LECTURE 1 BURNS AND SCALDS-SURGICAL NURSING 2.pdf
- 1. JOHN BLESS AKORTIAKUMAH [email protected] SURGICAL NURSING LEVEL 200: PHN &MIDWIFERY Burns & Scalds
- 3. OBJECTIVES 1. By the end of this topic, students will be able to: 2. Define burns 3. Outline the causes/risk factors of burns 4. State the types/classifications of burns 5. Describe the pathophysiology of Burns 6. State the clinical manifestations of Burns 7. List the complications of Burns 8. State the diagnostic investigations of Burns 9. Outline Medical management of Burns 10. Surgical treatment of Burns 11. Describe the nursing management of Burns 12. State the Health education/prevention of Burns 5/6/2024 J.B.K. AKORT 3
- 4. Burns- problem of the day Madam Kafui was involved in a gas explosion accident and sustained burns on both upper limbs, front and back of the trunk, Head and neck. On observation and examination, there is complete destruction of the epidermis and the dermis involving underlying tissues, supporting structures and nerves. 1. How will you classify this type of burn? 2. Using the Wallace Rule of Nines Chart, estimate the percentage of Total Body Surface Area (TBSA) burned. 3. Calculate the amount of intravenous Normal Saline to be given within the first 24 hours if she weighs 40Kg 4. Calculate the MAP if she has BP of 90/60mmHg 5. Describe the nursing management of this patient 5/6/2024 J.B.K. AKORT 4
- 5. Burns & Scalds • Burns are the most devastating form of trauma that has afflicted mankind • Ability to treat burns has improved due to: – Better understanding of “burn shock” – Advances in fluid therapy and antibiotics – Improved ability to excise dead tissue – Dressings – Formation of specialized teams 5/6/2024 J.B.K. AKORT 5
- 7. SKIN • The epidermis, the outermost layer of skin, provides a waterproof barrier and creates our skin tone. The skin’s color is created by special cells called melanocytes, which produce the pigment melanin. Melanocytes are located in the epidermis • Enclosed within the dermis are: Nerve endings, Blood vessels, Sweat glands, Hair follicles • Beneath the dermis is the subcutaneous layer. • Beneath the subcutaneous layer are the muscles, tendons, bones, and vital organs. 5/6/2024 J.B.K. AKORT 7
- 8. Functions of the skin • Regulation of body temperature • Protection (Protects underlying tissue from injury/exposure) • Prevents excessive loss of water • Sensation (Keeps the brain informed about environment) • Excretion • Synthesis of Vitamin D • Formation of personal identity 5/6/2024 J.B.K. AKORT 8
- 9. Burns & Scalds • Burns and scalds are damages to the skin caused by heat. • Burns is a type of injury caused by dry heat (fire, sun, and hot metal), electricity, radiation or friction • A scald is caused by wet heat, like steam or a hot cup of tea or hot water. 5/6/2024 J.B.K. AKORT 9
- 10. INCIDENCE • Worldwide, about two million people get burnt, up to 80,000 are hospitalized and 6500 die of burn wounds every year. • Very young and elderly are at greatest risk for burn injuries. • Burns are the second most important cause of accidental deaths in childhood. • Black, poor and single parent children are at high risk. 5/6/2024 J.B.K. AKORT 10
- 11. PATTERN OF INJURY AMONG DIFFERENT AGE GROUPS • Infants and toddlers are especially prone to scald injuries. • School age children may incur flame burns as a result of playing with matches and gasoline. • Teenage boys have a high incidence of electrical injuries. • Males are more commonly injured by burns than females. • Psychiatric and Epileptic patients are at higher risk. 5/6/2024 J.B.K. AKORT 11
- 12. Aetiology / Causes of Burns • Direct contact with a flame or hot object • Exposure to bare electrical wires • Contact with hot liquid such as hot oil or hot water • Contact with corrosive chemicals e.g. HCL, alkaline, caustic soda etc. • Radiations e.g. over exposure to sun, or atomic radiation in radiological treatments. • Friction e.g. contact with a revolving wheel 5/6/2024 J.B.K. AKORT 12
