Burn is the type of injury that is caused by excess heat ,flame ,radiations, chemical or electricity . Burn injuries occurs when heat energy transfer to skin and damage the layers , muscles and tissue of the skin.
Young ,children and older adults continue to have increased morbidity and mortality when compared to other age group which similar injuries and present a challenge for the burn team.
BURN :-
Tissue injury caused by application of thermal energy in any form to the body surface is termed as burn.
Or
Cell destruction of the layers of the skin and the resultant depletion of fluid and electrolytes.
Types of burns/causes:-
Thermal
Scaled
Flame
Radiation
Chemical burn
Electrical burn
CHARACTERISTICS OF BURN ACCORDING TO DEPTH :-
4 th degree burn
EXTENT OF BODY SURFACE AREA INJURED:-
1. Rule of nine :-This system is based on dividing anatomic regions, each representing approximately 9% of the TBSA, allowing clinicians to quickly obtain an estimate.
2. Lund and broader method :-Lund and browder method, which recognises the percentage of surface area of various anatomic parts, especially the head and legs, as it relates to the age of the patient . By dividing the body into very small areas and providing an estimate of the proportion of TBSA accounted for by each body pats, clinicians can obtain a reliable estimate of TBSA burned.
3. Palmer method :- In patients with scattered burns, the Palmer method may be used to estimate the extent of the burns. The size of the patient's hand including the fingers, is approximately 1% of patient's TBSA.
PATHOPHYSIOLOGY
PATHOPHYSIOLOGICAL CHANGES :-
MANAGEMENT OF BURN INJURY:-
Burn care is typically categorised into 3 phases of care :-
⮚ Emergent /resuscitative phase.
☆On the scene care.
☆Medical management.
☆Nursing management.
⮚ Acute /intermediate.
⮚ Rehabilitation.
PRE HOSPITAL MANAGEMENT:-
✔ Rescuer to avoid injuring yourself
✔ Remove patient from source of injury
✔ Stop burn process
✔ Burning clothing ;jewelary ,watches , belts to be removed
✔ Pour ample water on burnt
1. EMERGENT/RESUSCITATIVE PHASE :-
On scene care :-The first step in management is to remove the patient from the source of injury and stop the burning process while preventing injury to rescuer. Rescue worker priorities include establishing an airway, supplying oxygen, inserting atleast one large bore IV line , and converting the wound.
An immediate primary survey of the patient is carried out to assess the ABCDE
A – Airway
B - Breathing
C - Circulatory and cardiac status
D - Disability
E - saintaing warm environment
The secondary survey focuses on –
● Obtaining a history
● The completion of the total body system assessment (TBSA)
● Initial fluid resuscitation
● Provision of psychosocial support of the conscious patient.
MEDICAL MANAGEMENT:-
★ Initial priorities in the emergency department remain airway , breathing and circulation
★ For mild pulmonary injury , 100% humidified oxygen is administered and the patient is encourage to cough so that secretions can be expectorated or removed by suctioning .
★ For more severe situation of cough , administer bronchodilator and mucolytics agent.
★ Once urgent respiratory need are appropriately addressed , fluid resuscitation is initiated in burns greater than 20% TBSA .
Fluid Replacement therapy :-
1. Parkland formula
Fluid of choice.
1. Lactate Ringer’s (RL)
2. Normal saline.
Formula :- 4ml *%of burn * weight(kg) in 24 hours.
★ first half of total volume given in the first 8 hour.
★ Remaining half of total volume given over following 16 hours
Next 24hrs.
★ Total volume half of first day.
★ Colloids (0.5ml/kg/%).
★ 5%glucose to make up the rest.
2. Brooke formula.
Formula :- 2ml *% of burn * weight (Kg) in 24 hrs.
★ first half of total volume given in the first 8 hrs.
★ Remaining half of total volume given over following 16 hrs.
Next 24hrs.
★ Total volume half of first day.
★ Colloids(0.3 – 0.5ml/kg/%).
3. Evan's formula.
Requirement for first 24hrs
Colloids: 1ml/kg/%burn
Saline :1ml/kg/%burn
D5 :- 2000ml
Requirement for second 24hrs
Half of first 24hrs.
2. Acute phase :-
The acute phase of burn care follows the emergent resuscitative phase and begins 48 to 72hrs after the burn injury.
During this phase, attention is directed towards continued assessment and maintenance of respiratory and circulatory status ,fluid and electrolyte balance ,and GI and kidney function.
1. Infection prevention :-
A multiple – strategies approach is crucial in prevention and control of wound infection. such strategies includes:-
The use of barrier techniques eg. Gowns ,gloves, eye protection , and mask.
★ Environmental cleaning with periodic cultures of patient care equipment.
★ Application of appropriate topical antimicrobial agents.
★ Early excision and closure of the burn wound.
★ Appropriate use of systemic antibiotic and antifungal agents .
2. Wound cleaning :-
Proper management of burn wounds is required to prevent wound deterioration .
Gentle cleaning with mild soap ,water and a wash cloth can prevent infection by decreasing bacteria and debris on the wound surface.
Goals :-
The goal of wound care is debridement of nonvisible tissue.
● Removal of previously applied topical agent and
● Application of new topical agent
3. Topical antibacterial therapy :-
The goal of topical therapy is to provide a dressing with the following characteristics :-
■ Is effective against gram positive and gram negative organisms and fungi
■ Penetrates the eschar but it not systematically toxic
■ Is cost effective , available, and acceptable to the patient .
■ Is easy to apply and remove and decrease the frequency of dressing changes, decrease pain and minimizes nursing time.
