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BURNS
MR. Prasanth.K
MSc cardiothoracic
nursing
ANATOMY OF SKIN
The Skin
 Membrane that covers entire
body
 Largest, most dynamic
organ
 Epidermis
 Dermis
 Subcutaneous layer
(super...
Definition
 Injury to the tissues of the body caused by
heat, chemicals, electric current, or
radiation.
Incidence
 Domestic cases – 93-95%
 India – 0.4million / year
 Women are more affected than men – 1.6:1
 Overall morta...
Burn wound healing
 Inflammation
 Proliferation
 Remodeling
Inflammation
 Platelet adhesion
 Fibrin deposit
 Thrombus + vasoconstriction
 Hemostasis
 Local vasodilatation and in...
Proliferation (2-3 days post burn)
 Number of fibroblasts at peak
 Granulation
 Reepithelialization
Remodeling (lasts for years)
 Collagen fibers are reorganized
 Scars contract and fade in color
When burn extends to dermal tissue scars
developed are
- hypertrophic- overgrowth of dermal tissue
remains in the boundari...
ETIOLOGY
TYPES
Thermal
Caused by – flash , flame , scaled, contact
with hot objects
Management – extinguish flame
Flush with cool water
Chemical
Agent Forms Management
Acid House hold
cleaners
HCL, oxalic,
Water
irrigation
Irrigate skin
with soup
solution
Re...
 Dry chemical –
Brush away from skin
Irrigate skin
Smoke and inhalation injury
Agent Injury signs and
symptoms
Management
Carbon monoxide
poisoning -
Incomplete combustion
o...
Injury above glottis –
Usually thermally
produced
Inhalation f hot air ,
steam , or smoke
Especially .- burn in
enclosed s...
Injury below glottis –
Chemically produced
Pulmonary edema
ARDS
Close observation for
ARDS
Electrical burns
 Damage to the nerves and vessels
 Factors related to severity
voltage
Tissue resistance
Current pathwa...
S/S
Ice berg effect
Chance of cervical spine injury (fall)
Muscle contraction – fracture
Dyarrhythmias- AF, VF
Cardiac arr...
Management
 Disconnect source of current
 CPR
Cold thermal injuries
 Frostbite – gangrene
Radiation
 Source – solar, X ray , radioactive agent
 Management
Shield
Move client away
PATHOPHYSIOLOGY
AMERICAN BURN ASSOCIATION - burn unit
referral criteria
 Burn injuries that should be referred to a burn unit include the...
CLASSIFICATION OF BURN
INJURY
 Severity determined by –
Depth of burn
Extent of burn – calculated by TBSA
Location of bur...
Classification based on depth
 Superficial
 Partial thickness
superficial partial thickness
deep partial thickness
 Ful...
Superficial burns
 Involves epidermis
 ---- UV rays, sun burn, minor flash injury,
mild radiation
 s/s
Skin color – pin...
Partial thickness
Superficial partial thickness Deep partial thickness
Affected - Dermis and papillae
of dermis
Bright red...
Full thickness burn
 Epidermis + dermis + epidermal
appendages + subcutaneous fat+
connective tissue + muscle + bone
 Pa...
Classification by extent of burn
 Lund- Browder chart
 According to Rule of nine
( not accurate for estimating the perce...
Classification according to ABA
Minor burn injury Moderate burn injury Major burn injury
Excludes electrical
injury, inhal...
DIAGNOSTIC EVALUATION
 Sodium
hyponatreamea - dilutional Hyponatreamea
Water intoxication
Potassium – hyperkalemea – rena...
MANAGEMENT
 Pre hospital care
 Emergent phase
Air way management
Fluid therapy
Wound care
PRE HOSPITAL CARE
 Remove person from the source of burn
 Self shield – by rescuers
 Small burns <=10% TBSA – covered w...
EMERGENT PHASE
(resuscitative phase)
Air way management
 Early Endotracheal / orotracheal intubation
 Ventilatory assistance – with PEEP
 assess ABG values
...
 Assess lower respiratoty tract by –
fiberoptic bronchoscopy
 For inhalation injury – no intubation
perfornmed
Humidifie...
