I

MANAGEMENT OF A PATIENT WITH CONDITIONS AFFECTING THE

INTEGUMENTARY SYSTEM:

SKIN BURN.

A SEMINAR PRESENTATION

BY:

IHEWUOKWU CHIAMAKA SARAH

REG NO:

MCN/22/347

SUBMITTED TO:

MERIT COLLEGE OF NURSING SCIENCES, UMUOWA, ORLU, IMO

STATE.

SUPERVISOR:

MR. EMMANUEL NKWOCHA.

MARCH, 2024.
 II

TABLE OF CONTENTS. PAGES

 Cover page i

 Table of content ii

 Abstract iii

 Introduction 1

 Review of related literature 3

 Nursing diagnosis

 Nursing care plan

 Nursing implication

 Conclusion

 Reference
 III

ABSTRACT

Burns are commonly known as injury to the skin caused by excessive heat. More broadly, burns result
from traumatic injuries to the skin or other tissues primarily caused by thermal or other acute exposures.
It occurs when some or all of the cells in the skin or other tissues are destroyed by heat, electrical
discharge, friction, chemicals, or radiation. Burns are acute wounds caused by an isolated, non-recurring
insult, and healing ideally progresses rapidly through an orderly series of steps. However, burns are
classified by their depth and severity, and treatment varies accordingly. Wound care, pain management,
infection prevention, nutrition, and psychological support are all important aspects of burn treatment.
Prevention is also key- taking safety precautions around heat sources, hot liquids, and chemicals can
help reduce the risk of burn injuries. Research is ongoing to improve treatment options and reduce the
long-term consequences of burn injuries. Furthermore, advances in the management of burn patients
have contributed to significant improvements in morbidity and mortality over the last century. The
physiologic insult from this injury pattern, however, still requires extensive surgical intervention,
resuscitation and multidisciplinary care. Burns are noted as injury caused by heat, chemicals, electricity,
or radiation. They can range from mild to severe, depending on the degree of damage to the skin and
underlying tissues. Mild burns may cause redness and pain, while severe burns can cause blisters,
swelling, and shock. Treatment for burns depends on their severity, but may include wound care, pain
management, IV fluids, skin grafts, and antibiotics. Prevention is key to reducing the risk of burns, and
includes taking safety precautions around heat sources, hot liquids, and chemicals. Burn injury is a
complex and challenging medical condition. Even after initial successful management, burn patients can
develop a wide range of complications. In addition to recognizing and managing the physical
consequences of the burn, it is important to identify potential psychological or social complications, as
well as possible long-term sequelae, in order to provide comprehensive care to burn patients and their
families. Complications can be separated into general medical complications and those that are
specific to burn injury.

Key Words: Burns, burn injury, integumentary, degree, wound care, skin grafts, burn severity, etc.
IV
 1

INTRODUCTION

According to Rice and Orgil, (2023) Burns are a type of integument disorder that can be classified as

first-degree, second-degree, or third-degree burns. First-degree burns are the least severe and only affect

the outermost layer of the skin. Second-degree burns are more severe and can cause blistering and

damage to the second layer of skin. Third-degree burns are the most severe and can cause damage to all

layers of the skin, as well as nerves and blood vessels. Burns can be caused by thermal, chemical, or

electrical sources.

The epidemiology of burns includes studying the incidence, prevalence, mortality, and morbidity of burn

injuries. In the United States, the incidence of burn injuries is about 20 per 100,000 populations. The

incidence varies by age, with the highest rate occurring in children under 4 years old. The leading cause

of burn injuries in this age group is scalding from hot liquids. In older children and adults, the leading

cause is fire. The incidence also varies by gender, with males having a higher incidence than females.

The incidence of burns varies by age, sex, and socioeconomic status. According to the American Burn

Association, about 486,000 people are burned each year in the United States, with about 40,000 of those

requiring hospitalization. Most burns occur in children and young adults, with males having a higher

incidence than females. Low socioeconomic status and lower educational levels are associated with an

increased risk of burn injuries.

