Burn Injury: An Introduction to Burn Wound Care
24/02/2015 Burn Injury: An Introduction to Burn Wound Care Jennifer Hyson RN Clinical Nurse Educator Capital Health Overview Burn Injury Review • Types (Cause) • Severity • Extent (TBSA) • Classification (Depth) Burn Wound Care • Goals • Burn Care and Dressings • Skin Grafts/Donor Site Care Types (cause) of Burn Injuries Thermal • Dry heat • Moist heat • Direct contact • Extreme cold Chemical • Acids • Alkalis Electrical 1 24/02/2015 Thermal Burns • Dry heat • Moist heat • Contact • Frostbite Chemical Burns • Acids and Alkalis • Damage to skin proportional to type, amount and strength of substance, duration of contact and mechanism of action • Treatment depends on specific chemical Electrical Burns • Small portion of the burn population • Entry and exit points • Difficult to assess injury because much of it is internal • Damage may show up later as heart arrhythmia, eye injury or bleed 2 24/02/2015 Burn Severity • Classified as Minor or Major • Severity Factors ▫ Extent ▫ Depth ▫ Age ▫ Part of the body burned ▫ Past medical history Burn Severity: Extent Calculation of the total body surface area [TBSA] • Palm Method • Rule of Nines • Lund and Browder Rule of Nines 3 24/02/2015 Lund and Browder Method Burn Severity: Depth Factors that influence depth: • Intensity • Duration • Thickness of the skin Burn Depth Terminology Older Terminology Newer Terminology First Degree Superficial Second Degree Superficial Partial Thickness Deep Partial Thickness Full Thickness Third Degree Fourth Degree 4 24/02/2015 Superficial First Degree • Damage to the epithelium • Red and dry • Blanches with pressure • No blisters • Tender/painful • Heals in 3 to 5 days Superficial Partial Thickness Second Degree • Destruction of epidermis, superficial damage to dermis • Epidermal appendages intact • Red, wet, blisters • Blanches with pressure • Extremely painful • Heals in 14-21 days 5 24/02/2015 Deep Partial Thickness Second Degree • Destruction of epidermis, damage to dermis • Some epidermal appendages intact • Less moist, pale • No/delayed blanching • Deep pressure sensation/No pinprick sensation • Prolonged healing 6 24/02/2015 Full Thickness Third Degree • Complete destruction of epidermis, dermis and epidermal appendages • Dry, leathery • Mottled, brown, red • No sensation/pain • Requires excision and grafting 7 24/02/2015 Full Thickness Fourth Degree • Complete destruction of epidermis, dermis and epidermal appendages • Involves connective tissue, muscle and bone • Dry • Black or brown • No pain • Limited movement of limb/digits 8 24/02/2015 Burn Wound Care Goals of Wound Care • • • • • • Prevention of conversion Removal of devitalized tissue Preparation of healthy granulation tissue Minimize systemic infection Completion of the auto grafting process Limiting scars/contractures Wound Care Procedure Before you begin: • Prepare supplies and environment • Premedicate patient • Wear the proper PPE • Keep in mind patient allergies General principles: • Dressing removal and cleansing = clean technique • Dressing application = sterile technique • Wound cleansing includes debridement 9 24/02/2015 Wound Care Procedure During the dressing: • Assess vital signs • Assess wound for healing • Assess wound for infection • Assess distal circulation • Passive or active ROM Superficial burns (first degree) Wound Care • Bath or shower • Moisturizing agent • May apply dressing for comfort Superficial Partial Thickness Second Degree Wound Care • Cleanse with warm N/S • Non adherent dressing • Cover with gauze Keep in mind: • Budding • Soak dressings that have adhered to wound 10 24/02/2015 Deep Partial Thickness/Full Thickness Deep seconds & third degree Wound Care • Cleanse with warm N/S • Apply gauze coated with 1% silver sulphdiazine • Cover with protective/absorbent layer Keep in mind: • Do not apply SSD to intact skin or less severe burns • Manage exudate Full Thickness Fourth Degree Wound Care • Cleanse with warm N/S • Cover exposed bone, tendon with hydrogel • Cover with Jelonet and gauze Eshcarotomy Care • Cleanse with warm N/S • Cover with thick strips of Jelonet • Manage exudate 11 24/02/2015 Care of Facial Burns • Warm N/S soaks followed by gentle wiping action • Remove any devitalized tissue • Apply thin layer of polysporin ung QID • If male, shave daily using SSD and a disposable razor Keep in mind: • Watch for pressure areas on back of head, ears • No pillow for neck burns Hand and Foot Dressings Important Points: • Wrap each digit separately • Use enough kling to secure the dressing and still allow for movement of the fingers and toes • Monitor distal circulation • Keep arms and legs elevated on pillows 12 24/02/2015 Skin Grafts & Donor Sites Skin Grafting Types of Skin Grafts • Autograft • Allograft Graft Care • • • • • • • Bedrest 5-7 days PO Initial dressing taken down by physician Dressing are removed gently With sterile q-tips reapply any loose graft Cleanse the area gently with NS Apply jelonet cut to size Cover with gauze, and an outer dressing and secure with kerlix (where possible) or tape 13 24/02/2015 Donor Site Care • Covered in foam dressing for 7-10 days • Frequently assessed for bleeding and reinforced within the first 24hr • Assess for signs of infection • Painful • Remove gently on 10th day (or as ordered) ▫ Cleanse with NS ▫ Cover with Vaseline mesh dressing (Jelonet) ▫ Cut back Jelonet with scissors as wound heals and Jelonet releases • Once wound has closed coat with lanolin or available moisturizer daily 14 24/02/2015 Questions 15
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