NOTES ON BURN INJURY

LEARNING OUTCOME
At the end of the session student should be able to:
1. Identify different layers& function of the skin
2. Apply Rule of Nine to BSA burn
3. Describe different degrees of burn
4. Know when to refer a patient
5. Implement immediate and continuous Nursing Care plan

Largest area on the body and has a surface area of about 1.5 – 2m² in adults
In certain areas it contains accessory structure; glands, hair and nails
There are two main layers.
The Epidermis which covers the Dermis
Between the skin and the underlying structure is a subcutaneous layer composed of areolar tissue and adipose (fat)
tissue

EPIDERMIS

Most superficial layer and composed of stratified keratinized epithelium

It varies in thickness. Being thickest in the palms of the hands and soles of the foot
There are no blood vessels or nerve endings in the epidermis, but its deeper layers are bathed in interstitial fluid
from the dermis – Which provides oxygen and nutrients and drains away as lymph

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Stratified Keratinized epithelium
This is found on dry surfaces subjected to wear and tear; i.e. Skin, hair and nails
The surface area consists of dead epithelial cells that have lost their nuclei and contain the protein keratin.
This forms a tough relatively waterproof protective layer that prevents drying of the live cells underneath
The surface area of the skin is rubbed off and is replaced from below
Non- Stratified Keratinized epithelium
Non –keratinized stratified epithelium -this protects moist surface subjected
to wear and tear and prevents them from drying out, e.g. the conjunctiva of the eyes,
The lining of the mouth, the pharynx, the esophagus and the vagina

There are several layers of cells in the epidermis which extends from the deepest germinate layer to the most
superficial stratum corneum
Epidermal cells originate in the germinate layer and undergo gradual change as they progress towards the skin
surface

THERE ARE FIVE LAYERS OF EPIDERMIS

Stratum corneum: This is the outermost or top layer of the epidermis. It's made of dead, flat keratinocytes that
shed approximately every two weeks
Stratum lucidum: This layer exists only on the palms of the hands and soles of the feet. 
Stratum granulosum: This layer contains more keratinocytes moving toward the surface.
Stratum spinosum: This layer, which is also known as the squamous cell layer, is the thickest layer of the epidermis.
It contains newly formed keratinocytes, which are strengthening proteins.
It also contains Langerhans cells that help prevent infection.
Stratum basale: This bottom layer, also known as the basal cell layer, has column-shaped basal cells that divide and
push older cells toward the surface of the skin. As the cells move up through the Skin, they flatten and eventually
die and shed.

DERMIS
The dermis is tough and elastic, formed from connective tissue and the metric contain collagen fibres interlaced
with elastic fibres. Rupture of elastic fibres occur when the skin is overstretched, resulting in permanent striae or
stretch marks. Collagen fibres bind water and give the skin its tensile strength but as this ability declines with age
wrinkles develop.

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The structures in the Dermis are:
 Blood and lymph vessels
 Sensory nerve ending
 Sweat glands and their ducts
 Hairs, erector pili muscles and sebaceous glands

The Dermis is composed of two layers:

The upper papillary layer is in contact with the epidermis
Numerous projections called papillae, extend from the upper portion of the dermis in to the epidermis
Papillae form the base for the friction ridges on the fingers and toes

HYPODERMIS OR SUBCUTANEOUS TISSUE

BURNS injuries involve damage to the skin and underlying tissues.

 This leads to varying degrees of cellular skin damage as well as

 Systemic response that leads to altered body functions
 A major burn affects every body system and organ
Usually requiring painful treatment, skin grafting, and a long period of

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CAUSES OF BURN

Thermal the most common type typically results from:

 Residential fires
 Automobile accidents
 Playing with matches
 Improper handling of fire crackers
 Scalding and kitchen accidents
 Abuse (in children or elderly people)
 Clothes that have caught on fire

Chemical burns result from contact, ingestion, inhalation, or injection of acids, alkali's or vesicants (blistering
agents)
Electric burns usually result from contact with faulty electrical wiring and cords or high voltage power line

Burn injuries are categorized based on depth of injury

 The longer and more intense the exposure to the burning agent
 The greater is the depth of injury
 A burn injury is described as either a partial- thickness or full- thickness injury
 Relative to the layers of skin and tissues injured

