Nursing

1. Prepared By: Justin V Sebastian, MSc N, RN, PhD Scholar

2. Integumentary System

3. • This system is divided into:
1- skin
2- hair
3- glands
4- nails
5- nerve endings
Skin
Skin is an organ because it consists of different
tissues that are joined to perform a specific function.
Largest organ of the body in surface area and weight.
Dermatology is the medical specialty concerning the
diagnosing and treatment of
skin disorders.

5. Anatomy (structure)
Epidermis (thinner outer layer of skin)
Dermis (thicker connective tissue layer)
Hypodermis (subcutaneous layer or Sub-Q)
Muscle and bone
Physiology (function)
1- Protection
- physical barrier that protects underlying
tissues from injury, UV light and bacterial
invasion.

6. 2- Regulation of body temperature
- high temperature or strenuous exercise;
sweat is evaporated from the skin surface to
cool it down.
- vasodilatation (increases blood flow) and
vasoconstriction (decrease in blood flow)
regulates body temp.
3-Sensation
- nerve endings and receptor cells that
detect stimuli to temp, pain, pressure and touch.

7. 4- Excretion
- sweat removes water and small amounts of
salt, uric acid and ammonia from the body
surface
5- Blood reservoir
- dermis houses an extensive network of
blood vessels carrying 8-10% of total blood
flow in a resting adult.
6- Synthesis of Vitamin D (cholecalciferol)
-UV rays in sunlight stimulate the production
of Vit. D. Enzymes in the kidney and liver
modify and convert to final form; calcitriol
(most active form of Vit. D.) Calcitriol aids in
absorption of calcium from foods and is
considered a hormone.

8. Definitions
1. A burn occurs when there is an injury to the
tissues of the body caused by heat, chemicals,
electric current, or radiation
lewis’s
The effects are influenced by
• The temperature of the burning agent
• Duration of contact time
• Type of tissue that injured

9. 2,
Burns are a form of traumatic injury caused
by thermal, electrical, chemical, or radioactive
agents.
Lippincott
3,
Burns are caused by transfer of energy from
a heat source to the body
Brunner and suddarth’s
The depth of injury depend on:
• Temperature of the burning agent
• Duration of contact with it

10. Incidence
• Males have greater then twice the chance of
burn injury than females.
• The most frequent age group for contact burns
is between 20 to 40 years of age.
• The national fire protection association reports
4,000 fire and burn deaths each year. Of these,
3500 deaths occur from residential fires and
the remaining 500 from other sources such as
motor vehicle crashes, scalds, or electrical and
chemical sources.

11. Etiology and types
1. Thermal burns may result from any external heat
source (flame, liquids, solid objects, or gases).
2
,
Radiation burns most commonly result from
prolonged exposure to solar ultraviolet radiation
(sunburn) but may result from prolonged or intense
exposure to other sources of ultraviolet radiation (eg,
tanning beds) or from exposure to sources of x-ray or
other non solar radiation.

12. 3, Chemical burns may result from strong acids, strong
alkalis (e.g, lye, cement), phenols, cresols,
mustard gas, or phosphorus. Skin and deeper
tissue necrosis due to these agents may progress
over several hours.
4, Smoke and inhalation injury
Result from the inhalation of hot air or noxious
chemicals and can cause damage to the tissues of
the respiratory tract.
There are three types of inhalation injury
Carbon monoxide poisoning
Inhalation injury above the glottis
Inhalation injury below the glottis

13. 5, Electrical burns result from the electrical
generation of heat; they may cause extensive deep
tissue damage despite minimal apparent cutaneous
injury.
6, Cold injury
A general term for an injury induced by low
ambient temperatures ( eg. Frostbit), which may
be accompanied by tissue freezing.
Risk groups includes infants, young children,
elderly, alcohol use

14. Common places and causes of burn injury
❖ Occupational hazards
• Tar
• Chemicals
• Hot metals
• Steam pipes
• Combustible fuels
• Fertilizers/pesticides
• Electricity from power
lines
• Spark from live
electric sources
❖ Home and
recreational hazards
• Pressure cookers
• Microwaved food
• Hot water heaters
• Defective wiring
• Radiators
• Carelessness with
cigarettes or matches
• Storage of flammables
( e.g.,kerosene)

15. Risk Factors

16. Non Modifiable Risk Factors
•Age: Children under 4 who are
poorly supervised are at particular
risk.
•Gender: Males are more than
twice as likely to suffer burn
injuries.

