BURN 3.

Fluid- remobilization phase :

General Information  Also known as diuresis stage
 Involve destruction of the epidermis, dermis, or  Starts about 48 hours after initial burn
subcutaneous layers of the skin  Fluid shifted back to vascular compartment
 Can be permanently disfiguring and incapacitating  Edema at burn site decreased, blood flow to kidneys
and possibly life-threatening increased, increased urine output
 General Information  Fluid and electrolyte imbalances can still occur
 Associated imbalances result from alterations in skin
integrity and internal body membranes, and from 4.Convalescent phase:
effect of heat on body water and solute loss that may  Begins after first two phases has been resolved
result from cellular destruction  Characterized by healing or reconstruction of burn
 General Information wound
 Type and severity of imbalance depends on burn type  Major fluid shifts now resolved but possible further
and depth, percentage body surface area involved fluid and electrolyte imbalances exist as a result of
and burn phase inadequate dietary intake
 Anemia is common – severe burns typically destroy
Pathophysiology red blood cells
1.Burn Phase:
Refer to stage that describe physiologic changes Characteristics
occurring after a burn 1. Minor Burns
a) Partial thickness burns are no greater than 15% of
2.Fluid-accumulation phase: the TBSA in the adult
 Last from 36 to 48 hours after a burn injury b) Full thickness burns are < 2% of the TBSA in the
 Fluid shifts from vascular compartment to adult
interstitial space – third-space shift c) Burn areas do not involve the eyes, ears, hands,
 Edema caused by shifted fluid, which typically face, feet, or perineum
reaches maximum within 8 hours after injury d) There are no electrical burns or inhalation injuries
 Circulation possibly compromised and pulses e) The client is an adult younger than 60 y.o.
diminished from severe edema f) The client has no preexisting medical condition at
 Several reasons for fluid imbalances during fluid- the time of the burn injury
accumulation phase g) No other injury occurred with the burn
• Damage to capillaries causing altered vessel
permeability 2. Moderate Burns
• Diminished kidney perfusion a) Partial thickness burns are deep and are 15% to
• Production and release of stress hormones such 25% of the TBSA in the adult
as aldosterone and ADH b) Full thickness burns are 2% to 10% of the TBSA in
• Respiratory problems the adult
• Muscle and tissue injuries c) Burn areas do not involve the eyes, ears, hands,
• GI problems face, feet, or perineum
• Electrolyte imbalances: d) There are no electrical burns or inhalation injuries
- Common during fluid accumulation phase due e) The client is an adult younger than 60 y.o.
to body’s hypermetabolic needs and priority that f) The client has no chronic cardiac, pulmonary, or
fluid replacement takes over nutritional needs endocrine disorder at the time of the burn injury
during emergency phase g) No other complicated injury occurred with the
burn

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3. Major Burns Third degree
a) Partial thickness burns are > 25% of the TBSA in Assessment of Extent
the adult  Destruction of epithelial cells – epidermis and dermis
b) Full thickness burns are > 10% of the TBSA destroyed
c) Burn areas involve the eyes, ears, hands, face,  Reddened areas do not blanch with pressure.
feet, or perineum  Not painful; inelastic; coloration varies from waxy
d) The burn injury was an electrical or inhalation white to brown; leathery devitalized tissue is called
injury eschar.
e) The client is older than 60 y.o.  Destruction of epithelium, fat, muscles, and bone.
f) The client has a chronic cardiac, pulmonary, or Reparative Process
metabolic disorder at the time of the burn injury  Eschar must be removed. Granulation tissue forms to
g) Burns are accompanied by other injuries nearest epithelium from wound margins or support
graft.
Assessment of Burn Injury  For areas larger than 3-5 cm, grafting is required.
First Degree  Expect scarring and loss of skin function.
Assessment of Extent  Area requires debridement, formation of granulation
 Pink to red: slight edema, which subsides quickly. tissue, and grafting.
 Pain may last up to 48 hours.
 Relieved by cooling. Burn Classification
 Sunburn is a typical example. Superficial (1° burns)
Reparative Process  Involve only the epidermal layer of the skin.
 In about 5 days, epidermis peels, heals  sunburns are commonly first-degree burns.
spontaneously.
 Itching and pink skin persist for about a week. Partial thickness (2°burn)
 No scarring.  Present of blisters indicates superficial partial-
 Heals spont. If it does not become infected w/in 10 thickness injury.
days - 2 weeks.  Blister may ↑size because continuous exudation and
collection of tissue fluid.
Second degree  Healing phase of partial thickness, itching and
Assessment of Extent dryness because ↑vascularization of sebaceous
Superficial: glands, ↓reduction of secretions and ↑perspiration.
 Pink or red; blisters form (vesicles); weeping,
edematous, elastic. Full thickness (third-degree burn)
 Superficial layers of skin are destroyed; wound moist  Destruction of the epidermis and the entire dermis,
and painful. subcutaneous layer, muscle and bone.
Deep dermal:  Nerve ending are destroyed-painless wound.
 Mottled white and red: edematous reddened areas  Eschar may be formed due to surface dehydration.
blanch on pressure.  Black networks of coagulate capillaries may be seen.
 May be yellowish but soft and elastic – may or may  Need skin grafting because the destroyed tissue is
not be sensitive to touch; sensitive to cold air. unable to epithelialize.
 Hair does not pull out easily  Deep partial-thickness burn may convert to a full-
Reparative Process thickness burn because of infection, trauma or
 Takes several weeks to heal. ↓blood supply.
 Scarring may occur.

