4/1/2011

BURN INJURIES
Saepulloh, S.Kep, Ns

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 BURNS
Wounds caused by exposure to:
1. excessive heat
2. Chemicals
3. fire/steam
4. radiation
5. electricity

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 BURNS
Results in 10-20 thousand deaths annually
Survival best at ages 15-45

Children, elderly, and diabetics

Survival best burns cover less than 20% of TBA

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 TYPES OF BURNS
Thermal
exposure to flame or a hot object
Chemical
exposure to acid, alkali or organic substances
Electrical
result from the conversion of electrical energy into heat.
Extent of injury depends on the type of current, the
pathway of flow, local tissue resistance, and duration of
contact
Radiation
result from radiant energy being transferred to the body
resulting in production of cellular toxins
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THERMAL BURNS (CONT)

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Cover patient with a clean
cover

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Do NOT pull off clothing;
instead cut off clothing if
possibleWHY?
Keep respiration transport
Chemical Burns

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Remove person from
contact with agent

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Flush with water
continuously
Remove affected clothing
if possible
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Electrical burns
Coagulation necrosis

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Severity depends on voltage, amount
of resistance, time,
and current
pathways.
 Frequently only entry (yellow-
white) and exit (blow out) wounds

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are visible

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Extensive tissue damage is masked
ELECTRICAL BURNS (CONT)

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Patient at risk for
arrhythmias due to (1)_____,

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metabolic acidosis due to
(2)_____, and acute tubular
necrosis due to (3)______.

Current can be so strong to

fracture long bones and
cause respiratory muscles
to contract
INTERVENTIONS FOR ELECTRICAL BURNS

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Turn off source of electricity
if possible

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Remove current with dry
piece of wood
Initiate CPR and Transport
 CHEMICAL BURN

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 ELECTRICAL BURN

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 BURN WOUND ASSESSMENT
Classified according to depth of injury and
extent of body surface area involved
Burn wounds differentiated depending on
the level of dermis and subcutaneous
tissue involved
1. superficial (first-degree)
2. deep (second-degree)
3. full thickness (third and fourth
degree)

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 SUPERFICIAL BURNS
(FIRST DEGREE)
Epidermal tissue only affected
Erythema, blanching on pressure, mild swelling

no vesicles or blister initially

Not serious unless large areas involved
Sunburn, UV light, mild radiation,

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 DEEP (SECOND DEGREE)
*Involves the epidermis and deep layer of the
dermis
Fluid-filled vesicles red, shiny, wet, severe pain
Hospitalization required if over 25% of body surface
involved, Moist or dry,
i.e. tar burn, flame

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 FULL THICKNESS
(THIRDDEGREE)
Destruction of all skin layers
Requires immediate hospitalization

Dry, waxy white, leathery, or hard skin, no pain

Exposure to flames, electricity or chemicals can

cause 3rd degree burns

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CALCULATION OF BURNED BODY
SURFACE AREA

Calculation of Burned
Body Surface Area

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TOTAL BODY SURFACE AREA
(TBSA)
Superficial burns are not involved in the
calculation
Lund and Browder Chart is the most accurate
because it adjusts for age
Rule of nines divides the body adequate for
initial assessment for adult burns

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LUND BROWDER CHART USED FOR
DETERMINING BSA

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Evans, 18.1, 2007)
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RULES OF NINES

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 VASCULAR CHANGES
RESULTING FROM BURN
INJURIES
Circulatory disruption occurs at the burn
site immediately after a burn injury
Blood flow decreases or cease due to
occluded blood vessels
Damaged macrophages within the tissues
release chemicals that cause constriction
of vessel
Blood vessel thrombosis may occur
causing necrosis
Macrophage: A type of white blood that ingests (takes in) foreign
material. Macrophages are key players in the immune response to
foreign invaders such as infectious microorganisms.

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 FLUID SHIFT
Occurs after initial vasoconstriction, then
dilation
Blood vessels dilate and leak fluid into
the interstitial space
Known as third spacing or capillary leak
syndrome
Causes decreased blood volume and blood
pressure
Occurs within the first 12 hours after the
burn and can continue to up to 36 hours
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 FLUID IMBALANCES
Occur as a result of fluid shift and cell
damage
Hypovolemia

Metabolic acidosis

Hyperkalemia

Hyponatremia

Hemoconcentration (elevated blood

osmolarity, hematocrit/hemoglobin) due to
dehydration

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 FLUID REMOBILIZATION
Occurs after 24 hours
Capillary leak stops

See diuretic stage where edema fluid

shifts from the interstitial spaces into the
vascular space
Blood volume increases leading to
increased renal blood flow and diuresis
Body weight returns to normal

