BURNS

Tissue damage caused by exposure to excessive heat.

TYPES OF BURNS BY ETIOLOGY

 Thermal burns – dry heat, flames, hot objects, moist heat (comes from hot liquids), or exposure to
steam.
 Chemical burns – burns from acid and alkaloid substances
 Electrical burns – expose to electric currents
 Radiation burns – expose to radioactive agents such as nuclear energy, radiation therapy, x-ray

ANATOMY
Largest body organ that is involved in burn injuries, SKIN.
2 layers = epidermis and dermis.
Epidermis – outer layer
Lower – dermal layers

FUNCTIONS
Sensations
Protection
Temperature regulation
Fluid retention

BURN EPIDEMIOLOGY
 Third leading cause of trauma deaths
 180,000 deaths every year caused by burns
 47% injuries occurred at home, 27% on the road, 8% occupational, 5% recreational, remaining
are other sources
 Males have greater incidence than women.
 The most frequent age group is 20 to 40 years.

PATHOPHYSIOLOGY
 Loss of fluids because our skin play a role in fluid retention.
 Inability to maintain body temperature because the skin is damaged since the skin regulates
the temperature
 If skin is damaged, it may also lead to infection.

CRITICAL FACTORS
 Burn Depth
 Burn Extent

BURN DEPTH
 FIRST DEGREE – Superficial – Partial Thickness
o Skin is red
o Patient complains pain
o Tenderness
o Upon applying pressure there is blanches
 o There is swelling
o No blisters
o May heal in 7 days.
 SECOND DEGREE – Deep – Partial thickness
o It extends to the dermis through the epidermis
o Salmon pink in color
o Moist, shiny
o Painful
o Blisters may be present
o May heal 7-21 days.
 Burns that blister are second degree but all second degree burns don’t blister.
 THIRD DEGREE – Full thickness
o Reaches through the epidermis to dermis into the underlying structures such as muscles,
fascia, and even bones.
o Thick and dry
o Partial gray in color – charcoal black (inihaw)
o Burn may bleed from vessel damage
o Patient will feel no pain due to nerve damage.
o Requires grafting to replace protective covering.

*BURN DEPTH often cannot be accurately determined in acute stage. Infection may convert to higher
degree.
When in doubt of the depth, over-estimate so that management can cover the worst areas.

RULE OF 9s
Rule of 9s – it is a calculation used to estimate the extent of burns in adults through DIVIDING THE
BODY INTO MULTIPLES OF 9S and SUM TOTAL OF THESE PARTS IS EQUAL TO THE
TOTAL SURFACE BURN AREA.

*Why do we need to determine it? So that early treatment of possible complications may be
implemented to prevent further problems such as hypovolemic shock that is treated with IV fluids.
* Pwede mag-increase capillary permeability wherein the tissues are damage
* Pwede magkaroon ng shifting of fluids from one compartment to another.

Hypovolemic shock is one complication of burns.

Adults = Body divided into anterior and posterior portion where in the anterior is front and posterior is the
back of the body. Divided further to:
 Head and neck
 Trunk of the body
 Upper limbs
 Lower limbs
 Perineum
ADULTS
PORTIONS TSBA
Head and Neck 4.5% A + 4.5% P = 9%
Trunk 18% F + 18% P = 36%
Upper limbs (Left and Right arms) (4.5 + 4.5) F + (4.5 + 4.5) P = 18%
Lower limbs (Left and Right legs) (9 + 9) F + (9 +9) P = 36%
Perinuem 1%

1YR OLD AND BELOW

PORTIONS TSBA
Head and Neck 18%
Trunk 18% + 18% = 36%
Upper limbs (Left and Right arms) 9% + 9% = 18%
Lower limbs (Left and Right arms) 14% + 14% = 28%
Perineum 1%

*Each year over 1 year of age, Subtract 1% from the head then add equal to the legs.
Ex: 2 yrs. Old = subtract 1% then add to the legs; Head = 17% and Lower limbs = 14.5% for the Left
and Right legs.

RULE OF PALM
  Wherein we use patient’s palm.
 This is equal to 1% of the patient’s body surface area.
 We use to estimate percentage of scattered burns or smaller burns using the size of the patient’s
palm relative to the patient.
 According to the picture, three areas of small burns. Approximately equal to the size of the
patient’s palm.

BURN SEVERITY
Based on
 Depth – assessing full to partial thickness.
 Extent – involves determining total surface burned area of the patient.
 Location – It is because of what it might bring further damage to client.
 Cause – what was the cause of the burn? It assist the patient in preventing in repeating the injury.
 Patient Age
 Associated factors – medical history will also affect the treatment and burn injury. Ex: Diabetic
person – longer time for healing process to happen due to the existing condition. Heart failure –
may have difficulty in blood circulation due to the development of fluid shifting brought by the
burn injury.

