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«Caring for the Client with Burns Terms you’ll need to understand: ✓ Allograft ✓ Heterograft ✓ Autograft ✓ Homograft ✓ Biosynthetic graft ...»

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7

CHAPTER SEVEN

Caring for the Client with

Burns

Terms you’ll need to understand:

✓ Allograft ✓ Heterograft

✓ Autograft ✓ Homograft

✓ Biosynthetic graft ✓ Intermediate phase of burn injury

✓ Burn shock ✓ Jobst garment

✓ Consensus formula ✓ Lund and Browder method ✓ Contracture ✓ Palm method ✓ Debridement ✓ Parkland formula ✓ Donor site ✓ Rehabilitative phase of burn injury ✓ Emergent phase of burn injury ✓ Rule of Nines ✓ Eschar ✓ Total body surface area (TBSA)

Nursing skills you’ll need to master:

✓ Performing sterile dressing change ✓ Caring for central lines ✓ Administering medications ✓ Assessing a burn injury using the Rule of Nines ✓ Transfusing blood and blood products ✓ Calculation of IV fluid requirements ✓ Performing tracheostomy suction and using the Parkland formula and the care Consensus formula ✓ Monitoring central venous pressure 98 Chapter 7: Caring for the Client with Burns Although the incidence of burn injury has declined, burns still account for about 2,000,000 injuries each year in the United States. According to the American Burn Association (2000), more than 51,000 persons require hospital care each year for treatment of their injuries. Those with burns greater than 25% total body surface area (TBSA) are at risk of dying from smoke inhalation and other complications associated with burns. Young children and the elderly are particularly vulnerable to local and systemic effects of burns because their skin is naturally thinner. Burns are the third leading cause of death in children under age 14 and are in the top 10 of causes of death for all age groups.

Burns generally occur from one of three major sources:

. Thermal injuries (hot liquid, open flame). Electrical injuries (household current, lightning). Chemical injuries (alkaline or acid liquids or powders) Radiation injuries are most likely to occur with industrial accidents where radioactive energy is produced or in situations where radioactive isotopes are used. More discussion on radiation injuries can be found in Chapter 18, “Emergency Nursing.” Most burns are thermal injuries that occur in the home. Cooking accidents from hot grease or stove fires result in a significant number of injuries, as do scalds from bath water that is too hot.

CAUTION

To prevent burns, hot water heaters should be set no higher than 120° Fahrenheit.

Carbon monoxide, sulfur oxides, cyanide, chlorine, and other toxins are released from household contents during a fire. Inhalation of these gases damages the lower airway, resulting in the collapse of the alveoli and increasing the possibility of acute respiratory distress syndrome.

–  –  –

. Superficial partial thickness (first degree)—Tissue damage is confined to the epidermis and possibly a portion of the dermis. This is the type of injury produced by sunburn or a low-intensity flash. The skin appears red but blanches with pressure.

Blisters may or may not be present. The client usually complains of tingling, increased skin sensitivity, and pain that is relieved by the application of cool water or lotions containing aloe. The injury heals within a week. Although the skin peels, there is no scarring.

. Deep partial thickness (second degree)—Tissue damage involves the epidermis, upper dermis, and portions of the deeper dermis. Deep partial thickness injury is common in scalds and flash flames. The area involved appears blistered with weeping and edema. The client experiences pain and increased skin sensitivity, which increases with exposure to air. The use of sterile sheets and overbed cradles minimizes contact with the air and makes the client more comfortable. Morphine sulfate or other opiate analgesics are given intravenously to control pain.

CAUTION Pain medication is given intravenously to provide quick, optimal relief and to prevent overmedication as edema subsides and fluid shift is resolving.

Deep partial thickness injury generally heals in two to four weeks, although infection can delay healing. Infection can also take a deep partial thickness injury to a full thickness injury.

. Full thickness (third degree)—Tissue damage involves the epidermis and entire dermis. The damage usually extends into subcutaneous tissue, including connective tissue, muscle, and bone. Full thickness burns result from prolonged exposure to hot liquids or open flame, electrical current, or exposure to chemical agents. Depending on the source of the injury, the affected area can appear dry, pale white, edematous, leathery, or charred. Destruction of nerve endings leaves the affected areas relatively pain free.

