Health History and Review of System Assessment

Mr. MJ , 56 years old is brought to the Emergency Room after gas tank
explosion accident.

Vital signs Initial assessment revealed heart rate

is 142 bpm, RR- 36 breaths/min and
labored. BP- 98/60, Temp-36.8 C. He
states that his pain 10/10. Weight
176 pounds

Neurology He is alert and oriented and

experiencing severe pain associated
with burn injuries. He appears very
anxious.

Eyes and Ears The eyebrows, eyelashes and hair are

singed. There is soot in the nares
and mouth.

Respiratory Lung sounds indicate inspiratory and

expiratory wheezing and a persistent
cough reveals sooty sputum
production. The physician inserted a
large bore central line into Mr MJs
sublavian vein and started a rapd
infusion of lactated Ringers solution.
Mr MJ is receiving 40% humidified O2
via face mask. Initial ABG are as
follows: ph 7.49, pCO2 32
mmHg, HCo3 22 meq/L . PO2- 60
mmHG. A nasogastric tube is
inserted and MJ was placed on NPO
till further order.

Gastrourinary A Foley catheter is inserted and

initially drains a moderate amount of
dark, concentrated urine.

Integumentray There is thick, white leathery eschar

 on the chest, neck, whole part of his
back and circumferential burns on
his right arm. The skin of the face is
pink, moist and blistered.

MJ was started on fluid resuscitation using the Parkland formula as a guide.

For a 80kg patient with a 45% TBSA burn:

4Ml x 80KG x 45 TBSA burn = 14, 400 mL in 24 hr
- of total in first 8 hr = 7, 200 mL ( 900mL/hr)
- of total in second 8hr = 3, 600 mL ( 450mL/hr)
- of total in third 8 hr = 3,600 mL (450mL/hr)

The lab studies sent were CBC, ABG, urinalysis, BUN, Na, K det., total protein
and revealed the following findngs: H.gb -20g/dl; Hct 52%; glucose 168
mg/dl; BUN 27mg/dl. Urinalysis 20-30 pus cells/hpf

Day 2 lab test revealed Lab values Na -126 meq/L, K 6.0 meq /L,. ABG
revealed pH -7.30, pCO2- 35 mmHG, HCO3 -18 meq/L. , Decreasing urine
output. The decision to initiate dialysis was reached after thoughtful
discussion with the family members. Double lumen cuffed hemodialysis IJ
catheter was used in acute hemodialysis

Anatomy and Physiology of Burns

There are three major components of the skin. First is the hypodermis, which
is subcutaneous (just beneath the skin) fat that functions as insulation and
padding for the body. Next is the dermis, which provides structure and
support. Last is the epidermis, which functions as a protective shield for the
body.

Hypodermis
The hypodermis is the deepest section of the skin. The hypodermis
refers to the fat tissue below the dermis that insulates the body from
cold temperatures and provides shock absorption. Fat cells of the
hypodermis also store nutrients and energy. The hypodermis is the
thickest in the buttocks, palms of the hands, and soles of the feet. As
we age, the hypodermis begins to atrophy, contributing to the thinning
of aging skin.
 Dermis
The dermis is located between the hypodermis and the epidermis. It is
a fibrous network of tissue that provides structure and resilience to the
skin. While dermal thickness varies, it is on average about 2 mm thick.

The major components of the dermis work together as a network. This

mesh-like network is composed of structural proteins (collagen and
elastin), blood and lymph vessels, and specialized cells called mast
cells and fibroblasts. These are surrounded by a gel-like substance
called the ground substance, composed mostly of glycosaminoglycans.
The ground substance plays a critical role in the hydration and
moisture levels within the skin.
Epidermis
The epidermis is the outermost layer of the skin. Categorized into five
horizontal layers, the epidermis actually consists of anywhere between
50 cell layers (in thin areas) to 100 cell layers (in thick areas). The
average epidermal thickness is 0.1 millimeters, which is about the
thickness of one sheet of paper. The epidermis acts as a protective
shield for the body and totally renews itself approximately every 28
days.

The first layer of the epidermis is the stratum basale. This is the
deepest layer of the epidermis and sits directly on top of the dermis. It
is a single layer of cube-shaped cells. New epidermal skin cells, called
keratinocytes, are formed in this layer through cell division to replace
those shed continuously from the upper layers of the epidermis. This
regenerative process is called skin cell renewal. As we age, the rate of
cell renewal decreases. Melanocytes, found in the stratum basale, are
responsible for the production of skin pigment, or melanin.
Melanocytes transfer the melanin to nearby keratinocytes that will
eventually migrate to the surface of the skin. Melanin is
photoprotective: it helps protect the skin against ultraviolet radiation
(sun exposure).

