Nursing management of burn patient chapter bsc nursing 4 th semester

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1. BURN PRESENTED BY: MS NANDINI PRESENTED TO : BSC NURSING 4TH SEMESTER

2. CONTENT Assessment of Burn, Fluid and electrolyte loss Introduction Etiology Classification Pathophysiology Clinical manifestations Management Plastic surgery Congential Deformities

3. Assessment plays important role in initiating the treatment. It includes following: Assessment: Assess Airway, Breathing, circulation, disability and exposure and need for fluid resuscitation. Establish the cause. Assess for associated injury which occurs when victim attempts to escape from the fire. History Taking: Allergic history, past illnesses, enquire about environment related to injury, date and time of burn injury , contact duration, did the flame burn occurs in a enclosed space. Assessment of Burn, Fluid and electrolyte loss

4. Assessing burn severity The severity of burn is generally defined by the percentage total body surface area (%TBSA) burned and burn depth. Accurate %TBSA estimation is a critical step in guiding appropriate management as it determines the initial fluid volume requirements for resuscitation and whether patient needs to be consider for transfer to specialist care. Burns are classified according to depth of injury and as %TBSA. Percentage of burns is calculated by Wallace Rules of Nine chart and palm method.

5. Wallace Rule of Nine The chart divides the body into sections that represents the nine percent of the body surface area.

6. Palm Method When burn is scattered on the body palm method is used to assess the total burn surface area the palmer surface of patient hand.

7. According to depth of burn injuries 1st degree burn 2nd degree burn 3rd Degree burn 4th degree burn

8. According to degree/Depth of burn

9. Burn is a type of injury to skin which can be caused by heat, electricity, chemicals and radiations. Burns can be defined as any injury that results from direct contact or exposure to any thermal, chemical, electrical or radiation source . Burns

10. Thermal Burns Chemical Burns Electrical burns Radiation burns Inhalation burns Etiology of burn

11. Classification of Burn According to burn depth: Skin layer involvement According to burn extent : %TBSA

12. Pathophysiology of Burn Depending upon the extent, burn causes local or systemic effects . Local effect :Local pathophysiological changes consist in the formation o f three zones. Zone of coagulation(Inner) Zone of Stasis(Middle) Zone of hyperemia (Outer)

13. The release of cytokines and other inflammatory mediators at the site of injury has a systemic effect once the burn reaches 30% of total body surface area. Cardiovascular changes Respiratory changes Metabolic changes Immunological changes Thermoregulatory changes Systemic Responses of burn

14. Clinical Manifestations

15. Splotchy skin White Leathery Charred insensate eschar

16. Diagnostic evaluation of Burn History Taking Physical Examination Lab Test Assessment of burn severity Minor : Adults <10% TBSA, Children <5% TBSA Moderate :Adults 10-20% TBSA, Children 5-10% TBSA Severe :Adults >20% TBSA, Children >10% TBSA

17. Management of Burn Burn care is categorized into three phases of care Immediate/ Resuscitative phase Intermediate phase Rehabilitative phase

18. Immediate /Resusciative phase Medical Management Treat minor burns Monitor airway and breathing Reduce pain Prevent aspiration Minimize pain and anxiety Prevent hypovolemic shock

19. Calculation of fluids Ringer lactate =4ml X Kg body weight X %TBSA

20. 2. Acute/ Intermediate Phase Medical Management Prevent infection Minimize pain Provide wound care Maximise functions Provide psychological support Provide nutritional support : Curreri formula = 25 X body weight (kg) + 40 X % TBSA burned.

21. 3.Rehabilitation Phase Minimizing functional loss Provide psychological support Prevention and treatment of scars Change in appearance and functions

22. Complications of Burn Sepsis Acute respiratory failure Acute renal failure Psychological trauma Compartment syndrome Curling ulcers

23. Plastic surgery Plastic surgery is a surgical specialty involved with both the improvement in a person's appearance and the reconstruction of facial and body tissue defects due to illness, burns, trauma, or birth disorders. Plastic surgery restores and improves function, as well as appearance. It is divided into two types: Reconstructive surgeries Cosmetic Surgeries

24. Reconstructive surgeries Reconstructive surgery repairs parts of your body affected by defects you were born with, defects that have developed because of disease, or defects caused by an injury. Aims of reconstructive surgeries To improve functions To give normal appearance to a part of the patient's body that has been damaged.

