1. Discuss the pathophysiology of burns, including the classification of burn depth and severity of burn injury.

Burns are body tissue injuries caused by heat, cold, chemicals, electrical current, or radiation. The resulting effect of burns is influenced by the temperature of the burning agent, duration of contact time, and the tissue type injured. The extent is calculated by the percent of TBSA burned, location of the burn, and patient risk factors. Burns are defined as 1st, 2nd, 3rd, and 4th degree. 2nd, 3rd, and 4th-degree may either be partial thickness or full thickness burns. Partial- and fullthickness burn extent can be determined using TBSA based on the Lund-Browder chart and Rule of Nines. Face, neck, and circumferential burns to the chest/back area may inhibit respiratory function with mechanical obstruction resulting from edema or leathery, eschar formation. These injuries may cause inhalation injury and respiratory mucosal damage. (Lewis, Heitkemper, Dirksen, Bucher and Bucher, 2007) 2. Using the rule of nines chart, calculate the % of TBSA burned. Based on the TBSA % and depth of burn, how would you classify Mr. Lewiss burn? Using the rule of nines chart, Mr. Lewis sustained burns to 58.5% of his body. The Full thickness burns to the upper half of his chest and circumferential burns to both arms account for 27%, with another 27% due to the deep partial thickness burns to his entire abdomen, upper half of his back, and front of his upper legs. He also sustained superficial partial thickness burns to his face, neck, and both hands accounting for 4.5%. Each percent given amounts to 58.5% TBSA. According to the discrimination of Mr. Lewiss burn injury, he has sustained first, second, and third degree burns to over half of his body. (Lewis, Heitkemper, Dirksen, Bucher and Bucher, 2007)

3. Describe the 3 phases of burn physiology, including the effects on the following systems during the emergent and acute phases: CV, respiratory, immune system, GI/hepatic, GU, and neurologic. The emergent phase is the period of time required to resolve immediate, life-threatening problems. It usually lasts 48-72 hours from the time of the burn. During this phase, the greatest threat is hypovolemic shock and edema. Toward the end of the phase, if fluid replacement is adequate, the capillary membrane permeability is restored. Fluid loss and edema formation cease. The interstitial fluid gradually returns to the vascular space. Diuresis occurs with low urine-spec gravities. Areas of full-thickness and deep partial-thickness burns are initially anesthetic because the nerve endings are destroyed. Superficial to moderate partial-thickness burns are extremely painful. Most patients are alert. Loss of consciousness is usually a result of hypoxia due to smoke inhalation, head trauma, or excessive sedation. If inhalation injury has occurred, the upper airway is vulnerable to edema formation and obstruction of the airway. If the patient is hypovolemic, kidney blood flow may decrease, causing renal ischemia. If it continues, acute renal failure may develop. The acute phase begins with mobilization of ECF and subsequent diuresis and concludes when burned area is completely covered by skin grafts or when wounds are healed. This may take weeks or many months. Partial-thickness wounds form eschar, which begins separating fairly soon after injury; once removed, re-epithelialization appears as red or pink scar tissue. Margins of full-thickness eschar take longer to separate. As a result, they require surgical debridement and skin grafting for healing. Complications: wound infection, sepsis, Paralytic ileus, extreme agitation, withdraw, and limited ROM with contractures. The rehabilitation phase begins when wounds have healed and the patient is able to resume self-care activity. This may occur as early as 2 weeks or as long as 7- 8 months after the

burn. The new skin appears flat and pink, then raised and hyperemic; itching occurs with healing. Complications are skin and joint contractures and hypertrophic scarring. (Lewis, Heitkemper, Dirksen, Bucher and Bucher, 2007) 4. Based on Mr. Lewiss preburn weight, use the Parkland formula to calculate the fluid requirement for adequate resuscitation. Based on Mr. Lewiss preburn weight, he requires a total of 16,848 mL lactated Ringers SOLN in the first 24 hours (4mL 72kg 58.5% TBSA burn). Therefore, Mr. Lewis will receive 8424 mL the first 8 hours, 4212 mL the second 8 hours and 4212 mL the last 8 hours. (Lewis, Heitkemper, Dirksen, Bucher and Bucher, 2007) 5. What assessment findings are critical to establishing the presence of an inhalation injury? Which of Mr. Lewiss assessment findings warrant concern? Describe the treatment protocol of a burn patient with an inhalation injury or a suspected inhalation injury. Critical assessment findings that indicate the presence of inhalation injury include edema formation in the upper or lower respiratory system; rapid, shallow respirations; increasing hoarseness; coughing; singed nasal/facial hair; darkened oral/nasal membranes; smoky breath; carbonaceous, black, gray, or bloody sputum; dysphagia; cherry-red color (CO>20); AMS, confusion, or coma; decreased O2 sat. (Lewis, Heitkemper, Dirksen, Bucher and Bucher, 2007) On admission, Mr. Lewis has a productive cough of carbon-tinged sputum, increasing hoarseness, and absent bowel sounds. These signs and symptoms as well as his vital signs (RR 24, BP 140/90, and HR 110) warrant concern of inhalation injury. Lab results that warrant concern include a myoglobin value of 90, serum potassium 5.2, and serum sodium 151. (Lewis, Heitkemper, Dirksen, Bucher and Bucher, 2007)

6. Calculate Mr. Lewiss nutritional needs (e.g. his BMI [body mass index] and his required daily kcal). Discuss the need for a high-calorie, high-protein diet. Mr. Lewis has a BMI of 24.3 and requires about 2500 calories per day. The importance of a high-calorie, high-protein diet cannot be over emphasized. After a major burn injury, a hypermetabolic state occurs which may cause massive catabolism characterized by protein breakdown and increased gluconeogenesis. Inadequate nutrition leads to malnutrition and delayed healing. (Lewis, Heitkemper, Dirksen, Bucher and Bucher, 2007)

References: Lewis, S. L., Dirksen, S. R., Bucher, L., Heitkemper, M. M., and Camera, I. M. (2011). Medicalsurgical nursing, assessment and management of clinical problems. (8th ed., Vol. 2). St. Louis, MO: Mosby Inc.