17. Modifiable Risk Factor
s
•Careless smoking: Cigarettes are the leading cause of house
fires.
•Absent or nonfunctioning smoke detectors: The presence of a
functioning smoke detector decreases risk of death by fire by 60
percent.
•Use of wood stove
s
•Exposed heating sources or electrical cords
•Unsafe storage of flammable or caustic materials
•Water heaters set above 120°F
•Microwave heated foods and containers
•Substandard or older housing
•Substance abuse: Use of alcohol and illegal drugs increases risk.

18. Classification of burn in jury
1. Depth of burn
2. Extent of burn
3. Location of burn

19. Assessment of depth of Burn Injury
Takes several weeks to heal.
Scarring may occur.
Takes several weeks to heal.
Scarring may occur.
Superficial:
Pink or red; blisters form (vesicles);
weeping, edematous, elastic.
Superficial layers of skin are destroyed;
wound moist and painful.
Deep dermal:
Mottled white and red: edematous
reddened areas blanch on pressure.
May be yellowish but soft and elastic –
may or may not be sensitive to touch;
sensitive to cold air.
Hair does not pull out easily
Second degree
(deep partial-
thickness)
In about 5 days, epidermis peels, heals
spontaneously.
Itching and pink skin persist for about a
week.
No scarring.
Heals spont. If it does not become infected
w/in 10 days - 2 weeks.
Pink to red: slight edema, which
subsides quickly.
Pain may last up to 48 hours.
Relieved by cooling.
Sunburn is a typical example.
First Degree
(superficial
partial-thickness)
Reparative Process
Assessment of Extent
Extent / Degree

20. Eschar must be removed. Granulation
tissue forms to nearest epithelium from
wound margins or support graft.
For areas larger than 3-5 cm, grafting is
required.
Expect scarring and loss of skin function.
Area requires debridement for formation of
granulation tissue, and grafting.
Destruction of epithelial cells –
epidermis and dermis destroyed
Reddened areas do not blanch with
pressure.
Not painful; inelastic; coloration varies
from waxy white to brown; leathery
devitalized tissue is called eschar.
Destruction of epithelium, fat, muscles,
and bone.
Third degree
(full- thickness)
Reparative Process
Assessment of Extent
Extent / Degree
Assessment of depth of Burn Injury
AGE AND GENERAL HEALTH
• Mortality rates are higher for children < 4 y.o, particularly those < 1 y.o., and for
clients over the age of 60 years.
• Debilitating disorders, such as cardiac, respiratory, endocrine, and renal,
negatively influence the client’s response to injury and treatment.
• Mortality rate is higher when the client has a preexisting disorder at the time of
the burn injury

22. Assessment of extent of burn injury
Various methods are used to estimate the TBSA
affected by burns; among them are
1.Rule of nines
Rule of Nines for Establishing Extent of Body Surface
Burned Anatomic Surface
• % of total body surface
• Head and neck
=9%
• Anterior trunk
=18%
• Posterior trunk
=18%
• Arms, including hands
=9% each
• Legs, including feet
=18% each
• Genitalia/Perineum
=1%
9
18
9
18
9
18
1

23. 2, Lund and browder method

24. 3,
Palmer method

25. Assessment of location of burn injury
The severity of the burn injury is
related to location of the burn wound
• Burns to the face and neck and
circumferential burns to the chest/back
• Burns of the hands, feet, joints, and eyes
• Burns to the ears and nose
• Burns to the buttocks and genitalia
• Circumferential burns to the extremities

