Case Report Burns
Transcript of Case Report Burns
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I. INTRODUCTION
Fire has been a metaphysical constant of the world. Fire represents the creativity
and passion that all intellectual and emotional beings have. It is an active force that
has the passion to create and animate things. The element is also very rational and
quick to flare up. Fire in many ancient cultures and myths has been known to purify the
land with the flames of destruction, but fire may also cause destruction to the human,
causing injury to the skin, and in severe cases, to its self-image.
A burn is a type of injury that may be caused by heat, cold, electricity,
chemicals, light, radiation, or friction. Burns can be highly variable in terms of the tissue
affected, the severity, and resultant complications. Muscle, bone, blood vessel, and
epidermal tissue can all be damaged with subsequent pain due to profound injury to
nerves. Depending on the location affected and the degree of severity, a burn victimmay experience a wide number of potentially fatal complications including shock,
infection, electrolyte imbalance and respiratory distress. Beyond physical
complications, burns can also result in severe psychological and emotional distress due
to scarring and deformity.
Burns are one of the most devastating conditions encountered in medicine. The
injury represents an assault on all aspects of the patient, from the physical to the
psychological. It affects all ages, from babies to elderly people, and is a problem in
both the developed and developing world. All of us have experienced the severe pain
that even a small burn can bring. However the pain and distress caused by a large burn
are not limited to the immediate event. The visible physical and the invisible
psychological scars are long lasting and often lead to chronic disability. Burn injuries
represent a diverse and varied challenge to medical and paramedical staff. Correct
management requires a skilled multidisciplinary approach that addresses all the
problems facing a burn patient.
A burn is an injury caused by thermal, chemical, electrical, or radiation energy. Ascald is a burn caused by contact with a hot liquid or steam but the term 'burn' is often
used to include scalds.
Most burns heal without any problems but complete healing in terms of cosmetic
outcome is often dependent on appropriate care, especially within the first few days
after the burn. Most simple burns can be managed in primary care but complex burns
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and all major burns warrant a specialist and skilled multidisciplinary approach for a
successful clinical outcome.
Statistics shows that the survival Rate for burn is 94.8%, while it is common among
men than female. Its prevalence to Caucasian is 63%, 17% African-American, 14%
Hispanic, 6% others. Admission Cause: 42% fire/flame, 31% scald, 9% contact, 4%
electrical, 3% chemical, 11% other. With regards to place of Occurrence: 66% home,
10% occupational, 8% street/highway, 16% other (Source: American Burn Association
National Burn Repository (2010 report))
A so-called dermal plates was designed by Cornell scientists that promote
vascular growth could hasten healing, encourage healthy skin to invade the wounded
area and reduce the need for surgeries for the victims of third-degree burns and other
traumatic injuries endure pain, disfigurement, invasive surgeries and a long time waitingfor skin to grow back which was published at the May 2011 issue of Biomaterials. These
so-called dermal templates were engineered in the lab of Abraham Stroock, associate
professor of chemical and biomolecular engineering at Cornell and member of the
Kavli Institute at Cornell for Nanoscale Science, in collaboration with Dr. Jason A.
Spector, assistant professor of surgery at Weill Cornell Medical College, and an
interdisciplinary team of Ithaca and Weill scientists. The dermal plates are composed of
experimental tissue scaffolds that are about the size of a dime and have the
consistency of tofu. They are made of a material called type 1 collagen, which is a well-
regulated biomaterial used often in surgeries and other biomedical applications. The
templates were fabricated with tools at the Cornell NanoScale Science and
Technology Facility to contain networks of microchannels that promote and direct
growth of healthy tissue into wound sites. The grafts promote the ingrowth of a vascular
system -- the network of vessels that carry blood and circulate fluid through the body --
to the wounded area by providing a template for growth of both the tissue (dermis, the
deepest layer of skin), and the vessels. Type I collagen is biocompatible and containsno living cells itself, reducing concerns about immune system response and rejection of
the template. A key finding of the study is that the healing process responds strongly to
the geometry of the microchannels within the collagen. Healthy tissue and vessels can
be guided to grow toward the wound in an organized and rapid manner.