 If spinal injury – reverse tendelberg position
 Deep breathing and coughing exercise
 Reposition every 1-2 hrs
 Bronc...
Fluid therapy
 Pt >15% TBSA – large bore I/V access
 >30% TBSA – central and arterial line
 Crystalloid solutions – RL
...
Formula First 24 hrs Second 24 hrs
Brooke
(modified)
Crystalloid colloids Glucose in
water
4ml RL X Kgbody wt X%TBSA
burn=...
Wound care
 Start until airway patency maintained
 Cleansing and gentle debridement
Necrotic skin removed
Escharotomies ...
Control of infection
Open method Multiple dressing change method
Burn covered with cover with topical
antimicrobial soluti...
Skin graft
 Porcine skin – hetero graft or xenograft
(different spicies)
Cadaveri skin – homograft or
allograft (same spicies)
Cultured epithelial autograft
Autograft – own skin
Porcine collagen bonded to
silicone memberane – Biobrane
 Bovine collagen and glycosaminoglycan
bonded to silicone memberane
 Acellular dermal matrix derived from
donated human ...
Care of facial burn
 Open dressing
 Ophthalmological examination – corneal
burns and edema
 Periorbital edema – reassur...
DRUG THERAPY
Analgesics
 I/v medications
 Mrphine
 Fentanyle
 Morphine
 NSAIDs
 Oxycodone
Sedatives
 Haloperidol
 Lorazepam
 Midazolam
Other medications
 Ranitidine
 Nystatin
 Antacids
 Tetanus immunization
If not had active immunization in 10 years –
go for tetanus immunoglobulin
Antimicrobial agents
 Silver sulfadiazine
 Mafenide acetate
 Oral infection – nystatin mouth wash
NUTRITIONAL THERAPY
 TPN
 High protein high cal – diet
ACUTE PHASE
 Wound care
Debridment of necrotic tissue
Enzymatic debridement
Use meshed dressing with paraffine oil
Moist ...
 Skin grafting
 Pain management
 Other pain management techniques
Guided imaginary
Relaxation therapy
Hypnosis
 Physical and occupational therapy
ROM
Nutritional care
Psychosocial care
REHABILITATION PHASE
 Manage emotions
Fear
Anger
Anxiety
Guilt
Depression
COMPLICATIONS
 Contractures – abnormal condition of a joint
characterized by flexion and fixation
NURSING DIAGNOSIS
 Impaired gas exchange related to carbon
monoxide poisoning as evidenced by labored
breathing
 Ineffec...
 Fluid volume deficit related to fluid loss as
manifested by decreased serum electrolyte
level and dry skin
 Acute pain ...
 Impaired skin integrity related to thermal
injury as manifested by blisters and lesions.
 Activity intolerance related ...
 Anxiety related to prognosis of disease
condition and disturbed body image.
 Risk for infection related to impaired ski...
 Ineffective individual coping related to fear
and emotional impact of burn injury as
evidenced by increased questioning
...
Research studies
 The treatment of pain produced during the
management of burn injury has been an
ongoing problem for physicians caring fo...
 The adverse effects of opioids are well
known but the long term use of opioids
which produces tolerance with
accompanyin...
 This syndrome is manifest as enhanced pain, sensitivity
and loss of analgesic efficacy in patients treated with
opioids ...
Burns
Burns
Burns
Burns
Burns
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Care of patients with burn is highly sophisticated area of nursing.

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Burns

  1. 1. BURNS MR. Prasanth.K MSc cardiothoracic nursing
  2. 2. ANATOMY OF SKIN
  3. 3. The Skin  Membrane that covers entire body  Largest, most dynamic organ  Epidermis  Dermis  Subcutaneous layer (superficial fascia)  Deep fascia
  4. 4. Definition  Injury to the tissues of the body caused by heat, chemicals, electric current, or radiation.
