BURN INJURY Sarah Bishop, Troy Davis, Laura Kiss-Illes Pathophysiology Burns are caused by a transfer of energy from a heat source to the body. Disruption of the skin can lead to increased fluid loss, infection, hypothermia, scarring, compromised immunity, and change in function and appearance of body. The depth of the injury depends on the temperature of the burning agent and the duration of contact with the agent. Types Thermal (includes electrical) Radiation Chemical http://www.youtube.com/watch?v=46hOeiN3Z3E Physiologic Changes Burns less than 25% total body surface area (TBSA) produce primarily a local response. Burns more than 25% may produce a local and systemic response, and are considered major burns. Systemic response includes release of cytokines and other mediators into systemic circulation. Fluid shifts and shock result in tissue hypoperfusion and organ hypofunction. Fluid and electrolyte shifts Fluid reenters the vascular space from the interstitial space Hemodilution Increased urinary output Sodium is lost with diuresis and due to dilution as fluid enter vascular space: hyponatremia Potassium shifts from extracellular fluid into cells: potential hypokalemia Metabolic acidosis Risk Factors Men have greater than twice the chance of burn injury than women Elderly because of reduced mobility, coordination, strength, and sensation. Vision changes also place them at high risk. Diabetics with neuropathy because they have decreased sensation Those with high risk jobs dealing with high heat Young Children General Goals Related to Burns Prevention Institution of lifesaving measures for the severely burned person Prevention of disability and disfigurement through early specialized and individualized care Rehabilitation through reconstructive surgery and rehabilitation programs Burn Severity Severity of Burn Injury Superficial Partial Deep-Partial Full Thickness Factors to consider How the injury occurred Causative agent Temperature of agent Duration of contact with the agent Thickness of the burn Phases of Burn Injury Emergent or resuscitative phase Onset of injury to completion of fluid resuscitation Acute or intermediate phase From beginning of diuresis to wound closure Rehabilitation phase From wound closure to return to optimal physical and psychosocial adjustment Emergent or Resuscitative Phase Prevent injury to rescuer Stop injury: extinguish flames, cool the burn, irrigate chemical burns ABCs: Establish airway, breathing, and circulation Start oxygen and large-bore IVs Remove restrictive objects and cover the wound Do assessment surveying all body systems and obtain a history of the incident and pertinent patient history Note: treat patient with falls and electrical injuries as for potential cervical spine injury Emergent or Resuscitative Phase Cont. Patient is transported to emergency department Fluid resuscitation is begun Foley catheter is inserted Patient with burns exceeding 20–25% should have an Ng inserted and placed to suction Patient is stabilized and condition is continually monitored Patients with electrical burns should have ECG Address pain; only IV medication should be administered Psychosocial consideration and emotional support should be given to patient and family Acute of Intermediate Phase 48–72 hours post injury Continue assessment and maintain respiratory and circulatory support Prevention of infection, wound care, pain management, and nutritional support are priorities in this stage Rehabilitation Phase Rehabilitation is begun as early as possible in the emergent phase and extend for a long period after the injury. Focus is upon wound healing, psychosocial support, self-image, lifestyle, and restoring maximal functional abilities so the patient can have the best quality life, both personally and socially. The patient may need reconstructive surgery to improve function and appearance. Vocational counseling and support groups may assist the patient. Treatments and Nursing Management Management of shock Fluid resuscitation Maintain blood pressure of greater than 100 mm Hg systolic and urine output of 30–50 mL/hr, maintain serum sodium at near-normal level Burn wound care Wound cleaning Hydrotherapy Use of topical agents Wound debridement Natural debridement Mechanical debridement Surgical debridement Wound dressing, dressing changes, and skin grafting Treatments and Nursing Management Burn wound care Wound cleaning Hydrotherapy Use of topical agents Wound debridement Natural debridement Mechanical debridement Surgical debridement Wound dressing, dressing changes, and skin grafting Treatments and Nursing Management Pain Management Analgesics Burn pain has been described as one of the most