26. Zone of burn

27. Zone of burn

28. Pathophysiology

30. Heat causes coagulation necrosis of skin and
subcutaneous tissue
Release of vasoactive peptides
Altered capillary permeability
Loss of fluid
severe hypovolemia

31. Decreased cardiac
decreased myocardial
output
function
Decreased renal
oliguria
blood flow
Altered pulmonary resistant and pulmonary edema
Infection
SIRS
MODS

33. Clinical features
❖Cardiovascular alterations
o Hypovolemia
o Decreased CO
o Burn shock
o Increase peripheral resistance
o Anemia
o Increased hematocrit
o Decreased platelets
o Diuresis

34. ❖Fluid and electrolyte alterations
o Edema
o Ischemia
o Hyponatremia
o Hyperkalemia
o Hypokalemia
❖Pulmonary alterations
o Hypoxia
o Loss of ciliary action
o Hyper secretion
o Mucosal edema
o Bronchospasm

35. o Atelectasis
o Restrictive pulmonary excursion
o Decreased lung compliance
o Decreased arterial O2 level
o Respiratory acidosis
o Pulmonary complications such as airway
obstruction, ulceration, pulmonary edema,
respiratory failure, ARDS and pneumonia can
develop.

36. ❖Renal alterations
o Altered renal function
o Hemoglobin in the urine
o Myoglobin in the urine
o Acute tubular necrosis
o Renal failure
❖Immunological alterations
o Infection and sepsis
❖Thermoregulatory alterations
o Hypothermia

37. ❖Gastrointestinal alterations
o Paralytic ileus
o Curling’s ulcer
o Gastric bleeding
o Infection

38. Diagnostic
Tests

39. •A detailed history and
physical examination is the
first step. The physician will
evaluate the type, duration,
and timing of the burn; the
burn location and severity;
and associated dehydration,
disfigurement, and infection.
•Fires in enclosed spaces
should raise the suspicion for
smoke–inhalation injury.

40. •Routine blood work for a patient with
a burn injury includes a complete blood
count, platelet count, clotting studies,
l i v e r f u n c t i o n s t u d i e s , a n d
carboxyhemoglobin, electrolyte, blood
urea nitrogen, glucose and creatinine
levels.
•Urinalysis may reveal myoglobinuria
and hemoglobinuria.
•If pt. is electric burn, he’ll also need an
electrocardiogram.
•Chest x-rays and arterial blood gas
levels allow the evaluation of alveolar
function. Fiberoptic bronchoscopy shows
the condition of the trachea and bronchi.

41. Management

42. Phases of burn care
I. Emergent/resuscitative phase
II.Acute/ intermediate phase
III.Rehabilitation phase

43. Emergent/resuscitative phase
From the onset of injury to completion of fluid
resuscitation.
Priorities
oFirst aid
oPrevention of shock
oPrevention of respiratory distress
oDetection and treatment of injuries
oWound assessment and initial care

44. On-the-scene care
oExtinguish the flames
oCool the burn
oRemove restrictive objectives
oCover the wound
oIrrigate chemical burn

45. ESCHAROTOMY
• A lengthwise incision is made through the burn eschar to relieve
constriction and pressure and to improve circulation
• Performed for circulatory compromise resulting from circumferential
burns
• After escharotomy, assess pulses, color, movement, and sensation of
affected extremity and control any bleeding with pressure
• Apply topical antimicrobial agents as prescribed

46. Medical management
❖The patient transported to the nearest ED
❖Initial priorities in the ED remain ABC and C spine
control
❖For mild pulmonary injury 100% humidified O2 is
administered
❖The patient is encouraged to cough
❖For more severe situations; administer
bronchodilator and mucolytic agents
❖If edema of airway develops, ET intubation may be
necessary
❖All clothing and jewellery are removed

47. Medical management ( cont..)
❖For chemical burn flushing of the exposed area
should be done
❖Validate an account of the burn scenario provided by
the patient or witnesses
❖A large bore ( 16 or 18 gauge) IV catheter should be
inserted
❖If burn exceeds 20% to 25% TBSA, a NG tube
inserted
❖Clean technique is maintained while assessing and
treating the burn wounds
❖Careful attention is paid to keeping the patient warm

