BURNS

E CHISALA
ROTN.BSCN
 Overview of the skin

The Skin has three layers :

• the epidermis - the outer, protective layer.

• the dermis - contains hair roots, sweat and

sebacious glands, nerves, and blood vessels.
• The Subcutaneous (fat layer): attaches the skin
to internal organs.
The skin
 BURNS

• DEFINITION
• Injury to the body tissue caused by dry heat,
chemicals, electrical current or radiation
(Lewis et al, 2004).
CAUSES OF BURNS

1. Thermal – by flame , or contact with

hot objects- the most common type

2. NB scalds -injury by moist heat

3. Chemicals -
– Acids common chemical injury .
– Alkaline substances - difficult to treat
 Causes

3. Hot air - cause damage to the respiratory

tract.
4. Electricity- intense heat generation from an
electrical current destructs the tissue.
5. Radiation - industrial or therapeutic
PATHOPHYSIOLOGY
• As a result of burns, physiological alterations in the
skin occurs. These include;
• Loss of protective barrier against the infections

• Escape of body fluids

• Loss of temperature control

• Destroyed sweat and sebaceous glands

• Diminished sensory receptors

PATHOPHYSIOLOGY

May be divided into stages;

1. STAGE OF NEUROGENIC SHOCK
• Burns irritate nerve endings in the skin .
• Patient experiences pain, fright, terror and
hysterical reactions.
PATHOPHYSIOLOGY

2. STAGE OF FLUID LOSS - HYPOVOLAEMIA

Systemic effect
• capillaries in the affected area dilate &
become more permeable
• plasma seep into the surrounding tissues

• blisters and edema develop.

PATHOPHYSIOLOGY

• increased fluid loss leads to reduced blood

volume and blood viscosity.
• leading to peripheral circulatory failure.

(hypovolaemic shock)
• hypotension, reduced urine output.
PATHOPHYSIOLOGY

3. STAGE OF BURN SLOUGH AND INFECTION

• Destroyed tissue separates from the
underlying viable tissue by the process of
liquefaction (slough formation).
• Open wound may become Infected
PATHOPHYSIOLOGY

4. STAGE OF REPAIR
• This stage is subdivided into two:

• Repair of the burnt area;

• starts when the area is free from sloughing.

• In superficial burns occurs from the remains of

the skin cells
Repair of the burnt area;

• In full thickness burns, repair begins from the

edges of the wound
• Repair is slower in order to permit overgrowth
of granulation tissue.
• skin grafting may be done.
PATHOPHYSIOLOGY

• Systemic repair

• includes such measures as blood transfusion

to overcome anemia.
• high protein, calorie and vitamin diet
promotes quick healing.
 CLINICAL MANIFESTATIONS
• s/s of shock due to pain and hypovolaemia

• Pain - severe in partial thickness less or absent

in full thickness burns
• Intense thirst due to fluid loss

• Reduced urinary output due to fluid loss

• signs of dehydration
 Assessing Severity of Burns

• Severity is dependent on the following

factors
• Age – the young and the elderly –usually
sustain severe burns
• Major joints – mostly severe

• Special sites like genitalia neck chest

• Surface area burnt

– 10 % or more in children - severe

- 15 % or More in adults - severe
• strength of source –if source is
stronger then burns will be severe
• distance from source – closer,
more likely severe
• amount of body exposed to the
source
- The lager surface likely to be more
• length of exposure - the longer the
exposure the more severe burns are
likely to be.
CLASSIFICATION OF BURNS
Burns are classified according to:
• depth of tissue burnt (degrees)

• surface area burnt ( %)

BURNS ACCORDING TO DEPTH
• 1st Degree burns (superficial )
• Epidermis is affected -appears red /dry
• Blanches with pressure
• Minimal or no edema.
• Recovery within a week
• No scarring
• Tingling sensation
• Mild pain
 2ND DEGREE BURNS (partial thickness)

• affects epidermis, upper dermis, portion of

the deeper dermis
• Very painful due to exposed nerve endings

• Sensitive to cold air

• Hyperesthesia

• Blisters
2 Degree Burns ctnued
nd

• Moist and red

• oedema

• Recovery in 2 to 4 weeks

• Some scarring and depigmentation

• Infection may occur

3 DEGREE BURNS (full thickness)
RD

• Affects epidermis , entire dermis

&subcutaneous tissue
• Less or no pain

• S/S of Shock

• Haematuria ( blood in urine)

 3 Degree burns ctnued
rd

• Dry white - brown, leathery appearance -Patchy

• Broken skin with fat exposed

• Oedema

• Slough/scar formation

• Grafting is necessary
4TH DEGREE BURNS

• entire skin , muscles & bone affected. Brown dry, charred

• Almost always no pain
• No sensation
• Shock
• Appearance as in third degree
• Tissue necrosis,
• skin grafting and may need amputation
 According to surface area burnt

