Burn

For B.Sc.Nursing 3rd Year Purbanchal University

1. Prepared by: Indira Shah BSN 4 th year

2. Introduction Burn is the damage of any part of the body by heat. Burn injury occurs when energy of heat source is transferred to the body. Thermal burn or injury are the 3 rd most common cause of accidental death in children.

3. definition A burn is a type of injury caused by heat, electricity, chemicals, light, radiation or friction. Most burns only affect the skin (epidermal tissue and dermis). Rarely, deeper tissues, such as muscle, bone, and blood vessels can also be injured. (According to Tumla Shrestha;2016 edition)

4. Contd … Burn is defined as a damage of any area of the body tissue with exposure to heat, fire, electricity, chemicals and radiation. It is the third important cause of accidental death among children throughout the worlds. Nearly 80% of burn injuries occur within home. (According to Kamala Uprety ; 2018 edition)

5. Incidence Burns are second leading cause of injury in age group between 1-14 years. 80% of burn injury occur in home.

6. types of burn Thermal Burn :- Thermal burns are generally the most common type of burn. They result from exposure to or contact with steam, flames, and hot surfaces or hot liquids with a temperature above 115℃(e.g. boiling water at 212℉ or 100℃). This type of burn commonly occurs in the home while doing ironing, cooking, or touching hot water.

7. Chemical Burn :- Chemical burns occur when the skin is in contact with strong acids or alkalis. Household chemicals that cause burns include bleach, boric acid, paint thinner. While many chemical burns occur in the home, they are also common in the workplace in certain industries.

8. Electrical Burn :- Electrical burns result from electric current flowing through tissues or bone. Electrical burns are one of the most serious and should be given immediate attention. This burn might not always be visible, but they can be serious because of potential damage to the internal organs.

9. Radiation Burn : - A radiation burn is damage to the skin or other biological tissue caused by exposure to ionizing radiation. The most common type of radiation burn is sunburn caused by UV radiation.

10. Inhalation Burn Injury :- Smoke inhalation injury commonly results from the breathing in of harmful gases, vapours , and hot smoke. Person who are trapped in fires may suffer from smoke inhalation alone as well as skin burns.

11. assessment of burn wound (Classification of Burn Extent) The severity of the burn injury is assessed on the basis of the percentage of body surface area burned and the depth of the burn. The Extent of Body Surface Area Burn, Depth of Burn (according to tissue destruction) & Severity of Burn Injury (Classification according to severity of burn).

12. The Extent of Body Surface Area Burn:- The burn injury is usually expressed as a percentage of total body surface area (TBSA) which is most accurately estimated by using specially designed age related chart which is given below. Various methods are used to estimate the TBSA affected by burn. Among them: Lund and Browder Method Palm Method Rule of Nine

13. Lund and Browder Method This method modifies the percentage of the body area according to age, and changes with growth and provides more accurate estimate of burn size. So, commonly used in children.

14. Palm Method In scattered burns, a palm method is used to estimate the burn. The size of the patient’s palm is approximately 1% of TBSA.

15. Rule of Nine This is a quick method to estimate the extent of burn. In this method, the body is divided into anatomical sections, each representing 9% or multiple or 9% of the TBSA. It is useful only for older children and adults.

16. Depth of Burn (according to tissue destruction):-

17. Depth of Burn (according to tissue destruction):- Superficial Burn (first degree burn) Partial thickness Burn (second degree burn) Full thickness Burn (third degree burn) Fourth degree burn

18. 1. First degree burn:- Superficial Burn (first degree burn) are usually of minor injury to the skin. Burn affects epidermis causing erythema , edema and pain.

19. 2. Second degree burn:- Partial thickness Burn (second degree burn) affects epidermis and dermis causing erythema, painful, moist, red and formation of blistered along with oozing of blistered. Dermal element are intact, therefore skin can regenerate. In partial thickness burn, burn injured 15% to 30% of body surface area.

20. 3. Third degree burn:- Full thickness Burn (third degree burn) affects entire epidermis and dermis and also extends into subcutaneous tissue. There is no pain due to destruction of nerve ending. Involvement of underlying structures such as muscle, fascia and bone can be life threatening. The wound appears dull and dry. The dead tissue and exudates change to a thick leathery eschar in 48 to 72 hours and need special care with long term management.

21. 4. Fourth degree burn:- Fourth degree burn are full thickness injuries that involve underlying structures such as muscle, fascia and bone. The wound appear dull and dry and ligaments, tendons and bone may be exposed. Wound are insensitive may require amputation or grafting.

