BURNS management and nursing care .pptx

Lecture notes on burns and how to manage them

1. DICKSON LUNGU 22-Oct-24 1 BURNS

2. ANATOMY OF THE SKIN 22-Oct-24 2

3. THE SKIN 22-Oct-24 3 The skin is the largest organ of the body While not very active metabolically, the skin serves multiple functions essential to the survival of the organism

4. LAYERS OF THE SKIN 22-Oct-24 4 Epidermis : This is the outermost layer composed of cornified epithelial cells Dermis : This is the middle layer composed of primarily connective tissue Hypodermis: This is a layer of adipose and connective tissue between the skin and underlying tissues

5. FUNCTIONS OF SKIN 22-Oct-24 5 It protects the body against the invasion of harmful agents such as micro organisms or chemical or ultraviolet rays. Helps in regulating the body temperature Prevents water loss from the deep tissue, thus serves as water proof layer for these tissues.

6. FUNCTIONS OF SKIN CON’T 22-Oct-24 6 4. Serves as an excretory organ, some small quantities of wastes (sweat) are excreted via the skin. 5. Serves as a site for the manufacturing of vitamin D with the aid of ultraviolet rays of the sun. Major burns compromise these functions

7. GENERAL OBJECTIVE 22-Oct-24 7 At the end of the lesson 1 st year Registered Nursing Students should be able to demonstrate an understanding of Burns and be able to manage a client with burns.

8. SPECIFIC OBJECTIVES 22-Oct-24 8 At the end of the course 1 st year Registered Nursing students should be able to: Define Burns. Mention the causes of burns Outline the types of burns State the classification of burns Explain the Pathophysiology of burns State the Signs and symptoms Discuss the management of patient with burns State the complications of burns

9. DEFINITION 22-Oct-24 9 Burns are injuries to skin or tissues caused by heat , cold, friction, electricity, radiation, chemicals , characterized by pain, blisters redness ( Basavanthappa , 2004).

10. 22-Oct-24 10

11. CAUSES 22-Oct-24 11 Flame of fire Steam or hot water Chemicals Lightening Electricity Friction (is an occasional cause)

12. TYPES OF BURNS 22-Oct-24 12 Hot thermal burns Electrical burns Chemical burns Radiation burns Inhalation burns Cold or frost burns

13. TYPES OF BURNS 22-Oct-24 13 Thermal burns Caused by exposure to flames, hot liquid, steam or hot objects It is the most common type of burns 2. Chemical burns Caused by tissue contact to strong alkali or organic compounds. Destruction from necrotizing substances . Mostly caused by acids

14. TYPES OF BURNS 22-Oct-24 14 3. Electrical burns Caused by heat generated from electrical energy as it passes through the body Results in internal tissue damage Cutaneous burns cause muscle and soft tissue damage that maybe extensive particularly in high voltage electrical injuries

15. TYPES OF BURNS 22-Oct-24 15 Alternating current is more dangerous than direct current because it is associated with CP arrest, ventricular fibrillation,tetanic muscle contraction and long bone or vertebral fractures. 4. Radiation burns Caused by exposure to ultra violet light (sunburn) x-rays or radioactive sources. Degree of injury depends on length of exposure, strength of radiation, distance from source Uncommon but can be very serious.

16. TYPES OF BURNS 22-Oct-24 16 5. Smoke and inhalation injury R esults from inhalation of smoke, hot air or noxious chemicals and can cause damage to tissue of the respiratory tract e.g. carbon monoxide inhalation.

17. INHALATION INJURIES 22-Oct-24 17 CARBON MONOXIDE POISONING CO is colorless ,odorless, tasteless gas that has an affinity for hemoglobin 200 times greater than that of oxygen Oxygen molecules are displaced and carbon monoxide reversibly binds to haemoglobin to form carboxyhemoglobin This can lead to coma and death

18. CLASSIFICATION OF BURNS 22-Oct-24 18 The classification of burns is determined by the depth of the tissue injured and the extent of the body surface area involved. The depth gives the description of the physical appearance of the burns and the extent indicates the percentage of the body surface area that has been damaged. Burns are classified as superficial, partial thickness or full thickness and complicated burns.

