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Burns

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Care of patients with burn is highly sophisticated area of nursing.

Care of patients with burn is highly sophisticated area of nursing.

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  • 1. BURNS MR. Prasanth.K MSc cardiothoracic nursing
  • 2. ANATOMY OF SKIN
  • 3. The Skin  Membrane that covers entire body  Largest, most dynamic organ  Epidermis  Dermis  Subcutaneous layer (superficial fascia)  Deep fascia
  • 4. Definition  Injury to the tissues of the body caused by heat, chemicals, electric current, or radiation.
  • 5. Incidence  Domestic cases – 93-95%  India – 0.4million / year  Women are more affected than men – 1.6:1  Overall mortality – 3.5/100000 popu
  • 6. Burn wound healing  Inflammation  Proliferation  Remodeling
  • 7. Inflammation  Platelet adhesion  Fibrin deposit  Thrombus + vasoconstriction  Hemostasis  Local vasodilatation and increase of capillary permeability  Neutrophil (24 hrs)  Monocyte  Macrophages  Consume pathogens and dead tissue  Secrete various growth factors  Proliferation of fibroblasts + deposited of a provisional wound matrix
  • 8. Proliferation (2-3 days post burn)  Number of fibroblasts at peak  Granulation  Reepithelialization
  • 9. Remodeling (lasts for years)  Collagen fibers are reorganized  Scars contract and fade in color
  • 10. When burn extends to dermal tissue scars developed are - hypertrophic- overgrowth of dermal tissue remains in the boundaries - Colloid – extends beyond boundaries
  • 11. ETIOLOGY
  • 12. TYPES
  • 13. Thermal Caused by – flash , flame , scaled, contact with hot objects Management – extinguish flame Flush with cool water
  • 14. Chemical Agent Forms Management Acid House hold cleaners HCL, oxalic, Water irrigation Irrigate skin with soup solution Remove the person or agent away. Take self precaution and remove the cloth which contain chemical. Alkali Drain cleaners Fertilizers Adhere to tissue and protein hydrolysis Irrigate skin with slightly acidic solutions like lemon water
  • 15.  Dry chemical – Brush away from skin Irrigate skin
  • 16. Smoke and inhalation injury Agent Injury signs and symptoms Management Carbon monoxide poisoning - Incomplete combustion of burning material Cherry red skin color 10-20% - head ach , dizziness , nausea, abdominal pain 21-41%- irritability , confusion , stupor, hypotension , bradycardia, pale to dark red skin color 41-60%- convulsion , coma, hypotension, tachycardia >60%- death 100% o2
  • 17. Injury above glottis – Usually thermally produced Inhalation f hot air , steam , or smoke Especially .- burn in enclosed space Mucosal burning of larynx and oropharynx Redness Blistering Edema Quick mechanical obstruction Singed nasal hair Hoarseness painful swallowing Darkened oral and nasal membrane Carbonaceous sputum Medical emergency
  • 18. Injury below glottis – Chemically produced Pulmonary edema ARDS Close observation for ARDS
  • 19. Electrical burns  Damage to the nerves and vessels  Factors related to severity voltage Tissue resistance Current pathways Surface area of contact Length of time
  • 20. S/S Ice berg effect Chance of cervical spine injury (fall) Muscle contraction – fracture Dyarrhythmias- AF, VF Cardiac arrest Metabolic acidosis Myoglobinuria lead to – acute renal tubular necrosis
  • 21. Management  Disconnect source of current  CPR
  • 22. Cold thermal injuries  Frostbite – gangrene
  • 23. Radiation  Source – solar, X ray , radioactive agent  Management Shield Move client away
  • 24. PATHOPHYSIOLOGY
  • 25. AMERICAN BURN ASSOCIATION - burn unit referral criteria  Burn injuries that should be referred to a burn unit include the following 1. Partial thickness burns more than 10% TBSA 2. Burns that involve s the face hands feet genitalia perineum or major joints 3. Third degree burns in any age group 4. Electrical burns including lightning injury 5. Chemical burns 6. Inhalation injury 7. Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality 8. Any patients with burns and concomitant trauma (fractures) in which the burn injury poses the greatest risk of morbidity or mortality. 9. Patients who will require special social, emotional, or long term rehabilitation intervention
