COLLEGE OF NURSING SILLIMAN UNIVERSITY Dumaguete City

Topic: Burn Injuries Dumaguete Topic Description: This topic deals with the care of patients with burns in the surgical City ward. It focuses on the categories and classifications of burns, phases of burn management and the nursing process involved in the care of patients with burns. Central Objective: At the end of the lecture discussion, the learners shall acquire comprehensive knowledge, strengthen skills and manifest positive attitudes in the care of surgical patients with burns. Time Allotment: 1 hour Specific Objectives Prayer With the use of various teaching strategies, the students shall: Content T.A. 2 mins. T-L Activities References Evaluation

I.
a. Recall the layers of the skin and determine the functions of each.

Introduction Layers of the Skin

II.

The epidermis which is contiguous with the mucous membranes and the linings of the ear canals, consists of live, continuously dividing cells covered on the surface by dead cells that were originally deeper in the dermis but were pushed upward by the developing , more differential cells underneath.

b. Dermis The dermis makes up the largest portion of the skin, providing strength and structure. The dermis is often is referred to as the true skin. c. Subcutaneous Tissue The subcutaneous tissue, or hypodermis, is the innermost layer of the skin. It is primarily adipose tissue, which provide cushion between skin layers, muscles, and bones. It promotes skin mobility, molds body contours, and insulates the body b. Differentiate the types of burn injuries.

III.

Types of Burn Injury

6 mins.

Lecture Discussion

Thermal burns which can be caused by flame, flash, scald, or contact with hot objects are the most common type of burns. b. Chemical Burns Chemical burns result from tissue injury and destruction of acids, alkalis, and organic compounds. Acids Are found in many household cleaners and include hydrochloric, oxalic, and hydrofluoric acid. Alkalis are found in oven and drain cleaners, fertilizers, and heavy industrial cleansers. c. Electrical Burns Electrical burn happens when and individual comes directly in

Brown, D. E., & Edwards, H. (2005). Lewiss medicalsurgical nursing: Assessment and management of clinical problems. Australia: Elsevier Mosby.

contact with an electric current. Contact with electric current greater than 40 volts can create burns in the internal tissues and organs of the body, current greater than 1000 volts can cause extensive tissue damage. The extent of the injury depends on the duration of contact, voltage, pathway of the current and the resistance of the tissues to the electrical current that passes through the body. d. Radiation Burns Radiation burns are the least common type of burn injury. It is the damage of the skin or tissue caused by the exposure to radiation. The most common type of radiation burn is sunburn caused by exposure to UV radiation. The amount of radiation received by the person depends on the distance of the individual from the source of radiation, the duration of the exposure, the strength of the source of the radiation, the body surface area being exposed and the protective barrier between the person and the source of radiation. e. Smoke and Inhalation It is the inhalation of asphyxiants (e.g. carbon monoxide), harmful gases, vapors, and particulate matter contained in smoke. People who are trapped in fires may suffer from smoke inhalation which can injure the airways and lungs and can cause possible death because of the result of hypoxia and carbon monoxide poisoning. c. Employ health assessment skills in the care of

IV.

Classification of Burn Injury Depth

10 mins

Lecture Discussion

Burke, K., et. Al. (2003). Medicalsurgical nursing care.

patients who underwent burn injuries

USA: Prentice Hall. Includes only the outer layer of skin, the epidermis. The skin is usually red and very painful, equivalent to superficial sunburn without blisters and dry in appearance. Healing occurs in 3-7 days, injured epithelium peels away from the healthy skin. Hospitalization is for pain control and maybe fluid imbalance b. Second-Degree Burn Injury Blisters can be present. Involve the entire epidermis and upper layers of the dermis. Wound will be pink, red in color, painful, wet appearing and will blanch when pressure is applied. Should heal in several weeks (10-21 days) without grafting, scarring is usually minimal. c. Third-Degree Burn Injury All layers of the skin are destroyed and extend into the subcutaneous tissues. Areas can appear black, brown, white or red, will be dry and can appear leathery in texture. Will not blanch when pressure is applied. Scarring is present. No pain felt upon palpation due to the damage of the nerve endings; however pain may be felt in the surrounding skin. d. Fourth Degree Burn Injury Extends through skin, subcutaneous tissue and into underlying muscle and bone. Skin appears black, charred with eschar (denatured skin) and dry. Painless upon palpation. Requires excision and skin grafting. Amputation, significant functional impairment, possible gangrene, and in some cases death happens.

d. Accurately 15 V. Extent of Body Surface Area Injured compute the mins body surface area a. Rule of Nines of a burned patient. It is a standardized method used to quickly assess how much body surface
area (BSA) has been burned on a patient. This rule was first introduced in the late 1940s. This rule is only applied to partial thickness (2nd degree) and full thickness (3rd degree) burns. The body is divided into anatomical sections and assigns an equivalent percentage to the different body sections using multiples of 9. The following are the different anatomical sections of the body and their corresponding percentage.

