Medical surgical Nursing

1. BURN MANAGEMENT AND PLASTIC
SURGERIES
PRESENTER
Mrs. Shaveta Sharma
Assistant Professor
Saraswati Nursing Institute, Kurali
Punjab

2. The burnspatienthasthe sameprioritiesas all other
traumapatients.
Assess:
- Airway
- Breathing: beware of inhalation and
rapid airway compromise
- Circulation: fluid replacement
- Disability: compartment syndrome
- Exposure: percentage area of burn.

3. Essential management points
- Stop the burning
- ABCDE
-Good IV access and early fluid replacement.
-Determine the percentage area of burn (Rule
of 9’s)
The severity of the burn is determined by:
- Burned surface area
- Depth of burn
- Other considerations.

4. Burn Management in Adults
• The “Rule of 9’s” is commonly used to estimate the
burned surface area in adults.
• The body is divided into anatomical regions that
represent 9% (or multiples of 9%) of the total body
surface. The outstretched palm and fingers
approximates to 1% of the body surface area.
• If the burned area is small, assess how many times
patient’s hand covers the area.
• Morbidity and mortality rises with increasing burned
surface area. It also rises with increasing age so that
even small burns may be fatal in elderly people.

5. Rule of Nines for Establishing
Extent of Body Surface Burned
Anatomic
Surface
% of total
body surface
Head and neck 9%
Anterior trunk 18%
Posterior trunk 18%
Arms, including
hands
9% each
Legs, including
feet
18% each
Genitalia 1%

6. Burn Management in Children

7. Depth of burn
Depth of burn Characteristics Cause
First degree burn • Erythema
• Pain
• Absence of blisters
• Sunburn
Second degree
(Partial thickness)
• Red or mottled
• Flash burns • Contact with hot
liquids
Third degree
(Full Thickness)
• Dark and leathery
• Dry
• Fire
• Electricity or
lightning
• Prolonged
exposure to hot
liquids/
objects

8. Serious burn requiring hospitalization
- Greater than 15% burns in an adult
- Greater than 10% burns in a child
- Any burn in the very young and the elderly or the
infirm
- Any full thickness burn
- Burns of special regions: face, hands, feet,
perineum
- Circumferential burns
- Inhalation injury
- Associated trauma or significant pre-burn illness:
e.g. diabetes

9. TREATMENT
• General information
– All burn patients should initially be treated with the
principles of Advanced Burn and/or Trauma Life
Support
• The ABC's (airway, breathing, circulation)
• Search for other signs of trauma
• Verified Burn Centers provide advanced support for
complex cases
– Certified by the American College of Surgeons (ACS)
Committee on Trauma and the American Burn
Association (ABA)
– Resources will give advice or assist with care
• Burn Unit Referral Criteria

10. AIRWAY
Burns to the head and Burns inside the mouth :-
Intubate early if massive burn or signs of
obstruction
Intubate if patients require prolonged transport and
any concern with potential for obstruction
If any concerns about the airway, it is safer to
intubate earlier than when the patient is
decompensating
Massive burns :-All patients with deep burns
>35-40% TBSA should be endotracheally
intubated

11. Signs of airway obstruction
• Hoarseness or change in voice
• Use of accessory respiratory muscles
• High anxiety
–Tracheostomies not needed during
resuscitation period
–Remember: Intubation can lead to
complications, so do not intubate if not
needed

12. BREATHING
Hypoxia:- Fire consumes oxygen so people may
suffer from hypoxia as a result of flame injuries
Carbon monoxide (CO)
Byproduct of incomplete combustion
Binds hemoglobin with 200 times the affinity of
oxygen
Leads to inadequate oxygenation

13. Diagnosis of CO poisoning
Nondiagnostic Diagnostic
PaO2
Oximeter
Patient
color
Carboxyhemo-
globin levels
<10% is normal
>40% is severe
intoxication
Treatment:-Remove source , 100% oxygen
until CO levels are <10% .

