burns liza jane c. bautista. skin skin functions epidermis protection from desiccation protection...

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

Dermisprotection from trauma due to elasticity, durability, propertiesfluid 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

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 burnsa. Large burns consist of 25% or more of the total body surface areab. The response of the body to the injury is systemicc. The burn affects all of the major systems of the body

BURN INJURY

• Rule of nines: assigns percentages in multiples of nine to major body surface areas

• 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.

ESTIMATING THE EXTENT OF THE INJURY

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

1. Superficial thickness burn

a. Involves injury to epidermal layer b. Erythema (pink to red) c. Skin blanchesd. Painful with tingling sensation, pain is eased by coolinge. Discomfort lasts 48 hrs healing occurs 3 to 5 daysf. No scarring; intact skin

BURN DEPTH

• 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.

NURSING MANAGEMENT

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 areac. 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 blistersd. Generally heals in 3-6 weekse. Scar formation

BURN DEPTH

• 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

NURSING MANAGEMENT

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

BURN DEPTH

d. Absence of sensation because of nerve ending destructione. Scarring and wound contractures are likely to develop without preventive measures

5. Deep full-thickness burn (subcutaneous)a. Extends beyond the skin into underlying fascia and tissues and damage to the muscle, bone, and tendons occursb. Injured area appears black and sensation is completely absentc. Eschar is hard and inelasticd. Healing time takes months and grafts are required

BURN DEPTH

• 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 burns1. 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 occur3. 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

NURSING MANAGEMENT

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

ZONES OF BURN INJURY

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

Clinical image of burn zones. There is central necrosis, surrounded by the zones of stasis and of hyperaemia

Jackson's burns zones and the effects of adequate and inadequate resuscitation

1. Burns of the head, neck, and chest are associated with pulmonary complications

2. Burns of the face are associated with corneal abrasion3. Burns of the ear are associated with auricular chondritis4. Hands and joints require intensive therapy to prevent disability5. The perineal area is prone to autocontamination by urine and feces6. 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

BURN LOCATION

PHASES OF MANAGEMENT OF THE BURN INJURY

• 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.

A. Thermal burns are caused by exposure to flames, hot liquids, steam, or hot objects

B. Chemical burns1. Burns are caused by tissue contact with strong acids, alkalis, or

organic compounds2. Systemic toxicity from cutaneous absorption can occur3. Deep partial-thickness injuries

TYPES OF BURNS

C. Electrical burns1. Burns are caused by heat generated by electrical energy as it passes

through the body 2. Electrical burns result in internal tissue damage3. 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 identify5. 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 )

TYPES OF BURNS

A. Smoke inhalation injury

1. Description: Injury results when the victim is trapped in an enclosed, hot, smoke-filled space.

2. Assessment:a. Facial burnsb. Erythemac. Swelling of oropharynx and nasopharynxd. Singed nasal hairse. Flaring nostrilsf. Stridor, wheezing, and dyspneag. Hoarse voiceh. Sooty (carbonaceous) sputum and coughi. Tachycardiaj. Agitation and anxiety

INHALATION INJURIES

B. Carbon monoxide poisoning

1. Desciptiona. Carbon monoxide is colorless, odorless, and tasteless gas that has an

affinity for hemoglobin 200 times than that of oxygenb. Oxygen molecules are displace and carbon monoxide reversibly binds

to hemoglobin to form carboxyhemoglobinc. Tissue hypoxia occurs

Mild: headache, nauseaModerate: dizziness, confusion, ataxia, visual changes, pallorSevere: dysrhythmias, coma, cherry red buccal membrane, cherry-red cast to skin

INHALATION INJURIES

HYPERBARIC MEDICINE

Hyperbaric Oxygen (HBO2) is a treatment in which the patient breathes 100% oxygen inside a pressurized chamber

PATHOPHYSIOLOGY OF BURNS

• 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

• 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.

• Emergent Phase• Resuscitative Phase• Acute Phase• Rehabilitative Phase



• 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.

Prehospital carea. 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 heatc. Remove the source of heatd. Assess the ABC’s – airway, breathing, circulatione. Assess for associated traumaf. Conserve body heatg. Cover burns with sterile or clean clothsh. Remove constricting jewelry and clothingi. Assess the need for intravenous fluidsj. Transport

Emergency room care is a continuation of care administered at the scene of the 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



Major burnsa. 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 areac. Monitor for respiratory distress and asses the need for intubationd. Assess oropharynx for blisters and erythemae. 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

h. Assess for hypovolemia and prepare to administer fluids intravenously to maintain fluid balance

i. Monitor vital signs closelyj. Insert a Foley catheter as prescribed, and maintain urine output at 30 to

50 mL/hrk. Maintain NPO statusl. Insert a nasogastric tube as prescribed to remove gastric secretion and

prevent aspirationm. Administer tetanus prophylaxis as prescribedn. Administer pain medication, as prescribed, by the IV routeo. Prepare the client for an escharotomy or faciotomy as prescribed


Minor burnsa. Administer pain medication in small doses of morphine sulfate or

meperidine (Demerol) as prescribedb. Instruct the client in the use of oral analgesics as prescribedc. Administer tetanus prophylaxis as prescribedd. 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



• 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

Pain management a. Administer morphine sulfate or meperidine (Demerol) as prescribed by the IV

routeb. 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

Nutritiona. Proper nutrition is essential to promote wound healing and prevent infectionb. The basal metabolic rate is 40 t0 100 times higher than normal with a burn

injuryc. Maintain NPO status until the bowel sound is heard, and then advance to clear

liquid as prescribedd. Nutrition may be provided via enteral tube feeding or parenteral nutritione. Provide a diet high in protein, carbohydrates, fats and vitaminsf. Monitor calorie intake


Fluid resuscitationa. 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/hrb. 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


Escharotomya. 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

Fasciotomya. 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


• 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.

Wound care1. Description: Cleansing, debridement, and dressing of burn wounds2. Hydrotheraphy

a. Wounds are cleansed by immersion, showering, or sprayingb. Hydrotherapy occurs for 30 minutes or less to prevent increased sodium loss though the burn wound, heat loss, pain, and stressc. Client should be premedicated before procedured. Hydrotherapy generally is not used for clients who are hemodynamically unstable or those with new skin graftse. Care is taken to minimize bleeding and maintain body temperature during the proceduref. 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 healingb. Debridement may be mechanical, enzymatic, or surgicalc. Deep partial- or full-thickness burns: Wound is cleansed and debrided, and topical antimicrobial agents applied once or twice daily



Wound closure1. Descriptiona. Wound closure prevents infection and loss of fluidsb. Closure promotes healingc. Closure prevents contractures d. Wound closure is performed on day 5 to 21, depending on the extent of burn2. 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 clientArtificial skin: create structure similar to normal dermisBiosynthetic: forms an adherent bond until epithelialization occursSynthetic: pain is reduced because covering prevents contact of wound w/ airAutograft: skin taken from clients own body

Artificial skin

Synthetic skin

Cultured skin

Biosynthetic skin

3. Autograftinga. Autografting provide permanent wound coverageb. Autografting is surgical removal of a thin layer of clients own unburned skin,

which layer is applied to the excised burn woundc. Autografting is performed in the operating room under anesthesiad. Monitor for bleeding following the graft because bleeding beneath an

autograft can prevent adherencee. 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


burns liza jane c. bautista. skin skin functions epidermis protection from desiccation protection...

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