BURNS

BY M. MUMBI
 OBJECTIVES
By the end of the study the learner will be able to:
• Describe types and prevention of burn injuries
• Describe burn injuries in terms of involved structures and
clinical appearance of full and partial thickness burns
• Identify the parameters used to determine the severity of
burns
• Describe the pathophysiological changes, clinical
manifestations, medical and nursing management
occurring each burn phase
• Explain fluid and electrolyte shifts during the emergency
and acute phase
 OBJECTIVES ctied
• Differentiate between nutritional needs of the
burn client during the three burn phases
• Explain the physiologic and psychosocial aspects
of burn rehabilitation
• Describe medical and nursing management of the
emotional needs of the burn client and family
• Describe the special needs of nursing staff caring
for burn client and possible ways to meet those
needs
 DEFINITION OF BURN INJURY
Refers to the injury to skin caused by:
• physical agent like the sun, excess heat or cold,
friction, nuclear radiations,
• chemical agents like acids or caustic alkalis
• Electrical current
Burns are described as being partial thickness
(involving the epidermis or full thickness
involving the dermis and the underlying
structures
 Incidence of burn injury
• On the decline
• Young and elderly people are at high risk
because their skin is thin and fragile
• Most burn injuries occur in the home
 Classification of burns
Burns injuries are described according to the
depth of the injury and extent of the body
surface area injured
 Burn depth
• The depth of a burn injury depends on the
type of injury, causative agent, temperature of
the burn agent, duration of contact with the
agent and skin thickness
• Burns are classified according to the depth of
tissue destruction:
 Superficial partial thickness burns(1 st
degree burn
• The epidermis is destroyed or injured and a
portion of the dermis maybe injured .
• Damaged skin maybe painful, appear red and
dry as in sunburn, hyperesthesia
• It completely recovers within a week with no
scarring
• Pain is soothed by cooling
 Deep partial thickness burns(2 nd degree

• Such as scald
• The epidermis and the upper layers of the
dermis to the deeper portions of the dermis
are injured
• Wound is painful, appears red and exudes
fluid (weeping skin)
• Takes long to heal as compared to the 1st
degree
 Full thickness burns (3 degree) rd

• Such as a burn from a from a flame or electric

current
• The epidermis, entire dermis and sometimes the
underlying tissue are injured
• Wound colour ranges widely from white to rd to
brown or black
• The burned area is painless because the nerve fibres
are destroyed
• Wound appears leathery, hair follicles and sweat
glands are destroyed
 The extent of surface burn
• How much surface area is burned is
determined by one of following methods:
 Rule of nines
• An estimation of the total surface area burned
by dividing the body into multiples of 9
 Totals
4 1 /2 %
Anterior and posterior
head and neck, 9%

Anterior and posterior

upper limbs, 18%
Anterior
4 1 /2 % trunk, 4 1 /2 % Anterior and posterior
18% trunk, 36%

9% 9%
(Perineum, 1%)

