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BUKOVINIAN STATE MEDICAL UNIVERSITY
DEPARTMENT OF PATIENTS CARE AND
HIGHER NURSE EDUCATION
“APPROVED”
on the methodical conference of department
of patients’ care and higher
nurse education
“ ” ________ 200_ protocol N __
Chief of department, associate professor
I.A. Plesh
METHODICAL INSTRUCTION
FOR SELF-PREPARATION OF STUDENTS
TO PRACTICAL CLASS №14
CARE OF PATIENTS WITH THERMAL INJURIES.
Discipline:
nursing in surgery
for 3nd year students
of medical faculty №4,
specialty "nurse business''
Methodical instruction was prepared by:
Assistant Riabyi S.I.
Chernivtsi - 2010
1. Topic: CARE OF PATIENTS WITH THERMAL INJURIES.
(Thermal trauma: definition, classification. Burns, classification of thermal burns.
Nurse’s diagnostic of deepness and area of burns. First aid and methods of patients’
treatment. General notions about burns disease. Frostbites: periods, degrees, clinical
signs. First aid and methods of patients’ treatment. Purpose and nurse’s task during
patients` care).
2. Duration of the class: 2 academic hour.
3. Study aim:
3.1. The student should know:
 Definition of term "burns";
 Main ethiologic factors of burns appearance;
 Classification of thermal burns;
 Methods of determination of square and depth of thermal damage;
 Appropriateness of burns' disease flow;
 Clinical signs of burns' shock;
 Clinical signs of acute burns' toxemia;
 Clinical signs of burns' septicotoxemia;
 General principles of burns' disease treatment;
 Methods of local treatment of burns;
 Ethiologic factors of frostbites' appearance;
 Classifications of frostbites;
 Clinical pictures of frostbites and prereactive and reactive period;
 General principles of frostbites' treatment;
 Peculiarities of the electricity's influence on the organism;
 Clinical signs of electricity trauma;
 First aid in electricity damage.
3.2. The student should be able:
 To determine the square of burns;
 To determine the depth of burns;
 To determine the hardness of the thermal damage;
 To determine the signs of burns' shock;
 To prescribe the rational infusion and transfusion therapy to a patient with the burns'
shock;
 To choose the optimal method of local treatment of burns;
 To provide a first aid to patient with the frostbite;
 To chose the tactics of treatment dependently from the period of disease;
 To provide a first in electricity damage.
3.3. The student should master practical skills:
 applying aerosol on burn surface;
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4.
applying ace-bag on burn surface;
dressing patients with burns;
dressing patients with frostbites;
assistance during necrotomy;
assistance during autodermoplastic.
Advice for students:
Burns and Frostbites
Bums are caused by the action of heat (flame, sun, hot liquid, contact with hot metal,
etc.), caustics, alkalis and certain drugs (silver nitrate, iodine tincture) on the body.
Characteristics of First-, Second-, and Third-Degree Burns
First' degree - exposure to sunlight or minor flash, red color, surface dry or small-to
moderate-sized blisters, sensation-painful, healing - 3 -6 days.
Second degree-limited exposure to hot liquid, flash, flame, or chemical agent. Colour
pink or mottled red, surface- bullae or moist, weeping surface, painful (deep second - degree
burns may be anaesthetic to pinprick with intact pressure sensation, healing 10-21 dayssuperficial second degree, more then 21 days-deep second degree.
Third degree - prolonged exposure to flame, hot object, or chemical agent. Contact
with high-voltage electricity. The colour is pearly white, charred, translucent, or parchmentlike. Deeply tanned-strong acid burns. Dark red-in young children. Surface dry, with
thrombosis of superficial vessels. Focal tissue loss - high-voltage electrical injury. Sensation
is absent. Requires grafting.
Other variant classification degrees of burns. Four degrees of burns are distinguished.
The first degree, the weakest burn, is characterised by an inflammatory process
accompanied by local dilation of the blood vessels and slight serous impregnation of the
tissues. The skin develops a redness and swelling and becomes painful. After 2 - 3 days of
treatment everything returns to normal and only a dark spot (pigmentation) on the burned
part remains.