14. Smoke inhalation injury
Smoke particles settle in distal bronchioles
Mucosal cells die
Sloughing and distal atelectasis
Increase risk for pneumonia

15. Diagnosis
HistoryBronchoscopy
Non-diagnostic
clinical tests
•Early chest x-ray
•Early blood gases
Nondiagnostic
clinical findings
•Soot in sputum or
saliva
•Singed facial hair
Treatment :-Supportive pulmonary management
and Aggressive respiratory therapy

16. CIRCULATION
Obtain IV access anywhere possible
Unburned areas preferred
Burned areas acceptable
Central access more reliable if
proficient
Cut-downs are last resort

17. Resuscitation in burn shock
(first 24 hours)
• Massive capillary leak occurs after major burns
• Fluids shift from intravascular space to
interstitial space
• Fluid requirements depends on severity of burn
• IV fluid rate dependent on physiologic response
– Place Foley catheter to monitor urine output
– Goal for adults: urine output of 0.5 ml/kg/hour
– Goal for children: urine output of 1 ml/kg/hour
– If urine output below these levels, increase fluid rate
• Preferred fluid: Lactated Ringer's Solution

18. RESUSCITATION FORMULAS
PARKLAND FORMULA
Fluid calculation
– 4 x weight in kg x %TBSA burn
• Give 1/2 of that volume in the first 8 hours
• Give other 1/2 in next 16 hours
– Adjust fluid rate to maintain urine output of 50 ml/hr
– Albumin may be added towards end of 24 hours if
not adequate response

19. RESUSCITATION ENDPOINT
Maintenance rate
• When maintenance rate is reached (approximately 24
hours), change fluids to D50, 5NS with 20 mEq KCl at
maintenance level
• Maintenance fluid rate = basal requirements + evaporative
losses
– Basal fluid rate
• Adult basal fluid rate = 1500 x body surface area (BSA) (for 24 hrs)
• Pediatric basal fluid rate (<20kg) = 2000 x BSA (for 24 hrs)
– May use
» 100 ml/kg for 1st 10 kg
» 60 ml/kg for 2nd 10 kg
» 20 ml/kg for remaining kg for 24 hrs
– Evaporative fluid loss
• Adult: (25 + % TBSA burn) x (BSA) = ml/hr
• Pediatric (<20kg): (35 + % TBSA burn) x (BSA) = ml/hr

20. COMPLICATIONS OF OVER-RESUSCITATION
LIMB COMPARTMENT SYNDROMES
• Symptoms of severe pain (worse with movement),
numbness, cool extremity, tight feeling compartments
• Distal pulses may remain palpable despite ongoing
compartment syndrome (pulse is lost when pressure >
systolic pressure)
• Compartment pressure >30 mmHg may compromise
muscle/nerves
• Measure compartment pressures with arterial line
monitor (place needle into compartment)
• Escharotomies may save limbs
• Fasciotomies may be needed if pressure does not drop
to <30

21. Chest Compartment Syndrome
• Increased peak inspiratory pressure (PIP)
due to circumferential trunk burns
• Escharotomies through mid-axillary line,
horizontally across chest/abdominal junction

22. Abdominal Compartment Syndrome
• Pressure in peritoneal cavity > 30 mmHg
• Signs: increased PIP, decreased urine
output despite massive fluids,
hemodynamic instability, tight abdomen
• Treatment
• Abdominal escharotomy
• NG tube
• Possible placement of peritoneal catheter to
drain fluid
• Laparotomy as last resort

23. Acute Respiratory Distress
Syndrome (ARDS)
– Increased risk and severity if over-resuscitation
– Treatment supportive
• Medications
– All pain medicines should be given IV
– Tetanus prophylaxis should be given as
appropriate
– Prophylactic antibiotics are contraindicated
– Systemic antibiotics are only given to treat
infections

24. SPECIAL BURNS
• Often require specialized care
• Calling a Verified Burn Center is advised
• Electrical injuries
– Extent of injury may not be apparent
• Damage occurs deep within tissues
• Damage frequently progresses
• Electricity contracts muscles, so watch for associated
injuries
– Cardiac arrhythmias may occur
• If arrhythmia present, patient needs monitoring
• CPR may be lifesaving

25. • Myoglobinuria may be present
– Color best indicator of severity
– If urine is dark (black, red), myoglobinuria needs to
be treated
• Increase fluids to induce urine output of 75-100 ml/hr in
adults
• In children, target urine output of 2 ml/kg/hour
• Alkalinize urine (give NaHCO3)
• Check for compartment syndromes
• Mannitol as last resort
– Long-term neuro-psychiatric problems may result
• CHEMICAL BURNS
– Brush off powder
– Prolonged irrigation required
– Do not seek antidote(Delays treatment ,May result in
heat production )
– Special chemical burns require contacting a Verified Burn
Center, for example: Hydrofluoric acid burn

