Integumentary System (II)

Burn assessment and wound

dressing / care

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 Upon completion of this laboratory, the
students have to familiarise with:
- the assessment of types / degree / wound
dressing material of burn injury.
- Anticipate nursing care related
- Assessment of inhalation injury (s/s) & shock
- Prepare client for intubation (taught)
- Assessment of haemodynamic state (taught)
- Assessment of renal function (will be taught)

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Timo Kaukonen has lost more than 10 kg. of weight since he was hospitalised for injuries
sustained in the Sauna World Championship competition in August. Since waking up
from his coma, Kaukonen’s mobility has been improving with every passing day.
http://www.youtube.com/watch?v=8642tag4o8I 3
 Burns
Etiology: Thermal, radiation, electrical, and
chemical (acids, bases) burns
Extent of the fluid and electrolyte loss
directly related to extent and degree of the
burn
- 1° (epidermis)
- 2° (superficial + deep partial-thickness)
- 3° (full-thickness) / 4° (full-thickness)

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Lund Browder Chart

Taylor, 20016
 Extent of Burn: TBSA

5 1 0
Rule of Nine Lund and Browder Chart
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Add up all columns and see…

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 Exercise
1. A small child, aged 3, was scald by a glass of
hot water toppled from the edge of the table.
His face, anterior trunk and left arm up to the
shoulder was red and edematous (Lund
Browder formula is used for his assessment).

2. A woman escaped from a burning unit was

found to be burnt on both lower limbs,
perineum and anterior abdomen. Please use
the rule of nine and calculate the TBSA

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 Classification of burns
• Minor burns
• Moderate burns
• Major burns

a) Involvement of hands, face, genitalia, or feet;

b) Extent for PTB
c) Extent for FTB
d) %TBSA
e) age; preexisting chronic health problem;
associated injuries

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 Clinical findings
1. Subjective: SAMPLE history
2. Objective
a) Skin appearance
b) Hematuria
c) ↑ hematocrit
d) Electrolyte imbalance
e) Hypovolemic shock
f) Neurogenic shock
g) Renal impairment
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 Therapeutic interventions
1. Inspect and establish airway; monitor breath
sounds, characteristics of respirations, O2 sat
2. Elevate head of bed and administer oxygen
3. IV replacement - %TBSA; half of fluid in first 8
hours; second half is administered over next 16
hours; hourly urine output monitor by Foley
4. IV during second 24 hours depends on urinary
output, blood work, and hemodynamic readings
5. Insertion of central line (e.g. CVP)
6. Vital signs monitored every 15 minutes
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 Therapeutic interventions (cont’d)
7. Monitor serum electrolytes and ABGs
8. Tetanus toxoid booster A.T.T.I. (tetanus human
immune globulin for passive immunity)
9. NPO for first 24 to 48 hours; clear liquids  high
protein, high CHO, high fat, high vitamin diet
as tolerated after 2 days
10. Observe for stress ulcer
11. Surgical asepsis + PPE
12. Daily hydrotherapy [tepid at 37.8°C]
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 Exercise 2
Calculate the volume required in the 1st 24 hours
and rate mL/hr of Lactated Ringer to be infused
to a client of 70kg with TBSA of 60% transfer
from the scene one hour ago by relatives.

Using the Parkland formula:

4 mL / kg / % TBSA per day & 50% in first 8 hours
& 50% in the remaining 24 hours

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 Exercise 3
The client developed respiratory difficulties
on Day 2. He has pink frothy sputum and
CVP was 18 cm H2O with widespread
wheezing. The urine output was 120 mL/hr
in the last hour. What additional
information you would collect and what
preliminary diagnosis could you draw from
the case?

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4th ICS
& MCL

Normal range:
4-10 cm H2O

Craven, 2017
 Exercise 4
The doctor prescribed Dopamine 200 mg in
100 mL D5% @ 5 mcg/kg/min.

Calculate the drip rate at mL/hr?

Concentration x rate
BW

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 Therapeutic interventions (cont’d)
13. Skin grafting
• Heterograft (xenograft)
• Homograft (allograft)
• Autograft
14. Surgical, mechanical, or enzymatic
debridement
15. IV antibiotics (C&S; e.g. Rocephin &
Fortum) and topical antibiotics
16. Opioids to reduce pain and sedatives to
decrease anxiety (via IV, IM, or oral)

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 Therapeutic interventions (Rehab)
16. Care for graft and donor sites*
17. Pressure garment over healed area (reduce
scarring)
18. Support joints and extremities in functional
position (reduce contractures)
19. Offer physical and emotional support while
encourage self care participation
20. Regular follow up after discharge and
possibility of reconstructive surgery if indicated
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 Method of dressing –
Open Dressing
Clean burn/scald area with Hibitane (aq.) or
NS and leave it open to air
• For superficial facial wound – sterile
paraffin oil will be applied
Advantage: allow continuous observation of
wound and minimize pseudomonas
micro-organisms with exposure to air
Disadvantage: more pain & discomfort, plus
psychological burden
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 Close Method
The burn/scald area is cleaned with NS or antibiotic
solution
Cover wound with suitable dressing materials
Cover up with burn gauze and secured by crepe
bandages
Advantage Vs Disadvantage:
• Good absorption and drainage of burn exudate
• Protect from bacterial contamination
• Prevention of post-burn contracture
• Prevention of heat loss and evaporative water
loss
• Earlier separation of eschar and debris
• Dressing change may be painful and time
consuming 21
 Properties of dressing make
burn wounds heal better!!
1. Sterile, free from particles and toxic
contaminants
2. Low adherence to wound surface
3. Maintains moist wound environment
4. Permeable to gases and water
5. Remove excess exudate
6. Impermeable to micro-organisms
7. Provides thermal insulation
8. Absorbs and neutralizes offensive odors
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Wound Dressings used in
Burns Unit

