BURNS

By G. Mwiti
 OBJECTIVES

By the end of the study the learner will be able to:

• Describe types and prevention of burn injuries

• Describe burn injuries in terms of involved structures

and clinical appearance of full and partial thickness

burns

• Identify the parameters used to determine the

severity of burns
 OBJECTIVES ctd;
• Differentiate between nutritional needs of the burn
client during the three burn phases
• Explain the physiologic and psychosocial aspects of
burn rehabilitation
• Describe medical and nursing management of the
emotional needs of the burn client and family
• Describe the special needs of nursing staff caring for
burn client and possible ways to meet those needs
 DEFINATION OF BURN INJURY
Refers to the injury to skin caused by:

 physical agent like the sun, excess heat or cold, friction, nuclear
radiations.

 chemical agents like acids or alkali.

 Electrical current

Burns are described as being partial thickness involving the

epidermis, or full thickness involving the dermis and the
underlying structures
 Incidence of burn injury
• Young and elderly people are at high risk because
their skin is thin and fragile.

• Reduced mobility, changes in vision, and decreased

sensation in the feet and hands place elderly people
at higher risk for burn injury.

• Most burn injuries occur in the home usually in the

kitchen while cooking and in the bathroom by means
of scalds or improper use of electrical appliances.
 CLASSIFICATION OF BURNS

• Burns injuries are described according to the

A. Depth of the injury.

B. Body surface area injured (degree of body burnt)

 A. DEPTH OF THE INJURY.
• The depth of a burn injury depends on the type of injury,
causative agent, temperature of the burn agent, duration
of contact with the agent and skin thickness
• Classification according to the depth of tissue destruction:

I. Superficial partial thickness burns ( 1st degree)

II. Deep partial thickness burns (2nd degree)
III. Full thickness burns (3rd degree)
i. Superficial partial thickness burns (1st degree)

• The epidermis is destroyed or injured and a portion of the

dermis may be injured .
• Damaged skin may be painful, appear red and dry, it may
blister.
• There is tingling and hyperesthesia (super sensitivity).
• It completely recovers within a week with no scarring
• Pain is soothed by cooling.
• Example ; sun burn.
ii. Deep partial thickness burns(2nd degree)

• The epidermis and the upper layers of the dermis to

the deeper portions of the dermis are injured.
• Wound is usually blistered.
• Wound is painful, appears red and exudes fluid
(weeping skin), hyperesthesia and edematous.
• Recovers in 2 to 4 weeks. There is scaring and
hyperpigmentation. Example scalds.
iii. Full thickness burns (3rd degree)

• The epidermis, entire dermis and sometimes the underlying

tissue, muscle and bone are involved.

• Wound colour ranges widely from white to red to brown or

black.

• The burned area is painless because the nerve fibres are

destroyed.

• Wound appears leathery, hair follicles and sweat glands are

destroyed e.g. flame burns or electric current
The extent of surface burn
• How much surface area is burned is determined
by one of following methods:

I. Rule of nines
II. Lund and Browder method
III. Palm method
 I. Rule of nines

• An estimation of the total surface area burned by

dividing the body into multiples of 9.
 Totals
4 1 /2 %
Anterior and posterior
head and neck, 9%

Anterior and posterior

upper limbs, 18%
Anterior
4 1 /2 % trunk, 4 1 /2 % Anterior and posterior
18% trunk, 36%

9% 9%
(Perineum, 1%)

Anterior and posterior

lower limbs, 36%
100%
II. Lund and Browder method

• A more precise method of estimating the extent of

burn.
• Takes into account that the percentage of the
surface area represented by various anatomic
parts changes with growth
III. Palm method

