THE INTEGUMENTARY SYSTEM
PATIENT WITH BURNS
TYPES OF BURNS
- ELECCTRICAL INJURY
- CHEMICAL INJURY
- THERMAL INJURY
Areas that are most vulnerable to burns:
CLASSIFICATION OF DEPTH OF BURNS
- SUPERFICIAL THICKNESS WOUND
- PARTIAL THICKNESS WOUND
- FULL THICKNESS WOUND
- DEEP FULL THICKNESS WOUND
1. SUPERFICIAL THICKNESS WOUND
- The burn affects the epidermis, causing erythema and pain.
- AREA IS REDDENED AND BLANCHES WITH PRESSURE
- NO EDEMA IS USUALLY PRESENT
- have the least damage because epidermis is the only part of the skin that is injured
- are usually caused by prolonged exposure to low intensity heat (eg. sunburn or short flash)
- redness with mild edema and pain
- peeling of dead skin (desquamation) occurs for 2-3 days after the burn
- the area heals rapidly in 3-4 days without a scar.
2. PARTIAL THICKNESS WOUND
(so this one affects both the dermis and the epidermis)
- involves the entire epidermis and varying depths of the dermis
- sub divided into superfiscial partial thickness and Deep Partial- Thickness Wounds
3. PARTIAL THICKNESS WOUND
- Superficial Partial- Thickness Wound
- Superficial partial thickness wounds are caused by heat injury to the upper third of the dermis
leaving a good blood supply.
- THE WOUNDS ARE RED, MOIST AND BLANCH (WHITEN) WHEN PRESSURE IS APPLIED.
HEAT DESTROYED EPIDERMIS WILL HAVE A BLISTER FORMATION.
- THE BLISTER WILL CONTINUE TO INCREASE IN
SIZE AFTER THE BURN AS CELL AND PROTEIN BREAKDOWN OCCURS
- increases pain sensation since nerve endings are now exposed
- any stimulation (touch or temp.) causes intense pain.
- can heal in 10 to 21 days with no scar
- Deep Partial thickness Wound
- extends deeper into the skin dermis, and few healthy cells remain.
- blister formation does not occur because the dead tissue layer is so thick and sticks
to underlying viable dermis that it does not readily lift off the surface.
- pain is present to a lesser degree
4. FULL THICKNESS WOUND
- occurs with destruction of the entire epidermis and dermis leaving no residual epidermal cells to repopulate.
- This wound therefore does not re-epithelialize and whatever area of the wound is not closed by wound
contraction will require grafting
- Full thickness injury has a hard dry, leathery eschar (burn, crust) that forms from coagulated particles
of the destroyed dermis. Eschar is dead tissue, it must slgh off or be removed from the burn wound before
healing can occur.
- Edema is pronounced under the eschar in a full-thickness wound.
- Escharotomies (incision through the eschar) or fasciotomies (incision through the eschar and fascia) may
be needed to relieve pressure and allow normal blood flow and breathing.
5. DEEP FULL THICKNESS WOUND
- Deep full thickness wounds extend beyond the skin into underlying fascia and tissues
- these deep injuries damage muscle, bone, and tendons and leave them exposed.
- these burns occur with flame, electrical and chemical injuries
- the wound is blacken and depressed and sensation is COMPLETELY absent.
- All full thickness wounds need early excision and grafting
- Grafting decreases pain and length of stay and accelerates recovery.
- amputation may be neededn when an extremity is involved
Vascular Changes in the Body
- circulatory disruption occurs at the burn site immediately after a burn
- blood flow decreases or ceases
ACUTE PHASE OF BURNS- 36 -48hrs post burn until complete wound closure. Multidisciplinary care toward continued assessment and maintenance of cardio and respir systems, GI, nutritional status, wound care, pain control, psychosocial interventions. Resolution of some earlier problems may develop new ones.
Assess for maintenance and to treat or prevent complications such as pneumonia that can progress to respiratory failure and mechanical ventilation. At risk for infections and sepsis, perform interventions from emergent phase for these problems.
Metabolic demands deplete nutritional stores in body. Weigh client daily w/o dressings or splints and compare to preburn weight (2% loss indicates mild deficit, 10% > weight loss requires eval and modification of calorie intake). Indirect Calorimetry- for very accurate calorie requirements, measures oxygen consumption and carbon dioxide production to determine kilocalories of energy expenditure. Measure at rest, 30 mins post dressing of wounds, 1xweekly until wounds closed.
At risk for infection r/t open wounds and reduced immune function- infection is leading cause of death in acute phase (burn sepsis). ASSESS- changes in wound appearance, neurologic, GI functions, vital signs. Handwashinig is key, use aseptic technique
MUSCULOSKELETAL- ASSESS active/passive ROM of all joints and neck, document
BURNS CARE MANAGEMENT:
·Parkland Formula: 4cc * Kg * BSA Burned = Total Volume Necessary
• 1st 8hrs – ½ total volume
• 2nd 8hrs – ¼ total volume
• 3rd 8 hrs – ¼ total volumes
The aim is to preserve integrity of nonburned skin, enhance wound healing, prevent complications
Nonsurgical Mgt of Impaired skin integrity:
Removing exudates and necrotic tissue, cleaning the area, stimulating granulation, applying dressings.
DEBRIDEMENT-removal of eschar and other cellular debris from the burn wound. Mechanical debridement- debrided during hydrotherapy(the application of water for treatment) 1-2x daily, RN, PCA, PT can do it, in tub, shower or simply wash small area
RN’s use forceps, scissors to remove loose, nonviable tissue, washcloths or sponges to remove soft eschar, wash w/mild soap and water, rinse.
- HOMOGRAFT (ALLOGRAFT)- HUMAN SKIN FROM CADAVER, FRESH OR FROZEN, WARM IN NORMAL SALINE, EXPENSIVE W/HIGH RISK OF TRANSMITTING BLOODBORNE INFECTION.
- HETEROGRAFT (XENOGRAFT)- ANIMAL SKIN (PIG), ASSESS DAILY FOR ADHERENCE
- AMNIOTIC MEMBRANE- BENEFITS ARE LARGE SIZE, LOW COST, EASY TO GET. FREQUENT CHANGES B/C DOES NOT DEVELOP A BLOOD SUPPLY AND DISINTEGRATES IN 48 HRS.
- ALWAYS KEEP ENDOTRACHEAL KIT AVAILABLE NEXT TO THE PATIENT.
- CALL THE PHYSICIAN IF THE CLIENT WITH INHALATION INJURY BECOMES MORE DYSPNEIC.
- GIVE ½ OF THE FLUID VOLUME CALCULATED FOR THE FIRST 24HRS AFTER BURN INJURY IN THE FIRST 8HRS POSTBURN
- POSITION PT TO PREVENT CONTRACTURES
- ASSIST PTS IN AMBULATING WHEN FLUID SHIFTS HAVE RESOLVED
- ENCOURAGE USE OF SPLINTS AND PRESSURE GARMENTS TO PREVENT JOINT IMMOBILITY