MEDICAL SURGICAL

NURSING II

UNIT :5: NURSING MANAGEMENT OF

PATIENT WITH BURNS AND
RECONSTRUCTIVE SURGERY

GETHCIA.I
MSN DEPARTMENT
 INTRODUCTION TO BURNS

Injuries that result from direct contact with or

exposure to any thermal, chemical, electrical, or
radiation sources.
Burn injuries occur when energy from the heat
source is transferred to the tissues of the body .
The depth of injury is related to the temperature of
the object and the duration of exposure or contact
with the hot objects.
 DEFINITION OF BURNS

Burns are defined as the injuries that result from

direct contact with or exposure to any thermal,
chemical, electrical, inhalational or radiation source

Burn is a wound that causes damage to the skin or

deeper tissues caused by sun, hot
liquids,fire,electricity, or chemicals.
 CAUSES/TYPES OF BURNS

1)Thermal burns: it is caused by exposure to or

contact with flame,hot liquids,semi
liquids(steam),semi solids(tar), or hot objects.

Specific examples are residential fire,explosive

automobile accidents,scald injuries,clothing ignition.
2)Chemical burns: are caused by tissue contact
with strong acids, alkalis or organic compounds.

Chemical burns are caused by sodium hydroxide or

silver nitrate,acids such as sulphuric acid and
hydrofluoric acid which can cause damage down to
the bones.
3)Electrical burns: are caused by exogenous
electric shock.electrical burns are caused by heat
that is generated by the electrical energy as it
passes through the body.

Electrical injuries are caused by faulty electrical

wiring,high voltage power lines or being
defibrillated without the conductive gel.
Very deep tissues can be damaged by electrical
burns.
4)Radiation burns: they are caused by exposure
to uv rays, radiation therapy, sunlamps, radioactive
substances and x rays.

tanning booths can cause damage to the skin,

irritation to the skin, redness, swelling, and
inflammation.
5) inhalation injury: may be upper airway and
may involve the lower airway and cause acute
respiratory distress syndrome.

Exposure to asphyxiants, smoke poisoning, and

direct thermal injury to the lungs.

Inhalation injury and associated pulmonary

complications are significant factor in mortality
and morbidity from burn injury.
 CLASSIFICATION OF BURNS

A)According to burn depth.

 1)Superficial partial thickness/first degree burns.
 2)Deep partial thickness burns/second degree
burns.
 3)Full thickness wound/third degree burns.
 4) fourth degree burns.
B) According to the burn severity.
1)Minor burns
2)Moderate burns
3)Severe burns

 C)According to extent of body surface area injured

1) Rule of nine
2)Lund and browder method
3)Palm method
4)Jacksons burn model
 According to burn depth

The depth of burn injury depends on the temperature of the

burning agent and the duration of contact with the agent.The
burn depth can be superficial, superficial partial thickness, deep
partial thickness, or full thickness burns.
1)Superficial partial thickness burns/first degree
the first degree burns usually produces a pink color
to reddish color on the burned skin and is very sensitive to touch,
and the skin will appear blanched or pale when light pressure is
applied on skin. These burns affect the outer layer of skin
causing pain, redness, swelling. It involves only the upper layer of
skin( Epidermis) . Healing time takes one or two days.
2) Deep partial thickness burns/Second degree burn
In second degree burns it can affect the outer
layer(epidermis) and the underlying layer(dermis)
causing pain, redness, swelling and blisters.

These burns often affect sweat glands, and hair follicles.

Usually second degree burns produce scarring, and if

the second degree burns are not treated properly it will
decrease blood supply to the tissues. Healing time takes
one to three weeks.
3) Full thickness burns / third degree burns.
third degree burns affects the epidermis, dermis,
and hypodermis causing charring of the skin or
translucent white color with caogulated blood
vessels visible just below the skin surface.

Both epidermis, and dermis are destroyed and the

other organs, tissues, muscles, and bones may be
involved. Third degree burns are considered most
serious. Healing takes very slow time, and may require
skin grafts. The surface appears dry, and waxy white,
leathery, brown or charred.
4)Fourth degree burns.
fourth degree burns extend to the underlying fascia
injuries damages the muscles, bones and tendons.
and leave them exposed.

These burns occur with deep flame, electrical, or

chemical injuries. The wound is blackened and
depressed, if extremity is involved amputation may
be required.
 B)ACCORDING TO BURN SEVERITY.
Burns are classified as minor,moderate, or severe.
 The severity determines how they are predicted to
heal and whether the complications are likely.

Doctors determine the severity of the burn by its

depth and by the percentage of the body surface
burnt.
1) Minor burns : All the first degree burns as well as the
second degree burns involve less than 10% of the body
surface usually are classified as minor.

2) Moderate burns: burns involving the hands, feet,

face and genitals. It is involving more than 10% of body
surface area.

3) Severe burns: burn involvement of 25% of body surface

area. Deep burns of head ,hands, feet, and
perineum ,inhalation injury, chemical or electrical burns.
C) According to the extent of body surface area
burnt
Burns can also be assessed in terms of total body surface
area burnt(TBSA), which is percentage affected by partial
thickness or full thickness burns.

The Rule of nine is the quick and useful way to estimate

the affected TBSA.

More accurate estimation can be done by using Lund and

browder method which take into account the different
proportion of body parts in adults and children.
 1)Rule of nine method.

It is one of the quick method to calculate the extent of burns.The

entire body system assigns percentages in multiples of nine to
major body surface areas.

It may be used to estimate the TBSA burnt.

By adding all the affected area percentage the total body surface
that is burnt is calculated.

