Luka bakar bedah

JUNI 10,FFJUNI 10,FF 11
LUKA BAKARLUKA BAKAR
(BURN)(BURN)

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Third – Degree BurnThird – Degree Burn

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Rule of NinesRule of Nines
surface ofsurface of
patient’spatient’s
palm = 1% BSApalm = 1% BSA

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Burn woundsBurn wounds occur when thereoccur when there
is contact between tissue andis contact between tissue and
an energy source, such asan energy source, such as
heat, chemicals, electricalheat, chemicals, electrical
current, or radiation.current, or radiation.
Burns and PatientBurns and Patient
ManagementManagement

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The resulting effects ofThe resulting effects of
the burn are influencedthe burn are influenced
by the:by the:
 intensity of the energyintensity of the energy
 duration of exposureduration of exposure
 type of tissue injuredtype of tissue injured

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Burn StatisticsBurn Statistics
 At least 50% of all burn accidents canAt least 50% of all burn accidents can
be preventedbe prevented
 children playing with fire account forchildren playing with fire account for
more than one-third of preschool deathsmore than one-third of preschool deaths
by fireby fire
 In the US, approximately 2.4 millionIn the US, approximately 2.4 million
burn injuries are reported each year.burn injuries are reported each year.
 Burn injuries are second to motorBurn injuries are second to motor
vehicle accidents as leading cause ofvehicle accidents as leading cause of
accidental death in the USaccidental death in the US

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What 2 types of clientsWhat 2 types of clients
account for 2/3 of all burnaccount for 2/3 of all burn
fatalities?fatalities?
 Older adultsOlder adults
• Children (especiallyChildren (especially
preschool aged children)preschool aged children)

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Where do most burnsWhere do most burns
occur?occur?
 Children, newborn to 4 y.o, from kitchenChildren, newborn to 4 y.o, from kitchen
and then the bathroomand then the bathroom
 ages 5-74, most burn injuries occurages 5-74, most burn injuries occur
outdoors with next area-kitchenoutdoors with next area-kitchen
 ages 75 and above, kitchen and thenages 75 and above, kitchen and then
outdoorsoutdoors

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Major cause of fires in theMajor cause of fires in the
homehome
 Carelessness with cigarettes!!Carelessness with cigarettes!!
 Hot water from water heaters set at high levelsHot water from water heaters set at high levels
above 140 degrees F (60 degrees C)above 140 degrees F (60 degrees C)
 cooking accidentscooking accidents
 space heatersspace heaters
 combustibles - gasoline, lighter fluids, etc.combustibles - gasoline, lighter fluids, etc.
 chemicalschemicals

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Types of Burn InjuryTypes of Burn Injury
 Thermal burnsThermal burns-can be caused by flame,-can be caused by flame,
flash, scald, or contact with hot objectsflash, scald, or contact with hot objects
 Chemical burnsChemical burns-are the result of tissue-are the result of tissue
injury and destruction from necrotizinginjury and destruction from necrotizing
substances.substances.
 Electrical burns-Electrical burns-results from coagulationresults from coagulation
necrosis that is caused by intense heatnecrosis that is caused by intense heat
from an electrical currentfrom an electrical current
 Smoke & inhalation injury-Smoke & inhalation injury- inhaling hotinhaling hot
air or noxious chemicalsair or noxious chemicals
 Cold thermal injury-Cold thermal injury- frostbite.frostbite.

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Referral CriteriaReferral Criteria
 22ndnd
or 3or 3rdrd
Degree Burns >10% BSADegree Burns >10% BSA
 Burns to Face, Hands , Feet, Genitailia,Burns to Face, Hands , Feet, Genitailia,
Perineum, or major Joints. ESPECIALYPerineum, or major Joints. ESPECIALY
CIRCUMFRENTIAL BURNSCIRCUMFRENTIAL BURNS
 Electrical BurnsElectrical Burns
 Chemical BurnsChemical Burns
 Inhalation InjuryInhalation Injury

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Referral CriteriaReferral Criteria
 Burns with pre-existing PMHX that couldBurns with pre-existing PMHX that could
complicate recoverycomplicate recovery
 Concomitant trauma (If Major Trauma,Concomitant trauma (If Major Trauma,
The Trauma Center , Not the Burn CenterThe Trauma Center , Not the Burn Center
should be the initial stabilizing unit)should be the initial stabilizing unit)
 When in doubt , consult with a burn centerWhen in doubt , consult with a burn center

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Thermal BurnsThermal Burns
 most common typemost common type
 result from residential fires, automobileresult from residential fires, automobile
accidents, playing with matches,accidents, playing with matches,
improperly stored gasoline, space heaters,improperly stored gasoline, space heaters,
electrical malfunctions, or arsonelectrical malfunctions, or arson
 inhaling smoke, steam, dry heat (fire), wetinhaling smoke, steam, dry heat (fire), wet
heat (steam), radiation, sun, etc...heat (steam), radiation, sun, etc...

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Chemical BurnChemical Burn
2 types of chemical burns2 types of chemical burns
 acids-acids-can be neutralizedcan be neutralized
 alkalinealkaline- adheres to tissue, causing- adheres to tissue, causing
protein hydrolyses andprotein hydrolyses and
liquefactionliquefaction
 examples: cleaning agents, drain cleaners,examples: cleaning agents, drain cleaners,
and lyes, etc...and lyes, etc...

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Chemical BurnChemical Burn
 Different typesDifferent types
of burnsof burns
1 Outer skin layer1 Outer skin layer
2 Middle skin layer2 Middle skin layer
3 Deep skin layer3 Deep skin layer
4 First degree burn4 First degree burn
5 Second degree5 Second degree
burnburn
6 Third degree6 Third degree

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Remember….Remember….
 With chemical burns, tissue destructionWith chemical burns, tissue destruction
may continue for up to 72 hoursmay continue for up to 72 hours
afterwards.afterwards.
 It is important to remove the person fromIt is important to remove the person from
the burning agent or vice versa.the burning agent or vice versa.
 The latter is accomplished by lavaging theThe latter is accomplished by lavaging the
affected area with copious amounts ofaffected area with copious amounts of
water.water.

