BURNS

Burn injuries
• are painful, costly, disfiguring and often associated with long term disability
• Most common signs:
o Blisters
o Pain
o Swelling
o White or charred (black) skin
o Peeling of skin
• Burn care includes:
o Optimal fluid resuscitation
o Infection control
o Early excision and grafting
o Enhanced team approach
o Emergence of specialized burn centers

• Role of nurse in the care and management is to provide holistic evident-based care during all phases of
burn injury recovery.

INCIDENCE
• Affects people of all ages and socioeconomic status
• In the Philippines there is a higher incidence of burn injuries between March and April.
• Higher incidence of burn injuries occur in men than women
• Largest proportion of burn injury is flame related.
• Age-related factors that predisposes older adults to burn injury:
o Diminished mobility
o Postural stability
o Strength
o Coordination
o Sensation
o Visual acuity
o Decline memory
• Mortality associated with burn is higher in patients 60 years and older than in younger adults
• Factors that contribute to mortality in older adults:
o The skin of older adults (less elastic and thinner) affects the depth of injury and would healing,
resulting in higher morbidity and mortality amongst aged population.
o Pulmonary function becomes impaired. There is altered airway exchange, lung elasticity, and
ventilation
o Decreased cardiac function.
o Malnutrition especially those who are institutionalized
o Decreased kidney and hepatic function which affects medication dosing due to altered medication
clearance.
PREVENTION
• Nurse plays an important role in providing education especially in the community and home setting
• The WHO recommends heightened awareness of the burn injury and its risk factors to develop an effective
burn prevention program.

TYPES of BURN INJURY

• Thermal burns: Burns due to external heat sources which 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 due to prolonged exposure to ultraviolet rays of the sun, or to other sources of
radiation such as x-ray
• Chemical burns: Burns due to 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)

BURN DEPTH CLASSIFICATION

• First Degree (partial thickness)
o Affects 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.
o Negative Nikolsky's sign (dislodgement of intact superficial epidermis by a shearing force)
o Caused by sunburn, splashes of hot liquid.
o Characteristic: erythema, blanching on pressure, no vesicles
• Second-degree (deep partial thickness)
o Involves the epidermis and part of the dermis layer of skin. The burn site appears
o Caused by flash, scalding or flame burn
o Very painful
o Characteristics: red, blistered, and may be swollen, shiny, wet after blister ruptures.
• Third-degree (full thickness) burns
o Destroys the epidermis and dermis. Third-degree burns may also damage the underlying bones,
muscles, and tendons. The burn site appears white or charred. There is no sensation in the area since
the nerve endings are destroyed.
o Caused by flame, chemicals, scalding, electric current
o Characteristic: wound dry, white, eschar (leathery or hard tissue due to loss of blood supply)

SOURCE <https://stanfordhealthcare.org/medical-conditions/skin-hair-and-nails/burns/types.html>

EXTENT OF BURN INJURY

Method used to estimate the Total Body Surface Area (TBSA) affected by burns

1. Rule of Nines
• The most common method used
• Based on the anatomic regions, each representing 9% of the TBSA.
• Guides clinician to quickly obtain an estimate burn size.
 The size of a burn can be quickly estimated by using the "rule of nines." This method divides the body's surface
area into percentages.

• The front and back of the head and neck equal 9% of the body's surface area.
• The front and back of each arm and hand equal 9% of the body's surface area.
• The chest equals 9% and the stomach equals 9% of the body's surface area.
• The upper back equals 9% and the lower back equals 9% of the body's surface area.
• The front and back of each leg and foot equal 18% of the body's surface area.
• The genital area equals 1% of the body's surface area.

