I. INTRODUCTION Fire has been a metaphysical constant of the world.

Fire represents the creativity and passion that all intellectual and emotional beings have. It is an active force that has the passion to create and animate things. The element is also very rational and quick to flare up. Fire in many ancient cultures and myths has been known to purify the land with the flames of destruction, but fire may also cause destruction to the human, causing injury to the skin, and in severe cases, to its self-image. A burn is a type of injury that may be caused by heat, cold, electricity, chemicals, light, radiation, or friction. Burns can be highly variable in terms of the tissue affected, the severity, and resultant complications. Muscle, bone, blood vessel, and epidermal tissue can all be damaged with subsequent pain due to profound injury to nerves. Depending on the location affected and the degree of severity, a burn victim may experience a wide number of potentially fatal complications including shock, infection, electrolyte imbalance and respiratory distress. Beyond physical

complications, burns can also result in severe psychological and emotional distress due to scarring and deformity. Burns are one of the most devastating conditions encountered in medicine. The injury represents an assault on all aspects of the patient, from the physical to the psychological. It affects all ages, from babies to elderly people, and is a problem in both the developed and developing world. All of us have experienced the severe pain that even a small burn can bring. However the pain and distress caused by a large burn are not limited to the immediate event. The visible physical and the invisible psychological scars are long lasting and often lead to chronic disability. Burn injuries represent a diverse and varied challenge to medical and paramedical staff. Correct management requires a skilled multidisciplinary approach that addresses all the problems facing a burn patient. A burn is an injury caused by thermal, chemical, electrical, or radiation energy. A scald is a burn caused by contact with a hot liquid or steam but the term 'burn' is often used to include scalds. Most burns heal without any problems but complete healing in terms of cosmetic outcome is often dependent on appropriate care, especially within the first few days after the burn. Most simple burns can be managed in primary care but complex burns

and all major burns warrant a specialist and skilled multidisciplinary approach for a successful clinical outcome. Statistics shows that the survival Rate for burn is 94.8%, while it is common among men than female. Its prevalence to Caucasian is 63%, 17% African-American, 14% Hispanic, 6% others. Admission Cause: 42% fire/flame, 31% scald, 9% contact, 4%

electrical, 3% chemical, 11% other. With regards to place of Occurrence: 66% home, 10% occupational, 8% street/highway, 16% other (Source: American Burn Association National Burn Repository (2010 report)) A so-called dermal plates was designed by Cornell scientists that promote vascular growth could hasten healing, encourage healthy skin to invade the wounded area and reduce the need for surgeries for the victims of third-degree burns and other traumatic injuries endure pain, disfigurement, invasive surgeries and a long time waiting for skin to grow back which was published at the May 2011 issue of Biomaterials. These so-called dermal templates were engineered in the lab of Abraham Stroock, associate professor of chemical and biomolecular engineering at Cornell and member of the Kavli Institute at Cornell for Nanoscale Science, in collaboration with Dr. Jason A. Spector, assistant professor of surgery at Weill Cornell Medical College, and an interdisciplinary team of Ithaca and Weill scientists. The dermal plates are composed of experimental tissue scaffolds that are about the size of a dime and have the consistency of tofu. They are made of a material called type 1 collagen, which is a wellregulated biomaterial used often in surgeries and other biomedical applications. The templates were fabricated with tools at the Cornell NanoScale Science and Technology Facility to contain networks of microchannels that promote and direct growth of healthy tissue into wound sites. The grafts promote the ingrowth of a vascular system -- the network of vessels that carry blood and circulate fluid through the body -to the wounded area by providing a template for growth of both the tissue (dermis, the deepest layer of skin), and the vessels. Type I collagen is biocompatible and contains no living cells itself, reducing concerns about immune system response and rejection of the template. A key finding of the study is that the healing process responds strongly to the geometry of the microchannels within the collagen. Healthy tissue and vessels can be guided to grow toward the wound in an organized and rapid manner. (Retrieved at: http://www.sciencedaily.com/releases/2011/05/110518075035.htm)

