BURNS - It take longer to heal and more likely to result in hypertrophic

scars.
 Are causes by a transfer of energy from a heat source to the body.  Full thickness-burn
 Heat destruction of the skin layers with resultant depletion of fluids - involves total destruction of epidermis and dermis and in some
and electrolytes. cases, underlying tissue as well
- wound color ranges widely from whit to red, brown, or black.
- The burn area is painless because nerve fibers are destroyed
PATHOPHYSIOLOGY: - Wound appears lethargy; hair follicles and sweat glands are
The skin and mucosa of the upper airways are the sites of tissue destroyed.
destruction. Deep tissues, including the viscera, can be damaged by
electrical burns or through prolonged contact with a heat source. EXTENT OF BODY SURFACE ARE INJURED
Disruption of the skin can lead to increase fluid loss, infection,
hypothermia, scarring, compromised immunity, and changes of function, • RULE OF NINES
appearance and body image. - is a quick way to calculate the extent of burns
The depth of the injury depends on the temperature of the burning - the system assigns percentages in multiples of nine to major
agent and the duration of contact with the agent. for example, in the case body surfaces.
of scald burns in adult, 1 second of contact with hot top water at 68.9 C • LUND AND BROWDER METHOD
(156 F) may result in a burn that destroys both epidermis and the dermis, - Recognizes that the percentage of the TBSA of various
causing full-thickness injury. anatomic parts, especially the head and the legs, and changes
with growth.
BURN SIZE - Divide the body into very small areas and providing an
estimate of the proportion of TBSA accounted for by such body
1. Major (Large) parts, one can be obtain a reliable estimate of the TBSA
• > 10% TBSA – child burned.
• > 25%TBSA – adult • PALM METHOD
2. Minor ( small) - a method is estimated the percentage of burn in the palm
• Localized effect ( inflammation) method
- the size of patient’s palm is approximately 1% of TBSA
TYPES • PARKLAND/BAXTER FOMULA
- 4ml x wt. in kg x body surface area
1. Thermal
2. chemical BURN LOCATION
3. radiation
4. electrical  Head, neck, chest – pulmonary complications
 Face – corneal abrasions
BURN DEPTH  Ear – articular chondritis
 Hand and joints – intensive therapy to prevent disability
 superficial partial thickness-burn  Perineal area – prone to avoid contamination
-The epidermis is destroy or injured and a portion of the dermis  Circumferential burn – compartment syndrome
may be injured.
- The damage skin may be painful and appear red and dry, as in s MANAGEMENT
unburn, or it may be blister.
EMERGENT/ RESUSCITATIVE PHASE
 Deep partial thickness-burn  Airway, breathing, circulation
- Involves the destruction of the epidermis and upper layes of  Emergency medical management:
the dermis and injury to deeper portion of the dermis. o Mild pulmonary injury- inspired air is humidified and encourage
- The wound is painful, appears red, and exudes fluid. to cough
- Capillary refill follows tissue blanching o Edema of the airway- endotracheal intubations
- Hair follicles remain intact
o A large-bore (16 or 18 gauge) intravenous catheter should be
inserted in a non-burned area
o Most patients have central venous catheter inserted so that
the large amounts of IV fluids can be given quickly and central
venous pressure can be monitored.
o If the burn exceeds 25% TBSA or if the patient is nauseated, a
nasogastric tube should be inserted an connected to suction to
prevent vomiting due to paralytic ileus (absence of peristalsis)
o Fluids loss and shock- IV lines and indwelling catheter are
place before implementing fluids resuscitation.
o Fluids replacement therapy- 30-5-mL/hour have been used
as goals.
 Nursing management:
o Provide humidified oxygen
