By:Ailyn Ibita

Definition
 Injuriesthat result from direct
contact with or exposure to any
thermal, chemical or radiation
source or termed burns
Etiology
 BURN injuries are categorized according to
mechanism of injury:
 Thermal burns
 Chemical Burns
 Electrical
 Radiation Burns
 Inhalation Injury
 Thermal
-exposure to flame or a hot object
 Chemical
-exposure to acid, alkali or organic substances
 Electrical
-Result from the conversion of electrical energy into heat.
Extent of injury depends on the type of current, the pathway
of flow, local tissue resistance, and duration of contact
 Radiation
-result from radiant energy being transferred to the body
resulting in production of cellular toxins
 Inhalation injury
- Result from inhalation of smoke or chemical products of
cumbustion
Skin Form & Function
Skin Anatomy
 Skin Layers
Epidermis
Dermis
Subcutaneous
tissue
Epidermis
 Outer layer
 Top (stratum corneum) consists of
dead, hardened cells
 Lower epidermal layers form stratum
corneum and contain protective
pigments
Dermis
 Elasticconnective tissue
 Contains specialized structures
Nerve endings
Blood vessels
Sweat glands
Sebaceous (oil) glands
Hair follicles
Subcutaneous/Muscle
 Fat(protective layer)
 Muscle for support, movement,
coordination
 Depth of burn?
 ENTRY OF
MICROORGANIS SEPTICEMIA
M

LOSS OF
FLUID HYPOVOLEMIA
SKIN LOSS/
DESTRUCTIO
N
LOSS OF
HEAT HYPOTHERMIA

IMMUNOSUPPRESION SUSCEPTIBILITY TO INFECTION

RELEASE OF
INFLAMMATI PAIN AND DEGRANUL NEUTROPHILS RELEASE OF FURTHER
NEUROPEPTIDES
ALTERATION ATION OF ATTRACTION AND FREE RADICALS DAMAGE
ON OF PROTEIN
AND ACTIVATION
MAST CELL GRANULATION AND PROTEASE TO TISSUE
OF COMPLEMENT

BURN

LOSS OF DIRECT FLUID

SKIN LOSS
CIRCULATORY SHOCK
CIRCULATORY
CHANGES
INCREASE THIRD SPACE
VESSEL COLLECTION
PERMIABILITY (NON-BURN
TISSUE
EDEMA)

KIDNEY

LUNGS
OTHER CHANGES
STOMACH

INTESTINE
BURN WOUND ASSESSMENT
 Classified according to depth of injury and
extent of body surface area involved
 Burn wounds differentiated depending on
the level of dermis and subcutaneous tissue
involved
1. superficial partial thickness injuries
(first-degree)
2. deep partial (second-degree)
3. full thickness (third degree)
Superficial Burns
 Superficial (First degree)
 Involves only epidermis
 Red
 Painful
 Tender
 Blanches under pressure
 Possible swelling, no
blisters
 Heal in ~7 days
Deep Partial Thickness Burns
 Partial Thickness
(Second degree)
 Extends through
epidermis into
dermis
 Salmon pink
 Moist, shiny
 Painful
 Blisters may be
present
 Heal in 2 to 4 weeks
Full Thickness Burns
 Full Thickness (Third
degree)
 Through epidermis,
dermis into underlying
structures
 Thick, dry
 Pearly gray or charred
black
 May bleed from vessel
damage
 Painless
 Require grafting
Burn Extent
Burn Extent: Rule of Nines
RULES OF NINES
 Each upper extremity (Arms) = 9%
 Head & Neck = 9%