Objectives I. General This case report aims to improve the knowledge of student nurses and the readers will gain knowledge and further understanding about the condition of Burns. II. Specific This case report aims to: 1. Gather necessary information about the condition such as predisposing and precipitating factors. 2. Study the anatomy and physiology of the integumentary system. 3. Obtain and trace the pathophysiology of burns. 4. Determine the appropriate diagnostic test. 5. Determine the appropriate medical and surgical management. 6. Identify the appropriate drugs, their action, side effects, indications,

contraindications and nursing responsibilities. 7. Formulate appropriate nursing care plans. 8. Determine appropriate health teachings and interventions as part of the holistic care to future patients.

II. ANATOMY AND PHYSIOLOGY The integumentary system is the largest organ in the body and accounts for 815% of a persons body weight. It must be tough to protect us but supple so that we can move and stretch. EPIDERMIS The epidermis is the uppermost part of the skin which is made up of stratified squamous epithelium that is capable of keratinizing (becoming hard and tough).It is composed of five layers termed as STRATA and it has no blood supply (avascular). It contains keratinocytes (keratin cells) which is responsible for producing keratin. This keratin found in the epidermal skin layer is a fibrous protein that makes the epidermis a tough protective layer.

Five STRATA of the Skin Stratum basale is the deepest layer of the epidermis which lies closely to the dermis. The epidermal cells of stratum basale receive the most adequate nutrition through diffusion from the nutrient supply in the dermis. Also called stratum

germinativum because epithelial cells in this layer are constantly undergoing cell division where a huge amount of new cells are produced per day. These cells move away from the said stratum and moves upward to the superficial epidermal layers. In this layer, melanin, the pigment of the skin is produced by melanocytes. Exposure to sunlight stimulates the melanocytes to produce more of the melanin pigment. Next to Stratum basale is Stratum Spinosum the followed by Stratum granulosum. Above is Stratum lucidum which is clear and when the cells move to this area, they become flat and contain a large amount of keratin. Eventually the cells die because they are now increasingly full of keratin. This layer is selectively found in the body. It is only seen in areas where the skin is hairless and extra thick (palms of the hands and soles of the foot). Stratum Corneum which is the outermost epidermal layer that is approximately 20-30 cell layers thick. The tough protein, keratin, is abundant in this layer to provide protection through a durable overcoat. Stratum corneum flakes off steadily and is replaced by the newly produced cells from the stratum basale. The epidermis renews its cells every 25-45 days.

DERMIS The dermis lies next to the epidermis, which is a strong and stretchable envelope holding the body together. This part of the skin is made up of the papillary and the reticular areas. Dermis is made up of dense connective tissues, and collagen and elastic fibers are located in this part of the skin. This layer is supplied with blood vessels that is vital in maintaining the normal body temperature. It has collagen fibers that gives the dermis its toughness and it helps the skin to be hydrated by attracting and binding to water. It has also elastic fibers that provides elasticity to the skin.

Two Layers of the Dermis Papillary Layer is the upper dermal layer that has dermal papillae, the fingerlike projections from the superior surface. The papillary layer has uneven surface and the dermal papillae are responsible for indenting the epidermis above. Dermal papillae is a very important part of the dermis as it is the one that house the capillary loops which provides nutrition to the epidermis and it also houses some of the pain receptors and touch receptors. The pain receptors are the free nerve endings and the touch receptors are called the Meissners corpuscles. Reticular layer is the deepest skin layer which contains the sweat glands, blood vessels and oil glands. It also houses the pressure receptors called the Pacinian corpuscles. The skins ability to fight infection is made possible because of the presence of phagocytes in this area that prevents bacteria which passed through the epidermis from penetrating deeper into the body.

