1/3/2008. Karen Burke Priscilla LeMone Elaine Mohn-Brown. Medical-Surgical Nursing Care, 2e Karen Burke, Priscilla LeMone, and Elaine Mohn-Brown

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1 Medical-Surgical Nursing Care Second Edition Karen Burke Priscilla LeMone Elaine Mohn-Brown Chapter 46 Caring for Clients with Burns Types of Burns Thermal Dry heat flame Moist heat steam or hot liquid Chemical Acid or alkaline agents Electrical current current or voltage Radiation sunburn or radiation treatment of cancer Figure Burn injury classification according to the depth of the burn. 1

2 Classification of Burn Depth Superficial first first degree Epidermal layer Sunburn, UV light, minor flash injury Classification of Burn Depth Partial-thickness second second degree Superficial dermis Surface appears red, moist with blister formation Deep dermis plus hair follicles Surface appears pale, waxy, and moist or dry Large, easily ruptured blisters Figure Partial-thickness thickness burn injury. (Courtesy of Dr. William Dominic, Valley Medical Center.) 2

3 Classification of Burn Depth Full-thickness burn third degree All layers of skin Extend to subcutaneous fat, connective tissue, muscle, and bone Appears pale, waxy, yellow, brown, mottled, charred, or nonblanching red Pain and touch receptors destroyed Figure Full-thickness burn injury. (Courtesy of Dr. William Dominic, Valley Medical Center.) Cardiovascular Loss of cell wall integrity at the injury site and capillary bed Massive fluid shift from the intracellular space to the interstitial i i space Fluid leads from the capillaries at the burn wound site Burn shock 3

4 Further Changes of the Cardiovascular System Vasoconstriction Platelet aggregation Ischemia and thrombosis Hemolysis of RBCs Elevated RBCs (hemoconcentration) and WBCs Edema Potassium loss and dysrhythmias Immune System Impairs active components of cell-mediated and humoral immunity Decrease in serum immunoglobulins Decrease in serum protein Acquired immunodeficiency and risk for infection Integumentary System Microcirculation If intact, cools and protects deeper layers If lost, continues to burn even if heat source removed Thickness of the dermis and epidermis i varies from one area to another in the body 4

5 Respiratory System Inhalation injury Carbon monoxide and smoke inhalation Gastrointestinal System Curling s ulcer Paralytic ileus Urinary System Massive fluid loss leads to dehydration, hemoconcentration, and decreased urinary output Hemoglobinuria Renal failure 5

6 Metabolism Ebb phase Decreased metabolic state First 3 days of injury Flow phase Hypermetabolic state Increased BMR twice normal rate Body weight and heat decrease Persists after wound closure and may reappear - Management Stabilization in the Emergency Department Transfer to critical care or specialized burn center Diagnostic Tests Cultures Urinalysis Complete blood count Serum electrolytes Total protein and albumin Arterial blood gases Pulse oximetry Chest x-ray and flexible bronchoscopy Electrocardiogram 6

7 Stages of Burn Injury Care Emergent or resuscitative stage Onset of injury through successful fluid resuscitation Acute stage Start of diuresis Ends with closure of burn wound Rehabilitative stage Wound closure to highest level of health Medications Narcotics for pain control Antimicrobials Systemic Topical Sulfamylon Silver sulfadiazine (silvadene) Other Fluid Resuscitation Necessary in all burn wounds that involve >20% TBSA Rule of Nines for calculating TBSA Colloids, crystalloids, blood, and blood products Goal ml/hr urine output Invasive monitoring, two large-bore IVs 7

8 Respiratory Management Elevate head of bed 30 degrees Monitor for airway obstruction Mechanical ventilation Nutrition Caloric needs increase to 4,000 6,000 kcal/day Enteral and parenteral feedings may be needed Monitor for Curling s ulcer, bowel obstruction, and ileus Wound Management Debridement is the process of removing dead tissue Cleansing with an antimicrobial soap Chlorhexidine gluconate Dial soap or Shurclens for the face Mechanical ld debridement Performed during hydrotherapy Removal of eschar and blistered skin Enzymatic debridement 8

9 Wound Management Surgery Debridement Escharotomy Autografting Cultured epithelial l autographing Biologic and biosynthetic dressings Temporary material Prepares the burn wound for permanent autograft coverage Wound Management When burns extend to dermal layer, the skin is repaired through scar formation Hypertrophic scar Overgrowth of dermal tissue within the boundaries of the wound Keloid scar Extends beyond the boundaries of the original wound People with dark skin are at greater risk for scars Burn scars shrink and become fixed and inelastic, leading to contractures Wound Management Wound dressings Open Open to air and covered with the topical antimicrobial agent Closed Topical antimicrobial agent Gauze or nonadherent dressing Wet-to-dry dressings 9

10 Wound Management Splints used to prevent contractures Uniform pressure garments Reduces hypertrophic scarring May be required to wear for 6 months to 1 year postgraft Wound Management Complementary therapy Aloe gel for minor burns Burn Injury Nursing Care Assessment Time of injury Cause of injury First aid Past medical history Age Medications Body weight 10

11 Figure The rule of nines is a way to estimate the percentage of TBSA affected by a burn injury. This quick method is useful in emergency situations, but it is not accurate for adults who are short, obese, or very thin. Burn Injury Nursing Care Impaired Skin Integrity Deficient Fluid Volume Impaired Physical Mobility Imbalanced Nutrition: Less than Body Requirements Acute Pain Powerlessness Burn Injury Nursing Care Evaluation Wound healing Fluid status Absence of infection Adequate nutrition Pain relief Client perceptions of control of outcomes, treatment, and care Effectiveness of exercises and prevention of contractures 11

12 Burn Injury Nursing Care Client teaching in all phases Include family Establish short-term term and long-term goals Burn Injury Nursing Care Prevention of infection and deformity Fluid resuscitation Nutrition Wound healing Pain control Role of therapies Emotional support 12