BURNS - MUNJILI.pptx

BURNS
GENERAL OBJECTIVE
At the end of the lecture students
should be able to demonstrate an
understanding of the management
of burns.

SPECIFIC OBJECTIVES
At the end of the lecture students should be
able to:-
• Review of anatomy and physiology of the
skin
• Define terms
• State the causes of burns
• Classify burns

……..
• Describe the pathophysiology
• Describe the management of
burns
• Outline the complications
• Skin Graft

Review of the anatomy and
physiology of the skin
• Draw a well labelled diagram
of the skin
• Functions of the skin

Functions of the skin
1. Protection
2. Regulation of body temperature
3. Heat production
4. Heat loss
5. Formation of vitamin D
6. Sensation
7. Absorption
8. Excretion

Definitions
1. BURN
This is the injury to the tissues of the
body due to heat, chemicals, electrical
current or radiation (Lewis, et al.,
2004).
2. SCALD
It is a burn caused by hot liquid or
vapour (Weller and Wells, 1991)

Causes of burns
1. Thermal causes- flame, scalds,
hot objects
2. Chemicals such as
hydrochloric acid, sulphuric
acid, alkaline etc

….
3. Electrical burns- due to
electrical current.
4. Radiation-exposure to
radioactive source such as
nuclear radiation, X-rays,
ultraviolet rays from the sun

……….
5. Mechanical causes that may lead to
friction due to contact with moving
objects
6. Flashes from lightening and explosions
7. Inflammable gases and liquids such as
Nitrous Oxide, Oxygen, Petrol can lead
to burns

CLASSIFICATION OF BURNS
• Burns can be classified according to degrees
i.e. first-degree, second-degree or third-
degree burns.
• The American Burn Association (ABA) now
advocates a more explicit categorization of
burns according to depth of skin destruction
that is: - Partial-thickness or Full-thickness in
trying to classify burns as whether minor,
moderate, uncomplicated or major.

…………..
• Smeltzer and Bare (2004), describes
burn injuries according to the depth
of injury and the extent of body
surface area injured and this is the
approach we shall follow in this
lecture

Classification of burns according to
depth

1. Superficial-partial thickness (First
degree burns )
- They are limited to the epidermis
- They are caused by superficial
sunburn, quick heat flash
- Signs and symptoms include redness,
pain, and minor swelling
- The skin is dry without blisters

…..
- Healing time is about 3 to 6 days
- The superficial skin layer over the
burn may peel off in 1 or 2 days.

2. Deep partial-thickness (Second
degree burns)
• Usually caused by hot liquids, steam,
flames, chemical tar.
• The epidermis and the dermis are
involved -reticular layer, including
superficial parts of hair follicles, sweat,
and sebaceous glands are destroyed

…..
• Signs and symptoms include:
- formation of blisters
- severe pain
- hyperesthesia
- hypersensitivity to cold air

……..
- molted red base
- broken epidermis
- weeping surface
- edema
- blanches

………….
-Recovery within 2/3 wks
-Some scaring & pigmentation may
form
-Infection may convert it to 3rd
degree

3. Full-thickness (Third-degree burns)
• Caused by fire, prolonged
exposure to hot liquid
• The epidermis, dermis and
the subcutaneous layers are
destroyed
• Nerve endings are destroyed too

………….
• Signs and symptoms include:
- Painless, except on the edges of the wound
- Symptoms of shock

…..
• Haematuria:When a large amount
of free haemoglobin is produced
in extensive third-degree burns,
unconjugated free haemoglobin
passes through the glomeruli and
is excreted in the urine

….
- haemolysis:
- appears dry and look waxy white, leathery,
brown
- edema

……
• Requires surgical repair,
sloughectomy and grafting
• Healing time depends on the
severity of the burn

…..
• Deep second- and third-degree
burns (called full-thickness burns)
will likely to be treated with skin
grafts.

4. 4th degree burns
• The epidermis, dermis,
subcutaneous fat, muscle, and
perhaps the bone are involved
• Requires reconstruction often
amputation as well as grafting

Classification of burns according to
extent of the Body Surface Area burnt
Rule of nines
• The rule of nine assesses the
percentage of burns and is used
to help guide treatment decisions
including fluid resuscitation.

THE RULE OF NINES CHART
KEY: HEAD AND NECK 9%
ARMS (2) 9%
ANT. TRUNK 18%
POST. TRUNK 18%
LEGS (2) 18%
PERINEUM 1%
TOTAL 100%

…..
• Head(neck) = 9%
• Chest (front) = 9%
• Abdomen (front) = 9%
• Each arm = 9%
• Each palm = 1%

…..
• Upper/mid/low back
and buttocks = 18%
• Groin/sexual
organs = 1%
• Each leg = 18%
- front = 9%
- back = 9%

….
• Example, if both legs (18% x 2 =
36%), the groin (1%) and the
front chest and abdomen were
burnt, this would involve 55% of
the body.

