I.

Burns are form of traumatic injury caused by thermal, electrical, chemical, or

radioactive agents.

II. A. Types of Burns

Thermal burns. Burns due to external heat sources that raise the temperature of the
skin and tissues and cause tissue cell death or charring. Hot metals, scalding liquids,
steam, and flames, when coming in contact with the skin, can cause thermal burns.
Radiation burns. Burns caused by prolonged exposure to ultraviolet rays of the sun,
or to other sources of radiation such as X-ray.
Chemical burns. Burns caused by strong acids, alkalies, detergents, or solvents
coming into contact with the skin and/or eyes.
Electrical burns. Burns from electrical current, either alternating current (AC) or direct
current (DC).

B. Classification of Burns
First-degree (superficial) burns
First-degree burns affect only the epidermis, or outer layer of skin. The burn site is
red, painful, dry, and with no blisters. Mild sunburn is an example. Long-term tissue
damage is rare and usually consists of an increase or decrease in the skin color. (Ex.
Sunburn, Low-intensity flash)
Second-degree (partial thickness) burns
Second-degree burns involve the epidermis and part of the dermis layer of skin. The
burn site appears red, blistered, and may be swollen and painful. (Ex. Scalds, Flash
flame, Contact)
Third-degree (full thickness) burns
Third-degree burns destroy the epidermis and dermis and may go into the
subcutaneous tissue. The burn site may appear white or charred. (Ex. Flame,
prolonged exposure to hot liquids, electric current, chemical, contact).
Fourth degree burns. Fourth degree burns also damage the underlying bones,
muscles, and tendons. There is no sensation in the area since the nerve endings are
destroyed
C. Phases of Burns
Emergent/resuscitative - from onset of injury to completion of uid resuscitation.
Acute/intermediate - 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.
III. ASSESSMENT

ACUTE OR INTERMEDIATE PHASE:

Focus on hemodynamic alterations, wound healing, pain and psychosocial
responses, and early detection of complications.
Measure vital signs frequently. Respiratory and fluid status remains highest
priority.
Assess peripheral pulses frequently for first few days after the burn for restricted
blood flow.
Closely observe hourly fluid intake and urinary output, as well as blood
pressure and cardiac rhythm; changes should be reported to the burn surgeon
promptly.
For patient with inhalation injury, regularly monitor level of consciousness,
pulmonary function, and ability to ventilate; if patient is intubated and placed on a
ventilator, frequent suctioning and assessment of the airway are priorities.
REHABILITATION PHASE:
In early assessment, obtain information about patients educational level,
occupation, leisure activities, cultural background, religion, and family interactions.
Assess self-concept, mental status, emotional response to the injury and
hospitalization, level of intellectual functioning, previous hospitalizations, response
to pain and pain relief measures, and sleep pattern.
Perform ongoing assessments relative to rehabilitation goals, including range of
motion of affected joints, functional abilities in ADLs, early signs of skin
breakdown from splints or positioning devices, evidence of neuropathies
(neurologic damage), activity tolerance, and quality or condition of healing skin.
Document participation and self-care abilities in ambulation, eating, wound
cleaning, and applying pressure wraps.
Maintain comprehensive and continuous assessment for early detection of
complications, with specific assessments as needed for specific treatments, such
as postoperative assessment of patient undergoing primary excision.
 IV. BURNS PATHOPHYSIOLOGY

Predisposing Factor Precipitating Factor

1. Age 20-30 years old 1. Electrical Engineer
2. Gender- Males 2. Exposure to electrical works

BURNS (TBSA of 72 %)

Chemical injury heat transfer

Histamine release

RR- 10 cpm Increased vascular permeability

edema Decreased intravascular

volume
Increased volume
Increased hematocrit
BP= 60/
40
Facial Increased viscosity mmHg
redness PR= 58
Evident bpm
swelling
Burn Shock

Precipitating
Factor
Acute respiratory failure
Predisposing Distributive Shock
Factor Acute kidney injury
Compartment syndrome
Signs & Paralytic ileus
Symptoms Curlings ulcer
LEGENDS:

Disease
Process

Complications
 V. NURSING DIAGNOSIS and COLLABORATIVE INTERVENTIONS
Emergent Phase of Burn Care:
1 . Impaired Gas Exchange related to upper airway obstruction
- Provide 1oo% humidified oxygen
- Assess breath sounds and respiratory rate, rhythm, depth and symmetry of chest
expansion
- Monitor arterial blood gas values, pulse oximetry readings

2. Ineffective airway clearance related to edema

- maintain patent airway through proper patient positioning, removal of secretions,
and artificial airway if needed
- provide 100% humidified oxygen
- encourage patient to turn, cough and deep breath
- encourage patient to use incentive spirometry and suction as needed

3. Deficient fluid volume related to increased capillary permeability and

evaporative losses from burned wound
- monitor vital signs, hemodynamics and urine output as well as strict intake and
output and daily weight
- maintain IV lines
- elevate patients head of bed and elevate burned extremities

4. Hypothermia related to loss of skin microcirculation and open wounds

- Assess core body temperature frequently
- Provide a warm environment by increasing room temperature or adjunct
therapies as needed
- Work quickly when wounds are to exposed

5. Risk for infection related to inadequate primary and secondary defenses

resulting from traumatized tissue, bacterial proliferation in burned wounds
- Administer tetanus prophylaxis per physicians order
- Use antimicrobial agents to deter the growth of bacteria on the surface of the
wound
- Maintain infection control techniques at all times to prevent cross-contamination
- Ensure aseptic technique when administering care to burned areas and
performing invasive techniques
- Enforce strict hand washing and instruct family members regarding infection
control measures
6. Impaired Physical Mobility related to tissue edema secondary to pain
- Encourage the client to participate in self care as tolerated
- Provide passive range of motion exercises at the earliest time possible
- Delay emergency department or room visits to motivate client to overcome fear
and dependence
- Assist patient to increase movement to help improve circulation and decrease
edema

7. Impaired Skin Integrity related to severe tissue injury

- Daily wound and skin care should be done aseptically throughout the duration of
hospitalization
- Clean burned areas, grafts and donor sites with mild soaps without fragrance and
water then rinse thoroughly
- Lubricate wound with non-irritating, alcohol free moisturizer at least three times a
day (3x/day)
- Regularly change wound dressings and note for any discharge

VI. MANAGEMENT OF BURN INJURY

A. NURSING MANAGEMENT
The ABCDEs of emergency burn care:
Airway maintenance with cervical spine protection
Breathing and ventilation
Circulation and cardiac status with hemorrhage control
Disability, neurologic deficit, and gross deformity
Exposure to Examine for major associated injuries and maintain warm
Environment

AIRWAY:
- Must always be the first priority
- It is also important to protect the cervical spine if there is obvious or suspected
traumatic injury.
 - Burn patients frequently become edematous because of the marked increase in
capillary permeability, which occurs as a response to burn injury. Edema is a
frequent culprit in compromising the airway of burn patients once emergency
medical services (EMS) has arrived, intubation will be required if airway is
compromised.

BREATHING & VENTILATION:

- Burns of the chest may restrict the expansion of the chest wall because of the
stiffening of the dermis in deep burns which can impact respirations.
- Inhalation of smoke impairs gas exchange (O2 and CO2) at the alveolar level.
Any patient with suspected smoke inhalation injury must be started on high-
flow oxygen (15L/min @ 100%) using a non-rebreather mask.

CIRCULATION & CARDIAC STATUS:

- Evaluate patients hemodynamic stability
- Edema can also impair peripheral circulation
- Assessment would include: HR, peripheral pulses, and skin color (of unburned
skin)
- Insert large-bore I.V. catheters for fluid administration to accommodate for the
shift of plasma into the interstitial tissue, which occurs as part of the physiologic
response to burn injury (fluid volume deficit is directly proportional to the extent
and depth of burn injury). Rationale: capillary permeability increases, permitting
fluid and protein to move from vascular to interstitial spaces (edema results) for
the first 24-36 hours, peaking at 12 hours post burn. Protein-rich fluid is lost in
blebs of burned tissues as well as by weeping of second degree wounds and
surface of the full thickness wounds. With reduced vascular volume, the patient
will go into shock if untreated)
- Continuous Cardiac Monitoring especially for electrical injury

