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BURNS
Liza Jane C. Bautista
SKIN
SKIN FUNCTIONS
Epidermis
protection from desiccation
protection from bacterial entry
protection from toxins
fluid balance:
prevents excess evaporative loss
neurosensory
social-interactive
Dermis
protection from trauma due to elasticity, durability, properties
fluid balance thru regulation of skin blood flow
thermoregulation thru control of skin blood flow
growth factors and contact direction for epidermal replication and dermal repair
BURN INJURY
Description: Cell destruction of the layers of the skin and the resultant
depletion of fluid and electrolytes
Burn Size
1. Small burns: The response of the body to injury is localized to the
injured area
2. Large or extensive burns
a. Large burns consist of 25% or more of the total body surface
area
b. The response of the body to the injury is systemic
c. The burn affects all of the major systems of the body
ESTIMATING THE EXTENT OF
THE INJURY
• Rule of nines: assigns percentages in multiples of nine to major
body surface areas
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Lund–Browder and Berkow method: divides the body into very
small areas and provides an estimate of the proportion of total body
surface area (TBSA) accounted for by the corresponding body parts
its most accurate of all the methods
This method is most often used to measure burns in infants
and young children because it allows for developmental changes in
percentages of body surface area A separate chart is used because
the surface area of the head and neck of children is larger and the
limbs are smaller than adults.
• Palm method: used in clients with scattered burns, the client’s palm
is calculated as approximately 1% of TBSA.
Adult Rule of Nines Chart
Child Rule of Nines Chart
Infant Rule of Nines Chart
Lund & Browder Chart Infant - 5yrs
Lund & Browder Chart 5yrs - Adult
Berkow Chart
BURN DEPTH
BURN DEPTH
1.
Superficial thickness burn
a. Involves injury to epidermal layer
b. Erythema (pink to red)
c. Skin blanches
d. Painful with tingling sensation,
pain is eased by cooling
e. Discomfort lasts 48 hrs
healing occurs 3 to 5 days
f. No scarring; intact skin
NURSING MANAGEMENT
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Run cool water over the burned area or soak it in a cool water
(NOT ICE WATER) bath. Keep the area in the bath for five
minutes.
After flushing or soaking the burn for several minutes, cover the
burn with a sterile non-adhesive bandage or clean cloth.
Protect the burn from friction and pressure.
Over-the-counter pain medications may be used to help relieve
pain; they may also help reduce inflammation and swelling.
BURN DEPTH
2. Superficial partial-thickness burn
a. Involves injury to the epidermis and the superficial layers of the dermis
b. Large blisters may cover an extensive area
c. Pink to red base and broken epidermis, with wet,
shiny and weeping surface
d. Excruciating Pain
e. Heals in 10 to 21 days
f. Some scarring and minor
pigment changes may occur
BURN DEPTH
3. Deep partial-thickness burn
a. Involves injury of most of the dermal layer
b. Pain is reduced
c. Wound surface is red and dry with white areas in deeper parts, no blisters
d. Generally heals in 3-6 weeks
e. Scar formation
NURSING MANAGEMENT
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Assure airway patency
Moist, sterile dressing to the affected area.