Appendages of the Skin

Sebaceous glands which are also called the oil glands are found all over the bodies except the palms of the hands and the soles of the feet. The secreted product is a mixture of oily substances and fragmented cells called SEBUM. Sebum plays a vital role in keeping the skin soft and moisturized. It also prevents the hair from being brittle. Aside from that, the mixture of oily substance and fragmented cells contains chemicals that KILLS bacteria. Thus, invading microorganisms are prevented from penetrating deep in

the skin. Activity of the sebaceous glands is heightened during the adolescent period where the levels of male sex hormones are increased.

Sweat gland that is also termed as sudoriferous glands are extensively spread all over the body. There are two types of sweat glands which are the eccrine and the apocrine glands. Eccrine glands produce sweat which outnumbers the apocrine gland in terms of distribution all over the body. Sweat produced by the eccrine glands is clear and composed of primarily water, some salts, vitamin C, few traces of ammonia, urea and uric acid and lactic acid. The pH of sweat is acidic which helps in inhibiting bacterial growth. The apocrine glands on the other hand are largely found on the axillary and the genital areas only. Unlike the eccrine glands, these glands produce a secretion that contains fatty acids and proteins which may have a milky or yellowish color.

Hair and hair follicles is formed by the adequately nourished stratum basale epithelial cells in the MATRIX (growth zone) of the hair bulb at the inferior end of the follicle.

Nails which has a free edge, a body (visible attached portion) and a root.

HYPODERMIS The hypodermis is not a skin layer but lies below the dermis, and is a subcutaneous tissue which contains fat, blood vessels and sensory receptors.

Functions of the SKIN Covers the body. Protects the body from mechanical damage. This function is done by insulating and cushioning the deeper body organs. Examples of mechanical damage are bumps and cuts. When a person is bumped, the uppermost layer of the skin toughens or hardens the cells. The toughening of the cells is due to the presence of keratin in the upper layer of the skin. Pressure receptors in the skin send an impulse to the nervous system about a possible damage. These receptors alert an individual to bumps and provide a great deal of information about the external environment. Protects the body from chemical damage. Acids and bases, when exposed to the body at high levels, can cause extreme damage to the internal organs. However, because of the presence of tough keratinized cells, damage to internal organs is prevented. Protects the body from bacterial damage. In preventing infection, one of the most important considerations to consider is an unbroken skin surface. The skin secretes urea, salt and water (acidic) when a person sweats, thus, inhibiting bacterial growth. Phagocytes are also located in the skin which is responsible for ingesting foreign substances and pathogens. Hence, bacterial penetration to deeper body tissues is prevented. Protects from ultraviolet radiation. The pigment or color of the skin depends on the presence of melanin. This melanin that is produced by the melanocytes is good at protecting the body from the damaging effects of the sunlight or UV damage. Protects the body from thermal damage. When the body is exposed to extreme heat or cold the heat and cold receptors located in the skin alerts the nervous system of the tissue-damaging factors. The brain, in response sends impulses to the site of damage or possible damage for the bodys compensatory mechanism. Protects the body from drying out. The skins outermost part, the epidermis, contains a waterproofing glycolipid and keratin in order to prevent water loss from the body surface.

Regulation of heat loss and heat retention. The body must maintain a constant core temperature. Any change in the environmental temperatures could possibly alter the required core temperature. The skin contains a rich capillary network and sweat glands which are controlled by the nervous system. These mechanisms play an important role in regulating heat loss or retention in the body. When the body is needs to loss heat, the skin receptors alert the nervous system which in response activates the sweat glands (sweat helps cool the body in a hot environment). The blood is also flushed into the skin capillary beds, making heat loss possible. When the body needs to retain heat, the blood is NOT allowed to be flushed into the capillary skin beds. This is the main reason why during cold weather, the palms of the hands are pale. Acts as mini-excretory system. The perspiration contains urea, uric acid and salts. Synthesizes Vitamin D. The skin produces proteins that are vital for the synthesis of the Vitamin D. When a person is exposed to sunlight, modified cholesterol molecules in the skin are converted to Vitamin D.

