BURN

BURN

y

known as diuresis stage

y

Also

Involve destruction of  the epidermis, dermis, or

y

Starts about

subcutaneous layers of  the skin

y

Fluid

y

Edema

General Information y

3. Fluid- remobilization phase :

Can

be permanently disfiguring and incapacitating

General

Information

y

Associated

shifted back to vascular compartment at burn site decreased, blood flow to kidneys

increased, increased urine output

and possibly life-threatening y

48 hours after initial burn

y

Flui d

and electrolyte imbalances can still occur

imbalances result from alterations in skin

integrity and internal body membranes, and from

4. Convalescent phase:

effect of  heat on body water and solute loss that may

y

Begins after first two phases has been resolved

result from cellular destruction

y

Characterized

y

General

y

Type

wound

Information

and severity of  imbalance depends on burn type

by healing or reconstruction of  burn

y

Major fluid shifts now resolved but possible further

and depth, percentage body surface area involve d

fluid and electrolyte imbalances exist as a result of 

and burn phase

inadequate dietary intake y

Anemia

is common  severe burns typically destroy

red blood cells

Pathophysiology

1.Burn 1. Burn Phase: Refer to stage that describe physiologic changes

Characteristics

occurring after a burn

1. Minor Burns a) Partial thickness burns are no greater than 15% of  the TBSA in the adult

2. Fluid-accumulation phase:

b) Full thickness burns are < 2% of  the TBSA in the

from 36 to 48 hours after a burn injury

y

Last

y

Fluid

adult

shifts from vascular compartment to

c) Burn areas do not involve the eyes, ears, hands,

interstitial space  third-space shift  y

Edema

face, feet, or perineum

caused by shifted fluid, which typically

d) There are no electrical burns or inhalation injuries

reaches maximum within 8 hours after injury y

Circulation

possibly compromised and pulses

diminished from severe edema

The

client is an adult younger than 60 y.o.

f)

The

client has no preexisting medical condition at

the time of  the burn injury

 Several reasons for fluid imbalances during fluid-

g) No other injury occurred with the burn

accumulation phase Damage

e)

to capillaries causing altered vessel

permeability Diminished

kidney perfusion

2.

Moderate Burns a) Partial thickness burns are deep and are 15% to the TBSA in the adult 25% of 

stress hormones such Production and release of  as aldosterone and ADH

b) Full thickness burns are 2% to 10% of  the TBSA in the adult

Respiratory problems Muscle and tissue injuries GI

c) Burn areas do not involve the eyes, ears, hands, face, feet, or perineum

problems

Electrolyte

imbalances:

d) There are no electrical burns or inhalation injuries

- Common during fluid accumulation phase due

e)

The

client is an adult younger than 60 y.o.

to bodys hypermetabolic needs and priority that

f)

The

client has no chronic cardiac, pulmonary, or

fluid replacement takes over nutritional needs

during emergency phase

endocrine disorder at the time of  the burn injury g) No other complicated injury occurred with the burn

1

3.

Major Burns

Third degree

a) Partial thickness burns are > 25% of  the TBSA in

Assessment of

the adult

y

b) Full thickness burns are > 10% of  the TBSA c) Burn areas involve the eyes, ears, hands, face, feet, or perineum

d)

The

Extent

Destruction of  epithelial

cells  epidermis and dermis

destroyed y

Reddened areas do not blanch with pressure.

y

Not painful; inelastic; coloration varies from waxy

burn injury was an electrical or inhalation

white to brown; leathery devitalize d tissue is called

injury

eschar.

e)

The

client is older than 60 y.o.

f)

The

client has a chronic cardiac, pulmonary, or

metabolic disorder at the time of  the burn injury

y

Destruction of  epithelium,

fat, muscles, and bone.

Reparative Process y

g) Burns are accompanied by other injuries

Eschar

must be removed. Granulation tissue forms to

nearest epithelium from wound margins or support graft.

Assessment First

of Burn Injury

Degree

Assessment of

Extent

y

Pink to red: slight edema, which subsides quickly.

y

Pain may last up to 48 hours.

y

Relieved by cooling.

y

Sunburn is a typical example.

For

y

Expect

y

Area

scarring and loss of  skin function.

requires debridement, formation of  granulation

tissue, and grafting.

Burn Classification

Reparative Process y

areas larger than 3-5 cm, grafting is required.

y

In about 5 days, epidermis peels, heals

Superficial (1°

burns)

y

Involve only the epidermal layer of  the skin.

y

sunburns are commonly first-degree burns.

spontaneously. y

Itching and pink skin persist for about a week.

y

No scarring.

y

Heals

Partial thickness (2°burn) y

spont. If  it does not become infected w/in 10

days - 2 weeks.

blisters indicates superficial partialPresent of 

thickness injury. y

Blister may

size because continuous exudation and

collection of  tissue fluid. Second degree Assessment of

y

Extent

glands, reduction of  secretions and perspiration.

