"Md Hormona) Therapy, felt by the ent. The techniques used may include Inspection ang A, sas” of temperature, blood pressure, pulse ang ant Auscultaton in adlton sepody systems such as the cardiovascular oy é y Documentation of the assessment oc : The assessment is documented in the patient: medical i hor nursing records, which may er or as part of the electronic medic, on paper oF as pi ‘dical record whic} ee Frealtheare tear which can be accessed by all members ‘Assessment tools A range of instruments has been developed to These include: Index of independence in a Barthel index Crighton royal behaviour rating scale Par = to the “yi ae ; e “vital eu ety Fate, and further examination of Sculoskeletal systems, sist nurses in their a: : tivities of daily living + Clifton assessment procedures for the elderly General health questionnaire Geriatric mental health state schedule Other assessment tools may focus on a specific aspect of the Patient's care. For example, the Waterlow score deals with a patient's risk of developing a Betlsore (decubitus ulcer), the Glasgow Coma Scale measures the conscious state of a person, and various Pain scales exist to assess the “fifth vital sign”. BURNS Burn injuries occur when energy from a heat source is transferred to the tissues of the body. Heat may be transferred through conduction or electromagnetic radiation. Injuries that result form direct contact with or exposure to any thermal, chemical, electrical, or Tadiation sources are termed as burns. A scald is a burn caused by contact with a hot liquid or steam but the term ‘burn’ is Often used to include scalds. Scalding is caused by hot liquids (water or oil) or gases (steam), most commonly occurring from exposure to high temperature tap water in baths or showers or spilled hot drinks. ic). Ti i dt Most burns only affect the skin (epidermal tissue and dermis). eae ae from coagulation, protein denaturation, or ionization of cm = re =e dguaeeniad Mucosa of the upper airways are the sites of tissue destruction. Finesancan leadl tS merece Muscle, bone, and blood vessels can also be injured. Disruption of ty, and changes in function, fluid loss, infection, hypothermia, scarring, compromised immunttY 4ppearance, and body image. painful and can result in on, ‘result commited by shock, infection, Managing burns is important because they are Hi isfi eon mn d f disfiguring and disabling scarring. Burn injuries can be comp eaptatory cites Lae ‘multiple organ dysfunction syndrome, electrolyte imbalan inst 60 years, have significantly eveloped in the Ia ie 4 young adults. t modern treatments, d Eat cach lly in children and P burns can be fatal, but burns, especial improved the prognosis of such TYPES OF INJURY A. The Primary Injury: It is the done to limit the primary injury in most ¢ heat eource and rapid cooling of the burn limits the exte It is deleterious effect resulting from the primary injury. A fecondary infection, endogenous and exogenous release fluid shift, coagulopathy, edema, constriction ge caused by the burn. Little can be ever a prompt removal of the immediately damaj ases of trauma. How ent of primary injury The Secondary Injury major burn can result in loss of fluid of toxins, powerful inflammatory response, caused by burn eschar Causes of Burns Burn injuries are categorized of substances and external source: according to the mechanism of injury. Burns are caused by a wide variet 5 such as exposure to chemicals, friction, electricity, radiation, and heat. Thermal Burn Inhalation Injury — a i > Chemical Burn ~ Electrical Burn Radiation Burn Thermal Burn: Thermal burns are caused by exposure to or contact with flame, hot liquids, semi-liquids (steam), semi-solids (tar) or hot objects. Specific examples are residential fire, explosive automobile accidents, scald injuries, clothing ignition, etc. Chemical Burn: Chemical burns are caused by tissue contact with strong acids, alkalis or organic compounds. Most chemicals that cause severe chemical burns are strong acids or bases. Chemical burns can be caused by caustic chemical compounds such as sodium hydroxide or silver nitrate, and acids such as sulfuric acid. Hydrofluoric acid can cause damage down to the bone and its burns are sometimes not immediately evident. Electrical Burn: Electrical burns are caused by an exogenous electric shock. Electrical burns are caused by heat that is generated by the electrical energy as it passes through the body. Electrical injuries can result from contact with exposed or faulty electrical wiring or high voltage power lines. Deep tissues, including the viscera, can be damaged by electrical burns or through prolonged contact with a heat source. Common causes of electrical burns include workplace injuries or being defibrillated or cardioverted without a conductive gel.adiation Burn: Radiation burns a rotracted exposure to UV lipht, tannin a F diation therapy, sunlamps, radiog and X-rays. By far the most common b with radiation is sun Rarcnnee ae perucated) Wavelengths of light UVA, and UVB the inept Wore dangerous. Tanning booths also enn one wavelengths and may cause similar damage aa Such as irritation, redness, swelling, and inflamma a ‘More severe cases of sun burn result in what is Tae as sun poisoning, ed ¢, Inhalation Injury: Inhalation injury may be uppe! airway (supraglottic) and incur injury aie hours or may involve the lower airway and cause acute respiratory distress syndrome. Exposure to asphyxiants, smoke poisoning and direct thermal injury . ? MMMM icy inhalation injury’and sssociatedlpumons Se eee feet cietor in mortality and morbidi pulmonary complications are a sign ‘ality and morbidity from burn injury (50% to 60% of fire deaths are secondary to inhalation injury). z . oe CLASSIFICATION OF BURNS ‘A number of different classification systems exist. The traditional system divided burns in first-, second-, or third-degree. This system is however being replaced by one reflecting the need for surgical intervention. A. ing to the Burn Depth: The depth of the injury depends on the temperature of fe burning agent and the duration of contact with the agent. The burn depths are described as superficial, superficial partial-thickness, deep partial-thickness, or full-thickness. The following are brief descriptions of these classes: aR anning, booths, tive substances Full thickness ‘ Superficial! Deep Superficial | dermal) : or on the burned skin and Thickness oF Fist Di ot ecuces a pink 10 reddish color On ‘ luce. a Pil fe ned when light pressure is applied sin will PPE, rinimal tissue damage and they involv aeptt (skin surface) These burns affect the oute sburn is a good example of a first-d 1. Superficial Partial ‘The first-« e burn ust very sensitive to touch, and th This is the least serious type : only the upper layer of skin, the epider and swellinj of skin causing P2 and swellir burn redr Erythema =) First Degree Burn (redness) Damage to the outer < Epidermis, { : layer of kin e Dermis {| xdness, and Hypodermis «Signs and symptoms: These burns produce redness, pain, and minor swelling. The skin is dry without