The document is about burns that occur in both adults and children

It's taking about burns, it's a medical document

1. BURNS
TERESA NYANCHAMA

3. Introduction

4. Anatomy
•Adult skin surface 1.5-2.0 m
2
(0.2-0.3 in
newborns); largest organ
•Skin thickness 1-2 mm; peaks age 30-40; M> F
•Functions include:
–protection from external environment
–maintenance of fluid/electrolyte homeostasis
–Thermoregulation
–immunologic function
–sensation
–Metabolic organ (i.e., Vit D synthesis)

5. Introduction

Burns - traumatic injury caused by thermal,
electrical, chemical, or radioactive agents.

50% to 60% of fire deaths are 2
0
to inhalation
injury.

Most accidents occur at home.

Flame injury - leading cause of accidents for
adults.

Scalding - leading cause of accidents for
children.

6. 
The very young and the elderly are at greatest
risk for burn injuries.

The skin and the mucosa of the upper airways
are sites of tissue destruction.

Tissue destruction results from –
Coagulation of cellular contents
Protein denaturation
Ionization of cellular contents

7. 
Burns that do not exceed 20% TBSA produce a
primarily local response.

Burns that exceed 20% TBSA –
Considered major burn injuries.
May produce both a local and a systemic
response.

8. Pathophysiology of Burn Injury

The extent of a burn injury is determined by –
Degree of heat
Duration of exposure of the tissue to the
source

The mechanism of injury can provide a useful
guide to the possible severity;
Fat scalds produce a deeper injury than
water scalds due to the density.

9. 
The three recognized zones of burn injury –
Zone of coagulation –
Irreversible coagulation of tissue protein
has occurred.
Area unsalvageable.
Zone of stasis –
Xrized by decreased tissue perfusion.
Initial burns mgt intended to improve
blood flow to this area.

10. Improved blood flow will prevent
extension of the injury.
Zone of hyperemia –
Has increased perfusion
Not at risk unless there are added factors
(infection).

12. 
Physiologic rxn to a burn is similar to the
inflammatory process:
Adjacent intact vessels dilate
Platelets and leukocytes begin to adhere to
the vascular endothelium
Increased capillary permeability produces
wound edema.
Influx of PMN leukocytes and monocytes
occurs at the injury site.

13. TYPES OF BURNS
•Thermal
exposure to flame or a hot object
•Chemical
exposure to acid, alkali or organic substances
•Electrical
result from the conversion of electrical energy into heat. Extent of injury
depends on the type of current, the pathway of flow, local tissue
resistance, and duration of contact
•Radiation
result from radiant energy being transferred to the body resulting in
production of cellular toxins

14. Chemical Burn

15. Electrical Burn

16. Determinants of severity of burns
1.Age of pts.
2.Depth of burns.
3.Amount of surface area of the body burned.
4.Presence of inhalation injury.
5.Presence of other injuries.
6.Location of injury[face, perineum, hands, or
feets].
7.Presence of a past medical history.

17. Classification of Burns

19. First-degree burns (superficial
partial thickness)
•epidermis
•symptoms
–redness
–pain
–dry skin
–no blisters
–no scars
•example – mild sunburn.
•Are erythematous, the epidermis is intact.

20. Superficial Partial thickness
burns
Sunburn is a very superficial burn.
Expect blistering and peeling in a few days.
Maintain hydration orally.
Heals in 3-6 days- generally no scaring
Topical creams provide relief.
No need for antibiotics

21. Second-degree burns ( deep partial
thickness)
•epidermis and part of dermis
•symptoms
•blisters
•deep redness
•wet and shiny
•very painful to touch
•no scars
•example – contact with hot objects or flame

22. DEEP (SECOND DEGREE)
*Involves the epidermis and deep layer of the
dermis
Fluid-filled vesicles –red, shiny, wet, severe pain
Hospitalization required if over 25% of body
surface involved
i.e. tar burn, flame

23. Deeper partial thickness(second
degree)
Blisters are typical of partial thickness burns.
Don’t be in a hurry to break the blisters.
Heals in 14-21 days
Blisters provide biologic dressing and comfort.
Once blisters break, red raw surface will be very painful.
Some scarring and depigmentation contractures
Infection may convert it to full thickness.

24. Third-degree burns
•epidermis and entire dermis
•symptoms
•dry and leathery skin
•swelling
•black, white, brown or yellow skin
•lack of pain
•example – electrical or chemical sources, flames

25. Fourth-degree burns
•epidermis, dermis and underlying tissue
•symptoms
•black skin
•no sensation
•example - flames

26. FULL THICKNESS (THIRD/FOURTH
DEGREE)
•Destruction of all skin layers
•Requires immediate hospitalization
•Dry, waxy white, leathery, or hard skin, no
pain
•Exposure to flames, electricity or chemicals
can cause 3
rd
degree burns

27. Full thickness burn
Yellow, “leathery” appearance; or charred
Often have no sensation (nerve endings destroyed)
Outer edges might be partial thickness.
Initial management same as partial thickness.
Later will need skin grafts.

