CHAPTER I

INTRODUCTION

A. BACKGROUNDA burn is a type of injury to flesh or skin caused by heat, electricity, chemicals, friction, or radiation. Burns that affect only the superficial skin are known as superficial or first-degree burns. When damage penetrates into some of the underlying layers, it is a partial-thickness or second-degree burn. In a full-thickness or third-degree burn, the injury extends to all layers of the skin. A fourth-degree burn additionally involves injury to deeper tissues, such as muscle or bone.

The treatment required depends on the severity of the burn. Superficial burns may be managed with little more than simple pain relievers, while major burns may require prolonged treatment in specialized burn centers. Cooling with tap water may help relieve pain and decrease damage; however, prolonged exposure may result in low body temperature. Partial-thickness burns may require cleaning with soap and water, followed by dressings. It is not clear how to manage blisters, but it is probably reasonable to leave them intact. Full-thickness burns usually require surgical treatments, such as skin grafting. Extensive burns often require large amounts of intravenous fluid, because the subsequent inflammatory response causes significant capillary fluid leakage and edema. The most common complications of burns involve infection.

While large burns can be fatal, modern treatments developed since 1960 have significantly improved the outcomes, especially in children and young adults. Globally, about 11 million people seek medical treatment, and 300,000 die from burns each year. In the United States, approximately 4% of those admitted to a burn center die from their injuries. The long-term outcome is primarily related to the size of burn and the age of the person affected.

B. PURPOSE1. General Purpose

Getting a real picture of the nursing care of burns thoroughly

2. Special Purposea. Knowing the medical concept of burnsb. Knowing the nursing concept of burns

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CHAPTER II

DISCUSSION

A. MEDICAL CONCEPT1. Defenition

Burns are caused by a transfer of energy from a heat source to the body. The depth of the injury depends on the temperature of the burning agent and the duration of contact with it (Brunner & Suddarth’s).

2. Classificationsa. First-degree burn.

This minor burn affects only the outer layer of the skin (epidermis). It causes redness and pain and usually resolves with first-aid measures within several days to a week. Sunburn is a classic example.

b. Second-degree burn. These burns affect both the epidermis and the second layer of skin (dermis), causing redness, pain and swelling. A second-degree burn often looks wet or moist. Blisters may develop and pain can be severe. Deep second-degree burns can cause scarring.

c. Third-degree burn. Burns that reach into the fat layer beneath the dermis are called third-degree burns. The skin may appear stiff, waxy white, leathery or tan. Third-degree burns can destroy nerves, causing numbness.

d. Fourth-degree burn. The most severe form of burn affects structures well beyond the skin, such as muscle and bones. The skin may appear blackened or charred. If nerve damage is substantial, you may feel no pain at all.

3. Etiologya. Thermal burns

Result from contact with hot substances that cause cell injury by coagulation, including flame, hot liquids, hot solid objects, and steam. The longer the skin is in contact with these hot substances the deeper the wound. Oil-based liquids such as grease and cooking oil have higher boiling points, and cause deeper burns than scalds with water or other liquids. Burns from hot solid objects such as solid metal, hot plastic, glass, or stone are all considered thermal burns.

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b. Chemical burnsDestroy tissue and continue to do damage up to 72 hours unless neutralized. Causes of chemical burns are strong acids, alkalis, and organic compounds. Acids are commonly found in household cleaners such as rust removers and bathroom cleaners, and cause protein coagulation, which results in less extensive injuries. Alkalis such as oven cleaners and fertilizers cause deeper burns due to liquefaction necrosis of tissue, which lets the chemical penetrate deeper into tissues. Organic compounds that cause chemical burns include gasoline and chemical disinfectants, which can cause severe coagulation necrosis and produce a layer of thick, nonviable tissue called eschar, which is normally present in full-thickness burns.

c. Electrical burnsElectrical burns are classified as low voltage (under 1,000 volts) or high voltage (1,000 volts or higher). Electrical injuries can cause death by producing ventricular fibrillation or paralysis of the respiratory muscles; dysrhythmias can occur with low voltage, but are more commonly seen in high-voltage injuries. The extent of damage from an electrical burn may initially appear minor—the patient may only have small entry and exit wounds. Extensive damage can appear within several days to weeks, a phenomenon known as the iceberg effect because the skin surface shows little injury and hides massive injury beneath. Instead of conducting the electricity, bones, muscle, tendon, and fat respond to electrical injury by producing heat. Most injuries occur to muscles surrounding the long bones.

