Care of Clients with Burns

Ø   

Severity of Burns

o   First Degree

§  Epidermis

§  Reddish, intact skin, painful

o   Second Degree

§  Dermis

§  Moist surface, with blisters, painful

o   Third Degree

§  Subcutaneous layer

§  Pearly white, no pain

o   Fourth Degree

§  Muscles and bones

§  Blackish or charred, no pain

Image source: https://media.springernature.com/full/springer-static/image/art%3A10.1038%2Fs41572-020-0145-5/MediaObjects/41572_2020_145_Fig1_HTML.png

Ø  Other Types of Burns:

o   Chemical

§  Coagulates cell proteins

§  Alkaline substances cause protein hydrolysis and liquefaction

o   Electrical

§  Causes violent muscle contraction

§  Causes degeneration of vessel walls à thrombi

§  Complications: cardiac arrest, severe metabolic acidosis, myoglobinuria

o   Smoke and Inhalation Injury

§  Carbon Monoxide Poisoning

·        “Cherry red” skin

·        CO have higher affinity in hgb than O2

§  Injury Above Glottis

·        Redness, blistering, edema of oropharynx

§  Injury Below Glottis

·        Pulmonary edema

·        ARDS

Ø  Pathophysiology

o   Shock/Fluid Accumulation/Emergent Phase

§  First 48 hours post burns

§  Fluid shift from IVC to ISC à generalized dehydration

§  Decreased blood volume à decreased C.O. à decreased renal perfusion à oliguria

§  Plasma is lost into the ISC à Hemoconcentration, increased Hct

§  Potassium release from cells à Hyperkalemia à metabolic acidosis

§  Sodium trapped in edema fluids à Hyponatremia

§  Sodium unavailable à excretion of bicarbonate  à metabolic acidosis

o   Diuretic/Fluid Remobilization Phase

§  Occurs 48 hours post burns

§  Shift of fluid from ISC to IVC

§  Hypervolemia, hemodilution, and decreased hematocrit occur

§  Increased renal tissue perfusion, decreased ADH and aldosterone secretion à Diuresis

§  Hypokalemia, hyponatremia à K moves back while sodium still trapped

§  Sodium unavailable à excretion of bicarbonate  à metabolic acidosis

o   Recovery Stage

§  5^TH day onwards

§  Hypocalcemia

·        Loss of calcium in the exudates

·        Utilization of calcium in the granulation tissue

§  Negative nitrogen balance

·        Increased CHON catabolism

·        Increased CHON demands for healing

·        Inadequate CHON intake

§  Hypokalemia

·        K has shifted back into the cells

Ø  Management

 Image Source: https://www.learningaboutelectronics.com/images/Rule-of-nines.png

o   Rule of 9’s

§  Head, face, neck – 9%

§  Anterior trunk – 18%

§  Posterior trunk – 18%

§  Upper extremities – 9% each

§  Lower extremities – 18% each

§  Genital – 1%

§  Total:

·        >25% - Major burn

·        <25% - Local burn

o   Baxter and Parkland Formula

§  4 ml LR x weight in kg x % of burns

§  Allocation of fluid replacement for the first 24 hours:

·        1^st 8 hours – 50%

·        2^nd 8 hours – 25%

·        3^rd 8 hours – 25%

o   Resuscitation/Emergent Phase

§  Maintain patent airway

§  Administer IVF

§  Prevent shock

o   Acute Phase

§  Infection control

§  Wound care

§  Restorative therapy

o   Rehabilitative

§  Gain independence and achieve maximal function

o   Skin Grafting:

§  Isograft/Syngenic Graft – identical twin

§  Autograft - self

§  Homograft/Allograft – another human

§  Heterograft/Xenograft - animal

o   Nursing Care Of Graft Site

§  Elevate and immobilize

§  Prevent pressure

§  Avoid weight bearing

§  Monitor for s/sx of infection

§  Protect from sunlight

§  Use splints and support garments as prescribed