Extent of surface area burned

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 Rule of nines-An estimated of the TBSA involved as a Electrical Burns:
result of a burn. - Caused by heat generated by electrical energy as it
 The rule of nines measures the percentage of the passes through the body
body burned by dividing the body into multiples of Results in internal tissue damage
nine. - Cutaneous burns cause muscle and soft tissue damage
 The initial evaluation is made upon arrival at the that may be extensive, particularly in high voltage
hospital. electrical injuries
- Alternating current is more dangerous than direct
Lund and Browder current because it is associated with CP arrest,
 More precise method of estimating ventricular fibrillation, tetanic muscle contractions, and
 Recognizes that the percentage of BSA of various long bone or vertebral fractures
anatomic parts. Potential Imbalance
 By dividing the body into very small areas and Hypovolemia
providing an estimate of proportion of BSA accounted  Approximately 10% of plasma volume lost into tissue
for by such body parts soon after a severe burn
 Includes, a table indicating the adjustment for  Occurs because of the third space shift causes
different ages multiple effects:
 Head and trunk represent larger proportions of body  With burn’s damage to the skin surface, decrease in
surface in children. skins ability to prevent water loss; patient can lose up
to 8L of fluid per day (400ml/hour)
Lund and Browder chart  Potential for blood loss, adding to fluid volume losses
Hypervolemia
Age in years 0 1 5 10 15 Adult  Usually develops 3 to 5 days after a major burn injury
 Occurs during the fluid remobilization phase, as fluid
A-head (back 9½ 8½ 6½ 5½ 4½ 3½
shifts from the interstitial space back to the vascular
or front)
compartment
B-1 thigh 2¾ 3¼ 4 4¼ 4½ 4¾  May be exacerbated by excessive administration of
(back or I.V. fluids
front) Hyperkalemia / Hypokalemia
Hypocalcemia
C-1 leg (back 2½ 2½ 2¾ 3 3¼ 3½ Hyponatremia / Hypernatremia
or front) Metabolic acidosis
Respiratory acidosis

TYPES OF BURNS NURSING PRIORITY

Thermal Burns: The client with burn injury is often awake, mentally
- caused by exposure to flames, hot liquids, steam or alert, and cooperative at first. The level of
hot objects consciousness may change as respiratory status change
Chemical Burns: or as the fluid shift occurs, precipitating hypovolemia. If
- Caused by tissue contact with strong alkali, or organic the client is unconscious or confused, assess him or her
compounds for the possibility of a head injury.
- Systemic toxicity from cutaneous absorption can
occur
Radiation Burns: Assess for:
- caused by exposure to UV light, x-rays, or radioactive  Patent airway
source
 Presence of adequate breath sounds
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 Symptoms of hypoxia
 Pulmonary damage
- Burns around the face, neck, mouth or in the oral
mucosal area
 Circulatory status
- Tachycardia and hypotension occur early
- Elevate UO
 GI function – check last time client ate
 Fluid status
- UO (30 ml/hr)
- Hypotension (< 90/60)
- Confusion / disorientation
 Circulatory status of the extremities

Treatment
 Respiratory status takes priority over the treatment of
the burn injury
 If burn area is small à cold compress or immerse in
cool water (not ice) to ↓ heat
 May have ointment on the burn area
 Analgesics IV, IM, SQ. oral forms may not be absorbed
effectively

Nursing intervention
 Maintain patent airway; prevent hypoxia
 Evaluate fluid status; determine circulatory status
 Prevent of decrease infection
 Maintain nutrition
 Prevent contractures and scarring
 Promote acceptance and adaptation to alterations in
body image

Considerations
AGE AND GENERAL HEALTH
 Mortality rates are higher for children < 4 y.o,
particularly those < 1 y.o., and for clients over the age
of 60 years.
 Debilitating disorders, such as cardiac, respiratory,
endocrine, and renal d/o, negatively influence the
client’s response to injury and treatment.
 Mortality rate is higher when the client has a pre-
existing disorder at the time of the burn injury