BURN WOUND DESCRIPTION AND CHARACTERISTICS

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 Cause of Injury Depth Characteristics Treatment and
recovery

First degree burn Prolonged UV light exposure Limited damage to Erythematous, Complete healing
(sun)Brief exposure to hot epithelium, hypersensitive no blister within 3 – 5 days
liquids skin remains intact formation without scarring

Superficial partial Brief exposure to flash, flame Epidermis destroyed Moist and weepy, pink or Complete healing
thickness (second or hot liquids Minimal damage to red blisters, blanching, within 21 days with
degree) burn superficial layer of hypersensitive minimal to no scarring
dermis

Deep partial Intense radiance energy, Epidermis destroyed Pale, decreased moisture, Prolonged healing
thickness (second scalding liquids semi liquids Underlying dermis blanching absent or (often > 21 days), may
degree) burn (e.g. tar), or solids; flame damaged, some prolonged, sensation to require skin graft to
epidermal appendages deep pressure, not achieve complete
remain intact pinprick healing with better
functional outcome

Full thickness Prolonged contact with Epidermis, dermis & Dry, leather-like, molted, Requires skin grafting
(third degree) burn flame, scalding liquids, epidermal appendages pale, brown or red,
steam, hot objects, chemical, destroyed, injury through thrombosed vessels
electrical currents dermis visible, insensate

Full thickness High- voltage electrical
(fourth degree) injuries, prolonged contact
burn with flame (often in a victim
who is unconscious)
Epidermis, dermis & Dry leather-like eschar; Requires skin graft, may
epidermal appendages, colour variable; charring require amputation of
fat, muscle and bone can visible in deepest area, extremities involved
be destroyed insensate, extremity
movement limited

ASSESSMENT -provides a general idea of burn severity.

First determine the depth of tissue damage. A partial thickness burn damages the epidermis and part of the
dermis. A full thickness burn also affects the subcutaneous tissue

SIGNS AND SYMPTOMS DEPEND ON THE TYPES OF BURNS AND MAY INCLUDE:

 Localized pain & erythema, usually without blisters in the first 24 hours (Superficial Burn)
 Chills, headache, localized oedema, and nausea & vomiting (more sever in Superficial Burn)
 Thin walled fluid filled blisters appearing within minutes of the injury, with mild to moderate oedema, and
pain (Superficial Partial Thickness Burn)
 White waxy appearance to damaged area that still blanches to pressure (Deep Partial Thickness Burn)
White, brown or black leathery tissue and visible thrombosed vessels due to destruction of skin elasticity
(dorsum of hand, most common site of thrombosed veins) without blisters that does not blanch to
pressure (full- thickness burn)
 Silver coated raised or charred area usually at the site of electrical contact (electrical burn).

TEST FOR MAJOR BURN INJURY

TEST PURPOSE ABNORMAL FINDING

Complete blood To assess for; Increased RBCs, Hgb, or Hct; 2° to under resuscitation
count: Hgb, Hct, polycythemia, anaemia, during the initial 24 hours post burn
RBC, WBC, Platelet inflammation, infection, Decreased levels may reflect; anaemia, infection or

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 count sepsis, coagulation inflammation may increase WBCs. Sepsis may increase or
disorder and decrease WBC. Thrombocytopenia (decreased platelets)
dehydration may reflect coagulation disorder or sepsis
Electrolytes To assess for potential Decreased K⁺. Mg²⁺ or Ca²⁺; May cause dysrhythmias
Potassium, dysrhythmias (from massive fluid shift)
magnesium, calcium Increased Na⁺ may indicate dehydration, low Na⁺ may
Sodium indicate fluid retention
Blood urea nitrogen To asses for renal failure Is elevated because of hypovolemic state, increased
(BUN) protein catabolism or possible acute renal failure
Persistent elevation of BUN may indicate and creatinine
signals inadequate fluid intake or acute renal failure
Urinalysis, culture To detect UTI A 24-hour urine collection to measure, total nitrogen,
and sensitivity test urea nitrogen, creatinine and amino acid nitrogen values
may indicate return of capillary integrity.
Myoglobin urea can result from muscle injury sustained
from an electrical injury or deep full thickness burn.