CRITERIA OF NURSING ASSESSMENT

I. Total Surface of Burned Area (T.S.B.A) – determines extent of damage.

Another method to determine the extent of burn: Lund and Browder chart
*the percentage changes by growth. It is developed according to the burned surface area associated as
we grow old or age.
II. Depth of Injury – Layers of skin damaged by heat.

LAYERS OF SKIN DEGREE MANIFESTATIONS

Epidermis First (Superficial) 1. Pain
Stratum Corneum 2. Erythema
Stratum Lucidum
Stratum Granulosum a. Redness
Stratum Spirosum b. Slight edema
Stratum Germinativum 3. Blisters

Dermis Second (Deep)

Hair root and shaft 1. Pain
Oil glands 2. Erythema
Sweat glands 3. Big Blisters

Third
Fatty Layer Fat involvement
White, opaque shiny
with thrombosed blood
vessels underneath
No pain
Fascia
Muscle Muscle involvement
Dark, red with raw base
Dark, brown, tan,
leathery

Fourth
Deep Muscle No Pain
Bones Appearance of bones

III. Location of Burns

 Head, neck, face
 Ears – decrease blood supply prone to infection
  Hands, feet – decrease nerve supply and nerve damage will also happen
 Joints - contractures may also happen (permanent tightening of tissues, severe
movements of joints); decrease ROM.
 Genitalia – urethral stricture may happen and decrease sensitivity.
 Circumferential burns of chest – may lead to restriction of breathing.

IV. Other injuries incurred with burns

 Fractures – it may happen due to the association of bone and calcium metabolism where
in the adversely affected by burn injury
 Major soft tissue damage – critical due to it can lead to severe problems
 Respiratory distress – once respiratory issues where sensed.
 Cerebral damage – increase intracranial pressure may also happen due to fluid shifts that
is happening inside our body because of burn injury.

V. Pre-existing Medical-surgical conditions

 DM – may slow the healing process.
 Coronary Artery D – they have the common symptoms of angina chest pain, client
may worsen and may lead to death of our patients.
 COPD – higher amount of CO2 in the body. May lead to irreversible damage to our
patients.
 CRF – cause problem because they may not function to the imbalances that would
happen due to the injury.
 Buerger’s (PVD) – blood circulation; vessels will not function properly expect
problems on tissue perfusion.

VI. Classification of Severity

 Critical burns
o > 25 – 30% TSBA (2ND DEGREE)
o > 10% TSBA (3RD DEGREE)

 Moderate burns
o >15%, <25-30% TSBA (2ND DEGREE)
o 2 -10% TSBA (3rd DEGREE)

 Minor Burns
o <15% (2nd DEGREE)
o <2% TSBA (3rd DEGREE)

PHASES OF BURNS
 Emergent / Resuscitative – “Shock phase” or “fluid-resuscitation phase”
 Acute / Intermediate – “ Diuretic phase”
 Rehabilitation – “Recovery phase”
 1. EMERGENT / RESUSCITATIVE

Priorities
 First Aid
 Prevention of shock – Hypovolemic shock
 Prevention of respiratory distress
 Detection and treatment of concomitant injuries
 Wound assessment
Emergency procedures
 Extinguish flames
 Cool the burn – do not pour cold or ice water to the burn injury
 Remove restrictive objects
 Cover the wound
 Irrigate chemicals
Treat with ABC
 Assess airway/ Breathing
o Start oxygen if:
 Moderate or critical burn
 Decreased LOC
 Signs of respiratory involvement
 Burn occurred in closed space
o Assist ventilations as needed
 Assess circulation
o Check for s/sx of shock – early shock resolves in burn itself. Emergency procedure is
respiration.

Stop burning process

Obtain Hx
 How long ago?
 What has been done?
  What caused burn?
 Burned in closed space?
 Loss of consciousness?
 Allergies/medications?
 Past medical history?

Assess for burn severity

Rapid Physical Exam – check for other injuries rapidly.
Treat burn wound – cover with dry clean sheets. Do not rupture blisters. Do not put grease on wound
because it is not clean.
Special Considerations
 Pediatrics
o Thin skin, increased severity
o Large surface to volume ratio
o Poor immune response
o Small airways, limited respiratory reserve capacity
o Consider possibility of abuse
 Geriatrics
o Thin skin, poorly circulation
o Underlying disease processes
 Pulmonary
 Peripheral vascular
o Decrease cardiac reserve
o Decrease immuned response
o Percent mortality
 Age + % TSBA

II. ACUTE / INTERMEDIATE

*Preferred fluid for this phase is hypertonic solution. Rapid infusion of hypertonic sodium solutions has
proven to increase the plasma osmolality.

