BURNS

A burn injury can affect people of all ages and

socioeconomic groups.
• Men > Women – incidence of burn injury
Ages: between 20 & 30 y.o
• Patients with burns:
o Have particularly prolonged hospital lengths of stay (LOS); requires
multiple surgical interventions.
o Extensive pain control
o Immobilization and rehabilitation
o Prolonged IV medication regimens (antibiotic and opioids)
CHARACTERISTICS OF BURN
(according to depth)
FIRST DEGREE CAUSES:
(superficial) • Sunburn
• Low-intensity flash
• Superficial scald

SKIN INVOLVEMENT:
• Epidermis
CLINICAL MANIFESTATIONS:
• Tingling
• Hyperesthesia (hypersensitivity)
• Pain that is soothed by cooling
• Peeling
• Itching

WOUND APPEARANCE:
• Reddened; blanches with pressure; dry
• Minimal or no edema
• Possible blisters
RECUPERATIVE COURSE AND TREATMENT

• Complete recovery within a few days

• Oral pain medications, cool compresses, skin
lubricants (e.g. ointments, emollients); topical
antimicrobial agents not indicated
 SECOND
DEGREE (Partial CAUSES:
Thickness) • Scalds
• Flash Flame

SKIN INVOLVEMENT:
• Epidermis, portion of dermis
CLINICAL MANIFESTATIONS:
• Pain
• Hyperesthesia
• Sensitive to air currents

WOUND APPEARANCE:
• Edema
• Blistered, mottled red base; disrupted epidermis weeping
surface
RECUPERATIVE COURSE AND TREATMENT:

• Recovery in 2 – 3 weeks
• Some scarring and depigmentation possible; may
require grafting
THIRD DEGREE CAUSES:
(full thickness) • Flame
• Prolonged exposure to hot liquids
• Electric current chemical
• Contact
SKIN INVOLVEMENT:
• Epidermis, dermis and sometimes subcutaneous tissue; may
involve connective tissue, and muscle.

CLINICAL MANIFESTATIONS:
• Insensate
• Shock
• Myoglobinuria (red pigment in urine) and possible hemolysis
(blood cell destruction)
• Possible contact points (entrance or exit wounds in electrical
burns)
WOUND APPEARANCE:
• Dry, pale white, red brown, leathery, or charred
• Coagulated vessels may be visible
• Edema

RECUPERATIVE COURSE OR TREATMENT:

• Eschar may slough
• Grafting necessary
• Scarring and loss of contour and function
 FOURTH DEGREE
(full thickness that includes fat, fascia, muscle and/ or bone)
CAUSES:
• Prolonged exposure or high voltage electrical injury

SKIN INVOLVEMENT:
• Deep tissue, muscle and bone

CLINICAL MANIFESTATIONS:
• Shock
• Myoglobinuria (red pigment in urine) and possible hemolysis
(blood cell destruction)
WOUND APPEARANCE:
• Charred

RECUPERATIVE COURSE OR TREATMENT:

• Amputation likely
• Grafting of no benefit, given depth and severity of wound(s)
BURNS
Pathophysiology
Pathophysiology
Burn injury is the result of chemical injury or heat transfer from one site
to another, causing tissue destruction through coagulation, protein
denaturation, or ionization of cellular contents.
The burn wound is not homogenous, rather, tissue necrosis occurs at the
center of injury with regions of tissue viability toward the periphery.
• When burns occur, cell proteins in the skin denature and coagulate and
thrombosis develops in the vessels. Vascular permeability increases
and denatured cell particles increase intercellular osmotic pressure.
• Vasoactive amines such as histamine, kinin, prostaglandin, and
serotonin are released from the burn developing tissue. Platelet and
leukocyte adhesion to endothelium occurs. The complement system is
activated cytotoxic T cells increase, and the tissue develops into an
open site for infection
• Heat injuries occur in two stages. First, coagulative type necrosis
develops in the epidermis and tissues. Afterwards, late type injury
occurs due to cell lysis as a result of progression of dermal ischemia
(within 24–48 hours). The depth of necrosis is determined by degree
of temperature it is exposed to and the time of duration 
• Burn injury causes both local and systemic changes. Vasodilatation and vascular
permeability are also increased in the skin and subcutaneous tissues due to local
reaction. As a systemic response, all internal organ systems are affected. In severe
burns, cytokines and other inflammatory mediators are released in excess both in the
burn area and in the unburned areas.
• These mediators cause vasoconstriction and vasodilatation, increase in capillary
permeability, and development of edema both in the burn site and in remote organs.
Pathological changes occur in metabolic, cardiovascular, renal, gastrointestinal, and
coagulation systems.
• With burn shock, blood volume and cardiac output are decreased, renal blood flow and
glomerular filtration rate decrease, gastrointestinal mucosal atrophy develops and
intestinal permeability increases. Catabolism is accelerated and often results in
widespread microthrombosis
A. The outermost zone, the zone of
hyperemia, sustains minimal injury and may
fully recover spontaneously over time.
B. The surrounding zone, the zone of stasis,
describes the area of injured cells that may
remain viable but, with persistent ischemia,
will undergo necrosis within 24 to 48 hours.
C. The central wound of the area is termed
the zone of coagulation due to the
characteristic coagulation necrosis of cells
that occurs
 NURSING DIAGNOSIS:
oImpaired gas exchange r/t carbon monoxide poisoning,
smoke inhalation, and upper airway obstruction