Lecture Discussion

Ignativicius, D., & Workman, M. (2006). Medicalsurgical nurding: Critical thinking for collaborative care (5th ed.). USA: Elsevier Saunders.

Head = 9% Chest (front) = 9% Abdomen (front) = 9% Upper/mid/low back and buttocks = 18% Each arm = 9% (front = 4.5%, back = 4.5%) Groin= 1% Each leg = 18% total (front = 9%, back = 9%) b. Lund and Browder Method

This method is more precise in estimating the extent of burn because it distinguishes the percentage of surface area of various anatomic parts in which it will relate to the age of the patient. A HW can consistently acquire estimated results of total body surface area (TBSA) as soon as the patient is brought to the hospital within the first 72 hours due to demarcations and depth of the wound is clearly identified at this time. It is done by dividing the body into very small areas and providing an estimate of the portion of TBSA accounted for each body part.

c. Palm Method This method is quicker in terms of assessing and estimating the extent scattered burns of patient. It also serves as a general measurement for all age groups; by the use of the patient palms excluding the surface area of the digits, its estimated TBSA is 1% while a palm without the fingers is 0.5%.

e. Critically analyze the role of the nurse in the different management of patients with burns.

VI.

Phases of Burn Management

20 mins

Lecture Discussion

This phase starts from the onset of injury to completion of fluid resuscitation. Its focus is physical stabilization. Pathophysiology and Clinical Manifestations Time required resolving the immediate problems resulting for the burn injury are 24-48 hrs. Begins with fluid loss and edema formation and continues until the diuresis begins Complications Cardiovascular After the burn, tachycardia and slight hypotension are expected this is in response to the release of catecholamine and to relative hypervolemia, but initial cardiac output decreases. Respiratory

Smeltzer, S., & Bare, B. (2008). Brunner & Suddarths textbook of medical-surgical nursing (11th ed.). USA: Lippincott.

Tachypnea may be exhibited but with patients with inhalation injury, respiratory insufficiency may develop when fluid shifts are greatest and the injured lung parenchyma is particularly susceptible to edema formation. If left untreated, respiratory failure may develop due to infection on the course of recovery often 10 days to 2 weeks after injury. Urinary Normally, after burn injuries client loses fluid volume and compromised hydration status. In an adult patient receiving insufficient fluid replacement has urine output that diminishes 30ml/hr. Physical findings of urine sample demonstrate dehydration, characterized by dark amber, concentrated urine and elevated specific gravity. Laboratory results include increase Blood urea nitrogen levels until the client is adequately hydrated.

Nursing and Collaborative Management 1. Airway Management o 100% humidified oxygen is administered for mild pulmonary injury. o Coughing is encouraged so that secretions can be removed by suctioning. o Endotracheal intubation is done when edema in the airway is developed o Continuous airway pressure and mechanical ventilation may also be required to achieve adequate oxygenation o Patient is positioned in a way that will prevent aspiration of vomitus

2. Fluid Therapy Indications o Burns greater than 20% BSA in adults o Burns greater than 10% BSA in children Parkland (Baxter) Formula (4 ml Lactated Ringers x kg BW x % TBSA burned o of total volume in 1st 8 hrs o of total volume in 2nd 8 hrs o of total volume in 2rd 8 hrs Administration of fluid and combination of colloids (whole blood, plasma, and plasma expanders) and crystalloids/electrolytes (physiologic sodium chloride or lactated Ringers solution) Mostly, fluid replacement formulas use isotonic electrolyte. Administration of hypertonic electrolyte solution is to maintain the same urine output. Careful monitoring of serum sodium level is required to prevent hypernatremia and acute renal failure. Calculate the patients expected fluid requirements Administering and IV monitoring IV therapy IV catheter should be inserted in a non-burned area so that large amount of IV fluids can be administered quickly and central venous pressures can be monitored. If the burn exceeds 20% to 25% TBSA, a nasogastric tube is

inserted and connected to low intermittent suction. An indwelling catheter is inserted to permit more accurate monitoring of urine output and renal functions for patients with moderate to severe burn. Strict monitoring of fluid intake and output is essential during the resuscitative phase along with reporting laboratory values Reporting patients response to the physician 3. Wound Care