d. Radiation burnsResult from exposure to sunlight, tanning booths, X-rays, or nuclear emissions or explosions. Ionizing radiation can produce tissue damage directly by striking a vital molecule such as DNA. Sunburn is usually a first-degree or superficial burn, but radiation therapy can cause full-thickness burns.

e. Smoke and inhalation burnsCan occur concurrently with thermal or chemical burns. If the patient has thermal burns, the signs of inhalation burns are facial burns, hoarseness, soot in the nose or mouth, carbon in the sputum, lip edema, and singed eyebrows or nasal hair. Manufacturing of illegal methamphetamine can cause thermal and chemical burns and associated inhalation burns. Regardless of the cause of the inhalation injury, the patient needs immediate respiratory interventions such as bronchoscopy, endotracheal intubation, and measurement of carboxyhemoglobin (COHgb) levels.

f. FrostbiteFrostbite is temporary or permanent tissue damage resulting from exposure to very cold temperatures. Any area left uncovered in very cold temperatures can

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become frostbitten, but the most commonly affected areas are the fingers, toes, chin, earlobes, cheeks, and nose.Blood flow to the skin's outer layer is reduced and the skin tissue freezes and begins to die. Without treatment, frostbite can progress to necrosis, gangrene, hypothermia, and cardiac arrest. Because frostbite causes damage to the skin, some patients are treated in the ICU as burn patients, although initial treatment for frostbite is different than that for burns.

4. Risc Factora. Highest rates are seen in children under the age of 5 and the elderly over the

age of 75. b. About 50% of burns and scalds occur in the kitchen.

5. Pathophysiological conceptBurns caused by the transfer of energy from a heat source to the body. Heat

can be transferred through conduction or radiation electromagnetic. Burns can be classified into thermal burns, radiation burns and chemical burns.

The first result was a shock burns with shock and pain.  Capillaries exposed to high temperatures damaged and permeability rising. Blood cells in it were damaged so that it can happen anemia. The increased permeability causing edema and cause bullae containing electrolytes. It leads to reduced intravascular fluid volume. Skin damage from burns caused fluid loss due to excessive evaporation, infiltration of liquids into the bull formed on the second-degree burns, and the discharge of scab third degree burns.

If the burn area is less than 20%, usually mechanism compensation body is still able to handle it, but if more than 20%, will hypovolemic shock occurs with typical symptoms such as restlessness, pallor, cold, sweaty, small and fast pulse, blood pressure decreased, and reduced urine production. Swelling occurs slowly, the maximum occurred after 8 hours

6. Burn PercentageThe rule of nines assesses the percentage of burn and is used to help guide treatment decisions including fluid resuscitation and becomes part of the guidelines to determine transfer to a burn unit.

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7. Clinical manifestationa. Pain

Pain is immediate, acute and intense with superficial burns. It is likely to persist until strong analgesia is administered. With deep burns there may be surprisingly little pain.

b. Acute anxietyThe patient is often severely distressed at the time of injury. It is frequent for patients to run about in pain or in an attempt to escape, and secondary injury may result.

c. Fluid loss and dehydrationFluid loss commences immediately and, if replacement is delayed or inadequate, the patient may be clinically dehydrated. There may initially be tachycardia from anxiety and later a tachycardia from fluid loss.

d. Local tissue oedemaSuperficial burns will blister and deeper burns develop oedema in the subcutaneous spaces. This may be marked in the head and neck, with severe swelling which may obstruct the airway. Limb oedema may compromise the circulation.

e. ComaFollowing house fires, the patient may be unconscious and the reason for this must be ascertained. Asphyxiation or head injury must be excluded. Burning furniture is particularly toxic and the patient may suffer from carbon monoxide or cyanide poisoning.

8. MedicationDepending on the severity of your burn, you may require: a. Intravenous (IV) fluidsb. Pain relieversc. Burn creamsd. Antibiotics

9. ComplicationDeep or widespread burns can lead to many complications, including: a. Infectionb. Low blood volume (hypovolemia)c. Dangerously low body temperature (hypothermia).d. Breathing (respiratory) problemse. Scarringf. Bone and joint problems

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10. Diagnostic testBasic laboratory tests include the following:a. Complete blood count (CBC) and Arterial blood gas (ABG) analysis,b. Urea and Electrolytes (U&E)c. Prothrombin time (PT) / Partial thrombin time (PTT) and International

Normalized Ration (INR),d. Sputum Culture and Sensitivity,e. Creatine Kinase (CK) and C-reactive protine (CRP),f. Blood glucose,g. Urine drug test,h. Human chorionic gonadotropin (B-HCG): if the patient is female,i. Albumin test.j. Thyroid values and myoglobin measures.