 This rule does not apply for the childrens and infants. Rule of
nine was introduced by Alexzander wallace.The patient own
hand(fingers and palm ) is 1% of body surface area.
RULE OF NINE
 2)Lund and browder charts
A more precise method of estimating the extent of
burns in Lund and browder method, which
recognises that the percentage of TBSA of various
anatomic parts , especially the head and legs changes
with growth.Partial thickness is represented as PT
and full thickness as FT.
Areas mainly concentrated are:

A HALF OF HEAD

B HALF OF ONE
THIGH
C HALF OF ONE LEG
 LUND AND BROWDER CHART.

AREA AGE 0 AGE 1 AGE 5 AGE AGE ADUL

10 15 T

A) HALF 9.5 8.5 6.5 5.5 4.5 3.5

OF HEAD

B)HALF 2.27 3.25 4 4.5 4.5 4.75

OF ONE
THIGH

C)HALF 2.5 2.5 2.75 3 3.25 3.5

OF ONE
LEG
 PALM METHOD

It is one of method to assess the scattered burns ,a

method to estimate the percentage of burns .

The size of one palm is approximately 1% of TBSA.

 JACKSONS BURN MODEL

A burn wound is dynamic and subject to the effect of

secondary injury.The burn may deepen if the blood supply
to the parts are impaired.

Jacksons model describes the distinct areas within every

burn wound.

Zones of Jacksons burn model :

1)zone of coagulation
2) zone of stasis
3) zone of hyperaemia
1) Zone of coagulation: this zone lies in the centre,
 which represents severe damage caused by
primary injury these tissues will not recover but will
slough(mass of dead tissue seperating from ulcer)
out in due time .
2)Zone of stasis: which comprises of less damaged
tissue in which inflammation occurs and vascularity
is impaired (supply of blood vessels is impaired).
3)Zone of hyperaemia: is tissue with intense
vasodilation and increased blood flow.
JACKSONS BURN MODEL
CLINICAL MANIFESTATIONS OF BURNS

FIRST DEGREE BURNS.

 Reddened skin
 pain at the burn site
 injury involves only epidermis
 blanch to touch
 have an intact epidermal barrier
 do not result in scarring
2) Superficial second degree burns
 intense pain
 white and red skin
 blisters
 involves the epidermis and papillary layer of
dermis
 spares hair follicles and sweat glands
 Erythematous and blanch to touch
 very painful and sensitive
 no or minimal scarring
3) Deep or second degree burns.
* injury to the deeper layer of dermis that is
reticular region of dermis is affected.
 Appears pale
 do not blanch to touch
 less painful
 affects the sweat glands , hair follicles,
keratinocytes
 severe scarring
 contractures are possible.(shortening or
hardening of muscles ,tendons, or other tissues).
Third degree burns
 burn injury is dry , leathery skin( white, dark
brown, or charred)
 loss of sensation
 patient feels little pain
 All dermal layers tissues will be destroyed

Fourth degree burns

 involves structure beneath the skin and muscles
and bones
 DIAGNOSTIC STUDIES IN BURNS

1) Complete blood count: initial increased

hematocrit(hct), Later there will be decreased hct
and RBC’S may occur due to heat damage to vascular
endothethelium. Leucocytosis ( decreased WBC ) can
occur due to loss of cells at wound site.
2) Arterial blood gas analysis (ABG Analysis)
baseline information of ABG analysis is necessary
with inhalation burn injury. Reduced Pao2 and
increased Paco2 may be seen certain times. Acidosis
may occur and may cause decreased renal function.
3) Carboxyhemoglobin (COHb)
Elevation of more than 15% indicates carbon
monoxide poisoning or inhalation injury.
4) Serum electrolytes:
Potassium levels may be initially elevated because of
injured tissues , RBC destruction and decreased
renal function. Hypokalemia can occur when diuresis
starts, magnesium level may be decreased, Sodium
level may be decreased with body water losses,
hypernatremia can occur in later stages when renal
conservation occurs.
5) Alkaline phosphatase:
elevated because of interstitial fluid shifts or due to
impairment of sodium pump

 6) Serum glucose:
elevation reflects stress response

 7) Serum albumin:
albumin and globulin ratio may be reversed as a
result of loss of protein in edema fluid.
8) Blood urea nitrogen/creatinine:
elevation reflects decreased renal perfusion or renal
function.cretinine level may increase due to tissue
injury.
 9) urine:
Presence of albumin, hemoglobin , and myoglobin
reflects deep tissue injury. Reddish black urine is due
to myoglobin .
10) Random urine sodium:
more than 20 meq/l suggests excessive fluid
resuscitation.
11) Chest x ray :
may appear normal in early postburn period even with inhalation
injury . But true inhalation injury may show infiltrates in lungs.

12) Fiberoptic bronchoscopy:

useful in diagnosing extent of inhalation injury,
findings can include edema , hemorrhage, ulceration of upper
respiratory tract.

13) Lung scan: may be done to determine the extent of

inhalation injury.

 14) Electrocardiogram: Myocardial ischemia, dysrhythmias.

 PATHOPHYSIOLOGY OF BURNS

 The burn injury produces local and circulatory

mediators that are released in the blood or released
by the cell seen mainly in thermal injury

They are Histamine, Prostaglandin E2, Prostacyclin,

leukotrienes, thromboxane, thromboxane
bradykinin, serotonin, lacto-calamines, epinephrine
and nor epinephrine, O2 radicals and platelets
aggregation factor.
Tissue destruction leads to shift of fluid from
vascular to interstitial or intracellular space causing
dehydration and hypovolemic shock.

This results in multiple organ failure due to

decreased tissue perfusion.

Burn injury can worsen due to the release of local

mediators, changes in blood flow, tissue edema and
infection.
 MANAGEMENT OF BURNS

B : breathing

U : urine output

R : Rule of nine /Resuscitation of fluid.

