BURNS, CALCULATION OF BURNS, CALCULATION OF FLUID REQUIREMENT AND MANAGEMENT.pdf
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The document outlines a nursing assessment of burns, detailing the collection of patient history, types of burns, and physical examination procedures. It includes guidelines for calculating burn area and fluid resuscitation using various formulas, as well as classifications of burns and their management. The document also discusses complications from burns, first aid measures, and nursing diagnoses and care strategies aimed at improving patient outcomes.
BURNS, CALCULATION OF BURNS, CALCULATION OF FLUID REQUIREMENT AND MANAGEMENT.pdf
- 1. BURNS PREPARED BY DOLISHA WARBI
- 2. NURSING ASSESSMENT OF BURNS: HISTORY COLLECTION: Ø Patient demographic detail: Ø Types of burns (chemical/electrical/flame/flash/etc..) Ø Time of injury: Ø Place of injury (open/closed): Ø Level of pain: Ø Level of consciousness: Ø Duration of exposure to agents: Ø Intentional burn injury: Ø Any known allergies: Ø Typical signs of burns: § Pain, § Redness, § Swelling, § Blister, § Scarring, Ø Chief complaint: Ø Past medical history: Ø Family history Ø Social history: Ø Last tetanus shot: Ø “AMPLE” §Allergies §Medication §Prior illnesses §Last meal time §Event preceding the injury
- 3. PHYSICALASSESSMENT / EXAMINATION OF BURNS: ü Airway ü Breathing: beware of inhalation and rapid airway ü Compromise ü Circulation: fluid replacement ü Disability: compartment syndrome ü Exposure: percentage area of burn. ü Fluid and electrolyte loss: ü Dept of burns: (superficial burns/partial thickness burns/ full thickness burns) ü Appearance description and location(s) § Redness § Blister § Edema § Weeping of fluid § Scarring § Sloughing of skin
- 4. ü Assess extent of body surface burns Area of face, hands and perineum Assess for dyspnea, stridor, hoarseness ü Assess extend of burns injury: Palmar method (1%) Role of nine – immediate appraisal
- 5. • The rule of nine assess the percentage of burns and is used to help guide treatment decisions, including food resuscitation and becomes part of the guidelines to determine transfer to a burns unit.
- 6. CALCULATION: According to Parkland formula § Head and Neck (anterior + posterior) 4.5%*2 = 9% § Trunk (anterior + posterior) 18%*2 = 36% § Upper extremities - Anterior (front – L&R 4.5%*2 = 9%), Posterior (back – L&R 4.5%*2 = 9%) Total = 18% § Perineum = 1% § Lower extremities – Anterior (front – L&R 9%*2 = 18%), Posterior (back – L&R 9%*2 = 18%) Total = 36% § Overall total (%) = 9+36+18+1+36 = 100% Test: A 35-year-old female patient has deep partial thickness burns on the front and back of both arms, anterior trunk, back of the leg, anterior and posterior sides of the right leg, posterior head and neck, and perineum. What is the total body surface area percentage that is burned?
- 7. CALCULATION of FLUID by PARKLAND FORMULA: Importance - First 8 hour is from the time of the bone injury, it is not from the time of evaluations or calculation. Only partial thickness and full thickness burn are included in the calculation
- 8. CALCULATION: According to Brooke formula; Crystaloid & coloids ratio (crystaloid- saline, RL) 1.5:0.5 respectively. Remaining 3500 in 16 hrs. 3500 --------- = 219ml/hr 16 Add 2L (2000ml) dextrose insensible loss/maintainance fluid. Test: An adult patient with a body weight is 70 kg and TBSA burned is 30%.calculate the fluid requirement of the patient.
- 9. CALCULATION: According to Evan’s formula; Saline - 1 ml/kg. of body wt/% of burns. Glucose in water - 2000 ml (D5% in water) Free water: dependent on age & insensible loss. 1/2 of the total is given the 1st 8 hrs and the remainder given the next 16 hours. Second 24 hours - Half of first requirement. Q. A patient weighs is 70 kg and 30% TBSA burned. Calculate the fluid requirement of the patient.