o Assess breath sounds and respiratory rte, rhythm,
depth and symmetry, monitor patient for sign of
hypoxia
o Monitor ABG values, pulse oxymetry readings, and
carboxyhemoglobin levels.
o Report labored respirations
o Prepare to assist with intubations and escharotomies
o Monitor mechanical ventilated patient closely.
ACUTE OR INTERMEDIATE PHASE
 Begins 48-72 hours after the bun injury
 Prevent infection
 Wound healing: hydrotherapy in form of shower carts
: 20-30 minutes period to prevent
chilling of the patient and
additional metabolic stress.
 Topical antibacterial therapy:
• Silver sulfadiazine (silvadene)
• Silver nitrate
• Mafenine acetate (sulfamylon)
 Wound debridement Natural debridement – the dead
tissue separates from the underlying viable tissue
spontaneously
 Mechanical debridement – involves using surgical scissors
and forceps to separate and remove the eschar.
- course- mesh dressing applied dry or
wet-to-dry.
 Surgical debridement – early surgical excision to remove
devitalized tissue along with early burn wound closure.
 Biologic dressing:
Homo grafts- are skin obtain from living or recently decreased
humans.
Hetero grafts- consist of skin taken from animals
Pain management
 3 Types:
• Background or resting pain – pain that exist on a 24-hour
basis.
• Procedural pain – pain cause by procedures such as burn wound
care or range of motion exercises
• Breakthrough pain – pain occurs when blood levels of analgesics
agents fall below the level required to control background pain.
 Opioid administration via the IV route, particularly in the emergent
and acute phases of burn management.
 Titrating analgesics agents to obain pain relief while minimizing side
effects is crucial.
 Morphine sulfate remains the analgesic of choice for treatment of
acute burn pain.
 Fentanyl is another useful opioid for burn pain, particularly procedural
burn pain.
Nutritional support
• Provide adequate nutrition
• Calories to decrease catabolism
• Optimized protein intake can decrease protein losses
• Vitamins and minerals
Disorder of wound healing
Scars- most devastating sequelae of a burn injury is the formation of
hypertrophic scars
keloids- a large, heaped-up mass of scar tissue, likely to recur after
surgical excision
failure to heal- factors including infection and adequate
nutrition.
Contractures- the burn wound tissue shortens because of the force
exerted by the firoblasta and the flexion Of muscle in natural wound
healing.
ASSESSMENT:
• Assess respiratory and fluids status
• Monitor v/s
• Observe for cardiac dysrhythmias resulting from potassium imbalance
• assess for excessive bleeding from blood vessels
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 (1st degree Burn)
response - The epidermis is destroyed or injured and a portion of the
• imbalance nutrition, less than body requirement, related to dermis is destroyed. The damaged skin may appear painful
hypermetabolism and wound healing needs and red, dry or may have blisters.
• acute pain related to exposed nerve, wound healing and treatments - Sunburns, Low-intensity flash
• impaired physical mobility related to burn wound edema, pain and
joint contractures. 2. Deep partial-Thickness Burn
(2nd degree Burn)
PLANNING and GOALS: - Involves the destruction of the epidermis and the upper layers
• restoration of normal fluid balance of the dermis injury to the deeper portions of the dermis. The
• absence of infection wound is painful, appears red and exudes fluid. Capillary refill
• attainment of anabolic state and normal weight follows tissue blanching. Hair follicle remains intact. Deep
• improved skin integrity partial-thickness burns take longer to heal and are more likely
• reduction of pain and discomfort to result in hypertrophic scars.
• optimal physical mobility - Scalds, flash flame contact

