Republic of the Philippines

Cavite State University

Don Severino de Las Alas Campus Indang, Cavite

S.Y. 2012 - 2013

BURNS
Submitted by HERNANDEZ, DARREL JESUS M. GROUP 4B BSN 4-2

Submitted to NORMIDIA QUION, RN, MAN Clinical Instructor

October 8, 2012

BURNS The skin has an important role to play in the fluid and temperature regulation of the body. If enough skin area is injured, the ability to maintain that control can be lost. The skin also acts as a protective barrier against the bacteria and viruses that inhabit the world outside the body. The anatomy of the skin is complex, and there are many structures within the layers of the skin. There are three layers: 1. Epidermis, the outer layer of the skin 2. Dermis, made up of collagen and elastic fibers and where nerves, blood vessels, sweat glands, and hair follicles reside. 3. Hypodermis or subcutaneous tissue, where larger blood vessels and nerves are located. This is the layer of tissue that is most important in temperature regulation. The amount of damage that a burn can cause depends upon its location, its depth, and how much body surface area that it involves.

Burns are caused by a transfer of energy from a heat source to the body. Heat may be transferred through conduction or electromagnetic radiation. Burns are categorized as thermal (which includes electrical burns), radiation, or chemical. Tissue destruction results from coagulation, protein denaturation, or ionization of cellular contents. The skin and the mucosa of the upper airways are the sites of tissue destruction. Deep tissues, including the viscera, can be damaged by electrical burns or through prolonged contact with a heat source. Disruption of the skin can lead to increased fluid loss, infection, hypothermia, scarring, compromised immunity, and changes in function, appearance, and body image. The depth of the injury depends on the temperature of the burning agent and the duration of contact with the agent. For example, in the case of scald burns in adults, 1 second of contact with hot tap water at 68.9C (156F) may result in a burn that destroys both the epidermis and the dermis, causing a fullthickness (third-degree) injury. Fifteen seconds of exposure to hot water at 56.1C (133F) results in a similar full-thickness injury. Temperatures less than 111F are tolerated for long periods without injury. CLASSIFICATION OF BURNS Burn injuries are described according to the depth of the injury and the extent of body surface area injured. Burn Depth Burns are classified according to the depth of tissue destruction as superficial partial-thickness injuries, deep partial-thickness injuries, or full-thickness injuries. Burn depth determines whether

epithelialization will occur. Determining burn depth can be difficult even for the experienced burn care provider.

In a superficial partial-thickness burn, the epidermis is destroyed or injured and a portion of the dermis may be injured. The damaged skin may be painful and appear red and dry, as in sunburn, or it may blister. A deep partial-thickness burn involves destruction of the epidermis and upper layers of the dermis and injury to deeper portions of the dermis. The wound is painful, appears red, and exudes fluid. Capillary refill follows tissue blanching. Hair follicles remain intact. Deep partial-thickness burns take longer to heal and are more likely to result in hypertrophic scars. A full-thickness burn involves total destruction of epidermis and dermis and, in some cases, underlying tissue as well. Wound color ranges widely from white to red, brown, or black. The burned area is painless because nerve fibers are destroyed. The wound appears leathery; hair follicles and sweat glands are destroyed (Fig. 57-1). The following factors are considered in determining the depth of the burn: How the injury occurred Causative agent, such as flame or scalding liquid Temperature of the burning agent Duration of contact with the agent Thickness of the skin Regardless of the type of burn, inflammation and fluid accumulation in and around the wound occur. Moreover, it should be noted that the skin is the body's first defense against infection by microorganisms. A burn is also a break in the skin, and the risk of infection exists both at the site of the injury and potentially throughout the body.

Only the epidermis has the ability to regenerate itself. Burns that extend deeper may cause permanent injury and scarring and not allow the skin in that area to return to normal function.