11. PreventionThe best way to fight burns is to prevent them from happening altogether. Certain jobs put you at a greater risk for burns, but the fact is that most of them happen at home. Infants and young children are the most vulnerable to burns. Here are some tips for the preventive measures you can take:a. Keep children out of the kitchen while cooking.b. Turn pot handles towards the back of the stove.c. Place a fire extinguisher near the kitchen.d. Test smoke detectors once a month.e. Replace smoke detectors every 10 years.f. Keep water heater temperature under 120 degrees Fahrenheit.g. Measure bath water temperature before use.h. Lock up matches and lighters.i. Install electrical outlet covers.j. Check and discard electrical cords with exposed wires.k. Keep chemicals out of reach, and wear gloves during chemical use.l. Wear sunscreen every day, and avoid peak sunlight. m. Ensure all smoking products are stubbed out completely.n. Clean out dryer lint traps regularly.

B. NURSING CONCEPT1. Assessment

The emergency management of a patient with a burn injury begins with the initial assessment and treatment of life-threatening injuries. Stabilize the patient's cervical spine if this hasn't already been done. The true mechanism of injury may not be clear (for example, the patient may have been burned and propelled in an explosion).Follow these specific aspects of the ABCDE (Airway, Breathing, Circulation, Disability, and Exposure/Environmental control)

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a. AirwayThe airway is the primary concern, especially if a patient has an inhalation injury. Assess for stridor (an ominous sign that suggests the patient's upper airway is at least 85% narrowed), facial burns, soot in the nares or mouth, singed facial hair or nasal hair, edema of the lips and oral cavity, coughing, hoarse voice, and circumferential neck burns

b. BreathingDetermine adequacy of ventilation by assessing the patient's respiratory rate and depth and observing for dyspnea and adventitious breath sounds. Obtain a pulse oximetry reading (remembering that it may be inaccurate in the presence of carbon monoxide), and a co-oximetry reading if indicated and available.

c. CirculationAssess for the presence, rate, and rhythm of pulses, evaluate capillary refill time, skin color, and temperature; and observe for obvious arterial bleeding.

d. DisabilityUse the AVPU (Alert, Verbal, Pain stimuli, Unresponsive) Scale (see A look at the AVPU scale) to determine the patient's level of consciousness and carefully evaluate any abnormalities. Assess for hypoxia, decreased cerebral perfusion related to hypovolemia, and cerebral injury resulting from head trauma. Assess the patient's pupillary response to light and sensory and motor function.

e. Exposure/environmental controlGently remove the patient's nonadherent clothing and jewelry to prevent continued tissue damage. If the patient's face is burned, remove glasses or contact lenses. Cover the patient with a dry sterile sheet to prevent further contamination of the burn wounds and to provide warmth.

2. Nursing Diagnosisa. Acute Pain, related to :

1) Destruction of skin/tissues; edema formation2) Manipulation of injured tissues, e.g., wound debridement

b. Impaired Physical Mobility, related to :1) Neuromuscular impairment, pain/discomfort, decreased strength and

endurance2) Restrictive therapies, limb immobilization; contractures

c. Disturbed Body Image, related to:Situational crisis: traumatic event, dependent patient role; disfigurement, pain

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d. Anxiety, related to :Situational crises: hospitalization/isolation procedures, interpersonal transmission and contagion, memory of the trauma experience, threat of death and/or disfigurement

e. Impaired Skin Integrity, related to :Disruption of skin surface with destruction of skin layers (partial-/full-thickness burn) requiring grafting

f. Knowledge Deficit, related to :1) Lack of exposure/recall2) Information misinterpretation; unfamiliarity with resources

3. Nursing plansa. Acute Pain, related to :

1) Destruction of skin/tissues; edema formation2) Manipulation of injured tissues, e.g., wound debridement

Desired Outcomes:1) Report pain reduced/controlled.2) Display relaxed facial expressions/body posture.

Nursing Intervention RationalAssess reports of pain, noting location and character and intensity (0–10 scale).

Encourage use of stress management techniques: progressive relaxation, deep breathing, guided imagery, and visualization.

Elevate burned extremities periodically.

Change position frequently and assist with active and passive

Pain is nearly always present to some degree because of varying severity of tissue involvement and destruction but is usually most severe during dressing changes and debridement. Changes in location, character, intensity of pain may indicate developing complications (limb ischemia) or herald improvement and/or return of nerve function and sensation.