oIneffective airway clearance r/t edema and effects of snoke

inhalation
THREE PHASES OF CARE
EMERGENT/RESUSCITATIVE CARE
• Primary Survey A,B,C,D,E
• Prevention of Shock
• Prevention of Respiratory Distress
• Detection and Treatment of Concomitant injuries
• Wound Assessment and initial care
ACUTE/INTERMEDIATE CARE
• Wound care and closure
• Prevention or treatment of complications, including infection
• Nutritional Support
REHABILITATION
• Prevention and treatment of scars and contractures
• Physical, occupational, and vocational rehabilitation
• Functional and cosmetic reconstruction
• Psychosocial counselling
EMERGENT/RESUSCITATIVE
Emergent/Resuscitative
Nursing Diagnoses
• Impaired Gas Exchange related to carbon monoxide poisoning, smoke inhalation, and upper airway
obstruction

• Ineffective airway clearance related to edema and effects of smoke inhalation

• Deficient fluid volume related to increased capillary permeability and evaporative losses from the burn
wound

• Hypothermia r/t loss of skin microcirculation and open wounds

• Acute Pain r/t tissue and nerve injury

• Anxiety r/t fear and the emotional impact of burn injury

ASSESSMENT
Impaired Gas Exchange
related to carbon monoxide poisoning, smoke
inhalation, and upper airway obstruction

• Assess breath sounds, and respiratory rate, rhythm, depth, and

symmetry of chest excursion
• Monitor patient for signs of hypoxia
• Observe the following:
Erythema or blistering of lips or buccal mucosa
Singed nasal hairs
Burns of face, neck, or chest
Increasing hoarseness
Soot in sputum or tracheal tissue in respiratory secretions
• Monitor arterial blood gas values, pulse oximetry readings, and
carboxyhemoglobin levels
Ineffective airway clearance
related to edema and effects of smoke inhalation

• Assess breath sounds, and respiratory rate, rhythm, depth, and

symmetry of chest excursion
• Monitor patient for signs of hypoxia
• Observe the following:
Erythema or blistering of lips or buccal mucosa
Singed nasal hairs
Burns of face, neck, or chest
Increasing hoarseness
Soot in sputum or tracheal tissue in respiratory secretions
• Monitor arterial blood gas values, pulse oximetry readings, and
carboxyhemoglobin levels
Deficient fluid volume
related to increased capillary permeability and
evaporative losses from the burn wound

• Monitor vital signs, hemodynamics, and urine

output, as well as strict intake and output of daily
weight
• Observe for symptoms of deficiency or excess of
serum sodium, potassium, calcium, phosphorus,
and bicarbonate
Hypothermia
r/t loss of skin microcirculation and open wounds

• Assess core body temperature frequently

Acute Pain
r/t tissue and nerve injury

• Use pain intensity scale to assess pain level

• Differentiate restlessness due to pain from
restlessness due to hypoxia
Anxiety
r/t fear and the emotional impact of burn injury

• Assess patient’s and family’s understanding of

burn injury, coping skills, and family dynamics
Collaborative Problems

Acute Respiratory Failure

Compartment Syndrome
Distributive Shock
Paralytic Ileus
Acute Kidney Injury
Curling’s Ulcer
Acute Respiratory Failure

