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  1. Prof.Dr.Chinna Chadayan.N RN.RM., B.Sc (N)., M.Sc (N)., Ph.D (N)., Professor, Adult and Elderly Health Nursing Department, Enam Nursing College – Savar, 1st yr M.Sc (N) 2nd batch Unit – 20.3b AEN Specialty 1
  2. BURNS ⦿Injuries that result from direct contact with or exposure to any thermal, chemical or radiation sources. ⦿Burns occurs when energy from heat source is transferred to the tissues of the body. Definition A burn is an injury to the skin or other organic tissue primarily caused by heat or due to radiation, radioactivity, electricity, friction or contact with chemicals. 2
  3. ETIOLOGY ⦿Thermal burns ⦿Chemicals ⦿Electricity ⦿Radiations ⦿ Inhalation injuries 3
  4. THERMAL BURNS ⦿These are caused by exposure to or contact with flame, hot liquids, semi liquids (steam), semi-solid (tar) or hot objects. CHEMICAL BURNS ⦿It is caused by contact of tissue to any strong acids, alkalis or organic compounds. CHEMICAL BURNS THERMAL BURNS 4
  5. ELECTRICAL BURNS ⦿These are the injuries caused by heat that is generated by the electrical energy as it passes through the body. ⦿It can result from contact with exposed or faulty electrical wiring or high voltage power lines. ⦿People struck by lightening also sustain electrical injury. ELECTRICAL BURNS 5
  6. RADIATION BURNS ⦿These are caused by exposure to radioactive source. ⦿E.g.  Nuclear- radiation accidents.  Use of ionizing radiation in industries  Therapeutic radiations  Sunburns from prolonged exposure to ultraviolet rays. RADIATION BURNS 6
  7. INHALATION INJURIES ⦿It may result from exposure to asphyxiants and smoke, if the victim was trapped in closed, smoke – filled area. ⦿It results in pulmonary pathophysiologic changes. 7
  8. BURN DEPTH ⦿Tissue damage due to burns is determined by:  Extent of burn  Depth of burn 8
  9. EXTENT OF BURNS ⦿The total body surface area (TBSA), can be determined by :  Rule of nines 9
  12. WALLA CE 12
  13. Measuring extent of burns according to Rule on nines ANTERIOR POSTERIOR TOTAL (anterior + posterior) Head and neck 4.5% Head and neck 4.5% 9% Upper limbs 9% Upper limbs 9% 18% Trunk 18% Trunk 18% 36% Lower limbs 18% Lower limbs 18% 36% Perineum 1% 13
  14. 14
  15. DEPTH OF BURN ⦿ 1st degree burns ⦿ 2nd degree burns ⦿ 3rd degree burns ⦿ 4th degree burns 15
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  17. Names Layers involved Appearance Texture Sensation Time to healing Complication s Example First degree Epidermis Redness (erythema) Dry Painful Increased risk to 1wk or less develop skin cancer later in life Second degree (superficial partial thickness) superficial (papillary) d ermis Extends into Red with with Blanches pressure clear blister. Moist Painful 2-3wks Local infection/cell ulitis Second degree deep (deep partial (reticular) thickness) dermis Extends into Red-and- white with bloody blisters. Moist Painful Weeks - may third degre e Scarring, contractures progress to (may require excision and skin grafting) (full thickness) Third degree Extends through entire dermis Stiff and white/brown Dry, leathery Painless Requires excision Scarring, contractures, amputation Fourth degree Extends through skin, subcut aneous tissue and into underlying muscle and bone Black; charred with eschar Dry Painless Requires excision Amputation, significant functional impairment, possible gang rene, and in some cases death. 17
  18. 1st degree burns ⦿ It involves epidermal layers of skin. ⦿The skin remains intact. ⦿Patient may have local pain and erythema. ⦿Blisters may form in first 24 hours. 18
  19.  C/M : ⦿Headache, ⦿ pain, ⦿nausea and vomiting. It heals in 3 – 5 days. 19
  20. 2nd degree burns ⦿It can be classified into : 1. Superficial burns 2. Deep or partial - thickness burns 20
