3rd bsc nursing

1. GOVERNMENT COLLEGE OF NURSING
RMC, KAKINADA
SEMINAR
ON
BURNS AND MANAGEMENT
Submitted to : Submitted by :
M.Uma sundari madam, S.V.Ramya Madhuri
Assistant professor, Roll no : 32,
Govt.clg of nursing, 3rd year, Bsc nursing
RMC, kakinada. Govt.clg of nursing,
RMC, kakinada

2. Identification data :
NAME : S.V. Ramya Madhuri
TOPIC : Burns and management
SUBJECT :Medical surgical nursing
GROUP :3rd year nursing students
SIZE OF GROUP : 46 members
VENUE : Govt College of nursing
A.V. AIDS : Powerpoint, flash cards,
flipchart, model, pamphlet
DURATION OF TEACHING. : 2 hrs
METHOD OF TEACHING : lecturer Cum discussion.
DATE OF PRESENTATION : May 15
TIME OF PRESENTATION : 2-4 pm
PREVIOUS KNOWLEDGE : students have Knowledge
regarding the burns.

3. OBJECTIVES :
GENERAL OBJECTIVES:
At the end of seminar the students will be able to
gain in depth knowledge regarding burns and develop right
attitude and skills towards providing comprehensive care to
clients with burns
SPECIFIC OBJECTIVES:
By the end of the class the students will be able to:
1.Introduces the topic burns.
2. discusses anatomy and physiology of skin
3. defines burns
4 gives incidence of burns world wide
5. classification of burns
6. lists clinical manifestations of buns
7. enumerates diagnostic tests for burn
8. explains management of each phase of burns
9. discusses the medical management of burns
10. explains surgical management of burns
11. describes nursing management of burs
12. Discuss the complication and prevention

4. BURNS
Introduction :
. Burn is the type of injury to skin caused by heat, electricity,
chemical, light, radiation or friction.
• Burn patients often require multiple surgical episodes and
dressing changes followed by prolong rehabilitation and victim can
be left with lifelong dysaesthetic scarring and potential
dysfunction.
• Burn wound injuries to the skin result in the loss of its protective
function as a barrier to the microorganism leading to the the risk of
infection.
• The treatment of burns includes removal of of dead tissue
(debridement), dressing of wound, fluid recovery, antibiotics
administration and skin grafting.

5. ANATOMY AND PHYSIOLOGY OF INTEGUMENTARY SYSTEM
ANATOMY OF SKIN
❖ The Integumentary system is the largest body organ
composed of the skin, hair, nails, and glands. The skin
was further divided into 3 layers. Those are:
1.Epidermis
2.Dermis
3. Hypodermis
EPIDERMIS:
➢The epidermis, the thin avascular superficial layer of the
skin, is made up dead cornified portion that serves as a
protective barrier and a deeper, living portion that folds
into the dermis.
➢Together these layers measures 0.05 to 0.1mm in
thickness.
➢The epidermis regenerates with new cells every 28 days

6. LAYERS OF EPIDERMIS : Layers from deep to superficial
1.Stratum basale or germinatum
2.Stratum spinosum
3.Stratum granulosum
4.Stratum lucidum
5.Stratum corneum
CELLS OF EPIDERMIS :
The two major types of cells are : 1 Melanocytes (5%)
2.Keratinocytes (90%)
1.Melanocytes are contained in the deep basal layer of the
epidermis.
2.keratnocytes synthesized from epidermal cells in the basal layer.
DERMIS :
Dermis is the connective tissue below the epidermis.
• Dermal thickness varies from 1 to 4 mm. The dermis is very
vascular
LAYERS OF DERMIS : 1. An upper thin papillary layer
2. A deeper thicker reticular layer
1.Papillary layer: The papillary layer is folded into ridges which
extend into the upper epidermal layer.
2.Reticular layer: It contains fat cells, blood, and lymph Vessels,
sweat glands, hair follicles and arrector pill muscle

7. HYPODERMIS/ SUBCUTANEOUS TISSUE:
✓The subcutaneous tissue lies below the dermis and is not part
of the skin.
✓The subcutaneous tissue is often discussed with the skin
because it attaches the skin to underlying tissues such as
muscles and bones.
✓The subcutaneous tissue consists of network of collision and
fat cells help conserve body heat while protecting other organs
from injury by acting as a “shock absorber”.
PHYSIOLOGY OF SKIN
1.Regulates body temperature -Regulates heat loss.
2.Help regulate fluid loss
• Absorbs water
• Prevent excessive water and electrolyte loss
• Slow loss Up to 600 ml daily by evaporation.
3.Immune response function.
4.Vitamin production
• Exposed to UV light a loss for the conversion of substances
necessary for synthesizing vitamin D.
• Necessary to prevent osteoporosis, rickets.
5.Excretion -Partial excretion of metabolic waste occurs through
the skin.
6. Transmits sensation -nerve receptors
7. Allows for feelings of temperature, pain, light, touch, and
pressure.

