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Epidermis (outer layer of the skin)● 0.15 mm thick but thinner in older adults● layer can grow back after a burn injury ● no blood vessels → nutrients are diffused from the dermis
Dermis ● Thicker than epidermis● made up of collagen, fibrous connective tissue, and elastic fibers● contains blood vessels, sensory nerves, hair follicles, lymph vessels, sebaceous
glands and sweat glands● skin cannot restore itself when entire layer of dermis is burned
Subcutaneous tissue lies beneath the dermis● with deep burns, the subcutaneous tissue may be damaged, leaving bones,
● Dry heat (flame): caused by open flame. Common in house fires and explosions. Ignited clothing from open flame accounts for the most injuries. Explosions usually result in flash burns because they produce a brief exposure to very high temperatures
● Moist heat (scald): contact with hot liquid or steam● more common among older adults● Hot liquid spills usually burn the upper, front areas of the body● Immersion scald injuries usually involve the lower body
● Contact: ● Chemical ● Electrical burns: entry and exit site
● Skin is a protective barrier and any break can increase the risk for infection● May also cause fluid and electrolyte imbalance → evaporation through
burned skin occurs 4x rapidly compared to intact skin● the rate of evaporation is in proportion to total body surface area burned and
depth of injury● burns reduces excretory ability → full thickness burns destroys sweat glands● pain
● partial thickness burns: nerve endings are exposed, increasing sensitivity and pain
● full thickness burns: nerve endings are completely destroyed, wounds may not transmit sensation except when sharp stimulus is applied, patients often have a dull or pressure type pain
● Vit D activation: ● Partial thickness burns: reduces the activation of Vit D● Full thickness burns: function is completely lost
● Temperature: heat source that exceeds the skin’s capacity to dissipate causes cell destruction and results in burns
● Psychosocial problems: reduced self image due to change in appearance
● Severity of injury is determined by ○ Depth of burn: how deep into the skin the burn goes○ how much body surface area is involved
● Degree of tissue damage is related to the agent causing the burn and to the temperature of the heat source, and how long the skin is exposed to it
● Watch location, thin areas like eyelids, ears, tops of the hands and feet● older adults have thinner skin which increases their burn severity even at low
temperatures and short durationSuperficial: Epidermis ● superficial thickness wounds have the least damage because only the
epidermis is injured○ Extent of burn in percent of TBSA( total body surface area)○ Location of burn○ Patient risk factors
● involves the epidermis, blistering, healing is rapid
● Superficial burns damage only the top layer of the skin- the epidermis
■ *the area heals rapidly in 3 - 6 days without a scar or other complication
■ No scar formation○ Caused by prolonged exposure to low intensity heat (sunburn) or short flash
exposure to high intensity heat. ○ Redness with mild edema, pain, and increased sensitivity to heat occurs○ Desquamation (peeling of dead skin) occurs for 2 or 3 days after the burn
○ Deep Partial: Involves the epidermis and dermis, redness or white to skin, moderate edema■ *Takes 3-6 weeks to heal■ *Scar formation does occur■ A few healthy cells remain■ These wounds can progress to full thickness wounds when tissue damage
increases with infection, hypoxia, or ischemia■ Surgical intervention with skin grafting can reduce healing time
○ Full Thickness: Involves the epidermis, dermis, and fat ■ wound may be waxy white, deep red, yellow, brown, black■ hard, dry, leathery eschar that forms from coagulated particles of destroyed
dermis■ Thrombosed vessels may be visible beneath the surface of the burn■ These dermal blood vessels are heat coagulated, causing the burned tissue to be
avascular (without blood supply)■ Sensation is reduced or absent because of nerve ending destruction■ Healing time depends on establishing good blood supply in the injured areas.
This can take weeks to months. ● Fatty tissue and blackened skin (eschar?) can be seen● Eschar: dead tissue; it must be slough off or be removed from the wound before healing can occur● Edema is severe under the eschar● When the injury is circumferential (completely surrounds an extremity or the chest), blood flow and
chest movement for breathing may be reduced by tight eschar. ● May see muscle or bone involved● The deeper it is, the less pain is felt: the nerve endings are destroyed● Will not heal on its own, skin and blood vessels are destroyed● Escharotomies (incision through the eschar) or fasciotomies (incision through eschar and fascia) may
be needed to relieve pressure and allow normal blood flow and breathing● Patient will require a skin graft
The nurse assesses the wound of a client burned as a result of stepping into a bathtub filled with very hot water. Which assessment finding of the burned areas on the tops of both feet does the nurse use as a basis to document a probable full-thickness injury?