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Smoke and InhalationSmoke and Inhalation
InjuryInjury
 Can damage the tissues of the respiratoryCan damage the tissues of the respiratory
tracttract
 Although damage to the respiratoryAlthough damage to the respiratory
mucosa can occur, it seldom happensmucosa can occur, it seldom happens
because the vocal cords and glottis closesbecause the vocal cords and glottis closes
as a protective mechanisms.as a protective mechanisms.

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3 types of smoke and3 types of smoke and
inhalation injuriesinhalation injuries
 1.1. Carbon monoxide poisoningCarbon monoxide poisoning (CO(CO
poisoning and asphyxiation count forpoisoning and asphyxiation count for
majority of deaths)majority of deaths)
 Treatment- 100% humidified oxygen-drawTreatment- 100% humidified oxygen-draw
carboxyhemoglobin level- can occur withoutcarboxyhemoglobin level- can occur without
any burn injury to the skinany burn injury to the skin

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 2.2. Inhalation injury above theInhalation injury above the
glottisglottis (caused by inhaling hot air,(caused by inhaling hot air,
steam, or smoke.)steam, or smoke.)
 Mechanical obstruction can occur quickly-Mechanical obstruction can occur quickly-
True ER! Watch for facial burns, signedTrue ER! Watch for facial burns, signed
nasal hair, hoarseness, painful swallowing,nasal hair, hoarseness, painful swallowing,
and darkened oral or nasal membranesand darkened oral or nasal membranes

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 33. Inhalation injury below glottis. Inhalation injury below glottis
 (above glottis-injury is thermally produced)(above glottis-injury is thermally produced)
 below glottis-it is usually chemicallybelow glottis-it is usually chemically
produced.produced.
 Amount of damage related to length ofAmount of damage related to length of
exposure to smoke or toxic fumesexposure to smoke or toxic fumes
 Can appear 12-24 hours after burnCan appear 12-24 hours after burn

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ELECTRICAL BURNSELECTRICAL BURNS
 Injury from electricalInjury from electrical
burns results fromburns results from
coagulation necrosiscoagulation necrosis
that is caused bythat is caused by
intense heatintense heat
generated from angenerated from an
electric current.electric current.

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Electrical BurnsElectrical Burns
 Can cause tissue anoxia and deathCan cause tissue anoxia and death
 The severity depends on amount ofThe severity depends on amount of
voltage, tissue resistance, currentvoltage, tissue resistance, current
pathways, and surface area in contact withpathways, and surface area in contact with
the current and length of time the currentthe current and length of time the current
flow was sustained.flow was sustained.

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Electrical injury canElectrical injury can
cause:cause:
 Fractures of long bones and vertebraFractures of long bones and vertebra
 Cardiac arrest or arrhythmias--can beCardiac arrest or arrhythmias--can be
delayed 24-48 hours after injurydelayed 24-48 hours after injury
 Severe metabolic acidosis--can develop inSevere metabolic acidosis--can develop in
minutesminutes
 Myoglobinuria--acute renal tubularMyoglobinuria--acute renal tubular
necrosis- myoglobin released from musclenecrosis- myoglobin released from muscle
tissue whenever massive muscle damagetissue whenever massive muscle damage
occurs--goes to kidneys--and canoccurs--goes to kidneys--and can
mechanically block the renal tubules duemechanically block the renal tubules due
to the large size!to the large size!

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cause:cause:
minutesminutes

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cause:cause:
minutesminutes

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Treatment of electricalTreatment of electrical
burns…burns…
 Fluids--Ringers lactate or other fluids-Fluids--Ringers lactate or other fluids-
flushes out kidneys--you want 75-100flushes out kidneys--you want 75-100
cc/hr until urine sample clearcc/hr until urine sample clear
 an osmotic diuretic (Mannitol) may bean osmotic diuretic (Mannitol) may be
given to maintain urine outputgiven to maintain urine output

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Cold Thermal InjuryCold Thermal Injury
(Frostbite)(Frostbite)
 Can be localized such as frostbiteCan be localized such as frostbite
 systemic (hypothermia)systemic (hypothermia)

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Classification of BurnClassification of Burn
InjuryInjury
 Treatment of burns is directly related toTreatment of burns is directly related to
the severity of injury!the severity of injury!
 Severity is determined by:Severity is determined by:
 depth of burndepth of burn
 external of burn calculated in percent of totalexternal of burn calculated in percent of total
body surface (TBSA)body surface (TBSA)
 location of burnlocation of burn
 patient risk factorspatient risk factors

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DEPTH OF BURNSDEPTH OF BURNS
 Burn injury involves the destruction ofBurn injury involves the destruction of
the integumentary system.the integumentary system.
 What is the function of theWhat is the function of the
integumentary system?integumentary system?
 ProtectiveProtective
 holds in fluids and electrolyesholds in fluids and electrolyes
 regulates heatregulates heat
 keeps harmful agents from injuring orkeeps harmful agents from injuring or
invading the bodyinvading the body

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Burns are defined by...Burns are defined by...
 Were defined by degrees in the past! First,Were defined by degrees in the past! First,
second, and third degreesecond, and third degree
 2 common guidelines now used are the:2 common guidelines now used are the:
 Lund-Browder ChartLund-Browder Chart
 Rule of NinesRule of Nines

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Rule of NinesRule of Nines
 In the adult, mostIn the adult, most
areas of the bodyareas of the body
can be dividedcan be divided
roughly into portionsroughly into portions
of 9%, or multiples ofof 9%, or multiples of
9. This division,9. This division,
called the rule ofcalled the rule of
nines, is useful innines, is useful in
estimating theestimating the
percentage of bodypercentage of body
surface damage ansurface damage an
individual hasindividual has
 In small children,In small children,
relatively more arearelatively more area
is taken up by theis taken up by the
head and less byhead and less by
the lowerthe lower
extremities.extremities.
Accordingly, theAccordingly, the
rule of nines isrule of nines is
modified. In eachmodified. In each
case, the rule givescase, the rule gives
a usefula useful
approximation ofapproximation of
body surface.body surface.