….
• After assessing the percentage of
burns using the rule of nine, the
burns are then graded using total
body surface area (TBSA) affected
by the burn.

…..
Minor burns :
• <10% total body surface area
(TBSA) in an adult
• <5% TBSA in young or elderly
• <2% full thickness burns

…..
Moderate burns
• 10-20% TBSA burn in an adult
• 5-10% TBSA in young or elderly
• 2-5% full thickness burn

…..
Major/Severe burns
• >20% TBSA burns in adult
• >10% TBSA burns in young or
elderly
• >5% full thickness burn

Pathophysiology of burns
Fluid and electrolyte
• The greatest initial threat to a
patient with major burn is
hypovolemic shock.

….
• It is caused by a massive shift of
fluids out of blood vessels as a
result of increased capillary
permeability.

…..
• As the capillary walls become
more permeable, water, sodium
and later plasma proteins
especially the albumin move into
the interstitial spaces and other
surrounding tissues.

…..
• The colloid osmotic pressure
decreases with progressive loss of
proteins from the vascular space
• This results more fluid shifting
out of the vascular space into
interstitial spaces

….
• The net result of fluid shift is the
intravascular volume depletion
• Oedema, decreased blood pressure,
increased pulse, cyanosis, pallor,
decreased urine output

….
• If not corrected these events can
lead to irreversible shock and
death.

…..
• Another source of fluid loss is
from insensible loss by
evaporation from large, denuded
body surface areas.

….
• The circulatory status is also
impaired because of haemolysis
of RBCs

Management of burns
AIM
To prevent infection, promote
healing, control pain and give
psychological care to the patient.

…
Resuscitation of the patient
Effective breathing
• Administer humidified air and 100%
oxygen as required especially the burns
of the neck and the chest.
• Place patient in fowlers position
• Encourage the patient to take deep
breath and cough.

….
• Encourage chest physiotherapy.
Fluid therapy
• Institute IV therapy as soon as possible for
burns greater than 15%.
• Crystalloid solutions are recommended such
as Normal Saline, Ringers Lactate or dextran.

Formula for fluid replacement.
Parkland formula
• This advocates for total volume of
the first 24 hours of resuscitation
at approximately 4ml/kilogram of
body weight per percentage burn
of TBSA.

….
• Half the volume is given in the
first eight (8) hours post burn,
with the remaining volume
delivered over 16 hours

….
• The Parkland formula for the total
fluid requirement in 24 hours is as
follows:
Fluids required = 4ml x TBSA (%) x
body weight (kg)

…………
• Example: - A man weighing 70kgs,
with burns of both legs and
perineum. Calculate the fluids to be
given and elaborate how these fluids
would be given?

ANSWER
• TBSA BURNT = 37%
• WEIGHT = 70KGS
• FORMULAR: FLUIDS REQUIRED = 4MLS X
WEIGHT X TBSA
• FR = 4 X 37 X 70 = 10 360
• YOU GIVE 5 180 MLS IN THE FIRST 8 HOURS,
THEN 5 180 MLS IN THE NEXT 16 HOURS

……
Environment
The patient should be isolated to
prevent getting infection as this
patient has low immunity

….
• Nurse patient in burn unit
• The patient can still be nursed within
the ward using reverse barrier
nursing

…..
• Keep room clean and dust free to
reduce micro-organisms in the room
that may predispose the patient to
infection
• Dumpdusting and moping of the
floor with 0.5% jik is important

…
• Maintain warm room to reduce heat
loss by using a heater if available or
providing enough beddings
• Radiant warms and heat reflecting
blankets can be used to reduce heat
loss.

….
Observations
• Temperature is done to rule out infection
as patient has low immunity.
• Pulse to rule tachycardia as patient may
have rapid pulse due to vascular fluid
loss.