Anterior and posterior

lower limbs, 36%
100%
 Lund and Browder method
• A more precise method of estimating the
extent of burn
• Takes into account that the percentage of the
surface area represented by various anatomic
parts (head and legs changes with growth)
 Palmer method
• Used to estimate percentage of scattered
burns using the size of the patients palm
(about 1%of body surface) to assess the
extent of burn
 PATHOPHYSIOLOGICAL CHANGES
• Burns that do not exceed 25% TBSA produce
primarily local response while those that
exceed may produce both local and systemic
response
 Integumentary system
• Loss of skin
• Inflammation response
• Thermoregulation problems
• Impaired immune response
 Fluid and electrolyte shifts
• The greatest initial threat to the burn patient is
hypovolemic shock which is caused by a massive
shit of fluids out of blood vessels.
• Shift is primarily caused by increased capillary
permeability resulting from histamine release
from injured cells, as well as direct injury
• Histamine a potent vasodilator promotes
increased blood supply to an injured area but also
causes loss of capillary integrity.
•
 CONT’D
• As the capillary walls become more permeable,
water, sodium and later plasma proteins esp.
albumin move into the interstitial spaces and
other surrounding tissue
• The colloidal osmotic pressure decreases with
progressive loss of protein from the vascular
space, this results into the interstitial spaces
 ctied
• The net result of the fluid shift is volume
depletion within the vasculature oedema, low
BP, increased pulse, hypovolemic shock.
• Fluid loss can also be caused by increased
insensible loss via evaporation from large,
denuded body surfaces. Normal insensible
loss of 30-50 ml/hr may increase to as much
as 500-700ml/hr in a severely burned client
 Ctied
• The circulatory status is also impaired due to
haemolysis of RBCs.
• The RBCs are haemolysed from direct insult of the
burn injury
• Thrombosis in the capillaries of burned tissue
causes an additional loss of RBCs
• An elevated hematocrit is due to
hemoconcentration
• Na+ and K+ are involved in electrolyte shifts.
• Na is rapidly shifted to the interstitial space and
remains there until oedema formation ceases
 Fluid ctied
• A K+ shift develops in the 1st 24-48 hours
because the injured cells and haemolysed RBCs
release K+ into the extracellular spaces
• To the end of the emergent phase, if fluid
replacement is adequate capillary membrane
permeability will be restored
• Fluid loss and oedema formation cease.
• Interstitial fluid will gradually return to the
vascular space
 CONT’D
• Clinically massive diuresis will be seen with
very low urine specific gravities
• Serum K+ will be markedly elevated initially as
fluid mobilization brings K+ from the
interstitial to the vascular space .
 Ctied
• Hypokalemia may result at this time or in a
few days due to loss of K+ in diuresis and K+
movement back into the cells serum sodium
will increase as sodium returns to the vascular
space
• Later normal serum Na values are found with
loss of Na in urine
 Cardiovascular system
• Complications include hypovolemic shock,
arrhythmias and cardiac arrest
• Circulation to extremities can be severely
impaired by circumferential burns and oedema
formation (escharotomies done to restore
circulation to compromised extremities
• Increased blood viscosity due to fluid loss
 Respiratory system
• Vulnerable to two types of respiratory injury
1. upper airway burns causing oedema formation
2. inhalation injury causing adult respiratory
distress syndrome.
• Thermal burns to the head and neck can occlude the
airway by oedema formation compressing the
trachea.
• Circumferential burns of the thorax prevent lung
expansion
 Renal system
• Hypovolamic state, blood flow to the kidneys is
decreased causing renal ischemia
• If this continues ,acute renal failure may develop
• With full thickness and electrical burns, myoglobin
(from muscle cell breakdown) is released into the
blood stream and occludes renal tubules
• Adequate fluid replacement and diuretics can
counteract myoglobin obstruction of the tubules
 Pre hospital care
• Remove victim from the scene of injury
• Roll the victim to extinguish flames and use cold water
• Do not remove charred clothing
• Cover burnt areas with clean material
• Cooling the injured area (if small) within 1min
minimises the depth of injury
• If the burn is large, primary consideration is focused on
the CAB
• If large, not advisable to immerse the burned body part
in cool water due to heat and electrolyte loss
 Criteria for admission
• Extent of burns : >10%(children) adult >15%
TBSA
• Pay special attention to the following :
– hands and feet
– face and neck
– perineum
– joints
 Other associated injuries