Characteristic

Depth of Involvement

1st DEGREE Superficial Thickness Epidermis

2ND DEGREE Partial Thickness Epidermis and dermal elements

3RD DEGREE Full Thickness All elements of the skin including subcutaneous layer Tan, brown, black or marble white Charred dry leathery tissue formation No pain Grafting needed

4TH DEGREE Deep Penetration Including fat, muscle, and bone

Color Skin Surface

Pain Healing Period

Pink or red/erythema Dry, flaking or peeling within 2-3 days Mild pain 3-5 days

Cherry red, or white and mottled Moist, blisters, minor scars with tissue formation Very painful 14-21 days

Black Charred dry scar tissue formation No pain Grafting needed

What about electrical burns? Electrical burns may cause serious injury that is not readily apparent. Often the entry and exit points for the electrical shock may not be easily found. Electricity flows more easily through tissues in the body that are designed to deal with electricity. Nerves and muscles are "wired" for this task and often are damaged. If significant muscle damage occurs, muscle fibers and chemicals can be released into the bloodstream causing electrolyte disturbances and kidney failure. What about chemical burns? Burns can also occur when chemicals are spilled onto the body and generate a reaction that creates heat. Chemical burns may be classified by their pH or acidity.

Acids are those with pH less than 7 and include common household compounds like acetic acid, hydrochloric acid, or sulfuric acid. Bases or alkali compounds have a pH greater than 7. Ammonia is a common alkali found in the home.

EXTENT OF BODY SURFACE AREA INJURED Various methods are used to estimate the TBSA affected by burns; among them are the rule of nines, the Lund and Browder method, and the palm method.

What is the significance of the amount of body area burned? In addition to the depth of the burn, the total area of the burn is significant. Burns are measured as a percentage of total body area affected. The "rule of nines" is often used, though this measurement is adjusted for infants and children. This calculation is based upon the fact that the surface area of the following parts of an adult body each correspond to approximately 9% of total (and the total body area of 100% is achieved): Head = 9%

Chest (front) = 9% Abdomen (front) = 9% Upper/mid/low back and buttocks = 18% Each arm = 9% Each palm = 1% Groin = 1% Each leg = 18% total (front = 9%, back = 9%)

As an example, if both legs (18% x 2 = 36%), the groin (1%) and the front chest and abdomen were burned, this would involve 55% of the body.

 How important is the location of a burn? Burn location is an important consideration. If the burn involves the face, nose, mouth or neck, there is a risk that there will be enough inflammation and swelling to obstruct the airway and cause breathing problems. If there are circumferential burns to the chest, as the burn progresses, the tissue involved may not allow enough motion of the chest wall to allow adequate breathing to occur. If circumferential burns occur to arms, legs, fingers, or toes, the same constriction may not allow blood flow and put the survival of the extremity at risk. Burns to areas of the body withflexion creases, like the palm of the hand, the back of the knee, the face, and the groin may need specialized care. As the burn matures, the skin may scar and shorten, preventing full range of motion of the body area.

LUND AND BROWDER METHOD A more precise method of estimating the extent of a burn is the Lund and Browder method, which recognizes that the percentage of TBSA of various anatomic parts, especially the head and legs, and changes with growth. By dividing the body into very small areas and providing an estimate of the proportion of TBSA accounted for by such body parts, one can obtain a reliable estimate of the TBSA burned. The initial evaluation is made on the patients arrival at the hospital and is revised on the second and third post-burn days because the demarcation usually is not clear until then. PALM METHOD In patients with scattered burns, a method to estimate the percentage of burn is the palm method. The size of the patients palm is approximately 1% of TBSA.

Pathophysiology Burns are generally characterized in terms of their thickness. Partial thickness burns are either superficial, penetrating only the epidermis or deep partial thickness with epidermal and dermal involvement. These burns hurt due to severed and exposed nerve endings and they generally blister, but they heal because epithelial cells are not actually destroyed. Deeper full thickness burns destroy the epidermis, dermis, nerve endings, and sometimes subcutaneous tissue, muscles, and bone. An eschar or thick, dry scab made of denatured protein develops over the injured area. Physiologically the first reaction to a burn is vasoconstriction of capillaries followed by vasodilation and discharge of plasma. Within a few days cells die, and there is considerable fluid and heat loss; clotting may occur, and metabolism steps up. Local sepsis is likely, which can destroy tissue and increase the burn thickness. The patient may go into burn or hypovolemic shock from fluid leaking into the area tissues, which become edematous. Hemodynamic changes can also cause systemic problems.