• Used to estimate percentage of scattered burns using

the size of the patients palm (about 1%of body surface)
to assess the extent of burn.
 PATHOPHYSIOLOGY OF BURNS
• With temperatures of 44 degree Celsius(111 f )protein begin to lose their
shape and start breaking down , this result in cell and tissue damage.
• Many of the direct health effect of a burn are secondary to disruption in
normal function of the skin. They include the disruption of the skins ;
sensation, ability to prevent water loss through evaporation, abilty to
control body temperature.
• Disruption of cell membrane causes cell to lose potassium to the space
outside the cell and to take up water and sodium.
• In large burns (>30% BSA) there is insignificant inflammatory response , this
result in increased leakage of fluids from the capillaries and subsequent
 PATHOPHYSIOLOGY CTD;
• This cause overall blood volume loss, with remaining blood
suffering significant plasma loss making the blood more
concentrate. Poor blood flow to organs such as kidneys and GIT
may result in renal failure or stomach ulcers.

• Increased catecholamine and cortisol can cause hyper

metabolism

• State that can last for years , this is associated with increased
cardiac output ,metabolism, fast heart rate and poor immune
functions
 PATHOPHYSIOLOGICAL CHANGES
• Burns that do not exceed 25% TBSA produce
primarily local response while those that exceed
may produce both local and systemic response.

• DRAW A DIAGRAM ON MED SURG PAGE 1708

Zones of burn injury.

Each burned area has three zones of injury.

i. Zone of coagulation. The inner area , where cellular

death occurs, sustains the most damage.

ii. Zone of stasis, the middle area, has a compromised

blood supply, inflammation, and tissue injury.

iii. the zone of hyperemia, the outer zone, sustains the

least damage.
1. Burn edema.
Local swelling due to thermal injury is often extensive

• burns involving less than 25% TBSA, the loss of capillary

integrity and shift of fluid are localized to the burn itself,
resulting in blister formation and edema only in the area of
injury.

• Patients with more severe burns develop massive systemic

edema.
• Edema is usually maximal after 24 hours. It begins to
resolve 1 to 2 days post burn and completely resolved in
7 to 10 days post-injury.
• Edema in burn wounds can be reduced by avoiding
excessive fluid during the early post burn period.
• Can complicate to compartment syndrome.
2. Fluid and electrolyte shifts

• Circulating blood volume decreases during burn due to evaporative

fluid loss through the burn and fluid shift, is primarily caused by
increased capillary permeability resulting from histamine release
from injured cells.

• Histamine a potent vasodilator promotes increased blood supply to

an injured area but also causes loss of capillary integrity.

• As the capillary walls become more permeable, water, sodium and

later plasma proteins esp. albumin move into the interstitial spaces
and other surrounding tissues.
• The colloidal osmotic pressure decreases. The net
result of the fluid shift is volume depletion within
the vasculature. Hence oedema, low BP, increased
pulse, hypovolemic shock.
• The circulatory status is also impaired due to
haemolysis of RBCs from direct insult of the burn
injury.
• Na+ and K+ are involved in electrolyte shifts.
• Na is rapidly shifted to the interstitial space and
remains there until oedema formation ceases.
• A K+ shift develops in the 1st 24-48 hours because
the injured cells and haemolysed RBCs release K+
into the extracellular spaces
• Red blood cells may be destroyed and others
damaged, resulting in anemia. Despite this, the
hematocrit may be elevated due to plasma loss.
3. Cardiovascular system
• Hypovolemia is the immediate consequence of fluid loss
leading to decreased perfusion and oxygen delivery,
decreased Cardiac output and blood pressure falls.

• In response, the sympathetic nervous system releases

catecholamines, resulting in an increase in peripheral
resistance (vasoconstriction) and an increase in pulse rate.

• Peripheral vasoconstriction further decreases cardiac

output.
• Increased blood viscosity due to fluid loss.