In second degree burns the inflammatory process produces a serous exudation which
comes to the foreground and fosters formation of blisters with a serous or jelly-like content
on the surface of the reddened and swollen skin. When a blister bursts, it reveals a bright-red,
painful, easily vulnerable epithelial layer of the skin tending toward infection. If the burn is
not infected, the content of the blisters is resorbed or they burst and dry up within 4 - 5 days.
The epidermis is restored from the edges, as well as from the depth. For some time
afterwards the skin is pink, delicate and quite vulnerable, but subsequently it resumes its
normal appearance and properties. No cicatrices are formed.
Second degree burns are often aggravated by infection. In some cases healing is
retarded, the content of the blisters assumes a purulent appearance, the blisters burst,
granulations appear on the bare surface of the epidermis and after healing a whitish or dark
superficial cicatrix may remain.
In third degree bums, a crust is formed on the burned surface because of coagulation of
proteins and destruction of tissues. The destruction of tissues may cause circulatory disorders
and obctrution of the blood vessels of the skin. In such burns the superficial layers of the skin
usually peel off and hang in tatters. Healing trites a long time. After disengagement of the
necrotic parts granulations begin to form on the new wound. Granulation takes from several
weeks to several months (in extensive burns). In cases of infection ichorous or purulent
complications, general exhaustion, etc. are possible.
After disengagement of the necrotic tissues epithelisation begins from the edges of the
wound and not infrequently forms large cicatrices which contract the surrounding tissues,
sometimes making it partly or completely impossible to use the burned pail, especially if the
cicatrices are located in the region of the joints (Fig. 156) and on the neck. Vast burns may
not heal completely, in which cases skin has to be transplanted to cover up such granulating
surfaces.
A fourth degree burn - charring of the tissues under the direct effect of flame or
eiectric current - is also distinguished.
If the injuries from a burn are very extensive or penetrate deep into the tissues, they are
dangerous to life. Burns involving one-third of the body surface, whatever their degree, are
usually followed by grave disorders which not infrequently lead to death. Burns of half the
surface of the body are almost always fatal. Burns are particularly dangerous for children,
since they may end fatally even if they are not so extensive.
General changes in the body may develop immediately after the burn has been
sustained, owing to stimulation of the nerve endings and reaction of the nervous system
(shock) and subsequently (affection of the internal organs - blood, kidneys, central nervous
system) as a result of absorption of the toxic products of decomposition from the burned
tissues.
Noninfectious toxicosis appeal's within 12-72 hours. Excitement or clouded
consciousness and then complete loss of consciousness, vomiting, convulsive muscle
twitching, pyrexia, rapid pulse, cyanosis, icterus and oliguria are characteristic of noninfectious toxicosis.
Infectious toxicosis develops in cases of infection of the burned surface and is
accompanied by pyrexia with considerable fluctuations (higher temperature in the evening),
and changes in the blood (leukocytosis and increasing anemia). The patient's condition is
aggravated by complications (erysipeals, pneumonia, etc.).
Treatment. First-aid to the burned at the place of accident consists in prevention
ofshock; the victim is administered morphine, kept warm and given hot drinks. The burned
part is covered with a sterile sheet or an aseptic bandage. The patient is covered up warmly
and is rapidly and carefully delivered to a medical institution (in short time - to the closest
casualty-clearing station), where he is administered antitetanic serum.
Patients with first degree burns and those with no marked intoxication and only small
burned areas, as well as those with second and third degree burns (except burns of the eyes,
perineum, genital organs and feet) are subject to ambulatory treatment. All the other burns
are treated in hospitals.
If large numbers of burned patients are admitted to a medical institution, they must be
assorted according to the urgency and sequence in which they are to he administered aid.
The victims to be administered urgent aid are those who are in a state of shock or have
considerable burned areas and may develop shock.
Firstaid in bums is aimed at terminating as swiftly as possible the action of heat and al
protecting the site of the burn from infection and trauma. The injured must be brought out of
the heat zone and his burning clothing must be extinguished either with water or a stream of
foam from a fire extinguisher. If such measures are impossible, the injured must be wrapped
in a blanket, overcoat, rug, etc. The clothing soaked in kerosene, benzine or napalm must be
extinguished only by this method.