….....
• Blood pressure is done to rule out
hypotension as patient loses
intravascular fluids
• Observe the wound for signs of
infection such as pus or the
process of wound healing

….
• Respirations to detect any
deviation from normal such as
rapid respirations
• Dyspnoea especially burns that
may affect the respiration system
such as burns of the chest

....….
• Observe the extent burns and signs
of healing
• Observe for any contractures as
these are common complications of
burns
• Weigh patient if the condition can
allow daily to determine weight loss

….
• Observe for signs of dehydration as
patient is losing a lot of fluids
especially through the open burns,
shift of fluids from intravascular
space into surrounding tissue at the
site of burns

………
• Observe the IV line for patency and maintain
the strict input and out put chart
• Observe the urine output to monitor kidney
function
• Observe the patient’s mental status and give
psychological care accordingly
• Observe the degree of pain and give the
appropriate analgesics

….......
Wound care
• Carry out daily cleaning of the
wound as ordered by the doctor
• The would may be dressed with
Vaseline gauze or left exposed

……..
• After 24 hours depending on the
physician’s preference the blisters may or
may not be punctured to ensure quick
healing of the wound
• Carry out daily saline soaks or baths to
facilitate quick healing
• Carry out daily dressing and apply
Silvadine or Flamazine to promote quick
healing

…
• Assess for the signs of infection
and wound healing.
• Check for any wound bleeding
• Remove the loose skin and where
necessary sloughectomy may be
done followed by skin graft

….
Pain management
• Burn patients are in pain 24 hours a
day because of unprotected nerve
endings until the wound heals or
grafted.

….
• Give prescribed analgesics such as
morphine, pethidine and other mild
analgesics such as codeine, panadol
depending on the extent of burns.

…..
• Monitor patient’s response to
analgesics to determine the
type of analgesic to give

…
• Explain the cause of pain to correct
misconceptions.
• Handle patient gently and with care
during nursing procedures
• Give some analgesics before wound
dressing

….
• Provide diversional therapy such
as radio, television according to
the patient’s preference.

….......
• Use bed cradle to lift line off the
burns to avoid weight of linen on
the wounds.

….
Medication
• Give tetanus toxoid 0.5mls subcut stat
to prevent tetanus
• Give topical antibiotics such as silver
sulfadiazine or silver nitrate
• Give systemic antibiotics to combat
infection e.g. Crystalline penicillin 2mu
QID x 7 to 10 days plus gentamycine
80mgs TID x 7 to 10 days

……
• Give strong analgesics initially e.g
pethidine 50-100mgs TID, then mild
analgesics such as paracetamol 1g
TID until the pain subsides
• Give iron tablets if there is evidence
of anemia e.g. Folic Acid 5 mgs OD
PO, Ferrous Sulphate 200 mgs TID

….
Nutrition
• Maintain warm environment to reduce
heat loss as this will reduce metabolic
requirements.

….
• Begin enteral feedings within the
first 24hours to 48hours post burn to
decrease the incidence of post-
traumatic ileus and maintain the
integrity of bowel mucosa.

….
•Oral feeds are started as
soon as patient can
tolerate them.

….
• Adequate nutrition is necessary for the
wound to heal well.
• The diet should be well balanced
• Give proteins such as beans, kapenta etc
for tissue repair
• Give foods rich in calories such as
nshima, porrdge for energy replacement

………..
• Give foods rich in vitamins, especially
vitamin C such as oranges and vegetables
to promote the immunity of the patient
and quick wound healing
• Give roughages and encourage fluid
intake to prevent constipation

…
• Avoid unpleasant procedures, sights
or odors just before and at mealtime
to provide conducive environment
for eating.

…..
• Give appetizing meals to
encouraging eating.
• Monitor the general nutritional
status of the patient.

…
Psychological care
• Burn patients presents with a lot of
psychological needs
• Patient with burns of the head, face,
neck or hands may be concerned
about the possibility of permanent
disfigurement or disability

….
• Encourage patient to verbalize
about his/her feelings
• If married, involve the spouse in
the care to promote the sense of
belonging

….
• Prepare the patient and visitors
for the patient’ appearance.
• Explain what the patient will see
to lessens shock

…
• Encourage the patient to look in
the mirror especially after
oedema has subsided.

….
• Discuss with the patient about
reconstructive surgery to allay
anxiety.

…..
• Encourage visiting from the
family members, girlfriends,
boyfriends or other friends to
prevent feeling of rejection and
social isolation.

…
• Answer questions honestly and
do not give false reassurance.

….
• Nurse patient in an isolated
room/burn unity and apply
reverse nursing care.

Prevention of infection
Wash hands before and
after attending to the burnt
patient.

….
• Patient should be nursed in a single
room as reverse nursed since the
immunity is low
• Use aseptic technique, wear mask,
gown and sterile gloves during
wound care to prevent
contamination.

…
• Carry out wound care daily to
minimize growth of micro-
organisms.

…
• Keep wound covered at all times
with topical agent to prevent
invasion of the wound by micro-
organisms
• Give the patient antibiotics to
combat infection

…
• Examine the wound for signs of
infection.
• Discourage patient from touching
his/her wounds
• Cut the nails short to prevent
habouring microbes and scratching

…..
Activities/rest
• Passive exercises should be done
by the nurse to prevent
contractures

…
• If patient has a skin graft,
encourage him/her to have bed
rest to give chance for healing to
take place.

