Critical care - Burns: Nursing

Burns are a type of injury where the skin and underlying tissues are damaged from exposure to heat chemicals, electricity or radiation.

As the nurse, you'll provide patient centered care for critically ill patients with burn injuries. Ok.

The skin is the largest organ in the body and provides important functions like temperature regulation protection, sensory perception and Vitamin D production.

Its two main layers. The epidermis and dermis rest upon the hypodermis or subcutaneous tissue.

Starting with the outermost layer. The epidermis is a waterproof barrier that shields underlying structures from mechanical stress and ultraviolet radiation.

Next is the dermis which contains hair follicles, nerves, sensory receptors, sweat glands and immune cells. Lastly is the hypodermis made of fat and connective tissue that insulates the body and connects the dermis to the underlying muscle.

Now, the type and severity of burn injury complications will depend on the depth and the size of the burn starting with burn depth.

Superficial burns also known as first degree burns involve only the epidermis. Partial thickness, burns or second degree burns can be either superficial or deep superficial partial thickness.

Burns involve the epidermis and the top layer of the dermis. While deep partial thickness, burns affect most of the dermis.

Finally, full thickness burns are called third degree burns when they extend through all layers of the skin and affect the subcutaneous tissue.

And they're called fourth degree burns when they extend to the underlying muscle tendons or bones. Next, the size of the burn involves calculating the percentage of the total body surface area or T BSA impacted by the burn.

One method of quickly estimating the T BSA uses the rule of nines which involves dividing the body into sections that each represent approximately 9% of the T BSA.

For burns that affect less than 20% of the T BSA. The effects are typically localized.

However, as the TB SA approaches 20% or greater severe systemic effects occur. So, local effects of a burn injury can be described in three zones.

First, the zone of necrosis is the central zone where the most damage occurs, resulting in coagulative necrosis and irreversible cell death surrounding.

This is the zone of stasis where damage to the microcirculation results in sluggish circulation. This zone is potentially salvageable with appropriate treatment.

Lastly, the outermost area is the zone of hyperemia characterized by vasodilation, increased blood flow and limited cellular damage that can heal on its own.

As far as systemic effects of burn injuries go cellular damage causes the release of inflammatory mediators and the resulting inflammatory response causes increased capillary permeability and vasodilation as capillary permeability increases.

Third spacing occurs as plasma proteins move out into the interstitial space, pulling fluid with them. This leads to an accumulation of fluid within the interstitial space and decreased intravascular volume.

This together with lost fluid through evaporation from the burn surface further decreases circulating volume, resulting in hypotension to make matters worse.

Vasodilation accentuates hypertension. This precipitates a fall in cardiac output which then culminates in a type of shock called burn shock.

And the resulting decreased tissue perfusion can result in metabolic acidosis. At the same time, increased sympathetic activity and release of stress hormones like catecholamines and cortisol produce a hypermetabolic state leading to accelerated protein and fat metabolism, increased glucose levels as well as increased oxygen demand.

Other problems that occur include hyperkalaemia as potassium is released from damaged cells and as a consequence of metabolic acidosis hypernatremia as sodium rich fluid is lost from the burn injury, impaired renal function due to hypoperfusion and the release of myoglobin from damaged muscle and impaired thermoregulation and increased risk of infection due to the loss of the protective layers of the skin.

In addition, it's important to keep in mind that burns are often accompanied by inhalation, injuries from breathing superheated air or noxious chemicals like carbon monoxide and cyanide that are produced during the burning process.

Airway edema and laryngeal constriction can occur as well as alveoli damage that may lead to acute respiratory failure and acute respiratory distress syndrome.

Now, the clinical manifestations of a burn depend on the depth and extent of the burn and the type of burn agent, superficial burns are red, dry and painful.

Usually without blisters, superficial partial thickness burns produce a moist, painful pinkish red wound with clear fluid filled blisters.

While deep partial thickness burns may look mottled with variable colors and can be moist or dry. Full thickness burns are often painless and the skin can have a dry leathery appearance, a layer of necrotic tissue called SAR develops and bone tendons and muscle might be visible, massive fluid shifts and shock will manifest as hypotension, tachycardia and tachypnea.

Hypoperfusion of organs and hypoxemia can present as decreased level of consciousness, decreased urine output and hypoactive bowel sounds.

Finally, signs of inhalation injuries include singed nasal hairs. So around the mouth, nose and in the sputum as well as hoarseness, dry cough, labored and rapid breathing, difficulty swallowing, stridor and wheezing.

All right. When caring for a critically ill patient with an acute burn injury, your goals include preventing complications, promoting wound healing and managing pain.

Begin by assessing their airway breathing and circulation or ABC S and placing them on a continuous monitor for any emergent life threatening findings activate emergency protocols as needed, then administer 100% humidified supplemental oxygen to treat hypoxia and help eliminate carbon monoxide that may have been inhaled during the burn.

Monitor your patient's level of consciousness and encourage them to cough and deep breathe to promote lung expansion. Also place two large bore intravenous catheters in the tissue, not affected by the burn and begin fluid resuscitation with warm IV fluids.

Administer albumin as prescribed to help pull fluids from the interstitial space back into circulation place an indwelling urinary catheter as ordered to monitor urine output.

In addition, assess capillary refill and check peripheral pulses using palpation or Doppler ultrasound, especially in extremities where the burn is circumferential, which can impair circulation when performing wound care, use the appropriate protective barriers as well as sterile technique to help decrease the exposure of the wounds to pathogens.

Be sure to note any exudate or odor that may indicate infection and administer the prescribed antibiotics. Be sure to assess your patient's pain level and administer the prescribed analgesic medications be proactive in pain management, especially during wound debridement dressing changes or when repositioning your patient.

Other interventions include providing early internal feedings to meet your patient's increased energy needs and to promote a positive nitrogen balance, administering prophylactic medications to prevent stress ulcer formation and maintaining normothermia by providing a warm environment and covering them with a clean blanket or sheet.

Also closely monitor laboratory test results including CBC arterial blood gas, carboxyhemoglobin, electrolytes glucose and B UN finally administer a tetanus booster as ordered.

If your patient's immunization status is unknown if their burns cover a significant T BSA or if there are partial or full thickness burns.

All right. As a quick recap, burns are a type of injury where the skin and underlying tissue are damaged from exposure to heat chemicals, electricity or radiation.

Clinical manifestation at the burn site depends on the depth of the wound and total body surface area of the injury. Nursing care for a critically ill patient with an acute burn injury includes managing airway breathing circulation and pain, preventing complications and promoting wound healing.