- 10. CALCULATION: Crystalloid Requirement Using Evans formula: • Crystalloid Requirement =1 ml × 70 kg × 30 • Crystalloid Requirement = 70 × 30 • Crystalloid Requirement = 2100 ml Colloid Requirement Using Evans formula: • Colloid Requirement = 1 ml × 70 kg × 30 • Colloid Requirement=70×30 • Colloid Requirement=2100 ml Maintenance Fluid • Maintenance Fluid=2000 ml Total Fluid Requirement in the First 24 Hours • Total Fluid Requirement=Crystalloid Requirement+Colloid Requ irement+Maintenance Fluid • Total Fluid Requirement=2100 ml+2100 ml+2000 ml • Total Fluid Requirement=6200 ml Fluid Administration • Crystalloids in the first 24 hours: 2100 ml • Colloids in the first 24 hours: 2100 ml • Maintenance fluids in the first 24 hours: 2000 ml
- 11. BURN: DEFINITION: Burns can be defined as any injury that result from the direct contact or exposure to any thermal chemical, electrical or radiation sources. A burns occur when there is injury to the tissues of the body.
- 12. CAUSES: • Fire/flame. • Hot liquid or steam. • Hot metal, glass or other objects. • Electrical currents. • Friction by rubs against a rough surface. • Radiation, such as that from X-rays. • Sunlight or other sources of ultraviolet radiation, such as a tanning bed. • Chemicals such as strong acids, dye, paint thinner or gasoline ( carbon monoxide). • Inhalation of hot gases, steam, or smoke during fires can cause burns to the airways and lungs, leading to respiratory injuries. • Abuse. ( Carbon monoxide (chemical formula CO) is a poisonous, flammable gas that is colorless, odorless, tasteless, and slightly less dense than air. High levels of CO enter the body, it can be deadly after only a few minutes. The most common symptoms of CO poisoning are a headache and shortness of breath).
- 13. CAUSES: - A chemical burn is damage to tissue on your body due to a harsh or corrosive substance. Most chemical burns are the result of accidentally spilling a chemical on ourself. Causes; Battery acid, Bleach, Detergents, Drain cleaners, Fertilizers, Hair relaxers, Metal cleaners and rust removers, Paint removers, Pesticides, Sanitizers and disinfectants, Swimming pool chemicals, Toilet bowl cleaners, Wet cement. Electrical burns may be caused by a number of sources of electricity. Examples include lightning, stun guns, and contact with job site or household current. Severe symptoms include; Severe burns, Confusion, Difficulty breathing, Irregular heart rhythm (arrhythmias), Does not have a pulse and is not breathing (cardiac arrest), Muscle pain and contractions, Seizures, Loss of consciousness Burns due to external heat sources which raise the temperature of the skin and tissues and cause tissue cell death or charring. Hot metals, scalding liquids, steam, and flames, when coming in contact with the skin, can cause thermal burns. Inhalation injuries are acute injuries to your respiratory system and lungs. They can happen if you breathe in toxic substances, such as smoke (from fires), chemicals, particle pollution, and gases. Inhalation injuries can also be caused by extreme heat; these are a type of thermal injuries. Over half of deaths from fires are due to inhalation injuries. Symptoms; Coughing and phlegm, A scratchy throat, Irritated sinuses, Shortness of breath, Chest pain or tightness, Headaches, Stinging eyes, A runny nose.
- 14. CLASSIFICATION: • First-degree (superficial) burns. First-degree burns affect only the outer layer of skin, the epidermis. The burn site is red, painful, dry, and has no blisters. Mild sunburn is an example. Long-term tissue damage is rare and often consists of an increase or decrease in the skin color. • Second-degree (partial thickness) burns. Second-degree burns involve the epidermis and part of the lower layer of skin, the dermis. The burn site looks red, blistered, and may be swollen and painful. • Third-degree (full thickness) burns. Third-degree burns destroy the epidermis and dermis. They may go into the innermost layer of skin, the subcutaneous tissue. The burn site may look white or blackened and scarred. • Fourth-degree burns. Fourth-degree burns go through both layers of the skin and underlying tissue as well as deeper tissue, possibly involving muscle and bone. There is no feeling in the area since the nerve endings are destroyed.
