XAVIER UNIVERSITY ATENEO DE CAGAYAN

DEPARTMENT OF NURSING

GROUP III: CASE STUDY ANALYSIS

In Partial Fulfillment for the Requirements of

NSG 10 Anatomy & Physiology

Submitted to:
Alan Elmer G. Celesios, RN, MN, MAN

Submitted by:
Eula Judea A. Bagayas

Lyka Mikaella C. Guitarte

Aleks Jimenez

Joram Ray B. Obiedo

Peachy C. Pagapong

Stephanie F. Sarmiento

Stephanie T. Torillas

Kristofer Dan A. Trugillo

Carille Diane I. Vergara

August 1, 2020
 Case Study Analysis
Case Number 2: Burns

Mr. X, a 27-year old male is involved in a gasoline

explosion, sustaining burns to the face, neck, chest and
arms. Upon arrival at the emergency room, he complains of
intense pain in the face and neck, while exhibiting extensive
blistering and erythema. These findings are all curiously
absent on the burned chest and arms, which have a pale,
waxy appearance. Examination reveals the skin on the
patient’s chest and arms are leathery in texture and without
sensation, including pain. The emergency room physician
comments to an observing medical arts student that third-
degree burns are present on the skin of these regions and
that excision of the burn eschar (traumatized tissue) with
subsequent skin grafting will be required.

Study Questions:

1. What are the main functions of the integumentary system?

What most people know about the skin or integumentary system is just the fact that
it is the covering of the human body, but what they do not exactly know are the important
functions it provides to the body that go beyond appearance. The main functions of the
body’s integumentary system include the following:

 Protection
The skin functions or serves as human beings’ defense and protection against
the external environment most especially from the ultraviolet sunlight.

 Sensation
The skin has the ability to sense change in the environment or has the ability to
detect temperature such as heat and cold, touch, deep pressure, pain, or anything.

 Regulation of temperature
The human body’s temperature is being regulated by the skin through the
release of sweat glands and the amount of blood flow or supply beneath the
surface of the skin.

 Production of Vitamin D
The epidermal layer of the skin has the ability to synthesize Vitamin D after
being exposed to the sun, which is a very essential vitamin because it functions as
a regulator of calcium and phosphate in the human body.

 Excretion
The waste products that we lose or excrete everyday are done through the skin
and in gland secretions.
 2. Given what you know about the Mr. X’s burns, which 2-3 functions of the skin
are most in danger?

Given that Mr. X suffered a third-degree burn, which destroyed his epidermis and
dermis, we have inferred that the functions that were most in danger were particularly:

 Skin as a protection barrier

The physical barrier of the skin can be broken with partial or full thickness burn
wounds. With these given severe burns, a hard-avascular eschar may form.

Figure 1: An eschar

An eschar is a slough or piece of dead tissue that is casted off from the surface of the
skin, particularly after a burn injury. The eschar provides its own environment wherein
the environment itself is prone to microbial growths of bacteria and can spread easily
thus having a skin infection. Additionally, an eschar makes the regeneration process of
the burned skin complicated because the eschar prevents the antibodies and antibiotics
in reaching the wound site.

 Skin as the regulator of fluid loss

The main function of one’s skin is to regulate fluid loss due to evaporation whereas
the waterproof layer of the skin further prevents dehydration wherein the water is
unable to leave the body through the means of passing throughout the skin. In line with
this, if large areas of the skin are burned especially in the case of Mr. X, the risk of
hypovolemia or the decrease in blood volume can rise substantially which can send Mr. X
into a shock. This hypovolemic shock is a life-threatening medical emergency wherein
during this inflammatory response of the burned skin, there is a fluid loss that can cause
a sharp and potentially a deadly drop in blood pressure in which the fluid becomes
trapped inside the body, leading to swelling known as edema. If tissues and organs do
not receive enough oxygen because of the shock, they suffer damage and can fail whereas
the lungs, heart, brain, and kidneys are highly susceptible.

This was further supported by the study of William et.al (2012) entitled, “Changes in
Cardiac physiology after severe burn injury’’ where he and his co-researchers stated that
the chronic cardiac stress resulted from the shock is usually experienced by patients from
the day that they were admitted to the hospital where it lasted for 2 years. With this in
mind, the heart rate, cardiac output and cardiac index from the burned patients showed
elevation from the normal ranges, which indicated a cardiac stress.
  Skin as regulator of the body temperature

One of the many aspects of the care of the burn patient that must be monitored is the
regulation of body temperature. Burned patients have lost their ability to maintain their
body temperature. The skin plays an important role in the regulation of body
temperature and protecting it from sudden temperature changes wherein the human
body needs to be kept at an optimum operating temperature in order for its cells to
perform properly. In deep second degree and in third degree burns, the sweat glands will
be destroyed and will not be replaced by new ones as the skin heals. Thus, these patients
such as Mr. X will often have difficulty in humid and hot situations because of the
destruction of sweat glands, which play a role in regulating the body temperature.

Because the evaporation of sweat is the body’s primary mechanism for heat loss, it is
believed that hypothermia would be a problem for most burned patients whereas
hypothermia is a medical emergency that occurs when your body loses heat faster than
it can produce heat, causing a dangerously low body temperature. Patients with severe
burns are prone to hypothermia due to the loss and degradation of skin particularly a
large component of thermoregulation in the body.

