Burn Management.pptx

Burn management

1. (part-2) MANAGEMENT OF BURN

2. MANAGEMENT OF BURN: The burning agent must be stopped from further damage, example: fires are extinguished. Hospitalization is necessary for optimal care of burns. Example: elevated a severely burned arm or leg above the level of the heart to prevent swelling is more easily accommodated in a hospital.

3. First aid for Burn injury: A person with a burn is to stop the burning process at the source, & cool the burn wound. First aid for Minor burn: (first-degree) If skin is not broken, run cool water over b urned area or soak in a cool water (not ice water) bath, if burn occur in cool environment water should be applied, a cold, wet towel will reduce pain

4. Burns can be painful, reassure the victim & keep them clean After flushing or soaking the burn for few minutes, cover the burn with a sterile non-adhesive bandage or clean cloth Protect burn from friction & pressure

5. 2. First aid for severe Burns: (second & third degree) Do not remove burnt clothing Check breathing, if breathing has stopped or victim’s airway is blocked, open airway & begin CPR If patient is breathing, cover burn with cool moist sterile bandage or clean cloth Do not use blanket/towel. Sheet can be used. Do not apply ointments & avoid breaking blisters If fingers/toes are burned, separate them with dry sterile, non-adhesive dressing

6. Elevate burned area & protect it from pressure or friction To prevent shock, lay victim flat elevates the feet about 12 inches, & cover victim with a coat or blanket, do not placed victim in shock position if a head, back, leg injured is suspected or if it makes victim uncomfortable Monitor victim’s vital sign’s continously

7. Do Not: Do not apply ointment, butter, ice, medications, fluffy cotton dressing, adhesive bandages, cream, oil spray or household remedy to a burn. .

8. Avoid breathing or coughing on burned area to avoid contamination Don’t apply cold compress & do not immerse a severe burn in cold water, can cause shock Do not placed a pillow under victim’s head if there is an airway burn & they are lying down.

9. Management of Burn According to Burn Phase: Immediate Management of Burn: Emergent period of burn management refers to first 48-72 hours post burn when patient is admitted to the hospital, it includes: 1. Airway Management: For mild pulmonary injury, inspired air is humidified & patient is encourage to cough so that secretions can be removed by suctioning, in more severe situations, secretions to be removed by bronchial suctioning & administer bronchodilators.

10. Endotracheal intubation & mechanical ventilation may be required, head & chest to be elevated by 20 degree to 30 degree to reduce neck & chest wall edema. If a full thickness burn of chest wall leads to severe restriction of chest wall motion, chest wall escharotomy may be required (burn incised into subcutaneous fat & underlying soft tissue)

11. ( Escharotomy is the surgical division of the nonviable eschar , the tough, inelastic mass of burnt tissue that results from full-thickness circumferential and near-circumferential skin burns.  An escharotomy is an emergency medical procedure that involves the removal of the full-thickness burn ( eschar ) down to the subcutaneous fat to release it and prevent further complications. It restores blood flow and allows adequate ventilation).

12. 2. Hyperbaric oxygen therapy (HBOT): It is a non-invasive mode of treatment. Here patient is entirely enclosed in a pressure chamber filled with oxygen at a pressure greater than one atmosphere, it can also be done in a mono place chamber (one patient), multiplace chamber (two patient). Chamber is pressurized with 100% pure oxygen, it delivers 100% O2 to an open, moist wound through special devices.

13. 3. Fluid Management: Burn cause fluid loss through wound as well as into the burn wound & adjacent tissues in the form of edema, fluid loss is replaced through 2 large caliber peripheral intravenous catheters Adults with more than 15% burn or a child with 10% burn of the body surface area require fluid resuscitation. Foley’s catheter is inserted to maintain intake & output chart.

14. Replacing body fluid: Guidelines & formulas for fluid replacement in burn patients: Consensus formula: Lactated ringer’s solution (or other balanced saline solution): 2-4ml × kg body weight × % body surface area (BSA) burned. Half of fluid is to be given in first 8 hours & remaining half to be given over 16 hours.

15. Evans formula: Colloids: 1ml ×kg body weight ×% body surface area (BSA) burned. Electrolytes (saline) : 1ml ×body weight × % body surface area (BSA) burned. Glucose: (5% in water): 2000 ml for insensible loss. Day 1: Half to be given in first 8 hours, remaining half over next 16 hours. Day 2 : Half of previous days colloids & electrolytes all of insensible fluid replacement Maximum of 10,000 ml is given over 24 hours

16. Brooke army formula: Colloids: 0.5 ml × kg body weight × % body surface area (BSA) burned. Electrolytes (saline): 1.5 ml × kg body weight × body surface area (BSA) burned. Glucose: (5% in water): 2000 ml for insensible loss Day 1: Half to be given in first 8 hours. Remaining half over 16 hours. Day 2: Half of colloids, half of electrolytes, all of insensible fluid replacement.