Silver-based ointment inhibits bacterial growth
Removal of jewelry and tight clothing not adhering to skin
Intravenous (IV) fluid replacement to prevent electrolyte and fluid
imbalances
Oxygen therapy as needed
Observe for signs of shock
Pain assessment and management with medications such as morphine or
hydromorphone hydrochloride (Dilaudid)
Wound debridement (removal of dead tissue)
Skin grafting may be required
BURN DEPTH
4. Full-thickness burn
a. Involves injury and destruction of the epidermis and the dermis, the wound
will not heal by re-epithelialization and grafting may be required
b. Appears dry, hard, leathery eschar
c. Appears as a waxy white, deep red, yellow, brown, or black
d. Absence of sensation
because of nerve ending
destruction
e. Scarring and wound
contractures are likely to
develop without preventive
measures
BURN DEPTH
5. Deep full-thickness burn (subcutaneous)
a. Extends beyond the skin into underlying fascia and tissues and
damage to the muscle, bone, and tendons occurs
b. Injured area appears black and sensation is completely absent
c. Eschar is hard and inelastic
d. Healing time takes months and grafts are required
NURSING MANAGEMENT
• Maintain airway
• Monitor for shock and infection
• Maintain fluid and electrolyte balance by way of intravenous fluids
• Maintain asepsis
• Debridement (surgical removal of nonviable tissue)
• Dressings for burns
1. Standard dressing involves use of moistened gauze with topical antibiotic and
wrapped with Kerlex (rolled gauze)
2. Biologic dressings are temporary skin covering with tissue or membranes from
human or animal donors until skin grafting can occur
3. Biosynthetic (combination of biologic and synthetic) or synthetic dressings
(dressings of silicone or plastic membranes)
• Permanent skin grafting
• Maintain nutritional support. May require enteral nutrition (nutrients provided
directly into stomach through a small tube inserted into the nose) to assure
calorie needs are met
• Pain assessment and management
• Prevent scars and contractures
• Psychosocial counseling
ZONES OF BURN INJURY
Each burned area has three zones of injury.
• The inner zone or area of coagulation, where cellular death occurs,
sustains the most damage.
• The middle area, or zone of stasis, decreased tissue perfusion. The
main aim of burns resuscitation is to
increase tissue perfusion here and
prevent any damage becoming
irreversible.
• The outer zone or zone of hyperemia,
sustains the least damage
Jackson's burns zones and the
effects of adequate and
inadequate resuscitation
Clinical image of burn zones.
There is central necrosis,
surrounded by the zones of
stasis and of hyperaemia
BURN LOCATION
1. Burns of the head, neck, and chest are associated with pulmonary
complications
2. Burns of the face are associated with corneal abrasion
3. Burns of the ear are associated with auricular chondritis
4. Hands and joints require intensive therapy to prevent disability
5. The perineal area is prone to autocontamination by urine and feces
6. Circumferential burns of the extremities can produce a tourniquet-like
effect and lead to vascular compromise (compartment syndrome)
7. Circumferential thorax burns lead to inadequate chest wall expansion
and pulmonary sufficiency
PHASES OF MANAGEMENT
OF THE BURN INJURY
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Rehabilitative Phase
The final phase of burn care.
This overlaps the acute care phase and goes well beyond hospitalization.
Goals: Designed so that the client can gain independence and achieve
maximal function.
Promote wound healing, minimize deformities, Increase strength and
function and provide emotional support.
TYPES OF BURNS
A. Thermal burns are caused by exposure to flames, hot liquids, steam, or
hot objects
B. Chemical burns
1. Burns are caused by tissue contact with strong acids, alkalis, or
organic compounds
2. Systemic toxicity from cutaneous absorption can occur
3. Deep partial-thickness injuries
TYPES OF BURNS
C. Electrical burns
1. Burns are caused by heat generated by electrical energy as it passes
through the body
2. Electrical burns result in internal tissue damage
3. Cutaneous burns cause muscle and soft tissue damage that may be
extensive, particularly in high-voltage electric injuries
4. The voltage, type of current, contact site, and duration of contact are
important to identify
5. Alternating current is more dangerous than direct current because it is
associated with cardiopulmonary arrest, ventricular fibrillation, tetenic
muscle contrations, and long bone or vertebral fractures
6. Subcutaneous (Fourth Degree)
D. Radiation burns are caused by exposure to ultraviolet light, x-rays or
radioactivity (superficial burn = sunburn )
INHALATION INJURIES
A. Smoke inhalation injury
1. Description: Injury results when the victim is trapped in an enclosed,
hot, smoke-filled space.