blisters. «Healing time: Healing t may peel off in 1 or 2 days. . Deep Partial Thickness or Second Degree Second-degree burns affect both the outer-layer (epidermis) and the under Iying layer of skin (dermis) causing, redness, pain, swelling and blisters. These bums often affect sweat and burned-through in a second- glands, and hair follicles. The epidermis is destroyed Segree burn. There are the same symptoms of pain and swelling but the skin color is usually 4 bright red and blisters are produced. Usually second-degree burns produce scarring. If a deep second-degree burn is not properly treated, swelling and decreased blood flow in the tissue can result in the burn becoming a third-degree burn. Bulla Gran (Blister = second Degree Bum “US)/ Damage to both outer fv" skin and underlying tissue layers (epidermis and dermis), 7 =| pain, Sa renee i i oe and blistering. oo burns produce blisters, severe pain, and redness. The blisters the area is wet looking with a bright pink to cherry red color. ime is about 3 to 6 days; the superficial skin layer over the burn ( | = Signs and symptoms: These sometimes break open and Healing time: Healing time varies depending on the severity of the burn. Second degree burns may take from one to three weeks to heal but are considered minor if they cover no more than 15% of the total body area in adults and 10% body area in children. } 3. Full Thickness Wound or Third Degree Burns ‘Third-degree burns affect the epidermis, skin ora translucent white color, with coagulated vessels visible just Both the dermis and epidermis are destroyed and other organs, tissues, dermis and hypodermis, causing charring of below the skin surface. muscle and bonesm be involved. Third-degree bums 80 ze burns is very slow due the fEimns usually result in extensive scarring ie desFe* ogmetic oF reconstructive surgery and sy set ly nerve endings which tranemit pais aves es since US a a nird Third Degree Bum awh Gamage extends” etn Int testa (epidermis, dermig Is, dorms J hypocermis) enue! | extensive iosan SH destruction. the skin (fy symptoms: The surface appears dry and Signs and symp! > dry and can look waxy w) : Ssinarred. There may be little or no pain ot the sca Gay fet ee nerve damage. ; : Healing time depends on the severity of the Healing time: Heal ty of the burn. Deep second- 5 degree burns (called full-thickness burns) will likely need to be treated with sin a in which healthy skin is taken from another part of the body and grafted ; 4, Fourth Degree Burns: Fourth degree bum extend into underlying fascia. These deep injuries damages muscle, bone and tendons and leave them exposed to the surface. These purns occur with deep flame, electrical or chemical injuries. The wound is blackened and sensation is completely absent. If extremity is involved, amputation may be depressed and P J P y y, brown, at first because of required. Very. Superficial Superficial / Partial Thickness Deep ~-=-~-f--}-- PartialiThi Subcutaneous fatt Fyll Thickness _ Muscle» derate, or severe. those.terms. For erson significant fi minor, mo al cing tthe Bum Seve: Bim rng These classifications may not cores Po ale ee though itcan cause the p example, doct lassify a burn as ‘ines how the pain and Ree i soreal activities. The cic eee the seventy Oe bums yal and whether complications are me Eesth t has second- OF third- ils depth and by the percentage of the body surface Me! 0 7 surface Special charts Be fed to show what percentage ©ung v jo quayxe arp Suneus9 30 poujaur asfoasd a10ur y :pouleIN yepmorq pue puny Z ove 22pueZaTY aA ‘kq paonposyut sem aust jo c= | eoue a0ejans Apoq % 1S! (! [fermeat | puv sioduy) puey uo yuaried ELL uamprn pue siuesut 0 Aidde he Jou saop 9Ih4 StU “PayeIna|e> bolas bq. wes yung st Tey aDejans ‘Kpoq, yei01 ayy Jo a8eyua2z0d | 6 |eieven fh ors \ fo diy are paj2ay7e ay 121719801 Surppe &q wing wore a0ejans “Apoa Tev08 aup yeuTTYS9 OF PORT 24 “aout S200 Apo s0{PU! 0} URE jo soqdoymr x soeyuansad suse Trovsks aug, ‘SUING JO SIUOPO OP premmoyeo 0} ea yornb © St AUN, yo apna UIN 30 91MM HLT im sug, peypsnsos pinous 70.352 uruayeonn 4 pus wos ‘a1 =PeOH 6 ite wrom the Lund ai anatomic par pody into Vv body pa y such for by su ie on the patient’s jation is mi eval third post-bur aes 4, Palm Method: In patients with scatte sually is x palm method. The size of th red bur e p days because the demarcat Par until th en. Ws Be thod to estim, Palm is approxima 08 Burn ‘ot Include deny erythema of burn 1s the atier ate the perce © percentage tely 1% of TREAE Bo cloar and acourat/ (Lund’ and Bro a eee Lund and Browder chart 4, Jackson’s Burn Model: A burn wound is dynamic and subject to the effect of secondary injury. The burn may deepen if the blood supply of the wound is impaired. Example - hypovolaemia, hypotension or if infection occurs. Jackson’s model describes the distinct areas within every burn wound. * Centrally lies the zone of coagulatio by primary injury, these tissues wil time. A i ‘h * Surrounding this lies the zone of stasis which comprises of less damaged ea eG fraimiaticn’oceuirs and vascularity is impaired. Tissue this zone has the P recover under correct conditions. * The outer layer the zone of hyper: blood flow. The margins between mn, which represents the zone of severe damage caused 11 not recover and will slough out in due course of ‘tat sed ith i dilation and increas with intense vas‘ ely patent aemia is tissue t static they are the zone are no!SYN ced blo Mrceseive oedema tends to extend the zone of care ete cee In favourable conditions the margin of once the area of tissue Ne ata d hence the area Of Hi ve of stasis shrinks as it is replaced by the zone systemic fi od flow, coagulation an the ntral zone T of hyperaemia emains static an‘ ‘Schematic representation ‘of Jackson's burn model Zone of ; Teas 4 — epidermis Zone of stasis pemie Subcutaneous tissue fhophysiology of Burns ‘A bur injury usually results from energy transfer from a heat source to the body. The type of burn injury may be flame/flash, contact, scald (water, grease), chemical, electrical, iZhalation, or any thermal source. Many factors alter the response of body tissues to these sources of heat. Burns that do not exceed 25% TBSA produce a primarily local response. Burns that exceed 25% TBSA may produce both a local and a systemic response and are considered major burn injuries. This systemic response is due to 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 progression of the burn injury. ‘As a result of burns, normal skin function is diminished, resulting in physiologic alteration. These include: = Loss of protective barriers against infection = Escape of body fluids = Lack of temperature control = Destroyed sweat and sebaceous glands = Decrease in the number of sensory receptors. _The severity of these alterations will depend on the extent of the burn and the depth to which damage has occurred. There are two stages that occur following severe burns: the immediate hypovolemic stage and the diuretic stage.ause and Hormonal enent Therapy onal Met 8ception hogs ek Types | Barrier mattods er