III. DIAGNOSTIC PROCEDURES y Total body surface area is used to assess the percentage of burn and is used to help guide treatment decisions including fluid resuscitation and becomes part of the guidelines to determine transfer to a burn unit.

a. Lund-Browder

Children have different proportions than adults and so the Rule of Nines is not accurate to calculate the percentage of a burn for children. The Lund-Browder chart, as displayed here (shown as Fig. 4-27 in your text), is used to calculate the percentage of body surface involved in the burns of children.

b. Rule of nine It divides the body into sections that represent nine percent of the total body surface area (TBSA). It can be used in conjunction with adult burn patients to determine the TBSA that has been burned. Sections include the head and neck, arms, torso (chest, anterior abdomen, upper and lower back), perineum and legs.

c. Palm trick Use the patients palm size to represent approximately 1% TBSA. Imagine a rectangle the width and length of your entire hand (from wrist to fingertips) and that is the size of one palm.

Biopsy refers to removing and studying sample tissue. It examines the extent of collagen damage to the skin, vascular damage to the tissue, and damage to cell proteins in the skin.

Thermography is used when attempting to determine the exact depth of a burn wound, doctors can use thermography as a diagnostic tool because deeper wounds are cooler than more superficial wounds. There is reduced vascular perfusion, or blood circulation, to the deeper wounds, leading to a lower temperature.

Complete blood count to assess for hemorrhage(decreased hemoglobin and hematocrit) , and infection (increase white blood cells).

Serum

electrolytes

to

determine

electrolyte

imbalance

specifically

hyponatremia and hypokalemia and hyperkalemia, and hypercalcemia, and hypocalcemia y BUN and creatinine to determine renal insufficiency d/t passage of RBCs to kidneys. y electrocardiogram (EKG) - if there is a history of high tension electrical injury or known history of heart disease y Arterial blood gas- is used to determine acidosis or alkalosis with regards to burn.

B. DEFINITION OF THE DISEASE A burn is damage to the body's tissues caused by heat, chemicals, electricity, sunlight or radiation. Scalds from hot liquids and steam, building fires and flammable liquids and gases are the most common causes of burns. Most burns heal without any problems but complete healing in terms of cosmetic outcome is often dependent on appropriate care, especially within the first few days after the burn. Most simple burns can be managed in primary care but complex burns and all major burns warrant a specialist and skilled multidisciplinary approach for a successful clinical outcome.

Mechanism of burns: y Scalds- these types of burns result when skin comes into contact with hot liquids (spilled liquids or food, hot bathwater) y Contact burns- these burns result from contact of the skin with hot items, including flames y Chemical burns- these burns result from contact of the skin with chemicals, or by ingestion of chemicals y Electrical burns- these types of burns result when a person comes into contact with a source of electrical energy; includes burns caused by electrocution and lightning strike a. true electrical injury exists when electricity passes through the body. An entrance and exit wound is produced, along with significant deep-tissue destruction. b. arc burns occur when electrical current jumps from one part of the body to another, producing scattered spots of injury which may be deep c. flame burns are caused by sparks sufficient to ignite clothing y Radiation burns- Accidents involving ionizing radiation are not common. Most frequently they are the result of a local accident (laboratory), from an industrial accident (Chernobyl, Russia in 1986), or from the detonation of a nuclear device.

Types of burns: y Superficial Burns

These types of burns cause superficial erythema (redness) and swelling and may be quite painful. The skin will blanch upon pressure. These types of burns involve only the outermost layer of skin, or the epidermis. Treatment generally involves cooling the burn with running water or the application of cool cloths and application of an over-thecounter burn ointment or a soothing agent, such as aloe cream or gel. These types of burns heal quickly and do not result in scarring. A physician should be consulted if superficial burns are extensive, especially in children or the elderly. y Partial-Thickness Burns