A Most of the wounded area is red.
B The client reports that the area hurts when touched.
C The area does not blanch when firm pressure is applied.
D Thrombosed blood vessels are visible beneath the skin surface.
● Disruption occurs at the burn site immediately after injury, vessels are occluded and blood flow is reduced or stopped
● blood vessel thrombosis occurs, causing necrosis and can lead to deeper injuries ● Fluid shift: also known as third spacing or capillary leak syndrome
● a continuous leak of plasma from the vascular space into the interstitial space**the loss of plasma and proteins causes decrease BP and blood volume**leakage causes extensive edema even in areas that are not burned● Imbalances of fluids, electrolytes, and acid-base occur as a result of fluid shift and
cell damage● Hypovolemia● Metabolic Acidosis● Hyperkalemia: direct cell injury that releases large amounts of cellular potassium● Hyponatremia● Hemoconcentration (elevated blood osmolarity, H&H): develops from vascular
dehydration. This increases blood viscosity, reducing flow through small vessels and increasing tissue hypoxia
● Fluid remobilization starts, 24 hours after the capillary leak stops● diuretic phase begins at about 48 - 72 hrs after the burn → capillary membrane
integrity returns and edema fluid shifts from interstitial space back into the intravascular space
● Diuresis: due to increased kidney blood flow unless kidney has been damaged● Hyponatremia: increased sodium excretion and the loss of sodium from wounds● Hypokalemia: potassium moves back into the cells and is also excreted in urine● Anemia results from hemodilution, but generally not severe enough to require blood
transfusion● Transfusions are given only if necessary: only if hematocrit is less than 20% to 25%
and patient has manifestations of hypoxia● Metabolic acidosis occurs due to loss of bicarbs
● HR increases and Cardiac output decreases because of the initial fluid shifts and hypovolemia that occur
● CO may remain low until 18-36 hours after burn injury● CO increases with fluid resuscitation● Proper fluid resuscitation and oxygen support prevent further complications
● Direct injury to the lung from contact with flames rarely occurs● Respiratory problems are caused by superheated air, steam, toxic fumes, or smoke.
Such problems are a major cause of death in patients with burns and are most likely to occur when the burn takes place indoors
● Respiratory failure: results from airway edema during fluid resuscitation, pulmonary capillary leak, chest burns restricting chest movements, and carbon monoxide poisoning
● Inhalation injury can occur in the upper and major airways, and lung tissue● upper airway (mouth and throat) is affected when inhaled smoke/irritants cause
edema and obstruct trachea● Chemicals and toxic gases causes more airway injury than heat● Lung tissue injuries result from toxic damage to the alveoli and capillaries. Leaking
capillaries cause alveolar edema which can lead to respiratory distress and pulmonary failure. This can lead to acute pulmonary insufficiency and infection.
● Decreased blood flow to the GI tract● Impaired mucosal integrity ● Impaired motility
● Peristalsis decreases● Paralytic ileus may develop● Abdominal distension: collection of secretions and gases● Curlings ulcer: acute gastroduodenal ulcer that occurs with the stress of severe injury
due to the reduced GI blood flow and mucosal damage● Mucus lining is destroyed, increasing hydrogen ion production, resulting in ulcers● Give histamine blockers, PPIs, GI protectants, and early enteral feeding
● any tissue injury can disrupt homeostasisInflammatory compensation● GOOD: helps trigger healing in the injured tissue● BAD: it causes fluid shifts ● Inflammatory compensation is intended to function on a local and short term basis.
When it is widespread or persistent, they can cause severe tissue damage.
SNS compensation● Stress response that occurs when any physical or psychological stressors are present● SNS compensation is most evident in cardiovascular, respiratory, and GI systems
● From inhalation of hot air or noxious chemicals● Cause damage to respiratory tract● Major predictor of mortality in burn victims● Need to be treated quickly
● The resuscitation phase is the first phase of a burn injury. It begins at the onset of injury and continues for about 24 to 48 hours. During this phase, the injury is evaluated and the immediate problems of fluid loss, edema, and reduced blood flow are assessed. The priorities for management during this period are to (1) secure the airway, (2) support circulation by fluid replacement, (3) keep the patient comfortable with analgesics, (4) prevent infection through careful wound care, (5) maintain body temperature, and (6) provide emotional support.