 Each lower extremity (Legs) = 18%

 Anterior trunk= 18%

 Posterior trunk = 18%

 Genitalia (perineum) = 1%
LUND BROWDER CHART USED FOR DETERMINING BSA
Burn Extent: Rule of Thumb/Palmer
method
 “Ruleof Palm”
Patient’s
palm equals
1% of his
body
surface area
Critical Burns
 Full-thickness burns involving hands, feet,
face, upper airway, genitalia, or
circumferential burns of other areas
 Full-thickness burns covering more than
10% of total body surface area
 Partial-thickness burns covering more than
30% of total body surface area
 Burns associated with respiratory injury
Critical Burns, continued
 Burns complicated by fractures
 Burns on patients younger than 5 years old
or older than 55 years old that would be
classified as moderate on young adults
Moderate Burns
 Full-thickness burns involving 2% to 10% of
total body surface area excluding hands, feet,
face, upper airway, or genitalia
 Partial-thickness burns covering 15% to
30% of total body surface area
 Superficial burns covering more than 50%
of total body surface area
Minor Burns
 Full-thickness burns involving less than 2%
of the total body surface area
 Partial-thickness burns covering less than
15% of the total body surface area
 Superficial burns covering less than 50% of
the total body surface area
MANAGEMENT
Initial Assessment
 Scene Safety
 BSI
 Determine MOI/Severity
 Number of Patients
 Additional Resources
Stop Burning Process!
 Remove patient from source of
injury
 Remove clothing unless stuck to
burn
 Cut around clothing stuck to burn,
leave in place
PHASES OF BURN INJURIES
Emergent/Resuscitative (24-48
hrs.)
Acute/ Intermediate
Rehabilitative/Rehabilitation
EMERGENT PHASE(24-48HRS.)
From onset of injury to completion of fluid
resuscitation
 Immediate problem is fluid loss, edema, reduced
blood flow (fluid and electrolyte shifts)
 Priorities
o First aid
o Prevention of shock
o Detection and treatment of concomitant injuries
o Wound assessment and initial care
 Medical management
Established adequate respiratory function
and circulatory status
o 100% oxygen
o Encouraged to cough so that the secretions
can be removed by suctioning.
o Endotracheal intubation ( if the patient
develop edema in the airway)
 Assess for cervical spine injuries or head
injury.
 Assess for burn wound
 Remove all clothing and jewelry
 Flushing of the exposed areas is continued
(For chemical burns)
 Check the patient if wearing contact lenses
 Validate an account of the burn scenario
provided by the patient, witness, and
paramedics
o Time of burn injury
o source
o Place
o Length of time the patient was in burning structure.
o first aid done at the scene
o History of falling or jumping at the scene
o History of preexisting diseases
o allergies
o medications
o Used of drugs, alcohol and tobacco
 Insert a large bore catheter in a non burned area (16 or 18
gauge).
 Insert an NGT (if burn exceeds 20%-25% TBSA)
 Clean technique is maintained while assessing and
treating the burn wounds.
 Assessment of both the TBSA burned and the depth of the
burn are completed after soot and debris have been gently
cleansed from the burn wound.
 Clean sheets are placed under and over the patient to
protect the burn wound from contamination.
 Insert an indwelling urinary catheter.
 Obtain baseline height, weight, ABG, hematocrit,
electrolyte values, blood alcohol level, drug panel,
urinalysis, and chest xrays.
 Obtain ECG ( elderly and electrical burn
patient).
 Administer tetanus prophylaxis
 Provide reassurance and support to the
patient.
 Transfer to a burn center
 a patent airway is ensured
 adequate peripheral circulation is
established in any burned extremity.
 a secure IV catheter is inserted with
lactated ringer’s solution infusing the rate
required to maintain a urine output of at
least 30ml/hour.
 an indwelling urinary catheter is inserted
 adequate pain relief is attained
 wounds are covered with a clean, dry sheet,
and the patient is kept comfortably warm.
IV FLUID THERAPY
 Infusion of IV fluids is needed to maintain sufficient
blood volume for normal CO
 Clients with burns involving 15% to 20% of the TBSA
require IV fluid
 Purpose is to prevent shock by maintaining adequate
circulating blood fluid volume
 Severe burn requires large fluid loads in a short time
to maintain blood flow to vital organs
 Fluid replacement formulas are calculated from the
time of injury and not from the time of arrival at the
hospital
 Diuretics should not be given to increase urine output.
Change the amount and rate of fluid administration.
Diuretics do not increase CO; they actually decrease
circulating volume and CO by pulling fluid from the
circulating blood volume to enhance diuresis
