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  1. 1. Third-year bachelor Second semester Prepared by: Dr./ Mona Nadr
  2. 2. 1- Anatomy and physiology of the skin. 2- Definition of burn. 3- Classifications of burn injury: * According to the causative agent. * According to the depth. * According to the extent
  3. 3. 3- Pathophysiology of burn: * Local effect. * Systemic effect. 5- Management of patient with burn injury in the three Phases: a- Emergent phase. b- Acute phase. c- Rehabilitation phase.
  4. 4. Anatomy and physiology of the skin: Skin is the largest organ of the body. The skin is composed of three layers: Epidermis, dermis and subcutaneous tissue. 1- Epidermis: It is an epithelial structure, where two layers types of cell are recognized namely: A- Keratinocytes: Is the main bulk of the skin responsible for prevent excessive fluid loss and repel pathogens.
  5. 5. B- Dendritic: Are mainly melanocytes and Langer hans cells. • Melanin is response about color of skin and hair. • Production of melanin control by hormone (Melanocytes). • Langer hans cell: play role in immune system and transport the antigens to the lymph system to active the lymphocytes
  6. 6. 2- Dermis: Composed of two layers: • Papillary: it produce one form of collagen and connective fibers. • Reticular: lies under the papillary layers also produce collagen and elastic bundles. • It contains sweat glands. 3- Subcutaneous tissue: • Is the inner most layer of the skin it is primarily adipose tissue, which provides a cushion between the skin layers, muscle and bones.
  7. 7. 1- Protection against invasion by bacteria. 2- Regulation of body temperature. 3- Sensation. 4- Formation of vitamin D. 5- Skin color. 6- Absorption (medications as ointment). 7- Excretion (sweat, urea, aromatic substances). 8- Reflection of internal feelings.
  8. 8. Classifications of burn According to causative agents : – Thermal – Chemical – Electrical – Radioactive According to depth of burn: -first-degree -Second-degree -Third –degree According to extent of burn:
  9. 9. Burns Classifications of burn According to causative agents : – Thermal – Chemical – Electrical – Radioactive
  10. 10. Classifications of burn According to depth of burn:
  11. 11. CLINI
  12. 12. 3- According to the extent of burn: A- Palm method.
  13. 13. B- Rule of nines.
  14. 14. C- Lund and browder.
  15. 15. 1-Local effect. If burn not exceed 25% TBSA. injured cell release histamine vasodilatation and an increase in capillary permeability Fluid shift to extra cellular space Hypovolemia and edema formation .
  16. 16. Less than 25% TBSA, the loss of capillary integrity and shift of fluid are localized to the burn itself, resulting in blister formation and edema only in the area of injury.
  17. 17. •Patients with more severe burns develop massive systemic edema. •As edema increases in circumferential burns, pressure on small blood vessels and nerves in the distal extremities causes an obstruction of blood flow and consequent ischemia. •This complication is known as compartment syndrome.
  18. 18. Hemoconcentration (increased heamatocreat) decreased urinary out put Hyponatremia, immediately after burn . It is also common during the first week of the acute phase, as water shifts from the interstitial to the vascular space. Hyperkalemia, results from cell destruction immediately after burn . Hypokalemia occur later with fluid shifts & inadequate K+ replacement . Anemia, Some RBCs may be destroyed and others damaged ↓ in platelets and prolonged clotting and prothrombin times. Metabolic acidosis 2- Effect on fluid and electrolytes:
  19. 19. 3- Cardiovascular Response: Burn injury Loss of plasma from circulation Hypovolemic shock Reduced cardiac output (thready pulse & hypotension ) Sympathetic stimulation (adrenaline and nor adrenaline) Peripheral vasoconstriction ( pallor, cold clammy skin)
  20. 20. 3- One third of all burn patients will have a pulmonary problem : Hypoxia or Inhalation injury. upper airway injury mechanical obstruction of upper airway Inhalation injury below the glottis Loss of ciliary action, hypersecretion, Bronchospasm, atelectasis. Inhalation injury
  21. 21. 4-Renal Response: Decreased blood volume Decrease blood pressure Decrease urine output Oliguria
  22. 22. 5-Immune Response: Impaired skin integrity Release of abnormal inflammatory factors Reduction in lymphocytes places the burn patient at high risk for sepsis
  23. 23. 6- Gastrointestinal Response: • Peristalsis decreases. • Gastric distention. • Nausea and vomiting. • Paralytic ileus. • Ischemia of the gastric mucosa lead to risk for duodenal ulcer and gastric ulcer manifested by occult bleeding and in some cases life- threatening hemorrhage.