The second layer of the epidermis is the stratum spinosum, or the

prickle-cell layer. The stratum spinosum is composed of 8-10 layers of
polygonal (many sided) keratinocytes. In this layer, keratinocytes are
beginning to become somewhat flattened.

The third layer is called the stratum granulosum, or the granular layer.
It is composed of 3-5 layers of flattened keratina tough, fibrous
protein that gives skin its protective properties. Cells in this layer are
too far from the dermis to receive nutrients through diffusion, so they
begin to die.
The fourth
layer in
the epidermis
is called the
stratum
lucidum,
or the clear
layer. This
layer is
present
only in the
fingertips,
palms,
and soles of
the feet. It is
3-5 layers of
extremely
flattened cells.

The fifth layer, or horny layer, is called the stratum corneum. This is
the top, outermost layer of the epidermis and is 25-30 layers of
flattened, dead keratinocytes. This layer is the real protective layer of
the skin. Keratinocytes in the stratum corneum are continuously shed
by friction and replaced by the cells formed in the deeper sections of
the epidermis. In between the keratinocytes in the stratum corneum
are epidermal lipids (ceramides, fatty acids, and lipids) that act as a
cement (or mortar) between the skin cells (bricks). This combination of
keratinocytes with interspersed epidermal lipids (brick and mortar)
forms a waterproof moisture barrier that minimizes transepidermal
water loss (TEWL) to keep moisture in the skin. This moisture barrier
protects against invading microorganisms, chemical irritants, and
allergens. If the integrity of the moisture barrier is compromised, the
skin will become vulnerable to dryness, itching, redness, stinging, and
other skin care concerns.
 1st Degree Burns

Damage has only been done to the first layer of skin (epidermis). The
skin will turn red, become inflamed and sore. These burns require minimal
treatment such as a damp/cool cloth over the affected area.

2nd Degree Burns

Damage has gone through to the second layer of skin (dermis). The skin
will turn pink/red, it may ooze liquid and blister. The affected area will swell
and can have intense pain. The area will have a blotchy discoloration when
pressure is applied. In extreme cases, hospitalization may be required.
Otherwise, it is suggested that a damp/cool cloth is used to cool the affected
area. Never use ice on a burn.

3rd Degree Burns

Damage has been done to all three layers of skin (to the subcutaneous
tissue). Skin of the affected area may be visually changed- physical
depression, charring, a leathery appearance, and skin of the affected area
may fall off. Internally, bones and muscles could be damaged as well. Third
degree burns usually result in irreversible nerve or tissue damage. To heal
the burns, skin grafts are sometimes necessary. Hospitalization is needed.

Assessment of the Adequacy of Fluid Resuscitation

The extent of the burn wound is assessed using a Lund-Browder and Rule of
Nines chart. This allows the accurate estimation of fluid resuscitation
requirements. The type of fluid replacement is determined by size and depth
of burn, age of the patient, and individual considerations, such as
preexisting chronic illness. Each burn facility has a preference for a
replacement regimen. Fluid replacement is accomplished with crystalloid
solutions (usually lactated Ringers), colloids (albumin), or a combination of
the two. Paramedics generally give IVV saline until the patients arrival at the
hospital.

The Parkland (Baxter) formula for fluid replacement is the most common
formula used followed by the modified Brooke formula.

Formula First 24 Hours Second 24 Hours

Crystalloids Colloids Glucose in Water
Parkland (Baxter) Lactated 0.3-0.5 Ml/kg/% Amount to
Ringers: 4.0 TBSA burn replace estimated
mL/kg/% TBSA evaporative
burn; given losses
 during first 8hr;
given each
next 8 hr
Brooke (Modified) Lactated 0.3-0.5 Ml/kg/% Amount to
Ringers: 2 TBSA burn replace estimated
mL/kg/% TBSA evaporative
burn; given losses
during first 8hr;
given each
next 16 hr

It is important to remember that all formulas are estimates and must be

titrated based on the patients physiologic response. For example, patients
with an electrical injury may have greater that normal fluid requirements.

Colloidal solutions (e.g albumin) may be given. However, administration is

recommended after the first 12 to 24 hours postburn when capillary
permeability returns to normal or near normal. After this time, the plasma
remains in the vascular space and expands the circulating volume. The
replacement volume is calculated based on the patients bodyweight and
TBSA burned. (e.g., 0.3 to 0.5 mL/kg/% TBSA burn)

Assessment of the adequacy of fluid resuscitation is best made using clinical

parameters. Urine output, the most commonly used parameter, and cardiac
parameters are defined as follows:

1. Urine output: 0.5 to 1 mL/kg/hr; 75 to 100 mL/hr/for electrical burn

patient with evidence of hemoglobinuria/myoglobinuria.
2. Cardiac factors: Mean arterial pressure (MAP) greater than 65 mm Hg,
systolic BP greater than 90 mm Hg, heart rate less than 120 beats per
minute. MAP and BP are most appropriately measured by an arterial
line. Peripheral measurement is often invalid because of
vasoconstriction and edema.