  21.  SUPERFICIAL BURNS: ⦿ It involves epidermal or dermal layer. ⦿It is red in color. ⦿Blisters forms immediately. ⦿Pain is present at the site of injury. ⦿It heals in 21 – 28 days. 21
  22. ⦿ DEEP BURNS: ⦿ In deep burns there is destruction of entire dermal layer of skin. ⦿ A flat dry blisters forms. ⦿ Pain is absent or dull. ⦿ It heals in one month. ⦿ Wound excision or skin grafting may be needed. 22
  23. 3rd degree burns ⦿These are also known as full thickness burns. ⦿It involves all layers of skin and subcutaneous tissues. ⦿The wound appears white, cherry red or black in color. 23
  24. ⦿Skin looses its elasticity and results in leathery appearance. ⦿It is painless. ⦿Superficial thrombosed blood vessels are evident. 24
  25. 4th degree burns ⦿It involves all layers of underlying tissues including bones, blood vessels, muscle and nerves. ⦿It requires skin grafting. ⦿Takes long time for healing. 25
  26. CLINICAL MANIFESTATIONS OF BURNS 1. Fluid and electrolyte imbalance like hyperkalaemia, Hyponatraemia occurs immediately after burns. ⦿Generalized body edema is seen in patients with greater than 25% burns. ⦿Increased hematocrit level. ⦿After 18 – 36 hours capillary membrane integrity begins to be restored. ⦿The body begins to reabsorb edema, fluid and excess fluid is excreted. 26
  27. 2. Alteration in respiration ⦿ It depends upon type of burns. ⦿ Manifested by dyspnea, rapid breathing , cyanosis, stridor. ⦿Thermal burns to the upper airway (mouth, nasopharynx and larynx) leads to mucosal edema, blisters, ulceration leading to upper airway obstruction. 3. Cardiac alterations ⦿Hypovlemia occurs immediately after the burns. ⦿Cardiac output decreases. ⦿Decrease in blood pressure. ⦿Anemia may occur as a result of damage to RBC’s. 27
  28. 4. Pain ⦿ Burn patients experiences two types of pain. ⦿Background pain and procedural pain. ⦿Background pain is experienced when patient is at rest. ⦿Procedural pain is experienced during the performance of therapeutic procedures like dressing, cleaning, etc. 5. Thermoregulatory alterations: ⦿ Loss of skin results in an inability to regulate body temperature. ⦿Patients may exhibit low body temperatures in the early hours after injury. 28
  29. PRE- HOSPITAL CARE ⦿THERMAL BURNS:  Lavage with water.  Assist the patient to drop and roll.  Cover body to prevent hypothermia. ⦿CHEMICAL BURNS:  Remove cloths.  Use shower to lavage the involved area. ⦿ELECTRIC BURNS:  Disconnect the source of electric current.  Monitor cardio pulmonary arrest.  Begin CPR if patient is unresponsive.  Place patient on spinal board and apply cervical collar and transport. 29
  30. MEDICAL MANAGEMENT ⦿There are three phases of treatment in care of the burn patients. ⦿These are: ⦿ Emergent / Resuscitative phase ⦿Acute phase ⦿Rehabilitation phase 30
  31. ⦿EMERGENT / RESUSCITATIVE PHASE: This phase lasts for 36 - 48 hours from the onset of injury. ⦿ACUTE PHASE: This phase begins with diuresis and ends with closure of the burn wound. ⦿REHABILITATION PHASE: This phase begins with wound closure and ends when client returns to the highest level of health. 31
  32. EMERGENT PHASE ⦿It lasts for 36– 48 hours after the onset on the burn injury. ⦿It ends when fluid resuscitation is complete. ⦿The management of burn patient begins at the scene of accident. ⦿Remove the patient from the area of danger. ⦿Stop the burning process. ⦿Implement basic life support. 32
  33. Medical management of emergent phase ⦿ Assess the burn severity. ⦿Assess the burn depth. ⦿ Assess burn extent using rules of nine ⦿Assess location of burn ⦿Identify the mechanism of injury. 33
  34.  Treatment of minor burns: ⦿Wound evaluation and initial care ⦿Tetanus toxoid immunization ⦿Pain management  TREATMENT OF MAJOR BURNS: Initial goals are : ⦿ Saving life ⦿ Maintaining and protecting airway ⦿ Restoring hemodynamic stability Later goals: ⦿ Replacement of missing skin. ⦿ Promoting healing ⦿ Assessing and correcting complications. 34
