Integumentary System

BURNS
direct tissue injury caused by thermal, electric, chemical & smoke inhaled (TECS) Nursing Priority infection (all kinds of burns) Head burn-priority- a/w 2nd priority for 1st & 2nd - pain 2nd priority for 3rd - F&E

a. b. c. d. 1. 2.

Thermal- direct contact flames, hot grease, sunburn. Electrictricity wires Chemical direct contact corrosive materials acids Smoke gas / fume inhalation

Stages: Emergent phase Removal of pt from cause of burn. Determine source or loc or burn Shock phase 48 - 72. Characterized by shifting of fluids from intravascular to interstitial space =Hypovolemia Signs & Symptoms BP decrease Urine output HR increase Hct increase Serum Na decrease Serum K increase Met acidosis

3. Diuretic/ Fluid remobilization phase - 3 to 5 days. Return of fluid from interstitial to intravascular space 4. Recovery/ convalescent phase complete diuresis. Wound healing starts immediately after tissue injury. Class: I. Partial Burn 1. 1st degree superficial burns - Affects epidermis - Cause: thermal burn - Painful - Redness (erythema) & blanching upon pressure with no fluid filled vesicles 2. 2nd degree deep burns - Affects epidermis & dermis - Cause chem. burns - very painful - Erythema & fluid filled vesicles (blisters) II Full thickness Burns 1. Third & 4th degrees burn - Affects all layers of skin, muscles, bones - Cause electrical - Less painful - Dry, thick, leathery wound surface known as ESCHAR devitalized or necrotic tissue.

ASSESSMENT FINDINGS

* Rule of nines Head & neck = 9% Ant chest = 18% Post chest = 18% @ Arm 9+9 = 18% @ leg 18+18 = 18% Genitalia/ perineum= 1% Total 100% Nursing Management: 1. Meds a.) Tetanus toxoid- burn surface area is source of anaerobic growth Claustridium tetany Tetany Tetanolysin Hemolysis tetanospasmin muscle spasm

b.) Morphine SO4 c.) Systemic antibiotics 1. Ampicillin 2. Cephalosporin 3. Tetracyclin 4. Topical antibiotic : 1. Silver Sulfadiazene (silvadene) 2. Sulfamylon 3. Silver nitrate 4. Povidone iodine (betadine) 2. Administer isotonic fluid sol & CHON replacements 3. Strict aseptic technique 4. Diet increase CHO, increase CHON, increase Vit C, and increase K- orange 5. If (+) to burns on head, neck, face - Assist in intubation 6. Assist in hydrotherapy 7. Assist in surgical wound debridement. Administer analgesic 15 30 minutes before debridement 8. Complications: a.) Infection b.) Shock c.) Paralytic ileus - due to hypovolemia & hypokalemia d.) Curlings ulcer H2 receptor antagonist e.) Septicemia blood poisoning f.) Surgery: skin grafting