Burn

 Burns are caused by a transfer of energy

from a heat source to the body.
 The depth of the injury depends on the
temperature of the burning agent and
the duration of contact with the agent.
 Pain is inversely proportional to burn
degree
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 CLASSIFICATION OF BURNS

Classification- based on cause

• Thermal burn
• Electrical burn
• Chemical burn
• Inhalation injury

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 Severity of burn

Severity of burn injury depends on;

The extent of burn
Depth of burn
Pre-existing medical problems
Location
Associated injuries

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 CLASSIFICATION OF BURNS

Burn Depth
SUPERFICIAL PARTIAL-THICKNESS (FIRST
DEGREE )BURN

 Involves only the epidermis and

possibly portion of dermis
 Erythema, blanching on
pressure, pain and mild
swelling, no vesicles or blisters
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 Swelling or discoloration of the injured area
Hyperesthesia (supersensitivity),
Superficial epidermal damage with hyperemia. Tactile
and pain sensation intact
Pain that is soothed by cooling
E.g. Sunlight, low-intensity flash,

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 Sun Burn

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 Deep partial-thickness (second degree) burns

• It is characterized by :
Red or mottled appearance ,
Development of blisters ,
Considerable swelling over a
period of several days ,
Wet appearance of the
surface of the skin due to
the loss of plasma through
the damaged layers of the
skin.

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 Involves destruction of the epidermis and
upper layers of the dermis and injury to
deeper portions of the dermis.
Severe pain caused by nerve injury.
Mild to moderate edema
Scalds (a burn cause by hot liquid or
steam).

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 Second degree Burn

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 Full-thickness (third-degree) burns

It is characterized by:
 Dry, waxy white, brown or
charred, leathery, or hard skin.
 Visible thrombosed vessels.

 Insensitivity to pain because of

nerve destruction.
 Possible muscle, tendon, and
bone involvement
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 All skin elements and local nerve endings destroyed.

 Surgical intervention required for healing

 Prolonged exposure to, hot liquids, electric

current, chemical

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 Con,t
Swelling occurs and discoloration of skin (red,
brown to black in color)
Crusty surfaces (Eschars) develop - impairs
circulation and Broken skin with exposed Fat
Dehydration resulting in shock and Scars
develop
No blisters observed

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• The location of the burn injury influences
the severity.
• Face, neck, and circumferential torso burns
may interfere with gas exchange.
• Edema from inflammation and fluid
resuscitation can narrow the airway.

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• Hand, foot, and joint burns can limit mobility
and function.
• Full-thickness circumferential extremity
burns can impair perfusion distal to the
injury
• Patients with buttocks or perineum burns are
at high risk for infection from urine or feces
contamination
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 Extent of Body Surface Area Injured

• Various methods to estimate TBSA affected by

burns the commons are rule of nines, and the
palm method.
• In palm method the size of the patient’s palm
is approximately 1% of TBSA.

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Rule of nine- the system that assign percent in
multiple of nine to a major body areas thus:
– Head = 9%
– Trunk = 36%
– Upper extremity each = 9%
– Lower extremity each = 18%
– Perineal area = 1%

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 Body Surface Area Estimation
• Rule of Nines
– Adult

• Palm Rule

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Severity of burn also depends on:
 Depth
 Extent
 Age
 Parts of body burned
 Concomitant injuries and illness
 Presence of inhalation injury

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The goal of initial burn management is to:
Limit extent of injury
Stop the burning process

• Assess type of burn

• Assure adequacy of ventilation and oxygenation.
• Initiate restoration of hemodynamic stability.
• Look for other traumatic injuries
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 Initial treatment in ER

• Establish airway

• Initiate IV therapy, weigh pt.

• Insert foley – hourly assessment of u/o

• Insert NG tube to remove contents.

• Insert CVP – hemodynamics

• Initiate treatment of burn wounds

• Initiate tetanus prophylaxis.

• Perform a head to toe assessment

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Zones of burn injury
• The inner zone (zone of coagulation) (C) , where cellular death
occurs, sustains the most damage.
• The middle area (zone of stasis) (B) , has a compromised blood
supply, inflammation, and tissue injury.
• The outer zone (zone of hyperemia) (A), sustains the least damage

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 Local and systemic response to burn
• Burns that do not exceed 25% TBSA produce a
primarily local response but if exceed 25% TBSA
may produce both a local and a systemic
response and are considered major burn injuries.
• The systemic response is due to release of
cytokines, mediators into the systemic
circulation, changes in blood flow, tissue edema,
and infection.

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• At the time of major burn injury, capillary permeability
increases
• All fluid components of the blood leak into the
interstitium, causing edema and a decreased blood
volume.
• Hematocrit increases.

• Blood becomes more viscous.