  35. 1. Monitor airway and breathing ⦿Maintaining patent airway and breathing are of prime importance. ⦿ Inspect oropharynx for erythema, blisters, ulcerations and need for endotracheal intubation. ⦿In inhalation injury administer 100% O2 via tight fitting mask. 35
  36. 2. Preventing burn shock ⦿In adultswith> 15%burnfluidresuscitation is required. ⦿2 largeboreneedlesareinsertedintravenously. ⦿Fluidresuscitation is usedto minimizetheharmful effect of fluid shift. ⦿The main goal is to maintain vital organ perfusion. 36
  37. ⦿ Formula for calculating the fluid: ⦿ CONSENCES FORMULA:  RL 2-4 ml / Kg / % TBSA ⦿In 1st 8 hrs ⦿ In next 8 hrs ⦿ In next 8 hrs first half of the amount ¼ of total amount ¼ of the total 37
  38. ⦿For example: 70 kg patient with 50% TBSA burn ⦿RL to be administered is……. 7000 ml in 24 hrs.  2 * 70 * 50 = ⦿In 1st 8 hrs ⦿ Next 8 hrs ⦿ Next 8 hrs 3500 ml 1750 ml 1750 ml 38
  39. Exercise: ⦿A 45 kg patient comes to emergency with 25% TBSA burn. Find out the amount of fluid to be administered using Consensus formula. ⦿RL to be administered : 2 * 45 *25 = 2250 ml ⦿In first 8 hrs – 1125 ml ⦿ In next 8 hrs- 562.5 ⦿ In next 8 hrs- 562.5 39
  40. ⦿EVAN’S FORMULA: ⦿ Electrolytes or saline- 1ml / kg / % TBSA ⦿Colloids- 1ml / kg / % TBSA + 2000ml dextrose in H2O. 40
  41. ⦿Day 1 – half of the amount to be given in 1st 8 hrs. ⦿Remaining half over next 16 hours. ⦿Day 2 – Half of the colloids and electrolytes. 41
  42. ⦿For example: 70 kg patient with 50% TBSA burn ⦿Electrolytes or saline to be administered: 1 * 70 * 50 = 3500 ml ⦿ Colloids to be administered : 1 * 70 * 50 + 2000 3500 + 2000 = 5500 ml. 42
  43. BROOKE ARMY FORMULA ⦿ Colloids – 0.5 ml * kg body wt * % TBSA burn ⦿ Electrolytes (RL) 0.5 ml * kg body wt* % TBSA ⦿GLUCOSE (5% in H2O) ; 2000ml for insensible loss. 43
  44. ⦿ Day 1 – half to be given in 1st 8 hours. ⦿Remaining half over next 16 hrs. ⦿Day 2 – half of colloids and half of electrolytes. 44
  45. PARKLAND / BAXTER FORMULA ⦿RL – 4 ml * kg body wt * % TBSA burned ⦿Day 1 – half to be given in 1st 8 hrs, rest half to be given over next 16 hours. ⦿Day 2 – colloids are added 0.3 – 0.5 ml / kg body wt / % TBSA. 45
  46. ⦿Colloid solutions are not administered in first 24 hours period. They are administered after 24 hours. ⦿Adequacy of fluid resuscitation is assessed by urine output. ⦿Indwelling catheter is inserted for keeping accurate monitoring of output. 46
  47. ⦿Vital signs are monitored frequently. ⦿Base line laboratory studies, BUN, Serum creatnine, serum electrolytes and hematocrit level. ⦿ECG monitoring , ABG analysis and chest X- ray. 47
  48. 3.PREVENTING ASPIRATION ⦿Nasogastric tube is placed to prevent vomiting and reduce the risk of aspiration which occur due to GI dysfunction resulting from the intestinal ileus or paralytic ileus. 4. MINIMIZING PAIN ⦿Pain management in moderate or major burns is achieved through IV administration of opoids like morphine sulphate. 48
  49. 5. WOUND CARE ⦿Immediate care ⦿Cover the wound with sterile towel and place on clean dry sheet. ⦿ Wound care for burns consists of : ⦿Cleansing ⦿Debridement ⦿Application of topical agents ⦿dressing 49
  50. 6. Preventing tetanus: immunization with tetanus toxoid. 7. Preventing tissue ischemia: ⦿Elevate the injured extremity above the level of heart and perform active exercises to reduce dependent edema formation. ⦿Immediately assess the distal extremity perfusion. 50
  51. Nursing diagnosis in emergent phase ⦿Impaired gas exchange related to carbon mono oxide intoxication, smoke inhalation and upper airway obstruction. GOAL: Maintenance of adequate tissue oxygenation ⦿ Ineffective airway clearance related to edema and effect of smoke inhalation. GOAL: Maintain patent airway. ⦿ Fluid volume deficit related to increased capillary permeability and evaporation losses from the burn wound. GOAL: Restoration of optimal fluid and electrolyte balance and perfusion of vital organs. ⦿Hypothermia related to loss of skin microcirculation and open wound. GOAL: Maintenance of adequate body temperature. ⦿Pain related to tissue and nerve injury and emotional impact of injury. GOAL: Control of pain 51