- 13. CAUSES/RISK FACTORS OF BURNS IN CHILDREN • Child turns on the hot water tap. • Children bathed with untested hot water. • Spilling of hot coffee/ tea on a child’s body. • Child climbing up to stove; clothing catches fire. • Child playing with matches, especially 5-10 years 5/6/2024 J.B.K. AKORT 13
- 14. CAUSES/RISK FACTORS OF BURNS IN CHILDREN • Playing or working with inflammables like gasoline. • Gas tank explosion during automobile accident. • Playing with electrical outlets or appliances. • Playing on railroad (burns from friction). • Neglect or child abuse. • Caustic acid or alkali burns from ingesting strong household cleaning products. 5/6/2024 J.B.K. AKORT 14
- 15. PATHOPHYSIOLOGY OF BURNS • Burns occurs when the skin/mucous membrane is exposed to injuring agents such as hot object, and the body react to it through inflammatory process in the damaged tissues. • This leads to stimulation of leukocyte and macrophages released through the capillary endothelium. • This phenomenon is initiated by the body to combat the damaged tissues and aid in wound healing. 5/6/2024 J.B.K. AKORT 15
- 16. PATHOPHYSIOLOGY OF BURNS CONTD. • Capillary permeability increases temporarily and fluid follow with leaking protein so that oedema forms, capillary dilatation increases and blood flow to the burnt site. • Hypovolemic shock commonly occurs with lost of fluid from the body and circulatory blood becomes decreased in volume. • Dilatation and destruction of capillaries contribute to blister formation, when fluid leaks into the interstitial spaces. 5/6/2024 J.B.K. AKORT 16
- 17. PATHOPHYSIOLOGY OF BURNS CONTD. • The circulatory reduction in volume leads to anoxia of the tissues especially the kidney tissues causing decreased urine output. • Fluid and electrolyte imbalance develops due to the escape of body fluid through the open wound, blister formation, oedema, and excessive release of potassium and electrolyte from the damaged tissues. 5/6/2024 J.B.K. AKORT 17
- 18. PATHOPHYSIOLOGY OF BURNS CONTD. • A burn injury involving 20% TBSA in children and 25% in adults results in ‘burn shock’. • Hypovolaemia result from both fluid losses through the burn wound and the movement of intravascular fluid into the interstitial spaces due to permeability and dilatation of the capillaries in the burnt area. • Shift of protein – rich fluid out of the vascular compartments leads to the formation of blisters and oedema. 5/6/2024 J.B.K. AKORT 18
- 19. PATHOPHYSIOLOGY OF BURNS CONTD. • The intravascular volume is reduced, CO decreased, BP falls and the blood flow through the tissues is reduced (hypovolaemic shock). • Decrease in the number of RBC’s especially in deep burns, due to heat injury of the blood cells in the skin capillaries at the time of the injury. • Normal RBC production may also be reduced because of depression of the bone marrow. 5/6/2024 J.B.K. AKORT 19
- 20. PATHOPHYSIOLOGY OF BURNS CONTD. • The urinary output is decreased as a result of the decreased intravascular volume and subsequent hypotension. • In severe burns gastrointestinal peristalsis is decreased; nausea, vomiting and abdominal distention. Hematemesis or Malena may develop. • Electrolyte imbalances • Immunity is compromised 5/6/2024 J.B.K. AKORT 20
- 21. PATHOPHYSIOLOGY OF BURNS CONTD. • Inhalation of smoke and chemical fumes may seriously impair ventilatory function; irritation of the mucosa may cause laryngeal oedema and airway obstruction, or pulmonary oedema and severe respiratory insufficiency. 5/6/2024 J.B.K. AKORT 21
- 22. PATHOPHYSIOLOGY OF BURNS CONTD. • Most burns injuries become colonized with bacterial even before hospital treatment which enters the lymphatic system and blood circulation causing septicemia. • Toxaemia also result from the release of chemicals into circulation by the damaged tissue, while anaemia result from the destruction of red blood cell. 5/6/2024 J.B.K. AKORT 22
- 23. PATHOPHYSIOLOGY OF BURNS CONTD. • Once the bacteria counts become high and infectious organisms enter the lymphatic system, the patient may develop septicemia. • Sepsis is the single largest cause of death in burns patient. • Multisystem organ failure secondary to sepsis. 5/6/2024 J.B.K. AKORT 23