  5. 5. Incidence  Domestic cases – 93-95%  India – 0.4million / year  Women are more affected than men – 1.6:1  Overall mortality – 3.5/100000 popu
  6. 6. Burn wound healing  Inflammation  Proliferation  Remodeling
  7. 7. Inflammation  Platelet adhesion  Fibrin deposit  Thrombus + vasoconstriction  Hemostasis  Local vasodilatation and increase of capillary permeability  Neutrophil (24 hrs)  Monocyte  Macrophages  Consume pathogens and dead tissue  Secrete various growth factors  Proliferation of fibroblasts + deposited of a provisional wound matrix
  8. 8. Proliferation (2-3 days post burn)  Number of fibroblasts at peak  Granulation  Reepithelialization
  9. 9. Remodeling (lasts for years)  Collagen fibers are reorganized  Scars contract and fade in color
  10. 10. When burn extends to dermal tissue scars developed are - hypertrophic- overgrowth of dermal tissue remains in the boundaries - Colloid – extends beyond boundaries
  11. 11. ETIOLOGY
  12. 12. TYPES
  13. 13. Thermal Caused by – flash , flame , scaled, contact with hot objects Management – extinguish flame Flush with cool water
  14. 14. Chemical Agent Forms Management Acid House hold cleaners HCL, oxalic, Water irrigation Irrigate skin with soup solution Remove the person or agent away. Take self precaution and remove the cloth which contain chemical. Alkali Drain cleaners Fertilizers Adhere to tissue and protein hydrolysis Irrigate skin with slightly acidic solutions like lemon water
  15. 15.  Dry chemical – Brush away from skin Irrigate skin
  16. 16. Smoke and inhalation injury Agent Injury signs and symptoms Management Carbon monoxide poisoning - Incomplete combustion of burning material Cherry red skin color 10-20% - head ach , dizziness , nausea, abdominal pain 21-41%- irritability , confusion , stupor, hypotension , bradycardia, pale to dark red skin color 41-60%- convulsion , coma, hypotension, tachycardia >60%- death 100% o2
  17. 17. Injury above glottis – Usually thermally produced Inhalation f hot air , steam , or smoke Especially .- burn in enclosed space Mucosal burning of larynx and oropharynx Redness Blistering Edema Quick mechanical obstruction Singed nasal hair Hoarseness painful swallowing Darkened oral and nasal membrane Carbonaceous sputum Medical emergency
  18. 18. Injury below glottis – Chemically produced Pulmonary edema ARDS Close observation for ARDS
  19. 19. Electrical burns  Damage to the nerves and vessels  Factors related to severity voltage Tissue resistance Current pathways Surface area of contact Length of time
  20. 20. S/S Ice berg effect Chance of cervical spine injury (fall) Muscle contraction – fracture Dyarrhythmias- AF, VF Cardiac arrest Metabolic acidosis Myoglobinuria lead to – acute renal tubular necrosis
  21. 21. Management  Disconnect source of current  CPR
  22. 22. Cold thermal injuries  Frostbite – gangrene
  23. 23. Radiation  Source – solar, X ray , radioactive agent  Management Shield Move client away
  24. 24. PATHOPHYSIOLOGY
  25. 25. AMERICAN BURN ASSOCIATION - burn unit referral criteria  Burn injuries that should be referred to a burn unit include the following 1. Partial thickness burns more than 10% TBSA 2. Burns that involve s the face hands feet genitalia perineum or major joints 3. Third degree burns in any age group 4. Electrical burns including lightning injury 5. Chemical burns 6. Inhalation injury 7. Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality 8. Any patients with burns and concomitant trauma (fractures) in which the burn injury poses the greatest risk of morbidity or mortality. 9. Patients who will require special social, emotional, or long term rehabilitation intervention