See Hypokalemia

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 CURLINGS ULCER
Acute ulcerative gastro duodenal disease
Occur within 24 hours after burn
Due to reduced GI blood flow and mucosal
damage
Treat clients with H2 blockers, mucoprotectants,
and early enteral nutrition
Watch for sudden drop in hemoglobin

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 PHASES OF BURN INJURIES
Emergent (24-48 hrs)
Acute

Rehabilitative

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 EMERGENT PHASE
*Immediate problem is fluid loss, edema,
reduced blood flow (fluid and electrolyte
shifts)
Goals:
1. secure airway
2. support circulation by fluid
replacement
3. keep the client comfortable with
analgesics
4. prevent infection through wound care
5. maintain body temperature
6. provide emotional support
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 EMERGENT PHASE
Knowledge of circumstances surrounding the
burn injury
Obtain clients pre-burn weight (dry weight) to
calculate fluid rates
Calculations based on weight obtained after fluid
replacement is started are not accurate because
of water-induced weight gain
Height is important in determining body surface
area (BSA) which is used to calculate nutritional
needs
Know clients health history because the
physiologic stress seen with a burn can make a
latent disease process develop symptoms
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 EMERGENT PHASE (CONT)

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Also called FLUID ACCUMULATION

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PHASE
The greatest initial threat to a major
burn victim is hypovolemic shock
See outline for detailsthis is a DING
DING!
 CLINICAL MANIFESTATIONS IN THE
EMERGENT PHASE
Clients with major burn injuries and with inhalation injury
are at risk for respiratory problems
Inhalation injuries are present in 20% to 50% of the clients
admitted to burn centers
Assess the respiratory system by inspecting the mouth, nose,
and pharynx
Burns of the lips, face, ears, neck, eyelids, eyebrows, and
eyelashes are strong indicators that an inhalation injury may
be present
Change in respiratory pattern may indicate a pulmonary
injury.
The client may: become progressively hoarse, develop a brassy
cough, drool or have difficulty swallowing, produce expiratory
sounds that include audible wheezes, crowing, and stridor
Upper airway edema and inhalation injury are most common
in the trachea and mainstem bronchi
Auscultate these areas for wheezes
If wheezes disappear, this indicates impending airway
obstruction and demands immediate intubation 39
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 CLINICAL MANIFESTATIONS
Cardiovascular will begin immediately
which can include shock (Shock is a
common cause of death in the emergent
phase in clients with serious injuries)
Obtain a baseline EKG

Monitor for edema, measure central and

peripheral pulses, blood pressure,
capillary refill and pulse oximetry

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 CLINICAL MANIFESTATIONS
Changes in renal function are related to
decreased renal blood flow
Urine is usually highly concentrated and
has a high specific gravity
Urine output is decreased during the first
24 hours of the emergent phase
Fluid resuscitation is provided at the rate
needed to maintain adult urine output at
30 to 50- mL/hr.
Measure BUN, creat and NA levels

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 CLINICAL MANIFESTATIONS
Sympathetic stimulation during the
emergent phase causes reduced GI
motility and paralytic ileus
Auscultate the abdomen to assess bowel
sounds which may be reduced
Monitor for n/v and abdominal distention
Clients with burns of 25% TBSA or who
are intubated generally require a NG tube
inserted to prevent aspiration and
removal of gastric secretions

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 SKIN ASSESSMENT
Assess the skin to determine the size and
depth of burn injury
The size of the injury is first estimated in
comparison to the total body surface area
(TBSA). For example, a burn that
involves 40% of the TBSA is a 40% burn
Use the rule of nines for clients whose
weights are in normal proportion to their
heights

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 IV FLUID THERAPY
Infusion of IV fluids is needed to maintain sufficient
blood volume for normal CO
Clients with burns involving 15% to 20% of the TBSA
require IV fluid
Purpose is to prevent shock by maintaining adequate
circulating blood fluid volume
Severe burn requires large fluid loads in a short time
to maintain blood flow to vital organs
Fluid replacement formulas are calculated from the
time of injury and not from the time of arrival at the
hospital
Diuretics should not be given to increase urine output.
Change the amount and rate of fluid administration.
Diuretics do not increase CO; they actually decrease
circulating volume and CO by pulling fluid from the
circulating blood volume to enhance diuresis
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 COMMON FLUIDS
Protenate or 5% albumin in isotonic saline (1/2
given in first 8 hr; given in next 16 hr)
LR (Lactate Ringer) without dextrose (1/2 given
in first 8 hr; given in next 16 hr)
Crystalloid (hypertonic saline) adjust to maintain
urine output at 30 mL/hr
Crystalloid only (lactated ringers)

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 ParklandBaxter Formula
Most widely used

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Formula:

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LR 4ml X Kg body weight X
TBSA% burned

that total amt. given 1st 8

hours
that total amt. given each
next 8 hours
OKAY NURSES LETS CALCULATE

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(4). What would the fluid
replacement be for patient who

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weighed 60kg and had 30%
TBSA burned???