2. Assessment:
a. Facial burns
b. Erythema
c. Swelling of oropharynx and nasopharynx
d. Singed nasal hairs
e. Flaring nostrils
f. Stridor, wheezing, and dyspnea
g. Hoarse voice
h. Sooty (carbonaceous) sputum and cough
i. Tachycardia
j. Agitation and anxiety
INHALATION INJURIES
B. Carbon monoxide poisoning
1. Desciption
a. Carbon monoxide is colorless, odorless, and tasteless gas that has an
affinity for hemoglobin 200 times than that of oxygen
b. Oxygen molecules are displace and carbon monoxide reversibly binds
to hemoglobin to form carboxyhemoglobin
c. Tissue hypoxia occurs
Mild: headache, nausea
Moderate: dizziness, confusion, ataxia, visual changes, pallor
Severe: dysrhythmias, coma, cherry red buccal membrane, cherry-red
cast to skin
HYPERBARIC MEDICINE
Hyperbaric Oxygen (HBO2) is a treatment in which the patient breathes
100% oxygen inside a pressurized chamber
PATHOPHYSIOLOGY
OF BURNS
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Following the burn, vasoactive substances are released from the injured
tissue; and these substances cause an increase in the capillary
permeability, allowing the plasma to seep to the surrounding tissues.
The direct injury to the vessels increases capillary permeability (capillary
permeability decreases 18 to 26 hours after the burn but does not
normalize until 2-3 weeks following the injury)
Generalized body edema and a decrease in circulating intravascular blood
volume results from extensive burns.
• Decrease in organ perfusion results from fluid losses
• Increase heart rate, decrease cardiac output, and drops in blood
pressure
• Hyponatremia and hyperkalemia will occur.
• Increases level of hematocrit due to plasma loss; this initial increase falls
to below normal at the 3 – 4 day after the burn as a result of the RBC
damage and loss at the time of injury.
PATHOPHYSIOLOGY
OF BURNS
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Oliguria results from shunting blood from the kidneys; then the body
begins to reabsorb fluid and diuresis of the excess fluid occurs for the
next days to weeks.
Intestinal ileus and GI dysfunction result from diminished blood flow
in GIT.
Immunosuppression & increase risk for infection and sepsis results
from depressed immune system.
Decrease in arterial O2 tension level and a decrease in lung
compliance results from development of pulmonary hypertension.
Greater than normal evaporative fluid losses through the burn wound,
and the losses continue until complete wound closure occurs.
Hypovolemic shock and death will occur, if intravascular space is not
replenished with IV administration of fluids.
PHASES OF MANAGEMENT OF THE BURN INJURY
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Emergent Phase
Resuscitative Phase
Acute Phase
Rehabilitative Phase
PHASES OF MANAGEMENT
OF THE BURN INJURY
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Emergent Phase
This begins at the time of injury and ends with the restoration of capillary
permeability, usually at 48-72 hrs following the injury.
Includes prehospital care and emergency room.
Goal: Prevent hypovolemic shock and preserve vital organ functioning.