  • 26. CLASSIFICATION OF BURN INJURY  Severity determined by – Depth of burn Extent of burn – calculated by TBSA Location of burn Patient risk factors
  • 27. Classification based on depth  Superficial  Partial thickness superficial partial thickness deep partial thickness  Full thickness
  • 28. Superficial burns  Involves epidermis  ---- UV rays, sun burn, minor flash injury, mild radiation  s/s Skin color – pink – bright red Slight edema Chills, nausea, vomiting – in extensive burns Management – I/V fluid treatment
  • 29. Partial thickness Superficial partial thickness Deep partial thickness Affected - Dermis and papillae of dermis Bright red color + moist + glistening appearance + blisters + blanching on pressure + pain response to temperature and air is severe Heal with in 21 days + minimal or no scaring Management – analgesics Skin substitutes for large disrupted blisters Dermis +more deeper Pale + waxy+ moist / dry large blisters + decreased capillary refill + less painful Heal – more than 21 days Complication Necrosis may lead to full thickness injury , contractures Management – excision and grafting
  • 30. Full thickness burn  Epidermis + dermis + epidermal appendages + subcutaneous fat+ connective tissue + muscle + bone  Pale ,waxy ,brown ,mottled ,leathery ,firm to touch  No sensation of pain Management – Skin grafting
  • 31. Classification by extent of burn  Lund- Browder chart  According to Rule of nine ( not accurate for estimating the percentage TBSA for adults who are short, obese or very thin. )  Sage burn diagram – computerized burn estimation tool. (www.sagediagram.com)
  • 32. Classification according to ABA Minor burn injury Moderate burn injury Major burn injury Excludes electrical injury, inhalation injury, and all clients at high risk Partial thickness burns of less than 15 % of TBSA in adults Full thickness burns of less than 2% of TBSA not involving special care areas. ( eye ,ear, hand , feet, face , joints , perineum ) Excludes electrical injury, inhalation injury, and all clients at high risk Partial thickness burns of less than 15 %- 25 % of TBSA in adults Full thickness burns of less than 10 % of TBSA not involving special care areas. ( eye ,ear, hand , feet, face , joints , perineum ) Includes electrical injury, inhalation injury, and all clients at high risk involving special care areas. ( eye ,ear, hand , feet, face , joints , perineum Partial thickness burns of more than 25 % of TBSA in adults Full thickness burns of 10 % or greater of the TBSA
  • 33. DIAGNOSTIC EVALUATION  Sodium hyponatreamea - dilutional Hyponatreamea Water intoxication Potassium – hyperkalemea – renal failure Adrenocortical insufficiancy Massive deep muscle injury Hypokalemea- dilution / GI wash…
  • 34. MANAGEMENT  Pre hospital care  Emergent phase Air way management Fluid therapy Wound care
  • 35. PRE HOSPITAL CARE  Remove person from the source of burn  Self shield – by rescuers  Small burns <=10% TBSA – covered with clean, cool, tap water-dampened towel.  Assesement and Management of ABC
  • 36. EMERGENT PHASE (resuscitative phase)
  • 37. Air way management  Early Endotracheal / orotracheal intubation  Ventilatory assistance – with PEEP  assess ABG values  Extubation- when edema resolves  Escharotomies - to relive respiratory distress secondary to circumferential, fulthickness burns to the neck and trunk
  • 38.  Assess lower respiratoty tract by – fiberoptic bronchoscopy  For inhalation injury – no intubation perfornmed Humidified Oxygen Position – high fowler’s position (not for pts with spinal injury)
  • 39.  If spinal injury – reverse tendelberg position  Deep breathing and coughing exercise  Reposition every 1-2 hrs  Bronchodilators  O2 therapy until carboxyhemoglobin become normal .