In spite of a decreasing frequency of burn-related injuries in the 21 st century due to improved

manufacturing production of commercial goods, thermal injury in the United States is still a major injury

pattern. Over 200,000 patients in the United States alone were burned between 2005 and 2016, resulting

in over 6000 deaths. Mankind has been dealing with thermal injuries for thousands of years; yet

“modern” burn care has evolved exponentially over the last 50–60 years. Advances in resuscitation,

operative care and grafting techniques, infection prevention and treatment, and mitigation of hyper

metabolism have all improved survival and recovery. In spite of these advances, however, questions and
 2

controversies regarding best practices are still prevalent, and numerous burn centers and laboratories

across the United States continue to research various aspects of burn care, from the resuscitation phase to

the reconstructive and recovery phase.

These advances in burn care have improved burn survival from a near 100% mortality seen with a burn

size of 30% in the early 1900s, to survival estimates over 50% in young, healthy patients with burn sizes

up to 95%. Nonetheless, the acute phase of resuscitation still generates significant controversy and is not

a standardized process. One can query the resuscitation protocols of various burn units throughout the

country and find many variations, from the usage of crystallized-only formula to adding colloid at

various time points in the acute period, to the usage of “rescue therapies” and what they constitute and

when to use them. While this review will not go into great detail of the variations, we will describe our

initial burn evaluation, subsequent resuscitation, and overall management plan in caring for a seriously

thermally-injured patient.

This presentation will be based on the following objectives:

 The anatomy and physiology of the integumentary system.

 The pathophysiology of burns.

 The classification and types of burn.

 The Nursing diagnosis for a patient with burns

 The Nursing care plan for a patient with burns.

 The implication of burns to nursing.

 3

REVIEW OF RELATED LITERATURE

Mathes and Hentz, (2018) stated that burns is an injury to the skin caused by thermal, chemical,

electrical or radiation energy, or by any combination thereof. Burns can range from mild to severe, and

can cause pain, swelling, blistering, and tissue damage. Severe burns can lead to shock, infection, and

even death. Dry heat, moist heat, direct contact with hot surfaces, chemicals, electricity and ionizing

radiation can cause b4urns, which result in cellular destruction of the skin layers and underlying tissue.

ANATOMY AND PHYSIOLOGY OF THE INTEGUMENTARY ORGAN

Waugh and Grant (2018), is of the view that the integumentary system is made up of the skin and its

associated structures, including the hair, nails and sweat glands. The skin is the largest organ of the body

and it has three main layers: the epidermis, the dermis and the outer layer of the subcutaneous tissue. The

epidermis is the outer layer of the skin, and it is made up of cells that are constantly being replaced. The

dermis is the middle layer of the skin and it contains blood vessels, hair follicles and sweat glands. The

subcutaneous tissue is the innermost layer of the skin. It is made up of fat and connective tissue, and it

helps to protect and insulate the body.

The five major function of the integument are:

 Protection.

 Temperature maintenance.

 Synthesis and storage of nutrients.

 Sensory reception.

 Water balance.
 4

CAUSES OF BURNS AND SCALDS (Clement, 2019).

 Electricity.

 Strong acids/alkalis (corrosive acids/chemicals).

 Hot liquids e.g. boiling water etc.

 Heat from fire or steam.

 Explosions of pressure stoves, petrol etc.

 Radiation.

PATHOPHYSIOLOGY OF BURNS.

Clement, (2019) induced that tissue destruction results from coagulation, protein denaturation, or

ionization of cellular components.

Local response: Burns that does not exceed 20% of TBSA according to the Rule of Nines produces a

local response.

Systemic response: Burns that exceeds 20% of TBSA according to the Rule of Nines produces a

systemic response.

The systemic response is caused by the release of cytokines and other mediators into the systemic

circulation. The release of local mediators and changes in blood flow, tissue edema, and infection, can

cause the progression of the burn injury.

 5

CLINICAL MANIFESTATIONS.

According to O’Connel, et al., (2018) the clinical manifestations of burns can vary depending on the

severity and location of the burn.

