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N124Prof. MGAP Batalla

7/19/12

Nursing Care of the Burn Patient

Anatomy and Physiology of the Skin

Skin

-

Largest organ

-

Parts: epidermis and dermis

-

Functions:

o Maintains body temperature

o

Acts as a barrier to water loss

o Produces Vit. D

Every 15 minutes in the sun

o Prevents microbes from entering the body

o Protects against environment

o Cosmetic

Burn

-

Injury that is d/t tissue damage or loss

-

Extent depends on:

o Temperature

o

Causticity of the burning agent

o

Duration of tissue contact with source (

length of exposure)

1 sec with hot tap water at 69

degrees Celsius: full thickness

burn

15 sec with hot water 15 degrees

Celsius: full thickness burn

Zones of injury

Jacksons thermal wound theory: zones of injury

-

Areas extending outward from the center area of

injury that sustain various degrees of damage

1.

Zone of coagulation

Most severe damage

Irreversible death occurs (no more

blood supply)

2.

Zone of stasis

Impaired circulation

Potentially salvageable

48-72 hours to determine extent

of damage

3.

Zone of hyperemia

Vasodilation and increased blood

flow

Minimal cell involvement

Early spontaneous recovery

Classification of burn injuries

Burn severity

Factors:

-

Depth and size

-

Body surface area burned

-

Age

- Preexisting medical condition

-

Associated trauma

o Blast

o fall

o Airway compromise

o Child abuse

Types of burn injuries

1.

Thermal burn

a.

From scalds, steam, and contact with

heat

b.

Tanning machines, radiation therapy

2.

Chemical

3.

Electrical

4.

Radiation

Depth classification

1.

Superficial (1stdegree)

a.

2 3 layers of the epidermis

b.

Usually heals in 2-7 days

c.

E.g. sunburn, minor steam burns

d.

Assessment findings

i.

Reddening

ii.

Tenderness and pain

iii.

Increased warmth

iv.

Blanches with pressure

v.

Edema may occur

vi. w/o blistering

2.

Partial thickness (2nd

degree)

a.

Upper third of the dermis

i. Superficial

1.

Light to bright red or

mottled

2.

Shiny appearance

3.

May contain bullae,

moist/wet weeping

4.

Very painful (due to

exposed nerve endings)

5.

Heals in 7-21 days

ii.

Mid-dermal

1.

Half the dermis is

destroyed

2.

Heals in 4-6 weeks

iii.

Deep-dermal

1.

Involves majority of the

dermal layer

2.

Red and dry with white

areas in deeper parts

3.

Healing is 4-10 weeks or

longer

4.

There is a certain degree

of pain (unlike 3rd

degree, no pain)

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3.

Full thickness (3rddegree)

a. All skin layers and sq fat are destroyed

b.

Painless

c.

Pain d/t intermixing with 2nd

degree burn

d.

Thick , dry, leathery

e.

Pale white/pearly grey/charred black, red,

brown

f.

Requires grafting

Size of injury

1.

Rule of nines

a.

The body surface is divided into areas

representing 9% or multiple

i.

9% head

ii.

9% arm

iii.

1% perineum

iv.

18% leg

v.

18% posterior trunk

vi.

18% anterior

2.

Palm rule

a. 1 % of body surface

3.

Lunder and browder

a.

Depends on age

*estimating TBSA (total body surface area) for fluid loss;

1stdegree burn is not included

Special considerations

-

Location

-

Age

o 60

Pediatric burns

-

thin skin

-

Delicate balance

- Large surface/volume ration

o Rapid fluid loss

-

Immature immunological response/sepsis

-

Always consider possibility of child abuse

Geriatric burns

-

less myocardial reserve

-

fluid resuscitation diff

-

PVD, DM,

o Slow healing

COPD

Complication of airway injury

poor immunological response

o Increase risk for sepsis

% of mortality is approx.: age + % BSA burned

Burn configuration

- circumferential burns can cause total occlusion of

circulation to an area d/t edema

Minor burn criteria

- 3 degree < 2% BSA

- 2nd

degree < 15 % BSA (10 % BSA

-

2 >30 % BSA (>20 % BSA pedia)

-

Burns with respiratory injury

-

Underlying health problems

-

Hands, face, feet or genitalia

-

Burns complicated by other trauma

Phases of burn management

1.

Resuscitation phase

2.

Acute phase

3.

Rehabilitation phase

Goals of initial burn management

1.

Save lives

2.

Minimize disability

3.

Prepare for definitive care

Initial Burn Management

-

ABC!

Respiratory Management

-

Circumferential full-thickness eschar to chest wall

can lead to decreased chest wall expansion and

compliance = chest wall restriction = CO2 retention

o Eschar

Black gulaman (Centillo, 2012)

Tough inelastic mass of burnt

tissue

May cause compartment

syndrome

Escharotomies may increase

compliance (too relieve pressure

of the burn area)

Circulatory Management

-

IV access

-

Fluid restriction

-

Continuous ECG monitoring

-

Urine output, HR, BP and LOC monitoring

Parkland Formula

o

50% of calculated amount of fluid is given

in the first * hours after injury

o 25% is given in the second 8 hours

o 25% in the third 8 hours

Lactated Ringers: fluid resuscitant of choice, for plasma

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-

Wound debridement

o Removal tissue and eschar

Natural

Mechanical

surgical

-

Skin grafting

o

Full thickness skin graft

o Sources

Homografts

From dead people

Heterografts

From animals

Autografts

From self

Biosynthetic

Artificial

Synthetic dressing (nylon

with collagen derivative)

Psychosocial Problems of the Burn Patient

Acute phase

- Facing reality of burn trauma

-

Grieving over obvious losses

o Depression

o Regression

o

Manipulative behavior

o Withdrawal

o Anger

Rehab phase

-

Include the patient in decision making

-

Help patient set realistic self goals