PHYSIOLOGY/PATHOPHYSIOLOGY

First aid for burns Seek Medical Help Immediately When:

You think your child has a second- or third-degree burn. The burned area is large (2-3 inches in diameter), even if it seems like a minor burn. For any burn that appears to cover more than 10% of the body, call for medical assistance. And don't use wet compresses or ice because they can cause the child's body temperature to drop. Instead, cover the area with a clean, soft cloth or towel.

The burn comes from a fire, an electrical wire or socket, or chemicals. The burn is on the face, scalp, hands, joint surfaces, or genitals. The burn looks infected (with swelling, pus, increasing redness, or red streaking of the skin near the wound).

For First-Degree Burns:

Remove the child from the heat source. Remove clothing from the burned area immediately. Run cool (not cold) water over the burned area (if water isn't available, any cold, drinkable fluid can be used) or hold a clean, cold compress on the burn for approximately 3-5 minutes (do not use ice, as it may cause more destruction to the injured skin).

Do not apply butter, grease, powder, or any other remedies to the burn, as these can make the burn deeper and increase the risk of infection.

Apply aloe gel or cream to the affected area. This may be done a few times during the day. The burn may be dressed with a topical antibiotic ointment like Bacitracin or Neosporin.

Give your child acetaminophen or ibuprofen for pain. Refer to the dosing guidelines on the label according to your child's age or weight.

If the area affected is small (the size of a quarter or smaller), keep it clean. You can protect it with a sterile gauze pad or bandage for the next 24 hours (but do not use adhesive bandages on very young kids, as these can be a choking hazard).

Tetanus immunization should be updated if needed.

For Second- and Third-Degree Burns:

Seek emergency medical care, then follow these steps until medical personnel arrive:
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Keep your child lying down with the burned area elevated.

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Follow the instructions for first-degree burns. Remove all jewelry and clothing from around the burn (in case there's any swelling after the injury), except for clothing that's stuck to the skin. If you're having difficulty removing clothing, you may need to cut it off or wait until medical assistance arrives.

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Do not break any blisters. Apply cool water over the area for at least 3-5 minutes, then cover the area with a clean dry cloth or sheet until help arrives.

For Flame Burns:

Extinguish the flames by having your child roll on the ground. Cover him or her with a blanket or jacket. Remove smoldering clothing and any jewelry around the burned area. Call for medical assistance, then follow instructions for second- and third-degree burns.

For Electrical and Chemical Burns:

Make sure the child is not in contact with the electrical source before touching him or her, or you also may get shocked.

For chemical burns, flush the area with lots of running water for 5 minutes or more. If the burned area is large, use a tub, shower, buckets of water, or a garden hose.

Do not remove any of your child's clothing before you've begun flushing the burn with water. As you continue flushing the burn, you can then remove clothing from the burned area.

If the burned area from a chemical is small, flush for another 10-20 minutes, apply a sterile gauze pad or bandage, and call your doctor.

Chemical burns to the mouth or eyes require immediate medical evaluation after thorough flushing with water. Although both chemical and electrical burns might not always be visible, they can be serious because of potential damage to internal organs. Symptoms may vary, depending on the type and severity of the burn and what caused it and may include abdominal pain.

Nursing Diagnoses for Burns Acute pain related to tissue destruction and exposure of nerves in partially destroyed tissue Compromised family coping related to prolonged disease or disability Contamination related to infective agents at place of injury Disturbed body image related to potential scarring Imbalanced nutrition: Less than body requirements related to increased metabolic needs of burn healing Impaired gas exchange related to airway burns and carbon monoxide inhalation Impaired physical mobility related to movement limitations from scar tissue or burn treatments Ineffective tissue perfusion (peripheral) related to: circumferential eschar formation on arms and legs compartment syndrome vascular disruption Powerlessness related to illness Risk for deficient fluid volume related to active loss through disrupted skin Risk for imbalanced body temperature related to infection Risk for impaired skin integrity related to nonadherence of graft and impaired donor site healing Risk for infection related to: decreased perfusion exposure to contamination impaired immunologic response loss of protective integument Risk for injury related to continued exposure to heat or chemicals

Reference: Book CRRN Exam Secrets Study Guide Youre Key to Exam Success Brunner and Suddarths Textbook of Medical Surgical Nursing Internet Kids Health - http://kidshealth.org/parent/firstaid_safe/emergencies/burns.html# Medicine Net - http://www.medicinenet.com/burns