Exit HESI: Burns

Tissue injury or necrosis caused by transfer of energy from a heat source to the body
thermal, radiation, electrical, chemical
Tissue destruction results from:
Protein denaturation
Ionization of cellular contents
Critical systems affected include
Severity is determined by burn depth
First degree
SUPERFICIAL partial thickness (sunburn)
Injury to the epidermis
Leaves skin pink or red, but NO blisters
Painful (relieved by cooling)
Slight edema
No scarring and skin grafts are not required
Second degree
DEEP partial thickness destruction of epidermis and upper layers of dermis
Injury to deeper portions of the dermis
Painful (sensitive to touch and cold air)
Appeared RED or WHITE, WEEPS FLUID, Blisters present
Hair follicles intact (i.e. hair does not pull out easily)
Very edematous
Blanching followed by capillary refill
Heals without surgical interventions, usually does not scar
Third degree
Full thickness and deep full thickness; involves total destruction of dermis and epidermis
Skin CANNOT regenerate
Requires skin grafting
Underlying tissue (fat, fascia, tendon, bone) may be involved
Wound appears dry and leathery as eschar develops
Severity is determined by extent of surface area burned.
Rule of nines:
Head and neck 9%
Upper extremities 9% each
Lower extremities 18% each
Front trunk 18%
Back trunk 18%
perineal area 1%
Head and neck
Upper extremities each
Lower extremities
18% each
Front trunk
back trunk
Perineal area
Lund and broder method:
estimates the percentage of the body surface area burned, percentages are assigned to specific body parts based on client’s age, critical body areas are face, hands feet, and perineum
Three stage of burn care
Stage 1: resuscitative/emergent phase
-begins at the time of injury and concludes with the restoration of capillary permeability, which typically reverses 48 to 72 hours following the injury
-is characterized by fluid shift from intravascular to interstitial and shock; focus of care is to preserve vital organ functioning
-expect to administer large volumes of fluid in this phase based on the client’s weight and extent of injury
-fluid replacement formulas are calculated from the time of injury and not from the time or arrival at the hospital
Stage II: acute phase
Occurs from beginning of diuresis (48-72 hours after injury) to near completion of wound closure
Is characterized by fluid shift from interstitial to intravascular
Focus is on INFECTION control, wound care and closure, pain management, nutritional support, and physical therapy
Stage III: rehabilitation phase
occurs from major wound closure to return to optimal level of physical and pscyhosocial adjustment (approx 5 years)
is characterized by grafting and rehabilitation specific to the client’s needs
Nursing assessment
absence of bowel sounds indicating paralytic ileus
Radically decreased urinary output in first 72 hours after injury, with increased specific gravity
Radically increased urinary output (diuresis) 72 hours to 2 weeks after initial after initial injury
Absence of bowel sounds indicating
paralytic ileus
Signs of inadequate hydration
decreased urinary volume and urinary sodium and increased urine specific gravity
Signs of inhalation burn
Red or burned face
Singed facial and nasal hairs
circumoral burns
Sooty nasal mucous or bloody sputum
Asymmetry of chest movements with respirations and use of accessory muscles indicative of pneumonia
Rales, wheezing, and rhonchi denoting smoke inhalation
Impaired speech and drooling indicating laryngeal edema
ABCs of assessment
Physiologic responses to burns
Increased HR
Increased release of glycogen stored
Increased blood sugar level
Skin vasoconstricted
Extremities pale, cool
Capillary refill slow
Decreased urine output
Increased specific gravity
Respirations rapid
Slow or no gastric motility
Decreased bowel sounds
Abdominal distention
Beginning ulceration of GI mucosa
Increased catecholamine secretion
Increased metabolic rate and caloric needs
increased secretion of aldosterone
Fluid retention
Generalized edema
Weight gain
Hemoccult positive stools
Nursing plans and interventions
****Emergent phase****: efforts are directed toward stabilization with ongoing assessment
=Assist with admission care:
-extinguish source of burn (burning may continue with clothing attached to skin)
Thermal: remove clothing, cool burns by immersion in tepid water, apply dry sterile dressings
Chemical: flush with water or NS
Electrical: separate client from electrical source
=Provide an open airway; intubation may be necessary if laryngeal edema is a risk
=Determine baseline data: vital signs, blood gases, weight
=Determine depth and extent of burn
=Administer tetanus toxoid
=Initiate fluid and electrolyte therapy: ringer’s lactate solution with electrolytes and colloids adjusted according to lab results find fluid resuscitation formula used
Nursing plans and interventions contd
Insert NG tube to prevent vomiting, abdominal distention, and gastric aspiration
Administer IV pain meds as prescribed
Monitor hydration status: record urinary output hourly (30-100ml/hr is normal range)
Maintain IV fluids titrated to keep urine output at 30-100 ml/hr
Accurately record I and O
Weigh daily
Observe for signs of inadequate hydration: restlessness, disorientation, hypothermia, decreased UO
Monitor respiratory functioning: provide care for the intubated client; suction endotracheal or nasotracheal tube; monitor ABGs; observe for cyanosis, disorientation; administer oxygen; encourage use of incentive spirometer, coughing, and deep breathing
Elevate HOB to 30* or more for burns of the face and head
Provide woundcare
use strict aseptic technique
Perform debridement and dressing changes according to client’s condition
