Burn and its management

Introduction
A burn occurs when some or all of the
different layers of cells in the skin are
destroyed by a hot liquid (scald), a hot
solid (contact burns) or a flame
(flame burns). Burns pose a serious
global public health problem with over
195 000 deaths annually from fire-
related burns alone.
ANATOMY OF THE SKIN
Definition
1. Burn injury is the result of heat transfer from one site to
another.
2. Burns disrupt the skin, which leads to increased fluid
loss; infection; hypothermia; scarring; compromised
immunity; and changes in function, appearance, and body
image.
3. The severity of each burn is determined by multiple
factors that when assessed help the burn team estimate the
likelihood that a patient will survive and plan for the care
for each patient.
Risk factors and causes
According to WHO…..
1. Gender - Females have slightly higher rates of death from burns compared to males
according to the most recent data. The higher risk for females is associated with open
fire cooking, or inherently unsafe cookstoves, which can ignite loose clothing.
2. Age - Along with adult women, children are particularly vulnerable to burns. Burns
are the fifth most common cause of non-fatal childhood injuries. While a major risk is
improper adult supervision, a considerable number of burn injuries in children result
from child maltreatment.
3. Socioeconomic factors - People living in low- and middle-income countries are at
higher risk for burns than people living in high-income countries. Within all countries
however, burn risk correlates with socioeconomic status.
Other risk factors
There are a number of other risk factors for burns, including:
1. Occupations that increase exposure to fire;
2. Poverty, overcrowding and lack of proper safety measures;
3. Placement of young girls in household roles such as cooking and care of
small children;
4. Underlying medical conditions, including epilepsy, peripheral neuropathy,
and physical and cognitive disabilities;
5. Alcohol abuse and smoking;
6. Easy access to chemicals used for assault (such as in acid violence attacks);
7. Use of kerosene (paraffin) as a fuel source for non-electric domestic
appliances;
8. Inadequate safety measures for liquefied petroleum gas and electricity.
TYPES OF BURN INJURY(EXPOSURE)
Classification
(A) Burns are classified according to
the depth of tissue destruction as
superficial partial-thickness injuries,
deep partial thickness injuries, or full
thickness injuries.
1. Superficial partial-thickness. The
epidermis is destroyed or injured and a
portion of the dermis may be injured.
2. Deep partial thickness. A deep partial
thickness burn involves the destruction
of the epidermis and upper layers of the
dermis and injury to the deeper
portions of the dermis.
3. Full thickness. A full thickness burn
involves total destruction of the
epidermis and dermis and, in some
cases, the destruction of the underlying
tissue, muscle, and bone.
CLASSIFICATION ACCODING TO DEGREE
Burns are classified as first-, second-, third-
degree, or fourth-degree depending on how
deeply and severely they penetrate the skin's
surface.
1. First-degree (superficial) burns. First-degree burns affect only
the outer layer of skin, the epidermis. The burn site is red,
painful, dry, and with no blisters. Mild sunburn is an example.
Long-term tissue damage is rare and often consists of an increase
or decrease in the skin color.
2. Second-degree (partial thickness) burns. Second-degree burns
involve the epidermis and part of the lower layer of skin, the
dermis. The burn site looks red, blistered, and may be swollen and
painful.
3. Third-degree (full thickness) burns. Third-degree burns destroy
the epidermis and dermis. They may go into the innermost layer
of skin, the subcutaneous tissue. The burn site may look white or
blackened and charred.
4. Fourth-degree burns. Fourth-degree burns go through both
layers of the skin and underlying tissue as well as deeper tissue,
possibly involving muscle and bone. There is no feeling in the area
since the nerve endings are destroyed.
Pathophysiology
Tissue destruction results from coagulation,
protein denaturation, or ionization of cellular
components.
DUE TO ETIOLOGICAL FACTORS