- 15. CLASSIFICATION: Acc. to American Association § First-degree burn of < 15% body surface area in adults. § Second-degree burn of < 10% body surface area in children. § Third-degree burn of < 2% body surface area § First-degree burn of 15–25% body surface area in adults. § Second-degree burn of 10–20% body surface area in children. § Third-degree burn of < 10% body surface area. § First-degree burn of > 25% body surface area in adults. § Second-degree burn of > 20% body surface area in children. § Third-degree burn of > 10% body surface area. § Most burns involving hands, face, eyes, ears, feet, or perineum
- 17. PATHOPHYSIOLOGY: Burn Ischemia of brain, kidney and vital organ Organ failure e.g. Kidney Reduce blood flow to the vital organ like a GI tract and kidney Fluid and blood is losses from vessel Fluid plasma accumulate and cause edema Fluid plasma leak out on the interstitial space Causes permeable to the vessel Due to etiological factor
- 18. CLINICAL MANIFESTATION: ü Pain ü Redness and inflammation ü Blistering ü Swelling ü Peeling and sloughing ü Numbness or tingling ü Charred or blackened skin ü Difficulty breathing ü Shock ü Scarring ü Injury to deeper lavers of dermis ü Cold and clammy skin üTachycardia üHypotension due to shift of fluid üDecreased heart rate üHoarseness of voice mostly due to smoke üConfusion üIrritability üSubconscious to unconscious üLoss of motor action
- 19. DIAGNOSTIC EVALUATION: § History Taking § Physical Examination § ABG § Chest x- ray, CT - scan § Pulse oximetry § Capnography § Fibreoptic laryngoscopy and bronchoscopy
- 20. MEDICAL MANAGEMENT: qCooling the burn with cool water for a few minutes. qOver-the-counter burn creams or ointments, such as aloe vera or petroleum jelly. qWound care, including cleaning the wound, debriding dead tissue, and applying topical antimicrobial agents. qPain medications, such as acetaminophen, ibuprofen, or opioids. qTopical treatments containing lidocaine or other numbing agents may be used to provide local pain relief. qFluid resuscitation aims to restore and maintain adequate hydration and circulation. qNutritional supplementation, including protein, vitamins, and minerals, to support tissue repair and immune function. qAntimicrobial dressings, topical antibiotics, or systemic antibiotics may be used to prevent or treat infections. qWound care, including cleaning and dressing changes, is essential to minimize the risk of infection. qPhysical therapy, occupational therapy, and psychological support to help patients recover function and adjust to any disabilities or changes in appearance.
- 21. SURGICAL MANAGEMENT: Ø Bursectomy - Removal of the affected bursa. Ø Open bursectomy - In open bursectomy, a larger incision is made directly over the affected bursa, and the bursa is removed surgically. Ø Arthroscopic bursectomy - A thin, flexible instrument with a camera (arthroscope) is inserted into the joint to visualize the bursa. Surgical instruments are then inserted through additional small incisions to remove the inflamed bursa. Ø Reconstructive surgery and comestic surgery. Ø Skin grafting - A patch of skin that is removed by surgery from one area of the body and transplanted, or attached, to another area.
- 22. NURSING DIAGNOSIS: • Ineffective airway clearance related to edema and effects of smoke inhalation as evidence by abnormal breathing sound, dyspnea... • Impaired skin integrity: related to thermal injury. • Acute pain: related to exposed nerve endings and inflammation. • Fluid volume deficit: related to fluid loss from the burn wound and increased vascular permeability. • Impaired physical mobility: due to pain, edema, or joint contractures. • Risk of infection r/t loss of skin injury. • Imbalance nutrition less than body required r/t hyper metabolism and wound healing need. • Ineffective coping r/t fear of dependency on health care providers. • Deficient knowledge r/t course of burns injury.