8. DEFINITION OF BURNS
❖According to LEWIS Burns occur when there is injury to the
tissue of the body caused by heat, chemicals, electric current,
or radiation. The resulting effects are are influenced by
temperature of the burning agent, duration of contact time
and type of tissue injured.
❖According to Joyce M Black Injuries that result from At contact
with or exposure to any thermal, chemical or 15 lon source are
termed as burns
❖According to BRUNNER AND SIDDHARTH Burn injuries are
painful, costly, disfiguring, require intensive and extensive
rehabilitation therapy, and are often associated with long term
disability.
❖According to Farlex Burns are injuries to tissues caused by heat
friction, electricity, radiation or chemical
❖According to Swornim Gyawali A burn is a coagulative
destruction of the surface layers of the body
❖According to Medical Net.com Damage to the skin or other
body parts caused by extreme heat, flame, contact with
heated object or chemical. Burn depth is generally categorised
as first, second, third.

9. INCIDENCE :
World India Andhra Pradesh
An estimated one million
Americans and 100,000
Canadians seek medical care
each year for burns.
Approximately 70,000 people
are hospitalized in U.S and
5000 in Canada, among them
1/3rd
refine specialised burn’s
units or centres, highest
fatality rates occur in children 4
yrs of age and younger and
adults over the age of 55 yrs.
More than
20,0000
people are
diagnosed
and 50-60,000
are
hospitalized.
survival rate is
20%,
mortality is
high.
More than 5000
people are
diagnosed and
200 are
hospitalised.
Survival rate is
20%, mortality
is high.
ETIOLOGY :
➢Burns are most common in the paediatrics.
➢The most common cause of burns are:
• Children playing with fire ignition sources such
as matches.
• Faulty or misused heating devices.
• Faulty or misused electrical devices.
• Careless smoking.

10. CLASSIFICATION OF BURNS
❖According to mechanism of injury there are 6 types of burns.
Those are:
1.Thermal burns
2.Chemical burns
3.Smoke and inhalation injuries
4.Electrical burns
5.Radiation burns
6.Scalding
1. Thermal burns: It is defined as tissue injury due to application of
heat in any form to the external or internal body surfaces.
• It may be - Dry heat - flame
Moist heat-scalds
Cold injuries.

11. 2.Chemical burns: Chemical burns are burns caused by acids and
bases that come into contact with tissues. Both acids and bases can
be defined as caustics.
- Acids may be hydrochloric acid, nitric acid, sulphuric acid, etc...
- Bases may be calcium hydroxide, ammonia, sodium hydroxide,
potassium hydroxide.
3.Smoke and inhalation injury: It can be defined as damage caused
by breathing in harmful gases vapours and particulate matter
contain in smoke.
• Smoke in inhalation injuries are three types:
A.Carbon monoxide poisoning
B. inhalation injury above the glottis
C. inhalation injury below the glottis.
A.Carbon monoxide poisoning: carbon monoxide causes
poisoning and asphyxia measure of death occur on spot
you to inhalation of carbon skin colour is often described
as “cherry red” in appearance with carbon monoxide
poisoning.
B. Inhalation injury above the glottis: It may be caused due
to inhalation of hot air steam or Smoke.
C.Inhalation injury below the glottis: Tissue injuries to the
lower respiratory tract is related to the duration of
exposure to smoke are toxic fumes clinical manifestations
such as pulmonary.

12. 4.Electrical burns : An electrical injury occurs when a current
passes through the body, interfering with the function of internal
organ or sometimes burning tissue.
• Voltage greater than 40 volts is more dangerous.
5.Radiation burns : These are caused by exposure to radioactive
source either by use of ionizing radiation in industries or
therapeutic eradication.
6.Scalding :It is caused by hot liquid or gases most commonly occur
in exposure to high temperature of hot tap water, forms a blister,
this type of burns doesn’t cause death.
❖ According to extent of burns there are 4 types of
burns. Those are :
1.First degree burns
2.Second degree burns
3.Third degree burns
4.Fourth degree burns

13. A. First degree burns :
First degree burns generally occur as a result of
short term heat & flame contact or long-term exposing
to intense sunlight.
• Only the outer layer of the epidermis and stratum
corneum are damaged, there is no the damage in
the dermis.
• It heals within a week.
B. Second degree burns :
These types of burns are deeper than first degree
burns and necrosis spread into the dermis.
• The burns in this group may be divided into 2 categories
termed as:
A. Superficial second degree burns
B. Deep second degree burns
A. Superficial second degree burns -
• It involves the epidermis and external part of the
dermis(papillary layer of dermis).
• It often seen with scalding injuries.
• Sensitive to light touch or pinprick.
• Recovery usually occurs within 3 to 4 weeks with zero or
very mild scaring.

14. B. Deep second degree burns –
• It involves the epidermis and the majority of the dermis.
• A Smaller amount sensitivity to light touch and pinprick than
superficial form.
• It resolves within two months if the only see properly
preserved.
C.Third degree burns :
These kinds of burns result from hot water, fire and
prolonged contact with electrical current.
• In the epidermis and the entire layer of the dermis , extended
to subcutaneous tissue.
• Appears dry, leathery and insensate.
• Can be difficult to differentiate from deep partial thickness
burns.
• Usually found when patients clothes caught on fire.
• Generally required transferred to burn surgeon for skin
grafting to heal.
• Permanent deep scars in the skin occur following healing in
these kinds of wounds and surgical intervention is usually
required to restore normal appearance.
D. Fourth degree burns :
• It occurs as a result of high voltage electric injury or severe
thermal burns which requires hospital admission.
• This refers to carbonization of burned tissue.
• It extends through skin, subcutaneous tissue and into
underlying muscles and bone.