Complicating the care of the client with full thickness injury is the development of hypovolemic burn shock, hyperkalemia, and anemia. Electrical injuries, which appear as whitish areas at the points of entry and exit, can result in changes in heart rhythm or complete cardiac standstill.

CAUTION The cardiac status of a client with electrical burns should be closely monitored for at least 24 hours following the injury to detect changes in electrical conduction of the heart.

100 Chapter 7: Caring for the Client with Burns CAUTION Full thickness burns can damage muscles, leading to the development of myoglobinuria, in which urinary output becomes burgundy in color. The client with myoglobinuria may require hemodialysis to prevent tubular necrosis and acute renal failure.





Burn Measurement with TBSA

A second means of classifying burns is based on the percentage of tissue injured. Three methods are used to determine the total body surface area injured in a burn:

. The Rule of Nines—The Rule of Nines assigns percentages of 9 to major body surfaces. The breakdown is as follows: head = 9%, anterior trunk = 18%, posterior trunk = 18%, arms = 9% each, legs = 18% each, and perineum = 1%. The rule is demonstrated in Figure 7.1.

–  –  –

. The palm method—The percentage affected by scattered burns may best be calculated using the palm method. The size of the client’s palm represents approximately 1% of the TBSA.

Minor burn injury involves a second degree burn or less than 15% of TBSA in adults and less than 10% in children. Or, it can involve a third degree burn of less than 2% TBSA but not involving areas requiring special care (face, eyes, ears, perineum, and joints of hands and feet).

Minor burns do not include electrical burn injury, inhalation injury, those clients with concurrent illness or trauma, or age-related considerations.

Moderate burn injury involves second degree burns of 15%–20% TBSA in adults, 10%–20% in children, or third degree burns less than 10% TBSA that do not involve special care areas.

Moderate burns, like minor burns, do not include electrical or inhalation injury, nor those with concurrent illness, trauma, or age-related considerations.

Major burn injury involves second degree burns greater than 25% TBSA in adults, 20% in children, or all third degree burns greater than 10% TBSA. Major burns include all burns involving the structures of the head and face, hands, feet, and perineum as well as electrical and inhalation injury, concurrent illness, and trauma regardless of age.

CAUTION It will be beneficial to review your nursing textbooks for local and systemic reactions to burns because these injuries affect all body systems and cardiovascular and renal function in particular.

Nursing Care for Burn Victims Caring for a burned client represents a unique challenge to even the most experienced nursing staff because few injuries pose a greater threat to the client’s physical and emotional wellbeing. There are three phases of burn injury, each requiring various levels of client care. The three phases are. Emergent. Intermediate. Rehabilitative 102 Chapter 7: Caring for the Client with Burns Psychological Care of a Burn Patient Although interventions are focused on meeting the client’s physiological needs during the emergent period, the nurse should keep in mind that the nature of the injury represents a time of extreme crisis for both the client and his family. Every effort should be made to provide emotional support by providing understandable explanations of procedures and making sure that the client is kept as comfortable as possible. When necessary, appropriate referrals should be made to clergy and other professionals.

Interventions directed at stabilizing the client’s condition as well as the type of emotional support will change as the client moves through the emergent, intermediate, and rehabilitative phases of injury.

The Emergent Phase The emergent phase begins with the onset of burn injury and lasts until the completion of fluid resuscitation or a period of about the first 24 hours. During the emergent phase, the priority of client care involves maintaining an adequate airway and treating the client for burn shock.

Emergency care of burns at the site of injury includes. Extinguishing the burn source. Soaking the burn with cool water to relieve pain and to limit local tissue edema. Removing jewelry and nonadherent clothing. Covering the wound with a sterile (or at least clean) dressing to minimize bacterial contamination. Brushing off chemical contaminants, removing contaminated clothing, and flushing the area with running water CAUTION The eyes should be irrigated with water immediately if a chemical burn occurs. Follow-up care with an ophthalmologist is important because burns of the eyes can result in corneal ulceration and blindness.

