1. The document discusses the anatomy and physiology of the skin, classification of burns, nursing assessment of burns, and pathophysiology of burns.
2. It describes the layers of the skin including the epidermis, dermis, and hypodermis. It also discusses glands of the skin.
3. Burns are classified based on depth, severity, and extent. Depth includes first, second, third, and fourth degree burns. Severity is classified by the American Burn Association based on percentage of total body surface area burned.
3. What we are going to learn?
• Introduction
• Review of anatomy and physiology of skin.
• Nursing assessment of burns.
• Etiology, classification, pathophysiology, clinical manifestation, diagnosis, treatment
modalities
• Medical and surgical nursing management of burns
• Re- constructive and cosmetic surgery
• Types of reconstructive and cosmetic surgery for burns congenital deformities, injuries and
cosmetic purposes
• Role of nurse
• Legal aspects
• Rehabilitation
• Psychosocial aspects
• Nursing procedures drugs used in treatment of burns
4. Introduction
WHAT IS BURN?
Burn are a form of traumatic injury caused by thermal,
electrical, chemical or radioactive agents.
Burn is defined as wound caused by exogenous agent leading
to coagulative necrosis of tissue.
Human skin can tolerate temp. up to 42-44℃ (107-111℉) but
above these , the higher the temperature the more severe the
tissue destruction.
Below 45℃ (113℉), resulting changes are reversible but >45℃,
protein damage exceeds the capacity of the cell to repair.
6. Definition :-
The skin is the largest organ system of the body and is
essential for human life.
The skin has up to seven layer of ectodermal tissue and
guards the underlying muscles, bone, ligaments, and
internal organs.
7. Function of skin
It plays vital body function:-
It forms a barrier between the internal and
external environment.
It protect the body from pathogens.
It helps regulate temperature and water loss.
It provide sensory input.
10. Epidermis:-
It is an outmost layer of stratified epithelial
cell.
It ranges in thickness from about 0.05mm on
the eyelids to 1.5mm on palm hand and soles
of feet.
The layers which is compose of epidermis
from innermost to outermost are:-
11.
12. Stratum corneum
1. This layer is the first line of defense against the environment
2. It is comprised of keratin and helps protect against bacteria and UV damage
3. It prevents moisture from escaping, which helps skin stay hydrated
Stratum lucidum
1. A thin clear layer that is only present in skin, such as palms of the hands and
soles of the feet.
2. It is meant to help the body withstand friction
Stratum granulosum
1. This layer acts as the water proofing layer and keeps the body from losing
water
2. The types of fats in this layer keep the skin cells attached to each other
13. Stratum spinosum
1. Also called the prickle cell layer
2. This layer contains dendritic cells, which are part of the body’s immune
system that helps fight against foreign invaders such as germs
3. This layer enables the epidermis (outer layer of skin) to better withstand the
effects of friction and abrasion
Stratum Basale
1. The deepest layer of the epidermis, also called the stratum germinativum
2. This is the layer of skin where cell division (mitosis) occurs and skin cells
are replenished
3. The cells in this layer produce keratinocytes, which produce keratin,
protein, and fats, help the body produce vitamin D when exposed to
sunlight
4. This layer also contains melanocytes, which produce melanin, the pigment
that colors the skin
14. Dermis:-
Corium is another name for the dermis. Corium is
A Latin word that means “leather” or “skin.”
It is consist of connective tissue.
It is compose of collagen, elastic and reticular
fiber.
Collagen fiber are very thick and provide
toughness to the skin.
Elastic fibers provide flexibility to the skin.
16. Papillary layer
1.This layer connects the dermis to the epidermis
2.It contains capillaries that bring nutrients to the skin and increase or
decrease blood flow to the skin which helps regulate temperature
3.It also contains sensory neurons that help sense heat, cold, touch,
pain, and pressure
4.This is the layer of skin that is responsible for fingerprints
Reticular layer
1.The deepest level of the dermis
2.A thick layer composed of dense connective tissue
3.This layer contains hair follicles, sweat glands, and oil-producing
glands (sebaceous glands)
4.The main functions are strengthening the skin and providing elasticity
to the skin
17. Hypodermis:-
Also known as subcutaneous tissue.
It is the inner most layer, composed of connective tissue, adipose
tissue, fat and large blood vessels.
It is much thicker then dermis.
It provide cushion between the skin layer, the muscle, and the
bone.
18.
19. Melanocytes:-
It is the special cell of epidermis which is primarily
involve in producing the pigment “melanin”, which
give color to the skin and hairs.
21. Sweat gland:-
Found in the skin over most of the body
surface, but they are most heavily
concentrated in the palms of the hands
and soles of the feet.
23. Conti.
Eccrine - The most numerous type that are found
all over the body, particularly on the palms of the
hands, soles of the feet fore head. Are active from
birth.
Apocrine - Mostly confined to the arm pits (axillae)
and the anal-genital area. Apocrine glands become
only at puberty.
24. Sebaceous glands:-
These glands are connected to
hair follicle.
The secretion are produced by the
breaking down of the cells, which
form the oil.
