Burn presentation12

Master in Pediatric Nursing, 2nd year, Bir Hospital Nursing Campus

1. BURN Anu Chalise MN 2 nd year 4 th batch

2. Objectives At the end of the session participants will be able to : define burn. state incidence of burn. state aetiology of burn. classify burn. describe pathophysiology of burn. describe therapeutic management of burn. describe nursing management of burn. list complication of burn. state prevention of burn.

3. Burn

4. Introduction A burn is a type of injury to tissue 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.

5. Incidence Globally, deaths from burn: 180 000/year and majority occurs in low and middle-income countries. Burns are the second most common injury in rural Nepal, accounting for 5% of disabilities. (WHO, 2018)

6. Aetiology 1. Thermal Burn C ontact with steam, flames and hot surfaces or hot liquids with a temperature above 115F(e.g boiling water at 212F or 100C). C ommonly occurs in home while doing ironing, cooking, or touching hot water.  

7. Contd... 2. Chemical Burn S trong acids or alkalis. Household chemicals : bleach, boric acid, paint thinner. common in the workplace in certain industries.

8. Contd... 3. Electrical Burn Electric current flowing through tissues or bone. I t effects on the muscles, veins, arteries, and nerves between the entry and the exit point of the electrical current.  

9. Contd... 4 . Radiation Burn sunburn caused by UV radiation . Radiotherapy 5. Inhalation burn injury: Breathing in of harmful gases, vapors, and hot smoke.  

10. Classification of Burn A. Burn Depth Burns are classified according to the depth of tissue destruction as: 1. Superficial Burn (1 st degree Burn): The epidermis is destroyed and a portion of the dermis. P ainful , hyperesthetic and appear red and dry. Erythema blanches with pressure. Heals in 5-10 days without scarring.

11. Contd... 2 . Partial thickness(2 nd degree Burn): D estruction of the epidermis and dermis In superficial partial thickness burn injury: Dermal elements are intact, sweat glands and hair follicles remain intact that appears thick walled blisters, wet shiny, weeping surface which is painful. Injury heals within 2-3wks if no infection.

12. Contd... Deep dermal burn injuries: Appears mottled, with pink, red or waxy white areas exhibiting blisters and edema formation. The wound is painful Deep partial thickness burns take longer time to heal and are more likely to result in hypertrophic scars.

13. Contd... 3. Full Thickness(3 rd Degree ) Burns: E ntire epidermis and dermis and extend into subcutaneous and other underlying tissue, nerve tissue, sweat glands and hair follicle. Wound color ranges widely from waxy white to red, brown or black and is distinguished by a dry, leathery appearances. The wound is painless because nerve fibres are destroyed.

14. Contd... N ot capable of re-epithelization and require surgical excision and grafting to close the wound . 4. Fourth Degree Burn: This burn is full thickness injuries that involve underlying structures such as muscle, fascia and bone.

15. Anatomy of Skin

16. Contd... B. Extent of body surface area The extent of a burn is expressed as a percentage of the total body surface area (TBSA). Lund and Browder method, palm method, and rule of nine.

17. Lund and Browder Chart

18. Palm Method

19. Rule of Nine

20. C. Severity of Burn Injury Minor Burn Injury Moderate Burn Injury Severe Burn Injury TBSA and Depth of Burn: <10yrs: <10%TBSA 2 nd degree burn >10yrs: <15%TBSA 2 nd degree burn <2% 3 rd degree burn TBSA and Depth of burn: <10yrs: 10-20% TBSA 2 nd degree burn >10yrs: 15-25% TBSA 2 nd degree burn <10% 3 rd degree burn TBSA and Depth of burn: <10yrs: > 20% TBSA 2 nd degree burn >10yrs: > 25% TBSA 2 nd degree burn All third degree burn exceeding 10%.

21. Pathophysiology Local response A. The three zones of a burn Zone of coagulation- T his occur at the point of maximum damage. In this zone there is irreversible tissue loss due to coagulation of the constituent proteins.

22. Contd … ii. Zone of stasis- T he surrounding zone of stasis is characterized by decreased tissue perfusion. The main aim of burns resuscitation is to increase tissue perfusion here and prevent any damage becoming irreversible.

23. Contd … iii. Zone of hyperemia: In this outermost zone tissue perfusion is increased. The tissue here will invariably recover unless there is severe sepsis or prolonged hypoperfusion.