22. Severity of Burn Injury: ( Classification according to severity of burn) :- Severity of burn injury depends upon total area injured, depth of injury , location of injury, age, general health of the child, presence of additional injury or chronic diseases and level of consciousness. Minor burn: Total body surface area (TBSA) and depth of burn, Moderate, uncomplicated burn injury TBSA and depth of burn & Major burn injury TBSA and depth of burn.

23. 1. Minor burns:- Partial thickness of burn <10 years : <10% TBSA 2nd degree burn >10 years : <15% TBSA 2nd degree burn Third degree burn of less than 2% TBSA, not involving areas at risk of cosmetic or functional impairment or disability such as the face, eye, ear, hands, feet, perineum. Excluded electrical injury, inhalation injury, concurrent trauma, poor general health.

24. 2. Moderate burns:- <10 years : 10-20% TBSA 2nd degree burns >10 years : <15-25% TBSA 2nd degree burns Third degree burn of less than 10% TBSA, not involving areas risk of cosmetics or functional impairment or disability such as the face, eye, ear, hands, feet, perineum. Excluded electrical injury, inhalation injury, concurrent trauma, poor general health.

25. 3. Major burns:- <10 years : >20% TBSA 2nd degree burns >10 years : <25% TBSA 2nd degree burns Third degree burn exceeding 10% TBSA Burn involving areas at risk of cosmetic or functional impairment or disability such as the face, eye, ear, hands, feet, perineum. High voltage electric burn injury, inhalation injury, concurrent trauma, poor general health.

26. Management of burn First Aid management (Resuscitation phase) Emergency Management Intermediate Management of Burn Rehabilitative Care

27. 1. First Aid management (Resuscitation phase):- Remove the child from the area of accidents. Reassure the child. If the victim’s clothing is on fire, lay the victim down and put out the flame with water or wrap with thick materials i.e. blankets. Lay the victim flat on the ground but don’t roll him/her. Put burn site in running cold water if burn is not so deep.

28. Contd … Remove the victim’s wet clothing, rings, shoes if any carefully. Cover the burn site with a clean cloth or dressing if available. Provide a fluid to child if child can drink. Seek medical help as soon as possible.

29. 2. Emergency Management:- Airway, Breathing; Arterial blood gas determinations should be obtained as a baseline but arterial PO 2 does not reliably predict CO poisoning. Therefore, baseline carboxyhaemoglobin levels should be obtained and 100% humidified oxygen should be administered. Elevation of the head and chest by 20-30 reduces neck and chest wall oedema. Endotracheal intubation and manual ventilation may be needed. Keep child in NPO. Transfer to burn centre .

30. 2. Emergency Management:- Circulation; Assess circulatory status quickly: monitor pulse, BP frequently. Careful watch for features of shock and prevent it. Assessment of the total body surface area affected (TBSA) and degree of burn.

31. Fluid Resuscitation (Replacement): Large-calibre intravenous lines must be established immediately in a peripheral vein. A child with more than 10% of the total body surface area burned requires fluid replacement. Replacement fluids required in the first 24 hours from the time of injury aim to maintain a good urine output – 0.5-1 ml/kg in adults, 1-2 ml/kg in children. 2. Emergency Management:-

32. Prevent hypothermia. Dressing of the wound. Administer tetanus prophylaxis. Insert Foleys catheter to facilitate urination and for accurate measurement of the urine output. Accurate monitoring of intake/output, electrolytes, vital signs and other general condition. N/G tube in continuous drainage if abdominal area affected of abdominal distension present. Management of pain by using analgesic. 2. Emergency Management:-

33. Parkland and Baxter Formula : RL: 4 ml ⅹ kg body weight ⅹ TBSA% Day 1 st : Half amount in 1 st 8 hours, remaining ½ in next 16 hours. Day 2 nd : Varies, colloids are added. Consensus Formula : Ringer lactate or normal saline : 2-4 ml ⅹ KG body weight ⅹ TBSA% Half amount in first 8 hours. Remaining half in next 16 hours. Guidelines and Formula for Fluid Replacement in Burn Patient:-

34. 3. Intermediate Management of Burn :- Continuous assessment of the condition and acute complication of the burn injury such as hypovolumic shock, signs of CHF, renal failure. Administration of fluid: colloid including blood, albumin, electrolytes according to client’s need. Pain management: Assessment of pain, administration of analgesics around 20 minute before painful procedure and adopt non pharmacological measures like distraction, relaxation, age appropriate play etc.