Pink or red; blisters form (vesicles); weeping, edematous, elastic.

y

Superficial layers of  skin are

Full thickness (third-degree burn)

destroyed; wound moist

y

and painful. Deep y

dermal:

Mottled white and red: edematous reddened areas blanch on pressure.

y

May be yellowish but soft and elastic  may or may Hair

does not pull out easily

Reparative Process several weeks to heal.

y

Takes

y

Scarring may occur.

Destruction of  the

epidermis and the entire dermis,

subcutaneous layer, muscle and bone. y

Nerve ending are destroyed-painless wound.

y

Eschar

y

coagulate capillaries may be seen. Black networks of 

y

Need skin grafting because the destroyed tissue is

not be sensitive to touch; sensitive to cold air. y

phase of  partial thickness, itching and

sebaceous dryness because vascularization of 

Superficial: y

Healing

may be formed due to surface dehydration.

unable to epithelialize. y

Deep

partial-thickness burn may convert to a full-

thickness burn because of  infection, trauma or

blood supply.

2

Radiation Burns:

Extent of surface area burned y

y

y

Rule of  nines-An estimated of  the TBSA involved as a

- caused by exposure to UV light, x-rays, or radioactive

result of  a burn.

source

The

Electrical Burns:

rule of  nines measures the percentage of  the

body burned by dividing the body into multiples of 

- Caused by heat generated by electrical energy as it

nine.

passes through the body

The

initial evaluation is made upon arrival at the

Results in internal tissue damage - Cutaneous burns cause muscle and soft tissue damage

hospital.

that may be extensive, particularly in high voltage electrical injuries

Lund and Browder y

estimating More precise method of 

- Alternating current is more dangerous than direct

y

various Recognizes that the percentage of  BSA of 

current because it is associated with CP arrest,

anatomic parts.

ventricular fibrillation, tetanic muscle contractions, and

y

By

long bone or vertebral fractures

divi ding the body into very small areas and

Potential Imbalance

BSA accounted providing an estimate of  proportion of 

Hypovolemia

for by such body parts y

y

Includes, a table indicating the adjustment for Head

and trunk represent larger proportions of  body

y

Occurs because of  the third space shift causes

multiple effects:

surface in children. y

Lund

plasma volume lost into tissue 10% of 

soon after a severe burn

different ages y

Approximately

With burns damage to the skin surface, decrease in

skins ability to prevent water loss; patient can lose up

and Browder chart

to 8L of  fluid per day (400ml/hour) Age

in years

0

1

5

10

15

Adult

y

Potential for blood loss, adding to fluid volume losses

Hypervolemia A-head

(back

9½

8½

6½

5½

4½

3½

or front)

y

Usually develops 3 to 5 days after a major burn injury

y

Occurs

during the fluid remobilization phase, as fluid

shifts from the interstitial space back to the vascular B-1 thigh

2¾

3¼

4

4¼

4½

compartment

4¾ y

(back or

May be exacerbated by excessive administration of  I.V. fluids

front)

Hyperkalemia / Hypokalemia C -1

leg (back

2½

2½

2¾

3

3¼

3½

or front)

Hypocalcemia Hyponatremia / Hypernatremia Metabolic acidosis Respiratory acidosis

TYPES OF BURNS Thermal Burns: - caused by exposure to flames, hot liquids, steam or hot objects

Chemical Burns: - Caused by tissue contact with strong alkali, or organic compounds - Systemic toxicity from cutaneous absorption can

NURSING PRIORITY The

client with burn injury is often awake, mentally

alert, and cooperative at first. The level of  consciousness may change as respiratory status change or as the fluid shift occurs, precipitating hypovolemia. If  the client is unconscious or confused, assess him or her for the possibility of  a head injury.

occur

3

Assess

for:

y

Patent airway

y

adequate breath sounds Presence of 

y

Symptoms of  hypoxia

y

Pulmonary damage - Burns around the face, neck, mouth or in the oral mucosal area

y

Circulatory

status

- Tachycardia and hypotension occur early - Elevate UO function  check last time client ate

y

GI

y

Flui d

status

- UO (30 ml/hr) - Hypotension (< 90/60) - Confusion / disorientation y

Circulatory

status of  the extremities

Treatment y

Respiratory status takes priority over the treatment of  the burn injury

y

If  burn area is small  cold compress or immerse in cool water (not ice) to  heat

y

May have ointment on the burn area

y

Analgesics

IV, IM, SQ  . oral forms may not be absorbed

effectively

Nursing intervention y

Maintain patent airway; prevent hypoxia

y

Evaluate

y

Prevent of  decrease infection

y

Maintain nutrition

y

Prevent contractures and scarring

y

Promote acceptance and adaptation to alterations in

fluid status; determine circulatory status

body image

Considerations AGE AND GENERAL HEALTH y

Mortality rates are higher for children < 4 y.o, particularly those < 1 y.o., and for clients over the age of  60 years.

y

Debilitating

disorders, such as cardiac, respiratory,

endocrine, and renal d/o, negatively influence the clients response to injury and treatment. y

Mortality rate is higher when the client has a preexisting disorder at the time of  the burn injury

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