OTHER TEST for Burn Injury but not limited to:

 ECG To assess cardiac health

 Pulse oximetry
 Glucose
 Coagulation profile
 ABG Analysis
 Chest radiograph
To assess oxygenation (not reliable in patients who are
profoundly hypovolemic)
May indicate premorbid medical condition
To assess for bleeding, clotting and DIC
To assess for acid base disorders
To aid in the assessment of pulmonary status

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 An assessment method that can be
used to determine the size of the
burn is the:

Rule of Nine chart, which determines

the percentage of body surface area
(BSA) covered by the burn

You can use a total rough estimate of

burn extent to calculate fluid
replacement needs

SOME REFERRAL GUIDELINES

 Partial –thickness burns > 10% Total Body Surface Area (TBSA) burn in patients
< 10 years or older than 50 years
 Partial –thickness burn > than 20% TBSA burn in patients 11 – 50 years’ old
 Full thickness burns in any age
 Electrical burns, chemical burns
 Burn Injury with associated inhalation injury
 Burn injury to patient with preexisting medical condition that could complicate
management, prolonged recovery or affect mortality
 Burn injury in children at hospitals without qualified personnel or equipment for
the care of children

COLLABORATIVE MANAGEMENT

Immediate measure:
Stop the burning process; remove any items that retain heat; clothing & jewelry

1. Manage hypoxia and protect upper airways by using humidified O₂ therapy

a. Treats hypoxia and prevents drying & sloughing of the mucosal lining of the tracheobronchial tree
b. Intubation maybe required if patient is stuporous
2. Support ventilation by providing intubation and mechanical ventilation
a. Endo Tracheal tube is indicated if respiratory distress or failure is present
b. Airway obstruction from laryngeal oedema associated with superheated gases is imminent
3. Relieve constriction of circumferential burns with escharotomy
(escharotomy is an incision through eschar to relieve constriction caused by circumferential full- thickness
burn)
4. Hydrate using large- bore IV access

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 5. if peripheral IV insertion is not possible, obtain central Venous line access (preferably through unburned
skin)
6. Fluid resuscitation
7. the goal is to maintain tissue perfusion and organ function, while avoiding the complications of
inadequate or excessive fluid therapy
8. Maintain an accurate record of the fluid balance
9. IDC insertion maybe essential for acute hourly measurement of urine output and evaluation of renal status
10. Facilitate core body temperature regulation
11. 2°C above normal (helps to attenuate the hyper metabolic response)
12. Prevent aspiration of gastric content by NG intubation
13. permits gastric decompression, reducing risk of aspiration
14. Provide proper patients position, nutrition and wound care
15. To reduce dependent oedema forming, prevent infection and promote healing
6. Prepare for surgery if required for skin graft and surgical debridement for major burns

PHARMACOTHERAPY
 Provide tetanus prophylaxis
 IV pain relievers and anxiolytics (Diazepam or Midazolam to relieve anxiety as it increases patient’s
perception of pain
 Administer antibiotic for known or suspected infections
 Provide DVT prophylaxis if necessary

NURSING CARE PLANS –BURNS

1. INEFFECTIVE AIRWAY CLEARANCE: related to increased pulmonary secretions& inflammation, swelling of
nasopharyngeal mucous membrane secondary to smoke irritation or impaired cough, potential of
constricting neck or thorax burns and decreased expansion of alveoli secondary to circumferential thorax
burn or pneumonia
Goal: The patient maintains a clear airway as evidenced by auscultation of normal
breath sounds over the lung fields and a state of eupnoea
NOC: Respiratory status: Airway patency
NIC: Airway Management
Assess and document respiratory status, noting breath sounds, rate & depth of
respirations.
Identify deteriorating respiratory status as evidenced by: crackles, rhonchi, stridor,
laboured breathing, Dyspnoea, tachypnea, restlessness & decreasing LOC.

2. IMPAIRED GAS EXCHANGE: related to inhalation injury with tracheobronchial swelling and
carbonaceous debris, competition of CO₂ with O₂ for Hgb. Hypoventilation associated with constricting
circumferential burns to the thorax or large fluid volume resuscitation

Goal/ Outcome:
The patient exhibits adequate gas exchange as evidenced by a approximately stable blood gas values

Respiratory Monitoring:
 Assess and document respiratory status, noting breath sounds, and LOC.