1. Local response. Burns that do not exceed 20% of TBSA

according to the Rule of Nines produces a local response.
2. Systemic response. Burns that exceeds 20% of TBSA
according to the Rule of Nines produces a systemic
response.
3. The systemic response is caused by the release of
cytokines and other mediators into the systemic
circulation.
4. The release of local mediators and changes in blood
flow, tissue edema, and infection, can cause progression
of the burn injury.
Clinical Manifestations
The changes that occur in burns include the following:
1. Hypovolemia. This is the immediate consequence of fluid loss and
results in decreased perfusion and oxygen delivery.
2. Decreased cardiac output. Cardiac output decreases before any
significant change in blood volume is evident.
3. Edema. Edema forms rapidly after burn injury.
4. Decreased circulating blood volume. Circulating blood volume
decreases dramatically during burn shock.
5. Hyponatremia. Hyponatremia is common during the first week of
the acute phase, as water shifts from the interstitial space to the
vascular space.
6. Hyperkalemia. Immediately after burn injury hyperkalemia results
from massive cell destruction.
7. Hypothermia. Loss of skin results in an inability to regulate body
temperature.
 DIAGNOSTIC EVALUATION
1. HISTORY COLLECTION
2. PHYSICAL EXAMINATION
3. BLOOD TEST
4. Various methods are used to determine the TBSA affected by burns.
(A) Rule of Nines. A common method, the rule of nines is a quick way to
estimate the extent of burns in adults through dividing the body into
multiples of nine and the sum total of these parts is equal to the total body
surface area injured.
(B) Lund and Browder Method. This method recognizes the percentage of
surface area of various anatomic parts, especially the head and the legs, as
it relates to the age of the patient.
(C) Palmer Method. The size of the patient’s palm, not including the surface
area of the digits, is approximately 1% of the TBSA, and the patient’s palm
without the fingers is equivalent to 0.5% TBSA and serves as a general
measurement for all age groups.
RULE OF NINE
RULE OF NINE ANIMATION
Medical Management
Burn care is a delicate task any nurse can have and being knowledgeable in
the proper sequencing of the interventions is very essential.

1. Transport. The hospital and the physician are alerted that the patient is en route so that
life-saving measures can be initiated immediately.
2. Priorities. Initial priorities in the ED remain airway, breathing, and circulation.
3. Airway. 100% humidified oxygen is administered and the patient is encouraged to cough so
that secretions can be removed by coughing.
4. Chemical burns. All clothing and jewelry are removed and chemical burns should be
flushed.
5. Intravenous access. A large bore (16 or 18 gauge) IV catheter is inserted in the non-burned
area.
6. Gastrointestinal access. If the burn exceeds 20% to 25% TBSA, a nasogastric tube is inserted
and connected to low intermittent suction because there are patients with large burns that
become nauseated.
MANAGEMENT CONT..
7. Clean beddings. Clean sheets are placed over and under the patient to protect the
burn wound from contamination, maintain body temperature, and reduce pain
caused by air currents passing over exposed nerve endings.
8. Fluid replacement therapy. The total volume and rate of IV fluid replacement is
gauged by the patient’s response and guided by the resuscitation formula.
SURGICAL MANAGEMENT
Burn wounds may be treated surgically by: tangential excision, fascial excision or
amputation.

• Tangential excision. The principle is to remove all the necrotic tissue and to preserve viable
dermis in the wound bed. This technique was based on the observation that deep donor sites
for skin grafts could be successfully over grafted with split thickness skin grafts . One of the
important advantages of this procedure is that the contours are better preserved, healing
taking over faster and the length of hospital stay is reduced.
• Fascial excision is an alternative that is quicker and easier to perform and, above all, the
degree of blood loss is low. However, it leads to contour defects and lymphedema. Moreover,
fascial excision is indicated in full thickness burns, in which the underlying subcutaneous
tissues are damaged. In addition, in life-threatening invasive wounds, in the presence of
sepsis, especially when fungal organisms are involved, fascial excision should be considered.
• Amputation is applicable in unsalvageable limbs, in very deep burns and electrocutions. It
eliminates the function as well as the burn; so it becomes an invalid procedure but should
not be disregarded and still should be taken into account in electrical injuries and war
wounds.
skin grafts procedure
NURSING MANAGEMENT
Nursing management in burn care requires specific knowledge on burns so that there could be
a provision of appropriate and effective interventions.