• Assess for increasing dyspnea, stridor, changes in respiratory

patterns
• Monitor pulse oximetry, arterial blood gas values
• Monitor chest x-ray results
• Assess for restlessness, confusion, difficulty attending to
questions, or decreasing level of consciousness
Distributive Shock

• Assess for decreasing urine output and alterations in vital

signs and hemodynamics

• Assess for progressive edema as fluid shift occurs

Acute Kidney Injury

• Monitor urine output, blood urea nitrogen (BUN), and serum

creatinine levels

• Assess urine for hemoglobin or myoglobin

• Assess need for fluid administration

Compartment Syndrome

• Assess peripheral pulses frequently with Doppler ultrasound

device if needed
• Assess warmth, capillary refill, sensation, and movement of
extremity frequently. Compare affected with unaffected
extremity
Paralytic Ileus

• Auscultate for bowel sounds, abdominal distention

Curling’s Ulcer

• Assess gastric aspirate and stools for blood

• Assess the need for administration of histamine-2 blockers
and/or antacids as prescribed
ACUTE/INTERMEDIATE CARE
Prioritized Care
• Restoring fluid balance
• Preventing Infection
• Modulating Hypermetabolism
• Promoting Skin Integrity
• Relieving Pain and Discomfort
• Promoting Mobility
• Strengthening Coping Strategies
• Supporting Patient and Family Process
• Monitoring and Managing Complications
REHABILITATION
Prioritized Assessment (General)
• Patient’s education level
• Occupation
• Leisure Activities
• Cultural Background/Religion
• Family Interactions
Prioritized Assessment (Psychosocial)
• Self Concept
• Mental
• Emotional Response to Injury and the subsequent hospitalization
• Level of Intellectual Functioning
• Previous Hospitalizations
• Response to pain and pain relief measures
• Sleep Patterns
• Emotional Needs
Prioritized Assessment (Physical)
• Range of Motion in affected joints
• Functional Abilities in ADL
• Early Signs of Skin Breakdown
• Evidences of Neuropathies
• Activity Tolerance
• Quality/Condition of Healing Skin
• Patient’s participation in care
• Ability to demonstrate self-care
Ambulation
Eating
Wound Cleaning
Toileting
Applying Pressure Wraps
• Ability to demonstrate self-care
Proper Documentation
MANAGEMENT OF BURN
The burns patient has the same priorities as all other trauma patients.

Assess:

- Airway
- Breathing: beware of inhalation and rapid airway compromise
- Circulation: fluid replacement
- Disability: compartment syndrome
- Exposure: percentage area of burn.
Essential management points:

- Stop the burning

- ABCDE
- Determine the percentage area of burn (Rule of 9’s)
- Good IV access and early fluid replacement.
The severity of the burn is determined by:

- Burned surface area

- Depth of burn
- Other considerations.
“Rule of 9’s”
The body is divided into anatomical regions that represent 9% (or multiples of 9%) of the total
body surface. The outstretched palm and fingers approximates to 1% of the body surface area.
 Daily treatment
• Change the dressing daily (twice daily if possible) or as often as necessary to prevent
seepage through the dressing. On each dressing change, remove any loose tissue.
• Inspect the wounds for discoloration or haemorrhage, which indicate developing
infection.
• Fever is not a useful sign as it may persist until the burn wound is closed.
• Cellulitis in the surrounding tissue is a better indicator of infection.
• Give systemic antibiotics in cases of haemolytic streptococcal wound infection or
septicaemia.
• Pseudomonas aeruginosa infection often results in septicaemia and death. Treat with
systemic aminoglycosides.
• Administer topical antibiotic chemotherapy daily. Silver nitrate (0.5% aqueous) is the
cheapest, is applied with occlusive dressings but does not penetrate eschar. It depletes
electrolytes and stains the local environment.
• Use silver sulfadiazine (1% miscible ointment) with a single layer dressing. It
has limited eschar penetration and may cause neutropenia.
• Mafenide acetate (11% in a miscible ointment) is used without dressings. It
penetrates eschar but causes acidosis. Alternating these agents is an
appropriate strategy.

• Treat burned hands with special care to preserve function.