Secretion of oil gland is known as
sebum. It function as the barrier,
emollient and a protective agent
against the bacteria and fungi.
28. History Taking:-
Ask history of burn.
Ask about the medical history, drug, food, other allergic
history.
When patient took her/his last meal.
Determine weather the injury is superficial or deep.
Assess the body response to the injury.
In chemical burn patient may complain about pain, difficulty
in swallowing, drooling of saliva and excoriation of mucous
membrane.
29. Head to toe physical
examination:-
Pt. may look anxious or in
pain.
Record vital signs.
Mouth examination.
Skin examination.
Look for edema.
30. Assess burn extent:-
Evaluating the burn severity by assessing depth and the % of
TBSA .
The % of the burn is calculated by Wallace rule of nines chart, in
adults, Palm method and Lund Browder chart.
31. Conti.
Wallace rule of nine:- the chart divides the body into sections
that represent nine percent of the body surface area. It is used
in adults only. It was introduce by Alexander Wallace.
Palm method:- when burn is scattered on body, palm method
is used to assess TBSA, here the palmer surface of patients
hand is consider equivalent to 1% TBSA.
Lund Browder chart:- The Lund-Browder chart is the most
accurate method for estimating TBSA for both adults and
children. Children have proportionally larger heads and
smaller lower extremities, so the percentage TBSA is more
accurately estimated using the Lund-Browder chart.
39. Cardio vascular system:-
Pulse may be fast or normal,
There may be tachycardia,
BP may be normal or
increased due to
catecholamine effect, become
low if hypovolemia develops.
40. Respiratory system:-
Lungs may be dry, respiratory rate
is increased, crackles appear.
Inhalation injury produce pulmonary
edema.
41. Nervous System:-
The patient is usually
awake, restlessness in
post burn period indicate
hypovolemia.
If fluid depletion is
excessive, the pt. may
become confused,
disoriented, delirium and
may lapse into coma.
42. Abdominal Examination:-
It may show distention of
abdomen, decreases or
absent peristaltic sounds
indicating paralytic ileus.
Bladder on percussion
my be empty.
43. Question?
1.A 25 year old female patient has sustained burns to the back of the
right arm, posterior trunk, front of the left leg, anterior head and neck,
and perineum. Using the Rule of Nines, calculate the total body
surface area percentage that is burned?*
A. 46%
B. 37%
C. 36%
D. 28%
44. How to measure burn which is scattered
on body surface?
A.Rule of 9
B.Lund Browder chart
C.Palm method
D.History taking
46. Etiology
At least 44°C of heat is required for the skin to
be burned. Besides, the duration of the heat is
also important; trans epidermal necrosis
occurring with 70°C of heat in A second,
occurs in 45 minutes with 47°C of heat.
47. Thermal Burns
It develops in two different ways as hot
water and flame burns.
Thermal burns are skin injuries caused
by excessive heat, typically from contact
with hot surfaces, hot liquids, steam, or
flame.
Thermal damage to skin results in
cellular death as a function of
temperature and length of contact time.
48. Conti.
Thermal burns are the most
common type of burn injuries,
making up about 86% of the
burned patients requiring burn
center admission.
About 70% of the burns in
children develop due to hot
water. It is most often caused by
hot drinks or hot bath water.
These burns are usually first-
degree or superficial second-
degree burns.
49.
50. Chemical Burn:-
Caused by tissue contact with strong
acid, alkali or organic compound.
Severity is determine by
concentration, volume, type of
chemical and duration of contact.
Usually occur as a result of industrial
accidents and with household
chemical product.
Alkaline tends to penetrate deeper
and cause worse burn then acids,
cement is common cause of alkaline
burn.
51.
52. Electrical Burn:-
Cause by heat i.e.; Generated
by electrical energy as it pass
through the body.
Extent of injury influenced by
duration of contact, type of
current and intensity of current.
53.
54. Radiation Burns
It is caused by the uptake of
radioactive material.
Extent of injury depends upon
strength, distance, duration
and surface area.
Radiation Burns are most
commonly seen as sunburn or
from over exposure on a sun
bed.
55.
56. Sunburns:-
Sunburn is an acute cutaneous
inflammatory reaction that follows
excessive exposure of the skin to
ultraviolet radiation (UVR).
It develops due to uncontrolled and
prolonged exposure to sun or light
sources containing UVB.
57. Conti.
While 20 minutes is enough to get a
minimal sunlight dose in a clear
summer day.
Most sunburns are classified as
superficial or first-degree burns.
61. Cold burn (frostbite)
It is developed with cooling of
the body.
The skin is frozen at −2 to −10°c
and irreversible changes occur
under −22°c.
Cold burn is different from
thermal burns.
Trauma occurs at the cellular
level and extracellular fluid
directly, at the organ functions
indirectly.
64. Local effect:-
Local pathophysiology changes (mentioned by Jackson)
consist in the formation of 3 zone:-
65. Zone Of Coagulation:-
This occur at the point of
maximum damage.
In this zone, there is
immediate tissue necrosis
(irreversible tissue loss),
as a result of denaturation
of proteins.