- 24. Types of Burns • Thermal- exposure to flame or a hot object - Dry burn – flame, hot objects, Moist heat burn (scalds) – steam, hot liquids. • Skin that comes in contact with a source of high temperature results in a thermal burns. It can occur when the skin is exposed to temperatures higher than 111°F (44°C). Severity correlates with: Temperature, concentration, or amount of heat energy, Duration of exposure 5/6/2024 J.B.K. AKORT 24
- 25. Types of Burns • Electrical Burns- results from the conversion of electrical energy into heat. Extent of injury depends on the type of current, the pathway of flow, local tissue resistance, and duration of contact. • Contact with household electrical appliances, car batteries, electrosurgical devices, high tension electrical wires, and lightening are common causes of electrical injury. 5/6/2024 J.B.K. AKORT 25
- 26. Types of Burns • Electrical injuries are classified as either a high voltage greater than 1000 volts of energy, or lower energy less than 1000 volts of energy. • Damage occurs at the point of entry and exit of the current. There may be a track of internal damage. The position and direction of entry and exit wounds will alert you to the likely extent of the hidden injury. 5/6/2024 J.B.K. AKORT 26
- 27. Types of Burns Some specific clinical manifestations of electrical burns include: 1. Unconsciousness 2. Signs of shock 3. Full thickness burns with swelling, charring at both entry and exit points 5/6/2024 J.B.K. AKORT 27
- 28. Types of Burns • Radiation- A radiation burn is damage to the skin caused by exposure to radiation. The most common type of radiation burn is a sunburn caused by UV radiation. • It includes burns resulting from nuclear sources. Common sources are extreme exposure to sunlight, radiation therapy and explosives (bombs). 5/6/2024 J.B.K. AKORT 28
- 29. Types of Burns • Inhalational injury - Breathing in hot air or gases can injure your lungs. Breathing in toxic gases, such as carbon monoxide, Smoke and fumes can cause inhalational burns. • Chemical Burns- Exposure to acid, alkali or organic substances. 5/6/2024 J.B.K. AKORT 29
- 30. Thermal & Electrical burns 5/6/2024 J.B.K. AKORT 30
- 31. Chemical Burns 5/6/2024 J.B.K. AKORT 31
- 32. Signs and symptoms of burns. Some chemicals give off deadly fumes so ensure your own safety. 1. There may be evidence of chemicals in the vicinity 2. Intense/severe pain of the skin may occur 3. Swelling and blister formation may occur 4. There may be deformity of the affected part 5. Skin may be stained or reddened at the affected part 5/6/2024 J.B.K. AKORT
- 33. Signs and symptoms of burns. • Blistering and peeling of skin may develop • There is damage to tissues. • There may be acute circulatory failure. • There may be dehydration due to loss of fluid. • There may be anemia due to destruction of red blood cells. • There may be edema due to loss of fluid to extracellular tissue. 5/6/2024 J.B.K. AKORT 33
- 34. S/S Cont.’ • There is low urine output due to decrease blood supply to the kidney. • There may be nausea and vomiting. • There may be persistent fever if infections develop. • There may be occult blood in stool. • There may be abdominal distention. • There may be insomnia. • There may be hypotension. 5/6/2024 J.B.K. AKORT 34
- 35. Characteristics of burn injuries The severity of a burn injury depends on; • Surface area of the burned • Depth of tissue damage (temp n duration) • Part of body burned • Age of patient 5/6/2024 J.B.K. AKORT 35
- 36. Classification of Burns by depth/ degree ▪ Classified according to depth of injury and extent of body surface area involved ▪ Burn wounds differentiated depending on the level of dermis and subcutaneous tissue involved 1. Superficial (first-degree) 2. Partial thickness (second-degree) 3. Full thickness (third degree) 5/6/2024 J.B.K. AKORT 36