• Usually in %
• Palm method:
• the palm of a patient is approximately 1 %
• Lund and Browder
• Rule of nine
RULE OF NINE FOR CALCULATING BURN SURFACE

• Head and neck 9%

• Left arm 9%
• Right arm 9%
• Anterior Trunk 18%
• Posterior Trunk 18%
• Left leg 18%
• Right leg 18%
• Perineum 1%
• Total 100%
RULE OF NINE
THE LUND-BROWDER CHART.
 THE LUND -BROWDER CHART.
HEAD 7% L. L. ARM 3%
NECK 2% R. HAND 2½%
ANT. TRUNK 13% L. HAND 2½%
POST. TRUNK 13% R. THIGH 9½%
R. BUTTOCK 2½% L. THIGH 9½%
LT. BUTTOCK 2½% R. LEG 7%
GENITALIA 1% L. LEG 7%
R. U. ARM 4% R. FOOT 3½
L. U. ARM 4% L. FOOT 3½%
R. L. ARM 3%
TOTAL 100%
 MANAGMENT
IMMEDIATE MANAGEMENT

History taking
• Find out about the cause /time of the burns

to determine the amount of fluid loss.

• Find out about measures taken before bringing
the patient to the health care facility.
 MANAGEMENT ctnued

Physical examination
• Airway – Look for the signs of upper airway
obstruction like, stridor, which may occur as a
result from thermal injury to the pharynx.
• Breathing – Signs of respiratory distress
(wheezing, tachycardia and cyanosis), may
result from direct inhalation of smoke.
 MANAGEMENT ctnued

• Circulation – Check the pulse rate, capillary

refill, skin color, skin temperature, peripheral
pulse.
• Assess the depth and the extent of the burns
to determine the severity of burns and
management
 LABORATORY INVESTIGATIONs
• Hemoglobin level - usually low due to bleeding
from the wound
• Blood Urea and electrolytes(BUN) – reveals low
serum protein, albumin & globulin
• Urinalysis – reduced amount, high specific gravity

• X-ray to determine bone/pulmonary involvement

 MANAGEMENT
Drug therapy
• Analgesics eg morphine to relieve pain

• Tetanus Toxoid 0.5 ml IM to prevent tetanus

• Topical antibiotic creams such as sulphur ,

zinc cream to combat bacterial infection.
• Systemic antibiotics eg ciprofloxacin 500mg bd
x5/7 according to culture results of pus swab
Fluid therapy

a) Using parklands (Baxter) formula;

• 4mls x kg bwt x total body Surface Area burnt.

=total fluid requirement first 24 hours.

½ of total in first 8 hrs

¼ of total in second 8 hrs

¼ of total in third 8 hours

 MANAGEMENT
APPLICATION
For a 70kg patient with 50% TBSA burn:
4 mls x 70kgx 50% TBSA burn=14,000mls/ 24 hrs

½ of total in first 8 hrs =7000mls

¼ of total in second 8 hrs =3500mls

¼ of total in third 8 hours =3500mls

Fluid therapy
Evans’ Formula
• Colloids (blood plasma or plasma expanders)

1ml per kgbwt xTBSA

plus (+)
• Electrolytes

1ml per kgbwt x (TBSA)

plus

2000mls insensible loss/24hrs

Evans’ Formula

• 1st 8 hours give half of above amount

• Give other half in next 16 hours

• Example

• Paul weighing 50 kg with 30% burns

• 1ml X 30X50= 1500 colloids

• 1ml X 30X50= 1500 electrolytes + 2000mls

• Total 1500+1500+2000mls= 5000mls
• First 8hrs= 2500 next 16hrs =2500
INDICATIONS FOR IV FLUID RESUSCITATION

 Children-burns involving more than 10% of

TBSA
 Adults-burns involving more than 15% of TBSA
 NURSING CARE

AIMS
To restore circulatory volume
To promote healing
 NURSING CARE ctnued

ENVIRONMENT
• Burns unit for appropriate care

• Bed cradle to guard linen against contact with

wounds.
• warm to prevent hypothermia .

• Clean to reduce risk of wound infection

• Barrier nursing to reduce acquisition of
infections
• Oxygen source within reach for possible
administration in case of hypoxia
Position

On un affected side to reduce pain.