severe forms of acute pain Role of anxiety in pain Pain accompanies care, and treatments such as wound cleaning and dressing changes Nonpharmacologic measures Types of burn pain Background or resting Procedural Breakthrough Effect of sleep derivation on pain Treatment and Nursing Management Nutritional Support Burn injuries produce profound metabolic abnormalities, and patient with burns have great nutritional needs related to stress response, hypermetabolism, and requirement for wound healing. Goal of nutritional support is to promote a state of nitrogen balance and match nutrient utilization. Nutritional support is based upon patient preburn status and % of TBSA burned. Enteral route is preferred. Jejunal feedings are frequently utilized to maintain nutritional status with lower risk of aspiration in a patient with poor appetite, weakness, or other problems. Treatment and Nursing Management Other care to consider Pulmonary care Psychological support of patient and family Patient and family education Restoration of function Medications Analgesics IV use during emergent and acute phases Morphine Fentynal Other Fluids Lab/Diagnostic Tests Labs Potassium (will be high initially, then will be low) Sodium (will be low) Blood pH (metabolic acidosis) Hematocrit (will be high) Diagnostics Determine what percentage of your total body surface area (TBSA) is involved. Rule of nines, Lund and Browder method, Palm method Depending on the severity of the burn and the circumstances that caused it, you may need lab tests, X-rays or other diagnostic procedures. Nursing Diagnosis Impaired gas exchange r/t carbon monoxide poisoning, smoke inhalation, and upper airway obstruction AEB labored breathing, hoarseness and dry cough Goal Maintenance of adequate tissue oxygenation Interventions Provide humidified oxygen Assess breath sounds/respiratory rate/rhythm/depth/symmetry. Monitor patient for signs of hypoxia Monitor ABGs, pulse oximetry Prepare to assist with intubation Nursing Diagnosis Ineffective airway clearance r/t edema and effects of smoke inhalation AEB bloody sputum and difficulty getting rid of secretions, O2 <90% Goal Maintain patent airway and adequate airway clearance Interventions Maintain patent airway through proper positioning, removal of secretions, and artificial airway if needed. Provide humidified oxygen Encourage patient to turn, cough, deep breathe. Encourage patient to use incentive spirometry Suction as needed Nursing Diagnosis Fluid volume deficit r/t increased capillary permeability and evaporative losses from burn wound AEB decreased urine output Goal Restoration of optimal fluid and electrolyte balance and perfusion of vital organs Interventions Observe vital signs, urine output, and be alert for s/s of hypovolemia or fluid overload. Monitor urine output hourly, daily weights Maintain IV lines Observe for symptoms of deficiency or excess of serum electrolytes (sodium, potassium, calcium, phosphorus, and bicarbonate) Patient/Family Teaching Teach about the injury, treatment, complications and planned follow-up care to reduce anxiety of family and patient Assess psychological reactions to burns and address patient’s fears and concerns (providing them with support and available health care teams that can help. Also journal keeping may be helpful) Available support groups (usually located at burn facility) Home/self-care. Prepare patient and family for the care that will continue at home, which include: measures and procedures they will need to perform (wash small areas of clean, open wounds that are healing slowly with mild soap and water and apply topical agent/dressing), written/verbal instructions about pain management, nutrition, and prevention of complications; information about exercises and use of pressure garments and splints. How to recognize abnormal signs and to report them to physician Case Study Bill is a 54-year-old Asian male who sustained a full-thickness burn to 20% of his body while at work 3 days ago. He was exposed to a hot liquid at temperatures exceeding 180°F. The burn occurred primarily on his right arm, hand, and right side of his chest. He is currently hospitalized in a burn unit and is in stable condition. How do thermal burns reduce irreversible cellular injury? What is the impact of this degree and extent of burn on Bill’s cardiovascular system What is the role of escar formation in a full thickness burn? How are full thickness burns different than partial thickness burns with regard to clinical manifestations? What complications are likely given the severity Would the burn Bill sustained be classified as minor, moderate, or major given the American Burn Association Classification?