method, apices , a Ree ENeEne Cees Stra Lt me 3 3 g2 ee q Epmercee hse 8 : 5 Simona cue. & cee cc eeee a pete ey 3 EE S3—yi 5 § 3 go B Be 3s Go é 3 5 s 8 8h/ ab 8 Sinaia a £ £ ergs eas 8 é o— & ec g = + Bears 5 & fe € 2 € g omens SaaS B § < CPt ta? ma 3 degen Pet-yiog tiga 6 S 8 & 5 3 3 = = 3 é 4 | a e 3 8 8 5 € z of s © 5 ; & © g 83 & 3 g — 83 fe paaas 3 2 SB 3—> GE g < ES 8 2 = 3 s & 3 @ 8 2 3 a a a | 5 2 5 Be 3 ge 2 A 2 £ 8 Siemans ee ez g & g Pathophysiology of Major Bum The hypovolemic stage begins at the time of the burn injury and ovolemic Stage: Tpit of fluid for the vascular bse fot mas for the first 48 to 72 hours. It ‘gs characterized by a rapit ae panent into the interstitial spac aay he burn, can continue for 24 to lotic pressure increases, ear tuid shift is most prevalen™ 1 the | 30 hours, peripheral edemé imbalances of fluid, electro!ice Menem PF ern’ are burned, vasodilation, increased capillary permeability and the ct peuneability of tissue cells in and around the burn area occur. As 4 result, abr nes 18 the ditants of extracellular fluid, sodium chloride and protein pass through the be Be either to cause blister and local edema or to escape through the open wound, ne’ ata Most of the fluid loss occurs dee ; fluid loss occurs deep in the wound, where the fluid extravasates into + peer tissue. Burns occurring in highly vascular areas such as muscle tissu Otome believed to cause a greater fluid shift than comparable burns oceutrin sof te ved ti é arable burns occurring on other parts o body. The fluid loss is depends upon the percent of burn injury. Fully half of the earns acellulay burn. Hypovolemic and inadequate blood flow and anuria. Death occurs within « fluid of the body can shift from its normal distribution to the site of a severe shock occurs, and there is a tremendous drop in blood pr through the kidneys, which in turn leads to further shock short time if treatment is not given promptly ssure As a result of these fluid shifts, dehydration of non-d. Initially, more fluid and sodium are lost from the the capillary osmotic pressure, le: amaged tissue cell may occur. capillaries than is protein. This increases ading to dehydration with pronounced edema in the burned area. Hypoproteinemia occurs when protein continues to be lost into the burned are a because of the increased capillary permeability. The increased ae f amount of protein in he tissue spaces leads to edema. The lymphatic system, which normally functions to remove increased fluid form the tissue, becomes overloaded and insufficient, thus contributing to edem is lost through the kidneys from catabolism, leading to significant negative Blood urea nitrogen (BUN) is elevated when oliguria is present. d With loss of fluid from the vascular system, hemaconcentration occurs and the hematocrit rises. Blood flow becomes sluggish in the burned area and cellular nutrition decreases. Large numbers of red blood cells becomes trapped in the burned area and are hemolyzed. Renal damage and hematuria may occur as a result of reduced blood volume and passage of the end products of the hemolyzed cells through the glomeruli. The decreased renal blood flow leads to oliguria. a. Nitrogen nitrogen balance Electrolyte imbalances also occurs form the burn injury. Hyperkalemia (elevated serum potassium) results form the release of potassium from damaged tissue cells and red blood cells and from decreased urinary output. Hyperkalemia may lead to heart block and ventricular failure. Potassium may be encouraged to move back into the cells by the administration of insulin, because potassium is transported back into the cells along with glucose. Sodium is retained by the body as a result of the endocrine response to stress. Aldosterone is increased, leading to increased sodium reabsorption by the kidney. However, sodium ee peetes into the interstitial spaces of the burned area with the fluid shift: Despite the increased amount of sodium in the body, most of the sodium is trapped in the edema fluid and a serum sodiw ici q i erfusion results in anaerobic metabolism and the acid end deficit occurs. Inadequate tissue perfusior SS ee products are retained because of the decreased kidney function. Me y occur. ; : i is irway obstruction or the effects of hypovolemic Respiratory res a cated by inflation of noxious agents or superheated See ene niuon of the airway, laryngeal edema and potential obstruction. : i >. Diuretic Stage: Return of vascular integrity begins in approx. 12 hours and rapidly ‘scges at 18 to 24 hours following the initial burn injury. The diuretic stage Degits * prea ts to 72 hours after the burn injury as capillary membrane integrity returns ande ot natal fe back from the interstitial spaces into the intravascular space. Blood volun ees hemding to increased renal blood flow and diuresis unless renal Ebi oat cenrel it levels will be decreased because of he tion. Flu Serum electrolyte an ert ofthe increase in inuavasclar volume, The paten’s wil ovsigns, uid 1 serve. A sodium deficit continues bec; breath sounds and urinary o, eplacement. Dehydration may Put are u 'Y Occur if raj qj from an increase in urinary ou into the cells or being excreted in the nyo Metabolic acidosis remains a possibility reo in urine and the increase in fat metabolism secgaue® Of the los 8 Y to a decrease g § OS a3 2 2 ag Souk enter eG Smee Bs 38 = 3 E 2 E é > & 3a = 35 8 nes 5 3 B a3 af z 3 = 8 E E § 8 § 3 3 2—F— > 5 & & 5 = § 3 2 2 2 8 5 8 2 a 3 ess 3 8 = g— B— Je OR REE s 8 ee & fts Resulting in Hyp Flow Diagram of Fluid Shi Decreased Intravascular fluid Hypovolemic Shock in carboi ovolemic ShockFollowing i lowing the period of fluid shifts, the patient remains acutely ill, This peri characterized by anemia and malnutrition. Anemia develops from the loss of Aa na ‘a cells. Negative nitrogen balance begins at the onset of the burn and is the result of tissue destruction, protein los Ho because of continued los and the stress response. It continues throughout the acute period of protein from the wound, tissue catabolism from immobility and decreased protein intake. Increased metabolism from loss of water and heat from th wound, loss of fluid during div sue breakdown all lead tc weight loss. eee sis and catabolism dui The Burn Syndrome Following a major burn injury a myriad of physiologic changes occur that together comprise the clinical scenario of the burn patient. These derangements include: 1. Fluid and Electrolyte Imbalance: The burn wound becom microvascular changes induced by direct thermal injury and by release of che mediators of inflammation. This results in systemic intravascular losses of water, sodium, albumin and red blood cells. Unless intravascular volume is rapidly restored, shock rapidly edematous due to ‘ical develops. 2, Metabolic Disturbances: This is evidenced by increased resting oxygen consumption (hypermetabolism), an excessive nitrogen loss (catabolism), and a pronounced weight loss (malnutrition). 