Burns

Burns 150 150 Tony Guo

Burns

 

  • Occur when there is injury to tissues of body caused by heat, chemicals, electrical current, or radiation
  • Should be viewed as preventable

 

Types of burn injury

  • Thermal burns
    • Caused by lame, lash, scald, or contact with hot objects
  • Chemical burns
    • Contact with acids, alkalis, and organic compounds
    • Alkali burns (from cement, oven and drain cleaners, and heavy industrial cleansers) can be more difficult to manage than acid burns (from hydrochloric, oxalic, and hydrofluoric acid), since alkalis adhere to tissue, causing protein hydrolysis and liquefaction.
  • Smoke inhalation injury
    • From breathing noxious chemicals or hot air can cause damage to the respiratory tract. 
    • Three types of smoke and inhalation injuries can occur: 
      • Metabolic asphyxiation
        • Inhaling certain smoke elements, primarily carbon monoxide (CO) or hydrogen cyanide
        • Increasing carboxyhemoglobin blood levels by 20% leading to death 
      • Upper airway injury
        • Inhalation injury to the mouth, oropharynx, and/or larynx
      • Lower airway injury.
        • Injury to the trachea, bronchioles, and alveoli
  • Electrical burns
    • Intense heat generated from an electric current such that direct damage to nerves and vessels, causing tissue anoxia and death,
  • Cold thermal injury
    • Frostbite

 

Classification of burn injury

  • Severity of injury is determined by 
    • Depth of burn
      • Burns have been defined by degrees (first, second, third, and fourth)
      • ABA advocates categorizing burn according to depth of skin destruction
  • Partial-thickness burn
  • Superficial partial-thickness burn
  • Involves epidermis
  • Deep partial-thickness burn
  • Involves dermis
  • Full-thickness burn
  • Involves all skin elements, nerve endings, fat, muscle, bone
  • Extent of burn in percent of TBSA
    • Two commonly used guides for determining the total body surface area
  • Lund-Browder chart
  • Considered more accurate because the patient’s age, in proportion to relative body-area size, is taken into account
  • Rule of Nines
  • Used for initial assessment of a burn patient because it is easy to remember.
  • Sage Burn Diagram
  • Location of burn
    • Severity of the burn injury is also determined by the location of the burn
    • Burns to the face and neck and circumferential burns to the chest or back may interfere with breathing as a result of mechanical obstruction from edema or leathery, devitalized burn tissue (eschar)
    • Burns to the hands, feet, joints, and eyes are of concern because they make self-care difficult and may affect future function
  • Patient risk factors
    • Any patient with preexisting heart, lung, or kidney disease has a poorer prognosis for recovery because of the increased demands placed on the body by a burn injury

 

Phases of burn management

  • Emergent (resuscitative)
    • Phase is the time required to resolve the immediate, life-threatening problems resulting from the burn injury
  • Acute (wound healing)
    • Begins with mobilization of extracellular fluid and subsequent diuresis
    • Concludes when 
      • Partial thickness wounds are healed and/or 
      • Full thickness burns are covered by skin grafts
    • Pathophysiology
      • Diuresis from fluid mobilization occurs, and patient is less edematous
      • Bowel sounds return
      • Healing begins as WBCs surround burn wound and phagocytosis occurs
      • Necrotic tissue begins to slough
      • Granulation tissue forms
      • Partial-thickness burn wounds heal from edges and from dermal bed
      • Full-thickness burns must have eschar removed and skin grafts applied
    • Clinical manifestation
      • Partial-thickness wounds form eschar
  • Once eschar is removed, reepithelialization begins
  • Full-thickness wounds require debridement
  • Nursing/Interprofessional management
    • Wound care
  • Daily observation
  • Assessment
  • Cleansing
  • Debridement 
  • Dressing reapplication
  • Appropriate coverage of graft
  • Gauze next to graft followed by middle and outer dressings
  • Unmeshed sheet grafts used for facial grafts 
  • Grafts are left open
  • Complication: Blebs
  • Monitor for electrolyte imbalance
  • Excision and grafting
  • Pain management
  • Patients experience two kinds of pain
  • Continuous background pain
  • IV infusion of an opioid
  • Or slow-release, twice-a-day oral opioid
  • Treatment-induced pain
  • Analgesic and an anxiolytic
  • Non-pharmacologic strategies
  • Relaxation breathing
  • Visualization, guided imagery
  • Hypnosis
  • Biofeedback
  • Music therapy
  • Physical and occupational therapy
  • Good time for exercise is during wound cleaning
  • Passive and active ROM
  • Splints should be custom-fitted
  • Nutritional therapy
  • Meeting daily caloric requirements is crucial
  • Caloric needs should be calculated by dietitian
  • High-protein, high-carbohydrate foods
  • Monitor laboratory values
  • Complication
    • Infection
    • Decreased ROM
    • Contractures
    • Paralytic ileus
    • Diarrhea
    • Constipation
    • Curling’s ulcer
    • Increased blood glucose levels
    • Increased insulin production
    • Hyperglycemia
  • Rehabilitative (restorative)
    • The rehabilitation phase begins when 
      • Wounds have healed 
      • Patient is engaging in some level of self-care

 

Gerontologic considerations

  • Normal aging puts the patient at risk for injury because of the possibility of
  • Unsteady gait
    • Limited eyesight
    • Diminished hearing
    • The fact that wounds take longer to heal

    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
    • Family and patient support groups

    Special needs of nursing staff

    • You may find it difficult to cope with burn injuries
    • Know you provide care that makes a critical difference
    • Practice good self-care

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