…
• Encourage patient to move up
and down if condition can allow.

,…
Hygiene
• Promote good hygiene as patient
is prone to infection.
• Keep room clean to reduce micro-
organisms in the room

….
• Wash hands appropriately before,
during and after attending to the
patient.
• Change soiled linen from the
wound discharge to promote
comfort.

…
• Bath patient daily if condition
allows.
• Type of bed bath will depend on
the severity of the condition
• Nail care is necessary to prevent
infecting the wound

……….
• Oral care daily to promote appetite
• Hair care to promote the self esteem
of the patient

Elimination
• Maintain intake and output
• Provide patient with clean bed
pan or urinal
• Escort the patient to the toilet
when the condition improves

Complications
1.Wound infection
• Wound infections are common
in burn wounds and are often the
source of bacteria responsible for
other systemic infections
including bloodstream infections
and pneumonia

….
2. Multisystem organ failure
• Wound infection can lead to
multisystem organ failure and
death as the bacteria spreads in
the blood stream.

….
• Sepsis can contribute to
multisystem organ failure and
death.

….
3 Bleeding
• Early wound excision is
associated with bleeding, a
complication that require
urgent transfusions

….
4. Shock
• The patient can have
hypovolemic shock, septic shock
and neurogenic shock

….
5. Scarring
• this is due to the healing process of
the burns
6. Contractures
• can come as a result of reduced joint
mobility due to pain especially if burns
involve the joints

……
7. Septicaemia
• this is the spread of infection to
other parts of the body from the local
wound infection

SKIN GRAFT
• Definition
• Indications
• Types
• Preoperative care
• Post-operative care

What is a skin grafting?
• Skin grafting is a surgical
procedure that involves removing
skin from one area of the body
and moving it, or transplanting it,
to a different area of the body
which is severely burnt

What are the indications of skin
grafting?
• A first degree or superficial burn
heals naturally because your body is
able to replace damaged skin cells
• Deep second, Third degree and full-
thickness burns require skin graft
surgery for quick healing and
minimal scarring

Types of skin grafts
• Autograft or Autologous graft: this is
the type of skin which is obtained
from the patient's own donor site
• Allograft or Heterologous graft: this
is the type of skin obtained from
another person

………
• Xenograft or Heterograft: this is the
type of skin graft where the skin as a
donor is obtained from other species,
such as pigs is
• Synthetic skin substitutes: This is the
type of skin graft which is obtained as a
manufactured product and that works
as skin equivalents

How is the procedure done?
• During a skin graft, a special skin-cutting
instrument known as a Dermatome removes
the skin from an area (the donor site) usually
hidden by clothing such as the buttocks or
inner thigh
• Once removed, the graft is placed on the area
in need of covering and held in place by a
dressing and a few stitches.

What are the Common Donor sites?
• The common areas for donor
sites are the thigh and upper arm
• Others are the back, buttocks or
abdomen
• The dressing used over the donor
site is known as Adhesive Retention
Tape

Pre-operative management of the
patient undergoing a skin graft
• It is an Elective Operation
• It is done under general
anesthesia
• Prepare as in General
preoperative care guide

Post-operative management of the
patient who has undergone a skin graft
• Take care of the grafted site
• Take care of the donor site
• Refer to the care of the skin graft
below
• No drains needed
• Plus general postoperative care
guide

……………
CARE OF THE SKIN GRAFT
• If skin graft is performed, ensure that the first
dressing is removed by the doctor
• Carry out daily dressings for both the grafted
site as ordered by the surgeon
• Clean and dress the donor site
• Observe for any tissue reaction which may
indicate rejection

REVISION QUESTIONS
• Mr Kawayawaya, a 30 year old farmer
and weighing 60kg is admitted to the
intensive care unity after sustaining
burns of the whole trunk, neck and the
left arm while boiling water for bathing.
• Draw a well labelled diagram of the skin
(10%)
• Outline four classifications of burns
according to depth (20%)

………….
• Discuss the nursing care that you
would give to Mr Kawayawaya in the
first 48hours of admission (50%)
• Explain five (5) complications that Mr
Kawayawaya may present with whilst
in hospital and how they can be
prevented (20%)

Question two
• Mrs. Chilemba a 33 year old secretary has
been brought to your ward with third degree
burns. She is scheduled for skin graft as soon
as the patient is stable.
a) i. Define a skin graft 5%
ii. State any five (5) functions of
the skin 15%
b) Describe the pathophysiology of burns 20%

…….
c) Explain the postoperative care of Mrs.
Chilemba following the skin graft 50%
d) List any five (5) specific complications that
Mrs. Chilemba may develop following skin
Graft 10%

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