BURNS

For Diploma, B.Sc and Post Basic and all nurses. 

Definition : 

Burns are a form of traumatic injury caused by thermal, electrical, chemical or radioactive agents. In other words injuries that result from direct contact or exposure to any thermal, chemical, or radiation source are termed “BURNS”. Burn injuries occur when energy from a heat source is transferred to the tissue of the body.

Or

Burns are due to dry heat (including friction), where as scalds are due to wet heat. Burn and scalds are considered together as burns as they produce the sever type of injury. It is more important that burns are scalds are treated correctly so as to limit the effects of the injury and to prevent possible long – term scarring.

Causes of burns

  1. Burns are caused by the following:
  • Fire explosions of pressure stoves, petrol burns, hot metals etc.
  • Electricity
  • Corrosive chemicals e.g. strong acid and strong alkalis.

Scalds are caused by the following:

  • Boiling water, steam, hot oil etc

The extent of injury caused by burns and scalds depends on the following two factors:

  1. The duration of contact between the skin and the substance causing injury.
  2. The strength of the substance. This is particularly important when chemicals and electric current are the causes of injury.

Types of Burns : Burn injuries are categorized according to the mechanism of injury. It may be thermal, chemical, electrical and radiation.

  1. Thermal Burn Injury: Most common type of burn, caused by exposure to or contact with flame, flash, hot liquids, semi- liquids, steam, contact (hot metals, grease)
  2. Chemical burn injury: Caused by tissue contact, ingestion or inhalation of acid, alkalis and vesicants.
  • Electrical burn injury: Electrical burn injury occurs from direct damage to nerves and vessels when an electrical current passes through the body.
  1. Radiation burn injury: Radiation burns are the least common type of burn injuries and are caused by exposure to a radioactive service. These types of injuries have been associated with nuclear radiation accidents, the use of ionizing radiation in industry and from therapeutic radiation.

Burns are classified according to severity of burn (American Burn Association) are-

Major Burn Injury

  • 25% total body surface (TBS) burn in adult  < 40 of age
  • 20% TBS burn in adults > 40 of age
  • 20% TBS burn in children < 10 of age

Or

Burns involving the face, eyes, ears, hands, feet and perineum likely to result in functional or cosmetic disability.

Or

High voltage electrical burn injury.

Or

All burns injuries with concomitant inhalation injury or major trauma.

Moderate Burn Injury

  • 15-25% TBS burn in adults <40 of age
  • 10-20% TBS burn in adult >40 of age
  • 10-20% TBS burn in children <10 of age

Burns are classified according to thickness of different layers of skin involved are-

  1. Superficial burns (First Degree Burns): Caused by prolonged exposure to low intensity of heat.
  • Epidermis looks red, painful, no blisters, heals rapidly in 3-5 days by epithelialisation, without scarring.e.g. Sunburn.
  1. Partial thickness burns (2nd degree burns): Occurs when both epidermis and part of dermis are destroyed.
    • They are characteristics by fluid filled blister appearing immediately after injury. It appears pink, moist and mottled. Healing takes place between 10-14 days after injury. It is painful as nerve are exposed..
  1. Full thickness burns (3rd degree burns): In full thickness burn the epidermis, dermis and dermal appendages are destroyed. The burns may extent to the subcutaneous fat, muscle or bone. It is painless as the nerve endings are damaged. Healing takes place in 30 days to many months. Skin grafts are applied to promote function and stability.

Assess the Severity of Burns

  1. Rule of Nines – Total Body Surface Area
  • 9% for the head
  • 9% % for right arm
  • 9% for the left arm
  • 18% for the anterior trunk
  • 18% for the posterior trunk
  • 1% for the Perinium
  • 18% for the right thigh and leg
  • 18% for the left thigh and leg

Pathophysiology

Tolerable temperature to human skin is to degree for a brief period.

Heat causes coagulation nectosis of skin and subculaneous tissue

Release of vasoactive peptides

Altered capillary permeability

Loss of fluid            Severe Hypovolaemia

Decreased                   Decreased

Cardiac                        myocardial

Output                         function

Decreased                   (Renal failure)

Renal blood Flow       oliguria

 

  • Altered pulmonary resistance causing pulmonary edema
  • Infection
  • Systemic inflammatory response syndrome (SIRS)
  • Multi organ dysfunction syndrome (MODS)
  • Massive edema in the body is due to altered pressure gradient because of the injury to the basement membrane.