17. Second & third degree (partial & full thickness) burns exceeding 50% of BSA are calculated on the basis of 50% BSA Parkland/Baxter formula: Lactated ringer’s solution (or other balanced saline solution): 4 ml × kg body weight × % body surface area (BSA) burned. Hypertonic saline solution: Concentrated solutions of sodium chloride (NACL) & lactate with concentration of 250-300 meq of sodium per liter, administered at a rate sufficient to maintain a desire volume of urinary output.

18. 4. Wound Management: Assessment to be done to determine burn area & depth, then debridement (removing devitalized tissue & contamination), cleaning than dressing.

19. (Debridement is a procedure for treating a wound in the skin. It involves thoroughly cleaning the wound and removing all hyperkeratotic (thickened skin or callus), infected, and nonviable (necrotic or dead) tissue, foreign debris, and residual material from dressings).

20. Circumferential burns of digits, limbs or chest may need urgent surgical release of burnt skin ( escharotomy ) to prevent problems with distal circulation or ventilation. Early excision & skin grafting of full thickness & deep dermal burn wounds.

21. 5. Analgesics & Sedation: Severely burned patient are restless & anxious from hypoxemia or hypovolemia rather than pain. Simple analgesics such as ibuprofen & acetaminophen, and Narcotics are used. A local anesthetic helps reduce pain in minor first degree & second degree burns. The patient then responds better to oxygen or increased fluid administration rather than to narcotic analgesics or sedatives may mask signs of hypoxemia & hypovolemia

22. B. Acute period or intermediate phase It begins at the end of emergent period & lasts until burn wound is healed. If burn is partial-thickness injury, acute period extends 10-20 days, if burn injury is a full thickness injury over a large percentage of body requiring surgery for skin grafting, the acute period can lasts for months.

23. During acute period, 2 main principle of management are: Treatment of burn wound & avoidance, detection & treatment of complications.

24. Infection prevention: Burned area is cleaned regularly. Wounds are cleaned & bandages changed 1-3 times per day. Infection is promoted by loss of epithelial barrier, by malnutrition induced by hypermetabolic response, post burn immunosuppression .

25. Tissue specimens are obtained for culture by swab, tissue biopsy, to monitor colonization of wound by microbial organisms.

26. Systemic antibiotics are administered when there documentation of burn wound sepsis or other positive cultures such as urine, sputum or blood. Infection control is a major role of burn team in providing appropriate burn wound care. Cap. Gown, mask & gloves are worn while caring for patient with open burn wounds.

27. b. Topical antimicrobials Application of topical agents to burn wound can help decrease infection & hasten healing. Topical agent includes: Silver sulfadiazine: Most commonly used topical antimicrobial agent in burn, its antimicrobial properties are derived from dual mechanism of its silver & sulfa moieties & has broad spectrum of microbial coverage. It is painless on application, has high patient acceptance, easy to use with or without dressing.

28. Allergic sensitivity can develop where patient will develop transient leukopenia 3 to 5 days following its continued use secondary to margination of circulating WBCs. If WBC count drops below 3000, medication to be withheld until WBC counts returns to >4000-5000

29. Mafenide : Broad spectrum of antimicrobial activity, unlike other topical agents, mafenide has good penetration through eschar , it is used on dirty or infected burn wounds or electrical burns and burn ears. after application, mafenide produces a manful sensation for several minutes, therefore it is called “white lightning’ Sites of mafenide application can be rotated every 2 hours until entire burn has been treated .

30. Silver Nitrate 0.5% solution: Broad spectrum, non penetrating , painless antimicrobial agent, requires multiple daily application on burn dressing & is messy & staining. This dressing is used in treatment of toxic epidermal necrolysis syndrome & in rare patient allergic to silver sulfadiazine or mafenide . The solution is hypotonic, so electrolyte leeching, hyponatremia & hypokalemia are common side effects.

31. Povidone iodine ( betadine ) ointment: Reddish brown germicidal preparation of 10% povidone iodine with broad spectrum microbial action, applied 3 times daily. Can be applied by spreading it with sterile gloved hand on to burned surface. Petroleum based antimicrobial ointments: Such as bacitracin or polymyxin B are clear on application, painless, allow easy wound observation. used for facial burns, grafts sites, healing donor sites & small partial thickness burns.