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Rules of NinesRules of Nines

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Location of BurnsLocation of Burns
 Has a direct relationship to the severity ofHas a direct relationship to the severity of
the burn.the burn.
 Face, neck & chest burns may inhibitFace, neck & chest burns may inhibit
respiratory illness RT mechanicalrespiratory illness RT mechanical
obstruction secondary to edema or escharobstruction secondary to edema or eschar
formationformation

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Complicating or Co-MorbidComplicating or Co-Morbid
FactorsFactors
 Associated TraumaAssociated Trauma
 Inhalation InjuriesInhalation Injuries
 Circumferential BurnsCircumferential Burns
 ElectricityElectricity
 Age (Young or Old)Age (Young or Old)
 Pre-Existing DiseasePre-Existing Disease
 AbuseAbuse

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3 Phases of Burn3 Phases of Burn
ManagementManagement
emergent (resuscitative)emergent (resuscitative)
acuteacute
rehabilitativerehabilitative

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Pre-hospital CarePre-hospital Care
 Remove from area! Stop the burn!Remove from area! Stop the burn!
 If thermal burn is large--If thermal burn is large--FOCUS onFOCUS on
the ABC’sthe ABC’s
 A=airway-A=airway-check for patency, soot aroundcheck for patency, soot around
nares, or signed nasal hairnares, or signed nasal hair
 B=breathingB=breathing- check for adequacy of- check for adequacy of
ventilationventilation
 C=circulation-C=circulation- check for presence andcheck for presence and
regularity of pulsesregularity of pulses

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Other precautions...Other precautions...
 Burn too large--don’t immerse in waterBurn too large--don’t immerse in water
due to extensive heat lossdue to extensive heat loss
 Never pack in iceNever pack in ice
 Pt. should be wrapped in dry cleanPt. should be wrapped in dry clean
material to decrease contamination ofmaterial to decrease contamination of
wound and increase warmthwound and increase warmth

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Emergent PhaseEmergent Phase
(Resuscitative Phase)(Resuscitative Phase)
 Lasts from onset to 5 or more days butLasts from onset to 5 or more days but
usually lasts 24-48 hoursusually lasts 24-48 hours
 begins with fluid loss and edema formationbegins with fluid loss and edema formation
and continues until fluid motorization andand continues until fluid motorization and
diuresis beginsdiuresis begins
 Greatest initial threat isGreatest initial threat is
hypovolemic shock to a major burnhypovolemic shock to a major burn
patient!patient!

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Complications duringComplications during
emergent phase of burnemergent phase of burn
injury are 3 major organinjury are 3 major organ
systems...systems...
CardiovascularCardiovascular
RespiratoryRespiratory
Renal systemsRenal systems

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Cardiovascular SystemsCardiovascular Systems
 Arrhythmias, hypovolemic shock which mayArrhythmias, hypovolemic shock which may
lead to irreversible shocklead to irreversible shock
 circulation to limbs can be impaired bycirculation to limbs can be impaired by
circumferential burns and then the edemacircumferential burns and then the edema
formationformation
 Causes: occluded blood supply thus causingCauses: occluded blood supply thus causing
ischemia, necrosis, and eventually gangrene.ischemia, necrosis, and eventually gangrene.
 Escharotomies (incisions through eschar) doneEscharotomies (incisions through eschar) done
to restore circulation to compromisedto restore circulation to compromised
extremities.extremities.

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Respiratory SystemRespiratory System
 Vulnerable to 2 types of injuryVulnerable to 2 types of injury
 1.1. Upper airway burnsUpper airway burns that cause edemathat cause edema
formation & obstruction of the airwayformation & obstruction of the airway
 2. Inhalation injury2. Inhalation injury can show up 24 hrs later-can show up 24 hrs later-
watch for resp. distress such as increasedwatch for resp. distress such as increased
agitation or change in rate or character of resp.agitation or change in rate or character of resp.
 preexisting problem (ex. COPD) more prone to getpreexisting problem (ex. COPD) more prone to get
resp. infectionresp. infection
 Pneumonia is common complication of major burnsPneumonia is common complication of major burns
 Is possible to overload with fluids--leading to pulmonaryIs possible to overload with fluids--leading to pulmonary
edemaedema

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Renal SystemRenal System
 Most common renal complication of burnsMost common renal complication of burns
in the emergent phase isin the emergent phase is ATN.ATN. BecauseBecause
of hypovolemic state, blood flowof hypovolemic state, blood flow
decreases, causing renal ischemia. If itdecreases, causing renal ischemia. If it
continues, acute renal failure maycontinues, acute renal failure may
develop.develop.

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Nursing management in theNursing management in the
emergent phase is...emergent phase is...
 Airway managementAirway management-early nasotracheal or-early nasotracheal or
endotracheal intubation before airway isendotracheal intubation before airway is
actually compromised (usually 1-2 hours afteractually compromised (usually 1-2 hours after
burn)burn)
 ventilator? ABGs? Escharotomies?ventilator? ABGs? Escharotomies?
 6-12 hours later-Bronchoscopy to assess lower6-12 hours later-Bronchoscopy to assess lower
resp. tactresp. tact
 high fowler’s position-cough & deep breathehigh fowler’s position-cough & deep breathe
every hour, turn q 1-2 hrs, chest physiotherapy,every hour, turn q 1-2 hrs, chest physiotherapy,
suction prnsuction prn

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Fluid ShiftsFluid Shifts
 Massive fluid shifts out of blood vesselsMassive fluid shifts out of blood vessels
as a result of increased capillaryas a result of increased capillary
permeability. When capillary wallspermeability. When capillary walls
become more permeable, water,become more permeable, water,
sodium, and later plasma protein (esp.sodium, and later plasma protein (esp.
albumin) moves into interstitial spacesalbumin) moves into interstitial spaces
& other tissues. The colloidal osmotic& other tissues. The colloidal osmotic
pressure decreases with loss of proteinpressure decreases with loss of protein
from the vascular space. This calledfrom the vascular space. This called
second spacing.second spacing.