Change dressings in minimum time (very painful); premedicate client; maintain sterile technique
Maintain room temperature above 90*, humidified and free of drafts
Monitor body temp frequently; have hyperthermia blanket available
Assess for paralytic ileus
absence of bowel sounds
Abdominal distention
Assist with management of pain
administer analgesics intravenously
teach distraction and relaxation techniques
teach use of guided imagery
Assess for circulatory compromise in burns that constrict body parts
Prepare client for escharotomy
Provide proper nutrition: maintain NPO status until bowel sounds are heard, and then advance to clear liquids as prescribed
Provide a diet high in protein, carbs, fats, and vitamins
Monitor caloric intake
***Acute phase***: characterized by fluid shift from interstitial to intravascular (diuresis begins); occurs from 72 hours to 2 weeks after initial injury to near completion of wound closure
Provide infection control, including the following:
Maintain protective isolation of entire burn unit
Cover hair AT ALL times
Wear masks during dressing changes
Use STERILE technique for hydrotherapy, dressing change, and debridement
Administer IV antibiotics if indicated
Be sure any live plants and flowers are REMOVED; they are prohibited
Splint and position client to prevent contractures. avoid use of pillows in cases of neck burns.****
Massive volumes of IV fluids are given
It is not uncommon to give over 1000ml/hr during various phases of burn care
hemodynamic monitoring must be closely observed o be sure the client is supported with fluids but is NOT overloaded
Infection is a LIFE THREATENING RISK for
those with burns
Acute phase contd
Perform ROM exercises; they are painful
-Administer pain med immediately prior to performing ROM exercises
-Perform active OM exercises for 3-5 mins frequently during the day
-Mobilize ASAP using splints designed for the client
Acute phase
Provide fluid therapy; may use COLLOIDS to keep fluid in vascular space
Monitor serum chemistries at all times
keep an IV site available; a saline lock is helpful
Maintain strict I and O
Encourage oral intake of fluids
Acute phase
Provide adequate nutrition
Provide high calorie (up to 5000cal/day), high protein, high carb diet
Give nutritional supplements via NG tube feeding at night if caloric intake in inadequate
Keep accurate calorie counts
Administer all meds with either MILK or JUICE
May require TPN
Weigh daily
Acute phase
Provide burn and wound care
Clean wound per agency routine (daily or up to 3x/day) in hydrotherapy or shower
Apply silver sulfadiazine (silvadene) or mafenide acetate (sulfamylon) or other antimicrobial agents to burn areas prescribed
Cover with dressing (closed method) or leave open (open method), according to agency policy or physician’s prescription
Prepare client for grafting when eschar has been removed
Prepare client for autografts (use of client’s own skin for grafting)
Use heat lamp to donor site following graft to allow area to reepithelialize
Rehabilitation phase: characterized by the ABSENCE of
infection risk
Ongoing discharge planning occurs
Client may return home when the danger of infection has been eliminated
High protein fluids with vitamin supplements are recommended
Pressure dressings such as Jobst garments may be worn continuously to prevent hypertrophic scarring and contractures
dressing changes are very painful. medicate client prior to procedure
Preexisting conditions that might influence burn recovery are
age, chronic illness (DM, cardiac problems)
physical disabilities, disease
meds used routinely and rug or alcohol abuse
Mafenide acetate (sulfamylon)
indications: treatment of burns; usually used with open method of wound care
Adverse reactions: painful; causes mild acidosis
Nursing implications: administer pain meds prior to dressing change
Penetrates wound rapidly
Silver sulfadizaine (silvadene)
Indications: treatment of burns; usually used with open method of wound care; used to avoid acid base complications; keeps eschar soft, making debridement easier
Adverse reactions: penetrates wound slowly
Nursing implications: administer pain med prior to dressing change
List four categories of burns
Thermal, radiation, chemical, electrical
Describe fluid management in the emergent, acute, and rehab phase of burned client
Emergent: replacement of fluids titrated to UO
Acute: patent infusion site is maintained in case supplemental IV fluids are needed; saline lock helpful; colloids may be used
Rehab: no extra fluids needed, but high protein drinks recommended
Outline admission care of burned client
Provide patent airway bc intubation may be necessary
Determine baseline data
Initiate fluid and electolyte therapy
pain med
determine depth and extent of burn
administer tetanus toxoid
insert NG tube
Nutritional status is a major concern when caring for a burned client. List 3 specific dietary interventions used with burned clients.
High calorie, high protein, high carb diet; meds with juice or milk****; no ‘free’ water; tube feeding at night. Maintain accurate, daily calorie counts. weight client daily
Describe the method of extinguishing each of the following burns: thermal, chemical, and electrical
Thermal: remove clothing, immerse in tepid water
Chemical: flush with water or saline
Electrical: separate client from electrical source
4 signs of inhalation burn
Singed nasal hairs, circumoral burns; sooty or bloody sputum, hoarseness, and pulmonary signs, including asymmetry of respirations, rales, or wheezing
Why is the burned client allowed no ‘free’ water?
Water may interfere with electrolyte balance. Clients need to ingest food products with highest biologic value