Partial-thickness burns affect both the epidermis and the dermis to varying degrees. Superficial partial-thickness burns do not involve the full thickness of the dermis, while deep partial-thickness burns may involve the dermis more extensively. Depending on how much of the dermis is affected, these types of burns may result in scarring and may require skin grafting to heal. It may be difficult to determine whether a burn affects the dermis superficially or more deeply; the difference lies partially in healing time, as superficial partial-thickness burns will heal more quickly, often in less than 3 weeks. These types of burns will cause blisters. Blisters should never be punctured but should be left intact, as rupturing them may increase the risk of infection. These types of burns may cause permanent disfigurement. They may also be quite painful, as nerves are intact and undamaged. y Full-Thickness Burns

Full-thickness burns extend down into the hypodermis, or subcutaneous tissue. These types of burns may affect underlying bone, nerves, tendons and other structures. These burns in themselves are generally not painful; however, there may be surrounding areas of partial-thickness burns that are painful. These burns will require surgery to close and may result in permanent disfigurement and disability, especially if they occur over a joint. The risk for complications, especially infection, is very high and these types of burns

may be life-threatening if they are extensive. These types of burns should be cared for in specialized burn centers. C. MODIFIABLE AND NON-MODIFIABLE FACTORS Modifiable factors y Drug use - Use of alcohol and illegal drugs increases risk of burns. For example, drugs that requires heat. y y Smoking - Careless smoking puts you at risk of burns. Sun exposure Too much exposure to the sun puts you at risk of burn injury due to the heat and indirect radiation it causes to the skin. y Unsafe heating practices Use of heated foods and containers, hot water heaters set above 130 F, and unsafe storage of flammable or caustic materials put you at higher risk of burns. Also, the use of wood stoves and exposure to heating sources or electrical cords puts you at risk of burns. Non-modifiable factors y Age - Children under 4 who are poorly supervised are at risk of burns. Additionally, children who live with abusive parents are at increased risk of burns. y Gender - Men are more than twice more likely to suffer burn injuries than women according to statistics. It may be due to occupation. For example, male electricians are at risk for electrical burns, and those who are working as firefighters which are predominantly male are at higher risk for thermal burns. y Seasonal Burns occur more often during holidays celebrated with fireworks and school breaks. y Socio-economic status People living in substandard or older housing, as well as those in low income neighbourhoods are more likely to experience burns. D. Signs and symptoms y Damage to skin layers this is caused by the damaging effects of burn on the skin

Infection due to the impaired skin integrity and absorption of decomposed products from dead tissue.

Fever may indicate infection due to the release of toxins called pyrogens, stimulating the hypothalamus to increase the bodys temperature to combat microorganisms.

Pain caused by injury to nerve endings; for superficial and partial-thickness burns, pain maybe severe. For full-thickness burns loss of sensation may occur due to damaged nerves.

Hypoxia (for thermal and chemical burns) which is brought about by inhalation of smoke and chemical fumes, causing damage to the respiratory tract that may precede swelling and irritation to the larynx causing airway obstruction, resulting to severe respiratory insufficiency decreasing oxygen circulating in the body.

y y

Hypoxemia due to hemolysis, decreasing blood carrying oxygen to the body. Passage of brownish, black urine due to hemolysis, causing liberation of large quantities of RBC and myoglobin blocking the renal tubules causing renal shutdown.

Dehydration due to severe loss of fluid brought about by the increased permeability of blood capillaries; may lead to hypovolemic shock if left untreated.

Oliguria possibly due to dehydration and bodys attempt to conserve fluid by means of increasing aldosterone in the body to conserve sodium and increase production of anti-diuretic hormone.

y y y

Hyperkalemia Initially, due to loss of potassium at damged cells. Hypokalemia later sign, due to excretion of potassium at renal tubules. Weight loss due to increase energy requirement, increasing glucose and fat breakdown. But if insufficient, will lead to protein breakdown, causing (-) nitrogen balance and increase ammonia, which may also cause liver impairment.

y y

Ketoacidosis brought about by the breakdown of fat. Curlings ulcer because of loss of plasma proteins at tissue, osmotic pressure

causing congestion at mucosal capillaries, resulting to gastric dilation. y Hematemesis/melena due to bleeding ulcers.