Materials adapted from

Miss Wong Tze Wing Amy,
Nurse Specialist, Burns Unit,
Dept of Surgery, PWH

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Wound cleansed and debris / necrotic
tissues excised in OTR…

Under General Anaesthesia (GA)

…. M & M (Morphine & Midazolam),
Propofol (Diprivan & MJ), K 仔

Subsequent dressing done in Burn unit

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 Autolytic debridement
Breakdown of necrotic tissue by body’s own
white blood cells (natural healing)
• rehydrate devitalized tissue
• Separation of viable from non-viable tissue
• Regenerate new blood vessels
• Painless but slow debridement
• e.g. Film dressing, Hydrocolloid, Hydrogel,
Hydrocolloid Foam
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 Film Dressing
- Allow oxygen and water vapor to pass
through but impermeable to fluid & bacteria

- Usage for minimal exudating wounds, use

as a secondary dressing to maintain
moisture & promote autolytic debridement
effect
e.g. OpSite, Tegaderm
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 Hydrocolloid
Occlusive or semi-occlusive, provide a moist
environment for clean wound
Interacts with wound exudate to form a soft
gel like substances
• Usage for stage II or III pressure ulcers
with moderate amount of exudate, has
autolytic debridement effect
• e.g. Comfeel, Duoderm [thin vs CGF]
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 Impregnated Gauze
Chemical compounds or agents added to gauze
material, some medicated & some non-
medicated
• Usage for wound coverage & wound protection,
initial dressing over skin grafts, donor sites,
plastic surgery or superficial exudating wounds
• Maintain moist environment
• Non-adherence to wound upon removal
• No pain, no bleeding, no maceration
• e.g. Jelonet, Bactigras, Physiotulle
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 Biological Dressing
Similar structure as human skin, no
connection between the graft and the
vascular system of the recipient
No antigenic antibody reaction
No local or general toxic reaction
Distinctive epithelialization effect
• Usage for partial thickness burn or scald
wound
• e.g. Pigskin or allograft skin
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 Hydrogel
Consists of both absorption power and give
moisture by its high water content
• Usage for stage III or IV wound with no or
minimal exudate, slough or eschar, for
autolytic debridement
• e.g. Duoderm gel, Intrasite gel, Suprasorb
G, Purilon gel

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 Alginate Dressing
Derived from seaweed, can absorb exudate
up to 20 times of their weight, and it has
the properties of hemostasis
• Usage for highly exudating wounds, stage
II to IV wounds, wounds with slough,
necrotic tissue or bleeding, & even
cancerous wound
• e.g. Kaltostat, Algisite M, Suprasorb A,
Seasorb
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 Hydrofiber
• Non-toxic
• Highly absorbent
• Autolytic effect
• Non traumatic to wound during removal
• Not suitable for dry wound
• Require secondary dressing
• e.g. Aquacel

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 Foam Dressing
Non-adherent, highly absorbent
• Usage for stage II to IV, surface to cavity
wounds,heavily exudating wounds, and
overgranulating tissue
• e.g. Allevyn, Biatain

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 Silver Dressing
Effective for infected wounds
• e.g. Acticoat, Aquacel Silver, Biatain Silver
Common concerns:
• Staining of wounds
• Toxicity
Advancement:
• Nanoparticles – increase surface area to release
silver ions
• Silver ions are locked inside the dressing
• Some may release silver ions on demand

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 Flamazine cream
(Silver Sulphadiazine 1.0%)
Indications:
• For prophylaxis and treatment of infection in burn
wounds
• as short term treatment of infection in leg ulcers &
pressure sores
• For prophylaxis of infection in skin graft donor sites and
extensive abrasions
• Conservative management of fingertip injuries
Actions:
• Has a strong bactericidal & bacteriostatic effect on gram-
positive & gram-negative micro-organisms

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 Flammacerium
Indication:
• Prevention and treatment of infections in severe
burn wounds
• Contain Silver sulfadiazine (effect on gram-
positive & gram-negative micro-organisms) and
cerium nitrate (enhances antimicrobial effect of
silver sulfadiazine)
• It forms a leathery eschar which reduces risk of
infection
• Cerium prevents deterioration of body’s immune
system

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 Acticoat: Ag

Changing perspectives in paediatric burns care 40

Biobrane

Brunner & Suddarth, 2008

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Comparison of Integra Template and
Split-Thickness Autograft

Brunner & Suddarth, 2008 42

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 SSG + Meshed SG

Splint 3-5 for SSG & 7-10 FTSG

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Burn Survival Rehabilitation 2007
 After the laboratory
Familiarise yourselves now with:
- Assessment of TBSA
- Calculation of drip rate for rapid
transfusion
- the CVP manometer and monitoring
- Urimeter
- Infusion pump

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 References
Joanne Biggs Institute (2006). Solutions,
technique and pressure in wound
cleansing. Best Practice. 10(2), 1-2.

Blunt, J. (2001). Wound cleansing:

ritualistic or research-based practice?
Nursing Standard. 16(1), 33-36.

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