Case Report Burns

8/3/2019 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 burnsthese burns result from contact of the skin with hot items,including flames

y Chemical burnsthese burns result from contact of the skin with chemicals, or byingestion of chemicals

y Electrical burnsthese 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/

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Case Report Burns

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