15. ❖ According to size and depth of burns there are three
types. Those are :
1.Minor Burns: Second degree burns of less than 10%
of body surface area or third degree burns of less than
2% of body surface area.
2.Moderate burns: second degree burns of affecting
10-25% of body surface area or third degree burn of
less than 10 % of body surface area.
3.Major Burns: Second degree burns exceeding 25 %
of body surface area or third degree burns of
face.hands, feet or over 10 % of other body surface
area
Zones of burn injury :

16. 1.Zone of coagulation – Inner zone :
• It sustains the most damage.
• Necrotic area with cellular distribution.
• Irreversible tissue damage.
2.Zone of stasis – middle zone :
• It has a compromised blood supply , inflammation
and tissue injury, can survive or go on to coagulative
necrosis depending on wound environment.
3. Zone of hyperaemia – outer zone
• It sustains the least damage.
Location of burns :
• Burns to face, neck, chest and back may inhibit
respiratory function due to mechanical
obstruction secondary to edema, eschar
formation.
• Burns to the ear, nose are susceptible to
infection because of poor blood supply.
• Burns to buttocks, genitalia are susceptible to
infection because of contamination.
• Burns on extremities cause circulatory
compromise and neurologic impairment.

17. PATHOPHYSIOLOGY
Decreased cardiac output – Decreased myocardial function

18. CLINICAL MANIFESTATIONS
1.First degree burns :
• Reddened skin
• Pain at the burn site
• Involves only epidermis
• Blanch to touch.
• Have an intact epidermal barrier
• Do not result in scarring
Eg - sun burn, minor scald from a kitchen
2.Second degree burns:
A. Superficial second degree burns
• Intense pain
• White to red skin
• Blisters
• Involves epidermis and papillary layer of dermis
• Spares hair follicle, sweat glands etc.
• Erythematous and blanch to touch.
• Very painful/ sensitive
• No or minimal scarring
• Spontaneously re-epithelization from retained
epidermal structures in 7-14 day

19. B. Deep second degree burns
• Injury to deeper lavers of dermis I.e., reticular dermis.
• Appears pale and mottled.
• Do not blanch to touch.
• Capillary return sluggish or absent. . .
• Less painful, remain painful to pinprick.
• Takes 14-35 days to heal by re-epithelization from hair follicles
and sweat glands, keratinocytes often with severe scarring.
• Contractures possible.
3.Third degree burns: Dry, leathery skin.
• Loss of sensation.
• All dermal layers/tissues may be involved.
4.Fourth degree burns :Involves structures beneath the skin,
muscles and bone.
GENERAL MANIFESTATIONS :
• Cold and clammy skin
• Tachycardia
• Redness
• Edema
• Hypotension
• Loss of sensation
• Blisters
• Respiratory distress

20. SYSTEMIC MANIFESTATIONS :
Cardiac system:
• Hypotension due to shift of fluid.
• Tachycardia: hypo perfusion and impaired blood flow to heart
leads to tachycardia.
• Decreased cardiac out put: Due to decreased renal perfusion.
• Decreased heart rate: Due to circulatory shock / hypovolemia.
Respiratory system:
• Edema due to shift of fluid from intracellular to extra cellular.
• Hoarseness of voice mostly due to smoke .
• Copious secretions as a result of allergens.
• Strider due to respiratory obstruction or secretions.
• Substernal and intercoastal retractions due to complete
respiratory arrest ,forceful expirations occurs resulting in
retractions.
• Total airway obstruction: due to noxious agents, foreign
particles ,smoke, secretions, congestion, etc..
Nervous system:
As the noxious substances crosses blood brain barrier these
symptoms result.
• Confusion: due to hypoxia,
• Irritability,
• Subconscious,

21. • Coma.
Integumentary system :
These symptoms result as a result of burns and fluid shift.
• Burns-all 3 layers involved
• Edema
• Blisters, muscle involvement, bone exposure.
• Presence of burns
Neuro muscular system:
• Loss of sensation: due to the damage / involvement of the
nerves.
• Pain
• Involvement of muscles
• Loss of motor action.

22. ASSESSMENT AND DIAGNOSTIC TESTS
Assessment of burns :
• Various methods are used to determine the the total body
surface area (TBSA) affected by burns. Those are :
1.Rule of nine
2.Lund and bowder method
3.Palmer method.
1.Rule of nine :
• Wallace’s rule of nine is used for the assessment of TBSA
affected.
• It is a quick way to calculate the extent of burns.
• It assigns percentage in multiples of nine and the sum total
of these is equal to the total body surface area injured.
Head and neck = 9%
Upper extremity (right +left) = 18%(9+9)
Lower extremity (right +left) = 36%(9+9)
Anterior trunk = 18%
Posterior trunk = 18%
Genitalia (perineum) = 1%

23. 2.LIND AND BROWDER METHOD :
• Better method for assessing the burns wound.
• This method recognizes the percentage of surface area of
various anatomic parts, especially the head and the legs, as
it relates to the age of the patient.
3.PALMER METHOD :
• The size of the patients palm, is approximately 1% of the
TBSA.
• Clean piece of paper is cut to the size of the hand and
through that percentage of burns is assessed.