Priorities
 Wound care and closure
 Prevention of infection
 Nutritional support
Prevention of infection
 Use aseptic technique
 Cap, mask, gloves are worn
 Antibiotics
Wound cleaning
 Hydrotherapy – luke warm water
 Topical antibiotic – silver sulfadiazine
Wound dressing
 Circumferential dressing
 Occlusive dressing – remain in 3-5 days. Air and water type dressing. Total sealed.

Debridement / Escharotomy – surgical procedure that removes damage tissues contaminated by bacteria
and foreign bodies. Healthy tissues are exposed to facilitate better healing.

Grafting
 Autograft / Allograft
 Heterograft / Xenograft
 Biologic dressing – biobrain

II. REHABILITATION

*Recovery phase happens 5 days onward.

Priorities
 Prevention of scars
 Physical, occupational rehabilitation
 Functional and cosmetic reconstruction
 Psychosocial Counseling

STAGES OF BURN CARE (SUMMARY):

FIRST-AID INTERVENTION
Goal: Stop the Burning process
 Smother the flames
o DO NOT run!
o Lie horizontally
o Discourage standing
o Remove clothing
 Remove metal objects, rings, wigs, synthetic materials
 Immerse in cool water

Avoid use of ice water – only can lead to capillary perforation and viability of injured area. This can
precipitate cardiac arrhythmias.

Management:
Fluid resuscitation for 24 hours
 50% - 1st = 8 Hours
 25% - 2nd = 8 Hours
 25% - 3rd = 8 Hours

Parkland Formula
 4ML (PLRS) x TSBA x Weight (KG)
 The first half of this amount is delivered within 8 hours from the burn incident, and the remaining
fluid is delivered in the next 16 hours.
 Ex:
o 4 x 50% TSBA x 60kg
o = 12000 cc in the 1st 24 hours

MANAGEMENT:
Brooke Formula
 2 – 3 ML (PLRS) x TSBA x Weight (KG)

*The modified Brooke formula is 2mls x body surface areas burned (BSAB) x weight. The Parkland
formula is 4mls x body surface areas burned (BSAB) x weight. Both formulas estimate the first 24 hour
fluid requirements from the time of the burn, with half the amount given in the first 8 hours.

Monafu Formula
 Hypertonic Na+ = 250 meq/l
 Lactate = 150 meq/l
 Cl- = 100 meq/l
NURSING CARE IN BURNS
NDx #1 Potential for actual:
 Ineffective airway clearance related to smoke inhalation
 Impaired breathing pattern
 Impaired gas exchange
Goal: Maintain adequate airway and ventilation

*treatment of doctors and nurses is based always on assessment on burned patients.

NDx #2 Alteration in Comfort; Pain

Goal: Relief of Pain
 Assess pain
 Administer analgesics as prescribed
 Doctors may give morphine sulfate as prescribed
 Take cautions to respiration rate

NDx #3 Alteration in Fluid Volume Deficit: Alteration in C.O.; Fluid Volume Deficit Potential
Goal: Maintain Adequate Fluid Balance (1st 48 Hours)
 Monitor VS
 Monitor input and output
 Hemodynamic status (important) to determine the appropriate Cardiac output to the heart =
BLOOD PRESSURE
 Lab Values
 Weight, Hematocrit, Intake and Output
 Level of Consciousness
 Hematuria is assessed to determine kidney injuries
o Urea, BUN, creatinine, waste products
 Assist patient with fluid support
 Fluid of choice for replacement: D5LR, PNSS
 Coloids and other plasma expanders
 Use of Brooke or Parkland formula for calculating the needed fluid resuscitation

NDx #4 Alteration in Nutrition: Body Requirement

Goal: Maintain Adequate Nutrition
 If client with diet, start with osteorized feeding or NGT.
 Protein or caloric supplements between meals to replace losses.
 Small frequent feedings is prescribed
 Support the client in eating and place in a nurse sitting position

NDx #5 Self-care Deficit: Potential for Infection

Goal: Prevent and Control Infections
 Provide isolation tent with positive air pressure units
 Promote cleanliness
 Educate patient with handwashing
 Diagnose infections early (Low WBC is expected; hypothermia may occur)
MANAGEMENT:
 Antibiotics
 IVF
 BLOOD TRANSFUSION

CARE OF THE BURN WOUND

 Cleanse with sterile NSS
 Debride detached epithelium
 Use sterile technique

Methods
 Open
 Semi-open
 Closed

Graft
 Close burn would prevent infection and fluid loss
 Restore appearance and function
 Use heat lamps – 15 inches from the site
 Prevent Edema – elevate the site
 Protect from:
o Motion
o Trauma
o Infection