-Inhalational burns
– chemical burns and electric burns
– other known pre existing diseases e.g. diabetes
– circumferential burns
– extremities of age i.e. <4yrs->50yrs
– patients with high morbidities e.g. HIV
– Concomitant trauma e.g. fractures
 Medical management
Major goals
• Prevention
• Institution of life saving measures of severely
burned
• Prevention of disability and disfigurement and
rehabilitation
 Phases of burn care
PHASE DURATION PRIORITIES
Emergent or resustative From onset of injury to First aid, prevention of
completion of fluid shock, prevention of
resuscitation respiratory distress,
detection and treatment of
concomitant injuries,
wound assessment and
initial care
Acute From beginning of diuresis Wound care and closure
to near completion of Prevention or treatment of
wound closure complications including
infection, nutritional
support
Rehabilitation From major wound closure Prevention of scars and
to return to individuals contractures, physical
optimal level of physical occupational and
and psychosocial vocational rehabitation,
adjustment functional and cosmetic
reconstruction,
psychosocial counselling
EMERGENT AND RECUSCITATIVE
PHASE
 Assessment
• Review the initial assessment data obtained by pre
hospital providers.
• If needed further assess the time of injury , mechanism
of burn, whether the burn occurred in a closed space,
the possibility of inhalation of noxious chemicals and
any related trauma
• Focus on the major priorities of trauma patient. CAB
(also cervical spine immobilization and cardiac
monitoring ) disability, exposure and fluid
resuscitation.
• The burn wound is a secondary consideration although
aseptic management of burn wounds is continued
 Ass ctied
• Assess respiratory status as first priority(airway
patency and breathing adequacy)
• Note any increased hoarseness, stridor,
abnormal respiratory rate and depth or mental
changes from hypoxia
• Evaluate circulation (apical, carotid any femoral
pulses) start cardiac monitoring if indicated e.g.
electrical injury, history of cardiac or respiratory
problems or dysrthmia
 Ass ctied
• Check vital signs frequently
• Check peripheral pulses on burned extremities
hourly
• Monitor fluid intake (iv fluids) and output
(urinary catheter) and measure hourly. Assess
urine specific gravity, PH, protein and
haemoglobin
• Note amount of urine obtained when catheter
is inserted (indicates pre-burn renal function
and fluid status)
 Ass ctied
• Arrange for patients with facial burns to be assessed for
corneal injury
• Assess body temperature, body weight, history of pre burn
weight, allergies, tetanus immunization, past medical
surgical problems, current illnesses and use of medication
• Assess depth of wound, and identify areas of full and
partial thickness injury
• Assess neurological status i.e. consciousness, psychological
status, pain and anxiety levels and behaviour.
• Assess patients and families understanding of injury and
treatment. Assess patients support system and coping
skills
DIAGNOSIS
 Nursing diagnosis
• Impaired gas exchange related to CO poisoning, smoke
inhalation , and upper airway obstruction
• Ineffective airway clearance related oedema and effects of
smoke inhalation
• Fluid volume deficit related to increased capillary
permeability and evaporative fluid loss from burn wound
• Hypothermia related to loss of skin micro circulation and
open wounds
• Pain related to tissue and nerve injury and emotional
impact of injury
• Anxiety related to fear and emotional impact of injury
 Collaborative problems/potential
complications
• Acute respiratory failure
• Distributive shock
• Acute renal failure
• Paralytic ileus
• Curling’s ulcer
 Planning and goals
Major goals for the emergent and rescustative
phase include;
• Patent airway and tissue oxygenation
• Optimal fluid and electrolyte balance and
perfusion of vital organs
• Adequate body temperature
• Minimal pain and anxiety
• Absence of complications
NURSING INTERVENTIONS
 Promoting gas exchange and airway
clearance
• Provide humidified oxygen and monitor arterial
blood gases, pulse oximetry and carboxy-
haemoglobin levels
• Assess breath sounds, respiratory rate, rhythm,
depth and symmetry; monitor for hypoxia
• Observe for signs of inhalation injury, blistering of
lips or buccal mucosa, burns of the face neck or
chest, increase hoarseness of voice or soot in the
sputum or respiration secretions
 CONT’D
• Report laboured respiratory, decrease depth of
respiration or signs of hypoxia to physician
immediately prepare to assist with intubation
and escharotomies
• Monitor mechanically ventilated patients
closely
 ctied
• Institute aggressive pulmonary care measures,
turning, coughing, deep breathing, periodic
forceful inspiration using spirometry and tracheal
suctioning
• Maintain proper positioning to promote removal
of secretions and patent airway and promote
optimal chest expansion, use airway as needed
• Maintain asepsis to prevent contamination of
respiratory tract and infection which increases
metabolic requirements
Restoring fluid and electrolyte balance
• Insert large- bore iv line and an indwelling
urinary catheter
• Monitor vital signs and urinary output (hourly),
central venous pressure, pulmonary artery
pressure and cardiac output. Note and report
signs of hypovolemia or fluid overload
• Provide iv fluids as prescribed and titrate with
urinary output.
• Document intake and output and daily weight
 Fluid replacement therapy
Guidelines and formulas for fluid replacement in burn
patient:
1. Parkland/ Baxter formula- 4×kg body weight× % TBSA
burned.
day1: half to be given in first 8hrs
half to be given over next 16 hours
day 2: varies. Colloids is added (colloids- blood dextran,
plasma (in burns >30% app 250ml of plasma required for
each 20%
2. Consensus formula- 2-4ml× kg body weight× %TBSA
burned half to be given in the first 8hrs, remaining half
given over 16hours
 CONT’D
The first 24 hours means since time of burn not
since admission
• Elevate head of bed and burned extremities
• Monitor serum electrolyte levels
• Recognise developing electrolyte imbalances
Maintaining normal body temperature