Extinction with sand or earth is contraindicated because it infects the burn.
With his clothing on fire the patient must lie down rather than move about. After
extinction of the flame, water must be poured on the smouldering parts of the clothing and
the latter must be removed. Drops of napalm must not be spread or removed with an
unprotected hand. The burning part must be completely immersed in water or compressed
with the clothing.
Recurrent combustion of napalm which contains phosphorus is prevented by moist
bandages soaked in a 5 % blue vitriol solution. The clothing covered with napalm or
saturated in hot liquid must be quickly removed without injuring the burned parts. The
clothing adhering to the surface of the burn must not be torn off but rather cut away without
touching the surface of the burn.
Administration of pantopon is desirable before removal of the clothing and application
of the first dressing. It is desirable soon (during the first minutes after the burn has been
sustained). To immerse the burned part in cold water or pour water from the top over it for
several minutes, or treat it with alcohol (toilet water alcoholic liquor). In burns caused by
caustics the affected surface should be washed with large amounts of water. In burns
produced by quicklime no water must be used; in these cases the burned surface of the body
must be covered with an oil. In burns made by acids, alkaline solutions (soda, calcium or
soapy water) are used or the affected part is powdered with chaik, magnesium or tooth
powder. In burns caused by alkalis weak acid solutions (acetic, citric, etc.) are used. The
victims of burns experience unendurable suffering and, to alleviate the pain in first degree
burns moist dressings containing a potassium permanganate solution, lead water or other
solutions are applied to the burned surface.
In the emergency room, a large - caliber intravenous cannula should be placed and
fluid infusion begun using a balanced salt solution. As far as possible, a history should be
obtained, with emphasis on determining the circumstances of the injury, the presence of preexisting disease, and medications taken prior to injury.
Fluid needs are then estimated based on extent of burn and body weight, and the fluid
infusion is adjusted accordingly with accurate recording of the volume and type of all
administered fluids. The ventilatory status should again be assessed in terms of the need for
endotracheal intubation, the need for oxygen administration, and the need for mechanical
ventilatory assistans. A urethral catheter should be placed in all patiens requiring intravenous
fluid therapy and the hourly urinary output measured and recorded. ECG monitoring is
continued for at least 48 hours in all patients with high-voltage electrical injury, and if such
patients manifest cardiac irregularity, the monitoring should be continued for 48 hours
beyond the last episode of arrhythmia.
The burned areas should be cleansed gently using a surgical soap or detergent,
following which loose nonviable skin should be debrided. Bullae that are less than 2 cm in
diameter can be left intact, but larger bullae cvMwuowty vuptuve, are easily u\ tec ted, &&<
$ should be excised. The 'palm' rule is based on that ihe area of the patient's palm makes
approximately 1% of his total skin area. The essence of "nines" rule lies in the fact that the
total skin area is divided into parts divisible by 9. Thorax and abdomen make 18 % of the
total skin area, lower extre-mities - in 18 %, upper extremities - in 9 %, head and neck - 9 %,
perineum - 1 %.
Average quantity of total area of human body is taken as 16.000 cm2.
During this disease distinguish periods of burn shock, acute bum toxaemia, burn
septicotoxaemia and convalescence.
Burn shock. It develops due to the irritation of a great number of nerve elements of a
vast area of lesion and more complicated the shock takes its course. In burns with more than
50 % of body surface, shock is observed in all the victims and is the main cause of death. In
burn shock a prolonged erectile phase is observed. For the development and course of shock,
besides the flow of very powerful neuroreflex impulses i'rom the burn area into the central
nervous system, a large loss of plasma (particularly marked in vast burns of the 2nd degree),
and also toxemia with the products of tissue disintegration are of a great importance.
Toxaemia. It begins from the first hours after the burn, gradually increases and after
the way out of shock determines the condition of a victim in future. In the development of
toxaemia an absorption of products of tissue and toxins disintegration from the burn area
plays its part. In its development hypochloremia, hypoproteinemia, disturbances of
metabolism are of importance.