3. Bacterial Contamination of Tissues: The damaged integument creates a vast area for surface infection and invasion of microorganisms. Burned patients with a major thermal injury are unable to mount an adequate immunologic defense, increasing the risks for septic shock. 4. Complications from Vital Organs: All major organ systems are affected by the burn injury. Renal insufficiency can result from hypoperfusion or from nephron obstruction with myoglobulin and hemoglobin. Pulmonary dysfunction may be caused from initial respiratory tract damage of from progressive respiratory insufficiency due to pulmonary edema, adult respiratory distress syndrome or bronchopneumonia. Gastrointestinal complications include paralytic ileus and gastrointestinal ulcerations. Small bowel ischemia and stasis promote bacterial translocation as a mechanism for endogenous infection. Multi-system organ failure is a common final pathway leading to late burn mortality. Diagnostic Studies in Burn Complete Blood Count heat damage to vascular can occur because of loss of Arterial Blood Gases (ABGs): B injury. Reduced Pao2/increased Paco2 may be se ‘Acidosis may occur because mechanisms. Carboxyhemoglobin (COHD) poisoning / inhalation injury. f cells at wound site and inflammatory response to injury. (CBC): Initial increased hematocrit (Hct) suggests hemocon- centiation due to fluid shift/loss. Later decreased Hct and RBCs may occur because of endothelium. Leukocytosis (decreased white blood cells [WBCs}) jaseline especially important with suspicion of inhalation en with carbon monoxide retention. of reduced renal function and loss of compensatory respiratory ); Elevation of more than 15% indicates carbon monoxidefen Dates of Cysts anit gerum electrolytes: Potassium | RBC destruction and decreas, starts; magnesium level may be gon? body water losses; hypernatremia gest Sodium level may initiatn Alkaline phosphatase: Eleyateg becausi ee ar € Of intey Serum glucose: Elevation re; eaUSe of in ; i jure Ypokalemia can occur when tsstes/ ire ly be decreas Tenal conservation occurs“ “th stitial fluid Shifts /i impairment of sodium edema fluid. Blood urea nitrogen (BUN) creatinine (CP): Bleysx function, lowever, Cr level can elevate because of or? “creased renal perfusion Urine: Presence of albumin, hemoglobin (Hb), and eo”: damage and protein loss (especially seen with sono Bhi indicates deep-tissue color of urine is due to presence of i us electrical burns). Reddish-blac ; ne myoglobin, i Random urine sodium: More than 20 mEq/L ind; : than 10 mEq/L suggests inadequate flurt aa ramen ccs fluid resuscitation; less for baseline data and repeated periodically. ns oe aay Be bead Chest x-ray: Ma’ i . true daha oti ermal in early postburn period even with inhalation injury; however, a nihafation injury presents as infiltrates, often Progressing to whiteout on xray (adult respiratory distress syndrome [ARDS)). Fiberoptic bronchoscopy: Useful in diagnosing extent of inhalation injury; findings can include edema, hemorrhage, and /or ulceration of upper respiratory tract. Flow volume loop: Provides noninvasive assessment of effects /extent of inhalation injury Lung scan: May be done to determine extent of‘inhalation injury Electrocardiogram (ECG): Signs of myocardial ischemia/dysrhythmias may occur with electrical burns. Photographs of burns: Provide documentation of burn-wound and comparative baseline to evaluate healing. Management of Burn damage. For example, (such as melted synthetic shirts), Before burns are treated, the burning agent must be stopped from inflicting futher fires are extinguished. Clothing—especially any that is smo pee covered with a hot substance (for example, tar), or soake: wil i is i diately removed. ith chemicals—is immediately imal care of bums. For example, elevating swelling is more easily cessary for opt arrying out essential italization i: imes ne Hospitalization is sometime: the level of the heart to prevent a severely burned arm or leg above ie Be its people from c: accommodated i ‘tal. In addition, burns that prevents peop . Severe burns, lated in a hospi a kes hospitalization eee ee ded daily functions, such as walking or eati ee ea deep second- and third-degree burns, burns occurring in the very ¥ bums involving the hands, feet, face, or gen Senters are hospitals that are specially equippe ted at burn centers. Burn itals are usually best treal i 6 .d and staffed to care for burn victims.Fi burning pro 1. 1 cars Popo Do op a Oo ‘PU A Text Book of Medical Surgical Nursi irst Aid for Burn Injury Regardless of the cause, the first ste at the source, and cool the burn wound t Aid for Minor Burns: (First-Degree) If the skin is not broken, run cool water over the bu (not ice water) bath. Keep the area in the bath for five minutes. If the burn occurred jn a cold environment, do not apply water. A clean, cold, wet towel will also help reduce p in managing a person with a burn is to stop the med area or soak it in a cool water pain. Burns can be extremely painful, reassure the victim and keep them calm After flushing or soaking the burn for several minutes, cover the burn with a sterile non-adhesive bandage or clean cloth Protect the burn from friction and pressure. Over-the-counter pain medications may be used to help relieve pain; they may also help reduce inflammation and swelling Minor burns will usually heal without further treatment. . First Aid for Severe Burns: (Second & Third-Degree) Do not remove burnt clothing (unless it comes off easily), but do ensure that the victim is not in contact with burning or smoldering materials. Make sure the victim is breathing. If breathing has sto} blocked then open the airway and if necessary begin CPR If the victim is breathing, cover the burn with a cool moist sterile bandage or clean cloth. Do not use a blanket or towel; a sheet is best for large burns. pped or the victim's airway is Do not apply any ointments and avoid breaking blisters. If fingers or toes have been burned, separate them with dry sterile, non-adhesive dressings. Elevate the burned area and protect it from pressure or friction. Take steps to prevent shock. Lay the victim flat elevates the feet about 12 inches, and cover the victim with a coat or blanket. DO NOT place the victim in the shock position if a head, neck, back, or leg injury is suspected or if it makes the victim uncomfortable. Continue to monitor the victim’s vital signs (breathing, pulse, blood pressure). Do Not 1. Do not apply ointment, butter, ice, medications, fluffy cotton dressing, adhesive bandages, cream, oil spray, or any household remedy to a burn. This can interfere with proper healing. Do not allow the burn to become contaminated. Avoid breathing or coughing on burned area. Do not disturb blisters or dead skin. Do not apply cold compresses and do not immerse a severe burn in cold water. This can cause shock. Do not place a pillow under the victim’s head if there is an airway burn and they are lying down. This can close the airway.Nursing Ma gement of Burn First Aid Pr Tevention of , n of shock Prevention of re Spiratory distress intermediate Phase: From beginning of diures esis near completion of wound closure a jeatment of complications Nutritional