• Prompt fluid resuscitation maintains the blood

pressure in the low-normal range and improves
cardiac output.
• Complications include hypovolemic shock,
arrhythmias and cardiac arrest.
4. RESPIRATORY SYSTEM
• During a burn injury a patient may sustain inhalation injury, one
third of burns patient have pulmonary problem related to burn
injury.
• Even without pulmonary injury hypoxia may be present in early burn
period.
• Catecholamine release in response to the stress of the burn injury
alters peripheral blood flow, thereby reducing oxygen delivery to the
periphery. Later, hypermetabolism and continued catecholamine
release lead to increased tissue oxygen consumption, which can lead
to hypoxia.
• Pulmonary injuries fall into two main categories;

I. Upper airway burns causing oedema formation

II. Inhalation injury.

• Thermal burns to the head and neck can occlude
the airway by oedema formation compressing the
trachea.
• Circumferential burns of the thorax prevent lung
expansion
Indicators of possible pulmonary damage include the following:

 History indicating that the burn occurred in an enclosed area

 Burns of the face or neck.

 Hoarseness, voice change, dry cough, stridor, sooty sputum

 Bloody sputum

 Labored breathing or tachypnea (rapid breathing) and other

 signs of reduced oxygen levels (hypoxemia)

 Erythema and blistering of the oral or pharyngeal mucosa

5. RENAL SYSTEM
• Hypovolamic state, blood flow to the kidneys is decreased causing
renal ischemia. If this continues acute renal failure may develop.
• Destruction of red blood cells at the injury site results in free
hemoglobin in the urine
• With full thickness and electrical burns, myoglobin (from muscle cell
breakdown) is released into the blood stream and occludes renal
tubules.
• Adequate fluid volume replacement restores renal blood flow,
increasing the glomerular filtration rate and urine volume.
• Adequate fluid replacement and diuretics can counteract myoglobin
and haemoglobin obstruction of the tubules
6. IMMUNOLOGIC SYSTEM.
• The immunologic defenses of the body are greatly altered by burn injury.

Serious burn injury diminishes resistance to infection.

• The loss of skin integrity is compounded by the release of abnormal

inflammatory factors, altered levels of immunoglobulins and serum

complement, impaired neutrophil function, and a reduction in lymphocytes

(lymphocytopenia).

• Research suggests that burn injury results in loss of T-helper cell lymphocytes

and there is impairment of the production and release of granulocytes and

macrophages from bone marrow after burn injury.

• Hence immunosuppression of burn patient and high risk for sepsis.

7. GASTRO INTESTINAL SYSTEM.

• Two potential gastrointestinal complications may occur:

paralytic ileus (absence of intestinal peristalsis) and

Curling’s ulcer.

• Decreased peristalsis and bowel sounds are manifestations

of paralytic ileus resulting from burn trauma.

• Gastric distention and nausea may lead to vomiting unless

gastric decompression is initiated.

• Gastric bleeding secondary to massive physiologic

stress may be signaled by occult blood in the stool,

regurgitation of “coffee ground” material from the

stomach, or bloody vomitus.

• These signs suggest gastric or duodenal erosion

(Curling’s ulcer).
8. THERMO REGULATION.

• Loss of skin also results in an inability to regulate

body temperature. Burn patients may therefore
exhibit low body temperatures in the early hours
after injury.
• Then, hyper metabolism resets core temperatures,
burn patients become hyperthermic for much of the
post burn period, even in the absence of infection.
END
Assignment.
Mr KJ, 34 yr old is admitted in burns unit with 30%, 3rd degree burns. He is scheduled for
debridement and there after grafting in theatre.

A.

I. Define debridement

II. Describe types of wound debridement

III. Describe importance of wound debridement.

IV. Nurses role post debridement.

B.

V. Define grafting

VI. Types of grafts

VII. Describe importance of grafing.

VIII.Nurses role in care of graft.

Mechanism of burns;

Thermal injuries

• Scalds—About 70% of burns in children are caused by scald. The

common mechanisms are spilling hot drinks or liquids.

• Flame—Flame burns comprise 50% of adult burns. They are often

associated with inhalational injury. Flame burns tend to be deep
dermal or full thickness.