1. Provide a warm environment through use

of heat shield, space blanket, heat lights,
or blankets.
2. Work quickly when wounds must be
exposed.
3. Assess core body temperature frequently.
 Minimize pain and anxiety
1. Use pain intensity scale to assess pain
level (i.e., 1 to 10). Differentiate from
hypoxia.
2. Administer analgesics and assess response
3. Provide emotional support and reassurance
4. Assess patient and family understanding of burn
injury coping strategies, family dynamics and
anxiety levels
5. Provide pain relief and anxiolytics if the patient
remains highly anxious and agitated after
psychological interventions
 Monitor and manage potential
complications
Acute Respiratory Failure
1. Assess for increasing dyspnoea, stridor, changes
in respiratory patterns.
2. Monitor pulse oximetry, arterial blood gas
values for decreasing PO2 and oxygen
saturation, and increasing PCO2.
3. Monitor chest x-ray results.
 CONT’D
4. Assess for restlessness, confusion, difficulty
attending to questions, or decreasing level of
consciousness.
5. Report deteriorating respiratory status
immediately to physician.
6. Prepare to assist with intubation or
escharotomies as indicated.
 Ctied
Distributive Shock
1. Assess for decreasing urine output, pulmonary
artery and pulmonary artery wedge pressures,
blood pressure, and cardiac output, or
increasing pulse.
2. Assess for progressive oedema as fluid shifts
occur.
3. Adjust fluid resuscitation in collaboration with
the physician in response to physiologic
findings.
 Ctied
Acute Renal Failure
1. Monitor urine output and blood urea nitrogen
(BUN) and creatinine levels.
2. Report decreased urine output or increased
BUN and creatinine values to physician.
3. Assess urine for haemoglobin or myoglobin.
4. Administer increased fluids as prescribed.
 Ctied
1. Assess neurovascular status hourly (warmth,
capillary refill, sensation, and movement of
extremity).
2. Compare affected with unaffected extremity.
3. Elevate burned extremities.
4. Report loss of pulse or sensation or presence
of pain to physician immediately.
5. Prepare to assist with escharotomies
 Ctied
Paralytic Ileus
1. Maintain nasogastric tube on low intermittent
suction until bowel sounds resume.
2. Auscultate for bowel sounds, abdominal
distension.
 Ctied
Curling’s Ulcer
1. Assess gastric aspirate for pH and blood.
2. Assess stools for occult blood.
3. Administer histamine blockers and antacids as
prescribed
ACUTE AND INTERMEDIATE PHASE
• Begins 42-72 hours after burn injury.
• Burn wound care and pain control are
priorities at this stage
 Assessment
• Focus on hemodynamic alterations, wound
healing, pain and psychosocial responses, and
early detection of complications.
• Measure vital signs frequently; respiratory and
fluid status are highest priority
• Assess peripheral pulses frequently for the first
few days after the burn for restricted blood
flow
 CONT’D
• Assess residual gastric volumes and pH in the
patient with a nasogastric tube (for clues to
early sepsis or need for antacid therapy
• Blood in the gastric fluid or the stools must
also be noted and reported.
• Observe electrocardiogram for dysrrhythmias
resulting from potassium imbalance, pre
existing cardiac disease or effects of electrical
injury or burn shock
 Ctied
• Assess wound for size, colour, odour, eschar,
exudate, abscess formation under the eschar,
epithelial buds (small pearl-like clusters of cells
on the wound surface), bleeding, granulation
tissue appearance, status of grafts and donor
sites, and quality of surrounding skin.
• Any significant changes in the wound are
reported to the physician
 Assess ctied
• Focus on pain and psychosocial responses,
daily body weights, caloric intake, general
hydration, and serum electrolyte,
haemoglobin, and hematocrit levels
• Assess for excessive bleeding from blood
vessels adjacent to areas of surgical exploration
and debridement
 Nursing diagnosis
• Excessive fluid volume related to resumption of
capillary integrity and fluid shift from the interstitial
to intravascular compartment
• Risk for infection related to loss of skin barrier and
impaired immune response
• Imbalanced nutrition, less than body requirements,
related to hyper metabolism and wound healing
needs
• Impaired skin integrity related to open burn wounds
• Acute pain related to exposed nerves, wound
healing, and treatments
 Nursing dx ctied
• Impaired physical mobility related to burn
wound, oedema, pain, and joint contractures
• Ineffective coping related to fear and anxiety,
grieving, and forced dependence on health care
providers
• Interrupted family processes related to burn
injury
• Deficient knowledge about the course of burn
treatment
 Collaborative problems/potential
complications
• Heart failure and pulmonary oedema
• Sepsis
• Acute respiratory failure
• Acute respiratory distress syndrome
• Visceral damage (electrical burns)
 Planning goals
Major goals:
• Restoration of normal fluid balance
• absence of infection
• Attainment of anabolic state and normal weight
• Improved skin integrity
• Reduction of pain and discomfort