19. CLASSIFICATION OF BURNS 22-Oct-24 19 1 . S uperficial burns(First degree) Involves only the epidermis . The area becomes hot, red, and more painful. Healing takes place between 2-10 days and the result of healing is a normal skin without scarring.

20. CLASSIFICATION OF BURNS 22-Oct-24 20 2. Partial thickness burns(Second degree) Involves the epidermis and the dermis . They are usually painful and blisters form due to the separation of the epidermal and dermal layers caused by collection of fluid . Healing takes places spontaneously between 10-14 days. The healing is normal to slightly pilled or poorly pigmented skin.

21. Deep partial-thickness burn 22-Oct-24 21

22. CLASSIFICATION OF BURNS 22-Oct-24 22 3. Full Thickness Burns (Third Degree Burns) Involves the epidermis, the dermis and the hypodermis . These burns are characterized by the destruction of the full skin thickness and its appendages i.e. hair follicles, sebaceous glands and underlying tissue e.g. subcutaneous tissue, fat, tendons etc. They appear white and waxy or charred.

23. Full-thickness burn 22-Oct-24 23

24. CLASSIFICATION OF BURNS 22-Oct-24 24 4. Complicated burns(Fourth Degree Burns) These burns involve the whole skin depth, underlying muscle and bones. These occur when one is continuously exposed to intense heat. They are fatal . This may result in a condition called compartment syndrome , which threatens both the life and the limb of the patient. Thus patient may require amputation.

25. FOURTH DEGREE BURNS 22-Oct-24 25 Also called complicated burns These burns involve the whole skin depth, underlying fat tissue, muscle, tendons and even bones. These are likely to occur when one is continuously exposed to intense heat. This may result in a condition called compartment syndrome , which threatens both the life and the limb of the patient.

26. PATHOPHYSIOLOGY 22-Oct-24 26 The pathophysiology of burns may be divided into four stages. These stages overlap each but in general they are as follows; Stage of neurogenic shock Stage of fluid loss Stage of infection and slough formation Stage of repair.

27. STAGE OF NEUROGENIC SHOCK 22-Oct-24 27 This is the first stage of a burns episode and it may prove to be fatal (dangerous). In this stage, there is flight, terror and hysterical or tension reaction of the individual. There is a lot of pain produced by the irritation of a thousand of nerve endings in the skin. The tension and terror flight factors in this stage precipitate the fall in blood pressure (hypotension) to shock levels from which the patient may never recover. This is especially true of the young and the very old.

28. STAGE OF FLUID LOSS – SHOCK 22-Oct-24 28 The systemic effects of burns is characterized by dilatation of the capillaries and the small blood vessels in the affected area, leading to an increase in capillary permeability and an increase in plasma seepage into surrounding tissue to produce blisters and oedema. The increased fluid loss will also lead to reduced blood volume-hence, the blood viscosity will result, leading to ineffective and inefficient circulation.

29. STAGE OF FLUID LOSS – SHOCK 22-Oct-24 29 Fluids containing water, sodium, chloride, and colloids escape from the intravascular compartment into the interstitial spaces. This creates blisters and swelling called burn edema. In addition to fluid shifts and loss, the destruction of cells and tissues is also responsible for the loss of electrolytes

30. SYSTEMIC EFFECTS OF THE STAGE OF FLUID LOSS 22-Oct-24 30 Initially,hyponatraemia and hyperkalaemia occur, followed by hypokalaemia as fluids shifts occur and potassium is not replaced. The haematocrit level increases as a result of plasma loss, this initial increase falls to below normal at the 3 rd and 4 th day post burn as a result of red blood cells damage and loss at the time of injury.

31. SYSTEMIC EFFECTS OF THE STAGE OF FLUID LOSS 22-Oct-24 31 Initially the body shunts blood from the kidneys causing oliguria,then the body begins to reabsorb fluids, and diuresis of the excess fluids occurs over the next days to weeks. Blood flow to the GIT is diminished leading to intestinal ileus and GIT dysfunction. Immune system function is depressed resulting in immunosuppression and this increases the risk of infection and sepsis

32. SYSTEMIC EFFECTS OF THE STAGE OF FLUID LOSS 22-Oct-24 32 Pulmonary hypertension can develop resulting in decrease in arterial oxygen tension and a decrease in lung compliance. Evaporative fluid losses from the burn wound are greater than normal and the losses continue until complete wound closure occur. If the intravascular space is not replenished with the IVFs,hypovolaemic shock and ultimately death will occur.