  52. ACUTE PHASE / INTERMEDIATE PHASE ⦿Acute phase begins when the patient is hemodynamically stable, capillary permeability is restored and diuresis begins. 52
  53. ⦿ This is generally considered to be at 48 – 72 hours after the time of burn injury. ⦿This phase continues until the wound closure is achieved. 53
  54. The management includes ⦿Wound cleansing ⦿ Topical antimicrobial therapy ⦿Wound dressing ⦿Wound debridement ⦿Grafting burn wound ⦿Pain management ⦿Infection control ⦿Nutrition therapy 54
  55. 1. Wound cleansing ⦿ It is done with the help of hydrotherapy. ⦿ Hydrotherapy is a form of shower carts. ⦿Individual showers and bed baths can be used to clean the wounds. 55
  56. ⦿The temperature of the water is maintained at 37.8 0 C. ⦿The temperature of the room should be maintained between 26.6 0 C to 29.4 0 C. ⦿Hydrotherapy should be limited to 20 – 30 minutes period to prevent chilling of the patient. 56
  57. ⦿Patient is encouraged to perform active exercises of extremities during hydrotherapy. ⦿Cross infection should be prevented by changing the plastic lining place inside the bathtub. ⦿Vital signs are monitored before and after hydrotherapy. 57
  58. 2. TOPICAL ANTIBACTERIAL THERAPY ⦿ It reduces the number of bacteria on the burn wound. ⦿ It promotes conversion of open, dirty wound to a closed, clean wounds. ⦿ E.g.  Silver Nitrate  Mafenide acetate  Silver sulfadiazine 58
  59. 3. WOUND DRESSING ⦿When the wound is cleaned the burned areas are patted dry and the topical agent is applied, the wound is covered with the several layers of dressings. ⦿A light dressing is used over joint areas to allow for motions. 59
  60. ⦿Dressing is changed 20 minutes after giving analgesics. ⦿ All PPE are used while dressing. 60
  61. 4. WOUND DEBRIDEMENT ⦿It is done to….  Remove tissues contaminated by bacteria and foreign bodies.  To remove devitalized tissue or burn eschar in preparation for grafting and wound healing. 61
  63. 5. GRAFTING OF THE WOUND ⦿ Grafting is done when wounds are deep or extensive or re- epithelialization is not possible. ⦿Patient’s own skin is used for graft. 63
  64. ⦿ The purpose is to…….. Decrease the risk for infection To prevent the loss of proteins, fluids and electrolytes through the wound To minimize heat loss 64
  65. ADVANTAGE ⦿It permits earlier functional ability and reduces contractures. ⦿It fills the space created by the wound, creates a barrier to bacteria and serves as a bed for epithelial cell growth. 65
  67. BIOLOGICAL GRAFTS ⦿ Provides temporary wound closure. ⦿ Protects granulation tissue until auto grafting is possible. ⦿ Used in patients with extensive burns. ⦿ It is of two types: ⦿ Homograft (Allograft) ⦿ Heterograft 67
  68. ⦿Homograft : These are obtained from skin of any living or recently dead humans. ⦿Amniotic membrane of placenta may also be used for homograft. ⦿Heterografts : These consists of skin taken form animals (pigs). 68
  69. ⦿Most biologic dressings are used as temporary coverings of burn wounds and are eventually rejected by the body’s immune reaction to them as foreign. 69
  70. BIOSYNTHETIC AND SYNTHETIC DRESSINGS ⦿Biobrane is most commonly used. ⦿It is composed of nylon, siliastic membrane with collagen derivative. ⦿It protects wound from fluid loss and bacterial invasion. 70
  71. DERMAL SUBSTITUTES ⦿They enhance the healing process of an open wound when autologous skin is unavailable or limited for use. ⦿Examples of dermal substitutes are: ⦿Integra (artificial skin) ⦿Alloderm 71