First degree burns typically cause redness, pain and swelling.

Second-degree burns may cause blistering, edema and weeping of the skin.

Third-degree burns cause extensive tissue damage, including charring and blackening of the skin.

Fourth-degree burns destroy all layers of the skin, including muscle and bones. This type of burn can

also cause permanent damage to the nerve, blood vessels and tendons.

Generally others include: discharge from the wound, fever dehydration hypothermia, elevated heart

rate (tachycardia), elevated respiratory rate (tachypnea) and low blood pressure (hypotension).

CLASSIFICATION OF BURNS

Clement, (2019) is of the view that Burns can be classified based on the following:

First degree (Superficial): burns damage only outer layer, or epidermis and symptoms include redness

and pain, but no blister. Pain subsides in 2-3 days and there is no scarring. Complete healing takes about

one week.

Second degree (Partial Thickness): burns involve entire depth of epidermis and portion of dermis.

Symptoms include redness, pain, and blistering. The extent of blistering is dependent on depth of burn

and blistering extends after initial burn. Blisters heal within 10–14 days if there are no complications,

with deeper second degree burns taking 1–3½ months. Scarring in second degree burns is common,
 6

Third degree (Full Thickness): burns affect all three layers of skin. Surface of burn has leathery feel

and will range in color from black, brown, tan, red, or white. Patient feels no pain because pain receptors

are destroyed; also sweat and sebaceous glands, hair follicles, and blood vessels are destroyed.

Fourth degree: are worst burns, it penetrates bone and causes bone damage.

Skin Involvements Degrees of Burns. (Sited from: I Clement 2nd Edition, 2019)

TYPES OF BURNS (Abujudeh, 2019).

Thermal burns: are caused by contact with hot objects, such as fire, steam, or hot liquids.

Chemical burns: are caused by contact with corrosive substances, such as acids or bases.

Electrical burns: are caused by contact with an electric current, such as lightening or an electrical

outlet.

Radiation burns: are caused by exposure to radiation, such as the sun or x-rays.
 7

CLASSFICATION OF BURN INJURIES. (Rice and Orgil, 2023)

Classifications of burns can be approached from two perspectives:

 Extent of body surfaces areas involved.

 The depth of the burn.

CLASSIFICATION ACCORDING TO BODY SURFACE AREA: the rule of nine method and palm

method is used.

 PALM METHOD.

Small or patchy burns can be approximated by using the surface area of the patient's palm. The palm

of the patient's hand, excluding the fingers, is approximately 0.5 percent of total body surface area,

and the entire palmar surface including fingers is 1 percent in children and adults

 LUND AND BROWDER METHOD.

The Lund-Browder chart is the most accurate method for estimating TBSA for both adults and

children. Children have proportionally larger heads and smaller lower extremities, so the

percentage TBSA is more accurately estimated using the Lund-Browder chart.

 RULE OF NINES.

For adult assessment, the most expeditious method to estimate TBSA in adults is the "Rule of

Nines"

The head represents 9% TBSA

Each arm represents 9% TBSA

Each leg represents 18% TBSA

The anterior and posterior trunk each represents 18% TBSA.

 8

Figure 1: Rule of Nine (Sited from: I Clement 2nd Edition, 2019)

Figure 2: Rule of nines, used for estimating the percentage of body surface burned.

A.Lund-Browder’s chart. B . Rule of nine chart.

The rule of nine is a quick way to estimate the extent of burns in adults through dividing the body into multiples of nine

and the sum total of these parts is equal to the total body surface area injured. (Sited From: RN Adult Medical Surgical

Nursing, 2021).

CLASSIFICATION BASED ON DEPTH OF BURNS

 Superficial partial thickness: These burns characteristically form blisters within 24 hours

between the epidermis and dermis. They are painful, red, weep, and blanch with pressure. Burns
 9

that initially appear to be only epidermal in depth may be determined to be partial thickness 12 to

24 hours later. These burns generally heal in 7 to 21 days; scarring is unusual, although pigment

changes may occur. A layer of fibrinous exudates and necrotic debris may accumulate on the

surface, which may predispose the burn wound to heavy bacterial colonization and delayed

healing. These burns typically heal without functional impairment or hypertrophic scarring.