28. Zones of Burn Wounds
Zone of Coagulation
devitalized, necrotic, white, no circulation
Zone of Stasis ‘circulation sluggish’
may covert to full thickness, mottled red
Zone of Hyperemia
outer rim, good blood flow, red

29. Inhalation Injury
•Heat dispersed in upper airways leads to edema
•Cooled smoke and toxins carried distally
•Increased blood flow to bronchial arteries causes
edema
•Increased lung neutrophils – mediators of lung
damage – release proteases and oxygen free
radicals (ROS)
•Exudate in upper airways – formation of fibrin casts

30. Stages of Inhalation Injury
•Stage 1 – acute pulmonary insufficiency
–Signs of pulmonary failure at presentation
•Stage 2 – 72-96 hrs after presentation (ARDS
picture)
– extravasation of water
–Hypoxemia
–Lobar infiltrates
•Stage 3 – bronchopneumonia
–Early – Staph pneumonia (frequently PCN resistant)
–Late - Pseudomonas

31. Inhalation Injury
Bronchoscopy:
- erythema
- intraglottic soot
- ulceration

32. Indication of pulmonary damage
due to inhalational burns
1.History indicating that the burn occurred in an enclosed
area
2.Burns of the face or neck
3.Singed nasal hair
4.Hoarseness, voice change, dry cough, stridor, sooty
sputum
5.Bloody sputum
6.Labored breathing or tachypnea
7.Erythema and blistering of the oral or pharyngeal mucosa

33. Factors Influencing Wound Depth
•Temperature and duration
•Thickness of skin (thin on eyelids, thick on back)
•Age (children and elderly have proportionally
thinner skin in comparison to adults)
•Vascularity
•Agent – oil vs water; acidic vs alkalotic
•Time to definitive care

34. Calculation of Burned Body Surface Area
•Calculation of Burned Body
Surface Area

35. TOTAL BODY SURFACE AREA (TBSA)TOTAL BODY SURFACE AREA (TBSA)
•Superficial burns are not involved in the
calculation
•Lund and Browder Chart is the most accurate
because it adjusts for age.
•Rule of nines divides the body – adequate for
initial assessment for adult burns.
•Palmer method-used pt with scattered burns,
size of pts hand including fingers equals to 1%

36. Lund Browder Chart used for determining BSA
Evans, 18.1, 2007)

37. RULES OF NINES
•Head & Neck = 9%
•Each upper extremity (Arms) = 9%
•Each lower extremity (Legs) = 18%
•Anterior trunk= 18%
•Posterior trunk = 18%
•Genitalia (perineum) = 1%

39. Area of Burns - Pediatric

40. Alternation of body systems due to
burns
Cardiovascular
•Hypovolemia[decre perfussion and
O2 delivery].
•Shift of fluid (greatest first 24-36
hours).
•Elevated hematocrit.
•Thrombocytopenia.
•Prolonged clotting and prothrombin
times
•Response catecholamine release.
•Edema.
•Cardiac depression
Fluids and electrolytes
•Edema-acts as tourniquet-
circumferential- compartment
syndrome[decompression-
escharotomy; fasciotomy].
•Results to:-
Hyperkalemia.
Hyponatremia[1st wk of acute
phase, fluid shift{I.S>V.S}.
Hypovolemia
Metabolic acidosis
Hemo-concentration[DeH2O].

41. Alternation of body systems due to
burns
Pulmonary Alteration
•Loss of ciliary action.
•Hypersecretion(triger bi infla).
•Severe mucosal edema
•Bronchospasm
•Reduced alveolar surfactant.
•Detoriated by bronch- and
chest contristriction.
Kidney Alteration
•Hemoglobinuria.
•Myoglobinuria.
•Acute tubular necrosis.
•25-50% of severe burns
patients develop acute
kidney injury.
Question:-Question:-
•AKI occur due to?AKI occur due to?

42. Alternation of body systems due to
burns
Immunologic alternations.
•Skin damage.
Question?Question?
Explain components of the skin Explain components of the skin
acting as first defense line?acting as first defense line?
Destruction of leukocyte and
endothelial cell dysfunction by
release of cytokines
Descreased the “killing
power” of neutrophils.
Thermoregulatory alterations
•Hypothermia-loss of skin

