Integumentary: Burns

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Integumentary Burns

• Marnie Quick, RN, MSN, CNRN

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Skin layers, hair follicle, nerves, sweat glands
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Types of burns

• Thermal
• Chemical
• Smoke and inhalation
• Electrical
• Radiation

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Thermal burn
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Cool burn with cold water until pain is relieved-
Do not apply to more than 20 body surface-
hypothermia may occur
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Chemical burn from sulfuric acid
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Smoke Inhalation Which is this?- CO injury
above glottis below glottis

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Electrical burns
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Depth of Burn
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Depth of burn Superficial partial (old 1st)
Deep partial-thickness
(old 2nd)
Full-thickness (old 3/4th)
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Deep partial-thickness burn- note blisters
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Partial-thickness (Second degree burn)
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Full-thickness
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Extent of Burn To calculate total burn with
rule of 9s-- ½ of anterior trunk9 and ¼ of
right arm burn3 TOTAL area
burn12TBS Rule of Nines chart
Lund Browder chart- age
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Location of Burn

• Location of the burn is related to the severity
  of the injury
• Face, neck, chest ? respiratory obstruction
• Hands, feet, joints, eyes ? self-care
• Ears, nose ? infection
• Circumferential burns of the extremities can
  cause circulatory compromise
• Patients may also develop compartment syndrome

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Phases of Burn Management

• Prehospital care
• Emergent (resuscitative- fluid)
• Acute (wound healing)
• Rehabilitative (restorative)

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Emergent/resuscitative

• Onset injury to successful fluid resuscitation
• Major concern- Fluid Resuscitation- prevent
  hypovolemic shock
• 2 large bore IVs in unburned area to restore bl
  vol due to inc capillary permeabilitygt 3rd
  spacing
• Guidelines burns gt20 TBSA- Parkland formula or
  Modified Brooke formula
• Need Weight and TBSA burned to calculate

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• Lactated Ringers solution 1st 24 hrs then add 5
  Dextrose to crystalloid fluid
• 50 of formula volume in first 8 hrs rest over
  next 16 hrs then maintain urinary output
• Hourly output 30-50 cc/hr (foley) heart rate
  less than 120/min SBPgt 90hemodynamic monitoring
• Elevate edematous part escharotomy

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Effects of Burn Shock
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Third spacing
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Burn with escarotomy
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Escarotomy
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Elevate arms to decrease swelling also note
escarotomy of arms and chest- assess CMS
(circulation/motor/sensory)
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Before the escharotomy, how would this eschar
affected his respirations?
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What are the Priorities in this patient???
Meet criteria for Burn Unit Referral?
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• What do you assess for here???

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Complications in emergent phase

• Cardiovascular
• Respiratory
• Upper/inhalation/lower
• Urinary
• Renal blood flow/GFR decrease causing release ADH
• Myoglobinurea- dark urine may block renal tubules

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Summary
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Acute Phase

• Start of diuresis and ends with closure of burn
• Major concern in this stage- infection
• Most common cause infection- pts own GI track
• Wound management-
• hydrotherapy, debridement of eschar
• topical antimicrobial creams (open/closed method)
  
• splints/exercise prevent contractures
• Excision/grafting of 3rd degree (temporary cover
  2nd )

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Decreasing of third spacing- Note
edema of the face decreasing
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Hydrotherapy Hubbard Tank
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Clean/debridement
Rt tank or Lt surgery
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Topical broad spectrum antimicrobials
Open method
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Separate skin use of splints
Closed method
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Skin will grow together if not separated
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Several patients utilizing closed method Who is
that nurse with white stockings cap?

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Removal of necrotic tissueEschar removed until
viable tissue
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Donor sitesafter harvesting healed donor
site
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Grafting (Lewis 498 Table 25-13)

• Permanent- if no infection
• Autograft
• CEA
• Integra/AlloDerm
• Temporary grafts
• Homograft- cadaver
• Heterograft- animal
• Synthetic

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Grafting
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Application of Cultured
Epithelial Autograft

• Cultured epithelial autografts
• Grown from biopsies obtained from the patients
  own skin
• Used in patients with a large body surface burn
  area or those with limited skin for harvesting

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Pressure garments
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What are your assessment findings?
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What are your nursing priorities for this patient?