PKI 5002

Chemical Burn Lecturer : Mdm Kosheila

Group Membersi) PLATINI KAWI (presenter) ii) PUNITHAMALAL A/P NARAYANAN (presenter) iii) ROHAIZA BINTI IBRAHIM (presenter) iv) RITA ANAK SITAM (presenter) v) RAFINAH BINTI ARIFFIN vi) RAZEENA BINTI OSMAN vii) ROHAYU BINTI LIP @ TALIB viii) NURZAWANI HANUM BINTI ZULKARNAIN ix) RENUGA A/P CHENDARASEGARAN x) PREMALATHA A/P KUPUSAMY 01-200901-00406 01-200901-00401 01-200901-00142 01-200901-00405 01-200901-00144 01-200901-00195 01-200901-00459 01-200901-00075 01-200901-00177 01-200901-00071 (Group Leader)

Learning OutcomeAt the end of this group presentation, we will be able to: i) ii) iii) iv) v) vi) vii) viii) ix) x) Define Chemical Burn. . Explain the etiology of Chemical Burn. Explain the pathophysiology Chemical Burn. State the characteristics of Chemical Burn. Identify clinical manifestation for Chemical Burn. Identify Diagnostic Test for Chemical Burn. Discuss the management for Chemical Burn. Discuss the Health Education for Chemical Burn. Discuss the Nursing Diagnosis and Care Plan for Chemical Burn. Discuss the Medication for Chemical Burn.

Chemical burny A chemical burn occurs when living tissue is exposed to a

corrosive substance such as a strong acid or base.y Chemical burns follow standard burn classification and

may cause extensive tissue damage.y The main types of irritant and/or corrosive products are:

acids, bases, oxidizers, solvents, reducing agents and alkyant.

y Chemical burns are commonly seen in the home but especially in the workplace. y The most common categories of toxic chemicals will be described. These chemicals can produce local tissue injury and some have potential to be absorbed resulting in body poisoning. y Toxic chemicals can be in the form of gases, liquids or solids. The gas form typically causes injury through breathing like smoke exposure. y The liquid and solid forms are more likely to cause damage to the skin, with the exception of fuming sulfuric acid, heat or thermal injury play a minor role in chemical burn.

Eti l gySulfuric acid ii) Alkaline iii) Lime powder iv) Tar v) Nitric acid vi) Sodium hydroxide vii) Bleach viii) Metal cleaner ix) Pool chlorinatori)

Nitric acid

Sulfuric acid

Sodium hydroxide

Lime powder

Characteristicy Usually deeper than it looks as the skin is destroyed mainly by chemicals. Appearance is often brown to gray as opposed to the typical white or char with a flame burn. y Continue to get deeper and later appearance is usually worse. y Severe persistent pain is often present indicative of ongoing skin damage. y Chemical toxins like phenol or hydrocarbons like gasoline may cause only skin irritations, but absorption can lead to systemic poisoning.

Burn is caused by a nitric acid spray. A brown discoloration is characteristic. Persistent pain is present.

Hot tar. Note the white area in the exposed wound, indicating the burn to be very deep. Pain is minimal and injury can be easily underestimated.

Note the brownish-gray appearance. Characteristic of a deep skin burn from a strong acid or alkali. Persistent pain is present. Wound usually looks deeper at 24 hours. Burn is Full Thickness.

Sodium hydroxide. Brownish dry appearance indicates the burn is full thickness. Patient did not seek medical attention for 24 hours.

Alkaline Burn eye cause damage of the cornea and other eyes lining.

Splattered alkali burn can cause permanent corneal damage

The asphalt was still hot upon contact. The burn was partial thickness. Initial management is cooling the tar with water then transport to Burn Center due to facial burn. An eye assessment will be needed.

Burned tongue

Pathop sioloy Most acids produce a coagulation necrosis by denaturing proteins,

forming a coagulum (eschar) that limits the penetration of the acid.

y Bases typically produce a more severe injury known as liquefaction

necrosis. This involves denaturing of proteins as well as saponification of fats, which does not limit tissue penetration.

y The severity of the burn is related to a number of factors including :

i) ii) iii) iv) v)

pH of the agent. Concentration of the agent. Length of the contact time. Volume of the offending agent. Physical form of the agent.