- 37. Classification of Burns cont.’ • Superficial (First degree) – This is the least serious burns in which only the outer layer of skin (epidermis) is burned. • They are typically caused by exposure of the unprotected skin to solar radiation (sunburn) or to brief contact with hot substances, liquids or flash flames (scalds) • The skin is usually red, slightly swelling, blisters may develop and pain. • Usually heal 7 withinto 10 days with no permanent changes in skin colour, texture, or thickness and without scarring 5/6/2024 J.B.K. AKORT 37
- 38. Superficial burns 5/6/2024 J.B.K. AKORT 38
- 40. 2. Partial thickness (Second degree) ✓ Partial thickness burns result when damage to the skin extends beneath the epidermis into the dermis. ✓ Blisters develop and the skin takes on an intensely reddened appearance, severe pain and swelling. ✓ It takes longer than three weeks to heal, but mostly heals within two to three weeks without scarring, but often with pigment changes to the skin. ✓ The worse the blisters are, the longer the burn will take to heal 5/6/2024 J.B.K. AKORT 40
- 41. Partial thickness (Second degree) 5/6/2024 J.B.K. AKORT 41
- 42. 3. Full thickness burns (Third degree burns) This is the most serious burns and involves all layers of the skin and causes permanent tissue damage. ▪ Fat, muscle and even bone may be affected. ▪ The burnt area may be charred black or appear dry and white. ▪ The sensory nerves in the dermis are destroyed in a full thickness burn, and so sensation to pinprick is lost. ▪ As a result of the extensive destruction of the skin layers, third-degree burn wounds cannot regenerate themselves without grafting. 5/6/2024 J.B.K. AKORT 42
- 43. Full thickness burns (Third degree burns) 5/6/2024 J.B.K. AKORT 43
- 44. Classification by severity/body surface area • Minor burns are those partial-thickness burns less than 15% Total Body Surface Area (TBSA) in adult and less than 10% total body surface area in children and do not apply for burns that includes eyes, ears, face and perineum. • Moderate burns -Partial-thickness burns between 15% and 25% in adults and between 10% and 20% TBSA in children. It also includes burns to the eyes, ears, face, or perineum which always need special burn care. • Major burns - Burns above 25% in adults or above 20% in children. 5/6/2024 J.B.K. AKORT 44
- 45. Calculation of Burned Body Surface Area • TOTAL BODY SURFACE AREA (TBSA) - The extent of burn, clinically referred to as the TBSA burned, is defined as the proportion of the body burned. • Lund and Browder Chart is the most accurate because it adjusts for age • Rule of nines divides the body – adequate for initial assessment for adult burns • Palm method: In patients with scattered burns, a method to estimate the percentage of burn is the palm method. The size of the patient’s palm is approximately 1% of TBSA 5/6/2024 J.B.K. AKORT 45
- 46. Assessment of Burns – Wallace rule of nine 5/6/2024 J.B.K. AKORT 46
- 47. Wallace rule of nine • This method varies in adults and pediatrics due to differences in the surface area proportion in children. • The rule of nine for adults includes; • Head and neck – 9% • Right upper limb – 9% • Left upper limb – 9% • Anterior trunk – 18% • Posterior trunk – 18% • Right lower limb – 18% • Left lower limb – 18% • Genital (perineum) – 1% 5/6/2024 J.B.K. AKORT 47
- 48. Wallace rule of nine • The rule of nine for children includes; • Head and neck – 18% • Right upper limb – 9% • Left upper limb – 9% • Anterior trunk – 18% • Posterior trunk – 18% • Right lower limb – 14% • Left lower limb – 14% • Genital(perineum)– 1% 5/6/2024 J.B.K. AKORT 48
- 52. Diagnostic/ laboratory investigations. • History taken, taking into consideration the cause, time, area of body surface involved. • Full blood count ❖Hemoglobin level estimation is done to rule out anemia. ❖White blood cell count is also done to rule out infections. • Kidney function test (Blood urea, Electrolyte and Creatinine) • Examination and Estimation of body surface area • Sickling test • Grouping and cross matching • Arterial blood gas studies 5/6/2024 J.B.K. AKORT 52
- 53. First aid / home management of burns ▪ Establish your own safety before attempting to treat the casualty ▪ Move casualty away from source of heat ▪ Remove the source of heat from the person. ▪ Deal with any airway problems (A, B, C) ▪ Run cool water over the burn for 10 to 20 minutes. ▪ Remove any jewelry or clothing at the site of injury. If clothing is stuck to the burn, do not remove it. ▪ Cover the burn area with a clean cloth to prevent infection. ▪ Seek medical attention immediately 5/6/2024 J.B.K. AKORT 53