N : Nutrition

S : Silvadene cream 1%(Antimicrobial)

 EMERGENCY TREATMENT FOR BURNS

The management of major burn injury is:

A : Airway
B : Breathing and ventilation
C : Circulation
D : Disability neurological status
E : Environmental control
F : Fluid resuscitation.
 MANAGEMENT OF BURNS

Before burns are treated the burning agent must be

stopped from inflicting /causing further damage , for
example like fires are extinguished, clothing such as
smoldering( such as synthetic shirts) must be
removed immediately.
 Hospitalization is sometimes necessary for optimal
care of burns, for example elevating the severely
burnt arm or leg above the level of heart to prevent
swelling.
Burns that prevent the people from carrying out
their daily activities such as walking, eating, makes
hospitlization necessary.
 FIRST AID FOR MINOR BURNS

FOR FIRST DEGREE BURNS:

If the skin is not broken , run cool water over the burnt area
or soak in cool water bath for 5 min .
Burns can be extremely painful reassure the victim and
keep them calm .
After flushing or soaking the burn for several minutes cover
the burn with non adhesive bandage or clean cloth.
Protect the burn from friction and pressure
OTC drugs can be administered for pain relief and to reduce
swelling.
Minor burns will usually heal without further treatment.
FIRST AID FOR SEVERE BURNS ( 2ND AND
3 RD DEGREE)
Do not remove burn clothing unless it comes of f
easily.
Make sure that the victim is breathing, if the
breathing has stopped begin with CPR
If the victim is breathing cover the burn with cool
moist sterile bandaging or clean cloth.
Do not use a blanket or towel , a sheet is best for
large burns.
DO not apply any ointment and avoid breaking
blisters.
If the fingers or toe have been burnt separate them
with the dry sterile non adhesive dressings.
Elevate the burnt area and protect from friction and
pressure.
Take steps to prevent the hypovolemic shock. Lay
the victim flat on the bed.
Continue to monitor the victims vitals signs
( breathing , pulse rate, temperature, blood
pressure).
MANAGEMENT ACCORDING TO BURN PHASE

1) EMERGENT OR IMMEDIATE PHASE : from

onset of injury to completion of fluid resuscitation.

2) ACUTE OR INTERMEDIATE PHASE : from

beginning of diuresis to completion of wound closure

3) LONG TERM PHASE OR REHABILITATION

PHASE: from major wound closure till patient
returns to physical or psychological adjustment.
 EMERGENT OR IMMEDIATE PHASE

Provide first Aid for burns

Prevention of shock
Prevention of respiratory distress
Detection and treatment of concomitant
injuries( associated health issues with burns)
Wound assessment or initial care
 ACUTE OR INTERMEDIATE PHASE

Wound care and closure

Prevention or treatment of complications including
infections
Nutritional support
 LONG TERM PHASE AND REHABILITATION

Prevention of scars and contractures

Physical, occupational, and vocational rehabilitation
Functional and cosmetic rehabilitation
Psychological counselling.
 PATHOPHYSIOLOGIC CHANGES

Pathophysiologic changes occuring in different

systems of the body is as follows.
1) Cardiovascular response
2) burn edema
3) Pulmonary response
4) Renal system response
5) Immune syetem response
6) Gastrointestinal response
7) Metabolic changes
8) Integumentary system
 Cardiovascular response.

 Major burns.

Fluid loss

decrease cardiac output

decrease blood pressure

burn shock( hypovolemic shock)

sympathetic system releases catecholamine

vasoconstriction and increased pulse rate.

further decrease in cardiac output

 BURN EDEMA

Major burns

Increased capillary permeability

NA, water and protein shift from intravascular to

interstitial spaces.

Increased concentration of RBC

 increase the blood viscosity

decrease the tissue perfusion

cellular dysfunction

cell swelling

edema

increased pressure on small blood vessels and nerves in distal extremities

obstruction to blood flow

ischemia
 PULMONARY RESPONSE

inhalation of carbon monoxide

combine with hemoglobin

carboxyhemoglobin

Hypoxemia

Tissue damage

potential tissue necrosis

RENAL SYSTEM RESPONSE

Burn injury

Hypovolemia

Decrease cardiac output

Decrease renal perfusion

Decrease renal blood flow

Risk of acute renal failure

 IMMUNE SYSTEM CHANGES

Major burns

loss of skin barrier

Thermoregulatory problem and inflammatory response

in skin

impairs immune system and cellular dysfunction

cell swelling
 METABOLIC CHANGES

Due to injury

rapid erosion of body mass

negative nitrogen balance

loss of intracellular constituents

decrease body weight due to increased metabolic activity

inadequate glycogen store in liver, protein loss and protein depletion

continues

hypoglycemia
 INTEGUMENTARY SYSTEM

Due to trauma

water evaporation

exudation of plasma in first 48 hours

evaporation of water from the site of burn

 GASTROINTESTINAL SYSTEM

Due to injury

flow to mesenteric bed is reduced

intestinal ileus and GI dysfunction(>25% burns)

small and superficial erosion to stomach and duodenum

if not treated with antacid and H2 histamine

Erosion will progress to ulcer

GI bleeding occurs
 IMMEDIATE MANAGEMENT OF BURNS

The therapists role when treating a patient with a

burn injury is to maintain function, improve
function, prevent deformity and contracture and
improve the appearance of the burn scar.
Hypertrophic scarring and contracture of the burn
scar are two impediments that prolong recoovery
following a deep burn injury .
Treatment following a burn is divided into three
stages.
 EMERGENT PHASE

Emergent phase of burns management refers to the first 48 to 72 hours

postburnnwhen the patient is admitted in the hospital ,the severity of the
injury is determined and the first aid and wound care is given.

During the Emergent period of burn injury the treatment includes airway
management and oxygenation, fluid resuscitation, wound management,
pain control, and tetanus prophylaxis.