48. Medical management ( cont..)
❖Photograph may be taken of the burn area initially
and periodically throughout treatment
❖Clean sheets are placed under and over the patient
❖An indwelling urinary catheter is inserted
❖Baseline data should be obtained ( such as height,
weight, ABG, electrolyte, blood alcohol, drug panel,
chest X rays etc..)
❖If the patent has an electrical burn, a baseline ECG
❖Tetanus prophylaxis
❖Attends the patient’s and family’s psychological
needs

49. Medical management ( cont..)
❖Transfer to a burn centre
Management of fluid loss and shock
Observation
o Generalized dehydration
o Reduction of blood volume
o Decreased urinary output
o Potassium excess
o Sodium deficit
o Metabolic acidosis
o Elevated hematocrit

50. FLUID REQUIREMENT
• Indications:
- Adults with burns involving more than 15% - 20% TBSA
- Children with burns involving more than 10-15% TBSA
- Patients with electrical injury, the elderly, or those with cardiac
or pulmonary disease and compromised response to burn injury
• The amount of fluid administered depends on how much
intravenous fluid per hour is required to maintain a urinary output
of 30 - 50 ml/hr
• Successful fluid resuscitation is evidenced by:
- Stable vital signs
- Palpable peripheral pulse
- Adequate urine output
- Clear sensorium
• Urinary output is the most common and most sensitive assessment
parameter for cardiac output and tissue perfusion
• If the Hgb and Hct levels decrease or if the urinary output exceeds
50ml/hr, the rate of IV fluid administration may be decreased
• Generally, a crystalloid (Ringer’s lactate) solution is used initially.
Colloid is used during the 2nd day (5% albumin, plasmate)

51. ½ in 1st 8 hours
½ in next 16 hours
crystalloid only
(lactated Ringer’s)
PARKLAND (Baxter)
4ml/kg/% BSA for 24hr
period
½ in 1st 8 hours
½ in next 16 hours
crystalloid, colloid
D5W maintenance
BROOKE
2ml/kg/% BSA + 2000ml/
24hr (maintenance)
Infusion Rate
Solution
Formula
Brooke and Parkland (Baxter) Fluid Resuscitation Formulas for 1st 24hrs
after a Burn Injury

52. PARKLAND FORMULA
Example: Patient’s weight: 70 kg; % TBSA burn: 80%
1st 24 hours:
4ml x 70kg x 80% TBSA = 22,400ml of lactated Ringer’s
• 1st 8 hours = 11,200 ml or 1400ml/hour
• 2nd 16 hours = 11,200 ml or 700ml/hour
BROOKE FORMULA
2nd 24 hours:
0.5ml colloid x weight in kg x TBSA + 2000ml D5W run
concurrently over the 24 hour period
0.5ml x 70kg x 80% = 2800 ml colloid + 2000 ml D5W
= 117 ml colloid/hour + 84 ml D5W/
hour

53. Acute/ intermediate phase
From beginning of diuresis to near
completion of wound closure ( 48 – 72
hrs )
❖Observation
oDecreased hematocrit
oIncreased urinary output
oSodium deficit
oPotassium deficit

54. Medical management (cont..)
❖Bronchial washing
❖Remove ET tube as soon as possible
❖Cautious administration of fluid and
electrolyte
❖Blood components are administered as
needed
❖Central venous, peripheral arterial or
pulmonary artery catheters may be
required

55. ❖Infection prevention
❖Wound cleaning
❖Topical antibacterial therapy
❖Wound dressing
❖Wound debridement
❖Wound grafting
❖Pain management
❖Nutritional support

56. Medical management (cont..)
❖Infection prevention
➢Early enteral feeding
➢Aseptic technique is used when caring directly for burn
wound
➢Gowns and gloves are worn by all caregivers and
visitors
➢Hand hygiene is used before and after leaving the
patient room
➢Constant monitoring and observation of the wound
➢Tissue specimen may be obtained for culture to
monitor colonization
➢Systemic antibiotics are administered when there is
documented sepsis