support Long term Phase: From major wound closure to return to individual’s optimal level of physical and psychosocial adjustment Prever Tevention of scars and contractures Physical, occu al, occupational, and vocation, rehabilitation ee Functional and cosmetic reconstruction Psychosocial counseling Immediate Management of Burn The therapist's role when treating a patient wi is improve function, prevent deformity and contracture sea ny © maintain function, burn scar. Depending on the level of the burn thecand Sees ie wel ve ae t c 5 Y y ing wi immediately and possibly for months following the injury. Heperio che eae contraction of the burn scar are the two impediments that prolong recovery following a deep bum injury. Treatment following a burn is divided into 4 stages as described below. A. Emergent Period or Immediate Phase: The emergent period of the of the burn management refers to the first 48 to 72 hours postburn when the patient is admitted to the hospital, the severity Of the injury is determined, and the first aid and wound careis given. The emergent period of therapy is defined as the time required resolving the immediate problem resulting from the burn injury. During the emergent period of burn injury, the patient's care is provided in a highly collaborative manner between nursing and medicine. These areas include airway management and oxygenation, wound management, fluid resuscitation, pain control and tetanus prophylaxis. is an extremely important 1, Airway Management: Airway management ob buries conducted. Persons . . i ications if not roperly, ce consideration that can lead to cevesiatns eae z ae a Flame, steam or smoke who are burned on the face and neck 01 ; obstruction. The f laryngeal edema and airway ObSHNCION shoul d closely for signs 0} : “a Pee vas pottie ian susceptible to obstruction because of expos For mild pulmonary injury, Cough so that secretions can be eee to remove secretions by br‘ and mucolytic agents. Early manageme! Teagzton. eal blood gas determinations ent is wuraged to inspired air is humidified and the patient E ate a oe ere by suctioning. ou mor gover ronchodilators joni! toa 7 jal suctioning an‘ E one dotracheal int ire ene gement may ed be obtained 38 @predict CO poisoning. Therefore, baseline carboxyhaemoglobin | should be obtained, and 100% oxygen should be administered. Elevation of the he chest by 20 to 30 degrees reduces neck and chest wall oedema. If a full-thickness burn of -e restriction of the chest wall motion, chest wall escharotomy (by chest wall leads to seve incised into subcutaneous fat and underlying soft tissue; no anaesthetic is required) m, required. Early escharotomy is needed in circumferential chest and limb burns w respiratory or circulatory disturbance is observed. sy (HBOT): F perbaric oxygen therapy is a non inva: nclosed in a pressure chamber 2. Hyperbaric Oxygen Ther mode “of medical treatment in which the patient is entirely filled with oxygen at a pressure greater than one atmosphere. It is a painless procedure that can be carried out in either in a monoplace chamber where only one patient is in the chamber, or a multiplace chamber where the patient along with someone else are inside the chamber The chamber is pressurized with 100% pure oxygen. Topical hyperbaric oxygen therapy technique includes delivering 100% oxygen directly to an open, moist wound at a pressure slightly higher than atmospheric pressure through special devices. The patients may be trained and can use these devices at home. There are many conditions that may benefit from hyperbaric oxygen therapy such as sores and gangrene that will not heal or that are related to diabetes, decompression sickness, osteomyelitis, severe anemia and others. Healing wounds and burn victims can benefit from this treatment with its effect on body tissues and wound healing. In severe thermal burns tissue damage will happens leading to hypoxia (insufficient supply of oxygen) and tissue death. Tissue damage may progress due to the failure of the surrounding tissue to supply borderline cells with oxygen and nutrients necessary to sustain viability. Hypoxia will prevent normal wound healing. HBOT will accelerate wound healing by providing the oxygen needed to stimulate and support wound healing. Burned patients have increased susceptibility to infection due to the loss of skin which acts as a barrier to bacterial invasion. HBOT can be useful in treating some of these infections. It can act by enhancing leukocyte and macrophage activity, potentiating the effects of antibiotics and act directly on anaerobic bacteria. . Hyperbaric oxygen therapy is also used in the treatment of smoke inhalation. Carbon monoxide has a high affinity to hemoglobin and when it is inhaled it will bind to hemoglobin forming a compound called carboxyhemoglobin (COHb), this will lead to hypoxia and decrease oxygen delivery to tissues. Hyperbaric oxygen decreases the half life of carboxyhemoglobin and fastens the disassociation of carbon monoxide from hemoglobin making hemoglobin available for oxygen. The Hyperbaric oxygen therapy course will vary depending on the mane rees and the response of the patient to therapy. “Fluid Management: After an airway has been established, support of circulation is ddressed. Burn injuries cause tremendous losses fluid through the wound as well as into the urn wound and adjacent tissues in the form of edema. Fluid loss is best immediately replaced hrough two large caliber peripheral intravenous catheters. To prevent the introduction of nfection, the lines are inserted through unburned area. Blood samples are taken for jaemoglobin, urea, electrolyte and grouping cross matching. Blood gas and blood analysis yr carbon monoxide are required in unconscious patients. Any adult with burns affecting ore than 15% of the body surface area or a child with more than 10% of body surface area fected requires fluid resuscitation. An indwelling Foley catheter is inserted to monitorCe i ik AA dental ethachbed bled Reconstructive and Cosmetic Surgery sine output accurately. Hourly urine output measurements are use as a guide to adequacy Jacement. All resuscitation formulae should be delivered as a ypovolaemic shock or over-hydration. @f fluid (plasma volume) rep geal directed therapy to prevent the complications of hPremorbid Psychopathology—Compared with the general population, res have a high rate of premorbid psychopathology. Patients with pro psychopathology typically cope with hospitalization through previousl? ax” dysfunctional and disruptive strategies. The most common premorbid pert! diagnoses are depression, personality disorders, and substance misuse ti psychopathology can have an adverse impact on outcomes, including iat hospitalizations and the development of more serious psychopathologies after ine ary * Grief—Patients may now begin the grieving process as they become more aware impact of the burn injuries on their lives. Family members, friends, or pets may hares in the incident, and patients may have lost their homes of personal property, in addr to these external