35. Maintain Temperature: Maintain room temperature especially during dressing, avoid unnecessary exposure, use of blankets heater according to situations etc. Infection Prevention: Use of aseptic technique in all invasive procedure, adopt hand washing practiced, follow isolation, visitor control, watch for sign of infection and administration of antibiotics. 3. Intermediate Management of Burn :-

36. Wound Care: Wound cleaning with warm normal saline. Topical antibacterial application. Wound dressing: exposure or occlusive method and daily or according to need. Wound debridement. Grafting the burn wound and dressing: Usually occlusive dressing to immobilize the graft Gentle dressing after 3-5 days of graft, elevate the part to edema if in extremities. Care of donor site: Gauge light pressure dressing to apply pressure for oozing. Keep clean, dry and free from pressure. Pain management, dry dressing as need.

37. Maintain adequate nutrition: Provide high calorie, high protein diet, encourage for oral feeding, provide supplementary vitamins (A, C, B) and minerals. Reassure child and parents, facilitate parent child interaction and teach parents about home care and prevention from complications such as apply splint if needed to prevent contracture.

38. Physical mobility and exercise: Position patient so that flexion and other types of contracture will be prevented Implement range of motion exercise several times a day Use splint and exercise device to maintain proper position of joints. Involve child and family in exercise and activity.

39. Strengthening coping strategies: Assess and encourage child and parent’s coping abilities Assist child and parent/family to set realistic goals. Use of multidisciplinary approach to promote rehabilitation Encourage child to participate in self care Support child and family.

40. Management of Chemical burns: Immediately flush away the chemical with large amounts of water for at least 20 to 30 minutes (longer for alkali burns). Alkali burns to the eye require continuous irrigation during the first eight hours after the burn. If dry powder is still present on the skin, brush it away before irrigation with water.

41. Management of Electrical Burns: Fluid administration should be increased to ensure a urinary output of at least 100 ml/hour in the adult. Metabolic acidosis should be corrected by maintaining adequate perfusion and adding sodium bicarbonate.

42. 4. Rehabilitative Care:- Burn injuries can have long term and short term impact on client life. If the injuries are major it takes long time to recover with complications, So to overcome from these complications rehabilitative care becomes prime component of burn management.

43. The main aims of rehabilitative care are:- To promote wound healing To provide psychological support To restore maximal function To reconstruction of damage. 4. Rehabilitative Care:-

44. Rehabilitative measures are:- Appropriate wound care Use of elastic bandage Lubricating and other wound care Promote physical activity Encourage for active and passive range of motion exercise Physiotherapy 4. Rehabilitative Care:-

45. Recreational / divertional therapy Provide information of the cosmetic treatment. Consultation with social worker, psychologist for support Promoting home and community base care Involving the patient and family in care activities Home care teaching Provide information on support group. 4. Rehabilitative Care:-

46. Indication of Referral to a specialist burns unit:- All complex injuries should be referred –particularly: Age under 5 years or over 60 years. Site of injury: face, hands, perineum, any flexure ( including neck or axilla ) and circumferential dermal burns or a full-thickness burn of the limb, torso or neck. Inhalation injury. Mechanism of injury: 4. Rehabilitative Care:-

47. Chemical burns affecting over 5% total body surface area burned (over 1% for hydrofluoric acid burns ). Exposure to ionizing radiation. High-pressure steam injury. High-tension electrical injury. Suspected non-accidental injury in a child. 4. Rehabilitative Care:-

48. Large affected area: Age under 16 years: over 5% total body surface area burned. Age 16 years or older: over 10% total body surface area burned. Co-existing conditions – e.g., serious medical conditions, pregnancy or associated fractures, head injury or crush injuries. 4. Rehabilitative Care:-

49. NURSING

50. Nursing management Nursing management in burn care requires specific knowledge on burns so that there could be a provision of appropriate and effective interventions.

51. Nursing Assessment Focus on the major priorities of any trauma patient.  the burn wound is a secondary consideration, although aseptic management of the burn wounds and invasive lines continues. Assess circumstances surrounding the injury.  Time of injury, mechanism of burn, whether the burn occurred in a closed space, the possibility of inhalation of noxious chemicals, and any related trauma. Monitor vital signs frequently.  Monitor respiratory status closely; and evaluate apical, carotid, and femoral pulses particularly in areas of circumferential burn injury to an extremity. Start cardiac monitoring if indicated.  If patient has history of cardiac or respiratory problems, electrical injury. Check   peripheral pulses  on burned extremities hourly; use Doppler as needed.