COMMON FLUIDS
• Protenate or 5% albumin in isotonic
saline (1/2 given in first 8 hr; ½ given
in next 16 hr)
• LR (Lactate Ringer) without dextrose
(1/2 given in first 8 hr.; ½ given in next
16 hr)
• Crystalloid (hypertonic saline) adjust to
maintain urine output at 30 mL/hr
• Crystalloid only (lactated ringers)
Determining fluid resuscitation
Parkland Formula
 V=(% area burns) x(kg weight)x(4ml/kg)
 Use ringer’s lactate in addition to the 2L of D5W
 Maximum % area is 50%
 Should subtract any fluids already given from the
total V
 Formula calculates additional fluids needed it does
not account for maintenance fluids. This should be
added on if necessary
Administration
 ½ V over the first 8 hours
 ½ V over the following 16 hours
 ½ V over the following 24 hours
 Use 6ml/kg in pediatric patients
 Determining fluid resuscitation: example
o A 32 year old man is intoxicated and was witnessed to trip and fall
into bonfire. He is rushed to the ED via EMS. He is breathing
adequately , there is no signs of smoke inhalation. IV access is
obtained and routine labs are pending. NG suction has been placed.
He is assessed to have sustained 2nd and 3rd degree burn to 15% of
his body. He weights192lbs (87kg). No fluids have yet been started.
What should be starting fluid rate?
o V=(% area burn) x (kg weight)x (4mL/kg)
o V=(15)X (87kg)X (4mL/kg)
o V=5,220 Ml LR
o ½ V over first 8 hrs. ½ V=2,610 ml LR over 8 hrs.= 326ml/hr LR
o Next 16 hours: 163 ml/hr. LR
o Next 24 hours: 81ml/hr. LR
NURSING DIAGNOSIS IN THE
EMERGENT PHASE
 Decreased CO
 Deficient fluid volume r/t active fluid
volume loss
 Ineffective Tissue perfusion
 Ineffective breathing pattern
ACUTE/INTERMEDIATE PHASE (48-72 HRS.)
• Lasts until wound closure is complete
• Care is directed toward continued assessment and
maintenance of the cardiovascular and respiratory system
• Pneumonia is a concern which can result in respiratory
failure requiring mechanical ventilation
• Infection (Topical antibiotics – Silvadene)
• Tetanus toxoid
• Weight daily without dressings or splints and compare to
pre-burn weight
• A 2% loss of body weight indicates a mild deficit
• A 10% or greater weight loss requires modification of
calorie intake
• Monitor for signs of infection
Medical management
 bronchial washing or bronchioalveolar lavage to assist the
diagnosis and treatment of pneumonia
 Remove the endotracheal tube as soon as possible so that
a route for pathogens is not accessible to the lungs.
 Cautious administrations of fluids and electrolytes
continues during this phase.
 Acetaminophen (Tylenol) , hypothermia blanket and
ancillary heating devices may be required to maintain body
temperature in a range of 37.2 C to 38.3 C.
 Central venous, peripheral arterial, or pulmonary artery
thermodilution catheters may be required.
 Infection prevention
 Wound cleaning
o Use of hydrotherapy
o 37.8 C (water temperature)
o 26.6 C and 29.4 C (room temperature)
 Topical antibacterial therapy
Agent Indication/comment Application Nursing implication
Silver sulfadiazine • Most bactericidal Apply 1/16 inch layer of • Watch for
(silvadene) water agent cream with a sterile leukopenia 2-3 days
soluble cream • Minimal penetration glove 1-3 times daily after initiation of
of eschar therapy.
• Anticipate formation
of pseudo eschar
(proteinaceous gel),
which is removed
easily after 72 hrs.
Mafenide acetate 5% • Effective against • Apply thin layer with • Monitor ABG levels
and discontinue as
to 10% (sulfamylon) gram negative and sterile glove twice a
gram positive day and leave open prescribed if acidosis
hydrophilic based occurs. Mefenide
organisms as prescribed; if the
cream • Diffuses rapidly wound is dressed, acetate is a strong
carbonic anhydrase
through eschar change the
inhibitor that may
• In 10% strength, it dressing every 6
reduce renal
is the agent of hours as buffering and cause
choice for electrical prescribed. metabolic acidosis.
burns because of its • Premidicate the
ability to penetrate patient with an
thick eschar. analgesics before
applying mafenide
acetate because this
agent causes severe
burning pain for up to
20 min. after
application.
Silver nitrate  Bacteriostatic and • Apply solution to • Monitor serum sodium
fungicidal gauze dressing and and potassium levels and
0.5% aqueous  Does not place over wound. replace as prescribed.
solution penetrate eschar Keep the dressing wet Silver nitrate solution is
but covered with dry hypotonic and acts as wick
gauze and dry for sodium and potassium.
blankets to decrease • Protect bed linen and
vaporization clothing from contact with
• Remoisten every 2 silver nitrate which stains
hours and redress everything it touches
wound twice a day. black.