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 Administer humidified oxygen therapy, mechanical ventilation or bronchodilator treatment.
 Monitor hypoxia and hypercapnia, serial ABG values, Pulse oximetry, End- tidal CO₂ monitoring
 Teach non intubated patient the necessity of deep breathing and coughing exercise every two hours
 Prepare items for intubation and mechanical ventilation if needed.

3. DEFICIENT FLUID VOLUME: related to active loss through the burn wound and leakage of fluid,
plasma proteins and other cellular elements in to the interstitial space

Goals/ Outcome: the patient fluid status stabilizes

FLUID Management:
 Monitor for evidence of fluid deficit
 Administer fluid according to Doctors orders
 Monitor intake and output,
 Record on a strict 24-hour fluid balance chart accurately
 Monitor weight daily during fluid resuscitation

4. INEFFECTIVE TISSUE PERFUSION, PERIPHERAL: related to thermal injury, circumferential burns, oedema,
Hypovolaemia.

Goal/ Outcome: the patient maintains adequate tissue perfusion

Circulatory Precautions:
 Monitor tissue perfusion hourly in burned extremities during the resuscitation phase of care. Note capillary
refill, temperature and peripheral pulse
 Elevate burned extremities at or above heart level to promote venous return, prevent excessive dependent
oedema, and reduce risk for compartment syndrome of the extremities

5. HYPOTHERMIA; related to exposure at the scene of injury, large body surface area burns,
administration of large volumes of un-warmed fluid

Goal/ Outcome: the patient’s temperature returns to normal or is slightly elevated within 24 hours of
this diagnosis.
Temperature Management:
 Warm fluids administered during the resuscitation phase until patient approaches desired core
temperature.
 Avoid unnecessary exposure of the patient’s body
 Keep patient covered with warm blanket
 Regular monitoring of core temperature

6. RISK FOR INFECTION: related to inadequate primary and secondary defenses secondary to traumatized
tissue, bacterial proliferation in burn wounds, presence of invasive IV lines or urinary catheter and
immunocompromised status

Goal/ Outcome: the patient is free of infection as evidenced by core temperatures and WBC less than
11, 000/ mmᶟ, negative culture results and absence of purulent matter and other clinical indicators.

Infection prevention:
 Practice universal precautions to prevent risk of transmission of microorganisms

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 Assess burn wound daily for signs of infection
 Report to physician if fever is greater than 39°C, elevated or decreased WBC, change in colour of wound
exudate

7. ACUTE PAIN: related to burn injury and treatment

Goals/ Outcome: within 30 minutes of treatment or intervention, the patient subjective evaluation of
discomfort and/ or nonverbal indicators of discomfort are absent or diminished

Pain Assessment and Management:

 Assess patient level of discomfort at frequent intervals.
 Patient with severe partial –thickness burn may experience severe pain because of damage and exposure of
sensory nerve endings
 Monitor patient for clinical indicators for pain; increased BP, tachypnea, shivering, rigid muscle tone or
guarded position.
 Administer opioid analgesics and anxiolytics as prescribed
 Provide simple explanations for all procedures
 If possible, avoid wound care procedures during sleeping hours
 Ensure that patient receives periods of uninterrupted sleep by grouping care procedures when possible

8. IMPAIRED TISSUE INTEGRITY: related to burn injury oedema

Goals/ Outcome: the patients wound exhibits evidence of healing

Healing:
 Assess and document extent and depth of wound
 Cleanse and debride the wound as prescribe
 Apply topical antimicrobial treatment as prescribed, using aseptic technique
 Elevate burned extremities, to reduce oedema formation

for patient with skin graft

 Help prevent graft loss if fluid collection under graft occurs
 Monitor type and amount of drainage from wound
 -Bright red bleeding would inhibit graft take
 -Purulent exudate will indicate infection
 Maintain immobility of graft site for 3 – 5 days as prescribed. Apply elastic wraps to legs that has grafts
and / or donor site to promote venous return and to promote graft adherence when out of be
 Provide donor site care and alert to donor site infection