The Stages of Burns

1. Shock Phase or Fluid Accumulation Phase or Emergent Phase

 - It occurs during the first 48 hours post-burns. Fluid shifts from
intravascular compartment to interstitial compartment (IVC to ISC).
This leads to generalized dehydration.
- Hypovolemia occurs due to plasma loss. This causes decreased
cardiac output and fall of BP.
- Hemoconcentration, increased hematocrit. Plasma is lost into the
interstitial compartment (ISC).
- Oliguria. This is due to decreased renal tissue perfusion, decreased
release of ADH and Aldosterone. These are bodys responses to
hypovolemia.
- Hyperkalemia and hyponatremia. This results from release of
potassium from damaged cells; sodium is trapped in the edema
fluids (ICS).
- Metabolic acidosis. This results from accumulation of metabolites,
hyponatremia and hyperkalemia. Primarily, it is due to
hyponatremia. Since sodium is unavailable because it it trapped in
the edema fluids, bicarbonate produced by the kidneys will be
excreted.
2. Diuretic or Fluid Remobilization phase
- This occurs after 48 hours post burns. Fluid shifts from interstitial
compartment to intravascular compartment (ISC to IVC).
- Hypervolemia, hemodilution and decreased hematocrit occur. This is
due to fluid shift from ISC to IVC.
- Diuresis. This is due to increased renal tissue perfusion, decreased
ADH and Aldosterone secretion.
- Hypokalemia, hyponatremia. Potassium moves back into the cells;
sodium is still trapped in the edema fluids.
- Metabolic acidosis. Decreased sodium levels cause of excretion of
bicarbonate by the kidneys.
3. Recovery Stage
- This occurs on the 5th day, onwards.
- Hypocalcemia. This results from loss of calcium in the exudates. It is
also due to utilization of calcium in the granulation tissue (scar)
formation in the areas of burns.
- Negative nitrogen balance. In stress like burns, there is increased
protein catabolism. Protein demands are increased for healing and
protein intake may be inadequate.
- Hypokalemia. Potassium has shifted back into the cells, serum
levels are decreased.

Management
The first aid intervention for burns are as follows:

Stop the burning process

1. Immerse the affected part in the cold water
2. Drop and roll. Advise the client to drop and roll on the ground if
clothing is in flame.
3. Throw a blanket over the client to extinguish the flame. This cuts off
source of oxygen from the environment and the flame will
spontaneously be extinguished.

Collaborative Management for clients with burns include the following:

1. Promote respiratory function

Assess for sooty sputum and singed hair in the nose and eye brows
(Singed hair is stiff and rigid burnt hair)
Establish an open airway
Administer oxygen therapy
2. Promote fluid-electrolyte and acid-base balance
Assess the following parameters:
- Vital signs
- Urine output
- Central Venous Pressure (CVP)
- Level of Consciousness
- Weight
- Percentage of Burns
The vital changes in dehydration are as follows:
- Weight loss
- Decrease urine output
- Decreased CVP
- Decreased level of consciousness
- Changes in vital signs: elevated body temperature, increased pulse
rate, rapid respiratory rate, low blood pressure.
The rule of 9s for determining percentage of burns in an adult
3. Relieve Pain
Administer Morphine Sulfate IV as prescribed. Monitor the client for
respiratory depression. Have Narcan (Naloxone) readily available.
Use bed cradle to relieve pressure from the top sheet and to prevent
sticking of exudates to the top sheet.
Avoid exposure of affected areas to draft. Sudden gush of wind causes
hypersensitivity of exposed nerve endings.
4. Prevent infection
Practice asepsis. Handwashing is the most important to prevent spread
of microorganism.
 Implement reverse or protective isolation
Administer tetanus immunization
Irrigate affected area with normal saline (NS) solution
5. Maintain adequate nutrition
Do not give oral fluids for the first 24 hours. To prevent paralytic ileus,
gastric dilation, and water intoxication.
Provide high calorie, high carbohydrates, high protein diet.
Provide diet rich in Vitamins A, B, and C. Vitamin A maintains skin and
mucous membrane integrity. Vitamin B enhances metabolism. Vitamin
C increases resistnace to stress and infection.
6. Provide wound care