(Retrieved at: http://www.sciencedaily.com/releases/2011/05/110518075035.htm)
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Objectives
I. General
This case report aims to improve the knowledge of student nurses and the
readers will gain knowledge and further understanding about the condition of Burns.
II. Specific
This case report aims to:
1. Gather necessary information about the condition such as predisposing andprecipitating factors.
2. Study the anatomy and physiology of the integumentary system.3. Obtain and trace the pathophysiology of burns.4. Determine the appropriate diagnostic test.5. Determine the appropriate medical and surgical management.6. Identify the appropriate drugs, their action, side effects, indications,
contraindications and nursing responsibilities.
7. Formulate appropriate nursing care plans.8. Determine appropriate health teachings and interventions as part of the holistic
care to future patients.
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II. ANATOMY AND PHYSIOLOGY
The integumentary system is the largest organ in the body and accounts for 8-
15% of a persons body weight. It must be tough to protect us but supple so that we
can move and stretch.
EPIDERMIS
The epidermis is the uppermost part of the skin which is made up of stratified squamous
epithelium that is capable of keratinizing (becoming hard and tough).It is composed of
five layers termed as STRATA and it has no blood supply (avascular). It contains
keratinocytes (keratin cells) which is responsible for producing keratin. This keratin found
in the epidermal skin layer is a fibrous protein that makes the epidermis a tough
protective layer.
Five STRATA of the Skin
Stratum basale is the deepest layer of the epidermis which lies closely to
the dermis. The epidermal cells of stratum basale receive the most adequate nutrition
through diffusion from the nutrient supply in the dermis. Also calledstratum
germinativum because epithelial cells in this layer are constantly undergoing cell
division where a huge amount of new cells are produced per day . These cells move
away from the said stratum and moves upward to the superficial epidermal layers. Inthis layer, melanin, the pigment of the skin is produced by melanocytes. Exposure to
sunlight stimulates the melanocytes to produce more of the melanin pigment. Next to
Stratum basale is Stratum Spinosum the followed by Stratum granulosum. Above is
Stratum lucidum which is clear and when the cells move to this area, they become flat
and contain a large amount of keratin. Eventually the cells die because they are now
increasingly full of keratin. This layer is selectively found in the body. It is only seen in
areas where the skin is hairless and extra thick (palms of the hands and soles of the
foot). Stratum Corneum which is the outermost epidermal layer that is approximately
20-30 cell layers thick. The tough protein, keratin, is abundant in this layer to provide
protection through a durable overcoat. Stratum corneum flakes off steadily and is
replaced by the newly produced cells from the stratum basale. The epidermis renews its
cells every 25-45 days.
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DERMIS
The dermis lies next to the epidermis, which is a strong and stretchable envelope
holding the body together. This part of the skin is made up of the papillary and the
reticular areas. Dermis is made up of dense connective tissues, and collagen and
elastic fibers are located in this part of the skin. This layer is supplied with blood vessels
that is vital in maintaining the normal body temperature. It has collagen fibers that gives
the dermis its toughness and it helps the skin to be hydrated by attracting and binding
to water. It has also elastic fibers that provides elasticity to the skin.
Two Layers of the Dermis
Papillary Layer is the upper dermal layer that has dermal papillae, the fingerlike
projections from the superior surface. The papillary layer has uneven surface and thedermal papillae are responsible for indenting the epidermis above. Dermal papillae is a
very important part of the dermis as it is the one that house the capillary loops which
provides nutrition to the epidermis and it also houses some of the pain receptors and
touch receptors. The pain receptors are the free nerve endings and the touch
receptors are called the Meissners corpuscles.
Reticular layer is the deepest skin layer which contains the sweat glands, blood
vessels and oil glands. It also houses the pressure receptors called the Pacinian
corpuscles. The skins ability to fight infection is made possible because of the presence
of phagocytes in this area that prevents bacteria which passed through the epidermis
from penetrating deeper into the body.