  24. 24. Management of patient with a burn injury: There are four major goals relating to burns: 1- Institution of lifesaving measures for the severely burned person 2- Prevention of disability and disfigurement 3- Rehabilitation through reconstructive surgery and rehabilitative programs
  25. 25. Burn care proceeds into three phases: a- Emergent / resuscitative phase. b- Acute /intermediate phase. c- Rehabilitation phase.
  27. 27. 1. Remove the person from the source of the heat. 2. Use water, blanket or roll the person on the ground to smother the flames. 3. Once the burning has stopped, remove the clothing and jewelry. 4. Manage the persons airway, as anyone with a flame burn should be considered to have an inhalation injury. 5. Cover the burn with a cool moist sterile bandage or clean cloth.
  28. 28. 6. Do not apply any ointments and avoid breaking blisters. 7. If fingers or toes have been burned, separate them with dry sterile, non-adhesive dressings. 8. Elevate the burned area and protect it from pressure or friction. 9. Prevent shock. 10. In chemical burns, flush the injured area with a copious amount of water. Don’t delay or waste time looking for or using a neutralizing agent. These may in fact worsen the injury.
  29. 29. Emergency medical management: • Initial priorities airway, breathing, and circulation. • Give patient, inspired humidified air and encouraged to cough. • For more severe situations, remove secretions by bronchial suctioning and to administer bronchodilators and mucolytic agents. • If edema of the airway develops, intubation may be necessary • Continuous positive airway pressure and mechanical ventilation may also be required to achieve adequate oxygenation.
  30. 30. • After adequate establishment of respiratory & circulatory status, the patient is assessed for cervical spinal injuries or head injury if the patient was involved in an explosion, a fall, a jump, or an electrical injury. • Once the patient’s condition is stable, attention is directed to the burn wound itself. • Information needs to include time of the burn injury, source of the burn, place where the burn occurred, how the burn was treated at the scene, and any history of falling with the injury.
  31. 31. • A history of preexisting diseases, allergies, and medications and the use of drugs, alcohol, and tobacco is obtained at this point to plan care. • A large-bore (16- or 18-gauge) intravenous catheter should be inserted , so that large amounts of intravenous fluids can be given & CVP monitored. • If the burn exceeds 25% TBSA or if the patient is nauseated, a nasogastric tube should be inserted and connected to suction to prevent vomiting due to paralytic ileus (absence of peristalsis).
  32. 32. • An indwelling urinary catheter is inserted to permit more accurate monitoring of urine output and renal function for patients with moderate to severe burns. • Baseline height, weight, arterial blood gases, hematocrit, electrolyte values, blood alcohol level, drug panel, urinalysis, and chest x-rays are obtained. • Because burns are contaminated wounds, tetanus prophylaxisis administered if the patient’s immunization status is not current or is unknown.
  33. 33. Management of fluid loss and shock Fluid Replacement Therapy The total volume and rate of IV fluid replacement are gauged by the patient's response and guided by the resuscitation formula. The adequacy of fluid resuscitation is determined by: • Urine output totals of 30 to 50 mL/hour (0.5 to 1.0 mL/kg/hour) • A systolic blood pressure exceeding 100 mm Hg • A pulse rate less than 110 beats/minute, or both.
  34. 34. Evan’s Formula: 2ml/kg TBSA + Basic requirement (2000-2500) glucose 5% What to give 1ml colloid (plasma, blood) First day + 1ml crystalloid (Ringer, normal saline) Second day 0.5 ml colloid + 0.5 ml crystalloid
  35. 35. [ What to give First day 1st 8 hours ½ of the amount 2nd 8 hours ¼ of the amount 3rd 8 hours ¼ of the amount
  36. 36. Second day: 1st 8 hours 2nd 8 hours 3rd 8 hour 1/3 of the amount 1/3 of the amount 1/3 of the amount
  37. 37. Consensus Formula 2–4 mL × kg body weight × % BSA (Body surface area) Half to be given in first 8 hours; remaining half to be given over next 16 hours. An example: - patient weight a 70-kg with 50 % (BSA) burn. 2 × 70 × 50 = 7000 ml/24 hours. Plan to administer = first 8 hours = 3500 ml, next 16 hours = 3500 ml.
  38. 38. Begins 48 to 72 hours after the burn injury. During this phase, attention is directed toward continued assessment and maintenance of respiratory and circulatory status, fluid and electrolyte balance, and gastrointestinal function. Infection prevention, burn wound care (ie, wound cleaning, topical antibacterial therapy, wound dressing, dressing changes, wound débridement, and wound grafting), pain management, and nutritional support are priorities at this stage and will be discussed in detail.
