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Chapter 66: Caring for Clients w/ Burns

front 1

Shifts in fluids and electrolytes w/ burn clients

back 1

AFTER A BURN, FLUID FROM THE BODY MOVES TO THE BURNED AREA, WHICH ACCOUNTS FOR EDEMA AT THE BURN SITE

SOME OF THE FLUID IS THEN TRAPPED IN THIS AREA AND RENDERED UNAVAILABLE FOR USE BY TEH BODY, LEADING TO INTRAVASCULAR FLUID DEFICIT

DECREASED BLOOD PRESSURE FOLLOWS

IF PHYSIOLOGIC CHANGES ARE NOT IMMEDIATELY RECONGIZED AND CORRECTED, IRREVERSIBLE SHOCK IS LIKELY

ANEMIA DEVELOPS B/C HEAT LITERALLY DESTROYS ERYTHROCYTES

front 2

What does a burn assessment include?

back 2

  • DETERMINATION OF THE DEPTH OF THE BURN
  • CONSIDERATION OF THE ZONES OF THE BURN INJURY
  • AN ESTIMATION OF THE EXTENT OF THE BURN INJURY BASED ON THE PERCENTAGE OF THE TOTAL BODY SURFACE AREA THAT HAS BEEN BURNED

front 3

This client presents w/:

  • sore throat
  • singed nasal hairs, eyebrows, eyelashes
  • hoarseness
  • carbon in sputum
  • soot around the mouth or nose
  • SOB
  • stridor

back 3

SIGNS OF HEAT OR SMOKE INHALATION INJURY

front 4

This burn is similar to a sunburn

  • epidermis is injured, dermis is UNAFFECTED
  • burn is red and painful
  • heals in less than 5 days
  • infection, increased metabolisms and scarring doesn't occur

back 4

SUPERFICIAL BURN

front 5

This burn:

  • affects the epidermis and dermis
  • hair follicles remain intact
  • client has mottled pink to red, painful, blistered or exuding fluid, blanches w/ pressure

back 5

SUPERFICIAL PARTIAL THICKNESS BURN

front 6

This burn:

  • affects the deeper layer of the dermis w/ damage to sweat and sebaceous glands
  • client has a variable color from patchy red to white, wet or waxy dry, doesn't blanch w/ pressure, sensitive to pressure only

back 6

Deep partial thickness

front 7

This burn:

  • affects the epidermis, dermis, and subcutaneous tissue (fat, fascia, muscle, bone)
  • destroys all layers of the skin
  • experiences NO pain
  • tissue appears lifeless
  • IF NOT DEBRIDED, THIS BURN CAN LEAD TO SEPSIS, EXTENSIVE SCARRING, AND CONTRACTURES
  • WILL NEED A SKIN GRAFT

back 7

FULL-THICKNESS BURN (3RD AND 4TH DEGREE BURNS)

front 8

a quick initial method of estimating how much of the client's skin surface is involved in a burn injury

back 8

"RULE OF NINES"

  • BE SURE TO LOOK OVER PERCENTAGES FOR EACH BODY PART FOR THE TEST!

front 9

What is the most accurate method of assessing TBSA?

back 9

LUND AND BROWDER METHOD

front 10

Initial first aid medical management for clients w/ burn injuries?

back 10

  • IF CLOTHING IS ON FIRE, CLIENT IS PLACED HORIZONTALLY ROLLED IN A BLANKET TO SMOTHER FIRE
  • LAY CLIENT FLAT
  • CLIENT IS TAKEN TO HOSPITAL FOR EXAMINATION
  • O2 AND IV THERAPY BEGINS

front 11

Acute care medical management for clients w/ burn injures?

back 11

  • MEDICAL TEAM ASSESS EXTENT OF BURN INJURY QUICKLY
  • MAINTAIN ADEQUATE VENTILATION AND INITIATE FLUID RESUSCITATION
  • VICTIMS OF CARBON MONOXIDE MAY REQUIRE HYPERBARIC OXYGEN TREATMENT
  • BLOOD SAMPLES ARE DRAWN
  • IV THERAPY (LACTATED RINGER'S AND OTHER COLLOID/CRYSTALLOID SOLUTIONS)
  • LOW DOES OF DOPAMINE TO ENSURE RENAL PERFUSION
  • IV ANALGESICS (MORPHINE)
  • TETANUS IMMUNIZATION

front 12

Wound management for clients w/ burn injuries?