MAIN AREAS:
1) Airway management
2) Hyperbaric oxygen therapy(HBOT)
3) Replacing body fluids/Fluid management
4)Wound management
5) Analgesia and sedation
 AIRWAY MANAGEMENT

Airway management of burns is an extremely important

consideration that can lead to devastating complications
if not properly conducted.
Persons who are burnt on the face, and neck or those who
have inhaled flame, steam, or smoke, should be observed
for signs of laryngeal edema,and airway obstruction.
For mild pulmonary injury ,inspired air is humidified and
the patient is encouraged to cough,so that secretions can
be removed by suctioning. Administer bronchodilators
and mucolytic agents to remove the secretions.
Early management may require Endotracheal
intubation, and mechanical ventilation.
Arterial blood gas analysis determinations should be
obtained as a baseline information, but arterial Po2
does not reliably predict the carbon monoxide
poisoning.Therefore baseline carboxyhemoglobin
levels should be obtained and 100% oxygen should
be administered.
Elevation of the head and chest by 20 to 30 degrees
reduces neck and chest wall edema.
Hyperbaric oxygen therapy(HBOT):
It is a noninvasive mode of medical treatment in
which the patient is enclosed in a pressure chamber
filled with oxygen at a pressure greater than
atmosphere . It is painless procedure that can be
carried out in either monophasic chamber where
only one patient is in the chamber or multiplace
chamber where patient along with someone else are
inside the chamber.
The chamber is pressurized with 100% pure oxygen.
Topical hyberbaric oxygen therapy technique
includes delivering 100% oxygen directly to an open,
moist, wound at a pressure slightly higher than
atmospheric pressure through special devices.
There are many conditions that benefit from HBOT
such as sores, and gangrene that will not heal related
to diabetes, ostomyelitis, severe anemia and others.
Healing wounds and burn victims can benefit from
this treatment with the effect on body tissues and
wound healing.
Hyperbaric oxygen therapy is also used in the
treatment of smoke inhalation.
Carbon monoxide has high affinity to hemoglobin
and when it is inhaled it will bind to hemoglobin
forming a compound called
carboxyhemoglobin(cohb), this will lead to decrease
oxygen to tissues and hypoxia.
Hyberbaric oxygen therapy decreases the half life of
carboxyhemoglobin and fastens the dissociation of
carbon monoxide from hemoglobin and making
hemoglobin available for oxygen.
 FLUID MANAGEMENT

After an airway has been established support of

circulation is addressed .Burn injuries can cause
tremendous loss of body fluid through the burn wound
and adjacent tissues the form of edema.
To prevent the introduction of infection the lines are
inserted through unburned area.
Any adult with burns affecting more than 15% of the
body surface or a child with more than 10% of body
surface area are affected requires fluid
Resuscitation.An indwelling foleys catheter is inserted
to monitor urine output accurately.
 REPLACING BODY FLUIDS

Replacing body fluids and electrolytes is an essential

part of the treatment of burn victims and is initiated
as soon as the severity of the burn and the patients
condition is known.
Fluid therapy is started within an hour after a severe
burn to prevent hypovolemic shock.
Fluids administered during the first 48 hrs are given
to maintain circulating blood volume.
Various types of fluids in calculating the
needs of the patient.
 1) Colloids: including plasma and plasma
expanders albumin, dextran.
 2) crystalloids : physiologic saline, lactated
Ringer’s , 5% dextrose ,and saline.
 3) colloidal solutions:example hespan, is
routinely given.
 4) Electrolytes :such as sodium chloride,
Hartmans solutions, and tyrodes solution.
 5) Non electrolyte fluids: such as distilled
water with 5% glucose.
 FORMULAS FOR FLUID REPLACEMENT
IN BURNS PATIENT

1) CONSENSUS FORMULA: Lactated ringer’s

solution or other balanced saline solution.

FORMULA :
2-4ml x kg body weight x body surface area
burned(TBSA).

Half of fluid is given in first 8 hours

Remaining half of fluid in next 16 hours.
EVANS FORMULA:
Colloids: 1ml x kg body weight x % of TBSA burned
Electrolytes: 1ml x kg body weight x TBSA burned
Glucose : 2000ml for insensible loss
( fluids lost from skin, respiratory system, fluids lost in
stools cant be calculated)

DAY 1: Half to be given in first 8 hours, remaining

half over next 16 hours.
DAY 2:Half of previous days colloids and electrolytes
of insensible loss fluid replacement.Maximum of
10,000 ml is given over next 24 hours.
BROOKE ARMY FORMULA:

Colloids: 0.5ml x kg body weight x TBSA burned.

Electrolytes:(saline) :1.5ml x kg body weight x TBSA
burned.
Glucose: 2000ml for insensible loss.

DAY 1:Half to be given in first 8 hours, remaining

half over next 16 hours.
DAY2: Half of colloids, half of electrolytes ,all of
insensible fluid replacement.
 PARKLAND/BAXTERS FORMULA

Lactated ringer’s solution or any balanced saline

solution.
Formula:
 4ml x kg body weight x % TBSA burned.

Day 1: Half to be given in first 8 hours, remaining

half over next 16 hours.
Day 2: various colloids is added.
 HYPERTONIC SALINE SOLUTION

Concentrated solutions of sodium chloride and

lactate with concentration of 250-300meq of sodium
per litre is administered to maintain desired urine
output.

Do not increase the infusion rate during the first 8

hours after post burn.

Serum sodium levels must be monitored closely.