26. WOUND CARE
FIRST AID
• If the patient arrives at the health facility without first aid having been
given, drench the burn thoroughly with cool water to prevent further
damage and remove all burned clothing.
• If the burn area is limited, immerse the site in cold water for 30
minutes to reduce pain and oedema and to minimize tissue
damage.
• If the area of the burn is large, after it has been doused with cool
water, apply clean wraps about the burned area (or the whole
patient) to prevent systemic heat loss and hypothermia.
• Hypothermia is a particular risk in young children.
• First 6 hours following injury are critical; transport the patient with
severe burns to a hospital as soon as possible.

27. Initial treatment
• Initially, burns are sterile. Focus the treatment on speedy healing and
prevention of infection.
• In all cases, administer tetanus prophylaxis.
• Except in very small burns, debride all bullae. Excise adherent necrotic
(dead) tissue initially and debride all necrotic tissue over the first several
days.
• After debridement, gently cleanse the burn with 0.25% (2.5 g/litre)
chlorhexidine solution, 0.1% (1 g/litre) cetrimide solution, or another mild
water-based antiseptic.
• Do not use alcohol-based solutions.
• Gentle scrubbing will remove the loose necrotic tissue. Apply a thin layer
of antibiotic cream (silver sulfadiazine).
• Dress the burn with petroleum gauze and dry gauze thick enough to
prevent seepage to the outer layers.

28. Daily treatment
• Change the dressing daily (twice daily if possible) or as often as
necessary to prevent seepage through the dressing. On each
dressing change, remove any loose tissue.
• Inspect the wounds for discoloration or hemorrhage, which indicate
developing infection.
• Fever is not a useful sign as it may persist until the burn wound is
closed.
• Cellulitis in the surrounding tissue is a better indicator of infection.
• Give systemic antibiotics in cases of haemolytic streptococcal
wound infection or septicaemia.
• Pseudomonas aeruginosa infection often results in septicaemia and
death. Treat with systemic aminoglycosides.

29. Administer topical antibiotic chemotherapy daily. Silver nitrate (0.5%
aqueous) is the cheapest, is applied with occlusive dressings but
does not penetrate eschar. It depletes electrolytes and stains the
local environment.
• Use silver sulfadiazine (1% miscible ointment) with a single layer
dressing. It has limited eschar penetration and may cause
neutropenia.
• Mafenide acetate (11% in a miscible ointment) is used without
dressings. It penetrates eschar but causes acidosis. Alternating these
agents is an appropriate strategy.
• Treat burned hands with special care to preserve function.
− Cover the hands with silver sulfadiazine and place them in loose
polythene gloves or bags secured at the wrist with a crepe bandage;
− Elevate the hands for the first 48 hours, and then start hand exercises;
− At least once a day, remove the gloves, bathe the hands, inspect the
burn and then reapply silver sulfadiazine and the gloves;
− If skin grafting is necessary, consider treatment by a specialist after
healthy granulation tissue appears.

30. • The depth of the burn and the surface involved
influence the duration of the healing phase. Without
infection, superficial burns heal rapidly.
• Apply split thickness skin grafts to full-thickness burns
after wound excision or the appearance of healthy
granulation tissue.
• Plan to provide long term care to the patient.
• Burn scars undergo maturation, at first being red,
raised and uncomfortable. They frequently become
hypertrophic and form keloids. They flatten, soften and
fade with time, but the process is unpredictable and
can take up to two years.
Healing phase

31. In children
- The scars cannot expand to keep
pace with the growth of the child and
may lead to contractures.
- Arrange for early surgical release of contractures before
they interfere with growth.
• Burn scars on the face lead to cosmetic deformity,
ectropion and contractures about the lips. Ectropion
can lead to exposure keratitis and blindness and lip
deformity restricts eating and mouth care.
• Consider specialized care for these patients as skin
grafting is often not sufficient to correct facial deformity.