25. Indications Closure of wounds. Removal of skin tumors Corrections of deformities Repair of cosmetics defects Repair of soft tissues injuries or burns To remove debris following severe infections and to repair the surrounding area.

26. Techniques of Reconstructive Surgery Skin Grafting Tissue expansion Flap Surgery

27. Skin Grafting It is a technique in which a healthy section of skin from one area of body is separated from its own blood supply and transferred as free tissues to a distant site. The piece of skin, i.e. moved is entirely disconnected and requires blood vessels to grow into it when placed in the recipient site.

28. Types of Skin Grafting Autograft: An autograft is tissues, obtained from the patient's own skin. Allograft : An allograft is tissues obtained from a donor of the same species. These grafts are also called homograft. Isograft : It is the tissue obtained from an identical twin. Xenograft : It is tissue taken from another species.

29. Graft Application The skin graft is taken from the donor or host site and applied to the affected site, called the recipient site or graft bed . For a graft to survive and be effective, certain conditions must fulfill: Ensure adequate blood supply at the recipient site. The area must be free from infection. 3. After grafting is done it may be left exposed or covered with a light dressing depending upon the area.

30. Tissue Expansion Tissue expansion is a procedure that enables the body to grow extra skin by stretching surrounding tissues. An expander (a ballon like device) is inserted under the skin near the area to be repaired, and is then gradually filled with salt, water, causing the skin to stretch and grow. The time involvement depends upon the individual case and size of the area to be repaired.

31. Tissue Expansion

32. Flap Surgery It is a type of surgery in which any type of tissue is lifted from a donor site and moved to a recipient site with an intact blood supply. This is distinct from a graft, which does not have an intact blood supply and therefore relies on growth of new blood vessels.

33. Nursing Management Maintain airway Relieve pain and discomfort Maintain adequate nutrition Enhancing communication Reassure and provide psychological support Promoting family coping

34. Cosmetic Surgeries Cosmetic surgery is the type of plastic surgery that aims to improve patient's appearance. The goal of cosmetic surgery is to improve a person's appearance by changing the way he/she looks. It can be done on any part of face or body. There are different types of cosmetic surgeries. Some of them are listed below :

35. Congenital deformities Physical abnormalities that are present at or before birth are called congenital. These deformities may affect the facial structure such as with cleft lip, or may be skeletal, such as with clubfeet or spina bifida.

36. Congenital deformities that are treated with reconstructive surgeries are : Cleft lip and palate: Using local flaps and grafts surgeons can repair the incompletely fused area of lip and palate.

37. 2.Small jaw and breathing problems: Most children tend to have smaller mandible compared to maxilla. Mandibular distraction is done in these cases. 3. Prominent ears, constricted ears: Reconstructive surgeries are used to correct all manner of ear defects.Otoplasty is the technique.

38. 4.Hypospadias: It is a birth defect in which the opening of urethra is on underside rather than on the end of penis. Soft tissue reconstruction is used to correct the defects. 5. Craniofacial Conditions: Reconstructive surgeries are used to correct a wide range of cranial and facial deformities such as craniosynostosis. 6.Congenital breast malformations: It occurs when either the breast, chest, or both develop abnormally leading to asymmetry compared to other side.

39. Gender Reassignment It is a surgical procedure by which a transgender person's physical appearance and function of their existing sexual characteristics are changed to resemble those socially associated with their identified gender Feminization Changes (Male t o female surgeries) Masculinization surgeries(Female to male surgeries) Types of Gender Reassignment

40. Management Preoperative care Patient must have ideal weight and BMI should fall in 20-25. Patient with diabetes, asthma and HIV can experience complications with future therapy and pharmacologic management as it includes hormonal therapy throughout and after the surgery.

41. Post Operative Care Male to female surgery care The patient has to stay in hospital for 10-12 days. The patient can perform light work min 4-6 weeks. Stretching of vaginal walls is done according to surgeon's instructions. Douching should be done according to physician order. Analgesics can be used to reduce pain.