43. Alternation of body systems due to
burns
Gastrointestinal alterations.
•Paralytic ileus( manifested
by decreased peristalsis and
Bowel sounds).
•Curlings ulcer(gastric or
duodenal erosion).
•Translocation of bacteria
(due to destruction gastric
mucosal barriers).
Question:-Question:-
•Explain the effects of burns to Explain the effects of burns to
any four body sytems?any four body sytems?
Curling ulcersCurling ulcers
•Acute ulcerative gastro duodenal
disease
•Occur within 24 hours after burn
•Due to reduced GI blood flow and
mucosal damage
•Treat clients with H2 blockers,
mucoprotectants, and early enteral
nutrition
•Watch for sudden drop in hemoglobin

44. Circumferential burn
Limb is burned all the way around.
Soft tissues under the skin always swell with burns
(due to capillary leak of fluids in first day or so).
There is a loss of skin expansion due to the loss of
turgor/elasticity in burned tissue
Pressure inside limb gradually increases.
Eventually, pressure inside limb exceeds arterial pressure.
This requires escharotomy to relieve the pressure.

45. Compartment syndrome
•Is a complication of burns.
•As edema increases in circumferential burns,
pressure on small blood vessels and nerves in
distal extremities causes an obstruction of
blood flow and consequent ischemia.
•Escharotomy may be needed in this case

46. Escharotomy - indications
Circulation to distal limb is in danger due to swelling.
Progressive loss of sensation / motion in hand / foot.
Progressive loss of pulses in the distal extremity by
palpation or doppler.
In circumferential chest burn, patient might not be able to
expand his chest enough to ventilate, and
might need escharotomy of the skin of the chest.

47. Escharotomy - complications
COMPLICATIONS
Bleeding: might require ligation of superficial veins
Injury to other structures: arteries, nerves, tendons
NOT every circumferential burn requires escharotomy.
In fact, most DO NOT need escharotomy.
Repeatedly assess neuro-vascular status of the limb.
Those that lose circulation and sensation need
escharotomy.

48. Escharotomy
Eschar = burned skin
Escharotomy = cut burned skin to relieve
underlying pressure
Similar to bivalving a tight cast.
Cut along inside and outside of limb from
good skin to good skin
Knife can be used, or cautery.
Use local or no anesthesia.
(Full-thickness burn should have no
sensation, but underlying tissues do!)

49. Escharotomy of forearm
Incise along medial
and/or lateral surfaces.
Avoid bony prominences.
Avoid tendons, nerves,
major vessels.

50. Escharotomy
Patient had escharotomy of
both legs.
Incisions will heal.
These large burns are often
treated by the “open” technique,
that is, without dressings.

51. Electrical burn
Outer skin might
not appear too bad.
But heat was conducted
along the bone.
Causes the most damage.
Burns from inside out.
Usually requires fasciotomy

52. Fasciotomy
Fascia = thick white covering of muscles.
Fasciotomy = fascia is incised (and often overlying skin)
Skin and fascia split open due to underlying swelling.
Blood flow to distal limb is improved.
Muscle can be inspected for viability.

53. Phosphorus
Particles of phosphorus must be
removed from under the skin.
Pick them off with forceps.
Must apply wet dressing to prevent
re-igniting.

54. PHASES OF BURN INJURIES
•Emergent/ resuscitative phase (24-48 hrsEmergent/ resuscitative phase (24-48 hrs)-from
onset of injury to completion of fluid
resuscitation.
•AcuteAcute/intermediate/intermediate-from begining of diuresis
to near completion of wound closure.(48-72
hrs post burn injury).
•RehabilitativeRehabilitative-from major wound closure to
returm to individual optimal level of physical
and psychosocial adjustment.

55. EMERGENT PHASE
*Immediate problem is fluid loss, edema, reduced
blood flow (fluid and electrolyte shifts)
•Goals:
1. secure airway breathing
2. support circulation by fluid replacement
3. keep the client comfortable with analgesics
4. prevent infection through wound care
5. maintain body temperature
6. provide emotional support

56. Priorities in emergent phase
•Primary survel: A,B,C,D,E.
•Prevention of shock.
•Prevention of respitaroty distress.
•Detection and Rx on concomitant injuries.
•Wound assessment and initial care.

57. Resuscitation Guidelines

58. COMMON FLUIDS
•Protenate or 5% albumin in isotonic saline
(1/2 given in first 8 hr; ½ given in next 16 hr)
•LR (Lactate Ringer) without dextrose (1/2
given in first 8 hr; ½ given in next 16 hr)
•Crystalloid (hypertonic saline) adjust to
maintain urine output at 30 mL/hr
•Crystalloid only (lactated ringers)

59. NURSING DIAGNOSIS IN THE EMERGENT PHASE
•Impaired gases exchangeR/T carbon monoxide poisoning, smok
inhalation.
•Ineffective airway clearance R/T edema and effects of smoke
inhalation.
•Deficient FV R/T increa. Capillary permeability
•Hypothermia R/T loss of skin microcirculation.
•Acute pain R/T tissue & nerve injury.
•Anxiety R/T fear and emotional impact of burn injury.
•Decreased CO R/T shift of fluid
•Ineffective Tissue perfusion R/T shift of fliuds
•Ineffective breathing pattern R/T pain associate with
inhalational and circumferential burns of the chest

60. Collaborative problems
•Acute respiratory failure.
•Distributive shock.
•AKI
•Compartment syndrome.
•Paralytic ileus.
•Curling’s ulcer.
Question?Question?
State atleast three priority nursing intervention for State atleast three priority nursing intervention for
prevention of each of the above complication?prevention of each of the above complication?