DISABILITY:
- Refers to the neurologic deficit and gross deformity
- Trauma injury may result in deformities such as open fractures
- Neurologic assessment should be done right after assessment of traumatic injuries
(with exception of smoke inhalation, burns should not necessarily affect the level
of consciousness; if there is altered LOC, consider other problems such as head
trauma, carbon monoxide poisoning, hypoxia, preexisting medical conditions, or
substance abuse.
EXPOSURE TO EXAMINE FOR MAJOR ASSOCIATED INJURIES AND
MAINTAINING A WARM ENVIRONMENT:

- Remove any clothing or jewelry that is restrictive or covering the body part that
was burned
- Quickly look/scan for any other injuries that might be present and cover the patient
- Never use ice or cold water because it will restrict peripheral circulation locally,
increasing the depth of the burn, and it may decrease body temperature.
- It is imperative to prevent hypothermia in burn patients, as body temperature below
36.5 degrees Celsius in the first 24 hours are associated with increased mortality.
- Cover the patient with a clean, dry covering such as a sheet or blanket to prevent
evaporation of heat loss.
- Tetanus Prophylaxis is administered if the patients immunization status is not
current or is known (because burns are considered contaminated)

EARLY INTERVENTIONS should be done such as:

1. A patent airway is ensured
2. Adequate peripheral circulation is established in any burned extremity
3. A secure IV catheter is inserted with Lactated Ringers solution infusing @rate
required to maintain a urine output of @ least 30ml/hr
4. An indwelling urinary catheter is inserted
5. Adequate pain relief is attained - IV analgesia (usually morphine) is administered
because poor tissue perfusion accompanies burn injuries
6. Wounds are covered with a clean, dry sheet, and the patient is kept comfortably
warm.

TREATMENT

Management of the acute burn injury includes:

hemodynamic stabilization
metabolic support
wound debridement
use of topical antibacterial therapy
biologic dressings
 HEMODYNAMIC STABILIZATION
Immediate I.V Fluid Therapy is indicated for adults with burns involving more than 18%
to 20% of TBSA and patients with electrical injury. these patients require meticulous
monitoring
Goal: to give sufficient fluid to allow perfusion of the vital organs without overhydrating
the patient and risking later complications and circulatory overload.
Crystalloid (Ringers Lactate) solution is used initially.
Colloid is used during the 2nd day (5% albumin, plasmanate, hestarch)
Formula for determining amount of fluid to be given in the first 8 hours:
The Parkland Formula
The Brook and Evans Formula
Parkland Formula (First 24 hours): 4ml of Ringers lactate x weight in kg x %TBSA
burned
1. of the fluid is given in the first 8 hours, calculated from time of injury.
2. Remaining half of the fluid is given over the next 16 hours.
3. Second 24 hours: 0.5ml colloid x weight in kg x %TBSA + 2,000 ml dextrose
5% in water (D5W) run concurrently over the 24-hr period. (D5W yields 117ml
colloid/hr and 84ml D5W/hr)

METABOLIC SUPPORT
NPO status until bowel sounds return (1-2 days)
Small amounts (5-10ml/hr) of isotonic enteral tube feedings are typically started
within 24 hours to help maintain a functioning GI tract
Erythromycin may be given in small amount to encourage GI motility
Maintain warm environment to reduce metabolic stress
When bowel sounds return, administer oral fluids and DAT.
Offer more solid food after 2-3 days postburn
TPN may be given when caloric requirements cannot be met by enteral feedings

WOUND CLEANSING AND DEBRIDEMENT

- Daily or twice-daily wound cleansing with debridement or hydrotherapy
(tubing/showering) and dressing changes. use mild antibacterial cleansing
agent and saline solution or water
- Enzymatic agents applied to the burn wound may be used for more rapid
debridement of eschar.
Wound Debridement
- The goal of debridement (the removal of devitalized tissue) includes the ff:
 Removal of tissue contaminated by bacteria and foreign bodies
Removal of devilatlized tissue or burn eschar in preparation for grafting and
wound healing
3 types of wound debridement:
1. Natural Debridement- the dead tissue separates from the underlying
viable tissue spontaneously.
2. Mechanical Debridement- involves the use of surgical scissors, scalpels,
and forceps to separate and remove eschar.
3. Surgical Debridement- is an operative procedure. Surgical excision,
primary or tangential, all nonviable tissue is removed down to the viable
base, which is covered with biological dressing: heterograft, homograft, or
autograft.