  39. 39. Burn wound is an excellent medium for bacterial growth and proliferation. The primary source of bacterial infection patient’s intestinal tract. After burn injury, the intestinal mucosal barrier becomes permeable. Because of this, the disturbed microbial flora and endotoxins found in the intestinal lumen pass freely into the systemic circulation, causing infection. A major secondary source of pathogenic microbes is the environment. Infection Prevention:
  40. 40. Infection Prevention • Cap, gown, mask, & gloves are worn in caring patient with open wounds. • Clean technique is used when caring directly for burn wounds. • Tissue specimens are obtained for culture regularly. • Systemic antibiotics are administered when there is burn wound sepsis or other positive cultures such as urine, sputum, or blood.
  41. 41. Wound Cleaning: Hydrotherapy in the form of shower carts, individual showers, and bed baths can be used to clean the wounds. •Total immersion hydrotherapy is performed in some settings. •Tap water alone can be used for burn wound cleansing. •The water temperature is maintained at 37.8oC and room 26.6o - 29.4 o C. •Hydrotherapy, should be limited to a 20- to 30-minute period. •During the bath, the patient is encouraged to be as active as possible. •Hydrotherapy exercising the extremities and cleaning the entire body.
  42. 42. Advantages: • Topical medications, adherent dressing, and eschar are more easily removed. • Provides an opportunity for the patient to practice range of motion exercises. • Total assessment of the burn area is facilitated; total body cleansing can be achieved. Disadvantages: • Loss of body heat; and loss of sodium. • Uncomfortable and at times painful for patient. • Maintenance of IV lines and ventilator care may be difficult during tubing. • The patient's anxiety level often increases.
  43. 43. Wound Dressing • Purpose of wound dressing: • To protect the wound from any infection. • To immobilized the wound. • To depride the wound from any dead tissues. • To inhabit or kill microorganism by using dressing with antiseptic properties. • To provide patient with physical comfortable. Types of wound dressing: Exposure method Occlusive method
  44. 44. Exposure method: wound is treated by exposing it to air, but no dressing applied. Precaution of exposed method: - Keeping the immediate environment free from microorganisms. - Every thing coming in contact with the Patient must be sterile (linen). - Instruct visitors to wear operative gown and not touch the bed or hand the patient or any things. - The patient’s room must be comfortably warm with 40% to 50 % humidity to prevent excessive evaporative. Occlusive method An occlusive dressing is thin gauze that is impregnated with a topical antimicrobial agent or applied after topical antimicrobial application.
  45. 45. Wound debridement: Definition: Removal of debris accumulates on the wound surface . There are three types of débridement: 1. Natural debridement Dead tissue separates from the underlying viable tissue spontaneously. 2. Mechanical debridement Mechanical debridement involves using surgical scissors and forceps to separate and remove the eschar. This technique done with daily dressing and wound cleaning procedures. 3. Surgical debridement Surgical debridement is an operative procedure involving either primary excision of the full thickness of the skin down to the fascia or shaving the burned skin layers .
  46. 46. Grafting the Burn Wound Definition: Skin graft is a surgical procedure in which a piece of skin is transplanted from one area to another. Often skin will be taken from unaffected areas on the injured person and used to cover a defect, often a burn. Types of skin graft: 1. Autograft: Patches of healthy skin taken from another location on a patient's body 2. Allograft (homograft): Skin taken from other human sources. 3. Xenograft (heterograft) Grafts made from the skin of other animal species.
  47. 47. Care of the patient with graft: • Occlusive dressings are used after grafting. 1st dressing change is usually performed 3 to 5 days after surgery. • If the graft is dislodged, sterile saline compresses will help prevent drying of the graft. • The patient is positioned and turned carefully to avoid disturbing the graft or putting pressure on the graft site. • If an extremity has been grafted, it is elevated to minimize edema. The skin graft may be rejected due to: • Movement • Bleeding • Infection • Poor nutrition.
  48. 48. Methods of nutritional support include: • Initially keep the patient on nothing per mouth (NPO) until bowel sounds return. • When bowel sounds return administer oral fluids and advance diet as tolerated. • Offer more solid food after 2 to 3 days post burn as tolerance to food improves. • Provide 3 g protein/kg body weight: 20% of needed calories in form of fats; remainder in carbohydrates. • The patient needs adequate vitamins and minerals. Provide potassium and vitamins and minerals supplements (zinc, iron, vitamin c). • Dietary consultations are useful in helping patients meet their nutritional needs.
  49. 49. Nursing care plan for burned patient: Assessment: 1. Vital signs are checked frequently. When all extremities are burned, determining blood pressure may be difficult a sterile dressing applied under the blood pressure cuff to protect wound from contamination. 2. Monitoring fluid intake and output. 3. Assess urine for presence of myoglobin from muscle damage. 4. Assessing the extent of the burn, patients level of consciousness, psychological status , pain and anxiety. 5. Assess general hydration and serum electrolyte, hemoglobin and hematocrite level. 6. Detection of potential complications. 7. Assessment R/T rehabilitation goals include, range of motion of affected joints, functional abilities and activities of daily living.
