burns

BURN INJURY

Burns are caused by a transfer of energy from a heat source to the body. It is a cell destruction of the layers of the skin and the resultant depletion of fluid and electrolytes. The depth of the injury depends on the temperature of the burning agent and the duration of contact with it. It disrupts the skin which leads to increased fluid loss, infection, hypothermia, scarring, and changes in function, appearance and body image.

A. Young children and elderly people are at higher risk for burn injury.
B. Those younger than 5 and older than 40 years old are at high risk for death after burn trauma.


CAUSES OF BURN INJURY

• Scalds (steam, hot bath water, tipped over coffee cups, cooking fluids, etc.)
• Contact with flames or hot objects (from stove, fireplace, curling irons, etc.)
• Chemical burns (from swallowing things like drain cleaner or watch batteries or spilling chemicals such as bleach on to skin.)
• Electrical burns (from biting on electrical cords or sticking fingers or objects in electrical outlets )
• Overexposure to sun.


ASSESSMENT OF BURN INJURY

First-degree burns (Superficial partial-thickness burns)
The epidermis and possibly a portion of the dermis are injured. (E.g. sunburn)

S/Sx:
a. Pink to red with slight edema which subsides quickly
b. Pain may last up to 48 hours
c. Relieved by cooling

Reparative process:
a. In about 5 days, epidermis peels.
b. Itching and pink skin persist for about a week.
c. No scarring.
d. Heals spontaneously if it does not become infected within 10 days-2 weeks.

Second-degree burns (Deep partial-thickness burns)
The epidermis and the upper to deeper portions of the dermis are injured. (E.g. Scald)

S/Sx:
a. Superficial layers of the skin are destroyed.
b. Pink or red
c. Blister form ( vesicles);weeping
d. Edematous, elastic
e. Wound moist and painful
f. Deep dermal
g. Edematous reddened areas blanch on pressure.

Reparative process:
a. Takes several weeks to heal.
b. Scarring may occur

Third-degree burns (Full-thickness burns)
The epidermis, entire dermis and sometimes the underlying tissue are injured. (E.g. Burns from a flame or electrical current.)

S/Sx:
a. Destruction of epithelial cells-epidermis and dermis destroyed.
b. Reddened areas do not blanch with pressure.
c. Not painful; coloration varies from white to brown leathery devitalized tissue- eschar.

Reparative process
a. Eschar must be removed.
b. For areas larger than 3-5 cm, grafting is required.
c. Expect scarring and losses of skin function.
d. Areas require debridement, formation of granulation tissue and grafting.

TYPES OF BURNS

a. Thermal burns: Caused by exposure to flames, hot liquids, steam or hot objects.
b. Chemical burns: caused by tissue contact with strong alkali or organic compounds, systemic toxicity from cutaneous absorption occurs.
c. Electrical burns: caused by heat generated by electrical energy as it passes through the body.
d. Radiation burns: caused by exposure to radioactive source, UV light and x-rays.

WHEN TO SEEK IMMEDIATE MEDICAL HELP?

a. You think the patient has a second or third-degree burn.
b. The burned area is large, even if it seems like a minor burn. For any burns that appears to cover more than 10% of the body. Do not use wet compresses because it can cause body temperature to drop. Instead cover the area with a clean, soft cloth or towel.
c. Burn comes from fire, an electrical wire or socket or chemicals.
d. The burn is on face, scalp, hands, joint surfaces or genitals.
e. The burn looks infected (with swelling, pus, and increasing redness).

METHODS IN ESTIMATING THE EXTENT OF THE INJURY

a. Lund and Browder Method- Modifies percentage s for body segment according to age. It provides more accurate estimate of the burn size. It uses a diagram of the body divided into sections with the representative % of the TBSA for ages throughout the lifespan.
b. Palm Method- It is used to estimate percentage of scattered burns using the size of the patient’s palm (1% of BSA) to assess the extent of burn injury.
c. Rule of nine Method- an estimation of the TBSA burned by dividing the body into multiples of nine

ASSESSMENT FOR THE PATIENT WITH BURNS

a. Review the initial assessment data obtained.
b. Focus on the major priorities of any trauma patient: Airway, Breathing, and Circulation.
c. Assess respiratory status as first priority (airway patency and breathing adequacy).
d. Note any increased hoarseness, stridor, and abnormal respiratory rate and depth or mental changes from hypoxia.
e. Evaluate circulation (apical, carotid and femoral pulses).
f. Check vital signs frequently.
g. Arrange for patient with facial burn to be assessed for corneal damage.
h. Assess depth of wound and identify areas of full and partial thickness injury.
i. Assess neurologic status: consciousness, psychological status, pain and anxiety and behavior.