losses, patients may also grieve for their former life (such as job, mobil” physical ability, appearance). Mental health professionals and other staff should hey patients to grieve in their own way and at their own pace a Treatment - Brief psychological counseling can help both depression and anxiety, but drugs may also be necessary. When offering counseling, it is often helpful to provide reassurance that symptoms often diminish on their own, particularly if the patient has no premorbid history « depression or anxiety. ri e Drugs and relaxation techniques may also be necessary to help patients sleep. Informin, patients that nightmares are common and typically subside in about a month can help ale concerns. Occasionally patients will benefit from being able to talk through the events of the incident repeatedly, allowing them to confront rather than avoid reminders of the trauma Staff often makes the mistake of trying to treat premorbid psychopathology during patients’ hospitalization. Referrals to community treatment programmes should be made once patients are ready for discharge. belo) (CTIVE AND COSMETIC SURGE: PLASTIC SURGERY The word “plastic” derives from the Greek plastikos meaning to mould or to shape; its use here is not connected with the synthetic polymer material known as plastic. Plastic surgeon typically mold and reshape the following tissues of the body; bone, cartilage, muscles, fat and skin. Plastic surgery is a medical specialty concerned with the correction or restoration of form and function of the body structures damaged by trauma, transformed by aging process, changed by disease process and malformed as a result of congenital defects. While famous for aesthetic surgery, plastic surgery also includes many types of reconstructive surgery, hand surgery, microsurgery, and the treatment of burns. The basic goals of the plastic surgery include following: Correction of perceived disfigurement Restoration of impaired function = Improvement of physical appearance The benefits of plastic surgery may include: = Correction of a congenital or acquired deformityOAc at ti aa d physical imperfection ete tion . a perceive, + Psychological benefits Basic principles of plastic surg gery + Achieving minimal scarring * Careful planning of incisions so th * Appropriate choice of w; « Use of best available sut at they fall in the ‘ound closure ! line of natural skin folds or lines ure materials * Early removal of exposed sutu Tes so that ti 2] + Documentation through phon, fhe wound is held closed by buried sutures X graph: Techniques and Procedures ae Common techniques used in plastic surgery are: 1. Incision Piet 3. Microsurgery 4. Chemosurgery 5, Electrosurgery 6. Laser surgery 7. Dermabrasion 8. Liposution In plastic surgery the transfer of skin tissue (skin grafting) is one of the most common procedures. Plastic surgery include closure of wounds, removal of skin tumors, Tepair of soft tissue injuries or burns, correction of deformities and repair of cosmetic defects. Plastic surgery can be used to repair many parts of the body and numerous structures such as bone, cartilage, fat, fascia, mucous membrane, muscle, nerve and cuteneous structures. During plastic surgery the following procedures are common: tissue may be removed to fill a depression to cover a wound or to improve appearance and tissue may be completely removed to alter the contours of a feature. Plastic surgery can be divided into two major areas: Reconstructive surgery and Cosmetic (aesthetic) surgery. RECONSTRUCTIVE SURGERY : ; ea oe tive surgery, in its broadest sense, is the use of surgery to restore the fo: and Fier Rr nae vay Raconstructive surgery attempts to restorea more normet spree ive plastic surgery is usually perform to an abnormal or absent body part. Reconstructive plastic st aes Pe i i i to approximate a normal s ao ction, but it may be done ° 5 ee ie eocesce coverage but this may change according to procedure require ional impaii ; burns, ii functional impairments caused by: burns, i ery is performed to correct funct me 3 Seats Sie edd bone fractures, congenital abnormalities such as set ine ae pal eeal abnormalities, infection or disease and removal of cancers palate, develop: such as mastectomy. Common Reconstructive Surgical P: [ There are several operative and A shape and enhance the beauty of various Pocy for various body parts are as follows: rocedures s aierere te procedures tive procedures available to Most commonly performAS Ene Breast Reconstruction 2. Face Injury Contracture Surgery for Burn 4. Hand and finger Injurieg 5. Cleft Lip and Palate 6. Injuries to Limbs 8. Amputations 7. Cranio-facial Defect 9. Ptosis or Drooping of Eyelids 10. Scars 11. Defects of Eras 12. Pressure Sores 13. Hand and Anomalies 14. Spinal cord Defects Reconstructive Modalities 1. Skin Grafting: Skin grafting is a type of medical grafting involving the transplantation of skin. Skin grafting is technique in which a section of skin is detached from its own blood supply and transferred as free tissue to a distant (recipient) site. Skin grafts are commonly used to repair defects that result from excision of skin tumors, to cover areas denuded of skin (burn) and to cover wound in which insufficient skin is available to permit wound closure They are also used when primary closure of the wound increases the risk for complications or when primary wound closure interfere with function. Skin grafts are often employed after serious injuries when some of the body’s skin is damaged. Surgical removal (excision or debridement) of the damaged skin followed by skin grafting. The grafting serves two purposes: it can reduce the course of treatment needed and it can improve the function and appearance of the area of the body which receives the skin graft. Skin grafts may be necessary to provide protection to underlying structures or to reconstruct areas for cosmetic or functional Purposes. Indications Skin grafting can be used to repair almost any type of wound and is the most common form of reconstructive surgery. Skin grafting is often used to treat * Extensive wounds or trauma | Burns | Specific surgeries that may require skin grafts for healing Areas pf prior infection with extensive skin loss Cosmetic reasons or reconstructive surgeries lassification Autografts: An autografts is tissue obtained from the patient’s own skin. Allografts: An allograft is tissue obtained from a donor of the same species; these grafts are also called allogenic or homografts. Xenografts: A xenografts or heterograft is tissue from a donor of a different species. assification by Thick ‘ess Split skin grafts: A split- b used to cover large wounds or defects for which a This type of skin graft is taken by shaving the sur r mi the Be with a ee knife called a dermatome. The shaved piece of skin is then ap] thickness graft can be cut at various thicknesses and is commonly full-thickness grafts or flap is impractical. idermis and dermis) of face layers (epidermis an ae eUna eee) utd SUC Ce Sfakin Braft is often taken from the le, a lesion on the lower leg . + a 2. Full