• Contact—direct contact with object extremely hot, these types of

burns are commonly seen in people with epilepsy or those who
misuse alcohol or drugs.
• Electrical injuries

Some 3-4% of burn unit admissions are caused by

electrocution injuries.
An electric current will travel through the body from
one point to another, creating “entry” and “exit”
points.

The injury can range from small to extensive injuries

with alteration of cardiac rhythm.
• Chemical injuries

Chemical injuries are usually as a result of industrial

accidents but may occur with household chemical
products.

These burns tend to be deep, as the corrosive agent

continues to cause coagulative necrosis until
completely removed.

Alkalis tend to penetrate deeper and cause worse burns

than acids. Cement is a common cause of alkali burns.
Major burns Moderate Minor burns
burns
Burn surface involvement Burn area of 15-25% body <15% body surface area.
of >25% body surface area. surface area. Nothing involving the head,
Full-thickness burns 10% Superficial partial-thickness feet, hands
body surface area. burns of the head, hands, or perineum.
Deep burns of the head, feet or perineum.
hands, feet, and perineum. Suspected child abuse.
Inhalation injury. Concomitant trauma.
Chemical or high-voltage Significant pre-existing
electrical burn. disease.
END
CARE OF PATIENTS WITH

BURNS
CARE OF PATIENTS WITH BURNS.
• Burn care must be planned according to the burn
depth and local response, the extent of the injury,
and the presence of a systemic response.
• Burn care then proceeds through three phases:

i. Emergent/resuscitative phase
ii. Acute/intermediate phase.

iii. Rehabilitation phase.

CRITERIA FOR ADMISSION
• Extent of burns : >10%(children) adult >15% TBSA
• Pay special attention to the following :
– hands and feet
– face and neck
– perineum
– joints
• other associated injuries
– inhalational burns
– chemical burns and electric burns
– other known pre existing diseases e.g. diabetes
– circumferential burns
– extremities of age i.e. <4yrs->50yrs
– patients with high morbidities e.g. HIV
Major goals
• Prevention.
• Institution of life saving measures of severely
burned
• Prevention of disability and disfigurement and
rehabilitation
 Phases of burn care
PHASE DURATION
Emergent or resustative From onset of injury to
completion of fluid
resuscitation
Acute From beginning of diuresis to
near completion of wound
closure
Rehabilitation From major wound closure to
return to individuals optimal
level of physical and
psychosocial adjustment
PRIORITIES
First aid, prevention of shock,
prevention of respiratory
distress, detection and
treatment of concomitant
injuries, wound assessment
and initial care
Wound care and closure
Prevention or treatment of
complications including
infection, nutritional support
Prevention of scars and
contractures, physical
occupational and vocational
rehabitation, functional and
cosmetic reconstruction,
psychosocial counselling
EMERGENT AND RECUSCITATIVE
PHASE
PRE HOSPITAL CARE (first aid)
1. Extinguish the flames, Roll the victim to extinguish flames and use cold water, if
electrical burn disconnect the source.

2. Cool the burn; Do not remove charred clothing soak them and cool burnt area with
cold water. Cooling the injured area (if small) within 1min minimises the depth of
injury. If large, not advisable to immerse the burned body part in cool water due to
heat and electrolyte loss.

3. Remove restrictive objects if possible e.g. jewellery.

4. Cover burnt areas with clean material, to reduce contamination, do not apply creams.

5. Irrigate chemical burns, with water.

• If the burn is large, primary consideration is focused on the ABC, organise and
transport patient to the nearest hospital.
HOSPITAL CARE;Assessment
• Review the initial assessment data obtained by pre hospital
providers. Further assess the 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

• Focus on the major priorities of burn trauma patient. ACB (also

cervical spine immobilization and cardiac monitoring ) disability,
exposure and fluid resuscitation.