57. Medical management (cont..)
❖Wound cleaning
➢Hydrotherapy
➢The temperature of the water is maintained at 37.8 C
➢During the bath, the patient is encouraged to be active
as possible
➢At the time of wound cleaning, all skin is inspected
➢Intact blisters should be left alone and debrided only if
they rupture or break
➢When nonviable loose skin is removed, aseptic
condition must be established
➢After the wounds are cleaned, they are gently patted
dry, and the prescribed method of wound care is
performed

58. ❖TOPICALANTIMICROBIAL THERAPY
Silver sulfadiazine
• Most widely used agent and least common incidence of side
effects
• May cause transient leukopenia that disappears 2-3 days of
treatment
• Use with either open treatment, light or occlusive dressings
• Applied once or twice daily after thorough wound cleansing
Mafenide acetate 10% cream or 5% solution (Sulfamylon)
• Painful during and for a while after application
• May cause metabolic acidosis, not used if >20% TBSA
• Cream must be reapplied 12 hours to maintain therapeutic
effectiveness
• Solution concentration is maintained with bulky wet dressings,
rewet every 2-4 hours
Silver nitrate (0.5% solution)
• Stains everything including normal skin brown or black
• Monitor electrolyte balance carefully

59. Medical management (cont..)
❖Wound dressing
➢After wound cleaning, prescribed topical agent is
applied; the wound is then covered with dressings
➢A light dressing is applied over the areas of splint,
joints
➢Circumferential dressing should be applied to distally
to proximally
➢The fingers and toes should be wrapped individually
➢Burns to the face may be left open/a light dressing can
be applied
➢Occlusive dressing may be used over new skin graft to
protect the graft. Ideally, these dressing remain in place
for 3 to 5 days

61. Medical management (cont..)
❖Wound debridement
Goals
• Removal of tissue contaminated by bacteria and
foreign bodies, thereby protecting the patient from
invasion of bacteria
• Removal of devitalized tissue or burn eschar in
preparation for grafting and wound healing
There are 4 types
➢Natural debridement
➢Mechanical debridement
➢Chemical debridement
➢Surgical debridement

62. Natural debridement
The dead tissue separates from the underlying
viable tissue spontaneously.

63. Mechanical debridement
Involves the use of surgical scissors,
scalpels, and forceps to separate and remove
the eschar.

64. Chemical debridement
Use of topical enzymatic debridement agents to
remove eschar.

66. Surgical debridement
It is an operative procedure involving either
primary excision of the full thickness of the skin or
down to the burned skin layers gradually down to
freely bleeding, viable tissue.

67. ❖Wound grafting
The purpose of wound grafting are:
oTo decrease the risk of infection
oTo prevent further loss of protein, fluids and
electrolytes
oTo minimize heat loss through evaporation
The main areas for skin grafting include the face
( for cosmetic and psychological reasons); functional
areas such as the hands and feet; and areas that
involves joints.
Methods
❖Biologic
❖Biosynthetic and synthetic
❖Autologous (autograft)

68. ❖Biological dressing( homograft and
heterograft)
➢It provide temporary wound coverage and protect the
granulation tissue until auto-grafting is possible
➢Once the biological dressing appears to be adhering to the
granulating surface with minimal underlying exudation , the
patient is ready for an autologous skin graft
➢They decreases pain by protecting the nerve endings and are
effective barrier against water loss and entry of bacteria
➢These dressing often require fewer dressing changes
➢Homograft are skin obtained from living or deceased
humans
➢Heterograft consist of skin taken from animals ( usually
pigs)

69. ❖Biosynthetic and synthetic dressings
➢A widely used synthetic dressing is Biobrane
➢It is semitransparent and sterile
➢Like biological dressing, Biobrane protects the
wound from fluid loss and bacterial invasion
➢When the Biobrane dressing is adheres to the
wound, the wound remain stable
➢It can remain in place until spontaneous
epithelialisation and wound healing occur
➢It can be laid on top of a wide meshed
autograft