- 23. NURSING MANAGEMENT: ü Monitor vital signs. ü Secure patient airway (ABC). ü Administered strong analgesic (pethidine). ü Provide enough fluid to the patient. ü Apply antiseptic topical cream to prevent from infection. ü Provide adequate nutrition to the patient. ü Provide psychological support to the patient and family. ü Assess the patient condition regularly. ü Regular dressing to the burns area with proper care. ü Administered the prescribed medication. ü Observed the healing process of the patient. ü Educate the patient condition and the important of the medical intervention. ü Assist the patient in needs. ü Instruct the patient for the rehabilitation and the need for follow up care.
- 24. Burn care is categorized into three phases of care. Ø Immediate/ Resuscitative phase Ø Intermediate phase Ø Rehabilitative phase Immediate /Resusciative phase Medical Management: § Treat minor burns § Monitor airway and breathing § Reduce pain § Prevent aspiration § Minimize pain and anxiety § Prevent hypovolemic shock
- 25. Acute/Intermediate phase Medical Management § Prevent infection § Minimize pain § Provide wound care § Maximise functions § Provide psychological support Rehabilitation Phase § Minimizing functional loss § Provide psychological support § Prevention and treatment of scars § Change in appearance and functions
- 26. FIRST AID: § Stop the burning § Assess ABC § Remove constricting jewelry and clothing. § Run burns under cool water for 10min. § Call for medical helps. § Cover the burns with sterile clean cloths § Assess for associate trauma § In case of chemical burns, clothing which has been soaked by the chemical agent must be removed immediately § Evaluate the degree of burns and treat the priority’s need first. § Administered 100% of oxygen as prescribed.
- 27. COMPLICATION: 1. Arrhythmia (electrical burn). 2. Dehydration. 3. Disfiguring scars and contractures. 4. Edema (excess fluid and swelling in tissues). 5. Organ failure. 6. Pneumonia and respiratory problem. 7. Seriously low blood pressure (hypotension) that may lead to shock. 8. Infection and sepsis. 9. Psychological impact. 10. Hypothermia.
- 28. COMPLICATION: Direct fluid loss from the burns, third space losses, and kidney injury can lead to electrolyte imbalance, commonly results in initial hypernatraemia; subsequent hypokalaemia, hypomagnesaemia, hypocalcaemia, and hypophosphataemia These include paralytic ileus, Curling’s ulcer (see below), and bacterial translocation, gastric distention and ↑risk of aspiration. Adverse scarring (including hypertrophy or keloid growth) and contractures can result from healing of deep burns. Curling’s Ulcer A Curling’s ulcer is a gastric ulcer that can occur following severe burns. The significant reduction in plasma volume following the injury can lead to gastric mucosa ischaemia, leading to ulcer formation Patients admitted with severe burns who subsequently develop features of upper GI bleeding or perforation should be suspected to have a Curling’s ulcer. Indeed, any patient with significant burn injury should be started on PPI-therapy at admission to reduce this risk.
- 29. § Blood pressure falls-fluid leaks from intravascular to interstitial (sodium and protein). § Hypotension. § Tachycardia Blood flow in intravascular is concentrated and cause static. § Cardiac output ↓, - Due to that tissue perfusion ↓, Renal blood flow decrease soon after injury due to hypovolemia, decreased cardiac output, and elevated systemic vascular § Oliguria § Vasoconstriction and fluid retention § Thrombocytopenia, abnormal platelete function, clotting factor. § Life span <RBC. § Blood loss during diagnostic and therapeutic procedure.
- 30. Majority of deaths from fire are due to smoke inhalation. § Pulmonary damage can be from direct inhalation injury or systemic respond to the injury. § Damage to cilia and cell in the airway- inflammation. § Mucociliary transport mechanism not functioning-bronchial congestion and infection. § Pulmonary edema, fluids escape to interstitial. § Airway obstruction
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