  26. 26. CLASSIFICATION OF BURN INJURY  Severity determined by – Depth of burn Extent of burn – calculated by TBSA Location of burn Patient risk factors
  27. 27. Classification based on depth  Superficial  Partial thickness superficial partial thickness deep partial thickness  Full thickness
  28. 28. Superficial burns  Involves epidermis  ---- UV rays, sun burn, minor flash injury, mild radiation  s/s Skin color – pink – bright red Slight edema Chills, nausea, vomiting – in extensive burns Management – I/V fluid treatment
  29. 29. Partial thickness Superficial partial thickness Deep partial thickness Affected - Dermis and papillae of dermis Bright red color + moist + glistening appearance + blisters + blanching on pressure + pain response to temperature and air is severe Heal with in 21 days + minimal or no scaring Management – analgesics Skin substitutes for large disrupted blisters Dermis +more deeper Pale + waxy+ moist / dry large blisters + decreased capillary refill + less painful Heal – more than 21 days Complication Necrosis may lead to full thickness injury , contractures Management – excision and grafting
  30. 30. Full thickness burn  Epidermis + dermis + epidermal appendages + subcutaneous fat+ connective tissue + muscle + bone  Pale ,waxy ,brown ,mottled ,leathery ,firm to touch  No sensation of pain Management – Skin grafting
  31. 31. Classification by extent of burn  Lund- Browder chart  According to Rule of nine ( not accurate for estimating the percentage TBSA for adults who are short, obese or very thin. )  Sage burn diagram – computerized burn estimation tool. (www.sagediagram.com)
  32. 32. Classification according to ABA Minor burn injury Moderate burn injury Major burn injury Excludes electrical injury, inhalation injury, and all clients at high risk Partial thickness burns of less than 15 % of TBSA in adults Full thickness burns of less than 2% of TBSA not involving special care areas. ( eye ,ear, hand , feet, face , joints , perineum ) Excludes electrical injury, inhalation injury, and all clients at high risk Partial thickness burns of less than 15 %- 25 % of TBSA in adults Full thickness burns of less than 10 % of TBSA not involving special care areas. ( eye ,ear, hand , feet, face , joints , perineum ) Includes electrical injury, inhalation injury, and all clients at high risk involving special care areas. ( eye ,ear, hand , feet, face , joints , perineum Partial thickness burns of more than 25 % of TBSA in adults Full thickness burns of 10 % or greater of the TBSA
  33. 33. DIAGNOSTIC EVALUATION  Sodium hyponatreamea - dilutional Hyponatreamea Water intoxication Potassium – hyperkalemea – renal failure Adrenocortical insufficiancy Massive deep muscle injury Hypokalemea- dilution / GI wash…
  34. 34. MANAGEMENT  Pre hospital care  Emergent phase Air way management Fluid therapy Wound care
  35. 35. PRE HOSPITAL CARE  Remove person from the source of burn  Self shield – by rescuers  Small burns <=10% TBSA – covered with clean, cool, tap water-dampened towel.  Assesement and Management of ABC
  36. 36. EMERGENT PHASE (resuscitative phase)
  37. 37. Air way management  Early Endotracheal / orotracheal intubation  Ventilatory assistance – with PEEP  assess ABG values  Extubation- when edema resolves  Escharotomies - to relive respiratory distress secondary to circumferential, fulthickness burns to the neck and trunk
  38. 38.  Assess lower respiratoty tract by – fiberoptic bronchoscopy  For inhalation injury – no intubation perfornmed Humidified Oxygen Position – high fowler’s position (not for pts with spinal injury)
  39. 39.  If spinal injury – reverse tendelberg position  Deep breathing and coughing exercise  Reposition every 1-2 hrs  Bronchodilators  O2 therapy until carboxyhemoglobin become normal .