 WOUND MANAGEMENT

The essential part of wound management are an

initial assessment to determine the burn depth and
then debridement ( removing devitalized tissue and
contamination), cleaning and then dressings.
Burn wounds are very painful so analgesia should be
given.
Circumferential burns of digits, limbs,or the chest
may need urgent release of burnt skin
(escharotomy)to prevent problem with distal
circulation or ventilation.
 ANALGESIA AND SEDATION

A number of different options are used for pain

management.
Simple analgesics: ibuprofen, acetaminophen and
narcotics.
Local anesthetic: to manage pain of first and second
degree burns.
Intravenous narcotic analgesic and sedatives may be
given in small frequent doses.
 ACUTE /INTERMEDIATE PHASE
MANAGEMENT

The acute period of treatmment begins at the end of

emergent period and lasts until the burn wound is
healed.The length of the period varies based on burn
injury.
If the burn is partial thickness injury the acute
period extends to 10 to 20 days .
If the burn injury is a full thickness injury over a
large percentage on the body requiring surgery for
skin grafting , then the acute phase lasts for months.
 TWO PRINCIPLES OF ACUTE PHASE

PRINCIPLES ARE:
1) treatment of the burn wound
2) detection and treatment of complications

care in this phase:

1) Infection prevention
2) Topical antimicrobials.
 INFECTION PREVENTION

Skin care is extremely important .keeping the burnt

area clean is essential, because the damaged skin is
easily infected .
Cleaning may be accomplished by gently running
water over the burns periodically.
Wounds are cleaned and bandages changed 1 to 3
times per day.
Skin grafts are needed to cover burns that will not
heal.
Infection is the most common complications of major burn
injury.
Sepsis accounts around 50 to 60 % of deaths in burn
patients despite the improvements in antimicrobial itherapy.
The burn wound is a ideal substrate for bacterial growth, the
bacterias such as Staphylococcus, proteus,
pseudomonas,Escherchia coli,klebsiella.
Tissue specimens are obtained for culture regularly to
monitor colonization by bacterial organisms, swab or tissue
biopsy cultures.
Cap, gown, mask, and gloves are worn while caring for the
patient with open burn wounds.
Clean technique is used when caring directly for burn
wounds.
 TOPICAL ANTIMICROBIALS

The application of topical agents to the burn wound

can help to decrease the infection and hasten
healing.
The topical antimicrobial agents are effective
because damage to the blood vessels in the burnt
area, prevents systemic antibiotics to reach the burn
wound site.
No single agent is effective as each agents has its
own advantages and disadvantages.
 BURN WOUND DRESSINGS
ANTIMICROBIAL SALVES

1) Silver sulfadiazine(SSD) Broad spectrum antibiotics and easy

to use.

2) Mafenide acetate (sulfamylon) Broad spectrum antibiotics ,

penetrates eschar wall.

3) Bacitracin Antimicrobial spectrum.

4) Neomycin Antimicrobial spectrum

5) Polymyxin B Antimicrobial spectrum

6) Nystatin (Mycostatin) Inhibits fungal growth

Mupirocin(Bactroban) Staphylococcal coverage, inhibits

epithelilization.
ANTIMICROBIAL SOAKS

1) 0.5% Silver nitrate Effective against all microorganisms.

But it stains contacted areas.

2) 5% Mafenide acetate Wide antibacterial coverage,

No fungal coverage.

3) 0.025% sodium hypochlorite Effective against all microbes,

particularly gram positive organisms.

4) 0.25% Acetic acid Effective against most microorganisms.

Particularly gram negative ones.
SYNTHETIC COVERINGS

1) Opsite Provides moisture barrier and decreases

Wound pain

2) Biobrane Provides wound barrier and decreases

pain

3) Transcyte Provides wound barrier and decreases

pain

4) Integra Provides complete wound closure.

BIOLOGIC COVERINGS

Completely closes the wound provides

1) Xenograft( pig skin) some immunologic benefits , it must be
removed later or allowed to slough out

Provides all normal functions of skin ,

2) Allograft (homograft,cadaver skin) epithelium must be removed or allowed
to slough out.
 BURN WOUND DRESSINGS
There are two methods of burns dressing
 1)Open or exposure method: it is a method of keeping
the burn wound open. The patients are washed daily and kept
of clean dry sheet with another sheet or mosquito net draped
in a frame to reduce contamination from environment.The
partial thickness burn will dry within 48 to 72 hours.
 2) Closed method or occlusive method:in this method
the wounds are washed and the dressings are changed at least
once a day.An occlusive dressing is a thin gauze impregnated
with topical antimicrobial agent, counter pressure is applied
using a bandage (elastic bandage).Occlusive dressings are
mostly used on new skin grafts.
 REHABILITATION/LONG TERM PHASE

Rehabilitation is to prevent the loss of

motion ,prevent or minimize anatomic deformities,
and also to return the patient to work or normal
activity a soon or completely as possible and
minimizing the effects of scar contraction.
TYPES OF SCARS:
 1) keloid scars
 2) hypertrophic scars
 3) contractures
1) Keloid scars: they are the overgrowth of scar
tissue.The scar will grow beyond the site of
injury.These scars are generally red or pink and will
become dark tan over time.
Keloids can be reduced in size by cryotherapy
(freezing),external pressure, cortisone injections,
radiation and surgical removal.
2)Hypertrophic scars: are red thick,and raised,
hyprtrophic scars will improve over time .
Mederma is a topical gel used to reduce the visibility of
scars.this gel should be applied 3 to 4 times daily for 3
to 6 months.
Cica care gel are designed to flatten and soften scars.
3) Contractures: A contracture scar is a
permanent tightening of skin that may affect the
underlying muscles and tendons that limits mobility
and degeneration of nerves.contractures develop
when the normal elastic tissues are replaced by
inelastic fibrous tissue.This prevents normal
movement of affected area.
Doctor may recommend Z-plasty or tissue
expansion.
 DERMABRASION

Dermabrasion :is a surgical procedure to improve

or minimize the appearance of scars,restore
function, and correct disfigurement resulting from a
injury.
Dermabrasion is used to smoothen scar tissue by
shaving or scraping off the top layers of skin.But it
cannot remove the scar completely.
Once the surgery is completed the skin will be
treated with an ointment, a wet or waxy dressing dry
treatment or combination of these.
 NURSING MANAGEMENT OF BURNS