• The burn wound is a secondary consideration although aseptic

management of burn wounds is continued
Ass ctd;
• Assess respiratory status as first priority(airway patency
and breathing adequacy)
• Note any increased hoarseness, stridor, abnormal
respiratory rate and depth or mental changes from
hypoxia
• Evaluate circulation (apical, carotid any femoral pulses)
start cardiac monitoring if indicated e.g. electrical injury,
history of cardiac or respiratory problems or dysrthmia
Ass ctd;
• Check vital signs frequently
• Check peripheral pulses on burned extremities hourly

• Monitor fluid intake (iv fluids) and output (urinary

catheter) and measure hourly. Assess urine specific
gravity, PH, protein and haemoglobin.
• Note amount of urine obtained when catheter is
inserted (indicates pre-burn renal function and fluid
status).
Ass ctd;
• Arrange for patients with facial burns to be assessed for corneal injury

• Assess body temperature, body weight, history of pre burn weight, allergies,

tetanus immunization, past medical surgical problems, current illnesses and

use of medication

• Assess depth of wound, and identify areas of full and partial thickness injury

• Assess neurological status i.e. consciousness, psychological status, pain and

anxiety levels and behaviour.

• Assess patients and families understanding of injury and treatment. Assess

patients support system and coping skills

DIAGNOSIS
Nursing diagnosis
• Impaired gas exchange related to CO poisoning, smoke inhalation and upper

airway obstruction as manifested by difficult in breathing, laboured

breathing.

• Ineffective airway clearance related oedema and effects of smoke inhalation

as manifested by dyspnoea

• Fluid volume deficit related to increased capillary permeability and

evaporative fluid loss from burn wound

• Hypothermia related to loss of skin micro circulation and open wounds

• Pain related to tissue and nerve injury and emotional impact of injury

• Anxiety related to fear and emotional impact of injury

Planning and goals
Major goals for the emergent and rescustative phase
include
• Patent airway and tissue oxygenation
• Optimal fluid and electrolyte balance and perfusion of
vital organs
• Adequate body temperature
• Minimal pain and anxiety
• Absence of complications
NURSING INTERVENTIONS
1. Promoting gas exchange and airway
clearance.
• Provide humidified oxygen and monitor arterial blood gases, pulse oximetry and
carboxy-haemoglobin levels

• Assess breath sounds, respiratory rate, rhythm, depth and symmetry; monitor
for hypoxia

• Observe for signs of inhalation injury, blistering of lips or buccal mucosa, burns
of the face neck or chest, increase hoarseness or sooty in the sputum or
respiration secretions

• Report laboured respiratory, decrease depth of respiration or signs of hypoxia to

sergeon immediately prepare to assist with intubation and escharotomies

• Monitor mechanically ventilated patient closely

Ctied;
• Institute aggressive pulmonary care measures, turning,
coughing, deep breathing, periodic forceful inspiration
using spirometry and tracheal suctioning.
• Maintain proper positioning to promote removal of
secretions and patent airway and promote optimal chest
expansion, use airway as needed.
• Maintain aseptic technique to prevent contamination of
respiratory tract and infection which increases metabolic
requirements.
2. Restoring fluid and electrolyte balance
• Insert large- bore iv line and an indwelling urinary
catheter
• Monitor vital signs and urinary output (hourly), central
venous pressure, pulmonary artery pressure and cardiac
output. Note and report signs of hypovolemia or fluid
overload
• Provide iv fluids as prescribed and titrate with urinary
output. Document intake and output and daily weight
Fluid replacement therapy
• Fluid is administered to all patients with burns of 15%
or more in adults and 10% or more in children.
Has guidelines and formulas for fluid replacement in burn
patient
Fluid used is Ringer's lactate or 0.9% saline.
1. Parkland/ Baxter formula- 4×kg body weight× % TBSA
burned.
day1: half to be given in first 8hrs
half to be given over next 16 hours
DAY TWO; Approximately half of the first day's fluid is given
in the next 24 hours
Colloids is added (colloids- blood dextran, plasma (in burns
>30% app 250ml of plasma required for each 20%)