33. SYSTEMIC EFFECTS OF THE STAGE OF FLUID LOSS 22-Oct-24 33 There is sluggish blood flow caused by the plasma portion of the blood which is escaping from the intravascular compartment as a result the blood becomes thick or haemoconcentrated. The haematocrit rises because there is less fluid to dilute the solid components of the blood.

34. SYSTEMIC EFFECTS OF THE STAGE OF FLUID LOSS 22-Oct-24 34 The sluggish blood flow results in a drop in the cardiac output, decreased tissue perfusion and hypoxia Haemoconcentration results into haemolysis which leads to anaemia . This is the reason why anaemia is commonly seen in severe cases of burns.

35. STAGE OF SLOUGH FORMATION AND INFECTION 22-Oct-24 35 This is the stage when the tissue devitalized by the burn (Eschar) separates from the underlying viable tissue by the process of Liquefaction (slough formation ) . This leaves a large open wound that is often infected.

36. STAGE OF SLOUGH FORMATION AND INFECTION 22-Oct-24 36 The infecting organisms vary. The infection reveals itself gradually by an increase in fever, local tenderness and tachycardia.

37. STAGE OF SLOUGH AND INFECTION FORMATION 22-Oct-24 37 NB : The burn wound itself is sterile immediately after injury and it soon colonised by bacteria, the commonest of which are the gram-positive e.g. staphylococcus aureus, streptococcus pyogens etc; gram-negative bacteria e.g. klebsiella , pseudomonas etc

38. STAGE OF REPAIR OF THE BURNT AREA 22-Oct-24 38 Repair of the burn wound left by the burn cannot begin until the area is free from the sloughing tissue. When the entire thickness of the skin has been destroyed by the burn, repair must begin at the edges of the wound. This takes long in large burns and permits an overgrowth of granulation tissue to occur. To minimize this excessive overgrowth of granulation tissue, the burn wound is covered with skin grafts

39. REPAIR OF THE BURNT AREA 22-Oct-24 39 Sometimes the burn wound may be covered with cadaver preserved in tissue banks. This provides an excellent temporally covering which must be replaced by grafts from the patient’s own skin. Xenografts (pig skin) provide another method of temporal coverage. This biologic dressing is changed every third day. This may be used in conjunction with the patient’s own skin (autograft).

40. SYSTEMIC REPAIR 22-Oct-24 40 Systemic repair includes measures such as blood transfusion to overcome the anaemia that usually occurs in the later stages. The high calorie and protein diet adds in replacing the nutritional elements lost from the draining wound and decreased food intake during the acute phase of the condition and treatment.

41. CLINICAL FEATURES 22-Oct-24 41 1. Pain This is usual but is most marked in superficial burns because the sensory nerve endings in the skin are exposed. In deeper burns, these nerves are destroyed and therefore there will be mild pain. 2. Blisters These result from collection of fluid between the epidermis and the dermis. This is common in superficial burns.

42. CLINICAL FEATURES 22-Oct-24 42 3. Acute Circulatory Failure This is present when the burns are moderately extensive and if more so it is more profound or severe. It occurs due to massive loss of body fluids because of the loss of the skin which plays a fluid conservative role.

43. EMERGENCY ROOM MANAGEMENT OF A BURNT CLIENT 22-Oct-24 43 PRE ADMISSION PREPARATION Once notified of admission of a severely burnt patient, preparation includes assembling of equipment and preparation of a special area or room for the patient. He/she will be admitted to a burns unit and emergency equipment should be at hand.

44. EQUIPMENT FOR BURNS PATIENT 22-Oct-24 44 Catheterization tray Intravenous solutions Sterile gloves and nasogastric tube, etc Bed cradle Clean bed linen Tracheostomy set Suctioning and oxygen therapy equipment Blood withdrawing syringes and needles Cross matching bottles Laboratory forms

45. CLINICAL ASSESSMENT OF A BURNT CLIENT 22-Oct-24 45 Assessment of a burn injury patient is necessary to help in the selection of the best method of treatment and to develop a guide for fluid management or replacement. The burn is assessed by determining the cause, the condition of the patient, the extent of the burnt surface and the depth of the burns.