32. OTHER WOUND CARE METHODS
Exposure Method:
Leaving a burn open is a poor option but where
dressings are not possible it may be the only
option.
The patients is washed daily and kept of clean
dry sheets with another sheet or mosquito net
draped over a frame to reduce the pain from
air currents and to reduce contamination from
the environment.
Ambient temperature control is important to
maintain normothermia.

33. Tubbing
Most modern burn units avoid the regular
immersion of patients in water both because they
practice early excision and grafting and because
of the high risks developing resistant strains of
bacteria in the tub environment and of patient
cross-infection. That said, tubbing can be helpful
to clean the wounds and gently remove eschar
as it separates.
When early wound infections develop avoid the
routine immersion of infected patients in
bathtubs.

34. Bland Dressings
These provide a clean, moist wound healing
environment, absorb exudates protect from
contamination and provide comfort. Paraffin
gauze is used and can be manufactured locally
i.e. Honey and ghee etc. Gauze sheets can be
applied directly to wound in a single layer and
covered with plain dry gauze to absorb
exudates,then wrapped.
Dressings should be changed
at least ever second day, or
when soiled.

35. Antimicrobial dressing
These are effective in delaying
the onset of invasive wound
infections. There are newer
silver-ionized agents that
can be used; however they
are often very costly and
inaccessible in low-income
countries.

36. SURGICAL TREATMENT OF BURNS
PLASTIC SURGERY FOR BURNS OR
WOUNDS

37. Time of performing procedure
Urgent procedures
• Exposure of vital structures (such as eyelid releases)
• Entrapment or compression of neurovascular bundles
• Fourth degree contractures
• Severe microstomia
Essential procedures
• Reconstruction of function (such as limited range of
motion)
• Progressive deformities not correctable by ordinary
methods
Desirable procedures
• Reconstruction of passive areas
• Aesthetics

38. Techniques for burn reconstruction
Without deficiency of tissue
• Excision and primary closure
• Z-plasty
With deficiency of tissue
• Simple reconstruction
• Skin graft
• Dermal templates and skin grafts
Transposition flaps (Z-plasty and modifications)
• Reconstruction of skin and underlying tissues
Axial and random flaps
Myocutaneous flaps
Tissue expansion
• Free flaps

39. Essentials of burn reconstruction
• Strong patient-surgeon relationship
• Psychological support
• Clarify expectations
• Explain priorities
• Note all available donor sites
• Start with a “winner” (easy and quick operation)
• As many surgeries as possible in preschool years
• Offer multiple, simultaneous procedures
• Reassure and support patient

40. Escharotomy
• Definition.—An escharotomy is defined as a
surgical incision through burn eschar (necrotic
skin). This procedure is usually performed
within the first 24 hours of burn injury. Burn
eschar has an unyielding, leathery consistency
and is characterized by denatured proteins
and coagulated vessels in the skin, which are
the result of thermal, chemical or electrical
injury.

41. Escharotomy

42. Debridement of Burn Wounds
• Definition—Debridement is the removal of loose,
devitalized, necrotic, and/or contaminated tissue,
foreign bodies, and other debris on the wound
using mechanical or sharp techniques (such as
curetting, scraping, rongeuring, or cutting). The
level of debridement is defined by the level of the
tissue removed, not the level exposed by the
debridement process.
• Purpose—Debridement cleans the wound and
allows it to heal more rapidly with reduced risk of
infection.

43. Excision of Burn Wounds
Definition—Excision is a surgical procedure requiring incision
through the deep of open wounds, burn scars. This entails
surgical removal of all necrotic tissue.
Purpose—Excision is typically performed on deep burns that
would not heal on their own. The goal is to remove all necrotic
and non-viable tissue and to prepare the wound for immediate
or delayed wound closure. Excisional techniques create a wound
surface that is fully vascularized and ready for application of
temporary or permanent skin replacement or substitute.
Technique—
Tangential excision involves surgical removal of successive layers
of the burn wound down to viable dermis.
Full thickness excision—often using electrocautery involves
removal of the burn wound down to viable subcutaneous tissue

44. Tangential excision Full thickness excision

45. Skin Grafts
Skin is removed from one area of the body and
transplanted to another. There are two types of skin
graft:
• split-thickness grafts in which just a few layers of
outer skin are transplanted
• full-thickness grafts, which involve all of the dermis.
There is usually permanent scarring that is
noticeable.