Appendages of the Skin
Sebaceous glands which are also called the oil glands are found all over the bodies
except the palms of the hands and the soles of the feet. The secreted product is amixture of oily substances and fragmented cells called SEBUM. Sebum plays a vital role
in keeping the skin soft and moisturized. It also prevents the hair from being brittle. Aside
from that, the mixture of oily substance and fragmented cells contains chemicals that
KILLS bacteria. Thus, invading microorganisms are prevented from penetrating deep in
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the skin. Activity of the sebaceous glands is heightened during the adolescent period
where the levels of male sex hormones are increased.
Sweat gland that is also termed as sudoriferous glands are extensively spread all over
the body. There are two types of sweat glands which are the eccrine and the apocrine
glands. Eccrine glands produce sweat which outnumbers the apocrine gland in terms
of distribution all over the body. Sweat produced by the eccrine glands is clear and
composed of primarily water, some salts, vitamin C, few traces of ammonia, urea and
uric acid and lactic acid. The pH of sweat is acidic which helps in inhibiting bacterial
growth. The apocrine glands on the other hand are largely found on the axillary and
the genital areas only. Unlike the eccrine glands, these glands produce a secretion that
contains fatty acids and proteins which may have a milky or yellowish color.
Hair and hair follicles is formed by the adequately nourished stratum basale epithelial
cells in the MATRIX (growth zone) of the hair bulb at the inferior end of the follicle.
Nails which has a free edge, a body (visible attached portion) and a root.
HYPODERMIS
The hypodermis is not a skin layer but lies below the dermis, and is a
subcutaneous tissue which contains fat, blood vessels and sensory receptors.
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Functions of the SKIN
Covers the body.
Protects the body from mechanical damage. This function is done by insulating and
cushioning the deeper body organs. Examples of mechanical damage are bumps and
cuts. When a person is bumped, the uppermost layer of the skin toughens or hardens
the cells. The toughening of the cells is due to the presence of keratin in the upper layer
of the skin. Pressure receptors in the skin send an impulse to the nervous system about a
possible damage. These receptors alert an individual to bumps and provide a great
deal of information about the external environment.
Protects the body from chemical damage. Acids and bases, when exposed to the
body at high levels, can cause extreme damage to the internal organs. However,because of the presence of tough keratinized cells, damage to internal organs is
prevented.
Protects the body from bacterial damage. In preventing infection, one of the most
important considerations to consider is an unbroken skin surface. The skin secretes urea,
salt and water (acidic) when a person sweats, thus, inhibiting bacterial growth.
Phagocytes are also located in the skin which is responsible for ingesting foreign
substances and pathogens. Hence, bacterial penetration to deeper body tissues is
prevented.
Protects from ultraviolet radiation. The pigment or color of the skin depends on the
presence of melanin. This melanin that is produced by the melanocytes is good at
protecting the body from the damaging effects of the sunlight or UV damage.
Protects the body from thermal damage. When the body is exposed to extreme heat or
cold the heat and cold receptors located in the skin alerts the nervous system of the
tissue-damaging factors. The brain, in response sends impulses to the site of damage or
possible damage for the bodys compensatory mechanism.
Protects the body from drying out. The skins outermost part, the epidermis, contains a
waterproofing glycolipid and keratin in order to prevent water loss from the body
surface.
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Regulation of heat loss and heat retention. The body must maintain a constant core
temperature. Any change in the environmental temperatures could possibly alter the
required core temperature. The skin contains a rich capillary network and sweat glands
which are controlled by the nervous system. These mechanisms play an important role
in regulating heat loss or retention in the body. When the body is needs to loss heat, the
skin receptors alert the nervous system which in response activates the sweat glands
(sweat helps cool the body in a hot environment). The blood is also flushed into the skin
capillary beds, making heat loss possible. When the body needs to retain heat, the
blood is NOT allowed to be flushed into the capillary skin beds. This is the main reason
why during cold weather, the palms of the hands are pale.
Acts as mini-excretory system. The perspiration contains urea, uric acid and salts.
Synthesizes Vitamin D. The skin produces proteins that are vital for the synthesis of the
Vitamin D. When a person is exposed to sunlight, modified cholesterol molecules in the
skin are converted to Vitamin D.
