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4/27/2011 1 1

BURN
Burn is an injury to tissues caused by the contact with heat, flame, chemicals, electricity, or radiation. First degree burns show redness; second degree burns show vesication; third degree burns show necrosis through the entire skin. Burns of the first and second degree are partial-thickness burns, those of the third degree are full-thickness burns.

CLASSIFICATION OF BURNS
Classification Of Burns

First-Degree (Minor)

The burned area is painful. The outer skin is reddened. Slight swelling is present.

Second-Degree The burned area is painful. The under skin is affected. (Moderate) Blisters may form. The area may have a wet, shiny appearance because of exposed tissue.

Third-Degree (Critical)

The burned area is insensitive due to the destruction of nerve endings. Skin is destroyed. Muscle tissues and bone underneath may be damaged. The area may be charred, white, or grayish in color.

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Wound healing process

Burn wound healing Process


Is a complex process a complex and dynamic process of restoring cellular structures and tissue layers.

Physiological Stages of wound healing


Physiological Stages of Wound Repair 1.)

Inflammatory Phase
y y y y y y y y y y

Initial response to injury Day 1-4 post injury Characterized by rubor, tumor, dolor, calor Platelet aggregation and activation Leukocyte (PMNs, macrophages) migration, phagocytosis and mediator release Venule dilation Lymphatic blockade Exudative In wounds closed by primary intention, lasts 4 days In wounds closed by secondary or tertiary intention, continues until epithelialization is complete

2.)

Proliferative Phase
y y y y y

Day 4-42 Fibroblast proliferation stimulated by macrophage released growth factors Increased rate of collagen synthesis by fibroblasts Granulation tissue and neovascularization Gain in tensile strength

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Wound healing process

3.) Remodeling Phase


y y y y y

6wks-1 year Intermolecular cross-linking of collagen via vitamin C-dependent hydroxylation Characterized by increase in tensile strength Type III collagen replaced with type I Scar flattens

Wound Closure
1.) Factors determining method of wound closure:
y y y y y y y y y

Type of wound Size of wound Location Age of wound Presence of infection General condition of the patient Urgency of closure Antibiotics needed Follow-up needed and achievable for patient

2.)

Requirements for skin graft success:

y y y

y y

Vascularized bed Contact with bed No "sheer" forces or movement of bed No infection No hematoma or seroma

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Wound healing process

Types of Wound Healing


1.) Healing by first intention
y

primary wound healing or primary closure Describes a wound closed by approximation of wound margins or by placement of a graft or flap, or wounds created and closed in the operating room. Best choice for clean, fresh wounds in well-vascularized areas Indications include recent (<24h old), clean wounds where viable tissue is tension-free and approximation and eversion of skin edges is achievable. Wound is treated with irrigation and dbribement and the tissue margins are approximated using simple methods or with sutures, grafts or flaps. Wound is treated within 24 h following injury, prior to development of granulation tissue. Final appearance of scar depends on: initial injury, amount of contamination and ischemia, as well as method and accuracy of wound closure, however they are often the fastest and most cosmetically pleasing method of healing.

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Wound healing process

2.)

Healing by second intention


y y

y y y y

y y

secondary wound healing or spontaneous healing Describes a wound left open and allowed to close by epithelialization and contraction. Commonly used in the management of contaminated or infected wounds. Wound is left open to heal without surgical intervention. Indicated in infected or severely contaminated wounds. Unlike primary wounds, approximation of wound margins occurs via reepithelialization and wound contraction by myofibroblasts. Presence of granulation tissue. Complications include late wound contracture and hypertrophic scarring

3.)

Healing by third intention


y y
. tertiary wound healing or delayed primary closure

y y

Useful for managing wounds that are too heavily contaminated for primary closure but appear clean and well vascularized after 4 -5 days of open observation. Over this time, the inflammatory process has reduced the bacterial concentration of the wound to allow safe closure. Subsequent repair of a wound initially left ope n or not previously treated. Indicated for infected or unhealthy wounds with high bacterial content, wounds with a long time lapse since injury, or wounds with a severe crush component with significant tissue devitalization. Often used for infected wounds where bacterial count contraindicates primary closure and the inflammatory process can be left to dbribe the wound. Wound edges are approximated within 3 -4 days and tensile strength develops as with primary closure.