32. In severely burned patients (>40% BSA), combination of mycostatin ointment or powder with other topical agents reduces incidence of fungal superinfection & improves antimicrobial action. Mycostatin 5-15 ml given orally 3 times daily reduces alimentary fungal overgrowth. Topical antimicrobial creams are used with closed dressings. Dressing to be change every 8-12 hours In contaminated area, wounds are washed with an antimicrobial soap or phosphate buffered 0.25% hypochlorite solution

33. Wound care: Untill complete re- epithelization occurs, burn dressing helps in protection against micro-organisms invasions, minimize metabolic losses Wound covering: 1. Dressing: Wet dressing may be used with silver nitrate or normal saline applications. Normal saline applied to clean granulation tissue or to new graft to maintain moisture Single layer of fine mesh gauze placed over the wound, covered with thick gauze pads to maintain moisture, & held in place with a gauze wrapping

34. Open or exposure method: Patient is washed daily & kept of clean dry sheets with another sheet to reduce contamination from the environment. Exudates of partial thickness burn dry in 48-72 hours, & forms a crust that protects the wound, epitheliazation occurs beneath this crust in 14-21 days & crust falls off. Dead skin of a full thickness burn is dehydrated & converted to black, leathery eschar in 48-72 hours. Exposure is less painful for full-thickness burn.

35. Loose eschar may be removed with the use of hydrotherapy & debridement, Lights & heat lamps to use with caution to provide warmth, Ambient temperature control is important to maintain normothermia . Advantages: Wound is easily inspected & patient has maximal freedom to perform exercises for prevention of contractures & improvement of circulation

36. b. Closed Method or occlusive method: In this wounds are washed & dressings are changed at least once a day. An occlusive dressing is thin gauze that is applied after topical antimicrobial application, pressure wrappings or elastic bandages may be applied. This dressings are used over areas with new skin grafts to protect the graft, this dressings remains in place for 3-5 days. Nursing observation includes: Monitoring for signs of impaired circulation

37. Nursing observation includes: Monitoring for signs of impaired circulation (numbness, pain, tingling) & signs of infection. C. Bland dressing: These provides a clean, moist wound healing environment, absorb exudates, protect from contamination & provide comfort at a fraction of cost of antibiotic dressings, paraffin gauze can be used.

38. Dressing guidelines for minor & moderate burns: Ensure that the patient is not allergic to any dressing. Use a dressing that both the patient & staff find acceptable & with which both will comply. Use a dressing that is cost effective ie , do not use expensive dressing if burn requires frequent dressing changes. Consider changing type of dressing as burn character changes in particular exudates control

39. Decrease the dressing bulk as soon as the wound will allow for greater freedom of movement as well as reducing “sick role” effect of bulky dressings on patients.

40. (Under wound care) 2. Biological Dressing: Biological dressing have no direct toxins or antmicrobial properties, however, it creates a wound environment that prevents dessication , diminishes bacterial proliferation, reduces loss of water, protein & red blood cells, promotes rapid wound healing, reduces burn pain. These materials may be organic or synthetic in origin.

41. Skin grafts: Skin grafts are applied to cover burn wound & speed healing, to prevent contractures & to shorten convalescence, successful grafting reduces patient’s vulnerability to infection & prevent loss of body heat & water vapor from the open wound.

42. Synthetic dressings: Helps increase rate of wound healing, reduce discomfort. Biobrane is a nylon material that contains a gelatin that interacts with clotting factors in the wound, it is a synthetic, bilaminate membrane with an outer semi-permeable silicone layer bonded to an inner collagen nylon matrix, its elasticity & transparency allows easy drape ability, fuller range of motion, easy wound inspection. It is suited to use on donor sites superficial partial thickness burns, & clean excised wounds prior to grafting.

43. Skin substitutes: Skin substitutes becomes incorporated permanently, in parts or as a whole, into the wound closure. An artificial skin developed by Burke, is composed of an outer silastic ‘epidermis’ (0.1mm thick), and an inner biodegradable bovine collagen glycosaminoglycan (GAG) based dermal analog, Inner surface provides good wound adherence while the outer layer prevents exogenous bacterial contamination

44. Surgical Treatment: Partial thickness burns should heal without surgical intervention, but full thickness requires surgical management. There are 2 alternatives treatment for deep burns: One can wait for spontaneous desloughing & apply split thickness skin graft at 3 weeks, this policy has the advantage that early operation can be avoided, but had disadvantage of slow healing & greater scarring. Early excision of burn is carried out with the application of skin cover by a skin graft or a flap, has advantage of rapid healing & early restoration of function.