• Optimal physical mobility
• Adequate patient and family coping,
• Adequate patient and family knowledge of burn
treatment
• Absence of complications
Nursing interventions
 Restoring fluid balance
• Monitor IV and oral fluid in take, using IV
infusion pumps or rate controllers
• Measure intake and output and daily weight
• Report changes in hemodynamic (pulmonary
arterial, CVP(central venous pressure) BP, pulse
rate and urine output(less than 30ml/h)
physician
 Preventing infection
• Provide a clean and safe environment; protect
patient from sources of cross- contamination
e.g. visitors, other patients, staff and
equipment
• Caution the patient against touching the
wound or dressings, bathe unburned areas
and change linen regularly
• Practise aseptic technique for wound care and
invasive procedures
 CONT’D
• Closely scrutinize wound to detect early signs
of infection
• Monitor culture results and wbc counts
• Administer antibiotics: topical: silver
sulfadiazine, mafenide(sulfamylon), silver
nitrate; systemic: penicillin, erythromycin,
gentamycin, amikacin
 Maintaining adequate nutrition
• Oral fluids should be initiated slowly when
bowel sounds resume
• collaborate with the dietician or nutrition
support team to plan a protein- and calorie-
rich diet that is acceptable to the patient
• Family members may be encouraged to bring
nutritious and favourite foods
 CONT’D
• Provide nutritional, vitamin and mineral
supplements
• Document caloric intake. Insert feeding tube if
caloric goals cannot be met by oral feeding
(for continuous or bolus feeding; note residual
volumes. Parenteral nutrition may be required
 Ctied
• Weigh patient daily and graph weights
• Encourage patient with anorexia to increase
food intake, provide pleasant surroundings at
meantime, cater for food preferences
• Offer a high protein, high vitamin snacks
 Promoting skin integrity
• Assess wound status
• Support patient during distressing and painful
wound care
• Coordinate complex aspects of wound care and
dressing changes
wound care
May be delayed until a patient airway and
adequate circulation is achieved
 Ctied
Goals will be:
• Cleanse and debride the area of necrotic tissue
and debris that would promote bacterial
growth
• Minimize further destruction to viable skin
• Promote client comfort
Cleansing and debridement is usually
accomplished in a bath tub
 Ctied
There two methods of wound treatment used to
control infection:
1. Open method- clients burn is covered with a
topical antibiotic and has no dressing
2. Closed method- employs sterile gauze
dressings impregnated with or laid over a
topical antibiotic
• These dressings are changed two to three
times every 24 hours
 CONT’D
• Administer TT routinely
• Assess and record any changes and progress
in the wound healing, inform all members of
the health care team of progress in the
wound or treatment
• Assess instruct, support and encourage
patient and family to take part in dressing
changes and wound care
 Relieving pain and discomfort
• Teach patient relaxation techniques, give some
control over wound care and analgesia, and
provide frequent reassurance
• Use guided imagery to alter patient’s
perceptions and response to pain.
• Distraction through video programs or video
games, hypnosis, biofeedback, and behavioural
modification.
 CONT’D
• Administer minor antianxiety medication and
analgesic agents before pain becomes too
severe. Assess and document patients
response to medication. Assess frequently for
pain and discomfort
 CONT’D
• Work quickly to complete treatment and
dressing changes. Encourage patient to use
analgesic medications before painful
procedures
• Promote comfort during healing phase, oral
antipruritic agents, a cool environment
lubrication of the skin , exercise and splinting
to prevent skin contractures and diversion
activities
 Promoting physical mobility
• Prevent complications of immobility (atelectasis,
pneumonia, oedema, pressure ulcers and
contractures) by deep breathing, turning and
proper positioning.
• Interventions are modified to meet the patient’s
needs. Early sitting and ambulation are
encouraged
• Whenever the lower extremities are burned,
elastic pressure bandages should be applied
before the patient is placed in an upright position.
 CONT’D
• Initiate passive and active range-of-motion
exercises from admission until grafting within
prescribed limitations
• Splints or functional devices may be applied to
extremities
• for contracture control. Monitor for signs of
vascular insufficiency and nerve compression.
 Strengthening coping strategies
• Assist patient to develop effective coping
strategies; set specific expectations for behaviour,
promote truthful communication to build trust,
help patient practise coping strategies and give
positive reinforcement when appropriate
• Demonstrate acceptance to the patient, enlist a
non involved person to vent feelings without fear
of retaliation
• Include patient in decisions regarding care ,
encourage patient to assert individuality and
preferences set realistic expectations for self care
Supporting patient and family processes