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Third SpacingThird Spacing
 Fluids goes into areas with no fluids andFluids goes into areas with no fluids and
this is called third spacing. Examples ofthis is called third spacing. Examples of
third spacing are exudate and blisterthird spacing are exudate and blister
formation.formation.
 Net result is decreased volume, depletionNet result is decreased volume, depletion
due to fluid shifts = edema, decreaseddue to fluid shifts = edema, decreased
blood pressure, and increased pulseblood pressure, and increased pulse

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Hypovolemic ShockHypovolemic Shock
 Occurs when there is a loss ofOccurs when there is a loss of
intravascular fluid volume. The volume isintravascular fluid volume. The volume is
inadequate to fill vascular space and isinadequate to fill vascular space and is
unavailable for circulation.unavailable for circulation.
 Also, burns have a direct loss of fluid dueAlso, burns have a direct loss of fluid due
to evaporation.to evaporation.

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Inflammation & HealingInflammation & Healing
 Burn injuries casue coagulation necrosisBurn injuries casue coagulation necrosis
whereby tissues and vessels arewhereby tissues and vessels are
damaged or destroyeddamaged or destroyed
 Wound repair begins within the first 6-12Wound repair begins within the first 6-12
hours after injury.hours after injury.

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Immunologic ChangesImmunologic Changes
 Are caused by burns.Are caused by burns.
 Skin barrier destroyed and all changesSkin barrier destroyed and all changes
make the burn patient more susceptible tomake the burn patient more susceptible to
infectioninfection
 Pt may be in shock from pain andPt may be in shock from pain and
hypovolemia.hypovolemia.

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Other factors to consider...Other factors to consider...
 Full-thickness burns and deep partialFull-thickness burns and deep partial
thickness burns are initially anestheticthickness burns are initially anesthetic
because nerve endings are destroyed.because nerve endings are destroyed.
 Superficial to moderate partial thicknessSuperficial to moderate partial thickness
burns are very painful.burns are very painful. Why?Why?

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Still more factors toStill more factors to
consider...consider... Severe dehydration is possible even thoughSevere dehydration is possible even though
the patient maybe edematous--the patient maybe edematous--Why?Why?
 May have an dynamic ileus RT body’sMay have an dynamic ileus RT body’s
response to massive trauma and potassiumresponse to massive trauma and potassium
shiftsshifts--Why?--Why?
 Shivering due to chilling caused by heat loss,Shivering due to chilling caused by heat loss,
anxiety, and painanxiety, and pain
 unable to recall events RT hypoxia associatedunable to recall events RT hypoxia associated
with smoke inhalation, or head trauma orwith smoke inhalation, or head trauma or
overdose of sedatives or pain medsoverdose of sedatives or pain meds

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Fluid TherapyFluid Therapy
 1 or 2 large bore IV replacement lines (may1 or 2 large bore IV replacement lines (may
need jugular or subclavian)need jugular or subclavian)
 Cutdown rare RT increased risk of infection &Cutdown rare RT increased risk of infection &
sepsissepsis
 Fluid replacement based on: size/depth of burn,Fluid replacement based on: size/depth of burn,
age of pt., & individualized considerations--ex.age of pt., & individualized considerations--ex.
Dehydration in preburn state, chronic illnessDehydration in preburn state, chronic illness
 options- RL, D5NS, dextam, albumin, etc.options- RL, D5NS, dextam, albumin, etc.
 there are formula’s for replacement: Parklandthere are formula’s for replacement: Parkland
formula and Brooke formulaformula and Brooke formula

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Assessment of adequacyAssessment of adequacy
of fluid replacementof fluid replacement
 Urinary output is most commonly usedUrinary output is most commonly used
parameterparameter
 urine OP-30-50 cc/hr in an adulturine OP-30-50 cc/hr in an adult
 cardiopulmonary factors- BP (systolic 90-100cardiopulmonary factors- BP (systolic 90-100
mmHg, pulse less than 100, resp 16-20 breathsmmHg, pulse less than 100, resp 16-20 breaths
per min. (BP more accurate with arterial line)per min. (BP more accurate with arterial line)
 sensoruim-alert, oriented to time, place, &sensoruim-alert, oriented to time, place, &
personperson

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Wound Care for BurnsWound Care for Burns
 Can wait until patent airway, adequateCan wait until patent airway, adequate
circulation, fluid replacement is in place!circulation, fluid replacement is in place!

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Full-thickness burns areFull-thickness burns are
 Will be dry and waxy white to dark brownWill be dry and waxy white to dark brown
 will have little to no sensation becausewill have little to no sensation because
nerve endings have been destroyednerve endings have been destroyed

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Partial thickness burnsPartial thickness burns
 Are pink to cherry red, wet, shiny withAre pink to cherry red, wet, shiny with
serous exudateserous exudate
 May or may not have intact blisters andMay or may not have intact blisters and
are very painful when touched or exposedare very painful when touched or exposed
to airto air

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Cleansing andCleansing and
DebridementDebridement
 Can be done in tank, shower, or bedCan be done in tank, shower, or bed
 Debridement may be done in surgery.Debridement may be done in surgery.
(Loose necrotic skin is removed)(Loose necrotic skin is removed)
 bath given with with surgical detergent,bath given with with surgical detergent,
disinfectant, or cleansing agent to reducedisinfectant, or cleansing agent to reduce
pathogenic organismspathogenic organisms

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Infection is the mostInfection is the most
serious threat to furtherserious threat to further
tissue injury and possibletissue injury and possible
sepsis.sepsis.
 SURVIVAL is related to prevention ofSURVIVAL is related to prevention of
wound contamination.wound contamination.
 Source of infection is pt’s own flora,Source of infection is pt’s own flora,
predominantly from the skin, resp. tract, andpredominantly from the skin, resp. tract, and
GI tract.GI tract.
 Prevention of cross contamination from otherPrevention of cross contamination from other
patients is the priority for nurses!patients is the priority for nurses!

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2 methods used to control2 methods used to control
infections in burninfections in burn
wounds...wounds...
 Open methodOpen method- pt’s burn is covered wit- pt’s burn is covered wit
ha topical antibiotic and has no dressingha topical antibiotic and has no dressing
 Closed method-Closed method-uses sterile gauzeuses sterile gauze
impregnated with or laid over a topicalimpregnated with or laid over a topical
antibiotic. Dressings changed 2-3 times qantibiotic. Dressings changed 2-3 times q
24 hrs.24 hrs.