66. Zone Of Stasis:-
Are surrounding zone
of coagulation
Cellular injury;
decreased blood flow
and cause
inflammation.
Susceptible to
additional injury.
67. Zone Of Hyperemia:-
It is that zone which retains its blood
flow and in most cases survives the
injury.
These 3 zone of burn are 3
dimensional and loss of tissue in the
zone of stasis will lead to the wound
depending as well as widening.
68. Systemic Response:-
The release of
cytokines and other
inflammatory mediator
at the site of injury has
a systemic effect once
the burn reaches 30%
of TBSA.
69. Cardiovascular changes:-
Capillary permeability increased, leading to
loss of intravascular proteins and fluids into
the intestinal compartment.
Decrease cardiac output.
Increased pulmonary resistance and
therefore increased right ventricular work-
load is an additional factor in cardiac
dysfunction.
70. Conti.
Patients with larger burns are more likely to
develop biventricular failure.
Ultimately, the cardiac deficit culminates in a
state of shock.
73. Immunological changes:-
Burn Injury
Destruction Of Skin Barrier
Favorable Space For Microorganism Growth
And Portal For Tissue Entry Of Microbes
Infection Of Tissues
Microbes’ Growth And Enters Blood Stream
Septicemia
74. Thermoregulatory alteration:-
Burn injury
Loss of skin surface, exposure to external
environment
Inability to regulate fluid leaks from the
Body temperature burn wound
Increase
evaporation from
the tissues
Evaporation causes
heat loss from the
body.
Hypothermia
75. Pulmonary alteration:-
Inhalation of direct heat, hot smoke, carbon
mono oxide gases
Direct burn injury to Upper airway
Release inflammatory mediators
Severe upper airway oedema, Bronchospasm
Decreased ventilation
Severe hypoxia/suffocation
Shock
77. According to depth:-
Partial thickness- superficial- first
degree burn:-
It cause minimal skin damage. They are
‘superficial burn’ as they effect the
outermost layer of skin. Epidermis is
destroyed or injured and a part of dermis
also may be injured.
78. Partial thickness- deep- 2nd degree
burn:-
It involves destruction of
epidermis and upper layer
of dermis, injury occur to
deeper portion of the
dermis.
79. Full thickness- 3rd degree burn:-
Total destruction of epidermis occur.
underlying tissue also may be involved.
There is wide spread thickness with a
white, leathery appearance.
80. 4th degree burn:-
Destruction of epithelium fat, muscle and bones
take place. Contain all 3rd degree burn
symptoms also extend beyond the skin to
tendons and bones.
81. According to severity:-
by American burn association
1. Major burn injury
25% TBSA burn in adults less than 40
years of age.
20% TBSA burn in adults more than
40 years of age
20% TBSA burn in children less than
10 years of age
Burns involving the face, eyes, ears,
hands, feet and perineum, likely to
result in functional or cosmetic
disability.
82. 2. Moderate burn injury
15% TBSA burn in adults less than
40 years of age.
10-20% TBSA burn in adults more
than 40 years of age.
10-20% TBSA burn in children
less than 10 years of age.
less than 10% TBSA full-thickness
burn without cosmetic or functional
risk to the face, eyes, ears, hands,
feet or perineum.
83. 3. Minor burn injury
Less than 15% TBSA burn
in adults less than 40 years
of age.
Less than 10% TBSA burn
in adults more than 40
years of age.
Less than 10% TBSA burn
in children less than 10
years of age. With Area.
Less than 2% full thickness
burn and no cosmetic or
functional risk to the face,
eyes, ears, hands, feet or
perineum. Abbrev.
84. Based on size of extent:-
It is classify on the basis of % of injured
skin, excluding the 1st degree burn.
There are 3 method for calculation of
burn %, these are:-
1.The rule of 9.
2.Lund Browder chart.
3.Palm method.
85.
86. A 66 year old female patient has deep partial-thickness burns to
both of the legs on the back, front and back of the trunk, both arms
on the front and back, and front and back of the head and neck.
Using the Rule of Nines, calculate the total body surface area
percentage that is burned?*
a) 72%
b) 63%
c) 81%
d) 45%
The answer is C. Both of the legs on the back (18%), front
and back of the trunk (36%), both arms on the front and
back (18%), front and back of the head and neck (9%)
which equals 81%.
90. Diagnostic evaluation:-
History taking:-
1.Time of injury
2. Place of injury (open/closed)
3. unconsciousness during incidence
4. Mechanism of burn injury/agent
5. Duration of exposure to agent
6. Last Tetanus shot
7. Any known Allergies
92. Lab Investigations:-
CBC
ABG
12 Lead EKG
Serum biochemistry
Chest X-ray
CT scan
Laser Doppler imaging :-
It is a non- invasive technique with
sensitivity of 97%. This scan allows early
diagnosis of deep burns and reduce the
length of stay and cost of treatment.
99. Medical Management:-
Generally the burn victims with major
burns are hospitalized and care is
provided in the burn unit or ward, the
proper sequencing of the interventions is
very essential.
• Transport. The hospital and the physician
are alerted that the patient is en route so
that life-saving measures can be initiated
immediately.
