of 2) Answer: C Growing small specimens of the patient’s skin into sheets to use as permanent skin coverage. Copyright © 2020 by Elsevier, Inc. All rights reserved. 124 Acute Phase (8 of 12) Nursing/Interprofessional Management ˜ Excision and grafting Ø Dermal substitutes Life-threatening full-thickness or deep partial-thickness wounds where conventional autograft is not available or advisable Consists of both dermal and synthetic elements Copyright © 2020 by Elsevier, Inc. All rights reserved. 125 Acute Phase (9 of 12) Nursing/Interprofessional Management ˜ Pain management Ø Patients experience two kinds of pain Continuous background pain † † † † IV administration of an opioid Or slow-release, twice-a-day oral opioid Patient-controlled analgesia Anxiolytics and adjuvant analgesics Treatment-induced pain † † Pre-medicate with analgesic and anxiolytic Nondrug strategies may also be used Copyright © 2020 by Elsevier, Inc. All rights reserved. 126 Acute Phase (10 of 12) Nursing/Interprofessional Management ˜ Pain management Ø Nondrug strategies Relaxation breathing Visualization, guided imagery Hypnosis Biofeedback Music therapy Copyright © 2020 by Elsevier, Inc. All rights reserved. 127 Case Study (11 of 13) ˜ ˜ ˜ M.K.’s skin grafts are healing well. His pain is now well controlled with oral morphine. M.K. begins a regular schedule of physical and occupational therapy. Copyright © 2020 by Elsevier, Inc. All rights reserved. 128 Acute Phase (12 of 12) Nursing/Interprofessional Management ˜ Physical and occupational therapy Ø Ø Ø Good time for exercise is during dressing changes Passive and active ROM Splints should be custom-fitted Copyright © 2020 by Elsevier, Inc. All rights reserved. 129 Acute Phase (12 of 12) Nursing/Interprofessional Management ˜ Nutritional therapy Ø Ø Ø Ø Ø Caloric needs should be calculated by dietitian High-protein, high-carbohydrate foods Antioxidant protocol may be beneficial Monitor laboratory values Weigh weekly Copyright © 2020 by Elsevier, Inc. All rights reserved. 130 Rehabilitation Phase ˜ The rehabilitation phase begins when Ø Ø Wounds have nearly healed Patient is engaging in some level of self-care Copyright © 2020 by Elsevier, Inc. All rights reserved. 131 Rehabilitation Phase Pathophysiologic Changes (1 of 3) ˜ ˜ ˜ Burn wounds heal either by spontaneous reepithelialization or by skin grafting Layers of keratinocytes begin rebuilding the tissue structure Collagen fibers add strength to weakened areas Copyright © 2020 by Elsevier, Inc. All rights reserved. 132 Rehabilitation Phase Pathophysiologic Changes (2 of 3) ˜ ˜ ˜ In about 4 to 6 weeks, area becomes raised and hyperemic Mature healing is reached about 12 months Often skin does not regain its original color Copyright © 2020 by Elsevier, Inc. All rights reserved. 133 Rehabilitation Phase Pathophysiologic Changes (3 of 3) ˜ ˜ ˜ Discoloration of scar fades somewhat with time Scar contour elevates and enlarges Newly healed areas can be hypersensitive or hyposensitive to cold, heat, and touch Copyright © 2020 by Elsevier, Inc. All rights reserved. 134 Case Study (12 of 13) ˜ ˜ M.K. progresses in his healing and is transferred to a rehabilitation facility. His parents have been very involved in his hospital care and are now ready to help him in this phase. Copyright © 2020 by Elsevier, Inc. All rights reserved. 135 Rehabilitation Phase Complications ˜ Skin and joint contractures Ø Ø Ø Most common complications during rehab phase Develops because of shortening of scar tissue in flexor tissues of joint Proper positioning, splinting, and exercise should be used to minimize contracture. Copyright © 2020 by Elsevier, Inc. All rights reserved. 136 Contracture of the Neck Fig. 24-14 Copyright © 2020 by Elsevier, Inc. All rights reserved. 137 Rehabilitation Phase (1 of 2) Nursing/Interprofessional Management ˜ Encourage both patient and caregiver to take part in care Ø Ø Ø ˜ Skills for wound care Dressing changes Scar management, moisturizing, sun protection Reconstructive surgery is often done after a major burn Copyright © 2020 by Elsevier, Inc. All rights reserved. 138 Rehabilitation Phase (2 of 2) Nursing/Interprofessional Management ˜ ˜ ˜ ˜ Ongoing pain management Nutritional needs PT and OT routines Encouragement and reassurance Copyright © 2020 by Elsevier, Inc. All rights reserved. 139 Gerontologic Considerations ˜ Normal aging process puts the patient at risk for injury because of Ø Ø Ø Ø Ø Unsteady gait Limited eyesight Decreased hearing Skin drier and more wrinkled Thinner dermis, reduced blood flow Copyright © 2020 by Elsevier, Inc. All rights reserved. 140 Emotional Needs of the Patient and Caregivers ˜ ˜ ˜ ˜ Many emotional and psychologic needs Assess circumstances of burn injury Burn survivors often have guilt, fear of dying, and frustrations New fears may occur during recovery Copyright © 2020 by Elsevier, Inc. All rights reserved. 141 Case Study (13 of 13) ˜ ˜ M.K. has been expressing some concern about his ability to return to work. He also states that he has trouble looking in the mirror and has been avoiding his girlfriend’s phone calls. Copyright © 2020 by Elsevier, Inc. All rights reserved. 142 Emotional Needs of Patient and Family ˜ ˜ ˜ ˜ Self-esteem may be adversely affected Address spiritual and cultural needs Issue of sexuality must be met with honesty Caregiver and patient support groups Copyright © 2020 by Elsevier, Inc. All rights reserved. 143 Special Needs of Nursing Staff ˜ ˜ ˜ ˜ You may find it difficult to cope with deformities of burn injury Know you provide care that makes a critical difference Ongoing support services or debriefings may be helpful Practice good self-care Copyright © 2020 by Elsevier, Inc. All rights reserved. 144