4. Wound dressing :-
After the ordered topical agent are applied , the wound is covered with several layer of dressing are:-
⮚ Lighter dressing is used over joint to allow for mobility .
⮚ Circumferential dressing should always be applied distally to proximally in order to promote return of excess fluid to the central circulation.
⮚ Occlusive dressing gauze and a topical antimicrobial agent may be used over areas with new skin grafts to protect the new graft and promote an optimal condition for its adherence to the recipient site.
5. Wound debridement :-
The goal of debridement (the removal of devitalized tissue)are:
● Removal of devitalized tissue
● Removal of tissue contaminated by bacteria and foreign bodies , thereby protecting the patient from invasion of bacteria.
Types of debridement: -
Natural debridement ,the devitalized tissue separates from the underline valuable tissue spontaneously bacteria present at the inter face of the burned tissue and the viable tissue gradually liquify of the collagen that hold the eschar in place.
Mechanical debridement involve the use of surgical tool to separate and remove the eschar .
Dressing changes and wound cleaning and the removal of wound debris
Wet to dry dressing are not advocated in burn care because of the chances removing viable cell along with necrotic tissue.
Chemical debridement ,Topical enzymatic agents are available to promote debridement of burn wound because such agents usually do not have antimicrobial properties ,they may be used together with topical antibacterial therapy to protect the patients from bacterial invasion.
Surgical debridement is carried out before the natural separation of eschar is allowed to occur.
The operative procedure involve either excision of the full thickness of the skin down to the fascia or shaving of the burned skin layers gradually down to freely bleeding ,viable tissue.
6. Wound grafting :-
Grafting permits earlier functional ability and reduces wound contacture (shrinkage of burn scar through collagen maturation )
If wound are deep or extensive, spontaneous re-epithelization is not possible.
Types
❖ Autografts
❖ Homograft and xenografts
❖ Biosynthetic and synthetic dressings
■ Autografts are the ideal means of covering burn wounds because the grafts are the patients own skin and therefore are not rejected by the patients immune system.
■ Homografts are skin obtained from recently deceased or living humans other then the patients . Xenografts consist of skin taken from animals (usually pig)
■ Biosynthetic and synthetic dressing , which may eventually replace biologic dressings as temporary wound covering . One widely used synthetic dressing is Biobrane, a dual layer dressing of nylon and silicon .
Biobrane protect the wound from fluid loss and bacterial invasion .it can remain it place until spontaneous re-epithelization and wound healing occur . it can also be laid on top to close the interstices.
7. Pain management :-
A burn injury considered one of the most painful types of truama that a patient can experience. To manage the pain follows are:-
★ Pharmacological treatment includes:-
● Opioids
● Nonsteroidal anti-inflammatory drugs.
● Anxiolytics.
● Anesthetic agent.
● Benzodiazepines.
★ Non pharmacological management :-
● Relaxation techniques.
● Music therapy.
● hypnosis.
● Distraction.
● Therapeutic touch.
● Humors.
● Virtual reality technique.
● Guided imaginary.
8. Modulation of hypermetabolism :-
Burn injuries produce profound metabolic abnormalities fueled by the exaggerated stress response to injury. Hypermetabolism can affect the morbidity and mortality by increasing the risk of infection and slowing the healing rate .
9. Nursing management :-
✔ Restoring normal fluid balance.
✔ Preventing infection.
✔ Modulating hypermetabolism.
✔ Promoting skin integrity.
✔ Relieving pain and discomfort.
✔ Promoting physical mobility.
✔ Strengtheing coping strategies.
✔ Supporting patients and family process.
✔ Monitoring and managing complication.
Nursing diagnosis :-
1. Ineffective airway clearance and impaired gas exchange related to tracheal oedema or interstitial oedema secondary to inhalation injury and /or circumsfrential torso burn manifested by hypoxemia and hypercapnia.
2. Deficient fluid volume secondady to fluid shifts into the interstitium and evaporative loss of fluids from the injured skin.
3. Ineffective tissue perfusion related to compression and impaired vascular circulation in the extremities with circumferential burns, as demonstrated by decreased or absent peripheral pulse.
4.Acute pain related to burn trauma.
5. Risk for infection related to loss of skin,
impaired immune response and invasive therapies.
6. Gastrointestinal bleeding related to stress response.
7. Risk for hypothermia related loss of skin and /or external cooling
REHABILITATION OF BURNS
Rehabilitation begins immediately after the burn has occurred and often extend for years after injury.
Burn rehabilitation is comprehensive and complex and requires a multidisciplinary approach to optimize the patient physical and psychosocial recovery related to the injury.
Goals :-
Return patients to the highest level of function possible within the context of their injuries.Occupational and physical therapies are essential to optimize patients goals and outcome.
Phases of rehabilitation :-
First phase:- it is initial evaluation and resuscitation, occurs on day 1- 3 days and requires an accurate fluid resuscitation and through evaluation f
or other injuries and comorbid conditions.
Second phase:- it's a initial wound excision and biological closure , includes the maneuver that changes the natural history of the disease. This as accomplished typically by a series of staged operations that are completed during the first few days after injury.
Third phase:- it is a wound closure , involves replacement of temporary wound covers with a definitive cover, there is also closure and acute reconstruction of areas with small surface area.
Final phase:- it is reconstruction and reintegration.
Acute rehabilitation for burns patients :-
▪ Performing ROM exercise.
▪ Splinting and antideformity positioning.
▪ Minimizing edema.
▪ ADL Training.
▪ Initial scar management .
▪ Preparing for work.
▪ Wound care.
Reference :-
Brunner and Suddarth's. Textbook of Medical - Surgical Nursing volume II published by Wolters Kluwer (India) Pvt,Ltd.New Delhi
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