• Priorities. Initial priorities in the ED remain
airway, breathing, and circulation.
100. • Airway. 100% humidified oxygen is
administered and the patient is
encouraged to cough so that
secretions can be removed by
coughing.
• Chemical burns. All clothing and
jewelry are removed and chemical
burns should be flushed.
• Intravenous access. A large bore
(16 or 18 gauge) IV catheter is
inserted in the non-burned area.
101. • Gastrointestinal access. If the burn exceeds 20% to 25%
TBSA, a nasogastric tube is inserted and connected to low
intermittent suction because there are patients with large
burns that become nauseated.
• Clean beddings. Clean sheets are placed over and under
the patient to protect the burn wound from contamination,
maintain body temperature, and reduce pain caused by air
currents passing over exposed nerve endings.
• Fluid replacement therapy. The total volume and rate of
IV fluid replacement is gauged by the patient’s response
and guided by the resuscitation formula.
102. Fluid
Management:-
The goal of fluid management in major burn
injuries is to maintain the tissue perfusion in the
early phase of burn shock.
Formal fluid resuscitation formulas which were
introduced in the 1960s and 1970s have been
used effectively all over the world.
The “Parkland” formula, which calculates the
amount of fluid required to resuscitate a patient
based on percentage-burn, remains the most
commonly used formula in the United Kingdom
and Ireland, where 78% of all burn units use it.
103. Similarly, a recent survey of burn
units in the United States and
Canada revealed that 78% of
units use the Parkland formula to
estimate resuscitation volumes.
Baxter found that patients with
inhalation injury required
additional fluid when compared to
others.
Pruitt reported that patients with
electrical burns and those in
whom resuscitation was delayed
routinely also required additional
fluid.
104. Parkland formula:-
For adults within 24 hours post thermal or chemical
burn is:
2 ml RL x patient's weight in kilograms x %TBSA 2nd, 3rd
and 4th-degree burns
For adults with electrical burns:
4 mL RL x Patient's weight in kilograms x %TBSA 2nd,
3rd, and 4th-degree burns
105. Conti.
The Delivery of half the volume is in the
first 8 hours post-burn, and the remaining
volume given over the next 16 hours.
For adults, a urine output of 30 to 50 mL
per hour is used as an indication of
appropriate resuscitation in thermal and
chemical injuries, whereas in electrical
injuries a urine output of 75 to 100 mL
per hour is the goal.
106. Conti.
Lactated ringers is the preferred choice
of crystalloid solution, as
it effectively treats both hypovolemia
and extracellular sodium deficits
caused by burn injury, and it is isotonic,
inexpensive, readily available, and
easily stored.
Also, large volumes of normal saline
solution can lead to hyperchloremic
acidosis.
107. A 45 year old female patient has superficial partial thickness burns on the
posterior head and neck, front of the left arm, front and back of the right arm,
posterior trunk, front and back of the left leg, and back of right leg. The
patient weighs 91 kg. Use the Parkland Burn Formula to calculate the total
amount of Lactated Ringers that will be given over the next 24 hours?
a. 22,932 mL
b. 26,208 mL
c. 16,380 mL
d. 12,238 mL
The answer is A: 22,932 mL
Formula: Total Amount of LR = 4 mL x BSA % x pt’s weight in kg.
Pt’s weight 91 kg.
BSA percentage: 63%… posterior head and neck (4.5%), front of the left arm
(4.5%), front and back of the right arm (9%), posterior trunk (18%), front and
back of the left leg (18%), back of right leg (9%) equals: 63%
4 x 63 x 91 = 22,932 mL
108. Question?
A 54-year-old man is deep-frying a turkey for Thanksgiving while enjoying
some cocktails with friends. In the process of removing the turkey from the
deep fryer, the pot overturns. The patient tries to grab it and sustains grease
burns to his right forearm, his anterior trunk, and the both legs. He is
transported by EMS to the hospital for care, nurse measure the pt’s. weight
which is 91kg. Using the rule of nines, what is his estimated TBSA?
Calculate the total amount of fluid that will be given over the next 24 hours?
a. Using the rule of nines, the patients estimated TBSA would be 40.5%
based on the right forearm (4.5%), the chest (18%), and the anterior surface
of both legs (18%).
b. 14,742
110. Choice of fluid
The ideal burn resuscitation is the
one that effectively restores plasma
volume, with no adverse effects.
Isotonic crystalloids, hypertonic
solutions and colloids have been
used for this purpose, but every
solution has its advantages and
disadvantages.
None of them is ideal, and none is
superior to any of the others.
111. Wound Cleaning
Proper management of burn
wounds is required to prevent
wound deterioration.
The goal of wound care is
debridement of nonviable tissue,
removal of previously applied
topical agents, and application of
new topical agents.
112. Conti.
Gentle cleaning with mild soap, water, and
a washcloth can prevent infection by
decreasing bacteria and debris on the
wound surface.
In addition, most burn experts recommend
debridement of blisters larger than 0.5 cm
to reduce risk of bacterial invasion.
Whatever method is used, the goal is to
protect the wound from overwhelming
proliferation of pathogenic organisms and
invasion of deeper tissues until either
spontaneous healing or skin grafting can be
achieved.