− Cover the hands with silver sulfadiazine and place them in loose polythene
gloves or bags secured at the wrist with a crepe bandage;
− Elevate the hands for the first 48 hours, and then start hand exercises;
− At least once a day, remove the gloves, bathe the hands, inspect the burn and
then reapply silver sulfadiazine and the gloves;
− If skin grafting is necessary, consider treatment by a specialist after healthy
granulation tissue appears.
Healing phase

• The depth of the burn and the surface involved influence the duration of
the healing phase. Without infection, superficial burns heal rapidly.
• Apply split thickness skin grafts to full-thickness burns after wound excision
or the appearance of healthy granulation tissue.
• Plan to provide long term care to the patient.
• Burn scars undergo maturation, at first being red, raised and
uncomfortable. They frequently become hypertrophic and form keloids. They
flatten, soften and fade with time, but the process is unpredictable and can
take up to two years.
• In children

- The scars cannot expand to keep pace with the growth of the child and may
lead to contractures.
- Arrange for early surgical release of contractures before they interfere with
growth.

• Burn scars on the face lead to cosmetic deformity, ectropion and contractures
about the lips. Ectropion can lead to exposure keratitis and blindness and lip
deformity restricts eating and mouth care.

• Consider specialized care for these patients as skin grafting is often not
sufficient to correct facial deformity.
Nutrition

• Patient’s energy and protein requirements will be extremely high due to

the catabolism of trauma, heat loss, infection and demands of tissue
regeneration. If necessary, feed the patient through a nasogastric tube to
ensure an adequate energy intake (up to 6000 kcal a day).

• Anaemia and malnutrition prevent burn wound healing and result in failure
of skin grafts. Eggs and peanut oil and locally available supplements are
good.
Wound care

First aid

• If the patient arrives at the health facility without first aid having been given,
drench the burn thoroughly with cool water to prevent further damage and
remove all burned clothing.
• If the burn area is limited, immerse the site in cold water for 30 minutes to
reduce pain and oedema and to minimize tissue damage.
• If the area of the burn is large, after it has been doused with cool water, apply
clean wraps about the burned area (or the whole patient) to prevent systemic
heat loss and hypothermia.
• Hypothermia is a particular risk in young children.
• First 6 hours following injury are critical; transport the patient with severe
burns to a hospital as soon as possible.
Initial treatment

• Initially, burns are sterile. Focus the treatment on speedy healing and prevention of
infection.
• In all cases, administer tetanus prophylaxis.
• Except in very small burns, debride all bullae. Excise adherent necrotic (dead) tissue
initially and debride all necrotic tissue over the first several days.
• After debridement, gently cleanse the burn with 0.25% (2.5 g/litre) chlorhexidine
solution, 0.1% (1 g/litre) cetrimide solution, or another mild water-based antiseptic.
• Do not use alcohol-based solutions.
• Gentle scrubbing will remove the loose necrotic tissue. Apply a thin layer of antibiotic
cream (silver sulfadiazine).
• Dress the burn with petroleum gauze and dry gauze thick enough to prevent seepage
to the outer layers.
 PREVENTION
The document A WHO plan for burn prevention and
care discusses these 7 components in detail.

• improve awareness
• develop and enforce effective policy
• describe burden and identify risk factors
• set research priorities with promotion of promising interventions
• provide burn prevention programe’s
• strengthen burn care
• strengthen capacities to carry out all of the above.
In addition, there are a number of specific recommendations for
individuals, communities and public health officials to reduce burn
risk.

• Enclose fires and limit the height of open flames in domestic

environments.
• Promote safer cookstoves and less hazardous fuels, and educate
regarding loose clothing.
• Apply safety regulations to housing designs and materials, and encourage
home inspections.
• Improve the design of cookstoves, particularly with regard to stability and
prevention of access by children.
• Lower the temperature in hot water taps.
• Promote fire safety education and the use of smoke detectors, fire
sprinklers, and fire-escape systems in homes.
• Promote the introduction of and compliance with industrial safety
regulations, and the use of fire-retardant fabrics for children’s
sleepwear.
• Avoid smoking in bed and encourage the use of child-resistant
lighters.
• Promote legislation mandating the production of fire-safe cigarettes.
• Improve treatment of epilepsy, particularly in developing countries.
• Encourage further development of burn-care systems, including the
training of health-care providers in the appropriate triage and
management of people with burns.
• Support the development and distribution of fire-retardant aprons to
be used while cooking around an open flame or kerosene stove.