Infection. In the development of infection on the burnt surface appear septic effects
(septic phase of the disease), body temperature increases, chills appear, leucocytosis and
neutrophilia increase, anaemia develops, etc.
Metabolism disturbances are characterised by dehydration, acidosis, hypochloraemia,
disturbance of oxidizing processes.
Marked disturbances are observed in the blood composition: haemoglobin level
increases, a number of erythrocytes averages to 7 – l0xl012/L and leucocytes - 30 - 35xl09/L.
Local changes of tissues in burns develop as follows: under the influence of
traumatising agent hyperaemia develops. It leads to the inflammatory exudation of tissues
development of oedema. Some tissues die due to the proper effect of high temperature and
due to the disturbance of blood circulation. Squeezing with an inflammatory exudation and
effect of tissue disintegration produced on nerve formations are accompanied by clearly
marked painful syndrome. In burns of the 1st degree blood circulation disturbances and
inflammatory exudation soon disappear, oedema decreases, pains disappear and the process
eliminates. If burns of the 2nd degree are not infected exudation absorbs, the surface of the
burn is covered by epithelium and in 14 -16 days recovery is observed. In infected burns of
the 2nd degree granulations are formed. They are gradually covered by epithelium.
In burns of the 3rd degree all the thickness of the skin, and sometimes deeper lying
tissues become necrosed. These burns are healed by the second intention. At first a rejection
of dead tissues takes place and then follows filling of defect by granulations with formation
of vast cicatrix, which often limit movements (cicatricial contractures) and are easily
traumatised, resulting in the formation of ulcers.
Treatment of burns may be divided into 4 groups:
a) closed;
b) open;
c) mixed;
d) operative.
Choice of method of treatment is determined by the heaviness of burn, time passed
from the moment of trauma, character of primary treatment and surroundings in which
treatment will be carried out. •
The open method is used for extensive burns in children, burns on the face, perineum
and buttocks of adults, and in cases of infection.
The patient is placed on sterile linens, the region of the burn is left opened and a grid
covered with a sterile sheet and a blanket on top of the sheet is placed over the bed (Fig-1). If
there is no grid, the sheet may be placed on strips of bandage stretched over the bed. Electric
bulbs are fastened to grid under the sheet to keep the patient warm. The toilet of the wound is
made, every day.
Fig.1. Open treatment of burn
Surgical treatment is administered at different periods in the course of third and fourth
degree burns: this consists in primary dermatoplasty during the first day after excision of
limited parts of the burn and delayed early dermatoplasty between the 7th and 24th day,
involving excision of necrotic layers and replacement of the defect with skin flaps taken from
healthy parts of the body. In cases of very extensive burns the skin for transplantation is
taken from volunteer donors or from corpses. Lastly, weeks and even months after the burn
has been sustained, large granulating surfaces, is well as cicatrices, may be subjected to
surgical treatment (delayed late dermatoplasty).
Frostbite (congelation) results from prolonged action of extreme cold, although it is
sometimes produced even at a temperature of about 0° or somewhat higher. The changes in
the tissues during frostbite are due mainly to thrombosis of the vessels and subsequent
disturbance in blood circulation.
The skin is pale, cold and sometimes hard (congealed), and its sensitivity is
diminished.
In first degree frostbite the vessels sharply contract (spasm), the skin becomes pale and
insensitive, and after warming bluish-red, painful and oedemalous. First degree frostbite lasts
only a few days, but sensitivity to cold and sometimes a bluish colouration of the skin
persists.
In second degree frostbite blisters with a serous or turbid content appear on the
footgear are factors predisposing to frost bite.
The degree of frostbite is established only during development of reactive phenomena,
sometimes within several days after the effect of the cold. During the first, latent period of
frostbite, in all its degrees, affected part, the skin around it becoming bluish-red. ,In this case
blood circulation is impaired and the exuding fluid raises the epidermis in the form of
blisters.