113. Conti.
Strategies for the prevention of cross-
contamination include the use of
plastic liners, water filters, and
thorough decontamination of
equipment.
During treatment, the patient is
continuously assessed for signs of
hypothermia. The temperature of the
water is maintained at 37.8°C (100°F),
and the temperature of the room
should be maintained between 26.6°C
and 29.4°C (80°F and 85°F) to prevent
hypothermia.
114. Wound Dressing
Topical agents are applied to the wound
(silver sulphadiazine 1%)
The wound is covered with several layers
of dressings. A lighter dressing is used
over joints to allow for mobility.
If the hand or foot is burned, the fingers
and toes should be wrapped individually
to promote function while healing.
Burns to the face may be left open to air
once they have been cleaned and the
topical agent has been applied.
115. Conti.
Careful attention is required to ensure that
the topical agent does not come in contact
with the eyes or mouth.
A light dressing can be applied to the face
to absorb excess exudates if needed.
Occlusive dressings, gauze, and a topical
antimicrobial agent may be used over
areas with new skin grafts to protect the
new graft and promote an optimal condition
for its adherence to the recipient site.
116. Conti.
Ideally, these surgical dressings
remain in place for 3 to 5 days, at
which time they are removed for
examination of the graft.
When occlusive dressings are
applied, precautions are taken to
prevent two body surfaces from
touching, such as fingers or toes, ear
and scalp, the areas under the
breasts, any point of flexion, or
between the genital folds.
117. Conti.
Sterile scissors and forceps should
be used to trim loose eschar and
encourage separation of devitalized
tissue.
During this procedure, the wound
and surrounding skin are carefully
inspected.
Documentation should include color,
odor, size, exudate, any changes
from the previous dressing change,
and other key characteristics Wound
Debridement.
118. Goals of debridement
Removal of devitalized tissue or burn
eschar in preparation for grafting and
wound healing.
Removal of tissue contaminated by
bacteria and foreign bodies, thereby
protecting the patient from invasion of
bacteria.
126. Soft kling dressings
A small, soft, stretchy wrap often used to cover burns
on fingers.
127. Silicone Dressings:
These types of dressings are coated with soft
silicone wound contact layer which allows for
removal without re-trauma to the wound or
surrounding tissue.
They are suitable for all types of minor
superficial dermal burns that do not require
anti-microbial dressings.
They are more expensive then other types of
dressings but have considerably longer wear
time for up to 7 days.
If the burn requires frequent assessment or
debridement following injury, silicone dressings
would be an expensive option to choose as
they would be replaced more frequently, other
product should be considered.
128. Foam Dressings
• Foam dressings are polyurethane covered foam
dressings that are non-adherent, available in
various sizes and thicknesses with or without
protective borders.
• They can absorb water and maintain a moist
interface at the wound surface, and are
permeable to water vapor but restricts
environmental pathogens.
• Foam dressings are useful for moderately or
heavily exuding wounds. They are not suitable
for lightly exuding wounds as they dry the burn
out.
• They can be left intact for several days
depending on the amount of wound moisture,
and if they do not have an inbuilt border, they will
need to be secured with tape.
129. Alginate Dressings
Alginate dressings are highly absorbent,
biodegradable products derived from
seaweed that are used to absorb wound
exudate.
The high absorption is achieved via strong
hydrophilic gel formation, and they maintain
a moist wound environment that promotes
healing and the formation of granulation
tissue.
They are useful for moderate to heavily
exuding wounds.
130. Hydrogel Dressings
Gel dressings are predominantly made of water and
are designed to donate moisture to the wound.
They are useful for dry wounds to create a moist
wound environment to promote wound healing, they
are also useful for burns which contain slough as it
will moisten the slough and facilitate debridement.
Gels come is sheets or creams and both require
secondary dressings.
The high water content can be soothing for the
wound which has benefits for superficial burns which
are usually painful.
Hydrogels are useful for epidermal burns such as
sunburn, the creams are soothing especially during
the first 48 hours when it is painful, and can
reapplied as required.
131. Gel dressings with melaleuca
These are hydrogel dressings with the addition of
melaleuca.
They provide moisture to the wound as other
hydrogel dressings do, and with the addition of
melaleuca they can minimize the risk of infection
and help to reduce pain as melaleuca has anti-
inflammatory and antimicrobial properties.
These products are not recommended best
practice for burn first aid, but they are a suitable
dressing for minor superficial burns.
after first aid has been completed, particularly if
pain is the biggest problem for the patient.
They definitely do not replace analgesia but can
contribute to pain relief.
132. Hydrocolloid dressings
Hydrocolloid dressings are self adhering wafer style
dressings which can absorb exudate and maintain a
moist wound healing environment, and are useful for
lightly to moderate exuding wounds.
They are impermeable to environmental
contaminants and are easy to apply and remove
without re-trauma.
They can autolytically debride and are useful or for
moist wounds that have sleigh or non-viable tissue
that need to be removed to facilitate wound closure.