24. DIAGNOSTIC TESTS FOR BURNS :
INVASIVE PROCEDURES –
1. Complete blood count (CBC): Initial increased haematocrit suggest
hemoconcentration due to fluid shift/loss. Later decrease
haematocrit and RBC's may occur because of heat damage to
vascular endothelium. Leucocytosis can occur because of loss of
cell at wound site and inflammatory response to injury.
2. Arterial blood gases (ABG’S): It is a baseline especially important
with suspicion of inhalation injury. Reduced pao2/increased paco2
may be seen with carbon monoxide retention. Acidosis may occur
because of reduced renal function and loss of compensatory
respiratory mechanism.
3. Carboxyhemoglobin (COHb): Elevation of more than 15% indicates
carbon monoxide poisoning/inhalation injury.
4. Serum electrolytes: Potassium level may be initially elevated
because of injured tissue/RBC destruction and decreased renal
function; hypokalaemia can occur When diuresis starts;
Magnesium level may be decreased. Sodium level may initially be
decreased with body water losses; Hyponatremia can occur later as
renal conservation occurs.
5. Alkaline phosphate: Elevate because of interstitial fluid
shifts/impairment of sodium pump.
6. Serum glucose: Elevation reflects stress response.
7. Serum albumin: Albumin/Globulin ratio may be reversed as a
result of loss of protein in edema fluid.
8. Blood urea nitrogen (BUN)/creatinine (cr): elevation reflects
decreased renal perfusion/function; however creatinine level can
elevate because of tissue injury.

25. Non invasive procedures -
1.Urine: Presence of albumin, hemoglobin and myoglobin
indicates deep tissue damage and protein loss (especially seen
with serious electrical burns). Reddish black colour of urine is
due to presence of myoglobin.
2. Random urine sodium: More than 20 mEq/L indicates
excessive fluid resuscitation.
Less than 10mEq/L suggest an adequate fluid resuscitation.
3.Wound culture : May be obtained for baseline data and
repeated periodically
4.Chest X Ray: May appear normal in early post burn period even
with inhalation injury, however a true inhalation injury present
as infiltrates, often progressing to White out on X Ray adult
respiratory distress syndrome( ARDS).
5.Fiberoptic bronchoscopy: Useful in diagnosing extent of
inhalation injury: findings can include edema, haemorrhage
and ulceration of upper respiratory tract.
6.Flow volume loop: Provide non invasive assessment of effects
of inhalation injury
7.Lungs scan: May be done to determine extent of inhalation
injury.
8.Electrocardiogram (ECG): Signs of myocardial
Ischemia/dysrhythmias may occur with electrical burns.
9.Photographs of burns: Provide documentation of burn wound
and compared to baseline to evaluate healing.

26. MANAGEMENT OF BURNS
First aid for burns :
• Burns first aid is a vital part of treating a burn injury.
• It helps to relieve pain, decrease cell and skin damage,
improve wound healing and scar formation.
Steps for providing burns first aid :
1.Step 1 - Stop, drop and roll :
Stop fire, drop to the ground, roll to put the fire out.
2.Step 2 - Remove:
Remove all heat sources including clothes, nappes
and jewellery
3.Step 3 - Cool :
place burn under running cool tap water for 20
minutes. Do not use ice
4.Step 4 - Cover :
Use cling film to cover and protect the burn.

27. Care for the burns in special areas :
Special areas includes -- 1. Face
2.Mouth
3. Neck
4. Hands and feet
5. Genitalia
1. Face :- Be Very concerned for the airway
• Eyelids, lips and ears often swell alarmingly.
• In fact, they look even worse the next day.
• But they will start to improve daily after that.
• Cleanse eyes with warm water & saline.
• Apply antibiotic ointment of liquid tears until lids are no longer
swollen shut.
• Bacitracin Cream /ointment will serve.
2.Mouth :-
• For immediate relief, suck on something cold like ice cubes or
Popsicles .
• Also yogurt, milk or honey can help by coating the burned .
• Warm salt water rinses also help. Salt is antiseptic and will clean and
disinfect the area.
• Ideally the patient with an electric bean to the mouth should be seen
by a dentist between 5-10 days after the accident.

28. 3.Neck :-
• Cool down the area. If the burn is on your neck or face, apply a cool
wet compress.
• Once cooled down the burn apply a moisturizing lotion to provide
relief and prevent the area from drying out.
4. Hands and feet :
• This is rather deep and might require grafting.
• But initial management is basic.
• Dressings should not impede circulation.
• Leave tips of fingers exposed.
• Keep limb elevated.
• Allow use of the hands in dressings by day.
• Splint in functional position by night.
• Keep elevated to reduce swelling.
• Fingers might develop contractures if active measures are not laken
to prevent them.
5. Genitalia :-
• Shower daily rinse off old cream, apply new cream.
• Insert foley catheter if unable to urinate due to swelling.
Pharmacological management :
• Tab. Amory clave 625 mg
• IV fluid - RL 1000 ml
• Tab. Dynapar 100 mg
• Tab. Gentamycin
• Oint. Silver Supherdiazene