71. Biosynthetic and synthetic dressings
(cont..)
Skin substitutes
It is believed that skin substitutes
enhance the healing process of an open
wound when autologous skin is
unavailable or limited for use

72. Biosynthetic and synthetic dressings (cont..)
Integra Artificial Skin
➢It is composed of two main layers
➢The epidermal layer consist of silicone, act as a bacterial
barrier and prevents water loss from the dermis
➢The dermal layer consist of animal collagen. It allows
migration of fibroblast and capillaries in to the material

73. ❖Auto graft
Autograft are the ideal means of
covering burn wound because the graft are
the patient’s own skin and therefore are not
rejected by the patients immune system
They can be
❖Split-thickness
❖Full thickness
❖Pedicle flaps
❖Epithelial graft

74. ❖Split thickness autograft
In this skin can be expanded by meshing so
that they cover 1.5 to 9 times more than a
given donor site area
❖Full thickness autograft
It consist of full thickness of the skin, with
little or none of the subcutaneous tissue
❖Pedicle flaps
Consisting of full thickness of the skin and
the subcutaneous tissue, attached by tissue
through which it receives its blood supply

75. ❖Epithelial graft
Transplantation of epithelial tissue
Cultured epithelial autograft (CEA)
➢Provides permanent coverage of large wound
➢This involves biopsy of the patient’s skin in a
unburned area. keratinocytes are isolated, an
epithelial cells are cultured in a laboratory.
Patient have longer hospital stay and higher
hospital cost
Therefore, CEA is very limited for patients whose
donor sites are limited

77. PAIN MANAGEMENT
• Administer morphine sulfate or meperidine (Demerol), as
prescribed, by the IV route.
• Avoid IM or SC routes because absorption through the soft tissue
is unreliable when hypovolemia and large fluid shifts are
occurring.
• Avoid administering medication by the oral route, because of the
possibility of GI dysfunction.
• Medicate the client prior to painful procedures.
NUTRITIONAL SUPPORT
• Essential to promote wound healing and prevent infection.
• Maintain nothing by mouth (NPO) status until the bowel sounds
are heard; then advance to clear liquids as prescribed.
• Nutrition may be provided via enteral tube feeding, or peripheral
parenteral nutrition.
• Provide a diet high in protein, carbohydrates, fats and vitamins.

78. Rehabilitation phase
Rehabilitation begins immediately after the
burn has occurred and often extends for years
after injury
oPsychological support
Complications in rehabilitation phase
oNeuropathies
Interventions
• Assess peripheral pulses and sensation
• Prevent edema and pressure by elevation
• Assess splints
• Consult OT and PT

79. o Heterotopic ossification
Intervention
• Perform gentle range of motion exercise
o Hypertrophic scaring
Intervention
• Keep the skin soft
• Massage
o Contractures
Intervention
• Perform gentle range of motion exercise
• Consult OT and PT

80. oWound breakdown
Interventions
• Teach patient about importance of nutrition
• Protect wound from pressure and forces
oComplex regional pain syndrome
Interventions
• Provide adequate pain management
• Consult OT and PT
• Promote gentle motion of affected
extremities

82. Actual:
•Impaired gas exchange
•Ineffective tissue perfusion

83. Potential:
• Risk for Infection
•Risk for Post traumatic stress
disorder (PTSD)

84. Interventions

85. BURN INTERVENTIONS
• MAINTAIN AIRWAY
• FLUID RESUSCITATION
• RELIEVE PAIN
• PREVENT INFECTION
• PROVIDE NUTRITION
• PREVENT STRESS ULCERATION
• PROVIDE PSYCHOLOGIC SUPPORT
• PREVENT CONTRACTURE

86. ASSIGNMENT ON NURSING PROCESS
:
• Care of the Patient During the Emergent/
Resuscitative Phase of Burn Injury
• CARE OF THE PATIENT DURING THE
ACUTE PHASE
• CARE OF THE PATIENT DURING THE
REHABILITATION PHASE

87. The END
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