• Support and address patients and family's

verbal and non verbal concerns
• Instruct family in ways to support patient
• Make psychological or social work referrals as
need
• Provide information about burn care and
expected course of treatment
• Initiate patient and family education during
burn management
REHABILATATION PHASE OF
BURN CARE
 Rehabilitation
• Begins immediately after the burn has occurred
—as early as the emergent period and often
extends for years after injury
• Wound healing, psychosocial support, and
restoring maximal functional activity remain
priorities
• maintaining fluid and electrolyte balance and
improving nutritional status continues.
• Reconstructive surgery to improve body
appearance and function may be needed.
 ASSESSMENT
• Information about the patient’s educational
level, occupation, leisure activities, cultural
background, religion, and family interactions is
obtained
• Assess mental status, activity tolerance,
neuropathies(neurological damage)
 NURSING DIAGNOSIS
• Activity intolerance related to pain on exercise,
limited joint mobility, muscle wasting, and
limited endurance
• Disturbed body image related to altered
physical appearance and self-concept
• Deficient knowledge about post discharge
home care and follow-up needs
 Potential complications
• Contractures
• Inadequate psychological adaptation to burn
injury
 Planning and goals
• Increased participation in activities of daily
living
• Increased understanding of the injury,
treatment, and planned follow-up care
• Adaptation and adjustment to alterations in
body image, self-concept, and lifestyle; and
absence of complications.
Nursing interventions
 Promoting activity tolerance
• Provide rest after changing dressings, exercises
because they are stressing to the burn patient
• Relieve their anxiety and fears related to
outcome of injury, administer hypnotics to
promote sleep
• Relieve pain, prevent chilling or fever and
promote physical integrity of all body systems
to help the patient conserve energy for
therapeutic activities and wound healing
 Improving body image and self concept

• This include body disfigurement, loss of

personal property homes, loved ones and
ability to work. The nurse should allay fears
from the client
• Encourage to join social groups, other burns
survivors
• Help patients build self esteem by recognising
their uniqueness
 CONT’D
• Can see psychologist, social workers,
vocational counsellors etc to assist regain their
self esteem
• Early and aggressive physical and occupational
therapy to avoid contractures.
• Surgical interventions indicated if a full range
of motion in the burn patient is not achieved
 MERCI
BEAUCOP