Posted on 22nd Sep 2024 08:48:51 PM Medicine
1.1 General Introduction
Severe burn injury causes extensive damage and are notoriously complicated by loss of body fluids. More often than not, such wounds become seriously infected further aggravating morbidity. Despite advances in burn management, the mortality rate of these injuries continues to be high and the search for economical and easily available topical measures to control burn wound infection continues (Gajiwala et al., 2004). Invariably, many of the different methods applied for local treatment are still controversial (Gobel et al., 1990). Irrespectively, the main requirement in burn wound management is an economical, easy to apply, readily available dressing or method of coverage that will provide good pain relief, protect the wound from infection, promote healing, prevent heat and fluid loss, be elastic and non-antigenic and adhere well to the wound (Gobel et al., 1990; Ravishanker et al., 2003) while waiting for spontaneous epithelialization of superficial partial thickness burns or for permanent coverage with autologous epithelium of deeper burn wounds. Methods for handling burn wounds have changed in recent decades. Increasingly, aggressive surgical approach with early tangential excision and wound closure is being applied. It is probably the most significant change in recent years leading to improvement in mortality rates of burn victims at a substantially lower cost (Atiyeh et al., 2005; Linn et al. 1979). By shortening hospital stay, early wound closure reduces pain associated with local burn wound care, number of operative procedures and infective complications. It also decreases the severity of hypertrophic scarring, joint contractures and stiffness, and promotes quicker rehabilitation (Lofts, 1991). Irrespective of any other consideration, early healing is paramount for good aesthetic and functional recovery. It has been clearly demonstrated that disruption of epidermal–mesenchymal communication due to a delay in epithelialization, increases the frequency of developing fibrotic conditions (Sawicki et al., 2005) such as scar hypertrophy and contractures.
Autografts from uninjured skin remain the mainstay of treatment for many patients and skin graft preservation for the purpose of delayed application is still a basic tool in burn treatment and plastic and reconstructive surgery (Ben-Bassat. 2001). Autologous skin, however, has limited availability and is associated with additional scarring (Gajiwala et al., 2004). Severe burn patients invariably lack sufficient adequate skin donor sites (Rubis et al., 2002; Mackie, 2002; Garfein et al., 2003) necessitating alternatives for burn wound coverage and healing. Additional limitation to the modality of autologous partial thickness skin grafting is the creation of additional donor site wounds equivalent to second degree burns thus further increasing the total body surface area (TBSA) affected (Atiyeh et al., 2005).
The devastating effects of burns are long lasting at both an individual and societal level. These impacts are compounded in resource-poor settings, where the human and material resources necessary to deal with this complex public health problem are lacking. Developing nations are disproportionately affected - 95% of the 322,000 global fire-related deaths in 2002 occurred in low to middle-resource countries (The injury chartbook, 2002). A structured and comprehensive approach to burn care must be applied to resource-poor settings in order to improve outcomes.
A combination of improved management and prevention strategies has resulted in important declines in morbidity and mortality in the developed world. A recent US study demonstrated a 50% decline in burn-related mortality and hospital admissions over a 20 year period (McGwin et al., 2003). Patients are frequently surviving even the most devastating burns due to advances in infection control, antimicrobial and biologic wound coverings, as well as a better understanding of resuscitation and the systemic effects of burn physiology and associated lung injury in burn patients. However, a stark contrast is seen when comparing the burn related mortality rates in high and low-income countries. For example, the WHO Global Burden of disease database has reported an over 10 fold difference between mortality rates in South East Asia and Europe (The injury chartbook, 2002).
Unfortunately, without adequate resources in first-aid, acute surgical management and rehabilitation facilities, patients that do survive their burn injuries in developing countries often have poor, disfiguring and disabling long term outcomes. A Ghanaian study found that 18 % of childhood burns patients had suffered a physical impairment or disability (Forjuoh et al., 2001).
While large burns can be fatal, modern treatments developed since 1960 have significantly improved the outcomes, especially in children and young adults. Globally, about 11 million people seek medical treatment, and 300,000 die from burns each year (Peck, M.D. 2011). In the United States, approximately 4% of those admitted to a burn center die from their injuries.[4] The long-term outcome is primarily related to the size of burn and the age of the person affected.