PHASES OF MANAGEMENT
OF THE BURN INJURY
Prehospital care
a. Prehospital care begins at the scene of the accident and ends when
emergency care is obtained
b. Remove the victim from the source of the heat
c. Remove the source of heat
d. Assess the ABC’s – airway, breathing, circulation
e. Assess for associated trauma
f. Conserve body heat
g. Cover burns with sterile or clean cloths
h. Remove constricting jewelry and clothing
i. Assess the need for intravenous fluids
j. Transport
Emergency room care is a continuation of care administered at the scene
of the injury
PHASES OF MANAGEMENT
OF THE BURN INJURY
Minor Burn Injury
• Second-degree burn of less than 15% total body surface area (TBSA) in
adults or less than 10% TBSA in children
• Third-degree burn of less than 2% TBSA not involving special care areas
(eyes, ears, face, hands, feet, perineum, joints)
Moderate, Uncomplicated Burn Injury
• Second-degree burns of 15%–25% TBSA in adults or 10%–20% in children
• Third-degree burns of less than 10% TBSA not involving special care areas
Major Burn Injury
• Second-degree burns exceeding 25% TBSA in adults or 20% in children
• All third-degree burns exceeding 10% TBSA
• All burns involving eyes, ears, face, hands, feet, perineum, joints
• All inhalation injury, electrical injury
PHASES OF MANAGEMENT
OF THE BURN INJURY
Major burns
a. Evaluate the degree and extent of the burn and treat life threatening
conditions
b. Ensure a patent airway and administer 100% oxygen as prescribed if
the burn occurred in an enclosed area
c. Monitor for respiratory distress and asses the need for intubation
d. Assess oropharynx for blisters and erythema
e. Monitor arterial blood gases and carboxyhemoglobin
f. For an inhalation injury, administer 100% oxygen via a tight-fitting
nonrebreather face mask as prescribed until the carboxyhemoglobin
level falls below 15%
g. Initiate peripheral intravenous (IV) access to nonburned skin proximal
to any extremity burn, or prepare for the insertion of a central venous
line as prescribed
PHASES OF MANAGEMENT
OF THE BURN INJURY
h. Assess for hypovolemia and prepare to administer fluids intravenously
to maintain fluid balance
i. Monitor vital signs closely
j. Insert a Foley catheter as prescribed, and maintain urine output at 30 to
50 mL/hr
k. Maintain NPO status
l. Insert a nasogastric tube as prescribed to remove gastric secretion and
prevent aspiration
m. Administer tetanus prophylaxis as prescribed
n. Administer pain medication, as prescribed, by the IV route
o. Prepare the client for an escharotomy or faciotomy as prescribed
PHASES OF MANAGEMENT
OF THE BURN INJURY
Minor burns
a. Administer pain medication in small doses of morphine sulfate or
meperidine (Demerol) as prescribed
b. Instruct the client in the use of oral analgesics as prescribed
c. Administer tetanus prophylaxis as prescribed
d. Administer wound care as prescribed, which may include cleansing,
debriding loose tissue, and removing any damage agents, followed by
application of topical antimicrobial cream and a sterile dressing
e. Instruct the client in follow-up care, including active range-of-motion
exercises and wound care treatments
PHASES OF MANAGEMENT
OF THE BURN INJURY
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Resuscitative Phase
This begins with the initiation of fluids and ends when capillary integrity
returns to near-normal levels and the large fluid shift have decreased.
The amount of fluid administration is based on the client’s weight and
extent of injury.
Goal: Prevent shock by maintaining adequate circulating blood volume
and maintaining vital organ perfusion
PHASES OF MANAGEMENT
OF THE BURN INJURY
Pain management
a. Administer morphine sulfate or meperidine (Demerol) as prescribed by the IV
route
b. Avoid intramuscular and subcutaneous medication routes because absorption
through the soft tissue is unreliable when hypovolemia and large fluid shift is
occurring
c. Avoid administering medication by oral route because of the possibility of
gastrointestinal dysfunction
d. Medicate the client before painful procedures
Nutrition
a. Proper nutrition is essential to promote wound healing and prevent infection
b. The basal metabolic rate is 40 t0 100 times higher than normal with a burn
injury
c. Maintain NPO status until the bowel sound is heard, and then advance to clear
liquid as prescribed
d. Nutrition may be provided via enteral tube feeding or parenteral nutrition
e. Provide a diet high in protein, carbohydrates, fats and vitamins
f. Monitor calorie intake
PHASES OF MANAGEMENT
OF THE BURN INJURY
Fluid resuscitation
a. The amount of fluid administration depends on how much intravenous
fluid per hour is required to maintain a urine output of 30 to 50 mL/hr
b. Successful fluid resuscitation is evaluated by stable vital signs, an
adequate urine output, palpable peripheral pulses, and a clear
sensorium
c. Urinary output is the most common and most sensitive noninvasive
assessment parameter for cardiac output and tissue perfusion
d. Intravenous fluid replacement may be titrated (adjusted) based on
urinary output plus serum electrolyte levels to meet the perfusion
needs of the client with burns
e. If the hemoglobin and hematocrit levels decrease or if the urinary
output exceeds 50 mL/hr, the rate of IV fluid administration may be
decreased
Escharotomy
a. A lengthwise incision is made
through the burn eschar to
relieve constriction and to
improve circulation
b. Escharotomy is performed for
circulatory compromise
caused by circumferential
burns
c. Escharotomy is performed at
the bedside without
anesthesia because nerve
endings have been destroyed
by the burn injury
d. Escharotomy can be performed
on the thorax to improve
ventilation
Fasciotomy
a. An incision is made extending
through the subcutaneous tissue
and fascia
b. The procedure is performed if
adequate tissue perfusion does not
return following an escharotomy
c. Fasciotomy is performed in the
operating room with the client under
general anesthesia
PHASES OF MANAGEMENT
OF THE BURN INJURY
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Acute Phase
This begins when the client is hemodynamically stable, capillary
permeability is restored, and diuresis has begun.