1) Assess the airway, breathing, circulation, disability,

exposure( prevent hypothermia) ,and the need for
fluid resuscitation. Also assess the severity of burns
and conscious level.
2) Establish the cause , consider non accidental injury.
3) Assess for associated injuries, associated injuries
may be sustained while the victim attempts to escape
fire.
4) Explosions may through the patient at some
distance and result in internal injuries or fractures.
Assess the burns sustained within an enclosed space
suggest possible inhalation injury.
Assess any preexisting illness , drug therapy, allergies
and drug sensitiveness are also important.
Establish the patients tetanus immunization status.
 ROLE OF NURSE IN BURN MANAGEMENT

1) Restoring normal fluid balance

2) preventing infection
3) maintaining adequate nutrition.
4) promoting skin integrity
5) relieving pain and discomfort
6) promoting physical mobility.
7)strengthening coping strategies
8) supporting patient and family process
 PREVENTING BURNS

Keep matches,lighters,chemicals,and lit candles out of kids

reach.
Put child safety covers on all electrical outlets.
Get rid of equipments and appliances with frayed cords that
look damaged.
Make sure that teens and older kids are especially careful when
using irons,or flat irons or curling irons.
Prevent house fires by making sure you have smoke alarm on
every level of your home.change the battery of alarm twice a
year.
Replace smoke alarms that are 10 years or older.
Don’t use fireworks, or sparklers.
 COMPLICATIONS OF BURNS

1) Infection: infection leading to organ system failure is

the leading cause of death among burn patients, caused
by pseudomonas and staphylococcus aureus.
2) Heterotrophic ossification:it can occur
throughout the body , common areas are elbows, hips,
shoulders.
causes of ossification is immobilization, and high protein
intake and sepsis.
3) Pulmonary complications:mainly in case of
inhalational burn injury,can cause lung damage
pulmonary edema, tracheal damage and pneumonia.
4) Metabolic complications: thermal injury
carries increased metabolic changes that rapidly
decreases the weight of patient.
5) Cardiovascular complications:decreases
cardiac output, decreases platelet count, clotting
factors, WBC,RBC, decreases hemoglobin, and
hematocrit levels.
6) Neuropathy:polyneuropathies.
7) Pathological scars:hypertrophic scars and
contractures require separate treatment.
 LEGAL ASPECTS IN BURN MANAGEMENT

1) Non maleficence

2) Standing orders
3) Medicolegal cases
4)Circumstances requiring a permit
5)Consent issues.

1) Non maleficence: it is doing harm of burn

patient purposefully.it is necessary to determine the
risk of harm to burn patient.
2) Standing orders : standing orders are the
policies made by the hospital management in
relation to administration of drugs or treatment
procedures without any medical orders during the
time of emergency.
3)Medicolegal cases: all the patients admitted
after accidents, suicide attempt burns are
medicolegal cases ,if such cases die is handed over
only after police clearance is obtained.
4)Circumstances requiring a permit:before
any surgical procedures or while administering
anesthesia it is necessary to obtain the consent form
signed at time of admission itself.

5)Consent issues: Nurse needs that burn

patient ,adult relative of patient signs the consent
form of hospital.
 PSYCHOSOCIAL ASPECTS OF BURNS

1) Depression and anxiety: are common in acute

phase of recovery.social support must be given.
2) Sleep disturbance: can be due to hospital
environment ,patients mood, agitation, night mares.
3) Premorbid psychopathology:can be due to
depression, personality disorder,or substance
misuse.
4) Grief: patients may now begin the grieving
process as they become more aware of burn injuries
 RECONSTRUCTIVE AND COSMETIC
SURGERIES

PLASTIC SURGERY:
 The word plastic derives from the greek word
“Plastikos” meaning to mould or to shape.Plastic
surgeon mould and reshape the following tissues of
the body ,bone,cartillage,muscles,fat and skin
Plastic surgery is a medical speciality concerned with
correction,or restoration of form of body structures
damaged by trauma transformed by aging
process ,changed by disease process and malformed
as a result of congenital defects.
 BASIC PRINCIPLES OF PLASTIC SURGERY

1) Achieving minimal scarring

2) Careful planning of incisions so that they fall in
the line of natural skin folds and lines.
3) Appropriate choice of wound closure
4) Use of best available suture materials
5) Early removal of exposed suture
6)Documentation through photography.
Common techniques used in plastic surgery.

1)Incision
2) Excision
3)Microsurgery
4)Chemosurgery
5)Electrosurgery
6) Laser surgery
7) Dermabrasion
8) Liposuction
 RECONSTRUCTIVE SURGERY

Reconstructive surgery in its broadest sense is the

use of surgery to restore the form and the function of
the body.

Reconstructive surgery is performed to correct

functional impairments caused by burns, traumatic
injury such as facial bone fracture, congenital
abnormalities such as cleft lip and cleft palate,
removal of cancers and tumors.
Common Reconstructive surgical procedures

1) Breast reconstruction

2) Face injury
3) Contracture surgery for burns
4)Hand and finger injuries
5) Cleft lip and palate
6) Injuries to limbs
7) Cranio- facial defects
8) Amputation
9) Ptosis or drooping of eyelids
10) Scars
11) Defects of ear
12) Pressure sores
13) Hand anomolies
14) Spinal cord defects.
 SKIN GRAFTING

Skin grafting is a type of medical grafting involving

the transplantation of skin.
As skin grafting is technique in which section of skin
is detached from its own blood supply and
transferred as a tissue to distant tissue
Skin grafts are commonly used to repair degects that
result from excision of skin tumors,to cover the
denuded area of skin(burn) and to cover wound in
which insufficient skin is available to permit wound
closure.
 INDICATIONS OF SKIN GRAFTING

Extensive burn injury

Burns
Specific surgeries that may require skin grafts for
healing.
Areas prior to infection with extensive skin loss
Cosmetic reasons/reconstructive surgeries.
 Classification of skin grafts

1) Autografts: an autograft is a tissue obtained from

patients own skin

2) Allografts : an tissue obtained from donor of same

species

3) Xenografts :a xenograft is a tissue obtained from

different species.
 Classification of skin graft based on thickness of
skin

1) Split skin grafts.

