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NCM 106


Submitted to:
Prof. Teresa Dela Torre
Submitted by:
Reynaldo M. Vianzon Jr.

I. Description
A burn is a type of injury to the skin caused by heat, electricity, chemicals, light, radiation or friction. Most
burns only affect the skin (epidermal tissue and dermis). Rarely deeper tissues, such as muscle, bone,
and blood vessels can also be injured. Managing burns is important because they are common, painful and
can result in disfiguring and disabling scarring. Burns can be complicated by shock, infection, multiple
organ dysfunction syndrome, electrolyte imbalance and respiratory distress. Large burns can be fatal, but
modern treatments, developed in the last 60 years, have significantly improved the prognosis of such burns,
especially in children and young adults
The anatomy of the skin is complex, and there are many structures within the layers of the skin. There are
three layers:

Epidermis, the outer layer of the skin


Dermis, made up of collagen and elastic fibers and where nerves, blood vessels, sweat glands, and
hair follicles reside.
Hypodermis or subcutaneous tissue, where larger blood vessels and nerves are located. This is the
layer of tissue that is most important in temperature regulation.


The amount of damage that a burn can cause depends upon its location, its depth, and how much body
surface area that it involves.
II. Pathophysiology
Burns are caused by a transfer of energy from a heat source to the body. Heat may be transferred through
conduction or electromagnetic radiation. Burns are categorized as thermal (which includes electrical burns),
radiation, or chemical. Tissue destruction results from coagulation, protein denaturation, or ionization of
cellular contents. The skin and the mucosa of the upper airways are the sites of tissue destruction. Deep
tissues, including the viscera, can be damaged by electrical burns or through prolonged contact with a heat
source. Disruption of the skin can lead to increased fluid loss, infection, hypothermia, scarring,
compromised immunity, and changes in function, appearance, and body image. The depth of the injury
depends on the temperature of the burning agent and the duration of contact with the agent. For example, in
the case of scald burns in adults, 1 second of contact with hot tap water at 68.9C may result in a burn that
destroys both the epidermis and the dermis , causing a full thickness (third-degree) injury. Fifteen seconds
of exposure to hot water at 56.1 C results in a similar full-thickness injury. Temperatures less than 111F
are tolerated for long periods without injury.
Classification of Burns:
By degree

First-degree burns are usually limited to redness (erythema), a white plaque and minor pain at
the site of injury. These burns involve only the epidermis. Most sunburns can be included as firstdegree burns.
Second-degree burns manifest as erythema with superficial blistering of the skin, and can involve
more or less pain depending on the level of nerve involvement. Second-degree burns involve the
superficial (papillary) dermis and may also involve the deep (reticular) dermis layer. Deep dermal
burns usually take more than three weeks to heal and should be seen by a surgeon familiar with burn
care, because in some people very bad hypertrophic scarring can result. Burns that require more than
three weeks to heal are often excised and skin grafted for best result.
Third-degree burns occur when the epidermis is lost with damage to the subcutaneous tissue.
Burn victims will exhibit charring and extreme damage of the epidermis, and sometimes

hard eschar will be present. Third-degree burns result in scarring and victims will also exhibit the loss
of hair shafts and keratin. These burns may require grafting. These burns are not painful, as all the
nerves have been damaged by the burn and are not sending pain signals; however, all third-degree
burns are surrounded by first and second-degree burns.
Other classifications A newer classification of "Superficial Thickness", "Partial Thickness"
(which is divided into superficial and deep categories) and "Full Thickness" relates more precisely to
the epidermis, dermis and subcutaneous layers of skin and is used to guide treatment and predict

III. Signs & Symptoms

The symptoms of burns could be summed up in two parts. Minor and severe burns. Minor burns are painful
and cause reddening and blistering of the skin while severe burns are painless causes white or charred area.
First-degree burns are mild and injure only the outer layer of skin. The skin becomes red, but will turn
white when touched. The area may also be painful to the touch.
Second-degree burns are deeper, more severe, and very painful. Blisters may form on the burned area.
This type of burn takes about 2 weeks to heal.
Third-degree burns are the deepest and most serious kind. The skin becomes white and leathery, but it
does not feel very tender when touched.
Burns with a "sock" or "glove-like" appearance on hands or feet and "doughnut" shaped burns on the
buttocks. These types of burns are usually caused by either dipping or forcing the child to sit in scalding
Burns which leave a pattern outlining the object which was used to make the burn such as an iron, electric
burner, heater or fireplace tool; Burns caused by rope friction, usually found on legs, arms, neck or torso as
the result of having been tied up.
Significance of the amount of body area burned
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 area 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%)

As an example, if both legs (18% x 2 = 36%), the groin (1%) and the front chest and abdomen were burned,
this would involve 55% of the body.
IV. Nursing Management
Airway , Breathing and Circulation

Although the local effects of a burn are the most evident, the systemic effects pose a greater threat to life.
Therefore, it is important to remember the ABCs of all trauma care during the early postburn period:
Circulation; cervical spine immobilization for patients with high-voltage electrical injuries and if
indicated for other injuries; cardiac monitoring for patients with all electrical injuries for at least 24 hours
after cessation of dysrhythmia
The circulatory system must also be assessed quickly. Apical pulse and blood pressure are monitored
frequently. Tachycardia and slight hypotension are expected soon after the burn. The neurologic status is
assessed quickly in the patient with extensive burns. Often the burn patient is awake and alert initially, and
vital information can be obtained at that time. A secondary head-to-toe survey of the patient is carried out
to identify other potentially life-threatening injuries.
V. Medical Management
Management of fluid loss and shock
Next to handling respiratory difficulties, the most urgent need is preventing irreversible shock by replacing
lost fluids and electrolytes. As mentioned previously, survival of burn victims depends on adequate fluid
resuscitation. Table 57-3 summarizes the fluid and electrolyte changes in the emergent phase of burn care.
Intravenous lines and an indwelling catheter must be in place before implementing fluid resuscitation.
Baseline weight and laboratory test results are obtained as well. These parameters must be monitored
closely in the immediate post-burn (resuscitation) period. Controversy continues regarding the definition of
adequate resuscitation and the optimal fluid type for resuscitation. Refinement of resuscitation techniques
remains an active area of burn research.
Fluid Replacement Therapy.
The total volume and rate of intravenous fluid replacement are gauged by the patients response. The
adequacy of fluid resuscitation is determined by following urine output totals, an index of renal perfusion.
Output totals of 30 to 50 mL/hour have been used as goals. Other indicators of adequate fluid replacement
are a systolic blood pressure exceeding 100 mm Hg and/or a pulse rate less than 110/minute.