Usually begins 48-72 hrs after the time of injury.
Restoration Therapy
Infection control, wound care, wound closure, nutritional support, pain
management and physical therapy.
PHASES OF MANAGEMENT
OF THE BURN INJURY
Wound care
1. Description: Cleansing, debridement, and dressing of burn wounds
2. Hydrotheraphy
a. Wounds are cleansed by immersion, showering, or spraying
b. Hydrotherapy occurs for 30 minutes or less to prevent increased sodium
loss though the burn wound, heat loss, pain, and stress
c. Client should be premedicated before procedure
d. Hydrotherapy generally is not used for clients who are hemodynamically
unstable or those with new skin grafts
e. Care is taken to minimize bleeding and maintain body temperature during
the procedure
f. If hydrotherapy is not used, wounds are washed and rinsed with the client in
bed before the application of antimicrobial agents
3. Debridement
a. Debridement is removal of eschar or necrotic tissue to prevent bacterial
proliferation under the eschar and to promote wound healing
b. Debridement may be mechanical, enzymatic, or surgical
c. Deep partial- or full-thickness burns: Wound is cleansed and debrided, and
topical antimicrobial agents applied once or twice daily
PHASES OF MANAGEMENT
OF THE BURN INJURY
Wound closure
1. Description
a. Wound closure prevents infection and loss of fluids
b. Closure promotes healing
c. Closure prevents contractures
d. Wound closure is performed on day 5 to 21, depending on the extent of burn
2. Wound coverings
Amnion: human placenta (disintegrates in about 48 hours)
Allograft/Homograft: human tissue from cadaver (rejection can occur - 24hrs)
Xenograft/Heterograft (animal tissue): pig skin (2-5 days)
Cultured skin: grown in lab from epidermal cells from unburned skin of client
Artificial skin: create structure similar to normal dermis
Biosynthetic: forms an adherent bond until epithelialization occurs
Synthetic: pain is reduced because covering prevents contact of wound w/ air
Autograft: skin taken from clients own body
Cultured skin
Biosynthetic skin
Artificial skin
Synthetic skin
PHASES OF MANAGEMENT
OF THE BURN INJURY
3. Autografting
a. Autografting provide permanent wound coverage
b. Autografting is surgical removal of a thin layer of clients own unburned skin,
which layer is applied to the excised burn wound
c. Autografting is performed in the operating room under anesthesia
d. Monitor for bleeding following the graft because bleeding beneath an
autograft can prevent adherence
e. If prescribed, small amount of blood or serum can be removed by gently
rolling the fluid from the center of the graft to the periphery with sterile gauze
pad, where it can be absorbed
f. For large accumulation of blood, the physician will aspirate the blood using a
small gauge needle and syringe
g. Autografting are immobilized following surgery for 3 to 7 days to allow time to
adhere and attach t the wound bed
h. Position the client for immobilization and elevation of the graft site to prevent
movement and shearing of the graft