thickness skin grafts: Full-thickne without the underlying fat. This type the wound. This type used after excision of 8, A split skin graft is often Ss graft consists of dermis and the entire dermis the skin with a scalper Ga Wort ore oF skin graft is taken by removing all the layers of piece of skin is cut into she oe Sat Tk is done in a similar way to akin’ excision, phe skin graftis often taken fren coet Shae, and then applied to the wound. This type of on the hand or fae ai nom the arm, neck or behind the ear. Itis often tsed after excbions e hand or face. It is used to cover wounds that are too large to be closed direct 3. ite Graft: A c Composite Graft: A composite skin graft is sometimes used, which consists of Combinations of skin and fat, skin and cartilage, or dermis and fat. Comporite cote ane used in patients whose injuries require three-dimensional reconstruction Forevarine a wedge of ear containing skin and cartilage can be used to repair the nose” Donor Site * The common areas which are used as donor sites are the buttocks, thighs and upper arms. " The donor site is dressed in theatre and the dressing will usually be left in place for 7 - 14 days. = We may have to re-pad the dressing as this area often oozes/ bleeds after the operation. * The donor site area is usually more painful than the grafted area as the top layers of the skin are removed exposing the nerve endings. Regular painkillers will need to be given to help ease the discomfort. » All dressing need to be kept dry and in place until you are told differently by the nursing staff. The dressing on the donor site will often become stiff and dry out. It may also separate from the skin and fall off, this is normal and is often a sign that the wound has healed underneath. However if the dressing falls off earlier than 7 -14 days, you will need to contact the nurses as a new dressing may need to be put on. The donor site is selected with several criteria in mid: = Achieving the closest possible color match = Matching the texture and hair bearing qualities Obtaining the thickest possible skin grafts without jeopardizing the healing of donor site = Considering the cos picuous location. GRAFT APPLICATION = The wound is prepped for surger “ pattern is Race for transfer over to the donor site. ia i ini ding on the size, thesia is administered. Depen : ea as the type of graft, the procedure may require bes : \ iv sedation, general anesthesia, or a one ace ne ee sap in i ted and prepared. The skin is ton +The donor a ar with the help ofa special harvesting mache = skin grafting metic effects of the donor site after healing so that it is in an incons- y. The wound is cleaned and measured, and then a severity, and location of the you al anesthesia, regional anesthesia,SGare( 658 [rate aan err a4 ; a wort 800k of Mosical Surgical Nersing ll ice The graft may also be “meshed,” a process wherein multiple controlled incisions ar, placed in the graft. This technique allows fluid to leak out from the underlying tissue and the donor skin to spread out over a much larger area. With a full-thickness o, composite graft, the donor site is then closed with sutures. With a split-thickness graf sutures are not needed at the donor site , The skin graft is taken from the donor or host site and applied to the desired site calle the recipient site or graft bed. It is held in place by a few small stitches or surgical staple Once in place, the graft is fastened to the surrounding tissues with sutures or staples. A pressure bandage is applied over the graft recipient site. A special vacuum apparatus called a wound VAC may be placed over the area for the first 3 to 5 days to contro} drainage and increase the graft’s chances of survival Healing begins. At first, the graft uses oxygen and nutrients from the tissue at the recipient site to survive. The graft is initially nourished by a process called plasmatic imbibitions in which the graft literally drinks plasma. New blood vessels begin to grow within the first 36 hours in a process called capillary inosculation, followed by new skin cells which then begin to grow from the graft to cover the recipient area with new skin. in graft to a recipient bed is = The process of revascularization and reattachment of skir referred to as a take. After a skin graft is put in place, it may be left exposed or covered with a light dressing or a pressure dressing depending on the area. Post-Op Care: Both the donor and recipient sites should be kept moist and well-protected. Physician will instruct patient on the proper use of medications and bandaging, a graft to survive and be effective, certain conditions must be met: 1. The recipient site must have an adequate blood supply so that normal physiologic function can resume. The graft must be in close contact with its bed to avoid accumulation of blood or fluid. The area must be free of infection The graft must be fixed firmly (immobilized) so that it remain in place on the recipient sites. Complications of skin grafts and donor areas If your child shows any of the following symptoms, on the ward or at home, please speak to the burns team for adv = Infection Smelly discharge from dressing - High temperature - Increased pain Redness and swelling around the skin graft and donor area » Bleeding through the dressing caused by trauma or infection which may cause clots and lift the graft = Loss of grafted skin 7" Rejection may occur in heterologous graft. To prevent this, the patient usually must be treated with log term immunosuppressant drugs.ourse Meese MSDS eed CCR ent Caring for the graft ’ After having a skin g ‘econstructive and Cosmetic Surgery Taft it is important to ke * Clean and free from infection ep both the graft and the donor site: * Avoid stretching or moving around the MMe eal cane Braft area or the affected limb unless you are ‘aff or the ph u are a siotherapist The graft will have a firm dressing in pl Patient might also need a plaster cee lace to help stop any movement and friction. nt extra movement near joints. * The pressure of the dressing will help t dressing is usually left over the skin g: child’s doctor or nurse. Aftercare nce 2 skin graft has been put in place, it must be maintained carefully even after it has healed. Patients who have grafts on their legs should remain in bed for seven to 10 days with their legs elevated. For several months, the patient should support the graft with an Ace bandage or Jobst stocking. Grafts on other areas of the body should be similarly supported after healing to decrease the amount of contracture. ae © stop fluid collecting under the new skin. The aft for 2-7 days, and then will be looked at by your Grafted skin does not contain sweat or oil glands, and should be lubricated daily for two to three months with mineral oil or another bland oil to prevent drying and cracking, The wounds will most probably itch, there is no treatment that can take away all the itching, but with time this will lessen. * Try to avoid scratching the wounds, as this may damage the ne Medication can be given, called anti-histamine. Usually “Piriton”, this helps take some of the itching away, but might make your child feel sleepy an and washed regularly on areas where there are no skin from healing. = Make sure your child is kept cle dressings. = Make sure patient wears cotton clothes to help stop them getting too hot. When the wounds have healed, patient will need to apply cream on to them, gently massaging them 2-3 times a day, to prevent them getting dry and flaky. The nursing/medical staff will tell patient when to start putting on the cream and what type of cream to use. Ss i e cl the sun as they will burn more The graft and donor site will need to be protected from y easily cee the rest of patient's skin. Sun block needs to be used on these areas and ore i 5 the wound heals scarring may occur. Pal areas with clothes. Use at least Factor 25. As aaa may be given pressure garments to wear, or a dressing or gel to be put on the scar. help flatten the scarring. a Skin Flaps: A flap is a segment of tissue that remains sea at oh et a , i . Its survival depen: o pedicle) while the other end is moved to a recipient area. Its s pee a Frterial and venous blood supplies and Nyaphalia crates g i e peli ore i i he tissue is a from a graft in that a portion of # supply. ; A skin flap consists of ski blood supply. Flaps may consi its own ives based on i sue that survi etnias ibcutaneous tis: : 4 rea ‘cle, adipose tissue, st of skin, mucosa, mu:FV A Text Book of Medical Surgical Nursing, and provide bulk, especially when bone, tendon, They are used for wound covera; els or nerve tissue is exposed. offer an aesthetic solution because a flap retains the color and textures of th, dicated when specialized tissue is needed to cover gliding ed sensory function. The area. Skin flaps are , for bulk tissue to fill contour defects and for speciali ation is necrosis of the pedicle or base as a result of failure of the bloog Indications Use a skin flap for wound coverage when inadequate vascularity of the wound bed ts skin grafts survival. ps are used to repair defects caused by congenital deformity, trauma, or tumor on in an adjacent part of the body Skin flaps are also being used to heal extensive wounds from pressure ulcers and long standing defects from osteomyelitis Use skin flaps for functional and cosmetic requirements for wound coverage on the face, particularly around the eye, nose and mouth FREE FLAPS A striking advance in reconstructive surgery is the use of free flaps or free tissue transfer achieved by microvascular techniques. Free flaps are harvested from one area of the body to reconstruct a defect in a distant area. The donor tissue (skin, muscle, bone or a combination these) is detached from its blood supply at the donor site and reattached by microvascular anastomosis to arteries and veins at the recipient site. Microvascular surgery allows surgeons to use a variety of donor sites for tissue reconstruction. Methods of Flap Movement Skin flaps can be moved to a local or distant site. A. Local Flaps: Use local flaps for defects that are adjacent to the donor site. There are 4 major types of local flaps based on the predominant type of movement. An advancement flap moves directly forward without lateral movement. A triangle of skin can be excised from the base of the flap to aid in closure. A rotational flap is a semicircular flap that rotates about a pivot point into an adjacent defect. Design the arc as large as possible. The secondary defect or donor defect can be closed primarily or grafted. 3. A transposition flap moves laterally about a pivot point into an adjacent defect. Usually, it is designed as a rectangle. Design the flap to be longer than defect, since transposition decreases the length. The donate site can be closed directly or closed with a skin graft or second skin flap. The Z plasty is a type of transposition flap in which two triangular flaps, designed with limbs of equallength, are interposed to exchange width and length. Classically, it is designed with 60 degree angles, which yield maximum length. Design the Limberg (rhomboid) flap in a rhomboid shape with 60 degree and 120 degree angles. Four flaps can be designed surrounding a rhomboid-shaped defect.Reconstructive and Cosmetic Surgery The interpolation flap rotates about with the pedicle passing above B. Distant Fla i Ps: Use distant flaps to co ohh laps Ver nonadjaci directly, tubed or tranferred by microvascular eae : , a es A direct flap is transferred to : @ pivot point into a nearby but not or below a skin bridge. sc vee t defects. They may be transferred a distant site directly g sites tane eran < ctly so that the donor site and recip Bee oximated. The flap is later divided after 1 to 3 weeks and inset. The tubed flap is ; ' Psi nara Hise with the lateral flap edges sewn together, Re eee Pirated from the distant end of the flap. Sewing the : : “teased risk of infection and contraction of the flap. A microvascular free flap is a type of distant flap in which the flap, with its vascular Pedicle, is divided completely from its donor vessels and anastomosed to the recipient vessels at the recipient site using a microvascular surgical technique. Preoperative Management 1. Medical history and examination should be evaluated particularly for latex sensitivity, cardiovascular problems requiring endocarditis antibiotic. prophylaxis, bleeding problems and high blood pressure. 2. Efforts should be made to enhance wound healing several months to several weeks before the procedure, such as smoking cessation, alcohol avoidance and proper nutrition. 3. Aspirin, NSAID and vitamin E are discontinued 14 days before the procedure. Prothrombin time and international normalized ratio should be measured before the procedure. 4. The procedure is usually done under local anesthesia, so no meals are withheld. 5. The operative site should be free of makeup. Postoperative Management Initial pressure dressing will be left in place for 24 to 48 hours. If wound begins to ooze apply firm pressure for 10-15 minutes. Do not give aspirin or aspirin-containing medication. Most skin grafts are held in place by a bolster dressing (cotton ball or foam). Clean site and apply ointment to the surrounding area of the bolster dressing. i i tibiotic ointment Keep the graft edges moist with an\ ; ‘ “ as the graft from the sun. The sun will cause pigmentation changes in the gré Inspect the dressing daily. Report inage or signs of an inflammatory Ce Inspect the di g daily. Report unusual drainag gns of : After 2 — 3 weeks, any water-based moisturizer may ee eae ‘Avoid strenuous exercise. Anything that causes face to flush w and impair healing. SePNanewnn _ S t or COSMETIC SURGERY formed to reconstruc popular form of the body's appearance. The Cosmetic surgery is a very tore or improve ic or appearance. f i fects or to resto) metic or ap] to alter congenital or acquired Geter ory thatis designed (0 ipo alter inherited features term cosmetic surgery refers ef for changes that result from aging, , Cosmetic surgery is performe: i or because of a client’s personal desire. ————————— plastic surgery per