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III. DIAGNOSTIC PROCEDURES
y Total body surface area is used to assess the percentage of burn and is used tohelp guide treatment decisions including fluid resuscitation and becomes part of
the guidelines to determine transfer to a burn unit.
a. Lund-Browder
Children have different proportions than adults and so the Rule of Nines is not accurate
to calculate the percentage of a burn for children. The Lund-Browder chart, as
displayed here (shown as Fig. 4-27 in your text), is used to calculate the percentage of
body surface involved in the burns of children.
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b. Rule of nine
It divides the body into sections that represent nine percent of the total body
surface area (TBSA). It can be used in conjunction with adult burn patients to
determine the TBSA that has been burned. Sections include the head and neck,
arms, torso (chest, anterior abdomen, upper and lower back), perineum and
legs.
c. Palm trick
Use the patients palm size to represent approximately 1% TBSA. Imagine a
rectangle the width and length of your entire hand (from wrist to fingertips) and
that is the size of one palm.
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y Biopsy refers to removing and studying sample tissue. It examines the extent ofcollagen damage to the skin, vascular damage to the tissue, and damage to
cell proteins in the skin.
y Thermography is used when attempting to determine the exact depth of a burnwound, doctors can use thermography as a diagnostic tool because deeper
wounds are cooler than more superficial wounds. There is reduced vascular
perfusion, or blood circulation, to the deeper wounds, leading to a lower
temperature.
y Complete blood count to assess for hemorrhage(decreased hemoglobin andhematocrit) , and infection (increase white blood cells).
ySerum electrolytes to determine electrolyte imbalance specificallyhyponatremia and hypokalemia and hyperkalemia, and hypercalcemia, and
hypocalcemia
y BUN and creatinine to determine renal insufficiency d/t passage of RBCs tokidneys.
y electrocardiogram (EKG) - if there is a history of high tension electrical injury orknown history of heart disease
y Arterial blood gas- is used to determine acidosis or alkalosis with regards to burn.
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B. DEFINITION OF THE DISEASE
A burn is damage to the body's tissues caused by heat, chemicals, electricity,
sunlight or radiation. Scalds from hot liquids and steam, building fires and flammable
liquids and gases are the most common causes of burns. Most burns heal without any
problems but complete healing in terms of cosmetic outcome is often dependent on
appropriate care, especially within the first few days after the burn. Most simple burns
can be managed in primary care but complex burns and all major burns warrant a
specialist and skilled multidisciplinary approach for a successful clinical outcome.
Mechanism of burns:
yScalds- these types of burns result when skin comes into contact with hot liquids(spilled liquids or food, hot bathwater)
y Contact burns- these burns result from contact of the skin with hot items,including flames
y Chemical burns- these burns result from contact of the skin with chemicals, or byingestion of chemicals
y Electrical burns- these types of burns result when a person comes into contactwith a source of electrical energy; includes burns caused by electrocution and
lightning strike
a. true electrical injury exists when electricity passes through the body. An
entrance and exit wound is produced, along with significant deep-tissue
destruction.
b. arc burns occur when electrical current jumps from one part of the body to
another, producing scattered spots of injury which may be deep
c. flame burns are caused by sparks sufficient to ignite clothing
y Radiation burns- Accidents involving ionizing radiation are not common. Mostfrequently they are the result of a local accident (laboratory), from an industrial
accident (Chernobyl, Russia in 1986), or from the detonation of a nuclear device.
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Types of burns:
y Superficial BurnsThese types of burns cause superficial erythema (redness) and swelling and may be
quite painful. The skin will blanch upon pressure. These types of burns involve only the
outermost layer of skin, or the epidermis. Treatment generally involves cooling the burn
with running water or the application of cool cloths and application of an over-the-
counter burn ointment or a soothing agent, such as aloe cream or gel. These types of
burns heal quickly and do not result in scarring. A physician should be consulted if
superficial burns are extensive, especially in children or the elderly.
y Partial-Thickness BurnsPartial-thickness burns affect both the epidermis and the dermis to varying degrees.