All clothing and jewelry should be removed and the patient is checked for contact lenses. For chemical burns, flushing of the exposed areas is continued. Validate an account of the burn scenario provided by the patient, witness at the scene and paramedics includes time of the burn injury, source of burn, place where the burn occurred, duration of the patient in the burning structure, how the burn is treated at the scene, history of falling and jumping at the scene, history of pre-existing diseases, allergies, medications and the use of drugs, alcohol and tobacco. Clean sheets are placed under and cover the patient to protect the burn wound form contamination, maintain body temperature and reduced pain caused by air currents passing over exposed nerve endings. Tetanus Prophylaxis is administered if patients immunization status is not current or is unknown. Wound Care Technique:

o Use proper hand washing technique o Use sterile technique during topical antibiotic application (sulfadiazine) and dressing changes o Start hydrotherapy, cleansing, debride as necessary o All burned areas with hair except eyebrows must be shaved, including head and perineum o Source of infection is patients own flora (skin, respiratory, git) o Pain medication before hydrotherapy and debridement o To remove loose, necrotic skin; large blisters may be opened to eliminate media for bacterial growth o Tap water need not be sterile not exceeding 40c (104f) o Bathed 2 times daily to limit the amount of bacterial growth (painful and psychologically demanding) 4. Drug Therapy Bronchodilators and Mucolytic agents are necessary especially in severe situations to remove secretions. IV analgesia (usually morphine) is administered. 5. Nutritional Therapy NPO is usually ordered to prevent nausea and vomiting caused by paralytic ileus resulting from stress of the injury. b. Acute Phase Pathophysiology and Clinical Manifestations

The acute phase of burn begins at about 36-48 hours after the injury and lasts until all the partial thickness wounds are healed. The physical healing time is determined an individuals nutritional status, existing medical condition and ability to heal. Care is directed to the continued assessment and restorative therapies.

Complications A comprehensive head-to-toe assessment should be done for maintaining the bodys different organ systems to treat and to note possible complications that may set in. Controlled fluid and electrolyte management with continuous and close meshed monitoring of various laboratory parameters decreases the risk of common complications of the burn injury. The most common complications are: o Pneumonia o Sepsis o Lung Failure o Acute Respiratory Distress Syndrome.

Severe complications such as cholecystitis or acute renal and organ failure must be detected early and treated adequately. Due to the necessary analgesia, patients often receive long term respiration. Bacterial infection is another common complication which can endanger the burned patient and threaten his life. The partially damaged integrity of the skin allows devastating superficial infection which, however, is rarely the direct cause of death. In contrast, if bacteremia and consecutive sepsis develop, mortality greatly increases. 75% of patients with extensive burns die

as a consequence of a severe infection. Nursing and Collaborative management 1. Wound care Wound care is one of the primary interventions done to facilitate healing. Wound care involves cleansing, debridement of devitalized tissue and dressing of the wound. Wound Cleansing o The practice of hydrotherapy is still the mainstay of burn treatment to cleaning wounds. Using a shower, tub or spray table facilitates the removal of topical medication, loosens debris and exudate. It permits the immersion of the patient into the water or antimicrobial solutions. Generally, tub therapy is limited to 30-minute intervals to prevent heat loss. Wound Debridement o This involves the removal of eschar, exudate and crusts. This prevents bacterial proliferation in and under devitalized tissue thus promoting wound healing. Debridement of wound is done through mechanical, enzymatic or surgical means.
Surgical Debridement

o Surgical debridement (also known as sharp debridement) uses a scalpel, scissors, or other instrument to cut dead tissue from a wound. It is the quickest and most efficient method of debridement. It is the preferred method if there is rapidly developing inflammation of the body's connective

tissues (cellulitis) or a more generalized infection (sepsis) that has entered the bloodstream. The procedure can be performed at a patient's bedside. If the target tissue is deep or close to another organ, however, or if the patient is experiencing extreme pain, the procedure may be done in an operating room. Mechanical Debridement o In mechanical debridement, a saline-moistened dressing is allowed to dry overnight and adhere to the dead tissue. When the dressing is removed, the dead tissue is pulled away too. This process is one of the oldest methods of debridement. It can be very painful because the dressing can adhere to living as well as nonliving tissue. Because mechanical debridement cannot select between good and bad tissue, it is an unacceptable debridement method for clean wounds where a new layer of healing cells is already developing. Enzymatic Debridement o Enzymatic debridement makes use of certain enzymes and other compounds to dissolve necrotic tissue. It is more selective than mechanical debridement. In fact, the body makes its own enzyme, collagenase, to break down collagen, one of the major building blocks of skin. Topical Antimicrobial Treatment o Burn wounds are initially treated with topical