Semi fowlers to promote pulmonary efficiency
Regular turnings to enhance blood circulation
Psychological care

• Reassure patient of best possible service from

health staff
• Encourage next of kin to give emotional
support
Hygiene
• Assisted baths to facilitate recovery.
• Saline baths to facilitate wound healing.
• Plus general
Wound care

• Bed cradle to lift weight of linen off the

wounds
• Saline baths to promote quick recovery

• Splinting of affected joints to prevent

contractures.
• prescribed antibiotics to combat secondary
bacterial infection
 Wound care ctnued

• Analgesics to relieve pain

• vaseline gauze when necessary especially
when joints are affected.
Nutrition

• High protein diet to facilitate tissue repair

• Foods rich in Potassium like bananas to
prevent hypokalaemia
• Vitamin C to promote healing
• Adequate fluids to relieve hypovolaemia
Elimination

• Monitor urine out put to determine renal

function
• Encourage foods rich in roughage to prevent
constipation
• Administer suppositories to relieve constipation
Observations

• Vital signs regularly for close monitoring

• Fever may indicate infection if so give
prescribed antibiotics
• Low BP and rapid pulse are suggestive of
shock, hence take measures like IVI
administration to correct it.
• Check the wounds for signs of infection like
pus discharge.
 COMPLICATIONS

1. hypovolemic shock - due to fluid loss

2. Airway obstruction – blocked airway due to

oedema in burns of t he neck and head

3. Renal failure – inability of the kidney to

function well due to hypovolemia and
resultant reduced blood supply
4.Curling’s ulcers – eroded GIT mucosa due to
decreased production of mucous and
increased gastric secretion
5. Contractures – shortening and hardening of
muscles due to fibrosis or scar tissue
6.Infection - due to the loss of the body first
defense; the skin.
 COMPLICATIONS CONT’

7. Anaemia - reduced red blood cells or their

haemoglobin due to depressed red bone
marrow and damaged red blood cells by heat
8. Hear failure – due to reduced blood returning
to the heart
 SKIN GRAFTING

• Surgical transfer of the skin from one part of the

body to the other.
• indications

• Extensive burns

• Radical mastectomy

• Extensive excision

• Extensive traumatic wounds

 Classification of skin graft

• Free graft – skin completely separated from

the donor site
• Pedicle graft (flap graft) – detatched end
moved to recipient area then the rest remains
intact until sufficient blood vessels form then
the flap gets separated from the donor area.
 TYPES

1. Auto graft (autogenous) – from clients own

body.

2.Isograft (isologous) – from identical twins.

3. Homografts (homologous) – from same species

4. synthetic (Substitute graft) – artificial skin

5.Heterograft – from different species eg animal
to man.
 Pre op care
• General elective

• Admit client several days pre op for adequate

preparation.

Nutrition
• Ensure patient is well nourished to facilitate
post op recovery.
Physical Preparation

donor site
• Keep the donor site clean and covered with a
clean dressing soaked in normal saline
• Avoid breaching agents on donor site before
surgery
• Do not shave the skin to avoid disturbing the
graft.
• Ensure donor is free of blood borne infections

Recipient site
• Keep it clean and soaked in saline.

• Ensure it is free of slough or pus to reduce

possibility of rejection.
• Avoid use of skin irritants.
Premedication

• Avoid drugs that may interfere with blood

clotting e.g Aspirin
• Give anti histamines to prevent itching on the
skin graft w/c can provoke scratching and
disrupting the graft.
• Immunosuppressants which suppress the
immune system to reduce risk of skin rejection.
 Skin grafting post op

General plus

Care of the graft sites

• Keep the donor area clean and covered with
Vaseline gauze
• Keep donor site dressing intact for not less than
36 hours as per post op instructions
• Clean with normal saline gently then apply
non sticky dressing to avoid disrupting the
graft.
• When allowed to bath ,wash the graft and
donor sites with mild soap and water.
• Limit movements, such as stretching to
prevent bleeding, shearing, and swelling in the
wound and graft sites.
• Protect the graft site from direct sunlight to
prevent scarring and skin colour changes.
Patient teaching
Inform pt to report in case:
• the skin is itchy, swollen, or has a rash.
• Blood soaks through the bandage.
• something is felt bulging out from the graft
site
• the graft or donor site has pus, or a foul-
smelling odor.
• more pain in the graft area.
 COMPLICATIONS

• Graft rejection. - rare in auto grafts, but

common in xenografts (skin from another

person.) To prevent this, prescribed

immunosuppressants are given

• Disfigurement due to mismatch of colour of the

donor and recipient’s skin tones.

• Bleeding

• Infection at the graft site.

• Graft versus host disease if not properly

screened.
• Nerve damage may occur at the site of
grafting.
• Practice question
 Match each terminology in column I with its appropriate
answer in column II
1.....chemotaxis a) engulfing invading organism or
foreign body
2.... diapedesis b) increased white blood cells
3.....margination c) motility towards capillary
endothelium
4.....phagocytosis d) reduced white blood cells
5....leukocytosis e) motility through capillary wall
f) motility in the direction of toxins produced by
injured
cells