Cardiac dysfunctions are due to –

  • Hypovolaemia
  • Release of cardiac depressants
  • Hormonal causes like catecholamine, vasopressin, angiotensins.

Renal changes are due to –

  • Release of ADH from posterior pituitary to cause maximum water reabsorption
  • Release of aldosterone from adrenals to cause maximum sodium reabsorption..
  • Toxins released from the burn wound and also sepsis causes acute tubular necrosis.
  • Myoglobin released from muscles, in case of electric injury or often from eschar is most injurious to kidneys.

 Pulmonary changes are due to –

  • Altered ventilation –perfusion ratio.
  • Pulmonary oedema due to burn injury, fluid overload, inhalation injury –
  • AIDS
  • Aspiration
  • Septicaemia

 GIT changes are due to –

  • Acute gastric dilatation which occurs in 2-4 days.
  • Paralytic ileus.
  • Curling’s ulcer.
  • Cholestasis and hepatic damage

Metabolic changes –

  • Hyper metabolic rate (BMR)
  • Negative nitrogen balance
  • Electrolyte imbalance
  • Deficiencies of vitamins, essential elements, etc
  • Metabolic acidosis due to hypoxia and lactic acid

Common infections are –

Streptococci (Beta haemolyticus Lancefield A) and Pseudomonas are common. Staphylococci, Candida albicans are other organisms.

Laboratory tests

  1. Arterial blood gas analysis ( ABG)
  2. Carboxy hemoglobin level
  3. Complete blood count
  4. Blood chemistry
  5. Coagulation studies
  6. Grouping and cross matching
  7. Urine analysis

Nursing management of burn according to nursing process

  Nursing assessment

  1. 1. Obtain a systematic history including-
  2. Causative agent- hot water, chemical, gasoline, flam, tar, radiation etc.
  3. Duration of exposure.
  4. Age
  5. Initial treatment including first aid, pre facility emergency care (including fluids, intubation etc) or care rendered to another facility (emergency facility).
  6. Pre-existing medical problems, such as heart disease, diabetes mellitus,
  7. Ulcers, alcoholism, COPD etc
  8. Tetanus immunization status
  9. Achieving Adequate oxygenation and Respiratory function
  10. Place the patient in semi-Fowler’s position to permit maximal respiratory functioning.
  11. Provide humidified 100% oxygen until carbon monoxide level is known.
  12. Monitor respiratory rate, rhythm, depth and though and ABG level.
  13. Auscultate chest and note breath sound.
  14. Provide mechanical ventilation, continuous positive airway pressure or posistive end-expiratory pressure if necessary.
  15. Promote clearance of secretion through chest physical therapy.
  16. Administer bronchodilator treatment as ordered.
  17. Facilitating Fluid balance ( a case of 30% burn of 40 years adult)
  18. Fluid replacement in adult is
  19. First day = 1 to 1.5 liter within 24 hours for 10% of burn
  20. Second day = Half of first day

So, fluid replacement will be

Total = 1000 to 1500 ml x 30/10 = 3000 to 4500 ml

For first 8 hour = 1500 to 2250 ml

Next 16 hours = 1500 to 2250 ml

Second day  = 1500 to  2250 ml

  1. Maintain accurate intake- output records.
  2. Weight the patient daily.
  3. Monitor potassium and others electrolyte levels.
  4. Administered diuretics as ordered.

Pain management

  1. Morphine IV before wound care, possible conscious sedation, antianxiety medication.
  2. Frequent assessment of pain, give medication before pain is sedvre to increase effectiveness.

 

Protecting and reestablishing skin integrity

  1. Cleanse wounds and change dressing twice daily. Use an antimicrobial solution or mild soap and water. Dry gently.
  2. Apply topical bacteriostatic agent as ordered.

 

  1. Avoiding wound and systemic infection
  1. Wash hand with antibacterial cleansing agent before and after all patient contact.
  2. Administer antibiotic as prescribed.

 

Maintain adequate nutrition

  1. Start oral fluid slowly when bowel sounds resume.
  2. Protein rich, calorie rich diet supplement as needed.

 

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