45. Early excision of skin grafting is the technique used for deep dermal burns, preferred within 48 hours, the layers of burned tissue are shaved with a split skin grafting knife until a healthy bleeding bed is reached, upon which partial thickness skin graft is applied. Surgical reconstruction of burn injury: Major complication of burn injury is scarring, hypertrophic scar or keloid scar can be prevented by application of pressure, & by giving routine Lycra pressure garments to wear for 14 months. When burn scar crosses a joint, contractures occur.

46. 3. Rehabilitation period or Long term phase: Rehabilitation care should commence on the day of injury. Goals are: Limit or prevent loss of motion Prevent or minimize anatomic deformities Prevent loss of lean muscles mass Return the patient to work or normal activities as soon & completely as possible

47. BARRIER NURSING CARE OF THE BURNS Restoring normal fluid balance: Nurse closely monitors patient’s IV & oral fluid intake, maintain intake & output chart, daily weight are obtained Changes in blood pressure, pulse rate to be observed & report to physician if any Administer medication as prescribed.

48. 2. Preventing infection : Detection & prevention of infection Aseptic technique used for wound care procedure & any invasive procedure Nurse protects patient from source of contamination. 3. Maintaining adequate nutrition: Nurse collaborate with the dietician to plan a protien & calorie-rich diet Family members to be encouraged to bring nutritious & favoured foods for patient

49. Feeding tube is inserted & used for continous or bolus feeding of specific formulas check patient weight daily to monitor weight loss & gain 4.Promoting skin integrity: Nurse serves as coordinator of complex aspect of wound care & dressing changes for patient Nurse must be aware & of the rationale & nursing implications for various wound management approaches. Nurse assists patient & family by instruction, support & encouragement to take an active part in dressing changes & wound care.

50. 5. Relieving pain & discomfort: Assessment of pain & discomfort, intervention to be made to relieve pain Analgesics & anti-anxiety medications as prescribed. Dressing change & complete treatment to be done to reduce pain & discomfort 6. Promoting physical mobility: Deep breathing, turning & proper repositioning are essential nursing practices to prevent atelectasis , pneumonia, edema, pressure ulcers & contractures.

51. Both passive & active exercise to be done from admission & to be continued after grafting, within prescribed limitations. 7. Strengthening coping strategies: Assist patients in developing effective coping strategies by promoting truthful communications to build trust, giving positive reinforcement when appropriate Helps patients set realistic expectations for self care, self feeding, assistance with wound care procedures, exercise.

52. COMPLICATIONS: Infections: Burn leaves skin vulnerable to bacterial infection & increase rick of infections, sepsis is a life- treatening infection that travels through bloodstream & affects whole body, progresses rapidly & can cause shock & organ failure Low blood volume: Burn can damage blood vessels & cause fluid loss, results in low blood volume

53. Hypothermia: Skin helps control body’s temperature so, when a large portion of skin is injured, patient lose body heat, it increases risk of hypothermia. Breathing problems: Breathing hot air or smoke can burn airways & cause respiratory difficulties, smoke inhalation damages lungs & cause respiratory failure. Scarring: Burns can cause scars & ridge areas caused by an overgrowth of scar tissue ( keloids )

54. Musculoskeletal problems: Deep burns can limit movement of bones & joints , scar tissue can form & cause shortening & tightening of skin, muscles or tendons (contractures), this conditions can permanently pull joints out of position.

55. Prevention & Health education: To reduce risk of common household burns: Never leave items cooking on the stove unattented Turn pot handles towards the rear of the stove Keep hot liquids out of reach of children & pets Keep electrical appliances away from water Test food temperature before serving a child, don’t heat a baby’s bottle in the microwave Never cook while wearing loose fitting clothes that could catch fire over the stove

56. 7. In presence of a small child, block his or her access to heat sources such as stove, outdoor grill, fireplace & space heater 8. Before placing a child in a car seat, check for hot straps or buckles. 9. Unplug irons & similar devices when not in use, store them out of reach of small children 10. Cover unused electrical outlets with safety caps, keep electrical cords & wires out of the way so that children don’t chew on them.

57. 11. Avoid smoking in the house & never smoke in bed 12. Keep fire extinguisher on every floor of your house. 13. Set water heater’s thermostat below 120 F (48.9 C) to prevent scalding, test bath water before placing a child in it.