Refocuses attention, promotes relaxation, and enhances sense of control, which may reduce pharmacological dependency.

Elevation may be required initially to reduce edema formation; thereafter, changes in position and elevation reduce discomfort and risk of joint contractures.

Movement and exercise reduce joint stiffness and muscle fatigue, but type of

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ROM as indicated.

Involve patient in determining schedule for activities, treatments, drug administration.

Administer analgesics (narcotic and nonnarcotic) as indicated: morphine; fentanyl (Sublimaze, Ultiva); hydrocodone (Vicodin, Hycodan); oxycodone (OxyContin, Percocet).

exercise depends on location and extent of injury.

Enhances patient’s sense of control and strengthens coping mechanisms.

The burned patient may require around-the-clock medication and dose titration. IV method is often used initially to maximize drug effect. Concerns of patient addiction or doubts regarding degree of pain experienced are not valid during emergent/acute phase of care, but narcotics should be decreased as soon as feasible and alternative methods for pain relief initiated.

b. Impaired Physical Mobility, related to :1) Neuromuscular impairment, pain/discomfort, decreased strength and

endurance2) Restrictive therapies, limb immobilization; contractures

Desired Outcomes:1) Maintain position of function as evidenced by absence of contractures.2) Maintain or increase strength and function of affected and/or

compensatory body part.3) Verbalize and demonstrate willingness to participate in activities.4) Demonstrate techniques/behaviors that enable resumption of activities.

Nursing Intervention RationalNote circulation, motion, and sensation of digits frequently.

Medicate for pain before activity or exercise.

Perform ROM exercises consistently, initially passive, then active.

Edema may compromise circulation to extremities, potentiating tissue necrosis and development of contractures.

Reduces muscle and tissue stiffness and tension, enabling patient to be more active and facilitating participation.

Prevents progressively tightening scar tissue and contractures; enhances maintenance of muscle and joint functioning and reduces loss of calcium

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Encourage family/SO support and assistance with ROM exercises

Encourage patient participation in all activities as individually able.

from the bone.

Enables family/SO to be active in patient care and provides more consistent therapy.

Promotes independence, enhances self-esteem, and facilitates recovery process.

c. Disturbed Body Image, related to:Situational crisis: traumatic event, dependent patient role; disfigurement, pain

Desired Outcomes1) Incorporate changes into self-concept without negating self-esteem.2) Verbalize acceptance of self in situation.3) Talk with family/SO about situation, changes that have occurred.4) Develop realistic goals/plans for the future.

Nursing Intervention RationalAssess meaning of loss or change to patient and SO, including future expectations and impact of cultural or religious beliefs.

Encourage patient and SO to view wounds and assist with care as appropriate.

Give positive reinforcement of progress and encourage endeavors toward attainment of rehabilitation goals.

Show pictures or videos of burn care and/or other patient outcomes, being selective in what is shown as appropriate to the individual situation. Encourage discussion of feelings about what patient has seen.

Encourage family interaction

Traumatic episode results in sudden, unanticipated changes, creating feelings of grief over actual or perceived losses. This necessitates support to work through to optimal resolution.

Promotes acceptance of reality of injury and of change in body and image of self as different.

Words of encouragement can support development of positive coping behaviors.

Allows patient and SO to be realistic in expectations. Also assists in demonstration of importance of and/or necessity for certain devices and procedures.

To opens lines of communication and

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with each other and with rehabilitation team.

Provide referral to reconstructive surgeon for the patient disfigured by burns.

provides ongoing support for patient and family.

Reconstructive surgery can help patient gain self-esteem and confidence.

d. Anxiety, related to :Situational crises: hospitalization/isolation procedures, interpersonal transmission and contagion, memory of the trauma experience, threat of death and/or disfigurement

Desired Outcomes1) Verbalize awareness of feelings and healthy ways to deal with them.2) Report anxiety/fear reduced to manageable level.3) Demonstrate problem-solving skills, effective use of resources.

Nursing Intervention RationalAssess mental status, including mood and affect, comprehension of events, and content of thoughts.

Encourage patient to talk about the burn circumstances when ready.

Explain to patient what happened. Provide opportunity for questions and give honest answers.

Create a restful environment, use guided imagery and relaxation exercises.

Initially, patient may use denial and repression to reduce and filter information that might be overwhelming. Some patients display calm manner and alert mental status, representing a dissociation from reality, which is also a protective mechanism.

