CONNIE JARLSBERG, RN, MSN WORLDVENTURE/NURSES CHRISTIAN FELLOWSHIP GLOBAL HEALTH MISSIONS CONFERENCE NOVEMBER 2012 Burn Care in Developing Countries.

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