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CONNIE JARLSBERG, RN, MSNWORLDVENTURE/NURSES CHRISTIAN FELLOWSHIP
GLOBAL HEALTH MISSIONS CONFERENCE NOVEMBER 2012
Burn Care in Developing Countries
Burn Prevention
50% of all burn accidents could be prevented
Most burns happen in an instant of carelessness
Most burn patients are victims of their own actions
“It’s a matter of degrees”
If its HOT enough for CHAI, It’s HOT enough to BURN!
If your clothes catch on fire:
STOP
ROLL
DROP
Communicating Prevention
• Urban vs Rural Areas
• Mothers/Children (big sisters)
• Local Languages
• Literacy
• Raising the national awareness
Functions of the Skin
Protection from infectionConservation of body fluidsTemperature regulationExcretionSecretionVitamin D productionSensationAppearance
Anatomy of the Skin
Determination of Burn Severity
Extent
Depth
Age of the patient
Past medical history
Part of the body burned
Out Patient Care
• Burns < 20% TBSA not involving the face or hands
• Children over 5 years old
• Adults based on assessment of their age significant medical history
Assess the patient and or family’s ability to care for the wound at home OR their ability to come for dressing changes.
Out Patient Care
Goal:
• Close the wound as soon as possible—within 3 weeks
• Decrease scar and contracture formation
• Maintain function of involved joints
DETERMINATION OF SIZE OF BURN
RULE OF NINES
Head: 9%Anterior: 18%Posterior: 18%Arms: 9% eachLegs: 18% eachPerineum: 1%___ Total 100%
Calculation of Percent with age consideration Berkow Method
DEPTH OF BURN
Superficial Partial Thickness (1st degree) Skin is red only epidermis perhaps part of the
dermis is injuredUsual causes: sunburn, hot liquidShould heal spontaneously within 3 weeks
Deep Partial Thickness (2nd degree)Skin is red, “weepy” some blister formation
Usual causes, hot thick liquids (porridge vs water)
Depth of Burn Con’t
Full Thickness (3rd and 4th degree) Skin appears “leathery” dry, brown, hardened all
epidermis and dermis is destroyed may have destruction of sub-dermal layers, subcutaneous
tissue and muscle as well.
Wound will not heal, needs skin grafting often results in significant scarring even with excellent wound care.
Admission 15 days post burn
Past Medical History and History of the Burn
Does the Patient1.Have a serious medical condition?2.Have symptoms of an unknown disease?3.Take medications?4.Have allergies to food or medication?
How did the burn occur?1.Source? Hot liquid, Flame? Caustic substance?2.Inside or Outside?3.Was there smoke? Was it inhaled?
Phases of Burn Care
Emergent Phase: The time required to resolve immediate problems resulting from the burn injury
Acute Phase: From the end of the Emergent Phase until the wound is closed
Rehabilitation Phase: The entire program of burn care is focused to this phase. From day one of the injury until the patient returns to a useful place in society
Emergent Phase
First Aid1. Maintain airway2. Assess for concurrent injuries (bleeding
does not occur secondary to burn injuriesIf there is external bleeding look for
other causes). NB: Burn patients are always alert
and oriented, if not assess for head injury
Burns to face and neck especially if in an enclosed space. Edema formation—increased capillary permeability
Potential for airway obstruction
Large volumes of fluid escape from the burn surface causing hypovolemia in any burn greater than 20% TBSAIV Therapy: An electrolyte balanced solutionRingers Lactate (Hartman’s solution) in quantities enough to maintain adequate BP and urine output 30ml/hr in adults and 0.5ml/kg in children
Fluid Therapy
Oral Fluid Replacement Therapy?
Effective resuscitation of small (5-10%)moderate and sometimes severe burn injury.
Where IV fluids may not be available or in situations with mass casualties with inadequate IV fluids.
Drinking or gastric infusion of buffered saline solution.Similar to WHO oral rehydration solution1 liter of water + 8 tsps. sugar + ½ tsp salt +½ tsp of sodium bicarbonate (baking soda)
Kramer, G.C., Michel, M.W. , et al (2003) Journal of Burns and Wound Care
Wound Care
Goal:
Close the wound as soon as possible
Prevent infection both in the wound and systemically
Complete grafting if necessary
Decrease incidence of scarring and contracture.
Wound Care
Topical Agents:
Silver sulfadiazine Other topical antimicrobials:
Mafanide Acetate (TM: Furacin) Saline, Hydrogen Peroxide &
Sterile waterBetadine/ Iodine
Honey and Ghee
General Considerations: Emergent Phase
Pain management
Nutrition therapy
Positioning /Splints
ACUTE PHASE
Avoid, Detect and TreatComplications
Wound Care
Encourage as much activity as possible
Grafting
NURSING CARE
Emotional support Rest/ComfortDietHygiene/Wound carePositioning
Sometimes its niceNOT to be the source of pain
Be sure pediatric patients have at least one placethey feel safe.
Try to make that place their bed
As wounds heal, pain decreases, happiness makes a comeback.
Nutrition and Diet
Rehabilitation Phase
Return the patient to a productive place in society
Accomplish functional and cosmetic reconstruction
Reconstructive Surgery
Myths and Cultural Care Practices
Rabbit fur (Rwanda)Powdered—un-reconstituted antibiotics
(Uganda)SugarHoney and Ghee (purified animal fat) Worldview
Resources
Artz, C.P.,Moncrief, J.A., Pruitt, B.A. (1979) Burns a team approach. Philadelphia, PA: W.B. Saunders.
Feller, I., Archambeault-Jones, C. (1978) Teaching basic care. Ann Arbor, MI: National Institute of Burn Medicine
Iwuagwu, F. C., Bailie, F. (1998) Oral fluid therapy in paediatric burns (5-10%): an appraisal. Burns 24 pp. 470-474.
Jarlsberg, C.R. (1992) Management of Patients with Burn Injury in Brunner and Suddarth’s Textbook of Medical Surgical Nursing 7th ed. Eds. Smeltzer, S.C., Bare, B. G. Philadelphia: Lippincott
Jarlsberg, C.R. (2006-2012) Unpublished original material
With thanks to Rein Zeeman and Ineka Storm International Plastic Surgery SocietyHolland for sharing photographs. And thanks to the patients at Mulago Hospital Kampala Uganda for their courage evidenced daily in facing the difficulty of recovering from burn injuries.
Kramer, G. C. et al. (2010) Oral and enteral resuscitation of burn shock. The historical record and implications for mass casualty care. Republished from Journal of Burns and Wound Care (2003) 2 (19) (no longer available).(no longer available) Open Access Journal of Plastic Surgery.
Resources Con’t