52. Monitor fluid intake ( IV fluids ) and output (urinary catheter) and measure hourly.  Note amount of  urine  obtained when catheter is inserted (indicates preburn renal function and fluid status). Obtain history.  Assess body temperature, body weight, history of preburn  weight, allergies, tetanus immunization, past medical surgical problems, current illnesses, and use of medications. Arrange for patients with facial burns to be assessed for corneal injury. Continue to assess the extent of the burn; assess depth of wound, and identify areas of full and partial thickness injury. Assess neurologic status: consciousness, psychological status, pain and  anxiety  levels, and behavior. Assess patient’s and family’s understanding of injury and treatment. Assess patient’s support system and coping skills. Nursing Assessment

53. Nursing diagnoses Nursing diagnoses for burn injuries include: Impaired gas exchange  related to carbon monoxide poisoning, smoke inhalation, and upper airway obstruction. Ineffective airway clearance  related to edema and effects of smoke inhalation. Fluid volume deficit  related to increased capillary permeability and evaporative losses from burn wound. Hypothermia  related to loss of skin microcirculation and open wounds. Pain  related to tissue and nerve injury. Anxiety  related to fear and the emotional impact of burn injury.

54. Nursing Interventions Nursing care of a patient with burn injury needs to be precise and effective. Promoting Gas Exchange and Airway Clearance Restoring fluid and Electrolyte Balance Maintaining Normal Body Temperature Minimizing Pain and Anxiety Monitoring and Managing Potential Complications Restoring Normal fluid Balance Preventing Infection Maintaining Adequate Nutrition Promoting Skin Integrity Supporting Patient and Family Processes

55. Promoting Gas Exchange and Airway Clearance Provide humidified oxygen, and monitor arterial blood gases ( ABGs ), pulse oximetry , and carboxyhemoglobin levels. Assess breath sounds and respiratory rate, rhythm, depth, and symmetry; monitor for hypoxia. Observe for signs of inhalation injury: blistering of lips or  buccal mucosa; singed  nostrils ; burns of face, neck, or chest; increasing hoarseness; or soot in sputum or respiratory secretions. Report labored respirations, decreased depth of respirations, or signs of hypoxia to physician immediately; prepare to assist with intubation and escharotomies . Monitor mechanically ventilated patient closely. Institute aggressive pulmonary care measures: turning, coughing, deep breathing, periodic forceful inspiration using  spirometry , and tracheal suctioning. Maintain proper positioning to promote removal of secretions and patent airway and to promote optimal chest expansion; use artificial airway as needed.

56. 2. Restoring fluid and Electrolyte Balance Monitor vital signs and urinary output (hourly), central venous pressure (CVP), pulmonary artery pressure, and cardiac output. Note and report signs of hypovolemia or fluid overload. Maintain IV lines and regular fluids at appropriate rates, as prescribed. Document intake, output, and daily weight. Elevate the head of bed and burned extremities. Monitor serum electrolyte levels ( eg , sodium, potassium, calcium, phosphorus, bicarbonate); recognize developing electrolyte imbalances. Notify physician immediately of decreased urine output; blood pressure; central venous, pulmonary artery, or pulmonary artery wedge pressures; or increased pulse rate.

57. 3. Maintaining Normal Body Temperature Provide warm environment: use heat shield, space blanket, heat lights, or blankets. Assess core body temperature frequently. Work quickly when wounds must be exposed to minimize heat loss from the wound.

58. 4. Minimizing Pain and Anxiety Use a pain scale to assess pain level ( ie , 1 to 10); differentiate between restlessness due to pain and restlessness due to hypoxia. Administer IV opioid analgesics as prescribed, and assess response to medication; observe for respiratory  depression  in patient who is not mechanically ventilated. Provide emotional support, reassurance, and simple explanations about procedures. Assess patient and family understanding of burn injury, coping strategies, family dynamics, and anxiety levels. Provide individualized responses to support patient and family coping; explain all procedures in clear, simple terms. Provide pain relief, and give antianxiety medications if patient remains highly anxious and agitated after psychological interventions.

59. 5. Monitoring and Managing Potential Complications Acute respiratory failure: Assess for increasing dyspnea , stridor , changes in respiratory patterns; monitor pulse oximetry  and ABG values to detect problematic oxygen saturation and increasing CO2; monitor  chest xray s ; assess for cerebral hypoxia ( eg , restlessness,  confusion ); report deteriorating respiratory status immediately to physician; and assist as needed with intubation or escharotomy . Distributive shock :  Monitor for early signs of shock (decreased urine output, cardiac output, pulmonary artery pressure, pulmonary capillary wedge pressure, blood pressure, or increasing pulse) or progressive edema. Administer fluid resuscitation as ordered in response to physical findings; continue monitoring fluid status. Acute renal failure :  Monitor and report abnormal urine output and quality, blood urea nitrogen (BUN) and  creatinine  levels; assess for urine hemoglobin or myoglobin ; administer increased fluids as prescribed.

