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Burns

This document discusses burns, including causes, types, assessment, management, and complications. It defines superficial partial thickness burns, deep partial thickness burns, and full thickness burns. It outlines the emergent, acute, and rehabilitation phases of nursing management for burns patients. Key focuses in management include wound care, pain control, fluid and electrolyte balance, nutrition, and preventing infection and complications like shock.

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Nursia
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27 views8 pages

Burns

This document discusses burns, including causes, types, assessment, management, and complications. It defines superficial partial thickness burns, deep partial thickness burns, and full thickness burns. It outlines the emergent, acute, and rehabilitation phases of nursing management for burns patients. Key focuses in management include wound care, pain control, fluid and electrolyte balance, nutrition, and preventing infection and complications like shock.

Uploaded by

Nursia
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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Republic of the Philippines

Mindanao State University -Sulu


Master of Science in Nursing
Major in Nursing Administration

Burns

Presented By:
Nursia Albin-Ammad,RN.

Presented To:

Prof.Kamala Sangkula-Elam,RN,MPA,MAN,DNM(CAR)
Burns
 Heat or chemical injury to tissue

Causes
 Radiation
 Mechanical
 Chemical
 Electrical
 Thermal

Superficial partial thickness


 The epidermis and portion of dermis is destroyed
 Slightly painful
 Appears red and dry(sunburn)
 Healing period is 3-5days
Deep partial thickness burn
 Destruction of epidermis and deeper layers of dermis.
 Burn wound is painfulWound appears red(blister and exudes fluid)
 Result to hypertrophic scar
 Healing period is 14-21days

Full thickness burn


 Involves total destruction of epidermis,dermis and underlying tissue.
 Wound color:white,red,brown or black.
 Painless
 Grafting is needed

Pathophysiology
 Due to Etiological Factor
 Heat causes coagulation necrosis to skin and subcutaneous tissue
 Release of vasoactive peptides
 Altered capillary permeability
 Fluid plasma leak into interstitial space
 Edema and dehydration
 Hypovolemic shock,decrease cardiac output,cellular shock,pulmonary edema
Assessment Findings

First Degree
 Erythema
 Edema
 Pain
 Blanching
Second-degree
 Pain
 Oozing fluid-Filled vesicles
 Erythema
 Shiny,wet subcutaneous layer after vesicles rupture

Third-degree
 Eschar
 Edema
 Little or no pain

Rule of Nines
Diagnostic test
 Blood chemistry
 ABG Analysis
 24 hour urine collection
 Hematology
 Urine chemistry

Medical Management
 Morphine sulfate and Fentanyl
 Silver sulfadiazine 1%
 Mafenide acetate
 Silver Nitrate 0.5%
 ATS
 TT
 Anxiolytics

Pre hospital Nursing Care


 Remove from source of burns
 Apply cool water,Never Apply ice directly
 Cover the wound with sterile dressing
 Do not Apply ointments
 Assess ABC,s
 Conserve body heat
 Transport

Nursing Management

Emergent phase
 Onset of injury-24-36 hours.
 Priorities:
 First Aid
 prevention of shock
 respiratory distress
 wound assessment and initial care.
Acute Phase
 48-72 hours after burn injury.
 Priorities:
 Maintain ABC,Fluid and electrolytes.
 prevent infection
 Wound Care
 Manage pain
 Provide adequate Nutrition
Rehabilitation phase
 Begins Immediately after burns and extends for years
 Priorities:
 Wound Healing
 Psychological support
 Restore maximal functional activities
 Maintain fluid and electrolytes balance
 Maintain nutritional intake
Nursing Management
 Administer oxygen and maintain patent airway
 Administer I.V fluids as directed
 Assess for signs of hypovolemia
 Assess respiratory status and fluid balance
 Assess pain level and neurovascular status
 Administer analgesics as prescribed and evaluate response
 Monitor V/S,I/O
 Maintain patient’s diet;withhold food and fluids as ordered
 Provide suctioning,Turning,coughing deep breathing exercises
 Provide tracheostomy care and ET care as indicated
 Administer TPN
 Encourage verbalization of feelings
 Allay patient’s anxiety
 Provide emotional support
 Elevate affected extremities
 Provide ROM exercises
 Maintain warm environment
 Provide skin and mouth care

Surgical Interventions
 Skin grafting
 Tissue debridement
 Escharotomy
Complications
 Hypovolemic shock
 Septicemia
 Acute respiratory failure
 Multiple organ dysfunction

Clinical Decision Making Study Guide


 Encourage Health care professionals to focus on individual patients perceptions of disease
impact and disease activity Measures.
 Maintain Aseptic/sterile technique during wound care
 Adherence to diet, medication and treatment regimen
 Avoid wearing restrictive clothing
 Observe for signs of complications
 Emphasize the importance of follow up check up.

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