They can be left intact for 3 – 5 days or until there is
strikethrough. The patient should be advised that the
dressing is expected to change color and form as
moisture is absorb and autolytic debridement occurs
underneath.
133. Low adherence dressings
Low adherent dressings are usually
fine weave tulle dressings
impregnated with a non-petroleum
based substance such as Vaseline.
They require more frequent
dressing change than other
products, make useful secondary
dressings over hydrogels if
required, and are low adherent on
removal.
134. Nursing Interventions:-
Maintenance of Optimal Fluid
Balance
Monitor vital signs of patient.
Maintain intake and output chart.
Notify physician, if urine output <30
ml/hr, weight gain, JVD, crackles
sound in respiration.
Set I.V. fluids flow rate.
Administer dopamine or diuretics as
prescribed by physician.
135. Surgical management:-
Definite wound care for a full-
thickness burn is achieved by
autografting.
Surgical removal of a superficial
layer of client’s own unburned
skin which is subsequently grafted
to the excised or granulating burn
wound.
136. Conti.
The procedure is performed in the
operation theater under general
anesthesia.
The autographs are placed either as
a sheet or in a meshed form.
Various types of grafts used & their
procedures have been
"Reconstructive & Cosmetic
surgery”.
137. Surgical nursing management:-
1. Preoperative care
Specific preoperative care for the burn injury which
includes:-
• providing information about the areas to be
excised,
• plans for pain control,
• the time to begin nil orally (NPO), i.e. nothing by
mouth status should be obtained.
138. Conti.
• Before skin grafting, the clients
need information on the type of
skin graft to be placed,
• location of the donor site,
• other procedures to be performed,
postoperative plans for pain control
and need for immobility and
elevation of the graft site
postoperatively.
• Severe anxiety and fears of the
client should be communicated to
the surgeon and anesthetist.
139. Postoperative Care:-
Routine postoperative care has
already been discussed. Care specific
to the excised wound includes:
(a) Assessment of bleeding and pain
control.
(b) Donor sites are dressed with
occlusive dressings.
(c) Skin-grafted sites must be
immobilized to promote adherence of the
graft to the wound bed.
140. Conti.
(d) Various techniques used include suture,
staples, and dressings.
(e) As hematomas may develop beneath the
sheet graft, postoperative dressings are often
removed within 24 hours for an assessment. If
blebs appear, these must be removed, otherwise
the risk of graft loss is high.
(f) Complete bed rest must be enforced. When the
graft is placed on the lower limb, the client is not
allowed to walk until the graft has adhered, i.e., up
to the 7th postoperative day.
142. Reconstructive surgery
Reconstructive surgery, in its broadest sense, is
the use of surgery to restore the form and
function of the body.
Maxillo-Facial Surgeons, Plastic Surgeons and
Otolaryngologists do reconstructive surgery on
the face after the trauma and to reconstruct the
head and neck after cancer.
143. Conti.
Other branches of surgery (i.e., general
surgery, gynecological surgery, pediatric
surgery, cosmetic surgery) are also related to
some reconstructive procedures.
The common feature of all the operations is
to attempt to restore the anatomy or function of
the body part to normal.
Reconstructive plastic surgeons use the
concept of a reconstructive ladder increasingly
to manage the complex wounds. This ranges
from very simple techniques, such as primary
closure and dressings, to more complex skin
grafts, tissue expansion and free flaps.
144. Indications:-
1.To restore functions of the deformed part of the body.
2. To prevent further loss of function.
3. To cosmetically improve congenital or acquired defects as a result of
disease, trauma and removal of a mole or wrinkles.
4. To use skin grafting as an emergency treatment to cover a large area of a
burnt part.
Reconstructive surgery can also help repair the part of a body which is
affected by any cause. According to the American Society of Plastic Surgeons,
nearly one million reconstructive surgery procedures are performed each year.
148. Benefits Of Reconstructive Surgery
Benefits of reconstructive surgery include:
Restoring proper functions of a body part.
Providing a more natural appearance where a defect
existed.
Gaining confidence due to restoration of normal
features and ability.
Reducing pain caused by the wear and tear of joints.
Fixing a congenital defects.
Providing the ability to perform daily activities more
easily.
160. Classification of Grafts
Grafts are classified on the basis of source, i.e.
1. An autograft. This is a graft taken from the receiver's body. It is a universal method.
2. Homograft. The graft (tissue) is taken from another human being. It is taken either
from the living person or shortly after death. Its survival rate is unsatisfactory. The
graft usually dies within 3 months. It is used as a temporary measure to prevent the
loss of body fluids, especially in cases of extensive body burns.
3. Heterograft/Xenograft in which one type of tissue is transferred to another type of
tissue. This is not preferred because of high antigenic reactions. The other inert or
inactive materials used as xenograft are Teflon, silicon, etc.
161. Types of skin thickness graft
Depending on the skin thickness, following types of grafts are employed:
1.Pinch graft (Reverdin graft).
2.Split thickness skin grafts.
(a)Thin split thickness graft (Thiersch graft).
(b)Intermediate thickness graft.
(c)Full thickness skin graft.