  • 40. Fluid therapy  Pt >15% TBSA – large bore I/V access  >30% TBSA – central and arterial line  Crystalloid solutions – RL  Colloids – albumin  Calculate fluid requirement brooke’s and (baxter) parkland formula
  • 41. Formula First 24 hrs Second 24 hrs Brooke (modified) Crystalloid colloids Glucose in water 4ml RL X Kgbody wt X%TBSA burn= total fluid repalcement for 1st 24 hrs Application ½ of total in 1st 8hrs ¼ of total in second 8 hr ¼ of total in third 8 hr 0.3- 0.5ml/kg/% TBSA Amount to replace estimated evaporative losses Parkland formula (baxter) RL 4ml X kgX %TBSA burn, ½ given first 8hr ¼ given each next 8 hr 20-60% of calculated plasma volume Amount to replace estimated evaporative losses
  • 42. Wound care  Start until airway patency maintained  Cleansing and gentle debridement Necrotic skin removed Escharotomies ( removal of dry scab) Fasciotomies  Hydrotherapy / cart shower Once daily shower and dressing
  • 43. Control of infection Open method Multiple dressing change method Burn covered with cover with topical antimicrobial solution with out dressing Sterile dressing impregnated with topical antimicrobial medication changed every 12 / 24 hrs or once in every 3 days. Moist wound healing method
  • 44. Skin graft  Porcine skin – hetero graft or xenograft (different spicies)
  • 45. Cadaveri skin – homograft or allograft (same spicies)
  • 46. Cultured epithelial autograft
  • 47. Autograft – own skin
  • 48. Porcine collagen bonded to silicone memberane – Biobrane
  • 49.  Bovine collagen and glycosaminoglycan bonded to silicone memberane  Acellular dermal matrix derived from donated human skin ( Alloderm )
  • 50. Care of facial burn  Open dressing  Ophthalmological examination – corneal burns and edema  Periorbital edema – reassurece
  • 51. DRUG THERAPY
  • 52. Analgesics  I/v medications  Mrphine  Fentanyle  Morphine  NSAIDs  Oxycodone
  • 53. Sedatives  Haloperidol  Lorazepam  Midazolam
  • 54. Other medications  Ranitidine  Nystatin  Antacids
  • 55.  Tetanus immunization If not had active immunization in 10 years – go for tetanus immunoglobulin
  • 56. Antimicrobial agents  Silver sulfadiazine  Mafenide acetate  Oral infection – nystatin mouth wash
  • 57. NUTRITIONAL THERAPY  TPN  High protein high cal – diet
  • 58. ACUTE PHASE  Wound care Debridment of necrotic tissue Enzymatic debridement Use meshed dressing with paraffine oil Moist dressing for donor site
  • 59.  Skin grafting  Pain management  Other pain management techniques Guided imaginary Relaxation therapy Hypnosis
  • 60.  Physical and occupational therapy ROM Nutritional care Psychosocial care
  • 61. REHABILITATION PHASE  Manage emotions Fear Anger Anxiety Guilt Depression
  • 62. COMPLICATIONS  Contractures – abnormal condition of a joint characterized by flexion and fixation
  • 63. NURSING DIAGNOSIS  Impaired gas exchange related to carbon monoxide poisoning as evidenced by labored breathing  Ineffective air way clearance related to edema and effects of smoke inhalation and evidenced by ventilatory support  Disturbed body image related to disfigurement secondary to burn as evidenced by verbalized negative comments about appearance.
  • 64.  Fluid volume deficit related to fluid loss as manifested by decreased serum electrolyte level and dry skin  Acute pain related to impaired skin integrity as manifested by facial expression and crying.
  • 65.  Impaired skin integrity related to thermal injury as manifested by blisters and lesions.  Activity intolerance related to weakness, as manifested by verbalization.
  • 66.  Anxiety related to prognosis of disease condition and disturbed body image.  Risk for infection related to impaired skin integrity and suppressed immune response  Risk for contractures related to the burn injury
  • 67.  Ineffective individual coping related to fear and emotional impact of burn injury as evidenced by increased questioning  Imbalanced nutrition less than body requirement related to inability to intake as evidenced by weight loss.  Hyperthermia, related to infection, as manifested by rise in body temperature..
  • 68. Research studies
  • 69.  The treatment of pain produced during the management of burn injury has been an ongoing problem for physicians caring for these patients. The main therapeutic option for analgesia has been the repeated and prolonged use of opioids.
  • 70.  The adverse effects of opioids are well known but the long term use of opioids which produces tolerance with accompanying dose escalation and dependence is most problematic. Another potentially important consequence of opioid exposure that sometimes masks as tolerance is that of opioid induced hyperalgesia.
  • 71.  This syndrome is manifest as enhanced pain, sensitivity and loss of analgesic efficacy in patients treated with opioids who actually become sensitized to painful stimuli. This article focuses on the treatment of burn pain and how current analgesic therapies with opioids may cause hyperalgesia and affect the adequacy of treatment for burn pain. This article also provides possible modalities to help therapeutically manage these patients and considers future analgesic strategies which may help to improve pain management in this complicated patient population.

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