42. Female to male surgery The patient has to stay in hospital for 6-8 days . Small work can be resumed in two weeks. There will be less to moderate pain after surgery for few weeks painkillers can be taken according to physician order. Patient should be informed prior to surgery about the changes that are going to occur after surgery. Sutures are removed in about a week. Psychological support is most important in both surgeries .

43. Injuries and cosmetic purposes Trauma to the body with loss of form and function requires plastic surgical intervention include following injuries. Road traffic accident Firearm injuries Machine injuries Crush Injury Knife Injury Assault injury Dog bites

44. 8.Fall injuries 9. Sports Injuries 10. Blast Injury Plastic and reconstructive surgery plays a significant role in reconstruction of head and neck, limbs, trunk and perineum when there is tissue loss. General abrasions are often treated topically with ointments or special dressings.

45. Deeper lacerations typically require the repair of nerves, vessels, muscles or tendons. When there is large amount of skin loss, skin grafts or reconstruction may be necessary.

46. Legal and ethical aspects in plastic Suregery Ethics define what is acceptable behaviour of plastic surgeon and his/her team. Following are the legal and ethical aspects of plastic surgery: Surgical team is cosmetic surgery should follow the principles of beneficiaries, non-maleficence autonomy and justice. Beneficence Non-maleficence

47. Autonomy Justice 2. Instead of considering it a business in a today's consumer oriented societies, where attention to body image has become very popular, surgeon should always accept and follow moral principles. 3. Patient who choose cosmetic surgery are healthy individuals, so consultations may be required before any plastic surgery.

48. 4. As transgender surgery performed on minors may result in catastrophic outcomes such as post trauma stress disorder and suicide. Surgeon should not perform surgery on children until they are old enough to give informed consent and to assign such infants in the gender to which they will probably best adjust. 5. Standard of care -surgery can be difficult to obtain due to financial barriers, insurance coverage, and lack pf providers. Plastic surgeon must ensure adequate resources before conducting cosmetic surgery.

49. 6. Informed consent must be taken before conducting plastic surgeries. 7. Plastic surgeon should provide trustworthy services in the quality of care and should keep the patient in reality is very important. 8. Quality of life and physical health : Patients may experience changes in their physical health and quality of life, the side effects of surgery and management should be well informed before choosing too undergo cosmetic surgery.

50. Special Therapies Laser Assisted Drug Delivery LADD is an advanced drug delivery i.e. used to improve the efficacy of local skin treatments . Here laser pre treatment is followed by topical drug application by doing so drug reaches to target skin in greater amount and thus improve the efficacy of numerous topical treatments.

51. Devices for LAD CO2 Er: YAG Indications LAD is primarily used in conjunction with photodynamic therapy especially for patients with severe sun damage or recurring solar keratosis. LAD is used in conjunction with corticosteroid treatment of various forms of scars.

52. 3.It seems useful for actinic cheilitis, non-melanoma, skin cancer, rhytides, photoaging, onychomycosis, warts, hemangiomas and vitiligo. 4. It is not an FDA - approved treatment and other approved first-line therapies are often pursued before laser assisted drug delivery is attempted.

53. Working Initially ,pre-treatment with a fractional ablative laser device is conducted. The laser generates microscopic channels in the skin, penetrating its natural barrier and providing direct access to underlying akin layers. With the subsequent application of ma topical drug the laser channels facilitate drug delivery providing a faster and greater drug deposition in the skin.

54. The increased drug deposition intensifies the treatment often resulting in greater efficacy when compared to conventional topical treatments conducted on intact skin. Complications Patient may experience increased pain and inflammation during and after treatment. Increased risk of infection. Hypersensitivity reactions.

55. Vaccum Assisted Dressing It is also known as negative pressure wound therapy (NPWT) refers to wound dressing systems that continuously or intermittently apply sub atmospheric pressure to the system, which provides a positive pressure to surface a wound. Vaccum therapy is an efficient alternative to conservative wound care.

56. Purposes To accelerate the formation of granulation tissues. To improve perfusion through the removal of excess interstitial fluid. to reduce bacterial colonization. To enhance epithelial migration.