46. CLINICAL ASSESSMENT OF A BURNT CLIENT 22-Oct-24 46 It is also necessary to know if the patient was in an open area, closed area or semi closed area at the time of injury in order to determine whether actual or potential endotracheal injury has occurred after burn accident. Take a full assessment as follows;

47. PRIMARY SURVEY 22-Oct-24 47 Airway maintenance Stabilize the neck for suspected cervical spine injury. Inspect the airway for foreign material/oedema. If the patient is unable to respond to verbal commands open the airway with a chin lift and jaw thrust. Insert a Guedel Airway if airway patency is compromised. Think about early intubation.

48. BREATHING AND VENTILATION 22-Oct-24 48 Administer 100% oxygen Expose the chest and ensure that chest expansion is adequate and bilaterally equal Beware circumferential deep dermal or full thickness chest burns – is escharotomy required? Palpate for crepitus and for rib fractures Auscultate for breath sound bilaterally

49. BREATHING AND VENTILATION 22-Oct-24 49 Ventilate via a bag and mask or intubate the patient if necessary. Monitor respiratory rate – beware if rate <10 or > 20 per minute. Apply pulse oximeter monitor Consider carbon monoxide poisoning – non burnt skin may by cherry pink in colour in a non-breathing patient Send blood for carboxyhaemaglobin

50. CIRCULATION WITH HAEMORRHAGE CONTROL 22-Oct-24 50 Inspect for any obvious bleeding – stop with direct pressure. Monitor and record the peripheral pulse for rate, strength (strong, weak) and rhythm, Apply capillary blanching test (centrally and peripherally to burnt and non-burnt areas) – normal return is two seconds.

51. CIRCULATION WITH HAEMORRHAGE CONTROL 22-Oct-24 51 Longer indicates poor perfusion due to hypotension, hypovolaemia or need for escharotomy on that limb; check another limb Monitor circulation of peripheries if there is a circumferential burn present. Firstly elevate the limb to reduce oedema and aid blood flow. If this does not prove effective then it may be necessary to perform an escharotomy.

52. DISABILITY: NEUROLOGICAL STATUS 22-Oct-24 52 Establish level of consciousness: A - A lert V - Response to V ocal stimuli P - Responds to P ainful stimuli U - U nresponsive Examine pupils response to light for reaction and size. Be alert for restlessness and decreased levels of consciousness – hypoxemia, CO intoxication, shock, alcohol, drugs and analgesia influence levels of consciousness.

53. EXPOSURE WITH ENVIRONMENTAL CONTROL 22-Oct-24 53 Remove all clothing and jewellery . Keep patient warm Hypothermia can have detrimental effects on the patient. It is important to ensure that the patient is kept warm, especially during first aid cooling periods. Log roll patient, remove wet sheets and examine posterior surfaces for burns and other injuries.

54. CLINICAL ASSESSMENT OF A BURNT CLIENT 22-Oct-24 54 Associated injuries which may be present and result from blunt trauma sustained from falls or jumping in escape attempts or even from explosions etc. State of health as preexisting medical problems may affect the type of management.

55. CLINICAL ASSESSMENT OF A BURNT CLIENT 22-Oct-24 55 Assess the parts of the body involved : Face and neck; the burns of the face and neck are likely to be associated with the inhalation of fumes and lead to damage to the respiratory tree and subsequent oedema. Oedema of these areas may result in airway obstruction. Observe the colour of sputum and the presence of burnt hair in the nasal passages.

56. CLINICAL ASSESSMENT OF A BURNT CLIENT 22-Oct-24 56 Even if the patient’s breathing seems to be normal and the chest sounds are clear, there is danger still that the patient may develop problems in the next 48 hours in spite of his normal breathing. The signs that will show that there is an obstruction due to oedema are respiratory distress and stridor

57. CLINICAL ASSESSMENT OF A BURNT CLIENT 22-Oct-24 57 Extremities (both hands and legs); in these areas be alert for the presence of jewels and these must be removed. Genitalia; the burns of the genitalia have a higher risk of infection. Pay extra attention for these areas. Take the weight of the patient if he is able to stand.