1.2. Etiology and epidemiology
In order to understand and overcome the challenges in the management and prevention of burns in low-income countries, a close look at the epidemiology and causal factors involved is required. It is also necessary to understand the local economic constraints and the available health-care infrastructure.
There exist numerous hospital or clinic-based studies describing epidemiological characteristics of their burn population. Forjuoh has published a review of 117 articles from 34 low and middle-income countries (Forjuoh et al., 1995). The majority of these studies dealt with the pediatric population, with the highest incidence of burns occurring in infants and toddlers (ages 0-4 years) who are dependent on others for their care. In a study from Angola which looked at all age groups, the pediatric population accounted for as much as one third of all burn victims (Barss, 1983). A comprehensive population-based study in Ghana identified and calculated the strength of specific risk factors found in childhood burns; the presence of a pre-existing impairment such as epilepsy was associated with 6.7 greater odds of a burn, a finding supported by many other studies. Other risk factors identified in case-control studies include history of a burn or burn-death in a sibling, low income, illiteracy, poor living conditions and careless practices (Singh et al., 1998). All these reflect the importance of identifying and developing prevention strategies that reach marginalized populations.
In many countries in Africa and Asia, young women are also at particular risk. A reversal of gender distribution is seen compared to most other injury mechanisms. Women in East Asia account for 26% of the burn deaths worldwide, the highest burn mortality rates of any population (Gupta, 1988). This risk is attributed to the domestic role of women cooking in the home, using unsafe ground-level stoves oil-lanterns or open-fires and frequently wearing highly flammable synthetic, loose clothing (Daisy et al., 2001). Some authors have found that violence against women is a frequent underlying causal factor in fatal burns, often billed as suicide in newlywed young women.
Most burns occur in the home, commonly in the cooking area, accounting for the high proportion of scald burns, followed by flame burns. Combined, they account for over 80% of all burns seen in low-income countries (Peck, 2011). Electrical burns are also frequently seen in low-income areas where building codes may be less stringent and homes may be built near high tension wires. Although most studies report higher burn rates in urban settings, this could be due to a publication bias, with few district hospitals having the means to carry out and publish results (Damo, et al., 1995). Given the lack of first-aid resources and longer distances to travel to medical care in rural settings, it is not surprising that outcomes are worse in these locations. This is intuitively understood and is illustrated in a South African study showing that the average pre-hospital delay was 42 hrs in rural South Africa, with high rates of wound infection (22%), contractures (6%) and prolonged length of stay (Chopra et al., 1997).
1.3 Pathophysiology
At temperatures greater than 44 °C (111 °F), proteins begin losing their three-dimensional shape and start breaking down. This results in cell and tissue damage. Many of the direct health effects of a burn are secondary to disruption in the normal functioning of the skin. They include disruption of the skin's sensation, ability to prevent water loss through evaporation, and ability to control body temperature. Disruption of cell membranes causes cells to lose potassium to the spaces outside the cell and to take up water and sodium (Tintinalli, 2010).
In large burns (over 30% of the total body surface area), there is a significant inflammatory response. This results in increased leakage of fluid from the capillaries, and subsequent tissue oedema (Tintinalli, 2010). This causes overall blood volume loss, with the remaining blood suffering significant plasma loss, making the blood more concentrated (Tintinalli, 2010). Poor blood flow to organs such as the kidneys and gastrointestinal tract may result in renal failure and stomach ulcers (Hannon, 2010).
Increased levels of catecholamines and cortisol may result in a hypermetabolic state which can last for years. This is associated with increased cardiac output, metabolism, a fast heart rate, and poor immune function (Rojas, et al., 2012).