Clinical Manifestationy All chemical burns should be considered medical emer encies. y Most chemical burns occur on the face, eyes, and arms and legs. Usually a chemical burn will be relatively small and will require only outpatient treatment. y Chemical burns can be deceivin , however. Some agents can cause deep tissue damage not readily apparent when you first look at it.

Tissue damage from chemical burns depends on several factors : i) The strength or concentration of the agent. ii) The site of contact (eye, skin, mucous membrane). iii) Whether swallowed or inhaled. iv) Whether or not skin is intact. v) With how much of the agent you came into contact. vi) The duration of exposure and how the chemical works.

Signs and symptoms of chemical burns include the following:y Redness, irritation, or burning at the site of contact. y Pain or numbness at the site of contact. y Formation of blisters or black dead skin at the contact site. y Vision changes if the chemical gets into your eyes. y Cough or shortness of breath.

In severe cases, you may develop any of the following:y Low blood pressure. y Faintness, weakness, dizziness. y Shortness of breath or severe cough. y Headache . y Muscle twitching or seizures. y Cardiac arrest or irregular heartbeat.

Chemical burns can be ver unpredictable. Death from a chemical injury, although rare, can occur.

Dia nostic Testy Lab studies depend on the burn type and extent of exposure. y Severe burns :y Electrolytes y Creatinine y BUN y Glucose y Urinalysis y CBC y Creatine phosphokinase y Coagulation profile

y Localized burns - Usually no lab tests required

Hydrofluoric acid burns :y Calcium y Magnesium y Potassium

Ingestions of caustics :y Hemoglobin/hematocrit y Pulse-oximetry or ABG if respiratory symptoms. y Chest radiography if any respiratory symptoms. y Abdominal radiography (flat and upright) if signs of

peritonitis are present. y Endoscopy examination or gastric lavage.

Assessment & Mana ementsAirwa i) Support airway as fumes can cause swelling. Breathin i) Fumes or absorption of toxins cause injury to lungs. ii) Chemical explosions can cause chest damage. iii) Assess and assist breathing . REMEMBER!! DR. ABCDE

Circulationy Assess adequacy of circulation with vital signs, skin color and temperature (Hypovolemic shock is usually not present in the immediate post burn period). y Intravenous catheter indicated mainly for administration of medications. y Removal of constricting objects, like jewelry. y Deep chemical burn can produce constriction of local blood flow similar to thermal burn.

Disability Absorption of some chemicals can lead to impaired brain function. y Seizures. y Unconscious state. y Altered consciousness can also be due to head injury (if explosion). y Assess and document level of consciousness A-V-P-U. y Management based on protocol.

Expose & Examiney Remove clothing and constricting objects.

History Once the ABC s and initial removal of the chemical have been initiated,

further details as to history of the event must be obtained.y Place of exposure (was it enclosed?). y Nature of exposure (spill, fall, explosion?). y Duration of exposure (how long was the chemical exposure before initial

treatment). y What is chemical? (acid, alkaline or hydrocarbon).

Wound Mana ement i) Initial management of the chemical burn has a major impact on outcome. ii) Continuous water irrigation if the area should be initiated use of showers in the workplace is optimum :y Use tepid water if possible, to avoid long exposure to cold or

hot water.y Irrigation for strong acid or alkali exposure is 30-60 minutes.

y Continuous irrigation if eye is exposed to chemicals. y Do not attempt to neutralized acids with alkali or vice versa, just use copious water. y Continue irrigation through transport while maintaining body To . y Solid chemicals should be brushed off first prior to irrigation using safety gloves. y Cover the patient with clean dry sheet or blanket after irrigation stopped.

Pain Mana ementy Water irrigation should begin to decrease pain. y Pain medications (Intravenous administration in small amounts).

E e Injur (Prevention & Treatment)y Permanent eye damage con be prevented if copious, continuous

irrigation with water, saline or Ringer s Lactate . y Remove contact lenses. y Hold eyelids apart and begin gentle, continuous irrigation. y Use if IV bag and tubing provides continuous controlled irrigation.