46. Single- and Multiple-Stage Excision
and Grafting
Single-Stage Excision and Grafting :- Surgical closure of
burn wounds achieves two goals.
The first is to facilitate optimal and rapid healing of the
wound, minimizing deleterious consequences such as
scar contracture while maximizing the best functional and
cosmetic outcomes.
The second is to improve the adverse influence of the
burn wounds on the body’s systemic responses,
especially the immune and metabolic systems.
Meticulous wound preparation and application of skin
grafts leads to excellent functional and cosmetic results.

47. The single-stage approach to excision and grafting of
burn wounds includes seven intraoperative
components:
1. Initial decision-making
a. Area(s) to be excised
b. Depth of the excision
c. Location of donor sites
2. Excision of the burn wound,
3. Achieving hemostasis with
electrocautery and topical application
of solutions containing vasoconstrictive
agents (such as epinephrine or
phenylephrine) and/or pro-coagulants

48. 4. Harvesting the donor skin
5. Modification/expansion of the skin
graft by meshing.
6. Applying and securing the skin graft
to the excised wound
7. Placement of dressings and splints to
avoid mechanical shear of the grafts
and to maintain proper positioning.

49. Multiple-Stage Excision and Grafting
• It is performed in steps in a planned sequence where part of
the burn wound is excised initially and the remainder is
removed in one or more subsequent operations.
• This is often done with cosmetically important areas such as
the face, as well as with more extensive burns or burns in
physiologically less stable patients.
• The excision is done on the initial operative day and the
freshly excised wound bed is protected with a temporary
covering to prevent desiccation and infection.
• This is followed in one to two days by harvesting and
placement of the skin autografts.
• Staged skin grafting of face burns allows inspection for
hematomas or inadequately excised areas that would lead to
graft loss and can result in nearly 100% graft take.

50. Single-Stage Excision and
Grafting
Multiple-Stage Excision and
Grafting

51. BURN WOUND COVERAGE
• Covering the burn wound helps to prevent
infection, decrease fluid losses, and reduce
the risk of scar contractures.
• Simple, small burn wounds are excised and
covered by either a full thickness skin graft or
by a split-thickness skin graft. The thicker the
graft, the less it will contract and the more
difficult it is for the donor site to heal.

52. Skin Substitutes and Skin Replacements
Skin replacement: A tissue or graft that
permanently replaces lost skin with healthy
skin.
Skin substitute [commercial product]: A
biomaterial, engineered tissue or combination
of materials and cells or tissues that can be
substituted for skin autograft or allograft in a
clinical procedure

53. Temporary Wound
CoverageTemporary skin substitutes are used when the wound
is too extensive to be closed in one stage because:-
• there is not enough donor skin available
• the patient is too ill to undergo the creation of another
wound that results when skin is harvested from a
donor site
• there is a question regarding the viability of the
recipient bed
• concern regarding potential infectious complications.
• The gold standard temporary skin substitute is
cadaver allograft

54. Allograft
• Allograft is obtained from skin
banks to ensure quality and
safety. Allograft may be used as
fresh, refrigerated tissue or as
frozen tissue, which is thawed
immediately prior to use.
• Other temporary skin substitutes
are used to provide transient
wound coverage and to create a
physiologically homeostatic
environment. Skin Xenografts—
also termed heterografts .

55. Xenograft
Pigskin is used at many
institutions in the same
manner as allograft.
The application of
xenograft on a
debrided mid-dermal
burn might prevent/
obviate the need for
excision and auto-
grafting.

56. Permanent Wound
CoverageA full-thickness skin graft contains
epidermis, dermis, hair follicles and
nerve endings. The most important
advantage of full-thickness grafts is
decreased scar formation
the donor site of a full-thickness skin
graft must be closed either with
primary direct closure or with a split-
thickness skin

57. Split-thickness Skin
Graft
The split-thickness skin graft
is the most common method
used to achieve permanent
wound coverage. It includes
the entire epidermis but the
dermal layer is split by the
dermatome blade.

58. There are a number of commercially
available products
to facilitate permanent wound
coverage.• Acellular human dermal allograft
(Alloderm®)
• Dermal regenerative template (Integra®)
• Cultured epidermal autograft (CEA;
Epicel®)

59. OTHERS
Microsurgery Microsurgery
may allow organs to be re-
attached. Simply stated, it is
a procedure in which the
surgeon uses a microscope
for surgical assistance in
reconstructive procedures.
By using a microscope, the
surgeon can actually sew
tiny blood vessels or nerves,
allowing him or her to repair
damaged nerves and
arteries.

