Nursing Care & Interventions in the Client

with Burn Injury

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 Burn Injury
• Skin
• Epidermis
• Dermis
• Purposes
• Skin destruction
• Fluid/protein loss
• Sepsis
• Multi-system changes
• Dependant on age
• Health
• Depth of injury
• Body area involved

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 Depth of Burn Injury
• Superficial-thickness
• Epidermis only
• Partial-thickness
• Epidermis + partial Dermis
• Full-thickness
• Epidermis + all dermis + underlying
tissue/muscle/bone

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 Assessment: Superficial-thickness

• Pain
• Redness
• Heals in 3-5 days

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 Assessment: Partial-thickness

• Superficial partial thickness (2A)

• Deep partial thickness (2B)
• Red-blanch
• No blanch with deeper burn
• Blister and broken epidermis
• Painful
• Heal in 10-21 days , 2A (14days), 2B (21
days)

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 Assessment: Full-thickness

• Pale, white to red, yellow

• Charred eschar
• Leathery skin, dry surface
• Painless
• Edema present
• Signs of systemic shock may be present
• Needs grafting

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Wound Assessment

Wound Dimension (Jackson, 1953)

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Characteritic burn wound deep

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Burns: Vascular Changes
• Fluid shift
• Capillary leakage
• First 12 hours
• Lasts 24-36 hours
• Lyte & acid base imbalance
• Hypovolemia
• Hyperkalemia, hyponatremia
• Fluid remobilization
• Diuretic stage (48-72 hours)
• Hyponatremia
• hypokalemia

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Burns: Body System Assessment
• Cardiac
• HR increase
• CO decreased initially
• Respiratory
• Airway edema
• pulmonary cap. leakage
• GI
• Paralytic ileus
• Metabolic
• Increased due to catecholamines, cortisol and SNS
• Caloric needs double or triple
• Immune
• Diminished response
• Increased risk of infection 10
Emergency & Acute Management
• Primary Survey
• Airway
• Breathing
• Circulation
• C-Spine immobilization (when indicated)

• Secondary Survey
• Complete head to toe exam
• % of TBSA
• Depth of burn
• Part(s) of body burned
• Rule out other serious or life threatening injuries

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 Inhalation Injury: Assessment

Facial burns Severe cough

Singed nasal hairs Hoarseness
Stridor Shortness of breath
Anxiety

Symptoms
Signs

CO Poisoning Wheezing
•HA Dyspnea
•Nausea Disorientation
•Alterered LOC Obtunded
• Confusion Coma
• Coma
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 Burn Classification
• Minor
• <15% partial thickness
• Moderate
• 15-25% partial thickness
• <10% full thickness
• Severe
• >25% partial thickness
• >10% full thickness

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ABA Burn Referral Guidelines
• 2° Burns > 10% TBSA
• Burns involving the face,
hands, feet, genitalia,
perineum, & major joints
• 3° Burns in any age
group
• Electrical Burns
• lightning injuries
• Chemical Burns

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Laboratory Findings: First 48 hours
• Hgb/Hct : elevated
• Glucose : elevated
• Sodium : decreased
• Potassium : increased
• BUN/creatinine :increased
• Albumin: decreased
• ABG’s
• pO2 : Decreased
• pCO2 : increased
• pH : decerased metabolic acidosis
• CO : elevated (smoke inhalation)

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 Nursing Diagnostic Priorities: First 48 Hours

• Decreased cardiac output r/t…

• Deficient fluid volume r/t…
• Ineffective tissue perfusion r/t…
• Ineffective breathing pattern r/t…
• Acute pain r/t…

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Management : Fluid Resuscitation
• Nursing interventions
• Large bore IV/central IV access
• Lactated ringers
• Nursing Assessment
• I&O
• Urine output
• Daily weight
• Oxygenation needs
• Fluid overload
• VS
• Labs
• Creatinine
• Albumin
• lytes

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Fluid Recusitation
Consensus Formula
• RL solution (or other balanced saline solution): 2–4 mL× kg body
weight × % total body surface area (TBSA) burned. Half to be given
in first 8 hours; remaining half to be given over next 16 hours.
Monitoring
• Hematology indicators: haematocrit, serum electrolytes, osmolality, calcium, glucose, and albumin are
essential to help determine the appropriate method of fluid replacement.
• The best single indicator is the urine output on an hourly basis
• fluid infusion (ml/kg/% TBSA/kg) hourly
• urine output (ml/kg/hour)

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 Nursing Diagnostic Priorities: First 48 Hours

• Ineffective breathing pattern r/t…

• Respiration pattern
• Oxygenation
• ABG’s
• pH: 7.41….7.29
• p02: 73….55
• pCO2: 44….60

• Acute pain r/t…

• Opiods IV
• Fentanyl... Onset___ Peak___ Duration___
• Morphine… Onset___ Peak___ Duration___
• Dilaudid…Onset___ Peak___ Duration___

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Assessment Priorities: After 48 Hours
• Cardiopulmonary
• Pneumonia
• Neuroendocrine
• Increased metabolic demands
• Immune (risk of infection)
• Local
• Systemic
• VS
• Altered LOC
• u/o

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 Nursing Diagnostic Priorities: After 48 Hours

• Impaired skin integrity r/t…

• Risk of infection r/t…
• Imbalanced nutrition-less than body requirements r/t…
• Impaired physical mobility r/t…
• ROM
• Early ambulation
• Disturbed body image r/t…

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 Impaired Skin Integrity-Wound Care
• Debridement
• Hydrotherapy
• Wound dressings
• Antibiotic ointment
• Biologic
• Synthetic
• Skin grafts
• Autograft
• Artificial

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 Dressings: Topical Antibiotics
• Gel
• Hydrocollod Ag
• MEBO
• Silver Sulfadiazine
• Most frequently used topical
• Gram negative/positive organisms
• Penetrates eschar well
• Applied with a gloved hand, tongue depressor or impregnated in gauze
• Bacitracin
• Acceptable for use with superficial burns
• Least expensive antimicrobial agent

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Dressings
• Decrease pain
• Absorb drainage
• Preserve joint mobility
and allow ROM
• Provide protection and
isolation of wound from
environment

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Nutrition
• Metabolic changes • Net Results of Changes
• Hormone mediated • > Nitrogen losses
• > Catecholamines
• > Energy Expenditures and
• > Glucocorticoids and
glucose to insulin ratios nutrition metabolism
• Metabolic alterations • Results
• > Gluconeogenesis • Hypermetabolic - catabolic
• > Proteolysis state
• > Ureagenesis
• < Lipolysis & Ketone
utilization

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Enteral Feedings
• Preferred route
• Safety
• Better utilization of nutrients
• Gut integrity
• Lower cost
• Parenteral (TPN)
• Nonfunctional guts
• High risk for sepsis

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Mobilization assessment
• Rehabilitation is an essential and integral part of burn treatment
• Starts from day one of admission and continues for months and
sometimes years after the initial event
• The aims of burn rehabilitation are to minimise the adverse effects
caused by the injury
• maintaining range of movement,
• minimising contracture development and impact of scarring
• maximising functional ability

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Psychological Issues & Follow Up
• Inpatient
• PTSD
• Disfigurement
• Sexual issues
• Outpatient
• Ongoing therapy
• Support groups
• Burn Camp

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https://www.youtube.com/watch?v=WKGAs9uRlsI

https://www.youtube.com/watch?v=4hcPn9f2gNY

https://www.youtube.com/watch?v=bSQbgiy3KB0