In third degree frostbite the affected tissues become hard to touch and, when carelessly
handled, fragile. After warming-up, the blood circulation is deeply disturbed and nutrition of
the tissues is affected by occlusion of blood vessels. Disturbances in tissue nutrition are
sometimes discovered only within a few days, whereas in the beginning the frostbitten part
presents the same appearance as in second degree frostbite (it is blue-brown and covered with
blisters and crusts) and the soft tissues necrotise. Healthy and vigorous people can withstand
cold longer than weak, emaciated and anaemic people. The tips of the fingers and toes,
cheeks and tip of the nose are the parts most frequently affected. Four degrees of frostbite are
distinguished.
In fourth degree frostbite all soft tissues and bones necrotise, and gangrene, often
moist, develops; demarcation and healing proceed slowly. Frostbite is not infrequently
accompanied by tetanus.
In frostbite of the lower extremity it is first necessary to remove the footgear, which
has to be done carefully to avoid injury to the extremity. If the footgear has congealed, it is
best to cut it open.
Firstaid in frostbite consists primarily in restoration of the blood circulation.
Massaging the frostbitten part with the hand wearing a sterile glove is recommended. The
massage must be delicate and may be administered more vigorously only after signs of
restoration of the blood circulation have appeared. No rubbing down with snow or massaging
with dirty hands are allowed.
It is best to rub down the skin at first with a piece of cotton soaked in alcohol and then
with a piece of dry cotton. It is recommended to warm up the frostbitten extremities in a bath
the temperature of which is raised from 18°C to 37°C over a period of 20 - 30 minutes. The
extremity should simultaneously be washed with soap and water to be cleaned from
contamination.
If the patient applies for aid already during the stage of reactive phenomena, firstaid
will consist in treatment of the skin in the region of frostbite with alcohol and application of a
sterile gauze and cotton dressing.
The patient must be kept warm, protected against repeated exposure to cold and given
a prophylactic injection of antitetanic serum.
To protect the patient against infection in second, third and fourth degree frostbite, dry
aseptic warming bandages are applied, the blisters are lanced and the disengaged epidermis is
removed; during all these proceedures the rules of asepsis must be strictly observed. In third
and fourth degree frostbite the blisters are removed and the tissues affected with gangrene are
painted with iodine tincture.
To improve the blood cirulation, a novocain block is produced. To dry the tissues in
the region of necrosis, the affected parts are subjected to irradiation by a sun lamp and ultrahigh frequency current, and are kept in the open air (dry air baths). To alleviate pain,
narcotics and dry air baths are employed; to improve the blood circulation, the affected
extremities are raised (suspended), in fourth degree frostbite the necrotic tissues on the limbs
are dissected (necrotomy) or excised (necroectomy). As soon as the line of demarcation is
established and the blood circulation in the surrounding tissues has improved, the frostbitten
organ is amputated. In these cases the wound resulting from amputation not infrequently
heals slowly because of sluggish granulation.
Electric Shock. Extensive utilisation of electricity in industry and agriculture raises the
important question of preventing and treating electric shock. Passing through the body, high
voltage electric currents cause local and general injuries. It is impossible precisely to set the
dangerous limit of current tension because it varies with many factors, for example, the
humidity of the body. At any rate, a current above 100 V. is dangerous and above 500V.
almost always fatal.
Firstaid in electric shock and in injury by lightning must srart by disassociating the
subject from the source of current or putting the victim to the ground, must vary with the
condition. In cases of cardiac and respiratory arrest, measures to revieve the patient must be
taken during the very first minutes.
The first thing to do in such cases is to administer artificial respiration. According to
literature, there were cases in which a clinical picture of death caused by electric shock
seemed to be established and yet the patients were returned to life.
The most efficient and widespread method of artificial respiration must not be used. If
the ribs are injured, only pulling of the tongue should be resorted to.
Artificial respiration must be administered continuously and for a
long period of time. It is most appropriately administered with the aid of a special
apparatus resembling bellows developed by V. Negovsky; this apparatus blows air into the
lungs.
Simultaneously with administering artificial respiration it is necessary to keep the
victim warm, rub him down (preferably with pieces of cloth) and give him to smell ammonia
water.
In addition to artificial respiration during apparent death, it is necessary to administer
cardiac massage. To do this, the person administering aid places a hand on the region of the
victim's heart with fingers pointed towards the head. With palm of the hand he effects 20 -30
vigorous pushes against the part of the chest located under his hand.