• The combination of decreased blood volume and

increased viscosity increases peripheral resistance.
• Burn shock, a type of hypovolemic shock, rapidly
ensues and, if not corrected, can result in death.
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 Systemic Response to Burn Injury

• Hypovolemic shock
associated with:
 Pulmonary
– Decrease in venous return
 Gastrointestinal
• Decreased cardiac output
• Increased vascular  Musculoskeletal
resistance (except in zone
of hyperemia)  Neuroendocrine
– Renal failure may occur due
to:  Metabolic
• Hemolysis (destruction of
RBCs)  Immune
• Rhabdomyolysis (muscle
necrosis)
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 Burn Management

Burn care provided through three

phases.

1. Emergent/resuscitative phase

2. Acute/intermediate phase

3. Rehabilitation phase

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 Emergent/resuscitative phase
• From onset of injury to completion of fluid
resuscitation, and it include:
• Extinguishing of fire - when cloth catches on
Fire
– Drop and roll

– Use blanket, coat or any other material to off

the fire
• Remove restricting objects from the area.
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 Cover the wound with sterile or clean cloth
 Irrigate chemical burn
 Maintain or ensure Air way, Breathing and
Circulation.
 Prevent shock
 Urgently refer to hospital

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 Guidelines & Formulas for Fluid Replacement
in Burn Patients

Consensus Formula

• Lactated Ringer’s solution: 2 – 4 ml × kg

body weight × % TBSA burned.

• Half to be given in first 8 hours

• Remaining half to be given over next 16 hours

• This is the most common fluid replacement

formula in use today.
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• Ex: use of the formula in a 70-kg (168-lb) patient
with a 50% TBSA burn:

Consensus formula: 2 to 4 ml × kg × % TBSAB

• 2 × 70 × 50 = 7,000 ml/24 hours

Plan to administer:

• First 8 hours = 3,500 ml, or 437 ml/ hour;

• Next 16 hours = 3,500 ml, or 219 ml /hour

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Parkland (Baxter), fluid Resuscitation
• Calculation of fluids for 1st 24 hrs:
• Adults: Ringer’s Lactate 4ml/kg body
weight x
% TBSA burn.
• Infusion rate is regulated so 50% of
estimated volume is administered in the
first 8 hours post burn.
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Remaining 50% administered over next30
 Fluid Resuscitation Response
• Monitoring of Response- Hourly urine
output.
• Adults: 0.5 – 1.0 mL/kg/hr
• Children: 1.0 mL/kg/hr.
• Fluid and electrolytes
• Weigh patient daily
• Monitor vital signs, assess lung sounds.

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 Intermediate phase

 Wound care and closure, wound cleaning ,topical

antibiotics therapy ,wound dressing ,dressing
changes ,wound debridement ,and wound
grafting
 Prevention or treatment of complications,
including infection (heart Failure ,pulmonary
edema ,sepsis ,acute respiratory failure ,ARDS…)
 Pain management-
opoids ,NSAIDs ,anxiolytics,anesthetics
 Nutritional support
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 Rehabilitation phase.

• From major wound closure to return to individual’s

optimal level of physical and psychosocial adjustment.
• Focus of care

– Prevention of scars and contractures

– Physical, occupational, and vocational rehabilitation

– Functional and cosmetic reconstruction

– Psychosocial counseling

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 Specific Management
Flame Burns
 Smother the flames

 Remove smoldering clothing and all metal objects

Chemical Burns
 Brush off all chemicals present on the skin or clothing.

 Remove the clients clothing

 Ascertain the type of chemical causing the burn (acid or alkalai)

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Electrical Burn
At the scene, separate the client from the electrical
current
 Smother any flames that are present
 Initiate cardiopulmonary resuscitation

Radiation Burns
 Remove the client form the radiation source

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 Burn Complication
Keloids is an irregularly formed scar that
extends beyond the margins of the original
wound. They are large, nodular, and ropelike,
often causing itching and tenderness.
Failure to heal and Scars
Contractures (shrinkage of burn scar)

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NURSING DIAGNOSIS
 Impaired gas exchange

 Inadequate tissue perfusion

 Fluid volume deficit or fluid volume overload

 Impaired skin integrity

 Risk for infection

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 Wound Dressing
After burn wound is cleaned, dried and
topical agents are applied wound is covered
either with several layer dressing or light
layer dressing

An occlusive dressing is a thin gauze that is

impregnated with a topical antimicrobial
agent, most often used over areas with new
skin grafts
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 Wound Debridement
The objectives of wound debridement are
1. To remove tissue contaminated by bacteria
and foreign bodies, thereby protecting the
patient from invasion of bacteria.
2. To remove devitalized tissue or burn eschar in
preparation for grafting and wound healing.
• Three types of debridement—natural,
mechanical, and surgical

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Mechanical debridement- involves the
use of surgical scissors, scalpels, and
forceps to separate and remove the eschar.
This technique can be performed by skilled
physicians, nurses, or physical therapists
and is usually done with daily dressing
changes.

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 Enzymatic/natural- the dead tissue
separates from the underlying viable
tissue spontaneously by Proteolytic and
other natural enzyme
Surgical - involves excising burn wound,
then cover with skin graft or temporary
covering

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