2) Full thickness skin grafts
3) Composite skin grafts

1) Split skin grafts: a split skin grafts can be cut at

various thickness and is commonly used for cover large
skin wounds or defects. The type of skin grafts is taken by
shaving the surface layers (epidermis and dermis) of skin
with a large knife called a dermatome. The shaved piece
of skin is then applied to the wound. A split skin graft is
often used after excision of lesion on the lower leg.
2) Full thickness skin grafts: it consists of
dermis and the entire dermis without any underlying
fat.This type of skin graft is taken by removing all the
layers of the skin with scalpel.The piece of skin is cut
into correct shape and then applied on wound.This
type of skin graft is often taken from arm, neck, or
behind the ear.It is used to cover large wounds that
are too large to be closed directly.
3) Composite Graft: which consists of skin and
fat, skin and cartilage,or the dermis and fat.for
example the wedge of ear containing skin and
cartilage can be used to repair the nose.
 DONOR SITE SELECTION

The common areas are used as donor sites are

buttocks, thighs, and upper arms.
The donor site is dressed in theatre and the dressing
will be left for 7 days to 14 days.
We may have to repad the dressing as it may ooze or
bleed after the operation.
Site selection based on closest possible color match.
Matching the texture and hair bearing qualities.
Obtaining the thickest possible skin graft.
 GRAFT APPLICATION

The wound is prepared as for surgery, the wound is

cleaned and measured and then the pattern is traced
over the donor site.
Anesthesia is administered, depending on the size,
severity ,and location of wound, as well as the type of
graft , the procedure may require local anesthesia,
regional anesthesia, iv sedation, general anesthesia, or
a combination of both.
The donor skin is harvested and prepared .The skin is
either removed with skin grafting knives or with special
harvesting machine called dermatome.
The skin graft is taken from the donor or host site and
is applied to the desired site called the recipient site or
graft bed.
With full thickness or composite graft the donor site is
closed with sutures. with the split skin graft the
sutures are not needed at the donor site.
The pressure bandage bandage is applied over the
graft recipient site.A special vacuum apparatus called
the VAC may be placed over the area for first 3 to 5
days to control drainage and increase the chances of
graft survival.
Healing begins at first graft uses oxygen and nutrients
from the tissue of the recipient site to survive.
New blood vessels begin to grow within first 36
hours.
After the skin graft is put in place it may be left
exposed or covered with a light dressing or pressure
dressing depending on the area.

POST OP CARE.
Both the donor and recipient site should be well
protected .physician will instruct on proper use of
medications and bandaging.
 SKIN FLAPS

A flap is a segment of tissue that remains attached at one

end while the other end is moved to the recipient site .
Its survival depends on functioning arterial and venous
blood supplies in its pedicle or base.
A skin flap consists of skin and subcutaneous tissue that
survives based on its own blood supply
The flap consists of skin, mucosa,muscle,adipose
tissue,omentum(a fold of peritoneum that connects with
abdominal organs) and bone.
Flap retains the color and texture of donor area.
INDICATIONS OF SKIN FLAPS
To repair the defects caused by congenital
deformity ,trauma,or in tumor ablation.
To heal extensive wounds from pressure ulcer.
Wound coverage on face that is eye ,nose, and
mouth.
 COMPLICATIONS OF SKIN GRAFT

Infection
Smelly discharge from dressing
High temperature
Increased pain
Redness and swelling around the skin graft and
donor area.
Bleeding through the dressing caused by trauma or
the infection which may cause clots in the graft.
Loss of grafted skin.
 CARING FOR THE GRAFT

Keep the donor site clean and free from infection

Avoid streching or moving around the graft area,or
affected limb unless advised by doctor.
 The graft have a firm dressing in place to help stop
any movement and friction.
The pressure on the dressing will help to stop fluid
collecting under the new skin.
Antihistamine medication can be given ex.Piriton
this reduces the itching of the skin.
Advice patient to wear cotton clothes.
 COSMETIC SURGERY

Cosmetic surgery is a very popular form of plastic

surgery performed to reconstruct or alter congenital
or acquired defects or to improve bodys appearance.
Cosmetic surgeries is performed for changes that
result from aging.
VARIOUS TYPES OF COSMETIC SURGERIES:
1) body reshaping procedures
2) facial surgeries
3) breast reshaping procedures.
 BODY RESHAPING PROCEDURES

1) Liposuction( body and facial)

