Nursing Care of Burns

Average Length of stay
8 days but usually 1 day per total body surface area burned

Risk Factors
Not having smoke alarm, space heater use, winter time, candle use, 40% due to alcohol use

Burn Care Objectives
Prevent and treat hypovolemic shock, alleviate pain, control bacterial growth, convert open to closed wounds, preserve body function and appearance, health within a minimal length of time, preserve mental and emotional equilibrium, return client to social and work environment

In the emergent phase…
Time of injury 36-48 hours; goal – prevent hypovoelmia, edema, and shock.
Do a primary survey, check oral airways, give them high slow oxygen 15L at 100% with a nonrebreather, endotrachial tube

Primary Survey
Breathing and Ventilation (listen to chest), get 2 large IV catheters, assess neurological deficit, completely undress pt, make sure they have dry linen because they are at risk for hypothermia; cover patient with a towel

Secondary Survey
Focus on what happened, find out what caused the burns, get a good medical history, complete head to toe physical, labs, look for carbon monoxide toxicity

What labs to do in secondary survey
CBC, Chemistry with BUN, Creatinine, urinalysis, ABGs, chest x-ray, EKG, and glucose in children

S/S Carbon monoxide toxicity
**CHERRY RED SKIN WITH NORMAL PULSE OX**, HGB has 200-300 affinity for CO over O2, headache, nause, dyspnea on exertion

When suspeced of Carbon monoxide…
100% high flow oxygen. CO has half-life 4 hours when pts breathe room air but on oxygen CO has a half life of 45 min

Leading cause of death within 1st 24 hours
Acute Pulmonary insufficiency (first 36 hours), pulmonary edema (6-72 hours), bronchopneumonia (3-10 days)

Findings that are suggestive of inhalation injury
Confined area fire, singed nasal hairs, caronaceous sputum (black charcoal color), hoarseness, problems breathing (stridor, dyspnea) *Protect that airway*

If you suspect a mild injury…
HOB 30 degrees, aerosolized epi, 100% humidfied oxygen

If you suspect severe injury
may need to intubate and remember that tape does not adhere to skin will

Most common cause of death in first 7 days

Signs of infection and not signs of infection
Glucose in the urine is a sign of infection (maybe having difficulty controlling BG), maybe do a biopsy of a burned wound, WBC/temp will not be a good indicator.

Treating Chemical burns
Irrigate with copious amts of water, until pain is relieved or they are transferred to a burn center, and use universal precautions so it does not get on you, brush off any remaining agent

Electrical burns considerations
grand masquerader — lots can go on inside even though it doesn’t look that way on the outside

Findings that are suggestive of electrical burns
Loss of consciousness, paralysis, no peripheral pulse, myoglobinuria, serum CK above 1000, caused by lightening

ABCDE Primary Survey
Airway Maintenance, Breathing, Circulation, Disability (neurologic deficit), exposure (undress pt but maintain temp)

Strategies to prevent hypothermia
ensure no wet dressings, fluid warmer to infuse fluids, maintain warm room, cover pt with clean blanket, tuck sheet in under pt

Electrical injury effect determined by
Pathway of the current, duration of contact, area of contact, resistance of the body

Rule of 9s
Chest – 9, abdomen – 9, back – 9, front of leg – 9, back of leg – 9 , front of arm – 4.5, back of arm – 4.5, perineum – 1, front of head – 4.5, back of head – 4.5

Emergent Management principles
Stop the burning process, universal precautions, fluid resuscitation, vital signs, insertion of NG tube, insertion of Urinary Catheter, Assessment of Extremity perfusion, continues ventilatory assessment, pain management, psychosocial assessment

Burn Center Referral Criteria
1. Partial thickness burns greater than 10% TBSA
2. Burns that involve the face, hands, feet, genitalia, perineum, or major joints
3. Third degree burns in any age group
4. Electrical burns, including lightning injury
5. Chemical Burns
6. Inhalation injury
7. Burn injury in patients with pre-exsisting conditions
8. Any patient with burns and concomitant trauma
9. Burned children in hospital without qualified personal
10.Burn injury in patients who will require long-term rehabilitative intervention

Stabilization in prep for transfer
100% oxygen
Two 16 gauge IV’s (non-burned areas if possible) ( make sure well secured: Tape does not stick well to burned skin)
Begin Fluid Resuciation
Keep NPO until tranfer
Insert NG tube > 20% TBSA
Cover with Clean Dry Sheet
Pain Medication: IV
Tetanus Immunization: If due

Goals of wound management
Cover with dry sheets, elevate above the heart, watch pulses every hour, no wet dressings

Specific anatomic burns
facial burns — elevate hob 30 degrees and monitor respiratory status
Eyes – fluorescien used to detect corneal injury, ophthalmic solutions
Burns of ears – no pillow, blast injuries
hands and feet – elevate above heart, monitor pulses, maintain functionality
Burns of genitalia – insert foley immediately before

Nursing management during the rehab phase
pain management, nutritional therapy, physical and occupational therapy, psychosocial care

Shock and Fluid resuscitation
Fluid of choice is Lactated Ringers
Obtain a dry weight as early as possible
U/O, CVP, and PAP should be monitered hourly
Monitor for: Acidosis, Hyperkalemia, Hyponatremia

Shift of fluid vascular space to interstitial spaces (2nd spacing)
Shift of fluid to areas normally having minimal fluid (3rd spacing) (Blister formation & Edema in nonburned areas)
Insensible losses by evaporation
Hemolysis of RBC – Increased Hematocrit, Major shifts in Sodium and Potassium

Parkland Formula
Adults: Lactated Ringers (4 ml) X Body weight in kg X % TBSA burned.
First 8 Hours give ½ of calculated amount
Second 8 Hours give 25% is given
Third 8 Hours, remaining 25 % is given
(Formula is a guideline: Patients with electrical injury, inhalation injury, delayed resuscitation, and prior dehydration may need additional fluids).

Monitoring Resuscitation
Hourly Urinary Output = Adults: 0.5ml per KG per hour (30-50 ml/hr)
Management of Oliguria = Diuretics are contraindicated and Increase rate of fluid infusion
Management of Hemochromogenuria (Red Pigmented Urine) = Myoglobin and hemoglobin in the urine and Increase fluids to maintain U/O to 75-100 ml/hr

Acute Phase
Begins when patient is hemodynamically stable
Capillary permeability is restored
Diuresis has begun
48-72 hours

Rehabilitative Phase
Overlaps the acute and extends beyond the hospital
Goals are to:
Maximize function and emotional recovery
Wound healing, Physical Strength and Emotional Support

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