61. ACUTE PHASE OF BURN INJURY
•Lasts until wound closure is complete
•Care is directed toward continued assessment and maintenance of the
cardiovascular and respiratory system, F/E balance, GI and Kidney
functions.
•Pneumonia is a concern which can result in respiratory failure
requiring mechanical ventilation
•Infection (Topical antibiotics – Silvadene)
•Tetanus toxoid
•Weight daily without dressings or splints and compare to pre-burn
weight
•A 2% loss of body weight indicates a mild deficit
•A 10% or greater weight loss requires modification of calorie intake
•Monitor for signs of infection

62. LOCAL AND SYSTEMIC SIGNS OF INFECTION-
GRAM NEGATIVE BACTERIA
•Pseudomonas, Proteus
•May led to septic shock
•Conversion of a partial-thickness injury to a full-thickness injury
•Ulceration of health skin at the burn site
•Erythematous, nodular lesions in uninvolved skin
•Excessive burn wound drainage
•Odor
•Sloughing of grafts
•Altered level of consciousness
•Changes in vital signs
•Oliguria
•GI dysfunction such as diarrhea, vomiting
•Metabolic acidosis

63. LAB VALUES
•Na – hyponatremia or Hypernatremia
•K – Hyperkalemia or Hypokalemia
•WBC – 10,000-20,000

64. NURSING DIAGOSIS IN THE ACUTE PHASE
•Impaired skin integrity
•Risk for infection
•Imbalanced nutrition
•Impaired physical mobility
•Disturbed body image

65. Nursing management
•Restoring Normal fluid balance.
•Prevention of infection.
•Modulating hypermetabolism.
•Promoring skin intergrity.
•Relieving pain and discomfort.
•Promoting physical mobility.
•Strengthening coping strategies.
•Supporting patients and family processes.
•Monitoring and managing potential complication.

66. DEBRIDEMENT
•Done with forceps and curved scissor or through
hydrotherapy (application of water for treatment)
•Only loose eschar removed
•Blisters are left alone to serve as a protector – controversial
Goal
A.Removed burned tissue in preparation for grafting or wound
dressing.
B.Removal of tissues contaminated by bacteria and foreign
bodies
Types:- Natural, mechanical, chemical and surgical debridement

67. SKIN GRAFTS
•Done during the acute phase
•Used for full-thickness and deep partial-thickness
wounds
Types of skin grafting:-
Homografts (allograft)- is a transplant of a graft within
same species of organism eg human to human.
Xenograft(heterograft)- is a transplant of a graft among
different species of organism eg pig to human. Have
high rejection rate.

68. POST CARE OF SKIN GRAFTS
•Maintain dressing
•Use aseptic technique
•Graft should look pink if it has taken after 5
days
•Skeletal traction may be used to prevent
contractures
•Elastic bandages may be applied for 6 mo to 1
year to prevent hypertrophic scarring

69. Wound care
•Topical antibacterial therapy
•Wound dressing
•Wound debridement
•Autografts
•Pain management
•Nutritional support

70. Complication in rehabiitation phase of
Burns care
•Neuropathies and nerve entrapment.
•Hypertrophic scaring.
•Contractures.
•Joint instability.
•Complex pain.

71. REHABILITATIVE PHASE OF BURN INJURY
•Started at the time of admission
•Technically begins with wound closure and ends
when the client returns to the highest possible level
of functioning
•Provide psychosocial support
•Assess home environment, financial resources,
medical equipment, prosthetic rehab
•Health teaching should include symptoms of
infection, drugs regimens, f/u appointments, comfort
measures to reduce pruritus

72. Priorities in rehabilitation phase
Prevention and treatment of scars and
contracturers.
Physical, occupational, and vocational
rehabilitation.
Fuctional and cosmetic reconstruction.
Psychosocial counseling.

73. Nursing diagnosis at rehabilitation
phase
•Activity intolerance R/T pain with exercise,
limited joint immobility and limited endurance.
•Distrubed body image R/T altered physical
appearance and self-concept.
•Impaired physical mobility R/T contructures or
hypertrophic scarring.

74. Disorders of wound healing
•Scars
•Keloids
•Failure to heal
•contractures

75. Complications
•infection
•peripheral vascular resistance and
hypovolemia
•acute tubular necrosis
–cardiac arrhythmias
–cardiac arrest

76. THE END
QUESTIONS