REHABILITATION PHASE: 3. Full Thickness Burn

(3rd degree burn)
ASSESSMENT: - Involves total destructions of the epidermis and dermis layers
Physical assessment related to rehabilitation goals include: and in some cases, destruction of underlying tissues. Wound
o ROM of affected joints color varies widely from red, white, black and brown. The
o Early signs of skin breakdown from splints or poisoning devices burned area is painless due to the destruction of nerve
o Activity tolerance quality or condition of healing skin. endings. The wound appears leathery: hair follicle and sweat
glands are destroyed.
DIAGNOSIS: - Flames, Prolonged exposure to hot liquids, Electrical current,
o Activity intolerance related to pain exercise, limited joint mobility, Chemical contact
muscle wasting, and limited endurance.
Extent of Body surface injured
o Disturbed body image rlated to altered physical appearance and self-
concept
1. The Rule of Nines
o Deficient knowledge about post discharge home care and follow-up
- The system assigns percentages in multiples of nine to major
needs. body surfaces.
PLANNING and GOALS: 2. Lund and Browder Method
The major goals for the patient include increase participation in activities - Which recognizes the percentage of surface area of various
of daily living; increase understanding of the injury, treatment, and follow- anatomic parts, especially the head and legs, changes with
up care; adaptation and adjustment to alterations in body image, self
growth.. Because changes in body proportions with growth,
concept, and lifestyle; and absence of complications. the calculated TBS changes with age as well. By dividing the
body into very small parts and providing an estimate of the
NURSING INTERVENTIONS: proportion of TBSA accounted for by each body part, one can
o Promoting activity tolerance
obtain reliable estimate of TBSA burned. The initial evaluation
o Improving body image and self concept is made on arrival of the patient at the hospital and is revised
o Monitoring and managing potential complication on the second and third post burn days, because the
demarcation is not clear until then.
Burns
3. Palm Method
Classifications - The size of the patient’s palm is approximately 1% of the
TBSA.
1. Superficial Partial-Thickness Burn
 Phases of Burn
I. Emergent / Resuscitative
- From onset of injury to completion of fluid resuscitation.
- Priorities: First aid, Prevention of shock, Prevention of
respiratory distress, Detection of concomitant injury, Wound
assessment and initial care.
II. Acute / Intermediate
- from beginning of diuresis to near completion of wound closure
- Priorities: Wound care and closure, Prevention or treatment of
complications (infections), Nutritional support.
III. Rehabilitation
- From major wound closure to return to individual’s optimal
level of physical and psychosocial adjustment.
- Priorities: Prevention of scars and contractures, Physical,
occupational, and vocational rehabilitation, Functional and
cosmetic reconstruction, Psychosocial counseling.
Emergency Procedures at the Burn Scene
• Extinguish flames
• Cool the burn
• Remove restrictive objects
• Cover the wound
• Irrigate the chemical burns
Classifications of Extent of Burn injury
 Minor Burn Injury
- Second degree burn of <15% TBSA in adults or <10 % in
children
- Third degree burn of <2% TBSA not involving special care
areas (ears, eyes, face, hands, feet, perineum and joints)
- Excludes all patients with electrical injury, inhalation injury, or
concurrent trauma and all poor-risk patients (eg: extremes of
age, intercurrent disease)
 Moderate, Uncomplicated Burn Injury
- Second degree burns of 15-25% TBSA adults or 10-20% in
children.
- Third degree burns of <10% TBSA not involving special care
areas
- Excludes electrical injury, inhalation injury and all poor-risk
patients.
 Major Burn Injury
- Second degree burns >25% TBSA in adults or >20% in
children
- All third degree burns involving eyes, ears, face, hands, feet,
perineum and joints.
- All inhalation injuries, electrical injury, or concurrent trauma,
and all poor-risk patients.
Wound Cleaning
General Principles of Wound Care
1. Cardiopulmonary monitoring should continue during burn care. The
addition of medications for wound care itself can only lead to a potential
for further instability.
2. Invasive catheters, such as vascular and urethral, must not become wet
at the skin site or be submerged in water. These catheters are at high risk
for being a source of systemic infection.
3. The patient must not be allowed to have a significant heat loss.
Overhead heaters, warm water, and the Sequential management of the
wounds, rather than total patient exposure, are methods to avoid heat
loss.
4. The risks of bacterial cross-contamination must be controlled. Risks
related to transmission from personnel are minimized by the wearing of
caps, mask, gloves, and a gown. Transmission from a dirty wound to a
clean wound can be minimized by exposing and cleaning these areas
separately. Preferably, the less infected areas should be done first and
closed before approaching dirtier areas.
5. Principle is that adequate stress management, analgesia and sedation,
should be initiated before initiation of burn care. It is much easier to
control pain and anxiety by pretreatment than it is to treat once it
develops. Antipyretics given before burn care attenuate the fever seen
after wound manipulation. Pretreatment of the dressing change with an
antipyretic such as Ibuprofen, is indicated in patients who demonstrate a
marked temperature spike, i.e., >103ºF after wound care.
6. Principle is that motion should not be impaired (exception: a new graft).
The patient needs to maintain joint motion and muscle activity to avoid
stiffness and atrophy.
Wound Dressing
-Use comfortable but no immobilizing
dressing as muscle activity is important!

Managing the Dressing

Areas Covered with Grease Gauze
1. Inspect daily.
2. If gauze adherent and no exudates,
simply change outer dry gauze.
3. Change dressing, wash surface and
reapply if exudates present.
4. Use topical antibiotic if infection
Considered.

Topical Antibacterial Therapy

Criteria are:

 They are effective against gram-negative organisms and even

fungi.
 They are clinically effective
 They penetrate the eschar but are not systemically toxic.
 They do not lose their effectiveness, allowing another infection to
develop.
 They are cost effective, available and acceptable to the patient
 They are easy to apply and remove, minimizing nursing care time.

Commonly used TAB agents:

 Silver Sulfadiazine (Silvadene), Silver Nitrate, Mafenide Acetate

( Sulfamylon)
 Povidone Iodine 10% (Betadine), Gentamycin Sulfate,
Nitrofurazone ( Furacin)
 Darkin’s solution, Acetic acid, Miconazole and Clotrimazole