9. INEFFECTIVE TISSUE PERFUSION; GASTROINTESTINAL related to Hypovolaemia and interruption in blood

flow associated with Splanchnic vasoconstriction secondary to fluid shifts and catecholamine release

Goal/ Outcome:
The patient has adequate GI tissue perfusion, as evidenced by auscultation of bowel sounds within 48 –
72 hours after burn injury

Gastrointestinal Intubation
 Assess bowel function every 2 – 4 hours. Identify abdominal distension and decreased or no bowel sounds
 During period of absence bowel sounds, maintain gastric tube to intermittent low suction as prescribed
 Maintain NPO status until return of bowel sounds.
 Provide mouth care for comfort and hygiene

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 10. IMBALANCE NUTRITION, LESS THAN BODY REQUIREMENTS; Related to hyper metabolic
state

Goals/ Outcome: The patient has adequate nutrition as evidenced stable weight following resuscitation.

Nutrition Management:
 Collaborate with Dietician and Physician to estimate patient’s metabolic needs on basis of injury and extent
 Consider patient’s specific injuries, ability to consume diet, and pre-existing condition when planning
nutrition
 Provide diet as prescribed
 Record all intake for daily calorie count
 Monitor patients weight (without dressings or splints)

11. FEAR
Related to potentially threatening situation and supported by presence of pain and unfamiliarity and
noxious environmental stimuli present in critical care area, communication barrier (e.g. intubation),
sensory impairment from direct injury

Goals/ Outcome: The patient exhibits decreased symptoms of fear, apprehension, tension,
nervousness, tachycardia, aggressiveness and withdrawal
Anxiety Reduction
 Assess level of fear and understanding of present condition
 Plan care to provide as restful an environment as possible
 Provide information about NC, treatment plan and progress
 Promote visits by family members and significant others
 Offer to contact Hospital Spiritual care or the patients Clergy as preferred by the patient
 Assess and promote the patients usual coping strategies.
 Provide referral to burn survivor support groups

12. DISTURBED SENSORY PERCEPTION; TACTILE AND VISUAL related to altered reception
secondary to medication, sleep pattern disturbance, pain, swollen eyelids and full- thickness burn
wounds

Goal/ Outcome: The patient verbalizes orientation to time, place, and person and describes rationale
for necessary treatments

Sensory Perception Management

 Assess patient’s orientation to time, place and person
 Answer patients question simply and succinctly
 For patient with cutaneous burn injury, explain why tactile sensation is decreased or absent
 Explain that alterations in perception can be related to opioids and other medications commonly prescribed
during the acute phase of burn recovery

13. DISTURBED BODY IMAGE related to biophysical changes secondary to burn injury

Goals/ Outcome: The patient begins to acknowledge body changes and demonstrates movement towards
incorporating changes in to self- concept

Body Image Enhancement:

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  Assess patient perception and feelings about the burn injury and changes in lifestyle and relationships;
especially those with significant others
 Involve significant others as much as possible to maintain bond with patient
 Respect patients need to express anger over body changes
 Consider consultation with rehabilitation team
 Provide information concerning eventful appearance of grafts and donor sites

14. DEFICIENT KNOWLEDGE related to lack of knowledge regarding ability for self- care management and /
or use of resources for supportive care

Goals/ Outcomes; within 24 hours of initiation of acute care, the patient and
significant others verbalize knowledge about prescribe
medication and techniques that facilitate continued wound
healing and limb mobility

Teaching, Disease process:

Review the splinting and exercise program for contracture prevention
 Teach patient and SO to monitor for pain or pressure caused by improper applied splint, and to assess
splinted
 extremities for coolness, pallor cyanosis, decreased pulse and impaired function
 Discuss current skin and wound care plan
 Explain indicators of wound infection
 Review nutritional needs
 Review current pain and anxiolytic medications

_____________________________________________________________________________________________

REVIEW QUESTIONS

1. Name 3 layers of the skin 3marks

2. Identify 3 functions of the skin 3marks
3. Name 3 causes of burn injuries 3marks
4. There are different degrees of burn, Describe two only 4 marks
5. Name 3 type of burn cases that require referral to major hospitals 3marks
6. Describe 3 collaborative care 3marks
7.Identify 2 nursing diagnosis and your care plan 4marks

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