Superficial partial-thickness burns do not involve the full thickness of the dermis, while
deep partial-thickness burns may involve the dermis more extensively. Depending on
how much of the dermis is affected, these types of burns may result in scarring and may
require skin grafting to heal. It may be difficult to determine whether a burn affects the
dermis superficially or more deeply; the difference lies partially in healing time, as
superficial partial-thickness burns will heal more quickly, often in less than 3 weeks. These
types of burns will cause blisters. Blisters should never be punctured but should be left
intact, as rupturing them may increase the risk of infection. These types of burns may
cause permanent disfigurement. They may also be quite painful, as nerves are intact
and undamaged.
y Full-Thickness BurnsFull-thickness burns extend down into the hypodermis, or subcutaneous tissue. These
types of burns may affect underlying bone, nerves, tendons and other structures. These
burns in themselves are generally not painful; however, there may be surrounding areas
of partial-thickness burns that are painful. These burns will require surgery to close and
may result in permanent disfigurement and disability, especially if they occur over a
joint. The risk for complications, especially infection, is very high and these types of burns
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may be life-threatening if they are extensive. These types of burns should be cared for in
specialized burn centers.
C. MODIFIABLE AND NON-MODIFIABLE FACTORS
Modifiable factors
y Drug use - Use of alcohol and illegal drugs increases risk of burns. For example,drugs that requires heat.
y Smoking - Careless smoking puts you at risk of burns.y Sun exposure Too much exposure to the sun puts you at risk of burn injury due
to the heat and indirect radiation it causes to the skin.
y Unsafe heating practices Use of heated foods and containers, hot waterheaters set above 130 F, and unsafe storage of flammable or caustic materials
put you at higher risk of burns. Also, the use of wood stoves and exposure to
heating sources or electrical cords puts you at risk of burns.
Non-modifiable factors
y Age - Children under 4 who are poorly supervised are at risk of burns.Additionally, children who live with abusive parents are at increased risk of burns.
y Gender - Men are more than twice more likely to suffer burn injuries than womenaccording to statistics. It may be due to occupation. For example, male
electricians are at risk for electrical burns, and those who are working as fire-
fighters which are predominantly male are at higher risk for thermal burns.
y Seasonal Burns occur more often during holidays celebrated with fireworks andschool breaks.
y Socio-economic status People living in substandard or older housing, as well asthose in low income neighbourhoods are more likely to experience burns.
D. Signs and symptoms
y Damage to skin layers this is caused by the damaging effects of burn on theskin
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y Infection due to the impaired skin integrity and absorption of decomposedproducts from dead tissue.
y Fever may indicate infection due to the release of toxins called pyrogens,stimulating the hypothalamus to increase the bodys temperature to combat
microorganisms.
y Pain caused by injury to nerve endings; for superficial and partial-thicknessburns, pain maybe severe. For full-thickness burns loss of sensation may occur
due to damaged nerves.
y Hypoxia (for thermal and chemical burns) which is brought about by inhalationof smoke and chemical fumes, causing damage to the respiratory tract that
may precede swelling and irritation to the larynx causing airway obstruction,
resulting to severe respiratory insufficiency decreasing oxygen circulating in thebody.
y Hypoxemia due to hemolysis, decreasing blood carrying oxygen to the body.y Passage of brownish, blackurine due to hemolysis, causing liberation of large
quantities of RBC and myoglobin blocking the renal tubules causing renal
shutdown.
y Dehydration due to severe loss of fluid brought about by the increasedpermeability of blood capillaries; may lead to hypovolemic shock if left
untreated.
y Oliguria possibly due to dehydration and bodys attempt to conserve fluid bymeans of increasing aldosterone in the body to conserve sodium and increase
production of anti-diuretic hormone.
y Hyperkalemia Initially, due to loss of potassium at damged cells.y Hypokalemia later sign, due to excretion of potassium at renal tubules.y Weight loss due to increase energy requirement, increasing glucose and fat
breakdown. But if insufficient, will lead to protein breakdown, causing (-) nitrogenbalance and increase ammonia, which may also cause liver impairment.
y Ketoacidosis brought about by the breakdown of fat.y Curlings ulcer because of loss of plasma proteins at tissue, osmotic pressure
causing congestion at mucosal capillaries, resulting to gastric dilation.
y Hematemesis/melena due to bleeding ulcers.