- 54. First aid / home management of burns Stop the burning by rapid cooling to prevent further damage, reduce swelling, minimize shock and alleviate pain DO NOT: ▪ Break blisters, remove loose skin or interfere with the injured part. ▪ Overcool the casualty especially if burns cover a large area to prevent hypothermia ▪ Remove anything sticking to the burns. You may cause further damage and introduce infection into the burns ▪ Give a severely burnt person anything to eat/drink. 5/6/2024 J.B.K. AKORT 54
- 55. Medical management of burns. Goals of management. • Ensure patent airway • To replace fluid loss. • To relieve pain. • To promote healing of burns. • To prevent infection. • To avoid complications 5/6/2024 J.B.K. AKORT 55
- 56. Medical management ▪ Oxygen is administered to maintain adequate airway if it involves burns to the face. ▪ Fluids loss is replaced with infusions such as normal saline, ringers lactate and dextrose saline. ▪ Analgesics such as injection diclofenac, syrup or tablet paracetamol are given to relieve pain. ▪ Antibiotics such as Amoxiclav and metronidazole are given to control and prevent both local and systemic infections. 5/6/2024 J.B.K. AKORT 56
- 57. Flow Rate • Example: • Calculate the IV flow rate for 1200 mL of NS to be infused in 6 hours. The infusion set is calibrated for a drop factor of 15 gtts/mL. • Example • Calculate the IV flow rate for 200 mL of 0.9% NaCl IV over 120 minutes. • Infusion set has drop factor of 20 gtts/mL 5/6/2024 J.B.K. AKORT 57
- 58. Nursing management • Initial assessment and intervention. • Assess the airways for signs of obstruction and intervene appropriately. • Expose the body and make a rapid assessment of the burnt area. • Estimate the depth of the skin burnt. • Remove burnt clothing from the client 5/6/2024 J.B.K. AKORT 58
- 59. Nursing MGT • Psychological care. • Care of the wound • Observation • Nutrition and diet • Rest and sleep • Education and prevention of burns 5/6/2024 J.B.K. AKORT 59
- 60. Observation. • Observe vital signs (temperature, pulse and respiration) and intervene if necessary. • Observe wound for bleeding and any discharges. • Observe the skin for change in color. • Observe the level of consciousness of the client. • Observe intake and output pattern of the client. • Observe the level of pain from client using the pain assessment scale. • Observe the desired and adverse side effects of medication. 5/6/2024 J.B.K. AKORT 60
- 61. Wound Care • Take off dressing gently, and where it is stuck, soak in normal saline. • Observe the dressing or the wound for color of discharge, amount and odor. • Clean with appropriate antiseptic solution and cream and apply Vaseline gauze before bandaging. • Change of dressing depends on the nature of wound. • Use infection prevention technique when caring for the wound 5/6/2024 J.B.K. AKORT 61
- 62. Nutrition and diet. • Immediately after a significant injury, a client receives nothing by mouth for some hours due to decrease gastro intestinal motility leading to nausea and vomiting. • Once peristalsis resumes, food should be given by mouth or through nasogastric tube. • The diet must provide enough protein and energy. • Mother should constantly breast feed the child. • Diet rich in vitamin B and C should be given to enhance wound healing. • Client’s body weight should be measured twice weekly to help evaluate the effectiveness of the nutritional plan. • Rehydrate with intravenous fluids if required. 5/6/2024 J.B.K. AKORT 62
- 63. Rest and sleep • Reassure parents of competent nursing care and speedy recovery. • Provide a clean cot or bed to client. • Put client in a comfortable position with bed cradle and side rails. • Ensure a serene environment by making the place calm and well ventilated. • Serve prescribed analgesics to reduce pain. • Organize nursing activities to prevent disturbing the client. • Restrict the number of visitors to the client. • Elevate burnt limb on a soft pillow to prevent edema and reduce pain 5/6/2024 J.B.K. AKORT 63