1. Nursing Assessment
(A) The nursing assessment focuses on the major priorities for any trauma
patient; the burn wound is a secondary consideration.

(B) Focus on the major priorities of any trauma patient. the burn wound is
a secondary consideration, although aseptic management of the burn
wounds and invasive lines continues.
(C ) Assess circumstances surrounding the injury. 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.
(D) Monitor vital signs frequently. Monitor respiratory status closely; and
evaluate apical, carotid, and femoral pulses particularly in areas of
circumferential burn injury to an extremity.
 CONT..
(E) Start cardiac monitoring if indicated. If patient has history of cardiac or respiratory problems,
electrical injury.
(F) Check peripheral pulses on burned extremities hourly; use Doppler as needed.
(I) Monitor fluid intake (IV fluids) and output (urinary catheter) and measure hourly. Note amount
of urine obtained when catheter is inserted (indicates pre burn renal function and fluid status).
(J) Obtain history. Assess body temperature, body weight, history of pre burn weight, allergies,
tetanus immunization, past medical surgical problems, current illnesses, and use of medications.
(K) Arrange for patients with facial burns to be assessed for corneal injury.
(L) Continue to assess the extent of the burn; assess depth of wound, and identify areas of full
and partial thickness injury.
(M) Assess neurologic status: consciousness, psychological status, pain and anxiety levels, and
behavior.
(N) Assess patient’s and family’s understanding of injury and treatment. Assess patient’s support
system and coping skills.
 Acute Phase MANAGEMENT
The acute or intermediate phase begins 48 to 72 hours after the burn
injury. Burn wound care and pain control are priorities at this stage.
1. Acute or intermediate phase begins 48 to 72 hours after the burn injury.

2. Focus on hemodynamic alterations, wound healing, pain and psychosocial

responses, and early detection of complications.
3. Measure vital signs frequently. Respiratory and fluid status remains highest
priority.
4. Assess peripheral pulses frequently for first few days after the burn for
restricted blood flow.
5. Closely observe hourly fluid intake and urinary output, as well as blood
pressure and cardiac rhythm; changes should be reported to the burn surgeon
promptly.
6. For patient with inhalation injury, regularly monitor level of consciousness,
pulmonary function, and ability to ventilate; if patient is intubated and placed on
a ventilator, frequent suctioning and assessment of the airway are priorities.
Rehabilitation Phase MANAGEMENT
Rehabilitation should begin immediately after the burn has occurred. Wound healing, psychosocial
support, and restoring maximum functional activity remain priorities. Maintaining fluid and electrolyte
balance and improving nutrition status continue to be important.

1. In early assessment, obtain information about patient’s educational level, occupation, leisure
activities, cultural background, religion, and family interactions.
2. Assess self concept, mental status, emotional response to the injury and hospitalization, level of
intellectual functioning, previous hospitalizations, response to pain and pain relief measures, and sleep
pattern.
3. Perform ongoing assessments relative to rehabilitation goals, including range of motion of affected
joints, functional abilities in ADLs, early signs of skin breakdown from splints or positioning devices,
evidence of neuropathies (neurologic damage), activity tolerance, and quality or condition of healing
skin.
4. Document participation and self care abilities in ambulation, eating, wound cleaning, and applying
pressure wraps.
5. Maintain comprehensive and continuous assessment for early detection of complications, with
specific assessments as needed for specific treatments, such as postoperative assessment of patient
undergoing primary excision.
NURSING DIAGNOSIS
Nursing diagnoses for burn injuries include:

1. Impaired gas exchange related to carbon monoxide poisoning, smoke inhalation, and
upper airway obstruction.
2. Ineffective airway clearance related to edema and effects of smoke inhalation.
3. Fluid volume deficit related to increased capillary permeability and evaporative
losses from burn wound.
4. Hypothermia related to loss of skin microcirculation and open wounds.
5. Pain related to tissue and nerve injury.
6. Anxiety related to fear and the emotional impact of burn injury.
 Nursing diagnosis-
1. Impaired Physical Mobility May be related to Neuromuscular impairment, pain/discomfort, decreased
strength and endurance Restrictive therapies, limb immobilization; contractures.
2. Impaired Skin Integrity May be related to Disruption of skin surface with destruction of skin layers
(partial-/full-thickness burn) requiring grafting.
3. Imbalanced Nutrition: Less Than Body Requirements May be related to Hypermetabolic state (can be as
much as 50%–60% higher than normal proportional to the severity of injury) Protein catabolism, Anorexia,
restricted oral intake.
4. Fear/Anxiety May be related to Situational crises: hospitalization/isolation procedures, interpersonal
transmission and contagion, memory of the trauma experience, threat of death and/or disfigurement.
Planning & Goals
To implement the plan of care for a burn injury patient effectively,
there should be goals that should be set:

1. Maintenance of adequate tissue oxygenation.

2. Maintenance of patent airway and adequate airway clearance.
3. Restoration of optimal fluid and electrolyte balance and perfusion of vital organs.
4. Maintenance of adequate body temperature.
5. Control of pain.
6. Minimization of patient’s and family’s anxiety.
Nursing Priorities
1. Maintain patent airway/respiratory function.
2. Restore hemodynamic stability/circulating volume.
3. Alleviate pain.
4. Prevent complications.
5. Provide emotional support for patient/significant other (SO).
6. Provide information about condition, prognosis, and treatment.
 Nursing Interventions
(A) Promoting Gas Exchange and Airway Clearance

1. Provide humidified oxygen, and monitor arterial blood gases (ABGs), pulse oximetry, and
carboxyhemoglobin levels.
2. Assess breath sounds and respiratory rate, rhythm, depth, and symmetry; monitor for hypoxia.
3. Observe for signs of inhalation injury: blistering of lips or buccal mucosa; singed nostrils; burns of
face, neck, or chest; increasing hoarseness; or soot in sputum or respiratory secretions.
4. Report labored respirations, decreased depth of respirations, or signs of hypoxia to physician
immediately; prepare to assist with intubation and escharotomies.
5. Monitor mechanically ventilated patient closely.
6. Institute aggressive pulmonary care measures: turning, coughing, deep breathing, periodic forceful
inspiration using spirometry, and tracheal suctioning.
7. Maintain proper positioning to promote removal of secretions and patent airway and to promote
optimal chest expansion; use artificial airway as needed.
(B)Restoring fluid and Electrolyte Balance
1. Monitor vital signs and urinary output (hourly), central venous pressure (CVP), pulmonary
artery pressure, and cardiac output.
2. Note and report signs of hypovolemia or fluid overload.
3. Maintain IV lines and regular fluids at appropriate rates, as prescribed. Document intake,
output, and daily weight.
4. Elevate the head of bed and burned extremities.
5. Monitor serum electrolyte levels (eg, sodium, potassium, calcium, phosphorus,
bicarbonate); recognize developing electrolyte imbalances.
6. Notify physician immediately of decreased urine output; blood pressure; central venous,
pulmonary artery, or pulmonary artery wedge pressures; or increased pulse rate.
(C ) Maintaining Normal Body Temperature
1. Provide warm environment: use heat shield, space blanket, heat lights, or blankets.
2. Assess core body temperature frequently.
3. Work quickly when wounds must be exposed to minimize heat loss from the
wound.
4. ANTIPYRITIC MEDICATION ADMINISTRATION
 (D) Minimizing Pain and Anxiety
1. Use a pain scale to assess pain level (ie, 1 to 10); differentiate between restlessness
due to pain and restlessness due to hypoxia.
2. Administer IV opioid analgesics as prescribed, and assess response to medication;
observe for respiratory depression in patient who is not mechanically ventilated.
3. Provide emotional support, reassurance, and simple explanations about procedures.
4. Assess patient and family understanding of burn injury, coping strategies, family
dynamics, and anxiety levels. Provide individualized responses to support patient and
family coping; explain all procedures in clear, simple terms.
5. Provide pain relief, and give antianxiety medications if patient remains highly anxious
and agitated after psychological interventions.
 (e)Teaching Self-care
1. Throughout the phases of burn care, make efforts to prepare patient and family for the care
they will perform at home. Instruct them about measures and procedures.
2. Provide verbal and written instructions about wound care, prevention of complications, pain
management, and nutrition.
3. Inform and review with patient specific exercises and use of elastic pressure garments and
splints; provide written instructions.
4. Teach patient and family to recognize abnormal signs and report them to the physician.
5. Assist the patient and family in planning for the patient’s continued care by identifying and
acquiring supplies and equipment that are needed at home.
6. Encourage and support follow up wound care.
7. Refer patient with inadequate support system to home care resources for assistance with
wound care and exercises.
8. Evaluate patient status periodically for modification of home care instructions and/or planning
for reconstructive surgery.
Evaluation
In a patient with burn injury, the expected outcomes are:

Absence of dyspnea.
Respiratory rate between 12 and 20 breaths/min.
Lungs clear on auscultation,
Arterial oxygen saturation greater than 96% by pulse oximetry.
ABG levels within normal limits.
Patent airway
Respiratory secretions are minimal, colorless, and thin.
Urine output between 0.5 and 1.0 mL/kg/h.
Blood pressure higher than 90/60 mmHg.
Heart rate less than 120 bpm.
Body temperature remains between 36.1ºC and 38.3ºC
Discharge and Home Care Guidelines
The focus of rehabilitative interventions is directed towards outpatient care, home
care, or care in a rehabilitation center.

1. Wound care. The patient and the family are instructed to wash small clean, open wounds
daily with mild soap and water and to apply the prescribed topical agent or dressing.
2. Education. The patient and the family require careful written and verbal instructions about
pain management, nutrition, prevention of complications, specific exercises, and the use of
pressure garments and splints.
3. Follow up care. Patients who receive care in a burn center usually return to the burn clinic
periodically for evaluation, modification of burn care instructions, and planning for
reconstructive surgery.
4. Referral. Patients who return home after a severe burn injury, those who cannot manage
their own burn care, and those with inadequate support systems need referral for home care.
Documentation Guidelines
The nurse should document the following data to ensure that each care
documented is a care that is done.

1. Breath sounds and character of secretions.

2. Respiratory rate, pulse oximetry/O2 saturation, vital signs.
3. Plan of care and those involved in the planning.
4. Teaching plan.
5. Client’s response to interventions, teachings, and actions performed.
6. Use of respiratory devices or adjuncts.
7. Conditions that may interfere with oxygen supply.
8. I&O, fluid balance, changes in weight, urine specific gravity.
9. Attainment or progress toward desired outcomes.
10. Modifications to the plan of care.
PREVENTION
To promote safety and avoid burns, the following must be done to prevent
burns:
1. Advise that matches and lighters be kept out of reach of children.
2. Emphasize the importance of never leaving children unattended around
fire or in bathroom/bathtub.
3. Caution against smoking in bed, while using home oxygen, or against
falling asleep while smoking.
4. Caution against throwing flammable liquids onto an already burning fire.
5. Caution against using flammable liquids to start fires.
6. Recommend avoidance of overhead electrical wires and underground
wires when working outside.
7. Advise that hot irons and curling irons be kept out of reach of children.
8. Caution against running an electrical cord under carpets or rugs.
9. Advocate caution when cooking, being aware of loose clothing hanging
over the stove top.
10. Recommend having a working fire extinguisher in the home and
knowing how to use it.
COMPLICATION
There are a lot of consequences involved in burn injuries that may
progress without treatment.

1. Ischemia. As edema increases, pressure on small blood vessels and

nerves in the distal extremities causes an obstruction of blood flow.
2. Tissue hypoxia. Tissue hypoxia is the result of carbon monoxide
inhalation.
3. Respiratory failure. Pulmonary complications are secondary to
inhalational injuries.