Burns Concept Map - notes PDF

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Assessment History Cause of the burn (most commonly open flame or hot liquid) Preexisting medical conditions Physical Findings Superficial (first degree)—erythema of tissue; skin blanching with pressure; possible tenderness (resembles sunburn) Superficial partial-thickness (second degree)—red, blistered, highly tender skin and blanching with pressure, but no scarring Deep partial-thickness (second degree)—mottled appearance that may range from white to red; may appear wet or waxy; no blanching with pressure; significantly delayed or absent capillary refill time and impaired sensation; painful to pressure; blistering Full-thickness (third or fourth degree)—waxy white, leathery, or charred skin that does not blanch and is nonpliable to palpation; destruction of all layers of skin and subcutaneous layers, resulting in an avascular burn without tenderness; increased risk of infection and sepsis According to the American Burn Association, patients with a minor burn meet any of the following criteria: Less than 10% of total body surface area (TBSA) in adults Less than 5% TBSA in adults over age 50 Less than 2% full-thickness burn According to the American Burn Association, patients with a moderate burn meet any of the following criteria: 10% to 20% TBSA burn in adults 5% to 10% TBSA in adults over age 50 2% to 5% full-thickness burn High-voltage injury Suspected inhalation injury Circumferential burn Underlying medical problem, such as diabetes According to the American Burn Association, patients with a major burn meet any of the following criteria: Greater than 20% TBSA burn in adults Greater than 10% TBSA burn in adults over age 50 Greater than 5% full-thickness burn High-voltage burn Known inhalation injury Any significant burn to the face, eyes, ears, genitalia, or joints Significant associated injuries Respiratory distress and cyanosis Edema Alterations in pulse rate, strength, and regularity Stridor, wheezing, crackles, and rhonchi Hoarseness S3 or S4 heart sounds Hypotension Soot marks on face Blisters or edema of oropharynx

ETIOLOGY:

BURNS DIAGNOSTIC TESTS: Laboratory Arterial blood gas analysis may show evidence of smoke inhalation, decreased alveolar function, and hypoxia. Complete blood count (CBC) with differential may show decreased hemoglobin level and hematocrit, if blood loss occurs. Abnormal electrolyte levels may result from fluid losses and shifts. Blood urea nitrogen level may increase with fluid losses. Urinalysis may show myoglobinuria and hemoglobinuria. Carboxyhemoglobin level is increased (with inhalation burns and exposure with enclosed fires). Diagnostic Procedures Electrocardiography may show myocardial ischemia, injury, or arrhythmias, especially in electrical burns or carbon monoxide poisoning. Fiber-optic bronchoscopy shows edema of the airways from inhalation burns or steam injuries.

Causes Electrical: Contact with electrical source, faulty electrical wiring, or high-voltage power lines Thermal: Contact with heat, steam, or flames Scald: Contact with hot water Chemical: Contact, ingestion, inhalation, or injection of acids, alkali, or vesicants Radiation: Exposure to sun, sun-lamps, or radiation therapy Friction: Contact with rough surfaces, such as roadway, carpet, or gym floors Cold exposure: Exposure to extreme cold (also known as frostbite) Risk Factors Dementia Smoking Poor socioeconomic status Developmental disabilities (children) Adults with chronic illness with poor mobility Sun exposure without use of sunscreen Occupation with exposure to a burn source, such as firefighter, cook, electrician, chemical worker Drug or alcohol abuse

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Burns affect 1.2 to 2 million people each year in the United States. Most burns are thermal (from heat). Minor burns are the most common type of burn in young adults. 69% of burns occur in the home. Fourth-leading cause of accidental death

PATHOPHYSIOLOGY: Superficial Burns (First-Degree) MEDICAL-SURGICAL MANAGEMENT: Localized injury to the epidermis occurs. Elimination of the burn source; cessation of the burning process Decontamination of chemical burns The injury isn't life-threatening. Removal of constrictive clothing and jewelry Airway, breathing, and circulation assessed and secured; intubation for inhalation injury Oxygen administered to maintain oxygen saturation between 94% and 98% Superficial Partial-Thickness Burns (Second-Degree) Electrocardiographic monitoring during the first 24 hours Prevention of hypoxia The injury from of the epidermis intoor the superficial layer of the dermis. is present (if IV fluids through a large-bore IV line (see Fluid replacement after a burn); urine output of 0.5 to 1 mL/kg/hour unlessextends identification electrical injuries rhabdomyolysis or myoglobulinuria present, urine output of 1 to 2 mL/kg/hour) Thin-walled, fluid-filled blisters form. Nasogastric tube for gastric decompression and prevention of aspiration Urinary catheter insertion to monitor urine output hourly (for severe burns) Nerve endings are exposed to air when blisters break, causing pain. Wound care The skin loses some of its barrier function. Physical therapy, occupational therapy Venous thromboembolism (VTE) prophylaxis, if the patient is hospitalized Patient prepared for transport to burn center, if appropriate Nothing by mouth until severity of burn is established and then high-protein, high-calorie diet when bowel function returnsDeep Partial-Thickness Burns (Second-Degree) Increased hydration with high-calorie, high-protein drinks, not water Enteral feedings for patients unable to take food orally Injury extends from the epidermis into the deep layers of the dermis. Total parenteral nutrition (TPN) if patient is unable to take food by mouth or enterally Damage to hair follicles and glandular tissue occurs. Control of blood glucose levels because of hypermetabolic stress response if receiving TPN Limitations are based on the extent and location of burn and treatment Thicker-walled blistery areas form that usually present as red or waxy white. Physical therapy Surgery Nerve endings are exposed to air when blisters break, causing pain. Debridement Fasciotomy or escharotomy The skin loses its barrier function. Skin grafting

Grafting may be necessary.

MEDICATIONS: Booster of tetanus toxoid Analgesics for severe pain, such as IV morphine sulfate or methadone hydrochloride Oral analgesics for moderate pain, such as codeine phosphate-acetaminophen, oxyCODONE hydrochloride-acetaminophen, or HYDROcodone bitartrateacetaminophen Mannitol for treatment of oliguria in electrical burns Silver sulfadiazine topically to burn site; bacitracin ointment for superficial partial-thickness burns Mafenide for severe burns that are infected and not responsive to silver sulfadiazine Histamine-2 blockers for stress ulcer prophylaxis in severe burns, such as cimetidine, ranitidine, or famotidine, Insulin therapy for glycemic control for severe burns

Full-Thickness Burns (Third- and Fourth-Degree) Injury affects every body system and organ. Injury extends into the subcutaneous tissue layer. Muscle, bone, and interstitial tissues suffer damage (fourth-degree). Interstitial fluids result in edema. Immediate immunologic response occurs. Wound sepsis may occur.

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NURSING INTERVENTIONS with RATIONALE...