- 64. Education and prevention of burns • Educate mother to keep children out of reach of fire when cooking. • Educate mother the need to avoid leaving hot substances like boiling water on the ground. • Tell mother to always put off fire when not in use. • Gas tabs must be turned off as soon as cooking is over. • Avoid leaving children alone in the bathroom with hot water. 5/6/2024 J.B.K. AKORT 64
- 65. Prevention cont.’ • Avoid the use of electric heaters when children are around. • All electrical plugs and sockets must be in good order and the correct fittings must be done. • Keep matches out of reach of children. • Parents who smoke should avoid that in bed. 5/6/2024 J.B.K. AKORT 65
- 66. Surgical management of burns • Skin grafting. This is a technique in which a section of skin is detached from its own blood supply and transferred as free tissue to a distant site. • Debridement. This is the surgical removal of dead tissue from wound to promote healing and prevent infections. • Escharotomy. This is carried out in circumferential burns to prevent compartment syndrome 5/6/2024 J.B.K. AKORT 66
- 67. SKIN GRAFTING • Skin grafting is surgical transplantation of skin from one part of the body to another. • Autograph: Transfer of the skin from part of the same person • Homograft (Allograft) transfer of skin from one organism to another of the same species • Heterograft (Xenograft)-from one species to different one 5/6/2024 J.B.K. AKORT 67
- 69. Compartment syndrome 5/6/2024 J.B.K. AKORT 69
- 70. Complications of burns • Dehydration • Hypovolemic shock • Infection • Hemorrhage • Anemia • Pneumonia • Septicemia • Renal failure • Contractures • Formation of keloids • Sloughing of mucus membranes. • Multiple organ failure. • Loss of body image. 5/6/2024 J.B.K. AKORT 70
- 71. Summary • You will encounter some serious burn injuries during your career. • The skin has four functions: to protect the underlying tissue, to regulate temperature, to prevent excessive loss of water, and to act as a sense organ. • Burns are diffuse soft-tissue injuries created from destructive energy transferred via thermal, electrical, or radiation energy. 5/6/2024 J.B.K. AKORT 71
- 72. Summary • Significant burn damage to the skin may make the body vulnerable to bacterial invasion, temperature instability, and major disturbances of fluid balance resulting in burn shock. • Thermal burns include flame, scald, contact, steam • Burns can affect the cardiovascular, respiratory, renal, gastrointestinal, hematological etc 5/6/2024 J.B.K. AKORT 72
- 73. Summary • When burn shock occurs, the contents of the capillaries leak out of the circulation into the interstitial spaces. Adequate fluid resuscitation is needed. • Burn wounds may be superficial, partial thickness, or full thickness. • A superficial burn involves only the epidermis, and skin appears red and swollen. 5/6/2024 J.B.K. AKORT 73
- 74. Summary • A partial-thickness burn involves the epidermis and part of the dermis. • A full-thickness burn involves destruction of the epidermis, the dermis, and the basement membrane of the dermis. • Inhalation burns may cause rapid airway compromise. • Establishing scene safety should be your first priority in responding to a burn call. 5/6/2024 J.B.K. AKORT 74
- 75. Summary • Once ABCs are addressed, assess the total body surface area (TBSA) burned. • Three cornerstones of the emergency medical care of burns are airway management, fluid resuscitation, and pain management. 5/6/2024 J.B.K. AKORT 75
- 76. Summary • Many burn patients will ultimately require intubation. • Patients with more than 20% body surface area burns will need fluid resuscitation. • The Consensus formula is an equation used to determine the amount of fluid a burned patient will need during the first 24 hours. • Remember to assess the patient’s pain and provide aggressive pain management. 5/6/2024 J.B.K. AKORT 76
- 77. AKPE Thank you 5/6/2024 J.B.K. AKORT 77