■ Vascular changes that occur:● Fluid shifts from vascular to interstitial space ● capillary leak syndrome● concerned with the systemic effects of the burn: ABC’s are priority
BreathingKey signs that your patient is deteriorating for inhalation injury
● Hoarseness, brassy cough, difficulty swallowing, drooling, stridor → wheezing● Look at respiratory effort (use of accessory muscle)● If patient shows signs of inhalation injury, what will you as the nurse do?
○ Interventions■ Give oxygen■ Call Rapid Response! prepare for intubation
● Make sure there is intubation equipment at the bedside■ Once they are showing signs of inhalation injury, there are at risk for
respiratory arrest/failure, the airways getting more narrow■ Suction■ HOB elevated: Sit patient up, turning pt frequently ■ Encourage patient to use incentive spirometer■ Monitor ABG’s labs
● C - Patient is at risk for hypovolemic shock: big cause of death in this phase○ Fluid resuscitation must be started immediately!○ Monitor edema, urine output, vital signs (BP, pulse)○ To determine how much fluid infusion the pt needs we use Parkland formula
● A Patient weighing 154 lbs has a burn with a TBSA of 50%. The patient was found at home at 8am and arrived to the hospital at 10am.○ How much fluid should be administer in the first 8 hours? Calculate the
rate.
● 4 x patient weight in kg x TBSA : this will give you the total volume of fluid● First 8 hours administer half of the total volume● Must infuse within the first 8 hours: time starts from when the burn injury
occurred, not the time they arrived at the hospital.● Rate divided by 6 instead of 8● EX. A Patient weighing 154 lbs has a burn with a TBSA of 50%. The patient
was found at home at 8am and arrived to the hospital at 10am.
Incision made through tight eschar to relieve pressure and allow normal blood flow and breathing.
A surgical procedure in which an incision is made through the skin and subcutaneous tissues into the fascia of the affected compartment to relieve the pressure in and restore circulation to the affected area in the patient with acute compartment syndrome.
Infection prevention■ Sterile technique■ No flowers in the room■ At risk for pseudomonas■ Minimize visitors: children and those with illness should not be allowed■ Immunization: Depends on pt immunization status, tetanus ( burn wound
is breeding ground for the organism)■ Only give systemic antibiotics and only if patient is showing signs of
infections■ Signs of infection: look at the wound, temperature■ Hyperinflammatory response: high temperature - give nsaids, tylenol,
Wound care:● Debriding: remove dead tissue, ensure viable tissue to
promote healing● Risk for hypothermia - because skin is removed● Premedicate with pain medication before wound care ● Once debrided, a topical ointment is applied → Silvedine
A patient arrives to the ED with superficial facial burns from an explosion in his apartment building. He has productive carbonaceous sputum with labored respirations and singed hair.Based on these findings what is the highest priority of care for this patient?
○ Airway!○ Patient is showing signs of inhalation injury: carbonaceous sputum,
Twenty minutes later, assessment of the patient reveals loud wheezing on exhalation. What is the nurse’s best action at this time?
A. Check the patient’s SaO2 with pulse oximetry.B. Apply oxygen and call the Rapid Response Team.C. Call a CODE and bring the crash cart to the room.D. Call respiratory therapy for a treatment with a bronchodilator.
It has been 12 hours since a patient has been admitted for burns to his face and neck and for inhalation injuries. He had been wheezing audibly, but at this time the nurse notes that his wheezing has stopped. What should the nurse do?
Document this improvement in the patient’s condition. Re-assess his breathing in an hour.Check the patient’s SPO2 level.Notify the physician immediately.
A patient has been receiving dressing changes with silver sulfadiazine (Silvadene) for burn injuries over both lower arms. The nurse notices that the patient’s white blood cell count has dropped significantly over the past 4 days. What may this change indicate?
A. The patient’s infection is improving.B. The patient is having an allergic reaction to the silver sulfadiazine.C. The patient has kidney disease.D. The patient has an electrolyte imbalance.