 A deep partial-thickness burn: These burns extend into the deeper dermis and are

characteristically different from superficial partial-thickness burns. Deep burns damage hair

follicles and glandular tissue. They are painful to pressure only, almost always blister (easily

unroofed), are wet or waxy dry, and have variable mottled colorization from patchy cheesy white

to red (picture 3). They do not blanch with pressure. If infection is prevented and wounds are

allowed to heal spontaneously without grafting, they will heal in two to nine weeks. These burns

invariably cause hypertrophic scarring. If they involve a joint, joint dysfunction is expected even

with aggressive physical therapy. A deep partial-thickness burn that fails to heal in two weeks is

functionally and cosmetically equivalent to a full-thickness burn. Differentiation from full-

thickness burns is often difficult.

 A full-thickness burn involves total destruction of epidermis and dermis and, in some cases,

underlying tissue as well. Wound color ranges widely from white to red, brown, or black. The

burned area. *In full thickness wound (3rd degree) there is damage of the entire epidermis and

dermis leaving no residual epidermal cells to repopulate. It has a hard-dry leathery eschar (burn,

crust or a dead tissue that falls off from a healthy skin) that forms coagulated particles of the

destroyed dermis. There is edema under the Escher. Escher is dead tissue from burns

 In deep full thickness (4th degree), the wound extend beyond the skin into the underlying fascia

and tissues damaging muscles, bones and tendons, leaving them exposed. It occurs with flames,

electrical and chemical injuries. The wound is blackened and completely is involved. There is

decreased blood flow.

 10

SEVERITY OF BURNS (Brenda et al., 2021)

 Percentage of total body surface area (TBSA): use standardized charts for age groups to

identify the extent of the injury and calculate medication doses, fluid replacement volumes

and caloric needs.

 Depth of the burn: classify burns according to the layers of skin and tissue involved:

superficial, partial, full and deep full thickness.

 Body location of the burn: in areas where the skin is thinner, there is more damage to

underlying tissue (any part of the face, hand, perineum, and feet).

 Presence of other injuries: fractures or other injuries increase the risk of complications.

 Involvement of the respiratory system: inhalation of deadly fumes, smoke, steam and

heated air can cause respiratory failure or airway edema. Carbon monoxide poisoning also

can occur, especially if the injury took place in an enclosed area.

OVERALL SEEVERITY OF BURN INJURY

A combination of the burn mechanism, burn depth, extent, and anatomic location determine the overall

severity of the burn injury, which provides general guidance for the preferred disposition and care of

these patients.

Minor or mild burn injury: Minor or mild burns are those that can be treated in a physician's office or

in an emergency department as an outpatient.

Moderate burn injury: Moderate burns would be those that require admission to a hospital but not to a

burn center. These include superficial burns or deeper burns of limited extent.

Severe burn injury: Severe burn injury can be defined as burns that should be referred to, and treated

at, a designated burn center. (Rice and Orgil, 2023)

 11

MEDICAL-SURGICAL MANAGEMENT OF BURNS. (Schwartz et al., 2018)

Serious burns require immediate care. Once the client has stabilized the focus of care shifts to wound

healing and restoring function. Surgical intervention may be necessary.

Medical Management

The first step in management is to assess the severity of the burns and establish whether the patient needs

immediate medical attention. Once the severity is determined, treatment will involve cleaning and

dressing the wounds, administering pain medication (, and treating any other complications that may

arise, such as infection, dehydration, or shock.

Surgical Management

Surgical management is often required for severe burns, and it can involve debridement, skin grafting,

and other procedures. Debridement is the process of removing damaged tissue, which can help prevent

infection and promote healing. Skin grafting is a procedure in which healthy skin is transplanted to the

burned area to help replace the damaged skin. Other procedures may be needed to treat specific

complications of burns, such as contractures or abscesses.

