for 3rd b.sc nursing studnets

1. Presented by,
Swati G. Sheth.

2. Definition
• Burns are form of traumatic injury caused
by thermal, electrical, chemical or
radioactive agents.

3. Anatomy and
physiology of
skin.

4. Epidermis layer of skin

6. Stages of wound healing

7. Etiology
• Occupational hazards:
• Tar,chemicals, hotmetals, steam pipes
• Fertilizers,pesticides
• Electric burns
• Home and recreational hazards:
• Pressure cookers, microwaved food, hot water
heater, radiators,carelessness with ciggrates or
matches,improper use of imflammable.

8. Incidence
• 0.4 billion cases per year in india
• women:men (1.6:1)
• Fatal burn-6%-28%
• Mortality due to burn injuries 3.5/100,000
population
• Second leading cause of death in children.

9. Types of burn injury
• Thermal burns
• Chemical burns
• Smoke and inhalation injury
• Electrical burns
• Cold thermal injury

10. Classification of Burn Injury
• Depth of burn:

11. Extent of burn
• Lund browder chart
• Rule of nine
• Sage burn diagram

12. Lund Browder chart.

13. Location of Burn
• Severity of injury related to location
Location Effect of injury
Face and neck/circumferential burns to
chest or back
Inhibit respiratory function,eschar
formation
Hands, feets, joints and eye Self care deficit, jeopardize future
function
Ears and nose infection
Buttocks and genitalia Highly susceptible infection
Circumferential burns to extrimities Compartment syndrome.

14. Patient risk factors
• Age
• Any pre existing cardio vascular,
respiratory or renal disease
• Clients with DM and PVD
• Alcohol, drug abuse, mal nutrition.

15. Pathophysiology
Local response: described by jackson in 1947.

16. Clinical menifestation
• Hypovolemic shock
• Adynamic ileus, decreased bowel sounds
• Shievering
• Edema
• Hoarseness,difficulty in swallowing
• Stridor
• Altered mental status.

17. Diagnostic Evaluation
• CBC,ESR
• ABG
• S.carboxy hemoglobin
• Bronchoscpoy
• Ventilation perfusion scan
• Biopsy
• Thermography
• Video angiography

18. Complications of burns injury
Immediate:
• Compartment syndromes
Early:
• Infection
• Hypovolemia
• Acute renal failure
• Hyperkalemia
• Curling ulcer
• Bone marrow failure
• Multiorgan failure
• contracture

19. Continued..
Late :
• Disfiguration
• Diformities and mal functions
• Chronic pain
• Psychological problems

20. Management
• Prehospital care
• Emergent phase
• Acute phase
• Rehabilitation phase

21. Prehospital phase
• Electric injuries: remove the client from source of current
• Chemical burns:brushing solid partical of the skin and lavage
with water.
• Thermal burns:<10% TBSA covered with clean, cool, tap
waater dumpened towel
• Cooling with in one min. will minimize depth
• If burned area is large or >10%TBSA
• Focus on ABC
• Do not immerse the part in cool water.
• Burned clothing should be removed
• Wrap in clean dry sheet refer to hospital

22. Airway Management:
Endotracheal Intubation:
• Suspected inhalation injury ,circumferential burns
• Large TBSA burned
• Dyspnea, Coughing, Hoarseness ,Black sputum
• PO2 < 60, CO > 25%
• Burn in palate, tongue ,face(hair, lips)
• Edema in glottis, posterior pharynx
Ventilatory assistance
• If not intubated, provide humidified oxygen

23. Fluid therapy:
Indications for IV
• Pedriatic >10% TBSA
• Adult >20% TBSA
Types of fluids used
• Crystalloid : isotonic cheap no need of proteins
• Hypertonic:
 supposed to form less edema
 Na+ should not allowed to exceed 160 mEq/l
 Coloid
 Dextran

25. Parkland formula
• First 24 hours:
• RL+4ml/kg/%TBSA
• ½ given in first 8 hour
• 1/4th each next 8 hour
Brooks formula:
• RL+2ml/kg/%TBSA
• ½ first 8 hour
• ½ given in next 16 hour

26. Wound care
• Goals of wound care are
Cleanse and debride the area of necrotic
tisssue
Promote successful skin grafting
Treatment of the burn wound includes daily or
twice-daily wound cleansing with
debridement or hydrotherapy
(tubbing/showering) and dressing changes.

27. Continued..
• HYDROTHERAPY
• Hydrotherapy is bathing of the burn patient
in a tub of water or with a water shower to
facilitate cleansing and debridement of the
burned area.

28. Drug therapy
 Analgesics and sedatives:
• Pharmacological: opoids,NSAIDS, PCA
• Non pharmacologic management: relaxation tapes,
visualization, hypnosis, biofeedback, guided imagery.
 Nutritional support: multiviatmins, oxandrolone,
minerals
 GI support: ranitidine, antacids
 Antimicrobial agents: silver sulfadiazine, mafenide
acetate
 Oral infection treated with nystatin mouthwash.