60. 6. Restoring Normal fluid Balance Monitor IV and oral fluid intake; use IV infusion pumps. Measure  intake and output  and daily weight. Report changes (e.g., blood pressure, pulse rate) to physician.

61. 7. Preventing Infection Provide a clean and safe environment; protect patient from sources of cross contamination (e.g., visitors, other patients, staff, equipment). Closely scrutinize wound to detect early signs of infection.

62. 8. Maintaining Adequate Nutrition Initiate oral fluids slowly when bowel sounds resume; record tolerance—if  vomiting  and distention do not occur, fluids may be increased gradually and the patient may be advanced to a normal diet or to tube feedings. Collaborate with dietitian to plan a protein and calorie-rich diet acceptable to patient. Encourage family to bring nutritious and patient’s favorite foods. Provide nutritional and vitamin and mineral supplements if prescribed. Document caloric intake. Insert feeding tube if caloric goals cannot be met by oral feeding (for continuous or bolus feedings); note residual volumes. Weigh patient daily and graph weights.

63. 9. Promoting Skin Integrity Assess wound status. Support patient during distressing and painful wound care. Coordinate complex aspects of wound care and dressing changes. Assess burn for size, color, odor, eschar, exudate , epithelial buds (small pearl-like clusters of cells on the wound surface),  bleeding , granulation tissue, the status of graft take, healing of the donor site, and the condition of the surrounding skin; report any significant changes to the physician. Inform all members of the health care team of latest wound care procedures in use for the patient. Assist, instruct, support, and encourage patient and family to take part in dressing changes and wound care. Early on, assess strengths of patient and family in preparing for discharge and home care.

64. 10. Supporting Patient and Family Processes Support and address the verbal and nonverbal concerns of the patient and family. Instruct family in ways to support patient. Make psychological or social work referrals as needed. Provide information about burn care and expected course of treatment. Initiate patient and family education during burn management. Assess and consider preferred learning styles; assess ability to grasp and cope with the information; determine barriers to learning when planning and executing teaching. Remain sensitive to the possibility of changing family dynamics.

65. Complications Respiratssory distress from smoke inhalation or a severe chest burn. Fluid loss, hypovolaemia and shock. Infection. Increased metabolic rate leading to acute weight loss. Increased plasma viscosity and thrombosis. Vascular insufficiency and distal ischemia from a circumferential burn of limb or digit.

66. Complications Muscle damage from an electrical burn may be severe even with minimal skin injury; rhabdomyolysis may cause acute kidney failure. Poisoning from inhalation of noxious gases released by burning (e.g., cyanide poisoning due to smouldering plastics). Haemoglobinuria and renal damage. Scarring and possible psychological consequences. Hypertrophic scarring is more common following deeper burns treated by surgery and skin grafting than with superficial burns.

67. Prognosis Will depend on depth of burn and the body surface area affected. Superficial burns usually heal within two weeks without surgery. Death may result from severe extensive burns or electric shock.

68. There are many important aspects of prevention of burns, including: Safety in the workplace. Safety in the home, including regularly checking smoke alarms. Good parenting to protect children. Care of the frail elderly and the socially isolated. preventions

69. In the Kitchen : Keep hot liquids out of reach of your child. Put hot liquids on high counters or tables where toddlers or young children cannot reach them. Do not place hot liquids on placemats or tablecloths (children can pull the cloths and spill the hot liquid). Do not heat formula/milk in the microwave and always test the temperature of the baby’s formula and food before feeding. prevention

70. Never hold your infant or child while holding hot liquids or food. Turn pot handles towards the back of the stove and never leave food cooking on the stove unattended. Set your water heater temperature to 120° F / 48.9° C. Keep frying pans, pressure cookers, crock pots and coffee pots out of your child’s reach; tuck appliance cords away. Keep your children out of the kitchen. Do not allow your children to cook without supervision. prevention

71. prevention In the Bathroom : Never leave your child unattended near hot water sources, such as boiling water or steam baths. Always supervise children while bathing. Install temperature-regulated faucets and shower heads. Test the water temperature on the back of your hand before placing your child in the tub, even when using a tub tester. Never allow a young child to supervise another child while bathing.

72. Assignment Write the care plan of Burn.