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Wound healing process

.) Partial Thickness Wounds


Wound is superficial, not penetrating the entire dermis. st y Type of healing seen with 1 degree burns and abrasions. y Healing occurs mainly by epithelialization from remaining dermal elements. y Less contraction than secondary healing in full thickness wounds Minimal collagen production and scar formation
y

Dressings
Dressings protect the wound from further trauma and provide a moist, antibacterial environment for healing. Sometimes in addition to moist or medicated bandage, splinting or casting is performed on the affected limb. If aberrant scarring is suspected, pressure bandages can be used to suppress scar hypertrophy. Dressing changes at regular intervals is paramount to preventing infection and optimizing wound healing.
1.) The
y y y y y

Ideal Dressing
Provides protection from further injury or infection Permits movement of joints and body parts proximal to the wound Exercises some compression on the wound site to control bleeding and scarring Absorbs fluids draining from the wound Ultimately contributes to an improved esthetic outcome for the resulting scar

2.) Wound
y y y y y y y

Care Options

Ointments Impregnated gauze Gauze packing Hydrocolloids Hydrogels Alginates Adhesive films

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Wound healing process

Burn Wound Disorder


1.) Hypertrophic scars
y y y y

Remain within boundaries of original scar Common areas of occurrence are back, shoulders or sterum Red, raised and often pruritic Can resolve with time and often treated conservatively

2.) Keloid scarring


y y y y

Extend beyond boundaries of original scar Common areas of occurrence are sternum, deltoid and earlobe More frequently occur in darkly-pigmented people Do not spontaneously heal and demand treatment with pressure bandages, surgery, radiation or topical steroids; reoccurrence is common.

3.) Chronic Wounds


y y y y

y y y

Lacerations and open injuries older than 24h Require dbribement, irrigation, and healing by secondary or tertiary intention Wound sepsis is determined by the total bacterial load per gram tissue (>10 5 bacteria/gram tissue) Systemic antibiotics not useful, however topical antibiotic creams (silver sulfadiazine, bacitracin, Neosporin) for areas of partial thickness loss may be useful. Be aware that some of these agents inhibit epithelialization and the initial stages of wound healing Biological dressings can be used Final closure should be performed only after bacterial contamination is controlled Deep sutures should be kept to a minimum and monofilament. If any signs of infection seen on reevaluation, portion of wound is opened by removing sutures

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Wound healing process

Nutrition Guidelines to Improve Wound Healing


Good nutrition is necessary for healing. During the healing process, the body needs increased amounts of calories, protein, vitamins A and C, and sometimes, the mineral, zinc. The following guidelines will help you choose "power" foods to promote healing
Ways to prevent infection at the site of injury:

a. Gowns, masks, gloves b. Sterile linen c. Persons with URI should not come in contact with patient

WOUND CARE PRINCIPLES


1. GOALS
   

close wound prevent infection reduce scarring and contractures provide for comfort

2. Wound cleaning bed side hydrotherapy tanks tubbing spray table 3. Debridement mechanical surgical enzymatic 4. Topical antibacterial therapy mafenide (sulfonamide) sulfadiazine
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Nursing process
o o

assessment Objective  how burn occurred, when  duration  type of agent Subjective:  previous medical problems  size and depth of burn  age  body part involved  mechanism of injury

nursing Diagnosis
o o o o o o o

Airway clearance, ineffective Fluid volume deficit Fluid volume excess Hypothermia Infection, high risk for Pain (with partial thickness burns) Skin integrity, impaired Anxiety Knowledge

Nursing planning Return to normal respiration Fluid and electrolyte balance Prevent infection Reduce pain Decrease anxiety Nursing intervention
o o

maintain a patent airway - watch for laryngeal edema, 100% FiO2 mask (increase in carboxyhemoglobin) intubation for inhalation most often required

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Wound healing process

maintain circulation - fluid resuscitation crystalloids and colloids Crystalloids - may be isotonic or hypertonic 1. Isotonic - most common are lacted Ringers or NaCl (0.9%) - these do not generate a difference in osmotic pressure between the intravascular and interstitial spaces subsequently LARGE amounts of fluid are required 2. Hypertonic salt solutions create an osmotic pull of fluid from the interstitial space back to the depleted intravascular space (helps decrease the amount of fluid needed during resuscitation. decreases the development of burn tissue edema, pulmonary edema, and CHF)

Colloids - replacement begins during the second 24 hours following the burn to replace intravascular volume ONCE CAPILLARY PERMEABILITY SIGNIFICANTLY DECREASES
y y y

relieving anxiety, denial, regression, anger, depression wounds - REFER TO WOUND CARE nutrition (Nutritional assessment, pre albumin levels, large protein requirement, carbohydrates and fats for energy, mega vitamins, TPN, enteral tube feedings) ileus is common pain - around the clock management prevention of infection SEE WOUND CARE

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Wound healing process

References http:// www.google.com http:// www.wekipedia.org

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Wound healing process