58. CLINICAL ASSESSMENT OF A BURNT CLIENT 22-Oct-24 58 Assessment of a burnt surface area percentage (Body Surface Area – BSA); an approximation is done by dividing the body into multiples of nine (9). For adults known as the “Rule of Nines” explained as follows is used; Head and neck – 9% Front trunk – 18% Back trunk – 18% Upper limbs – 18% (9% each) Lower limbs – 36% (18% each) Perineal area – 1%

59. 22-Oct-24 59

60. CLINICAL ASSESSMENT OF A BURNT CLIENT 22-Oct-24 60 Children have different proportions and hence this rule is not accurate. But the approximations are as follows; Head and neck – 18% Front trunk – 18% Back trunk – 18% Upper limbs – 18% (9% each) Lower limbs – 27% (13.5% each) Perineal area – 1%

61. THE OBJECTIVES OF TREATMENT INCLUDE ; 22-Oct-24 61 To maintain a clear airway and normal fluids and nutritional status To prevent shock To prevent contamination and treatment of infection Provide nutrition To alleviate pain Provide psychological support To prevent contractures and deformities (complications) To maintain maximum rehabilitation of the client

62. INVESTIGATIONS 22-Oct-24 62 1. History taking Find out about the cause of the burns that is, is it chemical, electrical or thermal. Find out about the time of injury so as to determine the amount of fluid loss . 2 . Physical Examination To assess the extent of area burnt and the depth of the burns 3. Collect blood (Blood test) F or full blood in order to determine the haemoglobin count, erythrocyte sedimentation rate (ESR), blood urea nitrogen (BUN) levels.

63. INVESTIGATIONS 22-Oct-24 63 Carboxyhaemoglobin levels (if fire in confined space).  Collect bloods simultaneously for essential base line bloods - FBC/EUC/ LFT./Group & save or hold/Coagulations . 4 . Urinalysis It will reveals myoglobinuria , haemoglominuria as these sip through the glomeruli due to circulatory disturbance. 5 . Radiography (X-ray) M ay be done to determine if there is bone involvement.

64. Medical M anagement 22-Oct-24 64 Topical Antimicrobial Agents; 1.Silver Sulfadiazine Cream ( Silvadine ) Action: prophylaxis and treatment of sepsis Dose: apply 1-2 times daily until the wound is closed Side: skin discoloration, skin necrosis, burning sensation. Nursing implication : avoid eyes and nursing mothers are not recommended

65. Medical Management 22-Oct-24 65 2. Sulfamylon (Paraffin Gauze ) Action: prevent infections in severe burn and has better gramme negative and anaerobic coverage Side effects: skin rash, redness, nausea and vomiting Nursing implication: Ask if the patient has allergies

66. Medical Management 22-Oct-24 66 3.Tetanus Toxoid; Action: It promotes active immunity by inducing production of tetanus . Dose: is 0.5mls intramuscularly start. Side effects: mild fever, joint pain, muscle aches and tiredness.

67. MEDICAL AND SURGICAL TREATMENT OF BURNS 22-Oct-24 67 In burns, the main causes of death are shock and infection. Their prevention and treatment are main objectives of acute care. The shock due to burns occurs during the first 48 hours of injury (resuscitation phase) and from this time until the wound is healed (infection phase), there is the danger of infection.