The first 24 hours means since time of burn not since

admission
• Elevate head of bed and burned extremities
• Monitor serum electrolyte levels
• Recognise developing electrolyte imbalances
• Monitor urine output, minimum 1ml/kg/hr..
3. Maintaining normal body temperature

1. Provide a warm environment through use of heat shield,

space blanket, heat lights or blankets.
2. Work quickly when wounds must be exposed.
3. Assess core body temperature frequently.
4. Minimize pain and anxiety
1. Use pain intensity scale to assess pain level (i.e., 1 to 10).
Differentiate from hypoxia.

2. Administer analgesics and assess response.

3. Provide emotional support and reassurance.

4. Assess patient and family understanding of burn injury coping

strategies, family dynamics and anxiety levels

5. Provide pain relief and anxiolytics if the patient remains highly

anxious and agitated after psychological interventions
5. Monitor and managing potential
complications
Acute Respiratory Failure

1. Assess for increasing dyspnoea, stridor, changes in respiratory patterns.

2. Monitor pulse oximetry, arterial blood gas values for decreasing PO2 and

oxygen saturation, and increasing PCO2.

3. Monitor chest x-ray results.

4. Assess for restlessness, confusion, difficulty attending to questions, or

decreasing level of consciousness.

5. Report deteriorating respiratory status immediately to doctor.

6. Prepare to assist with intubation or escharotomies as indicated.

Mm ctied

Distributive Shock

1. Assess for decreasing urine output, pulmonary

artery pressure and and cardiac output, or
increasing pulse.
2. Assess for progressive oedema as fluid shifts occur.

3. Adjust fluid resuscitation in collaboration with the

doctor in response to physiologic findings.
Mm ctied
Acute Renal Failure

1. Monitor urine output and blood urea nitrogen

(BUN) and creatinine levels.

2. Report decreased urine output or increased BUN

and creatinine values to doctor.

3. Assess urine for haemoglobin or myoglobin.

4. Administer increased fluids as prescribed.
Mm ctied

1. Assess neurovascular status hourly (warmth, capillary

refill, sensation, and movement of extremity).

2. Compare affected with unaffected extremity.

3. Elevate burned extremities.

4. Report loss of pulse or sensation or presence of pain

to physician immediately.

5. Prepare to assist with escharotomies

Mm ctied

Paralytic Ileus

1. Maintain nasogastric tube on low intermittent

suction until bowel sounds resume.

2. Auscultate for bowel sounds, abdominal

distension.
Mmm ctied
Curling’s Ulcer

1. Assess gastric aspirate for pH and blood.

2. Assess stools for occult blood.

3. Administer histamine blockers and antacids as
prescribed
END
ACUTE AND INTERMEDIATE
PHASE
• It Begins 48-72 hours after burn injury. Burn wound
care and pain control are priorities at this stage
Assessment
• Focus on hemodynamic alterations, wound healing, pain and
psychosocial responses, and early detection of complications.

• Take vital signs frequently; respiratory and fluid status are highest
priority.

• Assess peripheral pulses frequently for the first few days after the
burn for restricted blood flow.

• Observe electrocardiogram for dysrrhythmias resulting from

potassium imbalance, pre existing cardiac disease or effects of
electrical injury or burn shock.
• Assess residual gastric volumes and pH in the
patient with a nasogastric tube (for clues to early
sepsis or need for antacid therapy
• Blood in the gastric fluid or the stools must also be
noted and reported.
Asss ctied