  40. 40. Fluid therapy  Pt >15% TBSA – large bore I/V access  >30% TBSA – central and arterial line  Crystalloid solutions – RL  Colloids – albumin  Calculate fluid requirement brooke’s and (baxter) parkland formula
  41. 41. Formula First 24 hrs Second 24 hrs Brooke (modified) Crystalloid colloids Glucose in water 4ml RL X Kgbody wt X%TBSA burn= total fluid repalcement for 1st 24 hrs Application ½ of total in 1st 8hrs ¼ of total in second 8 hr ¼ of total in third 8 hr 0.3- 0.5ml/kg/% TBSA Amount to replace estimated evaporative losses Parkland formula (baxter) RL 4ml X kgX %TBSA burn, ½ given first 8hr ¼ given each next 8 hr 20-60% of calculated plasma volume Amount to replace estimated evaporative losses
  42. 42. Wound care  Start until airway patency maintained  Cleansing and gentle debridement Necrotic skin removed Escharotomies ( removal of dry scab) Fasciotomies  Hydrotherapy / cart shower Once daily shower and dressing
  43. 43. Control of infection Open method Multiple dressing change method Burn covered with cover with topical antimicrobial solution with out dressing Sterile dressing impregnated with topical antimicrobial medication changed every 12 / 24 hrs or once in every 3 days. Moist wound healing method
  44. 44. Skin graft  Porcine skin – hetero graft or xenograft (different spicies)
  45. 45. Cadaveri skin – homograft or allograft (same spicies)
  46. 46. Cultured epithelial autograft
  47. 47. Autograft – own skin
  48. 48. Porcine collagen bonded to silicone memberane – Biobrane
  49. 49.  Bovine collagen and glycosaminoglycan bonded to silicone memberane  Acellular dermal matrix derived from donated human skin ( Alloderm )
  50. 50. Care of facial burn  Open dressing  Ophthalmological examination – corneal burns and edema  Periorbital edema – reassurece
  51. 51. DRUG THERAPY
  52. 52. Analgesics  I/v medications  Mrphine  Fentanyle  Morphine  NSAIDs  Oxycodone
  53. 53. Sedatives  Haloperidol  Lorazepam  Midazolam
  54. 54. Other medications  Ranitidine  Nystatin  Antacids
  55. 55.  Tetanus immunization If not had active immunization in 10 years – go for tetanus immunoglobulin
  56. 56. Antimicrobial agents  Silver sulfadiazine  Mafenide acetate  Oral infection – nystatin mouth wash
  57. 57. NUTRITIONAL THERAPY  TPN  High protein high cal – diet
  58. 58. ACUTE PHASE  Wound care Debridment of necrotic tissue Enzymatic debridement Use meshed dressing with paraffine oil Moist dressing for donor site
  59. 59.  Skin grafting  Pain management  Other pain management techniques Guided imaginary Relaxation therapy Hypnosis
  60. 60.  Physical and occupational therapy ROM Nutritional care Psychosocial care
  61. 61. REHABILITATION PHASE  Manage emotions Fear Anger Anxiety Guilt Depression
  62. 62. COMPLICATIONS  Contractures – abnormal condition of a joint characterized by flexion and fixation
  63. 63. NURSING DIAGNOSIS  Impaired gas exchange related to carbon monoxide poisoning as evidenced by labored breathing  Ineffective air way clearance related to edema and effects of smoke inhalation and evidenced by ventilatory support  Disturbed body image related to disfigurement secondary to burn as evidenced by verbalized negative comments about appearance.
  64. 64.  Fluid volume deficit related to fluid loss as manifested by decreased serum electrolyte level and dry skin  Acute pain related to impaired skin integrity as manifested by facial expression and crying.
  65. 65.  Impaired skin integrity related to thermal injury as manifested by blisters and lesions.  Activity intolerance related to weakness, as manifested by verbalization.
  66. 66.  Anxiety related to prognosis of disease condition and disturbed body image.  Risk for infection related to impaired skin integrity and suppressed immune response  Risk for contractures related to the burn injury
  67. 67.  Ineffective individual coping related to fear and emotional impact of burn injury as evidenced by increased questioning  Imbalanced nutrition less than body requirement related to inability to intake as evidenced by weight loss.  Hyperthermia, related to infection, as manifested by rise in body temperature..
  68. 68. Research studies
  69. 69.  The treatment of pain produced during the management of burn injury has been an ongoing problem for physicians caring for these patients. The main therapeutic option for analgesia has been the repeated and prolonged use of opioids.
  70. 70.  The adverse effects of opioids are well known but the long term use of opioids which produces tolerance with accompanying dose escalation and dependence is most problematic. Another potentially important consequence of opioid exposure that sometimes masks as tolerance is that of opioid induced hyperalgesia.
  71. 71.  This syndrome is manifest as enhanced pain, sensitivity and loss of analgesic efficacy in patients treated with opioids who actually become sensitized to painful stimuli. This article focuses on the treatment of burn pain and how current analgesic therapies with opioids may cause hyperalgesia and affect the adequacy of treatment for burn pain. This article also provides possible modalities to help therapeutically manage these patients and considers future analgesic strategies which may help to improve pain management in this complicated patient population.
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Care of patients with burn is highly sophisticated area of nursing.

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