Limitation to range of motion, and impairment at movement and coordination this is brought about by formation of severe scars from damaged skin, which stretches to cover wound as healing progresses.

Eschar - piece of dead tissue that is cast off from the surface of the skin, particularly after a burn injury

V. MEDICAL MANAGEMENT First aid Remove the casualty from further injury. Extinguish flames, remove clothing, turn off the electrical source, or douse the chemically burnt patient with water. Flames ascend so lie the patient down. Cover the burn with a clean dressing, avoid the patient getting cold and transfer to a hospital as soon as possible. Additional oxygen should be given during transfer. Primary management Airway - check the airway is clear. Endotracheal intubation is necessary if there are deep burns to the face and neck, soot in the nostrils, burns of the tongue and pharynx, stridor or hoarseness.
y

History including

time

and

nature

of

the

incident

(Wet

or

dry

burn/chemical/electrical/inside or outside).
y y y y y

Weigh the patient. Examine the burn and assess the size with the 'rule of nines' to give a %BSA. Intravenous access - obtain large bore venous access, even through burnt tissue. Analgesia - intravenous morphine, ketamine, or Entonox. Catheterize - assess urine output as a gauge of tissue perfusion and adequate resuscitation.

Reassess the patient thoroughly at regular intervals and also the burn.

Fluid resuscitation This should be instituted as soon as possible. There are two simple protocols that both depend upon the %BSA, time passed since injury and patients weight. The rule of nines may over-estimate the BSA, but the Lund and Browder chart gives a more accurate assessment. Fluid requirements may be greater than the protocols suggest.

Parklands: Crystalloid resuscitation with Hartmanns 24 hour fluid requirement = 4 x %BSA x Wt (Kg) Give half over the first 8 hours, and the remainder over the next 16 hours

Although there may be pronounced generalized edema initially, as large volumes are required, it is cheap and produces less respiratory problems later on.

Muir and Barclay: Colloid resuscitation with plasma The first 36 hours are divided into time periods of 4,4,4,6,6,12 hour intervals Each interval = 0.5 x %BSA x Wt (Kg)

With colloid resuscitation, less volume is required and the blood pressure is better supported. However they are expensive, often unavailable and tend to leak out of the circulation and may result in later edema especially in the lungs. Controversy remains as to which fluid should be used. Inhalational injury may increase fluid requirements by 50%. Both regimes require regular assessment as to the adequacy of resuscitation. This includes blood pressure, pulse, capillary return, urine output, level of consciousness and hematocrit. Additional fluid should be given if resuscitation is inadequate. Water loss is related to evaporative and other extrarenal losses and may lead to a hypernatremia. Salt intake should be balanced against the plasma sodium concentration, but is usually about 0.5mmol/kg/%BSA. If the burn is left exposed in an hot environment, sodium free water intake must be increased, but only to achieve a moderate hypernatremia. Aggressive water load may lead to a low plasma sodium and result in 'burn encephalopathy'. Hyperkalemia usually associated with severe muscle damage may require correction with insulin and dextrose.

Airway management A high index of suspicion is required regarding the patient's airway. Laryngeal oedema develops from direct thermal injury leading to early loss of the airway. With signs of an airway burn (soot in the nostrils/stridor/hoarse voice) consider early intubation of the patient. If in doubt, it is better to protect the airway (and be able to provide tracheobronchial tube) than to risk losing the airway altogether. A tracheostomy may be necessary if there is any delay in securing the 'at risk' airway. The airway is further endangered by an associated loss of respiratory drive due to a depressed level of consciousness (eg head injury or carbon monoxide poisoning). Again intubation may be required. Dressings Are necessary to reduce infection and absorb exudate. Bactericidal agents, such as silver sulphadiazine 1% and silver nitrate are used. Antibiotic preparations should be avoided to prevent resistant colonisation developing. Regular, often daily, dressing changes are recommended, and the patient should be washed with clean warm water. Diet Low protein and increase in zinc intake help to heal burns and helps promote tissue repair. Zinc is also known to help boost a persons immune system. Some of the sources of zinc include lean meats, yogurt, fruits, vegetables and shellfish. Vitamin C should also be considered an essential part of a burn victims diet. This vitamin works together Zinc and helps fight infections. Sources of vitamins C include fresh fruits and green leafy vegetables. Dehydration is common in people with burns. Intake of tomato or apple juice, chicken or beef broth helps in refueling the body with the required fluid. Taking as well 2 to 3 liters of water may be done, if not contraindicated.