PREVENTION. (Janzekovic, et al., 2018).

 Advice that matches, lighters, hot irons are kept out of reach of children.

 Emphasize the importance of never leaving children unattended around fire or in

bathroom/bathtub.

 Caution against smoking in bed, while using home oxygen, or against falling asleep while

smoking and throwing flammable liquids onto an already burning fire.

 12

 Recommend avoidance of overhead electrical wires and underground wires when working

outside and caution against running an electrical cord under carpets or rugs.

COMPLICATIONS OF BURNS.

There are a lot of consequences involved in burn injuries that may progress without treatment.

 Dehydration and hypovolaemia: these may occur in extensive burns when there is excessive

leakage of water and plasma proteins from the damaged skin surface.

 Renal failure: acute tubular necrosis occurs in severe burns when the kidney tubules are damaged

by the large amounts of waste from haemolysed erythrocytes, and inflamed and degenerating burn

tissue.

Others include:

Shock (hypovolemic), Contractures, Loss of body part, Acidosis, Keloids, Paralytic ileus, infection and

death. Although burns affect the skin, their systemic consequences can also be life-threatening or fatal

when they are extensive. (Janzekovic, et al., 2018).

 13

NURISING DIAGNOSIS

 Acute pain related to tissue and nerve damage evidenced by patient’s verbalization and facial

expressions.

 Fluid deficit related to increased capillary permeability and evaporative loses from the burns

wound.

 Risk for infection related to large surface area of skin loss and disruption of skin barrier.

 Impaired gas exchange related to carbon monoxide poisoning, smoke inhalation and upper

airway obstruction.

 Anxiety related to fear and the emotional impact of burn injury.

 14

NURSING CARE PLAN FOR A PATIENT WITH BURNS.

S NURISNG OBJEC NURSING SCIENTIFIC EVALUATION

/ TIVES PRINCIPLE/RATIONALE
DIAGNOSIS INTERVENTION/ORDER
N

1 Acute pain To 1. Monitor patient vital signs 1. To check for baseline data. Patient reports a pain level

. related to reduce 2 hourly. of 2 on a 0-10 pain scale,

2. To maintain patent
tissue and pain to a and exhibits normal facial
2. Place patient in a airway/respiratory function and
nerve damage minimum expressions.
comfortable position. alleviate pain.
evidenced by level.

patient’s 3. Deviational therapy. 3. To divert patient mind away

verbalization from pain and also to provide

4. Give prescribed drugs e.g.
and facial emotional support.
analgesics etc.
expressions.
4. To inhibit the pain receptor.
 15

2 Fluid deficit - 1. Monitor IV and oral fluid 1. To ensure that the patient is Patient maintains fluid

. related to Restorati intake: use IV infusion receiving adequate fluid balance as evidenced by

increased on of pumps. replacement and that the fluid are stable vital signs, adequate

capillary optimal delivered at the correct rate and urine output, and absence
2. Measure intake and output
permeability fluid and volume. of edema.
and daily weight
and electrolyt
2. To ensure that fluid balance is
evaporative e balance 3. Report changes (e.g.,
maintained.
loses from the and blood pressure, pulse rate) to

burns. perfusion physician. 3. To allow for prompt intervention

of vital and management of any potential

organs complications.

3 Risk for - For 1. Monitor vital signs and 1. To allow for early detection of Patient’s vital signs and

. infection patient to skin condition for signs infection, this can be treated skin condition are stable

related to verbalize infection. promptly to prevent further and infection-free

large surface understan complications. throughout hospitalization.