29. PHASES OF BURNS MANAGEMENT
Phases of burns management includes the 3 phases. Those are:
i. Emergent or Immediate resuscitative phases
ii. Acute phase (wound healing)
iii. Rehabilitation phase (Restorative)
i. Emergent or immediate resuscitative phases :
This phase may lasts from onset of injury to completion of fluid
resuscitation i.e., from 24-48 hrs after injury
Resuscitation phase characterized by:
• Life threatening airway problems
• Cardiopulmonary instability
• Hypovolemia
Goal – Maintain vital organ function and perfusion
Priorities : First aid
Prevention of shock (hypovolemic shock)
Prevention of respiratory distress
Detection and treatment of concomitant injuries
Wound assessment and initial care
prevent tissue ischemia
Minimizing pain and anxiety
Calculation of fluids :
Fluid resuscitation includes the : 1) parkland formula
2) Evans formula.
3) Brooke formula

30. 4) Consensus formula
1. Parkland formula:
Volume of fluid (RL)= 4ml x percentage of burns x Weight (kg) in 24 hrs
2. Evans formula:
Volume of fluid (RL)= 1 ml x percentage of burns x Weight (kg) in 24hrs
3. Brooke formula:
Volume of fluid(RL)= 2ml x percentage of burns x Weight (kg) in 24hrs
4. Consensus formula:
Volume of fluid(RL)=2-4ml x percentage of burns x Weight (kg)in 24hrs
Resuscitation solutions :
Colloids - Albumin, Dextran, Hetastarch
Crystalloids - RL, 25%dextrose, NS, Hypertonic saline
Nursing management of patient in emergent phase:
1. Maintaining proper oxygenation and tissue perfusion.
2. Maintaining fluid and electrolyte balance.
3. Relieving pain
4. preventing hypothermia
5. Providing initial wound care
6. preventing infection
7. Promoting comfort
8. Relieving anxiety and providing psychological support

31. ii. Acute / intermediate phase :-
• This phase begins 45 to 12 hours after the burn injury. –
• Burn wound care and pain control are priorities at this stage.
Medical management :
1. prevent infection : Asepsis
prophylactic antibiotics
Immunization
Environmental control
2 provide metabolic support –
Formula for daily Calorie expenditure estimate
= (25 kcal/kg body weight) + (40kcal x % TBSA burn)
3.Minimizing pain – patient controlled analgesia devices.
Inhalation analgesic (nitrous Oxide)
Oral analgesics; opioid analgesic; NSAIDs
Hypnosis, art and play therapy.
Guided imaginary, relaxation techniques
Distraction therapy, biofeedback
Music therapy
4.Provide wound care :- a, wound cleansing
b, Wound debridement
-Natural debridement
-Mechanical debridement
- Chemical debridement

32. - Surgical debridement
C, Topical antimicrobial treatment
- Silver sulfadiazine 1%
- Mafenide acetate 5%
- Silver nitrate 0.5%
- Acticoat
D, wound dressing
- Moist dressing
- Occlusive dressing for new.
- Non-adhesive dressings covers
5.Maximize Function :- Splinting
- positioning
Exercise
Ambulation performance of ADL
Pressure therapy
6.psychological support :- Meeting the psychological needs.
Involvement in physical therapy.
. Encouragement in wound care
Ventilation of feeling emotions, fear

33. Surgical management :
1.Escharotomy
2.Fasciotomy
3.Wound grafting
Nursing management
1. Maintaining proper oxygenation and tissue perfusion.
2.Maintaining fluid and electrolyte balance.
3.Relieving pain
4.preventing hypothermia
5.Providing wound care
6.Preventing infection
7.Relieving anxiety and providing psychological support.
8.Graft care
9.Nutritional support
iii. Rehabilitation phase
Medical management :-
1. Minimizing functional loss - Exercise
splinting
Positioning
2 provide psychological support - Self image issues
physical limitations

34. Reintegration into society
Fear of rejection
good communication
Encourage independence.
3. Abnormal wound healing - Hyper trophic
keloid scars
4- prevention and treatment of scars -
pressure use of topical silicon
Scar massage
Steroid injections
Application of elastic pressure garments
I cosmetic intervention .
Nursing management : -
I. Improving mobility
2. Improving self esteem
3. Promoting independence
4 Cosmetic counselling
5.vocational training
6.Improving body image

35. SURGICAL MANAGEMENT
Surgical treatment for burns was dependent on the depth of burns.
Superficial partial thickness burns - Conservative treatment
Deep partial and full-thickness burn- Excision and Auto grafting
Indeterminate depth burns - Conservative treatment (10-14 days)
followed by second inspection and definitive treatment (based on
healing time).
Surgical modalities :-
1) Escharotomy
2) Negative pressure wound therapy
3) Stem cell therapy
4) Skin grafting
5) Hyperbaric oxygen therapy
1) Escharotomy :-
• It is the surgical Incision of eschar for decompressing the
constructive effects caused by deep circumferential burns.
• ESCHAR-A thick Coagulated crust, slough which develops
following a burn injury or chemical or physical cauterization of
skin.
• In full-thickness circumferential burns, coagulated collagen
acts as a tourniquet in leading to vascular compromise of the
affected body parts.

36. • It is crucial for relief of peripheral ischemia or respiratory
embarrassment.
• It helps for decompression of neurovascular structure.
2. Negative pressure wound therapy:
It is a method of drawing out fluid and infection from the wound to
help it heal. A Special dressing (bandage) is roled over the wound
and a gentle vacuum pump is attached.
3.stem cell therapy:
It accelerates burn wound healing by inducing neo angiogenesis
collagen deposition in granulation tissue formation.
4.Wound debridement and skin grafting:
Wound debridement-It is the medical removal of dead tissue to
improve healing.
Skin grafting- skin grafting is a surgical Procedure involving
transplantation of Skin.
It involves: a, Biological graft
b, Synthetic graft
a, Biological graft –
• Auto graft - A graft of tissue from one point to another of the
same individual body .
• Isografts - A graft of tissue between two individuals who are
genetically identical .