Assess wound for size, colour, odour, eschar, exudate,

abscess formation under the eschar, epithelial buds
(small pearl-like clusters of cells on the wound surface),
bleeding, granulation tissue appearance, status of
grafts and donor sites, and quality of surrounding skin.
Any significant changes in the wound are reported to
the physician
Assess ctied;
• focus on pain and psychosocial responses, daily
body weights, caloric intake, general hydration, and
serum electrolyte, haemoglobin, and hematocrit
levels
• Assess for excessive bleeding from blood vessels
adjacent to areas of surgical exploration and
debridement
Nursing diagnosis
• Excessive fluid volume related to resumption of capillary integrity
and fluid shift from the interstitial to intravascular compartment

• Risk for infection related to loss of skin barrier and impaired immune
response

• Imbalanced nutrition, less than body requirements, related to hyper

metabolism and wound healing needs

• Impaired skin integrity related to open burn wounds

• Acute pain related to exposed nerves, wound healing, and

treatments
Nursing dx ctied;
• Impaired physical mobility related to burn wound
oedema, pain, and joint contractures

• Ineffective coping related to fear and anxiety, grieving,

and forced dependence on health care providers

• Interrupted family processes related to burn injury

•Deficient knowledge about the course of burn

treatment.
Planning goals
Major goals:

• Restoration of normal fluid balance

• absence of infection

• Attainment of anabolic state and normal weight

• Improved skin integrity

• Reduction of pain and discomfort

• Optimal physical mobility

• Adequate patient and family coping,

• Adequate patient and family knowledge of burn treatment

• Absence of complications
NURSING INTERVENTIONS
1. Restoring fluid balance

• Monitor IV and oral fluid in take, using IV infusion

pumps or rate controllers
• Measure intake and output and daily weight
• Report changes in hemodynamic (pulmonary
arterial, CVP(central venous pressure) BP, pulse rate
and urine output(less than 30ml/h).
2. Preventing infection
• Provide a clean and safe environment; protect patient from sources of
cross- contamination e.g. visitors, other patients, staff and equipment

• Caution the patient against touching the wound or dressings, bathe

unburned areas and change linen regularly

• Practise aseptic technique for wound care and invasive procedures

• Closely scrutinize wound to detect early signs of infection

• Monitor culture results and wbc counts

• Administer antibiotics: topical: silver sulfadiazine, mafenide(sulfamylon),

silver nitrate; systemic: penicillin, erythromycin, gentamycin, amikacin
3. Maintaining adequate nutrition
• Oral fluids should be initiated slowly when bowel sounds resume

• collaborate with the dietician or nutrition support team to plan a

protein- and calorie-rich diet that is acceptable to the patient

• Family members may be encouraged to bring nutritious and favourite

foods

• Provide nutritional, vitamin and mineral supplements

• Document caloric intake. Insert feeding tube if caloric goals cannot be

met by oral feeding (for continuous or bolus feeding; note residual
volumes. Parenteral nutrition may be required
• Weigh patient daily and graph weights

• Encourage patient with anorexia to increase food

intake, provide pleasant surroundings at meantime,
cater for food preferences
• Offer a high protein, high vitamin snacks
4. Promoting skin integrity

• Assess wound status

• Support patient during distressing and painful wound care

• Coordinate complex aspects of wound care and dressing
changes

wound care

May be delayed until a patient airway and adequate

circulation
goals will be:
• Cleanse and debride the area of necrotic tissue
and debris that would promote bacterial growth
• Minimize further destruction to viable skin
• Promote client comfort

Cleansing and debridement is usually

accomplished in a bath tub
There two methods of wound treatment used to control infection:

1.Open method- clients burn is covered with a topical antibiotic(silver-sulpha

diazine) and has no dressing

2.Closed method- employs sterile gauze dressings impregnated with or laid over a

topical antibiotic

• These dressings are changed two to three times every 24 hours

• Administer TT routinely

• Assess and record any changes and progress in the wound healing, inform all

members of the health care team of progress in the wound or treatment

• Assess instruct, support and encourage patient and family to take part in

dressing changes and wound care

5. Relieving pain and discomfort
• Teach patient relaxation techniques, give some control over
wound care and analgesia, and provide frequent reassurance

• Use guided imagery to alter patient’s perceptions and

response to pain. Distraction through video programs or video
games, hypnosis, biofeedback, and behavioural modification.