Acticoat • Effective against • Moisten with sterile • Do not use oil based
gram negative and water only (never use products or topical
gram positive normal saline). Apply antimicrobials with
organisms and directly to wound. anticoat burn dressing.
some yeasts and Cover with absorbent Keep anticoat moist. Not
molds secondary dressing saturated may produce
• Delivers uniform, remoisten every 3-4 pseudo escahar from silver
antimicrobial hr. with sterile water application.
concentration of • Can be left in place for 3-5
silver to the burn days also available in
wound. anticoat 7, which can be
left in place for up to 7
days without the need to
change the dressing.
Wound dressing
o light dressing use over joint areas/face
o Circumferential dressings should be applied
distally to proximally
o occlusive dressing may be used over areas with
new skin grafts
 Wound debridement
o Natural
o Mechanical
o Chemical
o surgical
 Wound grafting
 Biologic dressings
o Homografts (allografts)- skin obtained
from living or recently deceased human
o Heterografts (xenografts)- skin taken from
animals (usually pigs)
 Biosynthetic and synthetic dressings
NURSING DIAGOSIS IN THE ACUTE
PHASE
 Impaired skin integrity
 Risk for infection
 Imbalanced nutrition
 Impaired physical mobility
 Disturbed body image
REHABILITATIVE PHASE OF BURN INJURY
 Started at the time of admission
 Technically begins with wound closure and ends
when the client returns to the highest possible
level of functioning
 Provide psychosocial support
 Assess home environment, financial resources,
medical equipment, prosthetic rehab
 Health teaching should include symptoms of
infection, drugs regimens, f/u appointments,
comfort measures to reduce pruritus
 DIET

 InitiallyNPO
 Begin oral fluids after bowel sounds return
 Do not give ice chips or free water lead to
electrolyte imbalance
 High protein, high calorie
GOALS
 Prevent complications (contractures)
 Vital signs hourly
 Assess respiratory function
 Tetanus booster
 Anti-infective
 Analgesics
 No aspirin
 Strict surgical asepsis
 Turn q2h to prevent contractures
 Emotional support
POST CARE OF SKIN GRAFTS
 Maintain dressing
 Use aseptic technique
 Graft should look pink if it has taken after 5
days
 Skeletal traction may be used to prevent
contractures
 Elastic bandages may be applied for 6 mo to
1 year to prevent hypertrophic scarring
 THE END
QUESTIONS