BURN
y Cell destruction of the layers of the skin and the resultant depletion of fluid and electrolytes/
Can be classified as
First degree burn Second degree burn Third degree burn Fourth degree burn
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TYPES OF BURNS
Thermal burns
Caused by exposure to flames, hot liquids, steams, or hot objects
Chemical burns
Caused by tissue contact with strong acids, alkali or organic compounds Systemic toxicity from cutaneous absorption can occur
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TYPES OF BURNS
Electrical burns Caused by heat generated by electrical energy as it passes through the body Results in internal tissue damage Cutaneous burns cause muscle and soft tissue damage that may be extensive Radiation burns Caused by exposure to ultraviolet light, x-rays, or a radioactive source
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Rule of Nines
The body is divided into 5 surface areas. Head ( 9% ), anterior and posterior head and neck Arms ( 18% ), anterior and posterior upper Trunk ( 36% ), anterior and posterior trunk limbs Legs ( 36% ), anterior and posterior lower limbs Perineum ( 1% )`
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Major Burns >30% TBSA Possible inhalation Injury Lost of skin barrier
Cell Lysis Capillary permeability Hemolysis Hyperkalemia Sodium, H2O and Protein shift from Intravascular to Interstitial spaces Hemoglobin/ Myoglobin in urine
ThermoRegulation problem
Inflammatory response
Circulating Blood Volume (up to 50%) Concentration of RBC Massive stress Response, Sympathetic nervous System activation
Hypoxemia
Blood viscosity
Tachycardia
Hyperglycemia
Catabolism
T issue Perfusion
GI blood flow
Anaerobic Metabolism
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Risk of ileus
Metabolic acidosis
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EMERGENT PHASE
Begins at the time of injury and ends with the restoration of capillary permeability, usually at 48 to 72 hours after the injury The primary goal is to prevent hypovolemic shock and preserve vital organ functioning. Remove person from source of burn THERMAL BURN Smother burn beginning with the head CHEMICAL BURN Remove clothing that contains chemical
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EMERGENT PHASE
Lavage area with copious amount of water ELECTRICAL BURN
Note victim position Identify entry/ exist routes Maintain airway Lasts from the onset of injury through successful fluid resuscitation. Wrap in dry, clean sheet or blanket to prevent further contamination of wound and provide warmth Assess how and when burn occurred. Provide lV route if possible
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Fluid Resuscitation
The administration of intravenous fluids to restore the circulating blood volume during the period if increasing capillary permeability. To counteract the effects of burn shock, fluid resuscitation guidelines are used to replace the extensive fluid and electrolyte losses associated with major burn injuries. Fluid replacements necessary in all burn wounds that involve greater than or equal to 20% TBSA Crystalloid fluids are administered through two large- bore catheters, preferably inserted through unburned skin. 24
Fluid Resuscitation
Warmed Ringers lactate solution during the 24 hours after the burn injury. As it most closely approximately the bodys extracellular fluid composition. The amount of fluid administered depends on how much intravenous fluid per hour is required to maintain a urinary output of 30 to 50 mL per hour. Successful fluid resuscitation is evidenced by stable vital signs, an adequate urine output, palpable peripheral pulses, and a clear sensorium. URINARY OUTPUT is the most common and most sensitive assessment parameter for cardiac output and tissue perfusion.
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RESUSCITATIVE PHASE
Begins with the initiation of fluids and ends when capillary integrity returns to near normal levels and the large fluid shifts have decreased The amount of fluid administered is based on the clients weight and the extent of injury Most fluid replacement formulas are calculated from the time of injury and not from the time of arrival at the hospital The goal is to prevent shock by maintaining vital organ perfusion Fluid resuscitation
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PARKLAND FORMULA
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y The formulas specify the volume of fluid to be infused in the first 24 hours after the injury y 50% of the fluid to be infused during the first 8 hours y remaining 50% over the next 16 hours (25% per 8 hours)
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IMPLEMENTATION
Monitor pulse oximetry and prepare for ABGs and carboxyhemoglobin (COHB) levels if inhalation injury is suspected. Elevate the head of the bed to 30 degrees or more for burns of the face and head. Monitor temperature and assess for infection Initiate protective isolation techniques; maintain strict handwashing, use sterile sheets and linens when caring for the client, and use gloves, cap, masks, shoe covers scrub clothes and plastic spoons.
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IMPLEMENTATION
Monitor gastric output and pH levels for gastric comfort and bleeding. Administer antacids, H2 receptor antagonists as prescribed. Auscultate bowel sounds for ileus and monitor for abdominal distention and Gi dysfunction Monitor iv fluids and hourly intake and output. Prepare for fluids and hourly intake and output. Prepare for chest and other X-rays to rule out fractures or associated trauma.
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ACUTE PHASE
Begins when the client is hemodynamically stable, capillary permeability is restorted, and diuresis has begun Usually begins 48 to 72 hours after the time of injury Emphasis during this phase is placed on restorative therapy, and the phase continues until wound closure is achieved The focus is on infection control, wound care, wound closure, nutritional support, pain management, and physical therapy
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IMPLEMENTATION
Continue with protective isolation techniques Provide wound care as prescribed and prepare for wound closure Provide pain management Provide adequate nutrition as prescribed Prepare patient for rehabilitation
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PAIN MANAGEMENT
Administer morphine sulphate or meperidine (Demerol) as prescribed. Avoid IM or SC routes because absorption through the soft tissue is unreliable when hypovolemia and large volume fluids shifts are occurring. Avoid administering medication by the oral route, because the possibility of GI dysfunction Medicate the client prior to painful procedures.
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