60. Free flap
procedureA free flap procedure is often
performed during breast
reconstruction or following
surgery to remove head or neck
cancer. During the procedure,
muscle, skin, or bone is
transferred along with the original
blood supply from one area of the
body (donor site) to the surgical
site in order to reconstruct the
area. Total recovery may take six
to eight weeks or longer.

61. Tissue expansions
Tissue expansion is a medical
procedure that enables patient’s
body to "grow" extra skin for use in
reconstructive procedures. This is
accomplished by inserting san
instrument known as a "balloon
expander" under the skin near the
area in need of repair. Over time, this
balloon will be gradually filled with
saline solution (salt water), slowly
causing the skin to stretch and grow,
much the same way a woman's skin
stretches during pregnancy.

62. Dealing with deficiency of tissue
If there is no deficiency and local tissues
can be easily mobilised, excision and
direct closure or Z-plasties can be
performed.
(1) The burn scar, showing the skin
tension lines.
(2) Z-plasty is performed by rotating two
transposition flaps with an angle of
60° with the middle limb of the Z on
the scar.

63. Skin Changes After Cosmetic
Surgery
As patient continue to heal, patient will notice
changes in the color, appearance, and feeling
of patient’s skin at the surgical site. Patient
also may notice numbness, a tingling
sensation, or minimal feeling around patient’s
incisions. This is normal. These sensations
will continue to improve over the next few
months.

64. Perfusion and Circulation After
Cosmetic Surgery
After patient’s cosmetic surgery, it is important to
monitor perfusion and circulation of the wound
site.
Avoid wearing clothing that constricts or applies
pressure around patient’s wound.
Also, patient’s doctor may give patient a
additional instructions to help with circulation
to the wound.

66. Signs of Infection At
the Surgical Site
Notify patient’s doctor right away if patient
experience any of the following symptoms:
• White pimples or blisters around incision lines.
• An increase in redness, tenderness, or swelling of
the surgical site.
• Drainage from the incision line.
• A marked or sudden increase in pain not relieved
by the pain medication.

67. • A persistent elevation of body temperature greater
than 100.5 degrees Fahrenheit
• Sweats or chills
• Skin rash
• Sore or scratchy throat or pain when swallowing
• Sinus drainage, nasal congestion, headaches, or
tenderness along the upper cheekbones
• Persistent, dry or moist cough that lasts more than two
days
• White patches in patient’s mouth or on patient’s
tongue
• Nausea, vomiting, or diarrhea.
• Trouble urinating: pain or burning, constant urge or
frequent urination
• Bloody, cloudy, or foul-smelling urine.

68. POST-OPERATIVE DAILY EVALUATION
AND MANAGEMENT
• Operated Burn Wounds
• Care of Burn Wounds Unrelated To
Previously Operated Wounds
• Unrelated Conditions

69. POST-DISCHARGE BURN
WOUND MANAGEMENT
• Discharge and Follow Up
• Follow-up
• Scar prevention
• Contracture prevention
• Psychological sequelae

70. NUTRITIONAL MANAGEMENT
Assessment
• All inpatients with a deep burn injury are assessed by a
dietitian, in order to establish whether a need exists for
nutritional intervention.
Goals of nutritional management
• To promote optimal wound healing and rapid recovery
from burn injuries
• To minimise risk of complications, including infections
during the treatment period
• To attain and maintain normal nutritional status
• To minimise metabolic disturbances during the
treatment process

71. Objectives of nutritional management
• Provide nutrition via enteral route within 6 -
18 hours post burn injury
• Maintain weight within 5 % - 10 % of pre-burn
weight
• Prevent signs and symptoms of micronutrient
deficiency
• Minimise hyperglycaemia
• Minimise hypertriglyceridaemia

72. Nutritional Management
• Enteral Feeding Should Be Commenced Early
• Aggressive Nutritional Support is Often Required
• Energy Requirements are Elevated by the Burn
Injury
• Protein Requirements are Substantially
Increased
• An Increased Requirement Exists for Nutrients
Associated with Healing and Immune Function

73. COMPLICATIONS OF SURGERIES
FOR BURN MANAGEMENT
Complications to surgery in patients with
burns include bleeding, infection, or graft
loss. If infection is suspected, dressings
can be changed to include broad
spectrum aqueous Sulfamylon solution.