3. Skin flaps or pedicle graft.
4. Tube pedicle or suitcase graft.
5. Tattooing
6. dermabrasion
162. Procedures:-
Z-Plasty and Y-Plasty. The surgeon mobilizes the skin, by Z-
shape or Y-shape incisions, to cover the defect after release of
the contracture or scar. Stretchability of the skin, size of the scar
and its location are important factors in choosing this procedure.
The favored sites are axilla, inner aspect of elbow, neck and
throat.
Skin grafting. In such operations, either a patch of skin is
removed from the donor site and transplanted at the recipient
site, called skin grafting, or else its one end is left attached to
the donor site for nourishing the graft till its own circulation is
established at the recipient site.
163.
164. Medicolegal aspects of burns
The burns, for medicolegal purposes, are classified
as:
(i)suicidal,
(ii)homicidal or
(iii)accidental.
165. Psychosocial aspect and nursing
Nurses perceived that psychosocial care consists of
a) providing holistic care,
b) spiritual care,
c) support to the patient and family members, and
d) showing empathy.
e) Furthermore, psychosocial care is composed of
communication between nurses and the patient and
family members as well as communication among
nurses.
166. Drugs used in treatment of burn
Silver sulfadiazine topical
Generic name: silver sulfadiazine topical
Brand names: Silvadene, SSD, Thermazene, SSD AF
Drug class: Topical antibiotics
• Silver sulfadiazine is an antibiotic. It fights bacteria and yeast on
the skin.
• Silver sulfadiazine topical (for the skin) is used to treat or
prevent serious infection on areas of skin with second- or third-
degree burns.
• Silver sulfadiazine topical may also be used for purposes not
listed in this medication guide.
167. Silvadene
Generic name: silver sulfadiazine topical
Brand names: Silvadene, SSD, Thermazene
Drug class: Topical antibiotics
Silver sulfadiazine is an antibiotic. It fights bacteria and yeast
on the skin.
Silvadene (for the skin) is used to treat or prevent serious
infection on areas of skin with second- or third-degree burns.
Silvadene may also be used for purposes not listed in this
medication guide.
168. Lidocaine topical
Generic name: lidocaine topical
brand names: anecream, bactine, glydo, lidamantle
drug class: topical anesthetics
Lidocaine is a local anesthetic (numbing medication).
Lidocaine topical (for use on the skin) is used to reduce pain or
discomfort caused by skin irritations such as sunburn, insect
bites, poison ivy, poison oak, poison sumac, and minor cuts,
scratches, or burns.
Lidocaine topical is also used to treat rectal discomfort caused
by hemorrhoids.
Lidocaine intradermal device can be used in minor medical
procedures such as venipuncture or peripheral intravenous
cannulation.
169. Albumin (human)
Generic name: albumin (human)
brand names: albuked, albuminar-25, alburx, albutein, buminate
dosage form: intravenous solution
Albumin is a protein produced by the liver that circulates in plasma (the clear
liquid portion of your blood).
Medicinal albumin is made of plasma proteins from human blood. This medicine
works by increasing plasma volume or levels of albumin in the blood.
Albumin is used to replace blood volume loss resulting from trauma such as a
severe burns or an injury that causes blood loss.
This medicine is also used to treat low albumin levels caused by surgery, dialysis,
abdominal infections, liver failure, pancreatitis, respiratory distress, bypass
surgery, ovarian problems caused by fertility drugs, and other many other
conditions.
170. Gentamicin
Generic name: gentamicin
brand names: garamycin, cidomycin
dosage forms: injectable solution
drug class: aminoglycosides
• Gentamicin is an antibiotic that fights
bacteria.
• Gentamicin is used to treat severe or
serious bacterial infections.
• Gentamicin may also be used for purposes
not listed in this medication guide.
171. Vancomycin
Generic name: vancomycin (oral)
Brand names: FIRST-Vancomycin 25, FIRST-Vancomycin 50
Drug class: Glycopeptide antibiotics
Vancomycin is an antibiotic. Oral (taken by mouth) vancomycin fights bacteria in the
intestines.
Vancomycin is used to treat an infection of the intestines caused by clostridium difficile,
which can cause watery or bloody diarrhea. This medicine is also used to treat staph
infections that can cause inflammation of the colon and small intestines.
Oral vancomycin works only in the intestines and is not normally absorbed into the
body.
Vancomycin will not treat other types of infection. An injectable form of this medicine is
available to treat serious infections in other parts of the body.
172. Ibuprofen
Ibuprofen is an NSAID used to
treat fever and pain from arthritis, menst
rual cramps, and muscular aches. It
works by reducing inflammation.
Ibuprofen should be used only when
needed as it may increase risk of
stroke or heart attack and long term use
can cause stomach bleeding and ulcers.
174. First Aid
It assists with pain relief as well as
minimizing the progression of tissue
damage.
First aid is effective for up to three hours post
time of injury.
If appropriate first aid was not initiated and it
is still within the 3 hour time frame post burn
injury, first aid should be completed as
outlined below, prior to any wound care:
175. Conti.
The area of tissue damage should be
cooled with cool running water for 20
minutes.
Cooling for longer than 20minutes is
not beneficial.
