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Cavite State University
Don Severino de Las Alas Campus Indang, Cavite
S.Y. 2012 - 2013
Submitted by HERNANDEZ, DARREL JESUS M. GROUP 4B BSN 4-2
Submitted to NORMIDIA QUION, RN, MAN Clinical Instructor
October 8, 2012
The anatomy of the skin is complex. Burns are categorized as thermal (which includes electrical burns). Burns are caused by a transfer of energy from a heat source to the body. and there are many structures within the layers of the skin. 1 second of contact with hot tap water at 68. Deep tissues. compromised immunity. Fifteen seconds of exposure to hot water at 56. If enough skin area is injured. or full-thickness injuries. and changes in function. Burn depth determines whether . Tissue destruction results from coagulation.9°C (156°F) may result in a burn that destroys both the epidermis and the dermis. For example. made up of collagen and elastic fibers and where nerves. CLASSIFICATION OF BURNS Burn injuries are described according to the depth of the injury and the extent of body surface area injured. its depth. causing a fullthickness (third-degree) injury. where larger blood vessels and nerves are located. Temperatures less than 111°F are tolerated for long periods without injury. in the case of scald burns in adults. Hypodermis or subcutaneous tissue. 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. deep partial-thickness injuries. Burn Depth Burns are classified according to the depth of tissue destruction as superficial partial-thickness injuries. can be damaged by electrical burns or through prolonged contact with a heat source. Disruption of the skin can lead to increased fluid loss. and how much body surface area that it involves. including the viscera. Dermis. protein denaturation. the outer layer of the skin 2.BURNS The skin has an important role to play in the fluid and temperature regulation of the body. Epidermis. 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. radiation. hypothermia. The depth of the injury depends on the temperature of the burning agent and the duration of contact with the agent. or chemical. and body image. The skin and the mucosa of the upper airways are the sites of tissue destruction. and hair follicles reside. sweat glands. appearance. blood vessels.1°C (133°F) results in a similar full-thickness injury. scarring. There are three layers: 1. 3. Heat may be transferred through conduction or electromagnetic radiation. infection. or ionization of cellular contents.
brown. or black. appears red. and exudes fluid. In a superficial partial-thickness burn. Moreover. as in sunburn. hair follicles and sweat glands are destroyed (Fig. Determining burn depth can be difficult even for the experienced burn care provider. in some cases. The wound appears leathery. 57-1).epithelialization will occur. Capillary refill follows tissue blanching. Deep partial-thickness burns take longer to heal and are more likely to result in hypertrophic scars. A burn is also a break in the skin. The following factors are considered in determining the depth of the burn: • How the injury occurred • Causative agent. Wound color ranges widely from white to red. . A full-thickness burn involves total destruction of epidermis and dermis and. underlying tissue as well. or it may blister. inflammation and fluid accumulation in and around the wound occur. The damaged skin may be painful and appear red and dry. The wound is painful. The burned area is painless because nerve fibers are destroyed. and the risk of infection exists both at the site of the injury and potentially throughout the body. 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. A deep partial-thickness burn involves destruction of the epidermis and upper layers of the dermis and injury to deeper portions of the dermis. Hair follicles remain intact. it should be noted that the skin is the body's first defense against infection by microorganisms. the epidermis is destroyed or injured and a portion of the dermis may be injured.
. Often the entry and exit points for the electrical shock may not be easily found. Ammonia is a common alkali found in the home. Nerves and muscles are "wired" for this task and often are damaged. or sulfuric acid. Bases or alkali compounds have a pH greater than 7. brown. blisters. If significant muscle damage occurs. Burns that extend deeper may cause permanent injury and scarring and not allow the skin in that area to return to normal function. Electricity flows more easily through tissues in the body that are designed to deal with electricity. muscle fibers and chemicals can be released into the bloodstream causing electrolyte disturbances and kidney failure. hydrochloric acid.Only the epidermis has the ability to regenerate itself. Chemical burns may be classified by their pH or acidity. What about chemical burns? Burns can also occur when chemicals are spilled onto the body and generate a reaction that creates heat. flaking or peeling within 2-3 days Mild pain 3-5 days Cherry red. and bone Color Skin Surface Pain Healing Period Pink or red/erythema Dry. Acids are those with pH less than 7 and include common household compounds like acetic acid. black or marble white Charred dry leathery tissue formation No pain Grafting needed 4TH DEGREE Deep Penetration Including fat. muscle. 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. or white and mottled Moist. 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.
the Lund and Browder method. among them are the rule of nines. if both legs (18% x 2 = 36%). the total area of the burn is significant. and the palm method. Burns are measured as a percentage of total body area affected. What is the significance of the amount of body area burned? In addition to the depth of the burn. 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. the groin (1%) and the front chest and abdomen were burned. this would involve 55% of the body. though this measurement is adjusted for infants and children. The "rule of nines" is often used. .EXTENT OF BODY SURFACE AREA INJURED Various methods are used to estimate the TBSA affected by burns.