antimicrobial agents. The agents are applied after wound cleaning, debridement and wound inspection is done. Burn wounds are treated using the open or closed dressing technique. The antimicrobial agent is applied with a gloved hand and left wound open. Reapplication of the wound is done every 12 to 24 hours. Open wound method allows increased wound visualization, greater freedom for mobility and joint motion and simplicity in wound care; however is possess increased chance of hypothermia and pain from exposure. Closed method is done impregnating the gauze dressing with antimicrobial cream and applied to the wound. Closed method decreases evaporative fluid and heat loss from wound surface and may aid in wound debridement; however mobility is limited and decreased effectiveness of range of motion exercises. Dressing o Temporary wound coverings may be used on burn wounds. These covering protect wound thus promote healing. The dressing may be synthetic, biosynthetic or biologic. The type of dressing to be used depends on the depth of wound and the presence or absence of infection. The covering may be place on the wound for 1 day or until the wound is fully healed. 2. Excision and Grafting Excision is the most common treatment for full-thickness and deep partial-thickness wounds. The client is taken to the operating room within 5 days after surgery and again as

needed until all wounds are permanently closed. Autografting is done in a full-thickness burn. It is the removal of the superficial layer of the clients own unburned skin then is grafted into the burn wound. The term split thickness graft is coined because the epidermis is split rather than taken in full. Autograft is either applied as a sheet graft (applied to the excised wound without altering its integrity) or a meshed graft (contains many little slits that allow skin expansion). Culture epithelial autografting is a technique for closure of massive burn wounds. This process begins by taking the uninjured full-thickness specimen and then sent to the laboratory for culture and growth. After 3 to 4 weeks, sheets of cultures epithelial autografts are ready for application. Dressings are then applied with a moistened antimicrobial solution. 3. Pain Management Pain management is crucial during this part of recovery. In the resuscitative phase, the use of pharmacologic agents is the most common approach to pain control. Patientcontrolled analgesia devices, inhalation analgesics such as nitrous oxide, oral analgesic pain cocktails, and opioidantagonist maybe beneficial in this phase of burn injury. NSAIDS can also be prescribed to relieve mild to moderate pain but should be used with extra precaution to prevent gastric irritation. Nonpharmacologic treatment may also be used, such as guided imagery, hypnosis, relaxation techniques, distraction, art and music therapy and many more. 4. Physical and Occupational therapy

5. Nutritional therapy In burn injury, the loss of skin leads to enormous losses of fluids, electrolytes and proteins. Fluids and electrolytes are replaced by intravenous therapy immediately to prevent shock. o The hypermetabolic state after a serious burn continues until the skin is largely healed, so there is an enormous increase in energy needed for the healing process. Kcal requirements are based on weight (size), the total burned surface and the depth of burn. Protein needs can be high as 1.5 to 3.0 or more grams per kilogram of weight and fat intake, 15% to 20% of nonprotein calories. There is an increased need for vitamin C and zinc for healing, B vitamins for metabolism of the extra nutrients and vitamin A for the immune system and epithelial tissues. 6. Psychosocial Care It is the role of the nurse to assess and aid in this area because patients with burn injury may have emotional and psychological responses as they adjust to the acute phase. Patient may be anxious and depress by the physical changes that is happening his/her body. Withdrawal, depression and regression may result. The nurse should allow the expression of these feelings and offer emotional support. A thorough explanation and providing information about specific treatment measure could help reduce the anxiety and ensure cooperation from the patient.

c. Rehabilitation Phase It encompasses the time from wound closure to discharge and beyond; begins when burn wound is covered with skin or healed and patient is capable of assuming some self-activity and last for 23 months Complications Skin and joint contractures are among the most serious complication of burn followed by hypertrophic scarring which are results from an overabundant deposition of collagen in the healed wound. Nursing and Collaborative Management Proper exercising, splinting and positioning should be enhancing more. Through the use of massage and pressure therapy hypertrophic scarring could be reduced. Provide psychosocial support Nurses should be understanding to the patient acknowledge that feelings are valid and real do not belittle encourage expression issue of sexuality must be dealt with honestly (touch important part)

Open Forum

COLLEGE OF NURSING SILLIMAN UNIVERSITY Dumaguete City

Resource Unit on Clients with Burn Injuries Dumaguete City

Submitted to: Asst. Prof. Cabual Submitted by: Steffi An Navarra and Angeline Patricia M. Flores