24. Three zones of a burn

25. Contd … B. Edema formation: Thermal injury in the tissue results in increased capillary permeability and vasodilation. So, loss of water, protein and electrolytes from the circulating volume in to the interstitial spaces occur leading to edema.  

26. Contd … C. Fluid Loss: Burn-injured skin is more permeable to evaporative water loss( approximately 4000ml/m 2 total surface area). D. Circulatory Status: Reduced blood flow in the burned area In full thickness burn the vascular supply is completely occluded.

27. Contd … Systemic Response: The release of cytokines and other inflammatory mediators at the site of injury has a systemic effect.  

28. Contd … Cardiovascular changes Capillary permeability is increased, leading to loss of intravascular proteins, fluids and electrolytes into the interstitial compartment. Peripheral and splanchnic(organ) vasoconstriction occurs. Myocardial contractility is decreased. S ystemic hypotension and organ hypoperfusion.

29. Contd … Hematological Changes A significant loss of circulating red cell mass Respiratory Changes Inflammatory mediators cause bronchoconstriction and in severe burns respiratory distress syndrome can occur.

30. Contd …   Renal Changes R enal vasoconstriction. Reduced renal plasma flow and depressed glomerular filtration. Oliguria and acute renal failure. Blood urea(BUN) and creatinine levels are elevated from tissue breakdown and oliguria .

31. Contd … Metabolic changes The basal metabolic rate increases up to three times to its original rate. Neuro-endocrine change It stimulates various target organs of the neuroendocrine system . Increased amounts of the catecholamines ; epinephrine and nonepinephrin Aldosterone secretion is elevated There is release of antidiuretic hormone  

32. Therapeutic Management  A. Resuscitative Phase (First aid management) Remove the child from burn area. Extinguish the flames. Maintain A, B and C(airway, breathing, circulation) Cool the burn area. Remove restrictive clothes, objects.

33. Contd … Cover the wound with clean cloth/dress. Irrigate/wash out in running water if chemical burn. Place the victim in comfortable position. Reassure the victim. Refer the patient to health facilities with burn care facilities.  

34. Contd … B. Emergency Medical Management Airway, breathing Assess breathing, maintain patent airway. Administer 100% humidified oxygen. Endotracheal intubation and manual ventilation may be needed. NPO to prevent aspiration.

35. Contd … 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.

36. Contd …   Fluid Resuscitation Keep IV canula of large bore. Administer fluids and electrolytes according to depth of burn and TBSA affected. Assess vital signs (pulse:<110/m, BP: >100mmhg), tissue perfusion. Central venous catheter may be needed for fluid administration and fluid balance monitoring.

37. Contd … Monitor urine output (30-40ml/ hr ). If burn<20%, oral fluid replacement can be done. Keep the child warm . Assess body temperature frequently. Less exposure of wound, and keep warm.

38. Contd... Management of the pain usually pharmacologic management in this situation. Dressing of the wound. Administer tetanus prophylaxis . Insert Foleys catheter to facilitate urination and for accurate measurement of the urine output. N/G tube in continous drainage if abdominal area affected / abdominal distension present.

39. Contd... C. Guidelines and Formulas for Fluid Replacement in Burn Patient Consensus Formula Ringer Lactate (RL) or normal saline(NS): 2-4ml×Kg body weight×TBSA % Half amount in first 8hrs. Remaining half in next 16 hrs.  

40. Contd... Parkland and Baxter Formula :   RL : 4 ml × Kg body weight ×TBSA% Day 1 st : Half amount in 1 st 8hrs, remaining ½ in next 16hrs. Day 2 nd : Varies, colloids are added.

41. Contd... Intermediate Management of Burn Continous assessment of the condition and acute complication of the burn injury such as hypovolemic shock, signs of CHF, renal failure. Administration of fluid: colloids including blood, albumin, and electrolytes according to patient’s condition and response to therapy. Pain management: Pharmacological and non pharmacological

42. Contd... Maintain thermoregulation. Infection Prevention. Wound care Wound cleaning(tub bath, cleaning with warm NS) Topical antibacterial application(more effective than systemic) Wound dressing: exposure or occlusive method and frequency usually daily). Wound debridement(natural, mechanical, surgical).