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Wound Care continued...Wound Care continued...
 Staff should wear disposable hats, gowns,Staff should wear disposable hats, gowns,
gloves, masks when wounds are exposedgloves, masks when wounds are exposed
 appropriate use of sterile vs. nonsterileappropriate use of sterile vs. nonsterile
techniquestechniques
 keep room warmkeep room warm
 careful handwashingcareful handwashing
 any bathing areas disinfected before andany bathing areas disinfected before and
after bathingafter bathing

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 Coverage is the primary goal for burnCoverage is the primary goal for burn
wounds. Since usually not enoughwounds. Since usually not enough
unburned skin for immediate skinunburned skin for immediate skin
grafting, other temporary wound closuregrafting, other temporary wound closure
methods are usedmethods are used
 Allograph or homograft (same speciesAllograph or homograft (same species
which is usually from cadavers) is used forwhich is usually from cadavers) is used for
wound closure-- temporary--3 days to 2wound closure-- temporary--3 days to 2
wkswks
 Porcine skin-heterograft or xenograftPorcine skin-heterograft or xenograft
(different species)--temporary--3 days to 2(different species)--temporary--3 days to 2
wkswks
 autograft or cultured epithelial autograft-autograft or cultured epithelial autograft-

JUNI 10,FF 62
Surgeons use a dermatome (left) toSurgeons use a dermatome (left) to
remove donor skin and a mesherremove donor skin and a mesher
(right) to put holes in it.(right) to put holes in it.

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 Surgeons agree that no single product orSurgeons agree that no single product or
technique is right for every burn situation.technique is right for every burn situation.
And so far, there's no true replacement forAnd so far, there's no true replacement for
healthy, intact skin, which is the body'shealthy, intact skin, which is the body's
largest organ, and one of the most complex.largest organ, and one of the most complex.
It's the first line of defense againstIt's the first line of defense against
infection and dehydration, but it'sinfection and dehydration, but it's
more than just a physical barrier. Skinmore than just a physical barrier. Skin
also helps control temperature,also helps control temperature,
through adjustments of blood flow andthrough adjustments of blood flow and
evaporation of sweat. It's anevaporation of sweat. It's an
important sensory organ, too.important sensory organ, too.

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Other care measuresOther care measures
includeinclude
 Face is vascular and subject to increasedFace is vascular and subject to increased
edema- use open method if possible toedema- use open method if possible to
decrease confusion and disorientationdecrease confusion and disorientation
 eye care-use saline rinses, artificial tearseye care-use saline rinses, artificial tears
 hands &arms-extended and elevated onhands &arms-extended and elevated on
pillows or in slings to minimize edema,pillows or in slings to minimize edema,
may need splints to keep them inmay need splints to keep them in
functional positionsfunctional positions

JUNI 10,FF 65
 Ears- keep free of pressure. Ear burns-Ears- keep free of pressure. Ear burns-
no pillows! Neck burns should not useno pillows! Neck burns should not use
pillows in order to decrease woundpillows in order to decrease wound
contraction.contraction.
 Perineum-must be kept clean & dry.Perineum-must be kept clean & dry.
Indwelling foley will help in this & also toIndwelling foley will help in this & also to
provide hourly outputs.provide hourly outputs.
 Lab tests prn to monitor electrolyteLab tests prn to monitor electrolyte
imbalance and ABGsimbalance and ABGs
 Physical therapy stared immediatelyPhysical therapy stared immediately

JUNI 10,FF 66
Drug TherapyDrug Therapy
 Analgesics and SedativesAnalgesics and Sedatives
 given for pt comfortgiven for pt comfort
 IV pain meds initialy due to:IV pain meds initialy due to:
 GI function is slowed or impaired because ofGI function is slowed or impaired because of
shock or paralytic ileusshock or paralytic ileus
 IM injections will not be absorbed wellIM injections will not be absorbed well

JUNI 10,FF 67
Drug TherapyDrug Therapy
 Tetanus immunization-Tetanus immunization- given routinelygiven routinely
to all burn patients because of theto all burn patients because of the
likelihood of anaerobic burn-woundlikelihood of anaerobic burn-wound
contaminationcontamination
 Antimicrobial agents-Antimicrobial agents-usually topicalusually topical
due to little or no blood supply to the burndue to little or no blood supply to the burn
eschar so little delivery of the antibiotic toeschar so little delivery of the antibiotic to
woundwound
 Drug of choice is:Drug of choice is: Silver sulfadiazineSilver sulfadiazine

JUNI 10,FF 68
Nutritional TherapyNutritional Therapy
 Fluid replacement takes priority overFluid replacement takes priority over
nutritional needs in the initial emergentnutritional needs in the initial emergent
phase.phase. Why?Why?
 NG tube is inserted and connected toNG tube is inserted and connected to
low intermittent suction forlow intermittent suction for
decompression. When bowel soundsdecompression. When bowel sounds
return (48-72 hrs) after injury, start withreturn (48-72 hrs) after injury, start with
clear liquids and progress up to a dietclear liquids and progress up to a diet
high in proteins and calorieshigh in proteins and calories

JUNI 10,FF 69
 Burn patients need more calories & failureBurn patients need more calories & failure
to provide will lead to delayed woundto provide will lead to delayed wound
healing and malnutrition.healing and malnutrition.
 Give calorie containing liquids instead ofGive calorie containing liquids instead of
water due to need for calories andwater due to need for calories and
potential for water intoxicationpotential for water intoxication
 Enteral feedings into the duodenumEnteral feedings into the duodenum
(recommended) can: reduce n&v, more(recommended) can: reduce n&v, more
continuous feedings, and increase wdcontinuous feedings, and increase wd
healing!healing!

JUNI 10,FF 70
Acute PhaseAcute Phase
 Begins with mobilization of extracellularBegins with mobilization of extracellular
fluid and subsequent diuresis.fluid and subsequent diuresis.
 Is concluded when the burned area isIs concluded when the burned area is
completely covered or when woundscompletely covered or when wounds
are healed. May take weeks or months.are healed. May take weeks or months.
 Pt is no longer grossly edematous duePt is no longer grossly edematous due
to fluid mobilization, full & partialto fluid mobilization, full & partial
thickness burns more evident, bowelthickness burns more evident, bowel
sounds return, pt more aware of painsounds return, pt more aware of pain
and condition.and condition.