68. ESCHAROTOMY 22-Oct-24 68

69. 22-Oct-24 69

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72. FLUIDS RESUSCITATION 22-Oct-24 72 INDICATIONS Adults with burns involving more than 15-20% TBSA Children with burns involving more than 10-15%TBSA Patients with electrical injury, the elderly or those with cardiac or pulmonary disease and compromised response to burns injury . The amount of fluids administered depends on how much intravenous fluids per hour is required to maintain a urinary output of 30- 50mls/hr

73. FLUIDS RESUSCITATION 22-Oct-24 73 Successful fluid resuscitation is evidenced by; Stable vital signs P alpable peripheral pulse Adequate urine output Clear sensorium Urinary out put is the most common and most sensitive assessment parameter for cardiac out put and tissue perfusion

74. FLUIDS RESUSCITATION 22-Oct-24 74 If the haemoglobin and haematocrit levels decrease or if the urinary output exceeds 50mls/ hr , the rate of IV fluids administration may be decreased. Generally, a crystalloids (Ringers Lactate) solution is used initially. Colloid is used during the 2 nd day (5% albumin)

75. FLUIDS RESUSCITATION 22-Oct-24 75 Estimate burn area using Wallace’s Rule of Nines. For smaller burns the palmar surface (including fingers) of the patient’s hand (represents 1% TBSA) can be used to calculate the %TBSA burnt. Insert 2 large bore, peripheral IV lines preferably through unburned tissue.

76. PARKLAND FORMULA 22-Oct-24 76 Resuscitation fluid volume for the first 24 hours= 4mls x TBSA(%)X body weight (kg) Example : patient’s weight is 70kg; % of TBSA burn is 80% First 24 hours fluids replacement: 4mls x 70kgx80% TBSA burn= 22,400mls of Lactated Ringer’s solution First 8 hours= 11,200mls or 1400ml/hr Second 16 hours =11,200mls or 700ml/hr

77. PARKLAND FORMULA 22-Oct-24 77 Second 24 hours fluids replacement: 0.5ml colloids x weight in kg x TBSA + 2000ml D5W to run concurrently over the period of 24 hrs 0.5ml x 70kg x 80% =2800ml colloid + 2000ml D5W = 117ml colloid/hr + 84ml D5W/hour

78. GUIDELINES AND FORMULA FOR FLUID REPLACEMENT FOR BURNS 22-Oct-24 78 The Evans Formula According to the Evans’ Formula, partial thickness and full thickness (i.e. 2 nd , 3 rd and 4 th Degree Burns) and 50% body surface area burns irrespecteble of the degree, fluids are calculated as follows; Colloids; (blood plasma and dextran ) = 1ml X Kg body weight X % of area burnt Electrolytes ; (Normal saline and Ringers Lactate) = 1ml X Kg body weight X % of area burnt Glucose (5% in water) = 2000ml for insensible loss

79. GUIDELINES AND FORMULA FOR FLUID REPLACEMENT FOR BURNS 22-Oct-24 79 A maximum of 10,000mls of total fluid may be given in a 24 hour period as follows;  Half is calculated and given in the first 8 hours after burns; the remaining half is spread evenly over the remaining 16 hours. 

80. FLUID VOLUME, COMPOSITION AND RATE OF FLOW 22-Oct-24 80 The volume, composition and rate of fluids are based on the percentage of the body surface area burnt, the weight of the patient, the hourly urinary output, the arterial blood pressure, haematocrit reading and serum electrolyte concentration especially of potassium and sodium. An adult may require as much as 500mls per hour intravenously to maintain a urinary output of 30 – 60mls per hour.

81. FLUID VOLUME, COMPOSITION AND RATE OF FLOW 22-Oct-24 81 Haematocrit concentrations are usually done 4 – 6 hourly. Maintain strict input and output charts while the patient is on fluid replacement therapy. Make sure intravenous fluids are running sufficiently to avoid overloading of the circulatory system. Overloading of the circulatory system may be shown by a urinary output of more than 100mls per within the first 48 hours.

82. EARLY IRRIGATION AND DEBRIDEMENT 22-Oct-24 82 These are performed using normal saline and sterile instruments to remove all loose epidermal skin layers followed by the application of topical antimicrobial agents and sterile dressings. In general, it is safe to leave blisters intact because they permit healing in a sterile environment and offer some protection to the underlying dermis against contamination.

83. TYPES OF DRESSINGS USED FOR BURNS 22-Oct-24 83 Open or Exposure Method This method is usually used to treat burns of the face, neck and perineal area and extensive burns of the trunk. It allows the patient with exudates to dry and form a hard crust in about 3 days which protects the wound. The success of the open or exposure method depends on keeping the environment free of microorganisms which may be very difficult to achieve. 