2. Use asepsis in all aspects
area of skin ding of
 16

loss and signs and

of patient care.
disruption of symptom 2. Aseptic techniques minimize risk

skin barrier. s of 3. Adhere to the essential 4 of cross-contamination and spread

infection. moments of effective hand of bacterial contamination.

hygiene.
-For
3. Hand hygiene remains the single
patient to
most important infection control
demonstr
4. Monitor white blood cell measure and reduces the incidence
ate
(WBC) count, culture and of health care-associated infections
appropria
sensitivity results. (HAI).
te hand

hygiene
4. Increased WBC count indicates
and
5. Inspect wound for signs of infection. Culture and sensitivity
proper
infection, purulent drainage indicate microorganisms’ present
wound
or discoloration. and appropriate antibiotics to be
care.
used.
6. Provide regular linen
-For
changes, and assist patient
 17

5. Such signs indicate localized

patient to with personal hygiene.
infection.
maintain

a wound

infection- 7. Administer antibiotics as

6. These measures reduce potential
free prescribed.
bacterial colonization of burn
status
wound.
during

hospitaliz

ation.
7. Antibiotics reduce bacteria.
 18

NURSING IMPLICATION.

Pruitt.D, et al., (2016) induced that the nursing implications of burns can be divided into three

categories:

PHYSICAL IMPLICATIONS: these include:

Wound care: Nurses plays a key role in wound care for burn patients, including dressing changes,

debridement and monitoring for infection.

Pain management: Nurses need to be knowledgeable about pain management strategies for burn patients,

including medications, distraction techniques and psychological support.

Nutritional support: Burn patients often have special nutritional needs and nurses need to be aware of

these needs and help ensure that patients are getting the nutrition they need.

Skin care: nurses also need to be knowledgeable about skin care for burn patients, including moisture

management, which is an important aspect of skin care for burn patients.

PSYCHOLOGICAL IMPLICATIONS: these include:

Grief and loss: burn patient often experience grief and loss, including the loss of normal body function,

independence and social relationships.

Stress and anxiety: burn patients often experience high levels of this stage due to physical and

psychological trauma of their injuries.

Post-traumatic stress disorder (PTSD): some patient may develop PTSD, which can cause long-term

psychological distress. Symptoms of PTSD may include flashbacks, nightmares and intrusive thoughts

about the traumatic event.

 19

SOCIAL IMPLICATIONS: these include

Financial burden: burn injuries can result in significant financial burdens for patients and their families.

Nurses can help to connect patients with resources such as financial assistance and social services.

Isolation: burn patients may feel isolated from their friends and family due to their injuries. Nurses can

help to connect patients with social support networks and community resources.

Social stigma: they may face this due to their injuries. Nurses can help to educate the public about burn

injuries and reduce the stigma associated with them.

Rehabilitation: burn patients often require rehabilitation to regain their physical and emotional well-

being. Nurses can help to facilitate this process by providing emotional support, education and guidance

on self-care.

It is very important for nurses to understand these implications so that they can provide holistic care for

urn patients. It is also important for nurses to be aware of the unique challenges that burn patient’s face,

including their physical, psychological and social needs. This will help them provide the best possible

care for these patients.

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CONCLUSION

Burns are noted as a common medical emergency that can have a variety of causes. Treatment depends

on the severity of the burn, but it generally involves wound care, pain management, infection prevention,

nutrition, and psychological support. It's important to know the signs and symptoms of a burn, and to

seek medical attention as soon as possible if you think you or someone else has been burned. Prevention

is also key - taking safety precautions around heat sources, hot liquids, and chemicals can help reduce

the risk of burn injuries.

However, Care of the patient with a large body-surface area burn is complex, lengthy, and causes

potential complications. These complications can be anticipated and minimized in burn centers

accustomed to the complexities of major burn care; ultimately yielding improved survival and functional

outcomes. Burns are a common and serious medical condition. The treatment of burns involves a variety

of approaches, including resuscitation, wound care and prevention of infection.

The long-term outcomes of burns can be improved by timely and appropriate treatment. Burn injury is a

complex condition with many potential complications. In addition to the immediate physical and

psychological consequences of the burn, burn patients are at risk for long-term physical, social, and

psychological sequelae. These complications can be prevented or minimized by early recognition and

intervention. Burn patients require a comprehensive, multidisciplinary approach to management,

including collaboration between physicians, nurses, physical and occupational therapists, social workers,

and psychologists.
 21

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 22

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