37. • Allograft – A graft of tissue from a donor of the same species
as the recipient but not genetically identical.
• Xenograft – A graft of tissue from a donor of the different
species.
b, Synthetic graft – Biobrane
Integra
Calcium alginate
Non adhering fine mesh gauze
5.Hyperbaric oxygen therapy :-
• It is a medical therapy that enhances the body’s natural healing
process by breathing in 100% Oxygen in a pressurized
chamber.
• By providing pure oxygen in a pressurized chamber, HBOT
delivers 10-15 times more oxygen to tissues within the body..

38. PLASTIC SURGERY
• The name is taken from the Greek word “plastikos” which means
to form or mold.
• Plastic surgery is a special type of surgery that involves both a
person’s appearance and his are her ability to function.
Types of plastic surgery:
There are two main kinds of plastic surgeries. Those are:
1. Reconstructive surgery
2. Cosmetic surgery
RECONSTRUCTIVE SURGERY:-
Definition-
It is a branch of surgery that deals with the correction Restoration
and improvement in shape and appearance of body structures that
are defective damaged misshapen by injury diseases are growth.
• It is performed on abnormal structures of the body to improve
function are approximate normal appearance.
• It deals with the tumour removal, laceration repair, Scar repair,
hand surgery, cleft lip and cleft palate surgery.
TECHNIQUES OF RECONSTRUCTION SURGERY
1. Secondary wound closure
2. Excision and primary closure
3. Z plasty
4. Skin graft

39. 5. Flaps
6. Tissue expansion
7. Vacuum assisted closure
1.Secondary wound closure:
It referred to as closure by secondary intention.
The skin edges of the wound are not sutured together the wound
is left open. Dressings are applied regularly to keep the wound
clean and wound gradually closes and heels on its own.
2.Excision and primary closure:
Requiring incision through the deep dermis
(including subcutaneous and deeper tissues) of open wounds,
burn eschar or burn scars. The burn wound is surgically removed
and the edges are sutured together.
3.Z - plasty:
Z-plasty is a procedure used to release the contracture or
lengthen the contracture scar.
• Improve the functional and cosmetic appearance of scar.
• Used to flatten hypertrophic scars and elevate depresses scar.
• Z plasty is an effective method of wound irregularisation. Since
straight line scars draw attention easily, a z-plastic can break
up the scare into smaller units, making the scared less
noticeable.

40. 4.Skin graft:
It is a surgical procedure involving transplantation of skin.
5.Skin flap :
Skin flap contains its own vasculature and therefore can
be used to take over a wound bed that is avascular.
• Flaps are tissues that are transferred with a blood supply.
• There maybe local flap, regional flap, free flap.
6.Tissue expansion:
A surgical tissue expander is basically and expandable
balloon usually constructed of silicone rubber with a means of
introducing fluids at intervals usually self sealing port.
• The expander is placed beneath the skin adjacent to the defect
and fort Situated at a convenient place.
• This is achieved by injecting sterile saline through the skin into
the port.
• When the desired expansion is achieved the expanded skin
may be fashioned into a local distant are free flap and used to
close the defect.
7.Vaccum assisted closure:
• The form is connected by a tube to a suction device.
• There is effectively a negative pressure pump that can .
controlled to give intermediate section.

41. COSMETIC SURGERY :-
• It is an optional procedure that is performed on normal parts
of the body with the purpose of improving a person’s
appearance and/or removing signs of aging.
• It aims to improve the aesthetic appearance of a person.
THE MOST PREVALENT AESTHETIC/COSMETIC PROCEDURE
INCLUDE
1. Abdominoplasty(tummy tuck): reshaping and firming of the
abdomen.
2. Blepharoplasty (eyelid surgery): reshaping of the eyelids
3. Mammoplasty
• Breast augmentation (breast implant)
• reduction mammography (breast reduction)
• Mastopexy (breast lift)
4.Buttock augementation (butt implant)
5.Labiaplasty (reshaping of labia)
6.Chemical peel minimizing the appearance of acne and other
scars as well as wrinkles.
7.Otoplasty (reshaping of ear)
8.Rhinoplasty (reshaping of nose)
9.Rhytidectomy (face lift) – removal of wrinkles and signs of aging
from the face.
10.Lip replacement – improvement of lips though enlargement.