Ensure the unburnt areas of the
patient are covered and warm to
prevent hypothermia.
176. Emergency Nursing Assessment
Focus on the major priorities of any trauma
patient.
Monitor vital signs frequently.
Start cardiac monitoring if indicated.
Check peripheral pulses.
Monitor fluid intake (IV fluids) and output
(urinary catheter) and measure hourly.
Obtain history
patients with facial burns to be assessed
for corneal injury.
177. Conti.
Continue to assess the extent of the burn;
assess depth of wound, and identify areas of
full and partial thickness injury.
Assess neurologic status: consciousness,
psychological status, pain and anxiety levels,
and behavior.
Assess patient’s and family’s understanding
of injury and treatment.
Assess patient’s support system and coping
skills.
178. Acute Phase
• The acute or intermediate phase begins
48 to 72 hours after the burn injury.
• Burn wound care and pain control are
priorities at this stage.
• Acute or intermediate phase begins 48 to
72 hours after the burn injury.
• Focus on hemodynamic alterations,
wound healing, pain and psychosocial
responses, and early detection of
complications.
179. Conti.
Measure vital signs frequently.
Respiratory and fluid status remains highest priority.
Assess peripheral pulses frequently for first few days after
the burn for restricted blood flow.
Closely observe hourly fluid intake and urinary output, as well
as blood pressure and cardiac rhythm; changes should be
reported to the burn surgeon promptly.
For patient with inhalation injury, regularly monitor level
of consciousness, pulmonary function, and ability to ventilate; if
patient is intubated and placed on a ventilator,
frequent suctioning and assessment of the airway are priorities.
180. Rehabilitation Phase
Rehabilitation should begin immediately after the burn has
occurred.
Wound healing, psychosocial support, and restoring maximum
functional activity remain priorities.
Maintaining fluid and electrolyte balance and
improving nutrition status continue to be important.
In early assessment, obtain information about patient’s educational
level, occupation, leisure activities, cultural background, religion,
and family interactions.
Assess self concept, mental status, emotional response to the
injury and hospitalization, level of intellectual functioning, previous
hospitalizations, response to pain and pain relief measures,
and sleep pattern.
181. Conti.
Perform ongoing assessments related to
rehabilitation goals, including range of motion of
affected joints, early signs of skin breakdown from
splints or positioning devices, evidence of neuropathies
(neurologic damage), activity tolerance, and quality or
condition of healing skin.
Document participation and self care abilities in
ambulation, eating, wound cleaning, and applying
pressure wraps.
Maintain comprehensive and continuous assessment
for early detection of complications, with specific
assessments as needed for specific treatments, such as
postoperative assessment of patient undergoing primary
excision.
182. Nursing Interventions
Promoting Gas Exchange and Airway
Clearance
Restoring fluid and Electrolyte Balance
Maintaining Normal Body Temperature
Minimizing Pain and Anxiety
Restoring Normal fluid Balance
Preventing Infection
183. Conti.
Monitor culture results and white
blood cell counts.
Maintaining Adequate Nutrition
Promoting Skin Integrity
Relieving Pain and Discomfort
Promoting Physical Mobility
Strengthening Coping Strategies
Teaching Self-care
184. Discharge and home care guidelines
Wound care
Education
Follow up care
Referral
185. Nursing diagnosis:-
Impaired skin integrity related to burn injury causing
skin discoloration and eschar formation.
Disturbed body image related to burn trauma.
Risk for infection related to impaired skin integrity.
Decreased cardiac output related to hypovolemia.
Hypothermia related to loss of skin layer and open
wound.
Pain related to tissue and nerve injury.
Anxiety related to fear and emotional impact of injury.
Impaired gas exchange related to inhalation injury.
186. A. Preoperative care
1. Explanation about the
surgery.
2. Thorough medical check-up.
3. Preoperative instructions for
surgery.
4. An informed consent may be
obtained.
5. Preoperative investigations.
187. Conti.
7. Area for plastic and
reconstructive surgery should be
infection-free.
8. Preparation of donor site.
9. Preparation of recipient site.
10. Transfer to OT.
188. B. Postoperative care
1.Care of the graft.
2.Suture care.
3.Observation of dressing
4.Care of pt. in plaster cast
5.Psychological support
6.Rehabilitation
189. A 58 year old female patient has superficial partial-thickness
burns to the anterior head and neck, front and back of the left
arm, front of the right arm, posterior trunk, front and back of the
right leg, and back of the left leg. The patient weighs 91 kg..
Using the Rule of Nines, calculate the total body surface area
percentage that is burned, Use the Parkland Burn Formula to
calculate the total amount of Lactated Ringers that will be given
over the next 24 hours, how much fluid need to be administer in
2nd half hours, formulate the nursing diagnosis and make the
nursing care plan.
A.63%
B.81%
C.72%
D.54%
![VIVEKANANDA COLLEGE OF NURSING
TEACHING PRACTICE
PRESENTED BY:- APURVA DWIVEDI [M.Sc. Nursing 1ST Yr.]](https://image.slidesharecdn.com/burn-220717100444-6fae56fa/85/BURN-pptx-1-320.jpg)