  50. 50. 1. Nursing Diagnosis: Impaired gas exchange related to carbon monoxide poisoning, smoking inhalation, and airway obstruction. Goal: Maintain of adequate tissue oxygenation Nursing intervention: • Monitor arterial blood gas, pulse oximetry readings. • Assess breath sound respiratory rate. • Monitor patient for signs of hypoxia • Prepare to assist with intubations
  51. 51. 2. Nursing diagnosis: Fluid volume deficit related to increased capillary permeability and evaporative losses from the burn wound. Goal: Restoration of optimal fluid and electrolyte balance and perfusion. Nursing interventions: • Observe vital signs (central venous pressure or pulmonary artery pressure). • Observe urine out put. • Observe fore symptoms of deficiency or excess of serum sodium, potassium, calcium , phosphorus and bicarbonate. • Elevate patient’s head and burned extremities to promote venous return.
  52. 52. 3. Nursing diagnosis: Pain related to tissue and nerve injury and emotional Impact of injury. Goal: control of pain. Nursing intervention: - Use pain scale to Assess pain level. - Give patient analgesics as prescribed. - Provide emotional support and reassurance to reduce fear and anxiety level to reduce perception of pain.
  53. 53. 4. Nursing diagnosis: Fluid volume excess related to resumption of capillary integrity and fluid shift from interstitial to intravascular Goal: maintenance of optimal fluid balance. Nursing intervention: • Monitor vital signs. • Monitor intake and out put. • Assess weight, edema, jugular vein distention to detect fluid status. • Maintain IV fluids on pumps to prevent accidental fluid bolus. • Give patient diuretics or dopamine as prescribed.
  54. 54. 5. Nursing diagnosis: Risk for infection related to loss of skin barrier and impaired immune response. Goal: Absence of localized or systemic infection. Nursing intervention: • Use asepsis in all aspects of patient care. • Decrease number of visitors. • Exclude plants and flowers in water from patient room because water source of bacterial growth. • inspect wound for signs of infection. • Monitor white blood cell. • Gives patients antibiotics to reduce bacteria.
  55. 55. 6. Nursing diagnosis: Altered nutrition less than body requirements related to hyper metabolism and wound healing. Goal: Maintain of optimal nutritional status. Nursing intervention: • Provide high caloric, high protein diet to promote wound healing. • Administer supplemental vitamins and minerals as prescribed. • Report abdominal distention, large gastric residual volumes or diarrhea to physician.
  56. 56. 7. Nursing diagnosis: Impaired skin integrity related to open burn wound. Goal: Demonstration of improved skin integrity. Nursing intervention: • Clean wounds, body and hair daily to reduce bacterial colonization. • Provide wound care as prescribed to promote wound healing. • Prevent pressure, infection and mobilization of auto grafts. • Provide donor site care. • Assess wound and graft sites when present signs of poor healing, poor graft or trauma, and report to physician.
  57. 57. 8. Nursing diagnosis: Knowledge deficit about post discharge home care and follow-up needs. Goals: Patients’ education and home care considerations. Nursing intervention: • Encourage patient to participate their care if they are aware of the consequences of the injury, the goal of planned treatment, and their role in ongoing care. • Include families in planning and carrying. • Instruct patient and family in wound care, exercises and follow-up care. • Encourage patient to recognize abnormal signs to report the physician and available resources to help them meet their future needs.

Notes de l'éditeur

  • Hypovolemia - Massive fluid shifts out of blood vessels as a result of increased capillary permeability. When capillary walls become more permeable, water, sodium, and later plasma protein (esp. albumin) moves into interstitial spaces & other tissues

    Thermal burns- Any external heat source capable of raising temperature of skin
    Flame, scalding liquids, gases- effects mostly infants.
    Radiation Burns- Prolonged exposure to the sun’s ultraviolet radiation- Sunburn, tanning beds, x-ray
    Chemical burns- acids, alkali- househould cleaners. Remove person from the chemical as soon as possible and flush with water.

    Electrical burns-accounts for a small percent of burns but is the WORST type!!!

    generated from a electrical current, should be transferred to burn center; current travels through the body and destroys everything in its path (nerves, vessels). Monitor cardiac function, monitor for RENAL Failur myoglobin released from muscle injury), long board and C-collar to prevent spinal cord injury. (DIFFICULT TO KNOW EXTENT OF INJURY); check neuro function bc impairement can occur for up to 2 years following the injury.