3. Given the severity of Mr. X’s burns, label or note, which structures of the skin
may be damaged.

Basing on the severity of Mr. X’s burns, it highly shows a second-degree burn around
the face and neck whilst the chest and arm area shows a third-degree burn or known as
the full-thickness burn. In addition, the structures that may be damaged are the
epidermal, dermal structures and possibly some underlying tissues like subcutaneous
tissue.

Figure 2: The structures damaged are epidermis,

dermis and underlying tissues like subcutaneous tissue

4. Why does he feel pain on the face and the neck but not the chest and arms?
The reason why he was able to feel pain on his face and neck was due to the depth
of the burn.
 Examination Given Results

Face and Neck Chest and Arms

Extensive Blistering Pale waxy appearance

Erythema Leathery

Table 2: The particular appearance of the burnt areas

Based on the characteristics and appearance of the burnt areas, his face and neck
suffered from a second-degree burn, the depth is described as a superficial partial
thickness burn, while his chest and arms suffered from a third – degree burn, the depth
described as a full thickness burn.

Second Degree Burns have a superficial depth since it only damages the epidermis
and the upper dermis (papillary layer). Since the epidermis is affected, keratinocytes
(cells in the epidermis) triggers an immune response, activating immune cells such as
mast cells and macrophages, which will then secrete proinflammatory cytokines, a type
of signaling molecule, which stimulate nerve endings around the dermis affecting
nociceptors. Thus, a painful sensation is felt around the burnt area.

Figure 3: Second Degree burns

The reason by its appearance is that some cytokines will cause an increase on vascular
permeability. This makes fluid leak out which can result to hypotension or accumulate in
one area causing what we see now as a blister on the skin surface. This also can rupture
releasing fluid on the damaged area resulting in a moist appearance

Figure 4: Third Degree burns

 On the other hand, the reason why he was not able to feel pain on the chest and arm
area is that it was a third-degree burn. Since the depth is classified as a full thickness burn,
the damage extends all the way down to the hypodermis damaging the blood vessels
causing a dry non-blanching surface and inelastic resulting in a leather like appearance.
The damage on the area further extends on the reticular layer of the dermis destroying
nociceptors, which are the pain receptors, and other sensory nerve fibers. Thus, Mr. X
cannot feel pain or any sensation at all in the chest and arm area. Initially, pain can be
detected but as sensory nerve fibers are damaged, it results to hypoesthesia causing a
reduction in sensation.

5. Why was his skin blistering and showing erythema?

Based on the classification of burn by the depth and clinical feature, Mr. X’s skin was
showing signs of blistering and erythema due to a second-degree burn. With that being
said, second-degree burns are much more serious as it damages the top layer of skin
wherein this type of burn involves the epidermis and part of the dermis layer of skin that
cause the skin to blister and become extremely red and sore as part of the healing process.
In this sense, erythema is the redness of the skin, which is also known as the mucous
membranes, caused by hyperemia in superficial capillaries. In line with this, the most
common things Mr. X may notice at first are skin redness, pain, and swelling whereas
blisters often form to cover the burned area of the body to protect it from infections. As
white blood cells arrive to attack the bacteria, it is expected that a new layer of skin may
grow on the edges of the burn wherein these processes help the burn heal quicker.

Figure 5: (a). Erythema (b). Blisters

6. Why will skin grafting be required on the chest and arms but probably not on the
face and neck?

Given the absence of sensation and pain, we can infer that the chest and arms
encountered a third-degree burn or full-thickness burn wherein it conceptualizes that
both the epidermis and the dermis layer are completely destroyed. In this sense, unlike
the injuries found at the face and neck where partial-thickness burns are evident, it does
not have the stratum basale anymore where the epithelial stem cells are located to enable
regeneration nor does it have the epithelial tissue in hair follicles and sweat glands to
support healing due to the fact that the dermis layer is no longer present. With nothing
else to start from the site of injury, we can highly resort to skin grafting where the
epidermis and dermis are removed from another part of the body and then placed over
the burn. With this manner, this allows interstitial fluid from the burn to nourish the graft
until blood vessels can grow into it and allow recovery.

REFERENCES

BC Open Textbooks. (2013, March 06). Functions of the Integumentary System. Retrieved July 31,
2020, from https://opentextbc.ca/anatomyandphysiology/chapter/functions-of-the-
integumentary-system/

Heller JL. (2017, September 5). Burns. Retrieved July 30, 2020, from
http://www.nlm.nih.gov/medlineplus/ency/article/000030.htm

Medical News Today. (n.d.). Second-degree burn: Causes, symptoms, and treatment. Retrieved July
30, 2020, from https:// www.medicalnewstoday.com/articles/325189

University of Rochester Medical Center. (n.d.). Health Encyclopedia. Retrieved July 30, 2020 from
https://www.urmc.rochester.edu/encyclopedia/content.aspx?ContentTypeID=90

Villines Z. (n.d.). Second-degree burn: Causes, symptoms, and treatment. Retrieved July 30, 2020, from
https://www.medicalnewstoday.com/articles/325189

Williams. 2008. Parkland formula - fluid resuscitation in burns patients. Retrieved from:
https://www.nursingtimes.net/clinical-archive/accident-and-emergency/parkland-
formula-fluid-resuscitation-in-burns-patients-1-using-formulas/1060595.article