JUNI 10,FF 71
 Healing begins when WBCs haveHealing begins when WBCs have
surrounded the burn and phagocytosissurrounded the burn and phagocytosis
begins, necrotic tissue begins to slough,begins, necrotic tissue begins to slough,
fibroblasts lay down matrices offibroblasts lay down matrices of
collagen precursors to form granulationcollagen precursors to form granulation
tissue.tissue.
 Partial-thickness burns (if kept free fromPartial-thickness burns (if kept free from
infections) will heal from edges andinfections) will heal from edges and
from below. (10-14 days)from below. (10-14 days)
 Full-thickness burns must be coveredFull-thickness burns must be covered
by skin grafts.by skin grafts.

JUNI 10,FF 72
Laboratory ValuesLaboratory Values
 Sodium-Sodium- Hyponatremia can occur due to:Hyponatremia can occur due to:
silver nitrate topical oints as a result of sodiumsilver nitrate topical oints as a result of sodium
loss through eshcar, hydrotherapy, excessiveloss through eshcar, hydrotherapy, excessive
GI drainage, diarrhea, excessive water intakeGI drainage, diarrhea, excessive water intake
 S/S of hyponatremia: weakness, dizziness,S/S of hyponatremia: weakness, dizziness,
muscle cramps, fatigue, HA, tachycardia, &muscle cramps, fatigue, HA, tachycardia, &
confusionconfusion
 Hypernatremia can occur: too muchHypernatremia can occur: too much
hypertonic fluids, improper tube feedings,hypertonic fluids, improper tube feedings,
inappropriate fluid administrationinappropriate fluid administration
 S/S of hypernatremia: thirst; dried furry tongue;S/S of hypernatremia: thirst; dried furry tongue;
lethargy; confusion; and possible seizureslethargy; confusion; and possible seizures

JUNI 10,FF 73
 Potassium-Potassium- hyperkalemia is note if pt is inhyperkalemia is note if pt is in
renal failure, adrenocortical insufficiency, orrenal failure, adrenocortical insufficiency, or
massive deep muscle injury with lg. amts.massive deep muscle injury with lg. amts.
of potassium released from damaged cells.of potassium released from damaged cells.
Cardiac arrhythmias and ventricular failureCardiac arrhythmias and ventricular failure
can occur if K+ level greater >7mEq/L.can occur if K+ level greater >7mEq/L.
muscle weakness & EKG changes aremuscle weakness & EKG changes are
noted.noted.
 Hypokalemia is noted with silver nitrate therapyHypokalemia is noted with silver nitrate therapy
and long hydrotherapy. Other causes:and long hydrotherapy. Other causes:
vomiting, diarrhea, prolonged GI suction,vomiting, diarrhea, prolonged GI suction,
prolonged IV therapy without K+prolonged IV therapy without K+
supplementation. Constant K+ losses occursupplementation. Constant K+ losses occur

JUNI 10,FF 74
Complications of AcuteComplications of Acute
PhasePhase Infection-Infection- due to destruction of body’s 1stdue to destruction of body’s 1st
line of defense. Partial thickness wds canline of defense. Partial thickness wds can
convert to full-thickness wds with infectionconvert to full-thickness wds with infection
present. Pt may get sepsis from woundpresent. Pt may get sepsis from wound
infections. Signs of sepsis are: high temp.,infections. Signs of sepsis are: high temp.,
increased pulse & resp., decreased BP, andincreased pulse & resp., decreased BP, and
decreased urinary output, mild confusion,decreased urinary output, mild confusion,
chills, malaise, and loss of appetite. WBC bet.chills, malaise, and loss of appetite. WBC bet.
10,000 and 20,000. Infections usually gram10,000 and 20,000. Infections usually gram
neg. bacteria (pseudomonas, proteus)neg. bacteria (pseudomonas, proteus)
 Obtain cultures from all possible sources: IV,Obtain cultures from all possible sources: IV,
foley, wound, oropharynx, and sputumfoley, wound, oropharynx, and sputum

JUNI 10,FF 75
 Cardiovascular-Cardiovascular- same as in emergentsame as in emergent
phasephase
 Neurologic-Neurologic-possible from electrical injuriespossible from electrical injuries
 Musculoskeletal-Musculoskeletal- has the most potentialhas the most potential
for complications during acute phase due tofor complications during acute phase due to
healing and scar formation making skin lesshealing and scar formation making skin less
supple and pliant. ROM limited, contracturessupple and pliant. ROM limited, contractures
can occurcan occur
 Gastrointestinal-Gastrointestinal-adynamic ileus resultsadynamic ileus results
from sepsis, diarrhea or constipation (RTfrom sepsis, diarrhea or constipation (RT
narcotics & decreased mobility), gastricnarcotics & decreased mobility), gastric
ulcers RT stress, occult blood in stoolsulcers RT stress, occult blood in stools

JUNI 10,FF 76
Nursing management-acuteNursing management-acute
phasephase Predominant therapeuticPredominant therapeutic
interventions are:interventions are:
 fluid replacement, physical therapy, wd care,fluid replacement, physical therapy, wd care,
early excision and grafting, and painearly excision and grafting, and pain
managementmanagement
 Fluid replacementFluid replacement continues fromcontinues from
emergent phase to acute phases--emergent phase to acute phases--givengiven
for:for: fluid losses, administer medications,fluid losses, administer medications,
& for transfusions.& for transfusions.
 Physical therapy-Physical therapy- to maintain optimalto maintain optimal
joint functionjoint function
 Pain management-Pain management- most criticalmost critical

JUNI 10,FF 77
 Wound Care-Wound Care- the goals are cleanse andthe goals are cleanse and
debride the area of necrotic tissue &debris,debride the area of necrotic tissue &debris,
minimize further damage to viable skin,minimize further damage to viable skin,
promote patient comfort, & reepithelializationpromote patient comfort, & reepithelialization
or success with skin grafting.or success with skin grafting.
 Care for donor site and other graftsCare for donor site and other grafts
necessarynecessary
 Excision and grafting-Excision and grafting- eschar removed toeschar removed to
subcutaneous tissue or fascia, graft appliedsubcutaneous tissue or fascia, graft applied
to tissueto tissue
 Cultured epithelial autograft (CEA)uses patient’sCultured epithelial autograft (CEA)uses patient’s
own cells to grow skin-permanentown cells to grow skin-permanent
 artificial skin is the latest trend. Examples:artificial skin is the latest trend. Examples:

JUNI 10,FF 78
Rehabilitation PhaseRehabilitation Phase
 Defined as beginning when the patient’s burnDefined as beginning when the patient’s burn
wound is covered with skin or healed andwound is covered with skin or healed and
patient is capable of assuming some self-patient is capable of assuming some self-
care activity.care activity.
 Can occur as early as 2 weeks to as long asCan occur as early as 2 weeks to as long as
2-3 months after the burn injury2-3 months after the burn injury
 Goals for this time is to assist patient inGoals for this time is to assist patient in
resuming functional role in society &resuming functional role in society &
accomplish functional and cosmeticaccomplish functional and cosmetic
reconstruction.reconstruction.

JUNI 10,FF 79
Clinical ManifestationsClinical Manifestations
 Burn wd either heals by primary intentionBurn wd either heals by primary intention
or by grafting.or by grafting.
 Scars may form & contractures.Scars may form & contractures.
 Mature healing is reached in 6 months toMature healing is reached in 6 months to
2 years2 years
 Avoid direct sunlight for 1 year on burnAvoid direct sunlight for 1 year on burn
 new skin sensitive to traumanew skin sensitive to trauma

JUNI 10,FF 80
ComplicationsComplications
 Most common complications of burn injuryMost common complications of burn injury
are skin and joint contractures andare skin and joint contractures and
hypertrophic scarringhypertrophic scarring
 Because of pain, pts will assume flexedBecause of pain, pts will assume flexed
position. It predisposes wds to contractureposition. It predisposes wds to contracture
formationformation
 Use of physical therapy, pressureUse of physical therapy, pressure
garments, splints, etc. are usedgarments, splints, etc. are used

JUNI 10,FF 81
Nursing managementNursing management
during rehabilitation phaseduring rehabilitation phase
 Must be directed to returning patient toMust be directed to returning patient to
society, address emotional concerns,society, address emotional concerns,
spiritual and cultural needs, self-esteem,spiritual and cultural needs, self-esteem,
teaching of wound care management,teaching of wound care management,
nutrition, role of exercises and physicalnutrition, role of exercises and physical
therapy explained. A common emotionaltherapy explained. A common emotional
response seen isresponse seen is regression.regression.

JUNI 10,FF 82
Special needs of the nursingSpecial needs of the nursing
staffstaff
 The staff of burn units are prone to higherThe staff of burn units are prone to higher
rates of burn-out. The care of a burnrates of burn-out. The care of a burn
patient is a long journey that the patient,patient is a long journey that the patient,
nurse, and significant others must travel.nurse, and significant others must travel.
The road to recovery is full of potentialThe road to recovery is full of potential
threats to the patient. Support services arethreats to the patient. Support services are
necessary for the medical team of anynecessary for the medical team of any
long-term burn patients.long-term burn patients.

JUNI 10,FF 83
Care ofCare of BB UU RR NN SS
B -B - breathingbreathing
body imagebody image
UU - urine output- urine output
RR - rule of ninesrule of nines
resuscitation of fluidresuscitation of fluid
N -N - nutritionnutrition
SS - shock- shock
silvadenesilvadene

JUNI 10,FF 84
B- Breathing-B- Breathing- keep airwaykeep airway
open. Facial burns, singedopen. Facial burns, singed
nasal hair, hoarseness, sootynasal hair, hoarseness, sooty
sputum, bloody sputum andsputum, bloody sputum and
labored respiration indicatelabored respiration indicate
TROUBLETROUBLE!!
Body Image-Body Image- assist Bernie inassist Bernie in
coping by encouragingcoping by encouraging
expression of thoughts andexpression of thoughts and
feelings.feelings.

JUNI 10,FF 85
U- URINE OUTPUT-U- URINE OUTPUT- in anin an
adult, urine output should beadult, urine output should be
30-70 cc per hour, in the child30-70 cc per hour, in the child
20-50 cc per hour, and in the20-50 cc per hour, and in the
infant, 10-20 cc per hour.infant, 10-20 cc per hour.
Watch the K+ to keep itWatch the K+ to keep it
between 3.5-5.0 mEq/L. Keepbetween 3.5-5.0 mEq/L. Keep
the CVP around 12 cm waterthe CVP around 12 cm water
pressure!pressure!

JUNI 10,FF 86
R- RESUSCITATION OF FLUID-R- RESUSCITATION OF FLUID-
Salt & electrolyte solutions are essentialSalt & electrolyte solutions are essential
over the 1over the 1stst
24 hours. Maintain B/P at24 hours. Maintain B/P at
90-100 systolic. ½ of the fluid for the90-100 systolic. ½ of the fluid for the
first 24 hrs should be administered overfirst 24 hrs should be administered over
the first 8 hour period, then thethe first 8 hour period, then the
remainder is administered over the nextremainder is administered over the next
16 hours. First 24 hour calculation starts16 hours. First 24 hour calculation starts
at the time of injury.at the time of injury.
RULE OF NINE’S-RULE OF NINE’S- used for adults toused for adults to
determine burn surface area!determine burn surface area!

JUNI 10,FF 87
N-NUTRITION-N-NUTRITION- protein &protein &
calories are components ofcalories are components of
the diet! Supplemental gastricthe diet! Supplemental gastric
tube feedings ortube feedings or
hyperalimentation may behyperalimentation may be
used in pts with large burnedused in pts with large burned
areas. Daily weights will assistareas. Daily weights will assist
in evaluating the nutritionalin evaluating the nutritional
needs!needs!

JUNI 10,FF 88
S-SHOCK-S-SHOCK- Watch the B/P, CVP,Watch the B/P, CVP,
and renal function.and renal function.
Silvadene-Silvadene-for infection.for infection.
REMEMBER THESE PEOPLEREMEMBER THESE PEOPLE
ARE AFRAID AND NEEDARE AFRAID AND NEED
SUPPORT!!!!!SUPPORT!!!!!