Phar ac l gy herapyAnalgesics : Morphine sulphate , acetaminophen, ibuprofen. Antibiotics : Silver sulfadiazine, erythromycin ophthalmic ointment (eye). Polyethylene glycol : Skin cream. Anti tetanus toxoid : Prevent tetanus. IV ringer lactate/normal saline/DX 10%.

Complication of chemical Burny Respiratory distress from smoke inhalation or a severe chest burn. y Fluid loss, hypovolaemia and shock. y Infection. y Increased metabolic rate leading to acute weight loss. y Increased plasma viscosity and thrombosis.

y Vascular insufficiency and distal ischaemia from a circumferential burn of limb or digit. y Poisoning from inhalation of noxious gases released by burning (cyanide poisoning due to smoldering plastics). y Haemoglobinurea and renal damage. y Scarring and possible ps cholo ical consequences.

Nursi gi) ii) iii) iv) vi) vii)

iag

sis

Risk for ineffective airway clearance related to esophageal inflammation response. Fluid volume deficit related to active fluid volume loss. Acute and chronic pain related to damaged or exposed nerve ending. Impaired skin integrity related to burn wound or physical immobility. Risk for infection related to inadequate primary defenses. Body image disturbance related to changes in physical appearance and lifestyle.

Nursin Care PlanRisk for ineffective airwa clearance related to esopha eal inflammation response. Goal : To maintain normal airway clearance. i) Assess for sign and symptom of airway obstruction is presence such as difficulty in breathing, cyanosis and client s general condition. ( R ) To assess severity of condition and plan next course of action. ii) Monitor Vital sign hourly especially spo2,bp,pulse and respiration. ( R ) To detect if any abnormalities is presences that indicate respiratory problems. iii) Place client in fowler or semi fowler position. ( R ) To maintain airway patency and promote lungs expansion.

iv) Teach client s how to perform deep breathing exercise. ( R ) To promote appropriate breathing pattern and relaxation. v) Ask client s to inform the nurses or press call bell if any sign and symptom of ineffective airway clearance is occur. ( R ) Early detection and to prevent of any further complication. vi) Administer oxygen therapy as ordered by physician. ( R ) To maintain oxygen saturation and normal gas exchanges. Evaluation : Client s maintain normal breathing pattern evidenced by no sign an symptom of difficulty in breathing during hospitalization.

Fluid volume deficit related to active fluid volume loss. Goal : To maintain normal fluid volume in the body and prevent dehydration. i) Assess client s general condition such as dry skins, sunken eye , orthostatic hypotension and elimination pattern (urine). ( R ) To detect sign and symptom of dehydration and plan the next course of action. ii) Fluid monitoring such as color, quantity and specific gravity of urine. Also Vital sign (BP,pulse ,heart rates,Temp). ( R ) To asses renal function and vital sign for evidence based.

iii) Encourage client s to drink plenty of fluid. ( R ) To increase body fluid volume . iv) Administer IV fluid as ordered by doctor. ( R ) To maintain normal fluid volume, balancing electrolyte level and to restore kidney function. v) Keep accurate record of intake and output. ( R ) To monitor amount of client s intake and output. Evaluation : Client s body fluid volume restore to normal level as evidenced by no sign and symptom of dehydration during hospitalization.

Health Educatii) Practice safety measure at working place/home. ii) Secure all chemicals, in and out of the home, in locked cabinets or out of the reach of children. iii) When using chemicals, always follow directions and safety precautions on the label provided by the manufacturer. iv) Wear safety clothing and eye protection. v) Be alert of your environment. vi) SAFETY FIRST!!

Books:

References

i) Brunner and Suddarth s (2008) Text Book of Medical Surgical Nursing- 11th edition. Volume 1 and 2. ii) Mcgraw Hill International Edition (2008)-Essential of Anatomy and Physiology- 6th edition. iii) Note MUCH (Slide show) Intergumentary systems, Communicable Disease and Autoimmune System. (IPA 4002 ) (Burn). Websites : i) http://en.wikipedia.org/wiki/Chemical_burn ii) http://www.emedicinehealth.com/chemical_burns/article_em.htm