Under hospital conditions the fibrillation of the heart muscle may be discontinued and
the heart restored to normal activity by a single discharge of electric current from a special
device (defibrillator condenser), with a simultaneous imra-arterial blood transfusion.
It is also necessary immediately to protect the site of the burn against infection; as in
the other eases of burn, it is necessary to apply an aseptic-dressing with alcohol, a 4 %
potassium permangnale solution, rivanol, streptocid emulsion, etc.
The general measures include administration of glucose and large amounts of fluid,
inspiration of oxygen, etc. Treatment of bums produced by electric shock is usually the same
as it is in other burns.
In electric shock patients require close watching and thorough care owing to the
possibility of sudden death and considerable spread of necrosis in the region of affection.
5. Study questions:
1. Definition of term "burns";
2. Main ethiologic factors of burns appearance;
3. Classification of thermal burns;
4. Methods of determination of square and depth of thermal damage;
5. Appropriateness of burns' disease flow;
6. Clinical signs of burns' shock;
7. Clinical signs of acute burns' toxemia;
8. Clinical signs of burns' septicotoxemia;
9. General principles of burns' disease treatment;
10.Methods of local treatment of burns;
11.Ethiologic factors of frostbites' appearance;
12.Classifications of frostbites;
13.Clinical pictures of frostbites and prereactive and reactive period;
14.General principles of frostbites' treatment;
15.Peculiarities of the electricity's influence on the organism;
16.Clinical signs of electricity trauma;
17.First aid in electricity damage.
6. The literature:
6.1. Basic :
1. Textbook of basic nursing / Caroline Bunker Rosdahl. – J. B.Lippincott Company.
Philadelphia. - 6th ed. –1995.– 1518 p.
2. Fundamentals of nursing /Taylor Mary Carol, Mary Carol, Lillis Carol– J.
B.Lippincott Company. Philadelphia. - 1989.– 1356 p.
6.2. Аdditional:
1. Gostishev V.K. "Guidance to practical employments on general surgery". M.,
"Medicine" - 1987.
2. P. of Brown. Operating block. Operating brigade. – Kharkov, 1997. – with. 1-32.
Methodical instruction was prepared by
Assistant
A review is positive, associate professor
Riabyi S.I.
Chomko O.J.
Materials of control of base level of preparation of students: tests.
Multiple Choices.
Choose the correct answer/statement:
1. The square of the adult's hand is …% of body surface:
A. 1-1,1
B. 0,4-0,6
C. 2-2,1
D. 3-3,1
E. 4-4,1
2. For the local symptoms of the I degree burn is characteristic everything accept:
A. Hyperesthesia;
B. Hyperthermia;
C. Pain;
D. Hyperaemia;
E. Edema;
3. For the local symptoms of the II degree burn is characteristic everything accept:
A. Hyperesthesia;
B. Hyperthermia;
C. Pain;
D. Hyperaemia;
E. Edema;
4. Burns' disease occur in adults due to superficial burns with the square more than:
A. 25-30%;
B. 5%;
C. 10%;
D. 15%;
E. 20%;
5. Burns' disease occur in adults due to superficial burns with the square more than:
A. 10%;
B. 3%;
C. 5%;
D. 15%;
E. 25%;
Real-life situations to be solved:
6. A 2 years old child 60 minutes ago poured out on herself a pan of boiling water. Pale,
screaming, trembling, acrocianosis, one-time vomiting. Hyperemia on the anterior
body surface and upper extremities with the scraps of epidermis.
Your diagnosis and tactics?
7. To the reception was transported an injured person from the place of fire. The
consciousness is shadowed, face and hands smoked, the hair in the nose is burnt. The
breath is superficial, periodical cough, phlegm with additives of soot
Your diagnosis and tactics?
Answers to the Self-Assessment:
A;
A;
A;
A;
A;
Burns' shock. It's necessary to inject the pain-relief preparations, heat the patient, apply
the aseptic bandage with Novocaine, transport to specialized medical institution.
Burns with a flame of face and hands. Burns of the air ways. Patient requires
hospitalization to the intensive care unit.