84. TYPES OF DRESSINGS USED FOR BURNS 22-Oct-24 84 Closed Method This method is used primarily for burns of the feet and hands. The burnt area is highly cleaned and a topical microbial agent thinly applied followed by a dressing. The dressing is usually changed daily. Moist Dressing Moist dressings are usually applied to partial thickness burns to provide pain relief from air exposure

85. TYPES OF DRESSINGS USED FOR BURNS 22-Oct-24 85 Cool water is applied to partial thickness burns dressed with gauze especially in infants who are at high risk of hypothermia. Cold water may cause vasoconstriction and lead to the extension of the depth and surface area of the burn.

86. DEBRIDEMENT 22-Oct-24 86 Removal of eschar to prevent bacterial proliferation under the eschar and to promote wound healing. May be mechanical or surgical Deep partial or full thickness burns wound is cleaned and debrided and topical antimicrobial agents are applied once or twice daily

87. AUTOGRAFTING 22-Oct-24 87 Permanent wound coverage Surgical removal of a thin layer of the client’s own unburned skin which is then applied to the excised burn wound. Monitor for bleeding following the grafting because bleeding beneath an autograft can prevent adherence Immobilize after surgery for 3 -7 days to allow time to adhere and attach to the wound bed Care of the graft site Care of the donor site

88. NURSING CARE OF A PATIENT WITH BURNS 22-Oct-24 88 Environment The burns patient is best nursed or cared for in a burns unit W here aseptic are closely followed. The room should be free from all sources of infection to prevent infection. W ell ventilated to allow clean air in and bad area going outside. Good lighting system for easy observation. Warm environment with heaters to maintain warmth Warmth should be provided especially for patients who have sustained more than 50% burns surface area and infants and young children to prevent hypothermia.

89. ENVIRONMENT 22-Oct-24 89 The major tissue i.e. the skin that prevents excess loss of heat is destroyed. Depending on the part that is burnt, the patient should not lie on the side affected as this may disturb the healing process. Provide a mackintosh and draw sheet to prevent soiling the linen. A bed cradle will also be provided to lift the linen off the wound and prevent contamination.

90. ENVIRONMENT 22-Oct-24 90 In severe burns of the face, the patient may need oxygen therapy and when he presents with stridor prepare for tracheostomy trolley. The linen that the patient is using should be where possible surgically clean. The room should be kept humidified to prevent drying of the mucous membranes in order to prevent hypothermia having known that the skin that prevents excess loss of heat is destroyed.

91. OBSERVATIONS 22-Oct-24 91 The first 72 hours is the most critical period for a burnt patient. Establish the baseline data of vital signs from which you will make comparisons with subsequent findings of the vital signs. Vital signs are important to monitor because they give a picture of how the body is functioning like early signs of infection e.g. increased temperature, hypovolaemic shock evidenced by low blood pressure and weak thready rapid pulse.

92. OBSERVATIONS 22-Oct-24 92 Observe for signs of respiratory distress such as labored breathing or stridor and report appropriately or even commence the patient on oxygen therapy. Monitor the input and out to ascertain the function of the kidneys and also monitor the hydration status. Monitor the wound for signs of infection such as pus formation and for signs of healing such as granulation tissue. Weigh the patient daily if able to.

93. PAIN MANAGEMENT 22-Oct-24 93 Administer morphine sulfate as prescribed preferably by intravenous . Avoid intramuscular(IM) or subcutaneous (SC) routes because absorption through the soft tissue is unreliable when hypovolaemia and large fluid shifts are occurring. Avoid administering medication by the oral route because of the possibility of GIT dysfunction Medicate client prior to painful procedures

94. PAIN MANAGEMENT 22-Oct-24 94 Assess the patient for pain periodically. Reassure the patient to reduce anxiety and give him the prescribed analgesics to relieve pain and reduce anxiety since pain causes shock. Use bed cradle to keep linen off the wounds. Teach the patient relaxation and breathing exercises to help him cope with pain. Change his position if possible supporting the extremities with pillows if they are not involved.

95. NUTRITION AND FLUIDS 22-Oct-24 95 Essential to promote wound healing and preventing infection. Maintain NPO status until bowel sounds are heard; then advance to clear liquids as prescribed. Nutrition may be provided via enteral tube feeding or total parenteral feeding.