29. Continued..
• TOPICAL ANTIMICROBIALS
• Topical medications are used to cover burn
areas and to reduce the number of
organisms
.

30. Nutritional therapy:
Entral feeding: generally started 20 to 40
ml/hr
High protein and high cho diet
 3gm per kg body weight.

31. Exhision and Grafting
Tangential Excision
• A special blade is used to slice off thin
layers of damaged skin until live tissue is
evidenced by capillary bleeding.
• Commonly used with deep partial-thickness
burns and followed with immediate
coverage with a biosynthetic or biologic
dressing or an autograft.

32. Continued..
Fascial (Primary) Excision
• The skin, lymphatics, and subcutaneous
tissue are removed down to fascia, with
either immediate autografting or temporary
coverage with biologic or biosynthetic
dressings.
• This is repeated until all deep burn areas are
removed.

33. Cultured epithelial autografts

34. Continued.
• Physical and occupational therapy
• Psychosocial care

35. Rehehabilitation phase
• Starts when the wound is healed
• It depends on the severity of burns
• Assist the client to resume functional role in
society and accomplish cosmetic
reconstructive surgery.

36. Nursing Management
Assessment
• Obtain history
Causative agent
– Duration of exposure,Circumstances of injury
– Age,Initial treatment, including first aid
– Preexisting medical problems
– Current medications
– Tetanus immunization status.
– Height and weight.
Physical examination:

37. Nursing diagnosis
• Impaired Gas Exchange related to inhalation injry.
• Decreased Cardiac Output related to fluid shifts and
hypovolemic shock
• Ineffective Tissue Perfusion: Peripheral related to
edema and circumferential burns
• Risk for Excess Fluid Volume related to fluid
resuscitation and subsequent mobilization 3 to 5
days postburn
• Impaired Skin Integrity related to burn injury and
surgical interventions (donor sites)

38. Continued..
• Ineffective Thermoregulation related to loss
of skin microcirculatory regulation and
hypothalamic response
• Risk for Infection related to loss of skin
barrier and altered immune response
• Impaired Physical Mobility related to
edema, pain, skin and joint contractures
• Acute Pain related to injured nerves in burn
wound and skin tightness
• Disturbed Body Image related to cosmetic
and functional sequelae of burn wound

39. Impaired Gas Exchange related to
inhalation injry.
• 100% humidified oxygen.
• High fowlers position.
• Do ABG on room air.
• Note character and amount of respiratory
secretions. Report carbonaceous sputum, tracheal
tissue.
• Provide mechanical ventilation, continuous
positive airway pressure, or positive end-
expiratory pressure if requested.
• Keep intubation equipment nearby, and be alert
for signs of respiratory obstruction.

40. Ineffective Breathing Pattern related to
circumferential chest burn, upper airway
obstruction, or ARDS
• Observe rate and quality of breathing
• Assess tidal volume
• Encourage deep breathing and incentive spirometry
• Place patient in semi-Fowler's position to permit maximal
chest excursions if there are no contraindications, such as
hypotension or trauma.
• Make sure that chest dressings are not constricting.
• Prepare the patient for escharotomy and assist as indicated.

41. Risk for Excess Fluid Volume related to fluid
resuscitation and subsequent mobilization 3 to
5 days postburn
• Titrate fluid intake as tolerated. The initial
resuscitation formula is only a base.
• Maintain accurate intake and output records.
• Weigh the patient daily.
• Monitor results of serum potassium,sodium
• Be alert to signs of fluid overload and heart
failure, especially during initial fluid resuscitation
• Administer diuretics as ordered.

42. Impaired Skin Integrity related to burn injury
and surgical interventions (donor sites)
• Cleanse wounds and change dressings twice daily. Use an
antimicrobial solution or mild soap and water.
• Perform debridement of dead tissue .
• Apply topical bacteriostatic agents
• For grafted areas, use extreme caution in removing dressings; observe
for and report serous or sanguineous blebs or purulent drainage.
Redress grafted areas according to protocol.
• Observe all wounds daily and document wound status on the patient's
record.
• Promote healing of donor sites by:
– clean wounds.
– If exhudate is present swab the area for culture and apply an
antimicrobial topical cream. If the culture is positive, treatment
will be in accord with sensitivities.
– Allowing dressing to peel off spontaneously

43. Assignment

44. Bibliography
• Abrams,A.C, “Clinic Drug Therapy”, Philadelphia:
Lippincott’s Co; 4th edition, 1995.
• Black, J.M. and Jacobs, E.M. “Medical-Surgical
Nursing-Clinical management For continuity of
care”, Philadelphia W.B.Saunders ,Co; 5TH edition,
1997.
• Dossy, B.M. and Guzzatta, K. “Critical care
nursing-Body-Mind-Spirit”Philadelphia: Lippincott
Co; 3rd edition, 1992.
• Doenges,M.E. “Application of Nursing Process and
Nursing Diagnosis-An Interactive Text”, India;
Jaypee Brothers; 2nd edition, 1995.
• Pp no-29.