1.4 Estimate of TBSA
Total body surface area (TBSA) is an assessment measure of skin burns. As shown in Figure 1.1, in adults the "rule of nines" is used to determine the total percentage of the burned area for each major section of the body (O'Sullivan, et al., 2007). However, this rule cannot be used in pediatric burns. The Lund-Browder chart is one of the most accurate methods to estimate not only the size of the burn area but also the burn degree in each part. The use of this chart has shown an easy access and fast readability in the clinical practice as well as its use in pediatric burns (Hettiaratchy, 2004). It is available in many centres and also available online. Note that an internet address has been added at the end of this article to make it accessible for education purposes. Accurate estimation must be performed in order to estimate the amount of intravenous fluids, referral indications to the burn unit and indication of surgery as well as the estimation of prognosis.
The degree of burns is calculated to estimate the prognosis as well as the type of treatment and consequently the type of surgery that should be conducted.
Figure 1.1. The different parts of the body that equal 9% of the body surface area.
1.5 Burn Wound Management
Superficial burn (First Degree)
A superficial burn is confined to the epidermis and is not considered to be a significant burn. No barrier functions are altered. The most common form of superficial burn is caused by ultraviolet radiation from the sun. It generally heals by itself in less than a week without scarring. Skin moisturizers can be used to treat a superficial burn.
Partial-thickness burn (Second Degree)
A partial-thickness burn involves the destruction of the epidermal layer and portions of the dermis; it does not extend through both layers. There are 2 depths of partial-thickness burns superficial partial-thickness and deep partial-thickness and each corresponds with a predictable healing time, treatment modality, and outcome.
A superficial partial-thickness burn involves destruction of the entire epidermis and no more than the upper third of the dermis. The microvessels perfusing this area are injured, leading to leakage of large amounts of plasma. This lifts off the heat-destroyed epidermis and causes a blister to form. The resulting wound is pink, wet, and painful. These are the most painful burns because the nerve endings of the skin are exposed to air. Remaining blood flow is adequate and the infection risk is low. Despite loss of the entire epidermis, the zone of injury is relatively small and conversion is uncommon except with extremes of age or presence of chronic illness. Rapid healing occurs in 1 to 2 weeks. Scarring is uncommon unless the wound is grossly contaminated. Treatment begins with cleansing and debridement of loose epidermis and remaining large blisters from the wound surface. Large blisters should remain intact for no more than 2 days, as the infection risk is increased. A topical antibiotic is not required. Areas such as the face and ears are treated open, without a dressing; an ointment such as bacitracin is generally used to maintain wound moisture and control the predominantly Gram-positive bacteria on the face. Open areas are gently cleansed daily with a dilute chlorhexidine solution to remove crust and surface exudate. Areas such as the hands, upper and lower extremities, and trunk can be treated with petrolatum-impregnated gauze.
A petrolatum-impregnated gauze is covered with several layers of dry absorbent gauze. If the petrolatum-impregnated gauze appears well adhered to a superficial partial-thickness burn wound with no underlying exudate, the gauze does not need to be changed. If some exudate is present, the dressing should be removed, the wound gently cleansed, and the dressing reapplied. Silver sulfadiazine cream is not recommended for treatment of a superficial partial-thickness burn because the cream retards healing. An antibiotic ointment is a better choice. Exceptions include a dirty wound that has not been cleansed of initial debris or a perineal or buttock wound, for which a silverbased topical antibiotic is typically required. A superficial partial-thickness burn can also be managed with a temporary skin substitute, which protects the wound surface and provides moist wound healing. The outer layer of gauze needs to be changed when it becomes saturated with plasma from the wound surface. When the wound no longer oozes, the skin substitute can be left open to heal.
A deep partial-thickness burn involves destruction of most of the dermal layer, with few viable epidermal cells remaining. Reepithelialization is slow, sometimes taking months. Blisters do not generally form because the dead tissue layer is thick and adheres to the underlying viable dermis. The wound appears white and dry. Blood flow is compromised, making the wound vulnerable to infection and conversion to a full-thickness injury. The wound is often a mixed partial- and full-thickness injury. Direct contact with a flame source is a common cause; most chemical burns are also deep partial-thickness injuries. Pain is reduced because the nerve endings have been destroyed. It is difficult to distinguish between a deep partial-thickness and a full thickness burn wound by visualization; however, the presence of sensation to touch indicates that the burn is a deep partial thickness injury. Deep partial-thickness burn wounds heal in 4 to 10 weeks.