57. Indications Acute surgical wounds Pressure ulcers Diabetic wounds Skin Grafts Open abdominal wounds Partial thickness burns Necrotizing fasciitis

58. Contraindications Eschar Presence of necrotic and fibrotic tissue Malignant wounds Localised ischemia Do not place dressings in direct contact with exposed blood vessels, anastomotic sites, organs. Do not place therapy in proximity to vagus nerve.

59. Working Vaccum dressing removes excess fluid that interfers with cellular growth and proliferations. It improves blood supply to wound bed. Decrease chances of bacterial growth on wound surface. Decrease localize edema. Enhance formulation of granulation tissue. Advantages Savings with respect to the faster healing rates the reduced dressing changes as well as hospital stay and the care requirements and the reduction of subsequent illnesses compensate for the higher initial cost.

60. Laser Laser resurfacing i s a facial rejuvenation procedure that uses a laser to improve the skin's appearance or treat minor flaws. Types of Laser used in Laser assisted Drug Delivery Fully ablative lasers : Mainly CO2 and Er-YAG. These perform full, not fractional ablation, of the epidermis, thus enabling the drug to reach the dermis.

61. Ablative fractional lasers: These are a fractional version of the ablative lasers. They generate microscopic ablation channels through which the drugs reach the dermis. Non-Ablative Fractional Lasers: Such as Er.Glass 1550nm, which generate microscopic columns of coagulated tissue without ablating the epidermis. Non-Ablative dermal remodelling: This subtype includes all those lasers with chromophores other than water, which deposit energy in the area of the chromophore, generally in the dermis Eg with lasers used to treat vascular anomalies, such as the 585/595nm pulsed dye laser or Nd:YAG(1064nm)gr1

62. Users Laser resurfacing can decrease the appearance of fine lines in the face. It can also treat loss of skin tone and improve skin complexion of persons who have scars or sun damage. Side effects Ablative laser Acne Infection Changes in skin colour Redness, swelling and itching on treated skin

63. Liposuction It is a surgical procedure that uses a suction technique to remove fat from specific areas of the body in order to shape these areas. It aims to improve the body's contours and proportion by removing localised and disproportional deposits of fat. Indications It is done when fat from body is not reduced by diet or exercise. Breast Reduction Post ablative surgery Lipomas

64. Technique Suction assisted Lipectomy Ultrasonic Assisted Lipoplasty Mechanical Assisted Lipoplasty Laser Assisted Liposuction Complications Thermal burn Asymmetric skin Infection Delayed healing Unacceptable scarring Damage to deeper structures

65. Skin Health Rejuvenation It is done by the following: Natural peels : Natural peels are organic peels which can be made at home. These peels are beneficial to improve the skin texture, reduce acne and brighten skin naturally. Chemical peels: Chemical peels help to treat acne, scars, or wrinkles. Here, Chemical solutions containing phenol, trichloroacetic and alphahydroxy acids are applied to the skin in order to remove the outer layer of dermis.These are safe for both dark and light skin types.

66. Botux: Aims to improve appearance by treating wrinkles and facial creases. It acts by blocking the signal from nerves to the muscles that are injected. The injected muscles can no longer contract, or tighten, as forcefully as before and this leads to a controlled relaxation of the muscles. Lasers: Also known as facial laser resurfacing or laser skin treatment can help to reduce fine lines, wrinkles and abnormal pigmentation such as sunspots. Dermal Fillers: These are the collagen derived from humans and are injected into the skin and reduce the appearance of wrinkles for 2-4 months.

67. Derma Fillers These are also known as soft tissue fillers, injectable implants or wrinkle fillers, are medical device implants for use in helping to create a smoother and or fuller appearance in the face. Patients may need more than one injections to get the desirable smoothing or filling effect. Successful results will depend upon the health of the skin, skill of doctor and amount and type of filler used.

68. Uses Derma fillers are useful for the following: Correction of moderate to severe facial wrinkles and skin folds. Restoration and correction of signs of facial fat loss in people with HIV. Lip and cheek augmentation in patients over the age of 21, the correction of contour deficiencies such as wrinkles and acne scars. Hand augmentation which increases the volume of the back of the hands.

69. Cheek Augmentation Hand augmentation