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y Limitation to range of motion, and impairment at movement and coordinationthis is brought about by formation of severe scars from damaged skin, which
stretches to cover wound as healing progresses.
y Eschar - piece of dead tissue that is cast off from the surface of the skin,particularly after a burn injury
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V. MEDICAL MANAGEMENT
First aid
Remove the casualty from further injury. Extinguish flames, remove clothing, turn off theelectrical source, or douse the chemically burnt patient with water. Flames ascend so
lie the patient down. Cover the burn with a clean dressing, avoid the patient getting
cold and transfer to a hospital as soon as possible. Additional oxygen should be given
during transfer.
Primary management
y Airway - check the airway is clear. Endotracheal intubation is necessary if thereare deep burns to the face and neck, soot in the nostrils, burns of the tongue
and pharynx, stridor or hoarseness.
y History including time and nature of the incident (Wet or dryburn/chemical/electrical/inside or outside).
y Weigh the patient.y Examine the burn and assess the size with the 'rule of nines' to give a %BSA.y Intravenous access - obtain large bore venous access, even through burnt tissue.y Analgesia - intravenous morphine, ketamine, or Entonox.y Catheterize - assess urine output as a gauge of tissue perfusion and adequate
resuscitation.
y Reassess the patient thoroughly at regular intervals and also the burn.
Fluid resuscitation
This should be instituted as soon as possible. There are two simple protocols that both
depend upon the %BSA, time passed since injury and patients weight. The rule of ninesmay over-estimate the BSA, but the Lund and Browder chart gives a more accurate
assessment. Fluid requirements may be greater than the protocols suggest.
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Parklands: Crystalloid resuscitation with Hartmanns
24 hour fluid requirement = 4 x %BSA x Wt (Kg)
Give half over the first 8 hours, and the remainder over the next 16 hours
Although there may be pronounced generalized edema initially, as large volumes are
required, it is cheap and produces less respiratory problems later on.
Muir and Barclay: Colloid resuscitation with plasma
The first 36 hours are divided into time periods of 4,4,4,6,6,12 hour intervals
Each interval = 0.5 x %BSA x Wt (Kg)
With colloid resuscitation, less volume is required and the blood pressure is better
supported. However they are expensive, often unavailable and tend to leak out of the
circulation and may result in later edema especially in the lungs.
Controversy remains as to which fluid should be used. Inhalational injury may increase
fluid requirements by 50%. Both regimes require regular assessment as to the adequacy
of resuscitation. This includes blood pressure, pulse, capillary return, urine output, level of
consciousness and hematocrit. Additional fluid should be given if resuscitation is
inadequate.
Water loss is related to evaporative and other extrarenal losses and may lead to a
hypernatremia. Salt intake should be balanced against the plasma sodium
concentration, but is usually about 0.5mmol/kg/%BSA. If the burn is left exposed in an
hot environment, sodium free water intake must be increased, but only to achieve a
moderate hypernatremia. Aggressive water load may lead to a low plasma sodium
and result in 'burn encephalopathy'. Hyperkalemia usually associated with severe
muscle damage may require correction with insulin and dextrose.
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Airway management
A high index of suspicion is required regarding the patient's airway. Laryngeal oedema
develops from direct thermal injury leading to early loss of the airway. With signs of an
airway burn (soot in the nostrils/stridor/hoarse voice) consider early intubation of the
patient. If in doubt, it is better to protect the airway (and be able to provide tracheo-
bronchial tube) than to risk losing the airway altogether. A tracheostomy may be
necessary if there is any delay in securing the 'at risk' airway.
The airway is further endangered by an associated loss of respiratory drive due to a
depressed level of consciousness (eg head injury or carbon monoxide poisoning).
Again intubation may be required.
Dressings
Are necessary to reduce infection and absorb exudate. Bactericidal agents, such as
silver sulphadiazine 1% and silver nitrate are used. Antibiotic preparations should be
avoided to prevent resistant colonisation developing. Regular, often daily, dressing
changes are recommended, and the patient should be washed with clean warm
water.