  72. ⦿ INTEGRA / ARTIFICIAL SKIN ⦿It is composed of two layers…. ⦿The epidermal layer made up of silicon which acts as a bacterial barrier and prevents water loss from the skin. ⦿The dermal layer which is made up of animal collagen. It is adhered to the wound surface and helps in epithelialization. 72
  73. ⦿ Alloderm:  It is processed dermis from human cadaver skin, which can be used as the dermal layer for skin grafts.  Its use allows the surgeon to harvest a thinner skin graft from patient’s own body, consisting the epidermal layer only.  The patient’s epidermal later is placed directly over the alloderm base. 73
  74. AUTOGRAFTS ⦿Autografts are the preferred material for definitive burn wound closure. ⦿Patient’s own skin is taken for closing the burn wound. ⦿The main advantage is that they are not rejected by the patient’s immune system. 74
  75. Care of the graft site ⦿Dressings are applied over the grafts to immobilize. ⦿Splints may be used for immobilization. ⦿The first dressing is usually performed 2 – 5 days after surgery or earliest in the case of purulent drainage or foul odor. 75
  76. ⦿Patient should be positioned and turned carefully to avoid disturbing the graft or putting pressure on the graft site. ⦿If an extremity has been grafted, it is elevated to minimize edema. ⦿Patient is advised to exercise the grafted area 5 – 7 days after grafting. 76
  77. Cultured epithelial autograft ⦿It provides permanent coverage of large wounds. ⦿Biopsy of patient’s skin is taken from unburned area. 77
  78. ⦿Epithelial cells are cultured in the laboratory. ⦿Epithelial cells multiplies to 10,000 times in 30 days. ⦿These cells are then attached to the burn wounds. 78
  79. 6. PAIN MANAGEMENT ⦿Burn patients experiences severe pain. ⦿Morphine sulfate is administered IV. ⦿ Fentanyl may be used in procedural pain. 79
  80. 7. INFECTION CONTROL ⦿Strict sterile technique is used for wound care procedures. ⦿Provide safe and clean environment to the patient. ⦿Use of PPE. ⦿Invasive lines and tubing must be routinely changed. ⦿Regular changing of linen. 80
  81. 8. NUTRITIONAL SUPPORT ⦿Burn injuries produce profound metabolic abnormalities. ⦿Patient’s metabolic demands vary with the extent of burns. ⦿ The goal of nutritional support is to promote a state of positive nitrogen balance. 81
  82. ⦿High protein, lipid and carbohydrate diet should be given to the patient. ⦿Curreri formula can be used to estimate energy requirement. ⦿Energy requirement = (25 kcal * kg body weight) + (40 kcal * % TBSA burn) 82
  83. ⦿Method for delivering nutritional support include oral intake, enteral tube feeding , TPN and Parenteral nutrition. ⦿ These may be used alone or in combination. 83
  84. NURSING DIAGNOSIS ⦿Excessive fluid volume related to resumption of capillary integrity and fluid shift form the interstitial tot eh intravascular compartment. ⦿Risk of infection related to loss of skin barrier and impaired immune response. 84
  85. ⦿Imbalanced nutrition, less than body requirements related to hyper metabolism and wound healing needs. ⦿Impaired skin integrity related to open burn wounds. ⦿Acute pain related to burn wounds and procedures. 85
  86. REHABILITATION PHASE ⦿Rehabilitation should begin immediately after the burn has occurred. ⦿Wound healing, psychosocial support and restoration of maximal functional activity remain priorities so that the patient can have the best quality of life both personally and socially. 86
  87. ⦿Reconstructive surgery may be done to improve body appearance and function. ⦿Psychological counseling may be done to promote recovery and quality of life 87
  88. NURSING DIAGNOSIS ⦿Disturbed body image related to altered physical appearance and self concept. ⦿Activity intolerance related to pain on exercise, limited joint mobility. ⦿Deficient knowledge about post discharge home care and follow up. 88