JUNI 10,FF 89
 Burn Wound InfectionBurn Wound Infection
 An ability to make the diagnosis of burn wound infection is important. A clinicallyAn ability to make the diagnosis of burn wound infection is important. A clinically
focused set of burn wound infection definitions has recently been published and isfocused set of burn wound infection definitions has recently been published and is
summarized as follows:summarized as follows:
 Burn impetigoBurn impetigo
 Diagnostic points - Loss of epithelium from previously epithelialized surface; not related toDiagnostic points - Loss of epithelium from previously epithelialized surface; not related to
local traumalocal trauma
 Treatment strategies - Regular cleaning of debris and exudate; topical antistaphylococcalTreatment strategies - Regular cleaning of debris and exudate; topical antistaphylococcal
antibiotics; grafting of chronically unstable areas of epitheliumantibiotics; grafting of chronically unstable areas of epithelium
 Burn-related surgical wound infectionBurn-related surgical wound infection
 Diagnostic points - Infection in surgically created would that has not yet epithelialized;Diagnostic points - Infection in surgically created would that has not yet epithelialized;
includes loss of any overlying graft or membraneincludes loss of any overlying graft or membrane
 Treatment strategies - Regular cleaning of debris and exudate; systemic and topicalTreatment strategies - Regular cleaning of debris and exudate; systemic and topical
antistaphylococcal antibiotics; grafting of chronically unstable areas of epitheliumantistaphylococcal antibiotics; grafting of chronically unstable areas of epithelium
 Burn wound cellulitisBurn wound cellulitis
 Diagnostic points - Infection occurs in uninjured skin surrounding a wound; signs of localDiagnostic points - Infection occurs in uninjured skin surrounding a wound; signs of local
infection progress beyond what is expected from burn-related inflammationinfection progress beyond what is expected from burn-related inflammation
 Treatment strategies - Systemic antibiotics directed againstTreatment strategies - Systemic antibiotics directed against Streptococcus pyogenes;Streptococcus pyogenes; properproper
treatment of primary woundtreatment of primary wound
 Invasive burn wound infectionInvasive burn wound infection
 Diagnostic points - Infection occurs in unexcised burn and invades viable underlying tissue;Diagnostic points - Infection occurs in unexcised burn and invades viable underlying tissue;
diagnosis may be supported by results from histologic examination or quantitative culturediagnosis may be supported by results from histologic examination or quantitative culture
 Treatment strategies - Systemic antibiotics directed against presumed pathogen; woundTreatment strategies - Systemic antibiotics directed against presumed pathogen; wound
excision, with biologic closure when possibleexcision, with biologic closure when possible

JUNI 10,FF 90
 Outpatient wound care strategiesOutpatient wound care strategies
 Components of outpatient burn care include theComponents of outpatient burn care include the
following:following:
 Patient and family educationPatient and family education
 Wound cleansingWound cleansing
 Choice of topical or membrane dressingChoice of topical or membrane dressing
 Pain controlPain control
 Early return instructionsEarly return instructions
 Follow-up clinic visitsFollow-up clinic visits
 Long-term follow-up careLong-term follow-up care

JUNI 10,FF 91
 s:s:
 First-degree burns are usually red, dry, and painful. Burns initiallyFirst-degree burns are usually red, dry, and painful. Burns initially
termed first-degree are often actually superficial second-degreetermed first-degree are often actually superficial second-degree
burns, with sloughing occurring the next day.burns, with sloughing occurring the next day.
 Second-degree burns are often red, wet, and very painful. TheirSecond-degree burns are often red, wet, and very painful. Their
depth, ability to heal, and propensity to form hypertrophic scars (seedepth, ability to heal, and propensity to form hypertrophic scars (see
Media file 2Media file 2) vary enormously.) vary enormously.
 Third-degree burns are generally leathery in consistency, dry,Third-degree burns are generally leathery in consistency, dry,
insensate, and waxy. These wounds will not heal, except byinsensate, and waxy. These wounds will not heal, except by
contraction and limited epithelial migration, with resultingcontraction and limited epithelial migration, with resulting
hypertrophic and unstable cover (seehypertrophic and unstable cover (see Media file 3Media file 3). Burn blisters (see). Burn blisters (see
Media file 4Media file 4) can overlie both second- and third-degree burns. The) can overlie both second- and third-degree burns. The
management of burn blisters remains controversial, yet intact blistersmanagement of burn blisters remains controversial, yet intact blisters
help greatly with pain control. Debride blisters if infection occurs.help greatly with pain control. Debride blisters if infection occurs.
 Fourth-degree burns involve underlying subcutaneous tissue,Fourth-degree burns involve underlying subcutaneous tissue,
tendon, or bone. Usually, even an experienced examiner hastendon, or bone. Usually, even an experienced examiner has
difficulty accurately determining burn depth during early examination.difficulty accurately determining burn depth during early examination.
As a general rule, burn depth is underestimated upon initialAs a general rule, burn depth is underestimated upon initial
examination.examination.

JUNI 10,FF 92
 Wound dressing, whether one is usingWound dressing, whether one is using
topical medication or a wound membrane,topical medication or a wound membrane,
should provide 4 benefits, includingshould provide 4 benefits, including
(1) prevention of wound(1) prevention of wound
desiccation, (2) control of pain,desiccation, (2) control of pain,
(3) reduction of(3) reduction of
wound colonization and infection, andwound colonization and infection, and
(4) prevention of(4) prevention of
added trauma to the woundadded trauma to the wound

JUNI 10,FF 93
 Elaborate specific conditions mayElaborate specific conditions may
mandate an early return to the hospital.mandate an early return to the hospital.
Particularly important areParticularly important are
(1) pain and anxiety(1) pain and anxiety
associated with wound care to the degreeassociated with wound care to the degree
that wound care is compromised,that wound care is compromised,
(2) signs of(2) signs of
infection, or (3) ainfection, or (3) a
wound that appears deeper thanwound that appears deeper than
appreciated during the initial examination.appreciated during the initial examination.
Review wound care instructions withReview wound care instructions with
caregivers.caregivers.

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