Diet
Low protein and increase in zinc intake help to heal burns and helps promote tissue
repair. Zinc is also known to help boost a persons immune system. Some of the sources
of zinc include lean meats, yogurt, fruits, vegetables and shellfish.
Vitamin C should also be considered an essential part of a burn victims diet. This
vitamin works together Zinc and helps fight infections. Sources of vitamins C include
fresh fruits and green leafy vegetables.
Dehydration is common in people with burns. Intake of tomato or apple juice, chicken
or beef broth helps in refueling the body with the required fluid. Taking as well 2 to 3
liters of water may be done, if not contraindicated.
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Avoid caffeine since it is known to have a diuretic effect, caffeine enriched beverages
should be avoided, became the body must maintain fluids to heal. Examples are
coffee, and carbonated drinks.
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VI. SURGICAL MANAGEMENT
1. GRAFTING
Definition: Skin grafting is a surgical procedure in which skin or a skin substitute is placed
over a burn or non-healing wound.
Purpose: A skin graft is used to permanently replace damaged or missing skin or to
provide a temporary wound covering. This covering is necessary because the skin
protects the body from fluid loss, aids in temperature regulation, and helps prevent
disease-causing bacteria or viruses from entering the body. Skin that is damaged
extensively by burns or non-healing wounds can compromise the health and well-being
of the patient.
Procedure:
The patient's wound must be free of any dead tissue, foreign matter, or bacterial
contamination. After the patient has been anesthetized, the surgeon prepares the
wound by rinsing it with saline solution or a diluted antiseptic (Betadine) and removes
any dead tissue by dbridement. In addition, the surgeon stops the flow of blood into
the wound by applying pressure, tying off blood vessels, or administering a medication
(epinephrine) that causes the blood vessels to constrict. Following preparation of the
wound, the surgeon then harvests the tissue for grafting. A split-thickness skin graft
involves the epidermis and a little of the underlying dermis; the donor site usually heals
within several days. The surgeon first marks the outline of the wound on the skin of the
donor site, enlarging it by 35% to allow for tissue shrinkage. The surgeon uses a
dermatome (a special instrument for cutting thin slices of tissue) to remove a split-
thickness graft from the donor site. The wound must not be too deep if a split-thickness
graft is going to be successful, since the blood vessels that will nourish the grafted tissue
must come from the dermis of the wound itself. The graft is usually taken from an area
that is ordinarily hidden by clothes, such as the buttock or inner thigh, and spread on
the bare area to be covered. Gentle pressure from a well-padded dressing is then
applied, or a few small sutures used to hold the graft in place. A sterile nonadherent
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dressing is then applied to the raw donor area for approximately three to five days to
protect it from infection.
Normal results: A skin graft should provide significant improvement in the quality of the
wound site, and may prevent the serious complications associated with burns or non-
healing wounds. Normally, new blood vessels begin growing from the donor area into
the transplanted skin within 36 hours. Occasionally, skin grafts are unsuccessful or don't
heal well. In these cases, repeat grafting is necessary. Even though the skin graft must
be protected from trauma or significant stretching for two to three weeks following split-
thickness skin grafting, recovery from surgery is usually rapid. A dressing may be
necessary for one to two weeks, depending on the location of the graft. Any
exercise or activity that stretches the graft or puts it at risk for trauma should be avoided
for three to four weeks. A one to two-week hospital stay is most often required in cases
of full-thickness grafts, as the recovery period is longer.
Risks: The risks of skin grafting include those inherent in any surgical procedure that
involves anesthesia. These include reactions to the medications, breathing problems,
bleeding, and infection. In addition, the risks of an allograft procedure include
transmission of an infectious disease from the donor. The tissue for grafting and the
recipient site must be as sterile as possible to prevent later infection that could result in
failure of the graft. Failure of a graft can result from inadequate preparation of the
wound, poor blood flow to the injured area, swelling, or infection. The most common
reason for graft failure is the formation of a hematoma, or collection of blood in the
injured tissues.
2. FASCIOTOMY
Definition: is a surgical procedure that cuts away the fascia to relieve tension or
pressure.