74. Outcome and Prognosis
With the exception of infants, the prognosis for
survival in children and adolescents is quite
good.
In the past decade, the size of a survivable injury
has increased from 70% BSA burned to more
than 95% BSA burned in children younger
than 15 years.

75. NURSING MANAGEMENT
Assessment:-
• Obtain Thorough History including- Causative
agent, duration of exposure, circumstances of
injury, age, initial treatment taken, pre-
existing medical problems, allergies, tetanus
immunization, height, weight.
• Perform ongoing assessment of hemodynamic
and respiratory status, condition of wounds
and signs of infection.

76. Ineffective gas exchange related to
inhalation injury.
Goal:- Achieve adequate oxygenation and respiratory
functions.
Interventions:-
• Provide humidified 100% oxygen until CO level is
known.
• Assess for signs of hypoxemia.
• Note character and amount of respiratory
secretions.
• Provide mechanical ventilation when required.

77. Decreased Cardiac output related to
fluid shift and hypovolemic shock.
Goal:- support cardiac output.
Intervention:-
• Position the patient to increase venous return.
• Give fluids as prescribed.
• Monitor vital signs.
• Check level of conscious.

78. Ineffective peripheral tissue perfusion
related to edema.
Goal:-promote peripheral circulation.
Intervention:-
• Remove all jewelry and clothing.
• Elevate extremities.
• Monitor peripheral pulses hourly.
• Monitor tissue pressure.

79. Risk for infection related to
reconstructive surgeries.
Goal:- Prevent risk for infections.
Interventions:-
• Check vital signs.
• Assess signs of wound infection-redness and
discharge.
• Change dressing as prescribed.
• Apply antibiotic topically and also administer
through IV route.

80. • Risk for excess fluid volume related to fluid resuscitation.
• Impaired skin integrity related to burn injury and surgical
intervention.
• Impaired urinary elimination related to indwelling
catheter.
• Ineffective thermoregulation related to loss of skin
surface.
• Impaired physical mobility related to edema, pain, skin
and joint contractures.
• Impaired nutrition: less than body requirement related to
hypermetabolic response to burn injury.
• Risk for injury related to decreased gastric mobility and
stress response.
• Acute pain related to injured nerves in burn wound and
skin tightness.
• Ineffective coping related to fear and anxiety.
• Disturbed body image related to cosmetic and functional
sequelae of burn wound.

81. BIBLIOGRAPHY
BOOK REFERENCES:-
• Basavanthappa BT. A Textbook of Medical Surgical Nursing.NewDelhi. Jaypee
Brothers.ed.2nd
• Black M. A Textbook of Medical Surgical Nursing.Noida.Elsevier.ed.8th
• Brunner S. A Textbook of Medical Surgical Nursing.Philadelphia. Lippincott
Company.ed.5th.1982
WEBSITE REFERENCE:-
• Greenwood JE. Burn injury and explosions: an Australian perspective. Eplasty.
2009 Sep 16;9:e40. [PubMed Citation]
• Orgill DP. Excision and skin grafting of thermal burns. N Engl J Med. 2009 Feb
26;360(9):893-901. [PubMed Citation]
• Holmes JH 4th. Critical issues in burn care. J Burn Care Res. 2008 Nov-Dec;29(6
Suppl 2):S180-7. [PubMed Citation] 47
• American Medical Association. CPT Assistant. Skin Replacement Surgery and Skin
Substitutes. Volume 16, October 2006. Herndon DN, ed. Total burn care. 2nd ed.
London: WB Saunders, 2002.
• Engrav LH, Donelan MB. Operative techniques in plastic and reconstructive
surgery. Face burns: acute care and reconstruction. London: WB Saunders, 1997.
• Achauer BM. Burn reconstruction. New York: Thiene, 1991.
• Barret JP, Herndon DN. Color atlas of burn care. London: WB Saunders, 2001.
• Brou JA, Robson MC, McCauley RL. Inventory of potential reconstructive needs
in the patient with burns. J Burn Care Rehabil 1989;10: 555-60.