the face. as the burn progresses. LUND AND BROWDER METHOD A more precise method of estimating the extent of a burn is the Lund and Browder method. The size of the patient’s palm is approximately 1% of TBSA. fingers. PALM METHOD In patients with scattered burns. the same constriction may not allow blood flow and put the survival of the extremity at risk. These burns hurt due to severed and exposed nerve endings and they generally blister. muscles. mouth or neck. Hemodynamic changes can also cause systemic problems. the tissue involved may not allow enough motion of the chest wall to allow adequate breathing to occur. like the palm of the hand. which can destroy tissue and increase the burn thickness. nerve endings. but they heal because epithelial cells are not actually destroyed. If circumferential burns occur to arms. If there are circumferential burns to the chest. penetrating only the epidermis or deep partial thickness with epidermal and dermal involvement. How important is the location of a burn? Burn location is an important consideration. which become edematous. Local sepsis is likely. Deeper full thickness burns destroy the epidermis. preventing full range of motion of the body area. The patient may go into burn or hypovolemic shock from fluid leaking into the area tissues. Physiologically the first reaction to a burn is vasoconstriction of capillaries followed by vasodilation and discharge of plasma. dry scab made of denatured protein develops over the injured area. the back of the knee. the skin may scar and shorten. Pathophysiology Burns are generally characterized in terms of their thickness. clotting may occur. a method to estimate the percentage of burn is the palm method. and bone. and changes with growth. and the groin may need specialized care. nose. and sometimes subcutaneous tissue. there is a risk that there will be enough inflammation and swelling to obstruct the airway and cause breathing problems. Partial thickness burns are either superficial. The initial evaluation is made on the patient’s arrival at the hospital and is revised on the second and third post-burn days because the demarcation usually is not clear until then. An eschar or thick. . By dividing the body into very small areas and providing an estimate of the proportion of TBSA accounted for by such body parts. which recognizes that the percentage of TBSA of various anatomic parts. or toes. and metabolism steps up. As the burn matures. and there is considerable fluid and heat loss. dermis. legs. Within a few days cells die. especially the head and legs. If the burn involves the face. one can obtain a reliable estimate of the TBSA burned. Burns to areas of the body withflexion creases.
increasing redness. or genitals. then follow these steps until medical personnel arrive: o Keep your child lying down with the burned area elevated. For any burn that appears to cover more than 10% of the body. as it may cause more destruction to the injured skin). or red streaking of the skin near the wound). Apply aloe gel or cream to the affected area. hands. cold compress on the burn for approximately 3-5 minutes (do not use ice. The burn may be dressed with a topical antibiotic ointment like Bacitracin or Neosporin.and Third-Degree Burns: Seek emergency medical care. This may be done a few times during the day. joint surfaces. Tetanus immunization should be updated if needed. an electrical wire or socket. And don't use wet compresses or ice because they can cause the child's body temperature to drop.or third-degree burn. Run cool (not cold) water over the burned area (if water isn't available.First aid for burns Seek Medical Help Immediately When: You think your child has a second. Do not apply butter. any cold. The burn looks infected (with swelling. 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. keep it clean. call for medical assistance. The burn comes from a fire. For First-Degree Burns: Remove the child from the heat source. pus. as these can be a choking hazard). even if it seems like a minor burn. or any other remedies to the burn. . The burned area is large (2-3 inches in diameter). If the area affected is small (the size of a quarter or smaller). soft cloth or towel. Give your child acetaminophen or ibuprofen for pain. drinkable fluid can be used) or hold a clean. powder. grease. cover the area with a clean. For Second. Instead. scalp. Remove clothing from the burned area immediately. or chemicals. as these can make the burn deeper and increase the risk of infection. Refer to the dosing guidelines on the label according to your child's age or weight. The burn is on the face.
Call for medical assistance. Chemical burns to the mouth or eyes require immediate medical evaluation after thorough flushing with water. For chemical burns. Although both chemical and electrical burns might not always be visible. flush the area with lots of running water for 5 minutes or more. you may need to cut it off or wait until medical assistance arrives. . Remove smoldering clothing and any jewelry around the burned area. then follow instructions for second. If the burned area from a chemical is small. Cover him or her with a blanket or jacket. and call your doctor. apply a sterile gauze pad or bandage. Symptoms may vary. Remove all jewelry and clothing from around the burn (in case there's any swelling after the injury). flush for another 10-20 minutes. As you continue flushing the burn. If the burned area is large. Do not remove any of your child's clothing before you've begun flushing the burn with water.o o Follow the instructions for first-degree burns. then cover the area with a clean dry cloth or sheet until help arrives. or a garden hose. depending on the type and severity of the burn and what caused it and may include abdominal pain. shower. Apply cool water over the area for at least 3-5 minutes. you can then remove clothing from the burned area.and third-degree burns. except for clothing that's stuck to the skin. If you're having difficulty removing clothing. or you also may get shocked. buckets of water. they can be serious because of potential damage to internal organs. For Flame Burns: Extinguish the flames by having your child roll on the ground. For Electrical and Chemical Burns: Make sure the child is not in contact with the electrical source before touching him or her. o o Do not break any blisters. use a tub.
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 You’re Key to Exam Success Brunner and Suddarth’s Textbook of Medical – Surgical Nursing Internet Kid’s Health .medicinenet.http://www.html# Medicine Net .http://kidshealth.com/burns .org/parent/firstaid_safe/emergencies/burns.
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