Major Burns in the Emergent Phase If the injury is determined to be a major burn injury, the following additional interventions will be taken during the emergent phase of burn care. Assessment of the following needs to take

place during this phase:

. Airway. Breathing

–  –  –

CAUTION Important steps in treating a burn client include. Treat airway and breathing—Traces of carbon around the mouth or nose, blisters in the roof of the mouth, or the presence of respiratory stridor indicate the client has respiratory damage.

Endotracheal intubation with assisted ventilation might be required to achieve adequate oxygenation.

. Ensure proper circulation—Compromised circulation is evident by slowed capillary refill, a drop in normal blood pressure, and decreased urinary output. These symptoms signal impending burn shock.

These interventions come next:

. Insertion of a large bore catheter for administering IV fluids. Calculation of TBSA involved. Calculation of fluid needs according to one of the fluid resuscitation formulas CAUTION It is important to remember that the actual burns might not be the biggest survival issue facing burn clients. Carbon monoxide from inhaled smoke can develop into a critical problem as well. Carbon monoxide combines with hemoglobin to form carboxyhemoglobin, which binds to available hemoglobin 200 times more readily than with oxygen. Carbon monoxide poisoning causes a vasodilating effect, making the client have a characteristic cherry red appearance. Interventions for carbon monoxide poisoning focus on early intubation and mechanical ventilation with 100% oxygen.

In the hours immediately following a major burn injury, loss of capillary permeability allows intravascular fluid to flood into the extracellular space. During the emergent or resuscitative phase, efforts are directed at preventing or reversing burn shock using fluid replacement formulas. Although there are a number of acceptable formulas for calculating fluid requirements, the Parkland formula and Consensus formula are most often used.

The Parkland Formula The Parkland formula provides a large volume of IV fluid in the first 24 hours to prevent deepening hypovolemic shock and further acidosis. After the first 24 hours, the amount of fluid infused should be titrated according to the urinary output, with the goal of maintaining the output between 30 ml and 50 ml per hour.

The following example steps you through a calculation of TBSA using the Rule of Nines and

the fluid requirements using the Parkland formula:

104 Chapter 7: Caring for the Client with Burns A client receives full thickness burns of the arms, chest, back, and head at 0600 hours. The client weighs 180 pounds. Using the Parkland formula, how much fluid should the client receive by 1400?

Parkland formula:

Ringer’s Lactate 4 ml × kg body weight × % TBSA Half of the amount is to be infused in the first 8 hours.

The remainder is to be infused over the next 16 hours.

With this information, what steps should you follow? The steps given below will help you calculate this if you have difficulty:

1. Calculate the TBSA using the Rule of Nines:

arms (9% each arm) = 18% + chest (18%) + back (18%) + head (9%) = 63%

2. Convert the client’s weight from pounds to kilograms:

180 pounds ÷ 2.2 pounds (2.2 pounds = 1 kg) = 81.8 kg (round to 82 kg)

3. Calculate using the Parkland formula for fluid resuscitation:

4 ml × 82 kg × 63 = 20,664 ml in 24 hours According to the Parkland formula, half the calculated volume of Lactated Ringer’s solution is to infuse in the first 8 hours; one fourth is to infuse in the second 8 hours;

and one fourth is to infuse in the remaining 8 hours.

4. The injury occurred at 0600; the first 8 hours will end at 1400. Therefore, the client should receive one half the total amount or 10,332 ml.

The Consensus Formula

Here’s how you use the Consensus formula (for comparison with use of the Parkland formula):

Consensus formula:

Ringer’s Lactate or other balanced saline solution 2 ml–4 ml × kg body weight × % TBSA Half of the amount is to be infused over the first 8 hours.

The remainder of the amount is to be infused over the next 16 hours.

–  –  –

With this information, what steps should you follow? The steps given here will help you calculate this if you have difficulty:

1. Calculate the TBSA using the Rule of Nines:

arms (9% each arm) = 18% + chest (18%) + back (18%) + head (9%) = 63%



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