back 12

  • REMOVE ALL OF THE CLIENT'S CLOTHES
  • HEALTH CARE PROVIDERS WEAR POWDER FREE STERILE GLOVES TO REDUCE ACCUMULATION OF DEBRIS
  • BURNED AREAS ARE CLEANSED TO REMOVE DEBRIS
  • AFTER CLEANSING, TOPICAL ANTIMICROBIAL MEDS ARE APPLIED
  • WOUND IS EITHER LEFT UNCOVERED OR COVERED
  • WOUND IS THEN COVERED W/ A SKIN GRAFT OR SKIN SUBSTITUE OR APPLYING CULTURED SKIN

front 13

Exposure method

  • exposes the burned areas to air
  • virtually abandoned since the advent of effective topical antimicrobials
  • client is placed in isolation in a bed w/ sterile linen; healthcare members and visitors wear sterile gowns an masks;
  • skin of client is sensitive to drafts and temperature changes; therefore, a bed cradle or sheets are placed over client
  • room is kept warm and humidified
  • ESCHAR HAS TO BE REMOVED; PRONE TO INFECTION

back 13

OPEN METHOD

front 14

Current preferred method of wound management b/c it creates a microbial barrier, reduces heat loss through evaporation, provides a moist environment that facilitates healing

  • burn area is covered w/ nonabsorbent or absorbent dressings; gauze is impregnated w/ petroleum jelly or topical antimicrobials in solution cream, or ointment-based compounds
  • final covering is an occlusive or semi-occlusive dressing that is minimally permeable to water and oxygen
  • MAKE SURE DRESSING IS NOT TIGHT!!

back 14

CLOSED METHOD

front 15

Medications that help treat burns:

back 15

  • MUPIROCIN
  • BACITRACIN
  • SILVER NITRATE
  • SILVER SULFADIAZINE
  • ALL DRUGS ARE APPLIED USING STERILE TECHNIQUE!!!!

front 16

Removal of necrotic tissue

  • potentially painful and warrants premedication w/ an analgesic
  • disadvantage is bleeding, which can lead to secondary healing due to low RBC counts
  • tissue is to be covered w/ antimicrobial dressing, temporary skin substitute, skin graft, or cultured skin

back 16

Wound debridement

front 17

When a wound dressing alone is no longer appropriate for covering large areas of burn tissue, these may become advantageous?

back 17

  • SKIN SUBSTITUTE
  • SKIN GRAFTING

front 18

Purposes of a skin substitute or graft?

back 18

  • lessen the potential for infection
  • minimize fluid loss by evaporation
  • diminish pain
  • promote regeneration of tissue
  • reduce scarring
  • prevent loss of function

front 19

graft obtained from animals (pigs or cows)

  • temporarily used to cover large areas
  • rejected by the body in days to weeks and must be removed and replaced at that time

back 19

XENOGRAFT

front 20

Biologic source of skin similar to that of a client

  • may be obtained from a cadaver, from human donor cells, or amniotic membranes
  • can be rejected by the body

back 20

ALLOGRAFT

front 21

Uses the client's own skin, which is transplanted from one part of the body to another

back 21

AUTOGRAFT

front 22

What are the DISADVANTAGES for a client harvesting their own tissue?

back 22

  • IT COMPOUNDS THE CLIENT'S PAIN B/C IT CREATES A NEW WOUND
  • DONOR SITE HAS THE POTENTIAL FOR SCARRING AND ATYPICAL PIGMENT CHANGES
  • THERE IS A POTENTIAL FOR DONOR SITE INFECTION
  • THERE IS A DELAY IN WOUND CLOSURE WHILE WAITING FOR THE DONOR SITE TO HEAL AND BE REHARVESTED
  • DELAYS CAUSED BY WAITING FOR HARVEST SITES TO HEAL INCREASE COSTS AND CHALLENGE THE CLIENT'S ABILITY TO COPE W/ PROLONGED HOSPITALIZATION

front 23

Nursing management for clients w/ burn injuries?

back 23

  • assess the wound and determine how the burn injury has affected the client's status
  • calculate fluid replacement requirements and infuses the prescribed volume according to the agency's protocol
  • s/s of shock are quickly recognized and efficiently tx'd
  • administer analgesics to relieve/reduce pain
  • wound is cleansed, an antimicrobial agent is applied, wound is covered w/ prescribed dressing
  • monitor the wound to determine any infection
  • client and family are supported
  • encourage the client to perform exercises that minimize contractures
  • encourage adequate nutrition and provides supplements as ordered
  • before discharge, the nurse teaches the client about the use of pressure garment and methods for skin care

front 24

REVIEW CLIENT AND FAMILY TEACHING 66-1: USE OF A PRESSURE GARMENT

back 24

REVIEW CLIENT AND FAMILY TEACHING 66-1: USE OF A PRESSURE GARMENT

front 25

When should client be weighed w/ burn injuries?

back 25

Client should be weighed daily and sufficient fluid added to reflect the fluids lost in weight change