1st 8 hours= _____or ____cc/hr

2nd 8 hours= _____or ____cc/hr
3rd 8 hours= _____or ____cc/hr
 NURSING DIAGNOSIS IN THE
EMERGENT PHASE
Decreased CO
Deficient fluid volume r/t active fluid volume loss

Impaired Gas Exchange

Ineffective Tissue perfusion

Ineffective breathing pattern

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EMERGENT PHASE (CONT)

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Renal Failure

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Hypovolemia (Why?)
blood flow to kidneys

Renal ischemia
ARF may develop
EMERGENT PHASE (CONT)

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Renal Failure

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Full thickness & electrical
burns
Myoglobin from muscle cells
released
Hgb (from RBCs
breakdown) released into
bloodstream
Blocks renal tubules
EMERGENT PHASE (CONT)

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What is the treatment for these 2 renal
problems????

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 Summary of Emergent Phase:

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ACUTE PHASE OF BURN INJURY
BEGINS AFTER 48-72 HOURS
Lasts until wound closure is complete
Care is directed toward continued assessment and
maintenance of the cardiovascular and respiratory
system
Pneumonia is a concern which can result in respiratory
failure requiring mechanical ventilation
Infection (Topical antibiotics Silvadene)
Tetanus toxoid
Weight daily without dressings or splints and compare
to pre-burn weight
A 2% loss of body weight indicates a mild deficit
A 10% or greater weight loss requires modification of
calorie intake
Monitor for signs of infection

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 LOCAL AND SYSTEMIC SIGNS
OF INFECTION- GRAM
NEGATIVE BACTERIA
Pseudomonas, Proteus
May led to septic shock
Conversion of a partial-thickness injury to a full-thickness
injury
Ulceration of health skin at the burn site
Erythematous, nodular lesions in uninvolved skin
Excessive burn wound drainage
Odor
Sloughing of grafts
Altered level of consciousness
Changes in vital signs
Oliguria
GI dysfunction such as diarrhea, vomiting
Metabolic acidosis

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 LAB VALUES
Na hyponatremia or Hypernatremia
K Hyperkalemia or Hypokalemia

WBC 10,000-20,000

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 NURSING DIAGOSIS IN THE
ACUTE PHASE
Impaired skin integrity
Risk for infection

Imbalanced nutrition

Impaired physical mobility

Disturbed body image

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 PLANNING AND
IMPLEMENTATION
Nonsurgical management: removal of exudates
and necrotic tissue, cleaning the area,
stimulating granulation and revascularization
and applying dressings. Debridement may be
needed

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 DRESSING THE BURN WOUND
After burn wounds are cleaned and debrided,
topical antibiotics are reapplied to prevent
infection
Standard wound dressings are multiple layers of
gauze applied over the topical agents on the burn
wound

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 REHABILITATIVE PHASE OF
BURN INJURY
Started at the time of admission
Technically begins with wound closure
and ends when the client returns to the
highest possible level of functioning
Provide psychosocial support
Assess home environment, financial
resources, medical equipment, prosthetic
rehab
Health teaching should include symptoms
of infection, drugs regimens, f/u
appointments, comfort measures to reduce
pruritus
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 DIET
Begin oral fluids after bowel sounds return
Do not give ice chips or free water lead to
electrolyte imbalance
High protein, high calorie

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 GOALS
Prevent complications (contractures)
Vital signs hourly
Assess respiratory function
Tetanus booster
Anti-infective
Analgesics
No aspirin
Strict surgical asepsis
Turn q2h to prevent contractures
Emotional support

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 DEBRIDEMENT
Done with forceps and curved scissor or through
hydrotherapy (application of water for treatment)
Only loose eschar removed

Blisters are left alone to serve as a protector

controversial

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 SKIN GRAFTS
Done during the acute phase
Used for full-thickness and deep partial-
thickness wounds

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 POST CARE OF SKIN GRAFTS
Maintain dressing
Use aseptic technique
Graft should look pink if it has taken after 5 days
Skeletal traction may be used to prevent
contractures
Elastic bandages may be applied for 6 mo to 1
year to prevent hypertrophic scarring

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REHABILITATION PHASE

10/25/2017
Instruct client to wear JoBST pressure
garment up to 1 year

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 4/1/2011
THE END
PERTANYAAN ?
PERNYATAAN !
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