PHASES OF MANAGEMENT OF THE BURN INJURY

Emergent phase
Begins at the time of injury and ends with the restoration of capillary permeability usually at 48-72 hours after the injury. The primary goal is to prevent hypovolemic shock and preserve vital organ functioning. This includes prehospital care and emergency room care.

Resuscitative phase
Begins with the initiation of fluids and ends when capillary integrity returns to near normal levels and the large fluid shifts have decreased. The amount of fluid administered is based on the client’s weight and extent of injury. Most fluid replacement formulas are calculated from the time of injury and not from the arrival at the hospital. The goal is to prevent shock by maintaining adequate circulating blood volume and maintaining the vital organ perfusion.

Acute phase
Begins when the patient is hemodynamically stable, capillary permeability is restored and diuresis has begun. This usually begins 48-72 hours after the time of injury. The goal of this is infection control, wound care, wound closure, nutritional support, pain management and physical therapy.

Rehabilitative phase
This is the final phase of burn care. It overlaps the acute care phase and goes well beyond hospitalization. The goal of this phase is designed so that the client can gain independence and achieve maximal function.

MANAGEMENT OF BURN INJURY

Fluid Resuscitation
a. Indications:
a. Adults with burns involving more than 15%-20% TBSA
b. Children with burns involving more than 10%-15% TBSA.
c. Patient with electrical injury, the elderly, or those with cardiac or pulmonary disease and compromised response to burn injury.
b. The amount of fluid administered depends on how much intravenous fluid per hour is required to maintain a urinary output of 30-50ml/hr.
c. Successful fluid resuscitation is evidenced by stable v/s, adequate urine output, palpable peripheral pulses and clear sensorium.

Pain management
a. Administer Morphine SO4 or Demerol as prescribed by the IV route; avoid IM or SC routes because the absorption through the soft tissue is unreliable when hypovolemia and large fluid shifting are occurring.
b. Avoid administering oral medication because of the possibility of GI dysfunction.
c. Medicate the patient prior to painful procedures.

Nutrition
a. Maintain NPO status until the bowel sounds are heard; then advanced to clear liquids as prescribed.
b. Nutrition maybe provided via enteral tube feeding.
c. Provide a diet high in protein, carbohydrates, vitamins and minerals

Topical antimicrobial agents
Silver sulfadiazine
a. Most widely used agent and least common incidence of side effects.
b. May cause Transient leucopenia that disappears 2-3 days of treatment.
c. Used with open treatment, light or occlusive dressing.
d. Applied once or twice daily after thorough wound cleansing.

Mafenide acetate 10% cream or 5% solution (Sulfamylon)
a. Painful during and for a while after application.
b. May cause metabolic acidosis, not used if >20% TBSA
c. Cream must be reapplied 12 hours to maintain therapeutic effectiveness.
d. Solution concentration is maintained with bulky wet dressings, rewet every2-4 hours.

Other topical dressings:
a. Silver nitrate
b. Cerium nitrate
c. Povidone iodine
d. Gentamycin
e. Polymixin B-Bacitracin ointment

Auto grafting
It is a surgical removal of a thin layer of a patient’s own unburned skin, which is then applied to the excised burn wound.

Temporary wound coverings
Amnion
It comes from amniotic membrane from human placenta, dressing is changed q48hours.

Allograft (Homograft)
It is donated from human cadaver; skin is harvested within 24 hours after death. Monitor for wound exudates and infection. Rejection can occur within 24 hours.

Xenograft (Heterograft)
It is a porcine skin which is harvested after slaughter and preserved. Rejection can occur within 24-72 hours. It is replaced q2-5days until the wound heals naturally or until closure with autugraft is complete.

Biosynthetic and synthetic
A Visual inspection of the wound is possible; s dressings are transparent or translucent.

TYPES OF SKIN GRAFTING

Split thickness
Graft half of the epidermis, applied in sheets or postage stamp-like pieces.

Full thickness
Graft consisting of epidermis and dermis; it is commonly used for reconstructive surgery months or years after the initial injury.

Pedicle flap
Commonly used for reconstructive surgery months or years after the initial injury.

Cultured Epithelium
Used of the client’s unburned skin. Keratinocytes are isolated and epithelial cells are cultured in a laboratory; these cells then attached to the burned wound.






NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY
COLLEGE OF NURSING
General Tinio St. Cabanatuan City












Submitted by:
Karen Katrin M. Tabunan
BSN IV-J

Submitted to:
Ms. May-flor Lazatin
Ms. Marian Legaspi
Head nursing

Ms. Jean Christian Mangoba
Clinical instructor