Avoid caffeine since it is known to have a diuretic effect, caffeine enriched beverages should be avoided, became the body must maintain fluids to heal. Examples are coffee, and carbonated drinks.

VI. SURGICAL MANAGEMENT

1. GRAFTING Definition: Skin grafting is a surgical procedure in which skin or a skin substitute is placed over a burn or non-healing wound.

Purpose: A skin graft is used to permanently replace damaged or missing skin or to provide a temporary wound covering. This covering is necessary because the skin protects the body from fluid loss, aids in temperature regulation, and helps prevent disease-causing bacteria or viruses from entering the body. Skin that is damaged extensively by burns or non-healing wounds can compromise the health and well-being of the patient.

Procedure: The patient's wound must be free of any dead tissue, foreign matter, or bacterial contamination. After the patient has been anesthetized, the surgeon prepares the wound by rinsing it with saline solution or a diluted antiseptic (Betadine) and removes any dead tissue by dbridement. In addition, the surgeon stops the flow of blood into the wound by applying pressure, tying off blood vessels, or administering a medication (epinephrine) that causes the blood vessels to constrict. Following preparation of the wound, the surgeon then harvests the tissue for grafting. A split-thickness skin graft involves the epidermis and a little of the underlying dermis; the donor site usually heals within several days. The surgeon first marks the outline of the wound on the skin of the donor site, enlarging it by 35% to allow for tissue shrinkage. The surgeon uses a dermatome (a special instrument for cutting thin slices of tissue) to remove a splitthickness graft from the donor site. The wound must not be too deep if a split-thickness graft is going to be successful, since the blood vessels that will nourish the grafted tissue must come from the dermis of the wound itself. The graft is usually taken from an area that is ordinarily hidden by clothes, such as the buttock or inner thigh, and spread on the bare area to be covered. Gentle pressure from a well-padded dressing is then applied, or a few small sutures used to hold the graft in place. A sterile nonadherent

dressing is then applied to the raw donor area for approximately three to five days to protect it from infection. Normal results: A skin graft should provide significant improvement in the quality of the wound site, and may prevent the serious complications associated with burns or nonhealing wounds. Normally, new blood vessels begin growing from the donor area into the transplanted skin within 36 hours. Occasionally, skin grafts are unsuccessful or don't heal well. In these cases, repeat grafting is necessary. Even though the skin graft must be protected from trauma or significant stretching for two to three weeks following splitthickness skin grafting, recovery from surgery is usually rapid. A dressing may be necessary for one to two weeks, depending on the location of the graft. Any exercise or activity that stretches the graft or puts it at risk for trauma should be avoided for three to four weeks. A one to two-week hospital stay is most often required in cases of full-thickness grafts, as the recovery period is longer. Risks: The risks of skin grafting include those inherent in any surgical procedure that involves anesthesia. These include reactions to the medications, breathing problems, bleeding, and infection. In addition, the risks of an allograft procedure include transmission of an infectious disease from the donor. The tissue for grafting and the recipient site must be as sterile as possible to prevent later infection that could result in failure of the graft. Failure of a graft can result from inadequate preparation of the wound, poor blood flow to the injured area, swelling, or infection. The most common reason for graft failure is the formation of a hematoma, or collection of blood in the injured tissues. 2. FASCIOTOMY Definition: is a surgical procedure that cuts away the fascia to relieve tension or pressure.