96. NUTRITION AND FLUIDS 22-Oct-24 96 In addition to fluid therapy nutrition plays an important role in the recovery of a burnt patient. Ringers lactate is the fluid of choice for the replacement of fluids and electrolytes. For patients with severe burns, oral fluids are restricted for 24 – 48 hours because the initial hypovolaemia produces depletion of gastric motility leading to sluggish peristalsis.

97. NUTRITION AND FLUIDS 22-Oct-24 97 A nasogastric tube is inserted in this case for intermittent suctioning and oral intake introduced as the patient’s condition improves, signs of bowel movement are evident and he can tolerate oral intake At this time fluid foods are introduced slowly. A high calorie, high protein and high vitamin diet is recommended to provide essential nutrients for tissue repair and production of antibodies and blood cells

98. NUTRITION AND FLUIDS 22-Oct-24 98 Vitamin C is essential in tissue repair. Keep a record of calorie intake and supplement in between with protein, high calorie snacks.

99. EMOTIONAL SUPPORT 22-Oct-24 99 Following a severe burn the patient and his family experience emotional disturbances. Long periods of the patient being alone should be avoided if possible. Talk to the patient and not about him while performing procedures or assessing wound healing. Listen to the patient’s feelings.

100. EMOTIONAL SUPPORT 22-Oct-24 100 It is important to give the patient honest and realistic explanations of the prognosis. Arrange for the patient to talk to other patients with similar injuries and who are progressing satisfactorily well when the condition allows. Do not give the patient false hopes.

101. WOUND CARE 22-Oct-24 101 Aseptic technique should be strictly observed. Daily dressing changes while the wounds are exposed, the surgeon can properly assess the continued demarcation and healing of the injury.

102. WOUND CARE 22-Oct-24 102 Analgesia for dressing change is necessary for major burns. Valium 0.1mg per kg intramuscularly and ketamine 0.5mg per kg intramuscularly is a regimen that is usually well tolerated. Daily dressing changes while the wounds are exposed, the surgeon can properly assess the continued demarcation and healing of the injury.

103. CONTROL OF INFECTION 22-Oct-24 103 Isolate the patient to prevent infection Nursing personnel with infection should not attend to the patient e.g. those with sore throat Restrict the number of visitors to only close relatives and explain their role regarding protection of the patient from infection e.g. wearing protective gowns when appropriate

104. CONTROL OF INFECTION 22-Oct-24 104 Be alert for reservoirs of infection and sources of contamination in the environment Wash hands before and after attending or contact with antibacterial agents Use sterile gloves for all care involving patient contact Assess the wound daily for local signs of infection i.e. swelling, redness around wound edges also and purulent discharge, dislodgement and loss of grafts

105. CONTROL OF INFECTION 22-Oct-24 105 Promote optimal hygiene for the patient including cleaning of the burn wound. Pay particular attention to oral care Shave the area near the burn wound area Pay particular attention and give special care of intravenous and urinary catheter sites

106. POSITION AND EXERCISES 22-Oct-24 106 Turn the patient every 2 – 3 hours to prevent respiratory failure and secretion stasis. If the limbs are swollen, they must be elevated on pillows during the initial stage. Pay frequent attention to body alignment, flexion, contraction, outward rotation of thighs and foot drop should be prevented.

107. POSITION AND EXERCISES 22-Oct-24 107 The physiotherapist if available usually supervises exercises. Range of motion exercises are encouraged especially during soaking and dressing of wounds.  

108. COMPLICATIONS OF BURNS 22-Oct-24 108 IMMEDIATE Airway obstruction Hypovolaemic shock Hypothermia Electrolyte imbalance pain

109. COMPLICATIONS OF BURNS 22-Oct-24 109 INTERMEDIATE Burn wound sepsis Adult respiratory distress syndrome (ARDS) Sepsis Renal failure Stress ulcers

110. COMPLICATIONS OF BURNS 22-Oct-24 110 Scarring Cosmetic deformity/contractures Marjolin’s ulcer

111. 22-Oct-24 111

112. 22-Oct-24 112 THE END!!!!