Patient may need to tell the story of what happened over and over to make some sense out of a terrifying situation. Adjustment to the impact of the trauma, grief over losses and disfigurement can easily lead to clinical depression, psychosis, and posttraumatic stress disorder .

Compassionate statements reflecting the reality of the situation can help patient and SO acknowledge that reality and begin to deal with what has happened.

Patients experience severe anxiety associated with burn trauma and treatment. These interventions are

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Involve patient and SO in decision making process whenever possible. Provide time for questioning and repetition of proposed treatments.

soothing and helpful for positive outcomes.

Promotes sense of control and cooperation, decreasing feelings of helplessness or hopelessness.

e. Impaired Skin Integrity, related to :Disruption of skin surface with destruction of skin layers (partial-/full-thickness burn) requiring grafting

Desired Outcomes1) Wound Healing: Secondary Intention (NOC)2) Demonstrate tissue regeneration.3) Achieve timely healing of burned areas.

Nursing Intervention RationalAssess and document size, color, depth of wound, noting necrotic tissue and condition of surrounding skin.

Provide appropriate burn care and infection control measures.

Keep skin free from pressure

Wash sites with mild soap, rinse, and lubricate with cream several times daily after dressings are removed and healing is accomplished.

Evaluate color of grafted and donor site, note presence or absence of healing.

Provides baseline information about need for skin grafting and possible clues about circulation in area to support graft.

Prepares tissues for grafting and reduces risk of infection/graft failure.

Promotes circulation and prevents ischemia or necrosis and graft failure.

Newly grafted skin and healed donor sites require special care to maintain flexibility.

Evaluates effectiveness of circulation and identifies developing complications.

f. Knowledge Deficit, related to :

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1) Lack of exposure/recall2) Information misinterpretation; unfamiliarity with resources

Desired Outcomes1) Verbalize understanding of condition, prognosis, and potential

complications.2) Verbalize understanding of therapeutic needs.3) Correctly perform necessary procedures and explain reasons for actions.4) Initiate necessary lifestyle changes and participate in treatment regimen.

Nursing Intervention RationalReview condition, prognosis, and future expectations.

Discuss patient’s expectations of returning home, to work, and to normal activities.

Explain scarring process and necessity for and proper use of pressure garments when used.

Emphasize importance of sustained intake of high-protein and high-calorie meals and snacks.

Review medications, including purpose, dosage, route, and expected and/or reportable side effects.

Provides knowledge base from which patient can make informed choices.

Itching, blistering, and sensitivity of healing wounds or graft sites can be expected for an extended time, and injury can occur because of the fragility of the new tissue.

Promotes optimal regrowth of skin, minimizing development of hypertrophic scarring and contractures and facilitating healing process. Note: Consistent use of the pressure garment over a long period can reduce the need for reconstructive surgery to release contractures and remove scars.

Optimal nutrition enhances tissue regeneration and general feeling of well-being. Note: Patient often needs to increase caloric intake to meet calorie and protein needs for healing.

Reiteration allows opportunity for patient to ask questions and be sure understanding is accurate.

4. Implementation

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Implementation or execution is the initiative of a plan of action to achieve a specific goal. Implementation phase begins after the plan of action in the apartment and continued in nursing orders to help clients achieve the expected goals. The goal of the implementation is to assist clients in achieving the stated goals, which include improving health, disease prevention, health restoration and manifest coping. Planning nursing measures will be implemented properly, if the client has a desire to adapt the implementation of nursing actions. During the implementation phase, the nurse must perform data collection and choose the most appropriate nursing actions to client needs.

5. EvaluationEvaluation is an intellectual action to complete the nursing process that indicates how far nursing diagnosis, plan of action, and the implementation has been achieved.

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CHAPTER III

CLOSE

A. CONCLUSION1. Burns are caused by a transfer of energy from a heat source to the body. The

depth of the injury depends on the temperature of the burning agent and the duration of contact with it.

2. Classifications of burn are first-degree burn, second-degree burn, third-degree burn and fourth-degree burn.

3. Etiology of burn are thermal burns, chemical burns, electrical burns, radiation burns, smoke and inhalation burns and frostbite.

4. There ara 6 nursing diagnosis that may appear in burnsa. Acute Painb. Impaired Physical Mobilityc. Disturbed Body Imaged. Anxietye. Impaired Skin Integrityf. Knowledge Deficit

B. SUGGESTION..............................................................................................................................................................................................................................................................................................................................................................................................................................

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