42. NURSING MANAGEMENT
1.Nursing assessment :
Nurse collects history from the client if conscious, if not conscious
from the family members and other available sources.
• She assess the client to know
What type of burns he met?
in which phase he is ?
complications he is prone to develop or developed?.
• The information can be collected from clients verbal response
and physical examination (inspection, auscultation)
• Data depends on type, severity, and body surface area
involved.
ACTIVITY/REST : May exhibit
• Decreased strength, endurance
• Limited range of motion (ROM) of involved areas
• Impaired muscle mass, altered tone
CIRCULATION : May exhibit
• Hypotension (shock)
• Peripheral pulses diminished distal to extremity injury
• Vasoconstriction
• Tachycardia (shock/anxiety/pain)
• Dysrhythmias (electrical shock)
• Tissue edema formation

43. ELIMINATION : May exhibit
• Urinary output decreased/absent during emergent phase;
• Diuresis (after capillary leak sealed and fluids mobilised back
into circulation)
• Bowel sounds decreased/absent.
Fluid :
Generalized tissue edema.
Food :
Anorexia, nausea/vomiting
NEURO SENSORY : May exhibit
• Mixed areas of numbness, tingling,
• burning pain
• Changes in vision, decreased visual acuity (electrical shock)
• Changes in orientation, affect, behaviour
• Decreased deep tendon reflexes
• Paralysis (electrical injury to nerve pathways)
Pain/ discomfort -
• Pain varies,
eg, first-degree burns are extremely sensitive to touch
second degree burns are very painful
third-degree burns are painless

44. RESPIRATORY SYSTEM: May exhibit
• Hoarseness, wheezy cough, drooling oral secretions, and
Cyanosis
• Thoracic excursion may be limited in presence of
circumferential chest burns
• Upper airway stridor/wheezes
• Breath sounds: Crackles (pulmonary edema), stridor (laryngeal
edema).
INTEGUMENTARY SYSTEM :
• Exact depth of tissue destruction may not be evident for 3. 5
days because of the process of microvascular thrombosis in
some wounds.
• Assess the depth of burns using rule of nine
• Assess for the presence of fractures/ dislocation.

45. Nursing diagnosis :
1.Impaired gas exchange related to inhalation injury as
evidenced by direct upper airway injury by
chemicals/gases.
2.Fluid volume deficit related to loss of fluid from the burn
wound asmanifested by decreased urine output 30ml/hr.
3.Acute pain related to destruction of skin as evidenced by
facial expression.
4.Risk for infection related to loss of skin barrier and
impaired immune response.
5. Anxiety related to fear & emotional impact on injury as
evidenced by expressed concern regarding changes in
life..
6.Impaired skin integrity related to open burn wound as
evidenced by absence of viable tissue.
7.Activity intolerance related to pain as evidenced by
verbal response & facial expression
8.Body image disturbance related to physical appearance
as manifested by negative feelings about body/self.
9.Impaired family process related to burn injury as
evidenced by suffering of the family member, showing
grievance.
10. Knowledge deficit related to treatment as
manifested by asking repeated questions

46. 1.Diagnosis : Fluid volume deficit related to loss of fluid from the
burn wound as manifested by decreased urine output 30ml/hr.
Goal – to improve the fluid volume within 12 hours.
Intervention Rationale
Monitor vital signs, Central venous
pressure.
Serves as a guide to fluid
replacement needs Assess
cardio vascular response.
Monitor urinary output and specific
gravity
Generally fluid replacement
should be titrated to ensure
your average urinary output of
30 to 50ml/hr
Estimate wound drainage and
insensible loss.
Increased capillary permeability
affect the circulating volume and
urinary output.
Assess the weight daily Fluid replacement formulas
partly depend on admission wait
and subsequent changes.
Maintain intake output chart May be helpful in estimating the
fluid volume in the body.
Measure circumference of burned
extremities as indicated.
May be helpful in estimating
extent of edema/fluid shift.
Insert/ maintain IV catheter. Accommodates rapid infusion
of fluids.
Monitor lab studies (HB/ haematocrit
electrolytes, random urine sodium).
Identifies blood loss and fluid in
electrolyte replacement needs.
Administer medications as indicated. May be indicated to enhance
urinary output.

47. 2.DIAGNOSIS : Acute pain related to destruction of skin as evidenced by
facial expression.
Goal -to reduce pain within 12 hours.
Intervention Rationale
Cover on as soon as possible unless
open air exposure.
Temperature changes and air
movement can cause greater
pain to exposing nerve ending.
Elevate burned extremities
periodically.
Elevation may be required
initially to reduce edema
formation.
Provide bed cradle as indicated Elevation of linens from wounds
may reduce pain.
Change position frequently and assist
with active and passive range of
motion exercises as indicated.
Movement and exercises reduce
joint stiffness and muscle
fatigue.
Assess reports of pain, noting location
/ character and intensity of pain.
Changes in location character
intensity of pain may indicate
developing complication.
Encourage use of stress management
techniques.
Promotes relaxation and
enhances sense of control,
which may reduce
pharmacological dependency.
Promote uninterrupted sleep periods. Sleep deprivation can increase
perception of pain and reduce
the coping abilities.
Administer analgesics as indicated. Analgesics helps to reduce the
pain.

48. 3.Diagnosis – Risk for infection related to loss of skin barrier and impaired
immune response.
Goal – infection rate will come down are reduced within 12 to 24 hours.
Intervention Rationale
Implement appropriate isolation
techniques as indicated.
Isolation may range from simple
wound/ skin to complete or
reverse to reduce risk of cross
contamination.
Use gown, gloves, masks and strict
aseptic techniques during direct
wound care.
Prevent exposure to infectious
organism.
Remove dressing and clean burned
area in a hydrotherapy in a shower
stall with handheld shower head.
Water softens and aids in
removal of dressing and eschar.
Showering enhances wound
inspection and prevents
contamination from floating
debris.
Exercise and cover burn wounds
quickly.
Early excision is known to reduce
scaring and risk of infection
thereby facilitating healing.
Assist with excision biopsies when
infection is suspected.
Bacteria can colonize the wound
surface without invading the
underlying tissues therefore
biopsies may be obtained for
diagnosing infection.
Obtain routine cultures and
sensitivities of wounds/ drainage.
Allows early recognition and
specific treatment of wound
infection.