Purpose: When a fasciotomy is performed on other parts of the body, the usual goal is
to relieve pressure from a compression injury to a limb.. Blood vessels of the limb are
damaged. They swell and leak, causing inflammation. Fluid builds up in the area
contained by the fascia. A fasciotomy is performed to relieve this pressure and prevent
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tissue death. Similar injury occurs in high-voltage electrical burns that cause deep tissue
damage.
Procedure: Fasciotomy in the limbs is usually performed by a surgeon under general or
regional anesthesia. An incision is made in the skin, and a small area of fascia is
removed where it will best relieve pressure. Then the incision is closed.
Normal results: Fasciotomy in the limbs reduces pressure, thus reducing tissue death.
Risks: Risks involved with fasciotomy are those associated with the administration of
anesthesia and the development of blood clots or postsurgical infections.
3. ESCHAROTOMY
Definition: An escharotomy is a surgical procedure performed to allow greater
circulation to a part of the body. A severe injury, such as a burn, can cause skin and
tissue to swell so much that blood no longer flows easily past the injury.
Purpose: To prevent damage to the tissues that are not getting enough blood, surgical
incisions are made along the damaged area, which releases the pressure of the
swollen tissues and allows blood flow to resume. Because of the swelling of the
damaged tissue, the surgical incisions may spread open, showing the tissues and
structures beneath the skin. Any open wound has a risk of infection so the area may be
covered in sterile bandages.
Normal results: Escharotomy in the limbs reduces pressure, thus reducing tissue death.
Risks: Risks involved with escharotomy are those associated with the administration ofanesthesia and the development of blood clots and especially postsurgical infections
because it is left open to relieved the pressure.
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VII. NURSING CARE PLANS
1. Risk for infection related to inadequate primary defenses
2. Acute Pain related to destruction of skin and tissues, edema formation,manipulation of injured tissuesskin grafting
3. Ineffective airway clearance, related to increasing lung congestion secondaryto smoke inhalation
4. Impaired gas exchange related to ventilation perfusion imbalance secondary toinhalation of smoke/ chemical fumes
5. Decreased cardiac output related to altered afterload secondary tohypovolemic shock
6. Deficient fluid volume related to abnormal fluid loss secondary to burn injury
7. Ineffective tissue perfusion related to peripheral constriction secondary tocircumferential burn wounds
8. Impaired skin integrity related to destruction of epidermis, dermis
9. Impaired physical mobility related to skin contractures
10.Disturbed body image related to scar formation secondary to burn injury
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VIII. CONCLUSION
In this case report, I learned that getting burned not only will destroy your
physical appearance, but can also destroy your image of yourself and may also affect
self-confidence. I was reminded of my patient 2 years ago during my duty at pediatric
ward who suffered from electrical burns. During that time, I dont have any idea what
might an electrical burn brings, I didnt know that he had large blisters at his hands not
until I was given an order for wound cleaning. I didnt notice it because what I thought
is that it is only covered because of that he might have IV inserted at his hands that it
had to be reinserted on the other arm. In this case patients arent seriously burnt from
the outside, but are fatally injured in his internals. As I can see the most fatal of burn are
electrical in nature and my client is lucky to be alive, because when electrocuted thealmost all parts of the body is affected. This case report helps me learn more about the
nature of burns.
In addition, although recent advances in burn management have improved
survival in patient with burns, the burn patient continues to present a major therapeutic
challenge. Well-designed, prospective studies are needed to establish definitive
guidelines for optimal surgical and medical management of burns among adults.
Additionally, these patients have unique rehabilitation requirements that need to be
addressed in order to maximize return to pre-injury level of functioning. With the growing
number of burn survivors, it will be increasingly important to evaluate and improve the
long-term function and quality of life outcomes of this population. Finally, strategies for
burn prevention and education remain central to limiting the burden of burn injury
among patients.
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IX. REFERENCES:
y http://www.essortment.com/heal-burns-faster-diet-food-49062.htmly http://www.burnsurgery.org/Modules/orders/sec2.htmy http://www.anatomy.tv/StudyGuides/StudyGuide.aspx?guideid=18&nextID=1&
maxID=0&customer=primal
y http://www.patient.co.uk/doctor/Burns-Assessment-and-Management.htmy http://www.typesofburns.com/