2) Tummy tuck surgery(abdominoplasty surgery)
3) Brachioplasty surgery ( arm lift surgery)
4) Thigh lift surgery(thigh plasty)
5) Butt augmentation /implant
6) Male breast reduction( gynecomastia correction
7) Aesthetic genital surgery
1)Liposuction:liposuction is the common procedure
worldwide, liposuction is a procedure that permanently
removes the fat cells from body areas and the body is
sculpted back to shape.
Liposuction is not meant for weight loss , some weight loss
may occur due to fat removal.
Suction assisted lipectomy is done (SAL)
Ultrasound assisted lipectomy where the ultrasound energy
breaks the fat cells before suctioning them out.
The various fat store areas are abdomen, hips, thighs in
males and chest and abdomen in males.
Most liposuctions are performed under general anesthesia,
or local anesthesia.
Upto 18 litres of fat can be removed in well selected cases.
2) Tummy tuck ( abdominoplasty):sudden
massive weight loss and post pregnancy can make
the abdominal skin to droop , it can also occur in
people those who underwent bariatric surgery.
Liposuction is done before the surgery, followed by
abdominoplasty is done where the excess abdomen
skin , fat,is removed and the abdominal muscles are
tightened.
3)Brachioplasty: ( Arm lift surgery): it is a upper
arm lift surgery.The surgery removesupper arm excess
fat to create more firmer youthful looking arm
4) Thigh plasty ( thigh lift ):is done to remove excess
fat and skin from thighs especially the skin which is
sagging and loose is removed.
5)Butt augmentation /implant:flat buttocks can be
because of inborn trait or due to aging .Adequate butts
are required for good body profile and improves
attractiveness .butt lift or implant is common among
women it will reduce fat and reshape the butt region.butt
implants are made up of silicon and is safe and can be
used for long time, they are placed by hidden cuts.
6) Male breast reduction or gynecomastia
correction:having breasts can b much embarrasing for
man.During puberty hormonal changes occur in the
body,(unopposed female hormone or low levels of male
hormone) as a result breast tissue forms in some boys ,
this may disappear in certain cases overtime , if notbreat
reduction is done.
A big cut is done below the nipple and cutting off only the
breast tissue.
7) Aesthetic genital surgery: various surgeries are
penile lengthening, penile girth increase in males.
In females labia majora reduction,labia majora
enhancement, pubic fat liposuction, vaginal
tightening( vaginoplasty)
 FACIAL COSMETIC SURGERY

1) Blepharoplasty
2) Endoscopic forehead and brow lift
3) Rhytidectomy
4) Liposculpture
5) Nosesurgery / Rhinoplasty
6)Chin and cheek enhancement
7) Cleft lip nose deformity
8) Cleft lip correction
9)Cleft palate correction
1) Blepharoplasty: changes in the eyelid caused by droopy
or saggy skin as well as bags around the eye can be corrected
by eyelid surgery or blepharoplasty .upper and lower eyelid
can be corrected simultaneously and the procedure also
rejuvenates the eye protruding fat excess skin can be
addressed simultaneously by excision.
2) Endoscopic forehead and browlift: eyebrow and
forehead lift is performed to raise the eyebrows and reduce
ridges and furrows on forehead ,thus creating a smoother
and more youthful appearance.Endoscopic browlift is done
under local anesthesia or with sedatives or general
anesthesia.
Through a small incision in the hairline the peristeum is
skipped , and finally the closure of the incision is done by
two sutures or staples.
3) Rhytidectomy: ( face lift syrgery): it is designed
to restore a more youthful experience by removing
the major wrinkles and sagging skin , it involves
tightening of the facial and neck muscles as well as
removal of excess fat from skin.
The skin begins to wrinkle and sag as a result of
age ,sun exposure and genetics, young adults have
smooth and round faces due to evenly distributed
fatty tissues in face .overtime the skin sags and folds
under chin,jawline,neck.
4) Liposculpture: facial wrinkles and loss of
volume are part of ageing process liposculpture also
called autologous fat transplantationor
microinjection, it plumps up facial features with
patients own fat and is popular in antiageing
treatments. Liposculpture is designed to recontour
your face and can provide definition to your
cheeks.The liposuctioned fat from your thighs is then
transferred to any area of your body where it is
needed.It is very sucessful for the correction of
sunken cheeks.
5) Nose surgery rhinoplasty: nose forms the
centre of face and can make either good or bad
statements.The surgery involves change of all parts
or some of the parts of nose.The nasal septum must
be corrected.
Common concerns of this surgery is smoothing nose
humps narrowing of nose correcting the nose
deviation,and making nose much sharper.
6) chin and cheek enhancement:(genioplasty)
means shaping the chin,based on balance between
the forehead,nose, and chin such as rule of thirds.
Weak chin is called retognathia,more prominent
chin is called prognathism.
7) Cleft lip nose deformity:deformity of nose occurs in
varying degrees along with cleft lips .Although lips get
corrected early in life ,but the nose deformity persists as
stigma and it causes mental trauma to the
affected.cheiloplasty surgery is done for correction of cleft
lip.
The best time for correction of nose deformity is 14 to 16
years.The bony and cartilage framework can be altered to
create an aesthetically appealing nose.Skin excess can be
trimmed or adjusted.
8) Cleft lip:it results from failure of maxillary process to
fuse with nose elevation on frontal prominence.
Commonly done repair surgery is Ralph millards rotation
advancement technique for cleft lip repair.usual time for
surgery is at 3 yrs.
9) Cleft palate : failure of fusion of secondary
palate with eachother ,and with the primary
palate .The palate is closed between 12 to 15 months .

Techniques of cleft lip repair:

1. von langenback procedure.
2. veau wardill kilners three flap technique
3. millards island flap trans position for lengthening
the soft palate.
 BREAST RESHAPING PROCEDURE

1) breast implant /augmentation

2) breast reduction
3) breast lift
4) nipple , areolar reconstruction.
1) Breast
implant/augmentation(mammoplasty):breast
implants is an artificial reshaping or augmenting a
breast for cosmetic reasons.Enhancement of the
breast can be done at any age after the breasts are
developed.
Types of breast implants are saline breast implants
which is made up of silicone rubber or
elastomer.And other type is silicone gel breast
implants.
2) breast reduction:can be defined as a surgical
reduction in breast size to achieve a smaller size
breast.
3) Breast lift: breasts lose their shape and size due
to weight loss and following pregnancy and breast
feeding.here the breast reshaping is done and also
toa reposition the breast in its youthful position.
4) Nipple areolar reconstruction: nipple
reconstruction gives more natural appearance.this
surgery corrects the nipple and areola to achieve
symmetry in position, size, shape , structure,and
projection.