A burn is necrosis of the skin

that results from when the skin

comes in contact with intense
heat
Burns are categorized
according to the type of injury
For children
For adult
In addition to the depth of the burn, the total area of the burn
is significant. Burns are measured as a percentage of total body
area affected. The "rule of nines" is often used, though this
measurement is adjusted for infants and children. This
calculation is based upon the fact that the surface areas of the
following parts of an adult body each correspond to
approximately 9% of total (and the total body area of 100% is
achieved):
Head = 9%
Chest (front) = 9%
Abdomen (front) = 9%
Upper/mid/low back and buttocks = 18%
Each arm = 9%
Each palm = 1%
Groin = 1%
Each leg = 18% total (front = 9%, back = 9%)
 

1. Superficial thicknessburn(1stdegree)
Skin Involvement
Epidermis
Will remain intact with no blister formation
(may or may not blister)
Possible a portion of dermis is affected

Possible Causes
Sunburn
 Low intensity flash
Symptoms
Tingling
Hyperesthesia – Super sensitivity
Pain that is soothed by cooling
Pain (very painful because nerve endings are intact)
Exposed nerve endings sensitive to cool, moving air
Wound Appearance
 Redness and painful
Blanches with pressure
Dry
Minimal or no edema in region burned
Possible blisters that appear in 24 hrs or maybe no
blisters
Minimal but causes some discomfort
Recuperative Course
Heals in 3-5 days
Possible mild scarring or no scarring
Peeling – Regeneration of skin in 3-4 days
2. Partial thickness burn (2nd degree)
Causes
Scalds or flash flame

Skin Involvement
Epidermis, Upper dermis, portion of deeper
dermis

Symptoms
Pain
Sensitive to cold air
Wound Appearance
 Wet, shiny, weeping wound (serous drainage)
They are losing fluid
 Red and the wound will blanche under pressure
 Blistered, mottled red base
 Broken epidermis – Edema
 Very Painful
 Hair follicles remain intact
Recuperative Course
 Recovery in 2-4 weeks to months - depends on depth
may be longer than 21 days
 Grafting may be required
 Some scarring and depigmentation
 May develop contractures (feet, hands) neck with head
burns
 Place 4x4 between digits to insure healing individually
3. Full thickness burns (3rd degree)
Cause
 Flame
 Prolonged exposure to hot liquids
 Electric current
 Chemical

 
Skin Involvement
 Epidermis, entire dermis and sometimes subcutaneous
tissue
 May involve connective tissue, muscle and bone
 Extends to top layer of fat
Symptoms
No Pain due to nerve endings being destroyed.
But will have pain in surrounding region.
Shock - Hematuria and possible hemolysis

Wound Appearance
Hair follicles destroyed, sweat glands destroyed
Skin color may be charred, leathery, brown, or
pale white
Broken skin with fat exposed
Edema
No blisters present
Recuperative Course
 Grafting is required for any individual that has a full
thickness burn
 Scarring and loss of contour and function;
contractures – limited movement
 Loss of digits or extremity possible
 Eschar sloughs – dark leathery, scab like
Will not break like a scab and they may develop
compartment syndrome because they have a
tight band of old skin(eschar) around the
extremity and they will not have blood flow – MD
will have to do a Escardotomy or Fasciotomy.
May put in whirlpools to get the Escar to loosen
to create blood flow to the area.
4. Deep full thickness burn (4th degree)
Burn extension into muscle and to the bone
No pain
Grafting required
Amputation may be required for healing
Superficial Burns Partial Thickness Burns

Full thickness Burns

1.Upper area
 Could haveof body;
some suchcomplications
pulmonary as head, neck, and
because chest
of the burnarea.
area
close to lungs
 There will be enough inflammation and swelling to obstruct the airway
and cause breathing problems
 Respiratory burns will be evident in upper and lower airways
 Pen light to check nares to see if hair is singed or absent
 May look for black drainage from nose or black productive cough
 Black or bloody sputum
 Blisters on lips
 Blisters in oral cavity
 Raspy speech or hoarse
 Labored breathing
 Dry cough
 More restless than other burn patients
 Will do bronchoscopy
 Burn to the face is associated with corneal abrasions
 2. Circumferential burns to the chest

As the burn progresses, the tissue involved

may not allow enough motion of the chest
wall to allow adequate breathing to occur.
 
Circumferential burns occur to arms, legs, fingers, or toes

Same constriction may not allow blood flow

and put the survival of the extremity at risk.
a. Emergent Phase
At the scene and first at hospital
ABC’s
Note if inhalation injury
First 48-72 hours after the burn
Continuing to lose fluid and protein from their burn
site into the interstitial compartment
Elevated Hct
Hyperkalemia and Hyponatremia
Given fluids that are isotonic and will NOT be given
fluids that contain K+
Monitor K+ level – If low may have Cardiac Arrest
b. Acute Phase and Resuscitative phase
Begins 48-72 hours AFTER the injury
Fluid Shifts back into intravascular compartment
Fluid remobilization
Capillary wall is beginning to heal
Fluid volume excess R/T resumption of capillary
integrity and fluid shift from interstitial back to
intravascular compartment
Increase Hct and Decreased in Urine output
Hyponatremia continued until completely stabilized
Hypokalemia begin 4-5 day post burn – because
the K+ is no longer oozing out of the cells into the
circulation. The cells are beginning to heal and the
K+ is not able to escape from the cells into the
intervascular compartment.
Risk for Fluid Overload
Anemia – May get Fe 3 times a day to increase Hct
Metabolic Acidosis
Increased capillary permeability
b.1. Wound care
Medicated cream on the area to reduce the
likelihood of them developing infection or escar
tissue
 Silvadene
Still used some 1-3 times a day
 Sulfamylon
Penetrates thick escar tissue to let it fall off on its own
and aid in debredment
Wear gloves – because can cause metabolic acidosis
2 times a day, Diffuses through eschar
 Silver Nitrate – Not used much
b.2. Hydrotherapy
Helps to loosen skin QD or BID
Water temp 100oF – 37.8oC
Room temp 80-85oF – 26.6-29.4oC
Limited 20-30 min period to prevent
chilling and added metabolic stress
May add betadine to help disinfect skin
 
b.3. Debridement

To remove tissue contaminated by bacteria

and foreign bodies, thereby protecting the
patient from invasion of bacteria
Painful process; med 20-30o before process;
reach relaxation technique
Morphine 2mg or 25mg Demerol, Ativan or
Versed
b.4. Autografting
Done once all old necrotic tissue is removed from the body

 Types:
a. Auto Graft
Permanent graft with the persons own skin (Best)
Donor Site - The area from the tissue was removed
Be sure to assess donor site also
b. Homograft
Same Species; skin banks
c. Heterograft
Graft from a pig (temporary graft)
d. Aminograft
Placenta tissue (temporary)
d. Rehabilitation Phase
Can take months up to years depending upon the
degree of the burn
Own home or other agency long term care
Concern with body image related to scar
Jobst Stocking (Tighter than TED hose) 23 or of 24o
Compress scar from back out and blend into tissue
Activity Intolerance
Muscle Wasting
Decreased movement
Knowledge Deficit Client/Family