• Administer minor anxiolytics and analgesic agents before pain

becomes too severe. Assess and document patients response
to medication. Assess frequently for pain and discomfort
• Work quickly to complete treatment and dressing
changes. Encourage patient to use analgesic
medications before painful procedures
• Promote comfort during healing phase, oral
antipruritic agents, a cool environment lubrication
of the skin , exercise and splinting to prevent skin
contractures and diversion activities
6. Promoting physical mobility
• prevent complications of immobility (atelectasis, pneumonia, oedema, pressure ulcers
and contractures) by deep breathing, turning and proper positioning.

• interventions are modified to meet the patient’s needs. Early sitting and ambulation
are encouraged. Whenever the lower extremities

• are burned, elastic pressure bandages should be applied before the patient is placed in
an upright position.

• Initiate passive and active range-of-motion exercises from admission until grafting
within prescribed limitations

• Splints or functional devices may be applied to extremities

• for contracture control. Monitor for signs of vascular insufficiency and nerve
compression.
7.Strengthening coping strategies
• Assist patient to develop effective coping strategies; set specific
expectations for behaviour, promote truthful communication to build
trust, help patient practise coping strategies and give positive
reinforcement when appropriate

• Demonstrate acceptance to the patient, enlist a non involved person

to vent feelings without fear of retaliation

• Include patient in decisions regarding care , encourage patient to

assert individuality and preferences set realistic expectations for self
care
 8. Supporting patient and family
processes
• Support and address patients and family's verbal and non
verbal concerns
• Instruct family in ways to support patient
• Make psychological or social work referrals as need
• Provide information about burn care and expected course of
treatment
• Initiate patient and family education during burn management
REHABILATATION
PHASE OF BURN
CARE
Rehabilitation
• Begins immediately after the burn has occurred—as early as
the emergent period and often extends for years after injury
• Wound healing, psychosocial support, and restoring
maximal functional activity remain priorities
• maintaining fluid and electrolyte balance and improving
nutritional status continues.
• Reconstructive surgery to improve body appearance and
function may be needed.
ASSESSMENT
• Information about the patient’s educational level,
occupation, leisure activities, cultural background,
religion, and family interactions is obtained
• Assess mental status, activity tolerance,
neuropathies(neurological damage)
NURSING DIAGNOSIS
• Activity intolerance related to pain on exercise,
limited joint mobility, muscle wasting, and limited
endurance

• Disturbed body image related to altered physical

appearance and self-concept

• Deficient knowledge about post discharge home

care and follow-up needs
Planning and goals
• increased participation in activities of daily living

• increased understanding of the injury, treatment,

and planned follow-up care
• adaptation and adjustment to alterations in body
image, self-concept, and lifestyle; and
• absence of complications eg contractures
NURSING INTERVENTIONS
Promoting activity tolerance
• Provide rest after changing dressings, exercises because
they are stressing to the burn patient
• Relieve their anxiety and fears related to outcome of
injury, administer hypnotics to promote sleep
• Relieve pain, prevent chilling or fever and promote
physical integrity of all body systems to help the patient
conserve energy for therapeutic activities and wound
healing
 Improving body image and self concept

• This include body disfigurement, loss of personal

property homes, loved ones and ability to work. The
nurse should allay fears from the client

• Encourage to join social groups, other burns

survivors

• Help patients build self esteem by recognising their

uniqueness
• Can see psychologist, social workers, vocational
counsellors etc to assist regain their self esteem

• Early and aggressive physical and occupational

therapy to avoid contractures.

• Surgical interventions indicated if a full range of

motion in the burn patient is not achieved
END
Thank you.