43. Contd... Grafting the burn wound. auto graft(own body skin ) allograft(skin of others) synthetic graft material Care of the donor site Nutritional support: High protein, vitamins and minerals Parenteral or enteral feeding if oral intake inadequate.

44. Contd... Physical mobility and exercises to promote physical functioning and minimize scarring. Use splint and exercise device to maintain proper position of joints. Strengthening coping strategies Home care teaching Refer them to social services or other support groups

45. Rehabilitative Care The goals of rehabilitation are: To promote wound healing. To promote psychological support. To restore maximal function. To reconstruct the contracture.

46. Nursing Management Nursing Assessment Assess the child for extent of burned surface, aetiology of burn, hypovolemic shock etc.   Nursing Diagnosis Impaired physical mobility related to open burn wound, contracture, anxiety Deficient knowledge related to child condition and treatment Disturbed body Image related to burn wound Fear/Anxiety related to chlid’s physical condition, treatment procedure Impaired skin integrity related to burn wound

47. Contd … Nursing Diagnosis Imbalanced nutrition less than body requirements related to lack of knowledge Risk for ineffective tissue perfusion related to complication of burn Acute pain related to burn wound Risk for infection related to burn, invasive procedure Risk for deficient fluid volume related to loss of fluid from burn wound Risk for ineffective airway clearance related to immobilization

48. Contd … Nursing Intervention Promoting physical mobility of child Improve knowledge of child and parents Increasing acceptance of body image Providing emotional support Providing Skin Care Providing balanced nutrition Increasing tissue perfusion Decreasing pain

49. Contd … Prevention from infection Maintenance of fluid volume Increase airway clearance Evaluation Maintained strength and function of affected body part. Absence of contractures. Demonstrated techniques/behaviors that enable resumption of activities. Acceptance of body image and setting future goals.

50. Complications Acute complication Hypovolemic(Burn) shock Fluid and electrolyte imbalance H eart failure and pulmonary edema. Sepsis Renal hypo-perfusion and failure Gastrointestinal : paralytic illeus , curling ulcer Anaemia , Immuno-supression .

51. Contd... Long term complications Growth retardation Different types of contracture Body image disturbance Lowered self esteem, depression

52. Prevention Enclose fires and limit the height of open flames in domestic environments. Promote safer cookstoves and less hazardous fuels, and educate regarding loose clothing. Apply safety regulations to housing designs and materials, and encourage home inspections. Lower the temperature in hot water taps. Promote fire safety education and the use of smoke detectors, fire sprinklers, and fire-escape systems in homes. Use of fire-retardant fabrics for children’s sleepwear.

53. Summary A burn is a type of injury to tissue caused by heat, electricity, chemicals, light, radiation or friction. Globally, deaths from burn: 180 000/year and majority occurs in low and middle-income countries. Aetiology of burn includes thermal burn, chemical burn, electrical burn, radiation burn, inhalation burn. Burn is classified as 1 st degree, 2 nd degree, 3 rd degree and 4 th degree. The extent of burn surface is calculated through lund and browder method, palm method and rule of nine.

54. Contd … Management includes first aid management, emergency medical management, intermediate management and rehabilitation. Fluid resuscitation through consensus formula, parkland and baxtar formula. Wound care includes bathing, dressing, prevention of contracture, physiotherapy, grafting; autograft , allograft and synthetic materials, prevention of infection etc. Nursing management includes supportive care: Pain management, fluid volume maintenance, nutrition, infection prevention, range of motion exercise, emotional support.

55. Assignment Define Burn. State aetiology of burn and write emergency medical management of burn. (2+3+5)

56. References Hockenberry, M.J., Wilson, D. and Rodgers,C.C . (2018). Wong’s Essentials of Pediatric Nursing. 2 nd ed. India: Reed Elsevier. Uprety , K. (2018).Essential of Child Health Nursing. 1 st edition. Kathmandu: Akshav Publication. Shrestha, T. (2016). Essential Child Health Nursing. 2 nd edition. Kathmandu: Medhavi Publication. Kyle, T. and Carman, S.(2013). Essentials of Pediatric Nursing.2 nd edition. Philadelphia:Wolters Kluwer Health. Ball, J., Bindler , R., Cowen, K., Shaw, M.(2017). Principles of Pediatric Nursing. 7 th edition. America: Pearson Education . WHO.(2018). Retrived on 21/8/2020 from https://www.who.int/news-room/fact-sheets/detail/burns

57. Thank You