Wound breakdown is common because the new epidermis is thin and not well adhered to the dermis due to the lack of rete pegs. The focus of treatment includes removing eschar and using topical antibiotics during the debridement process or until surgical wound closure occurs. Excision and grafting is the preferred treatment because dense scarring is seen when these wounds are allowed to heal through primary intention. The predominant antimicrobial used in deep partial-thickness burn wounds is an agent containing silver, either in the form of a cream or silver-impregnated membrane used as a dressing on the wound surface. The cream must be removed and reapplied at least once a day. Silver dressings continuously release silver over several days, minimizing the need for frequent dressing changes. These dressings need to be kept moist to activate release of the silver; the wound fluid from the burn injury is often sufficient. Moist wound healing is preserved under the silver membrane. A dry gauze dressing is used over the silver cream or dressing.
Full-thickness burn (Third Degree)
A full-thickness burn results in complete destruction of the epidermis and dermis, leaving no residual epidermal cells to repopulate. Initially, the dead avascular burn tissue appears waxy white in color. If the burn produces char or extends into the adipose layer due to prolonged contact with a flame source, a leathery brown or black appearance can be seen, along with surface coagulation veins. Direct exposure to a flame source is the usual cause of a full-thickness burn injury; however, contact with hot liquids, such as grease, tar, or caustic chemicals, will also produce a full-thickness burn. Similar to a deep partial thickness burn, a full-thickness burn is also painless. One major difficulty is distinguishing a deep partial-thickness burn from a full-thickness burn; however, treatment is similar for both. Treatment of a full-thickness burn wound includes early surgical debridement and wound closure with a skin graft or permanent skin substitute. Before the planned surgery, the wound is treated with a silver-based antibiotic cream or dressing, using a closed dressing technique.
1.6 Objectives
1.6.1 General Objectives
The study was done with a view to assess the nurses knowledge regarding management of burn at Rajshahi Medical College Hospital.
1.6.2 Specific Objectives
The specific objective of the study were to-
• assess the knowledge about cause of burns
• assess the knowledge of nurses about management of burn
• assess the knowledge of nurses about complications of burn
• assess knowledge about rule of nine
1.7 Variable used in study
Independent variable
Age, sex, marital status, religion, academic qualification, professional qualifications, length of service etc.
Dependent variable
Knowledge of nurses regarding management of burn.
CONTENTS
ABSTRACT
Chapter-1 INTRODUCTION
1.1 General Introduction
1.2 Etiology and Epidemiology
1.3 Pathophysiology
1.4 Estimation of TBSA
1.5 Burn Wound management
1.6 Objectives
1.6.1 General Objectives
1.6.2 Specific Objectives
1.7 Variable Used in Study
Chapter-2 REVIEW OF LITERATURE
2.1 Review of Literature
2.1.1 Estimation of Burn Extent
2.1.2 Clinical Evaluation
2.1.3 Estimation of Burn Injury Severity
2.1.4 Acute Resuscitation
2.1.5 Burn Wound Excision and Reconstruction
Chapter-3 MATERIALS AND METHODS
3.1 Introduction
3.2 Study design and population
3.3 Study place and duration
3.4 Sample size
3.5 Sample technique
3.6 Research Instrument
3.7 Data collection procedure
3.8 Data analysis
3.9 Ethical consideration
Chapter-4 RESULTS
4.1 Demographic information of nurses
4.2 Knowledge related question to the nurse
Chapter-5 DISCUSSION
Chapter-6 CONCLUSION
Chapter-7 REFERENCES
Chapter-8 APPENDICES
List of Tables
Table-1 Demographic information of the participated nurses
Table-2 Information about nurses knowledge regarding management of burn
Thesis, Assessment, Nurses, Knowledge, Regarding, Management, Burn, Ward, Rajshahi, Medical, Nursing, College, Hospital, Skin, TBSA, Injury, Damage, Infected, Etiology, Epidemiology, Pathophysiology, Wound
Share on Facebook