Purpose: When a fasciotomy is performed on other parts of the body, the usual goal is to relieve pressure from a compression injury to a limb.. Blood vessels of the limb are damaged. They swell and leak, causing inflammation. Fluid builds up in the area contained by the fascia. A fasciotomy is performed to relieve this pressure and prevent

tissue death. Similar injury occurs in high-voltage electrical burns that cause deep tissue damage.

Procedure: Fasciotomy in the limbs is usually performed by a surgeon under general or regional anesthesia. An incision is made in the skin, and a small area of fascia is removed where it will best relieve pressure. Then the incision is closed.

Normal results: Fasciotomy in the limbs reduces pressure, thus reducing tissue death.

Risks: Risks involved with fasciotomy are those associated with the administration of anesthesia and the development of blood clots or postsurgical infections.

3. ESCHAROTOMY Definition: An escharotomy is a surgical procedure performed to allow greater circulation to a part of the body. A severe injury, such as a burn, can cause skin and tissue to swell so much that blood no longer flows easily past the injury.

Purpose: To prevent damage to the tissues that are not getting enough blood, surgical incisions are made along the damaged area, which releases the pressure of the swollen tissues and allows blood flow to resume. Because of the swelling of the damaged tissue, the surgical incisions may spread open, showing the tissues and structures beneath the skin. Any open wound has a risk of infection so the area may be covered in sterile bandages.

Normal results: Escharotomy in the limbs reduces pressure, thus reducing tissue death.

Risks: Risks involved with escharotomy are those associated with the administration of anesthesia and the development of blood clots and especially postsurgical infections because it is left open to relieved the pressure.

VII. NURSING CARE PLANS

1. Risk for infection related to inadequate primary defenses

2. Acute Pain related to destruction of skin and tissues, edema formation, manipulation of injured tissuesskin grafting

3. Ineffective airway clearance, related to increasing lung congestion secondary to smoke inhalation

4. Impaired gas exchange related to ventilation perfusion imbalance secondary to inhalation of smoke/ chemical fumes

5. Decreased

cardiac

output

related

to altered

afterload

secondary

to

hypovolemic shock

6. Deficient fluid volume related to abnormal fluid loss secondary to burn injury

7. Ineffective tissue perfusion related to peripheral constriction secondary to circumferential burn wounds

8. Impaired skin integrity related to destruction of epidermis, dermis

9. Impaired physical mobility related to skin contractures

10. Disturbed body image related to scar formation secondary to burn injury

VIII. CONCLUSION

In this case report, I learned that getting burned not only will destroy your physical appearance, but can also destroy your image of yourself and may also affect self-confidence. I was reminded of my patient 2 years ago during my duty at pediatric ward who suffered from electrical burns. During that time, I dont have any idea what might an electrical burn brings, I didnt know that he had large blisters at his hands not until I was given an order for wound cleaning. I didnt notice it because what I thought is that it is only covered because of that he might have IV inserted at his hands that it had to be reinserted on the other arm. In this case patients arent seriously burnt from the outside, but are fatally injured in his internals. As I can see the most fatal of burn are electrical in nature and my client is lucky to be alive, because when electrocuted the almost all parts of the body is affected. This case report helps me learn more about the nature of burns. In addition, although recent advances in burn management have improved survival in patient with burns, the burn patient continues to present a major therapeutic challenge. Well-designed, prospective studies are needed to establish definitive guidelines for optimal surgical and medical management of burns among adults. Additionally, these patients have unique rehabilitation requirements that need to be addressed in order to maximize return to pre-injury level of functioning. With the growing number of burn survivors, it will be increasingly important to evaluate and improve the long-term function and quality of life outcomes of this population. Finally, strategies for burn prevention and education remain central to limiting the burden of burn injury among patients.

IX. REFERENCES: y y y http://www.essortment.com/heal-burns-faster-diet-food-49062.html http://www.burnsurgery.org/Modules/orders/sec2.htm http://www.anatomy.tv/StudyGuides/StudyGuide.aspx?guideid=18&nextID=1& maxID=0&customer=primal y y http://www.patient.co.uk/doctor/Burns-Assessment-and-Management.htm http://www.typesofburns.com/