HYDROTHERAPY
tubbing, tanking, or showering is bathing of the burn patient in tub water or with a
water shower to facilitate cleansing and debridement of the burned area.
Advantages: topical meds, adherent dressing, and eschar are removed easily; provides
opportunity for the patient to practice range-of-motions (ROM) exercises; total
assessment of the burn area is facilitated; total body cleansing can be achieved
Disadvantages: loss of body heat; loss of sodium; uncomfortable or painful at times for
the patient

B. MEDICAL MANAGEMENT

TOPICAL ANTIMICROBIALS:

Silver Sulfadiazide 1%
- exerts antimicrobial effects against gram negative and gram positive bacteria and
yeasts at level of cell membrane and cell wall
- most widely used agent
Mafenide acetate (10% cream or 5% solution)
- Active against most gram positive organisms, active against common gram
negative burn wound pathogens but has little antifungal activity
- good penetrating power and useful for control of established invasive burn and
wound infection.
Silver Nitrate (0.5% solution)
- Has significant antimicrobial effects against common pathogens
- Nonallergenic and not usually painful on application
 - Best used in prophylaxis against infection
Silver sheeting (Anticoat 4 or 7, Silverlon 7)
- Silver impregnated on a neutral backing
Mupirocin (Bactroban)
- Ointment
- Active against Methicillin-resistant Staphyloccocus aureus (MRSA)

C. SURGICAL MANAGEMENT
SKIN GRAFTING- is a type of graft surgery involving the transplantation of skin. The
transplanted tissue is called skin graft. It is often used to treat extensive wounding or
trauma, and burns.
- Under General Anesthesia
- A skin graft is a patch of skin that is removed by surgery from one area of the body
to another area
- Donor site can be anywhere in the body, most times it is an area that is hidden by
clothes, buttocks or inner thighs-
- The main areas for skin grafting include the face, functional areas, such as hands
and feet, and areas that involved the joints-
- Grafting permits early functional ability and reduce wound contracture
General Considerations:
1. early surgical interventions reduces the potential for wound infection and speeds
the course of facility care.
2. As a general consideration, up to 190ml of blood may be lost per 1% of burn
excised in the adult patient

BURN WOUND COVERINGS

BIOLOGICAL DRESSINGS
- Used to cover large surfaces of the body
Allograft is a graft of skin taken from a person other than the burn
victim and applied to a burn wound temporarily. Cadaver is the most
common source. Other sources may be live donors having a
panniculectomy or other surgery.
Xenograft or heterograft- is a segment of skin taken from an animal
such as a pig. Useful in preparing debrided areas for grafting.
- usually secured with adhesive strips or staples or sutures
BIOSYNTHETIC DRESSING
- Temporary biosynthetic dressing helps prevent bacterial contamination
 - Used when permanent autograft is unavailable or unnecessary

Biobrane (Woodruff Laboratories) consists of custom-knit nylon fabric

mechanically bonded to an ultra thin silicone rubber membrane, to
which collagenous peptides of porcine skin are covalently bonded.
BCG Matrix temporary; known to stimulate macrophages, which are
vital in the inflammatory process of healing; a temporary wound
covering intended for use with partial-thickness burns and donor sites.
Op-Site- a thin, transparent, polyurethane elastic film, can be used to
cover clean partial-thickness wounds and donor sites.
Other synthetic dressings used for burn wounds include Tegaderm, N-
Terface, and DuoDerm.

- Is widely used for coverage of shallow wounds awaiting epithelialization, excised

wounds awaiting autografts until closure of interstices, and donor sites awaiting
healing.

ARTIFICIAL DERMIS
- Composed of porous collagen chondroitin 6-sulfate fibrillar mat covered with a
Silastic sheet.

2 dermal (skin) substitutes are Integra Artificial Skin and AlloDerm

- Used with an epidermal graft to provide permanent cover that is at least
satisfactory as other available grafting techniques
- Used with donor sites that are thinner and that heal faster.