49. 4.Diagnosis : impaired skin integrity related to open burn own as
evidenced by absence of viable tissue.
Goal - To improve the skin integrity.
Intervention Rationale
Assess size, colour, depth of wound,
noting necrotic tissue and condition of
surrounding skin
Provide baseline information
about need for skin grafting and
possible clues about circulation
in area to support graft.
Provide appropriate burn care and
infection control measures.
Prepare tissues for grafting and
reduce risk of infection/ graft
failure
Elevate grafted area if possible/
appropriate
Reduces swelling/ limits risk of
graft separation.
Keep skin free from Pressure. Promotes circulation and
prevents ischemia and necrosis.
Evaluate colour of grafted and donor
site.
Evaluate effectiveness of
circulation and identifies
developing complications.
Aspirate blebs cells under sheet graft
with sterile needle or roll with sterile
swab.
Fluid filled blebs prevent graft
adherence to underlying tissue,
increased risk of graft failure.
Prepare for/ assist with surgical
grafting are biological dressing.
Skin grafts obtained from living
person or cadavers are used as
temporary covering for
extensive burns untill persons
own skin is ready for grafting to
protect granulation tissue.

50. 5.Diagnosis – Body image disturbance related to physical appearance has
manifested by negative feelings about body/self.
Goal – To improve the physical appearance of the body.
Intervention Rationale
Assess meaning of loss /change to
patient including future expectations
and impact of culture and religious
beliefs.
Traumatic episode results in
creating feelings of grief over
actual or perceived losses. This
necessities support to work
through to optimal solution.
Acknowledge and accept expression
of feeling of frustration, anger, grief
Acceptance of these feelings
facilitates resolution.
Set limits on maladaptive behaviour
(eg manipulative/aggressive).
Maintain non judgemental attitude
while giving care.
Patient and significant others
tend to deal with this crisis in a
same way in which they have
dealt with problems in the past.
Be realistic and positive during
treatments, in health teaching and in
setting goals within limitations.
Enhances trust and rapport
between patient and nurse.
Encourage family interaction with
each other and with rehabilitation
team.
Maintains/ open lines of
communication and provides
ongoing support for patient and
family.
Role play social situations of consent
patient.
Prepare a patient for reactions
of others and anticipates ways
to deal with them.
Physical/occupational therapy,
vocational counsellor and psychiatric
counselling.
Helpful in identifying ways to
regain in maintaining
independence.

51. COMPLICATION
1. Burn shock (hypovolemic shock)
2.Pulmonary complications due to inhalation injury.
3.Acute renal failure.
4.Infections and sepsis.
5.Curling’s ulcer in large burns over 30% usually after 9th
day.
6.Extensive and disabling scaring.
7.Psychological trauma.
8.Cancer called marjolin’s ulcer may take 21 years to develop.
9.Laryngeal edema
10. Multi organ dysfunction syndrome(MODS).

52. PREVENTION
1.Keep matches and lighters out of the reach of children.
2.Emphasizes the importance of never living children and it
ended around fire.
3.Develop and practice a home exit fire drill.
4.Set the water heater temperature not higher than 70°C.
5.Don't smoke in bed, and caution against falling asleep while
smoking.
6.Caution against throwing flammable liquids into an already
burning fire.
7.Caution against using flammable liquids to start fire.
8.Caution against removing the radiator cap from a hot engine.
9.Watch for overhead electrical wires and underground wire
when working outside.
10. Keep hot irons out of reach of children.
11. Caution against running electrical cords under carpet or
rugs.
12. Avoid storing flammable liquids near a fire source.
13. Caution when cooking.
14. Keep working fire extinguisher in the home, and to know
how to use it.

53. CONCLUSION
• Burn injury is an important public health concern and its
associated with high morbidity and mortality.
• Burns are one of the most common household injuries,
especially among children.
• Burns are characterized by severe skin damage that causes the
affected skin cells to die.
• The degree of similarity of most bones is based on the size and
depth of burn.
• Some burns may be treated with first aid, most burns are
severe injuries that require immediate medical attention.
• In general, if you are unsure of the severity of any burn, seek
medical attention promptly.

54. SUMMARY
At the end of the class the students will be able to understand the
introduction, definition, etiology, classification, pathophysiology,
clinical manifestations, assessment and diagnostic tests, phases of
management, first aid, medical management, surgical
management, nursing management, complications, prevention,
conclusion and summary of burns.

55. BIBLIOGRAPHY
• Joyce M. Black, medical surgical nursing, first South Asia
edition, Elsevier publication south Asia , 2nd
volume, published
in 2006, page number – 1852 – 1876.
• Brunner and Siddhartha , medical surgical nursing, 14th
edition, 2nd
volume, published in 2017, November 7, page
number – 1931 to 1961.
• Lewis’s, medical surgical nursing, 11th
edition, published in
2019, page number – 562 to 598.
• Farlex, medical surgical nursing, AITBS publishers, India.
• Medical Net.com.