2. Lund and Browder Method

• More precise method
a method for estimating the extent of burns that allows for the varying proportion of body surface in persons
of different ages.
• It is used instead of the RULES OF NINE in children, in whom the head occupies a larger area and the lower
limbs are smaller than in adults.
• recognizes the percentage of surface area of various anatomic parts in relation to the age of the patient.
• Done by dividing the body into very small areas thus allowing clinicians to obtain a more reliable
estimation of TBSA burned.
• Evaluation should be made upon arrival and reassessed within the first 72 hours because demarcation of
the wound and its depth are more visible and clear at this time.
 3. Palmar Method
• Usually used in patients with scattered burns
SOURCE: Brunner and Suddarth's

MANAGEMENT of BURN INJURY

Burn care is typically categorized into three phases.

1. Emergent/Resuscitative Phase
• On-the-scene-care is the first step. This includes removing the patient from the source of injury and stop
the burning process.
• Duration is from onset of injury to completion of fluid resuscitation
• PRIORITIES:
o Primary survey: ABCDE
• Airway
• Breathing - supplying O2 of needed esp for carbon monoxide poisoning
• Circulation and cardiac status
• Disability - include neurologic deficit
• Expose and examine - while maintaining a warm environment
o Prevent Shock
• Fluid resuscitation is very crucial especially in burns greater that 20% TBSA to maintain adequate
organ perfusion.
• Peripheral IV line (large bore needle) should be established immediately.
o Prevention of respiratory distress
o Detection and treatment of concomitant injuries
o Wound assessment and initial care
• Wrap in dry, clean sheet to prevent wound contamination
• Tetanus prophylaxis

2. Acute/Intermediate Phase
• Follows the emergent phase and begins withing 48 - 72 hours after the burn injury
• PRIORITIES:
o Continued assessment and maintenance of respiratory and circulatory status, fluid and electrolyte
balance, and GI and kidney function.
o Infection prevention
• Burn patients incur the highest risk for health care associated infections (HAI) due to loss of skin barrier.
• Prevention of infection is crucial and can be achieved in various approach
• Use of barrier techniques - proper use of PPEs (gowns, gloves, mask and eye protection)
• Making sure that the environment is clean
• Application of appropriate topical antimicrobial agents
• Excision and closure of the burn wound
• Management of hypermetabolic response.
o Burn wound care - wound cleaning, debridement, topical antibacterial therapy, wound dressing, and
wound grafting if necessary)
o Pain management
o Nutritional support

3. Rehabilitative Phase
• From major wound closure to return to optimal level of physical and psychosocial adjustment.
• It is important to re-evaluate the patient for late complication related to burn injuries
• PRIORITIES:
o Prevention and treatment of scars and contractures
 o Physical, occupational, and vocational rehab
o Functional and cosmetic reconstruction
o Psychosocial counselling
o Psychological support.

FLUID and ELECTROLYE ALTERATIONS in BURNS

• Burn injury rapidly forms edema, caused by increased perfusion to the injured area, making the patients
prone to fluid and electrolyte imbalances.
• This fluid shift is caused by the stimulation of local and systemic reactions brought by inflammatory
mediators and results in extensive shift of intravascular fluid, electrolytes and proteins into the
surrounding interstitium.
• A superficial burn can form edema within 4 hours. While deeper burn continues to form edema up to 18
hours post injury.
• Reabsorption of edema begins 4 hours post injury and is complete by 4 days post-burn injury.
• Rate of reabsorption depends on the extent of tissue damage.
• Adequate fluid resuscitation is paramount in burn injury to maintain tissue perfusion. However, extreme
caution should be observe as excessive fluid administration causes edema to both burned and non-burned
tissue causing ischemia and necrosis.
• Hyperkalemia
o Immediately after the injury
o Results from massive cell destruction
• Hypokalemia
o May occur later with fluid shifts and inadequate potassium replacement
• Hyponatremia
o May be present as a result of plasma loss or as a result of water shift from the interstitial space and
returns to the vascular space.

POTENTIAL COMPLICATIONS in BURNS

• Heart failure: Assess for fluid overload, decreased cardiac output, oliguria, jugular vein distention,
edema, or onset of S3 or S4 heart sounds.
• Pulmonary edema: Assess for increasing CVP, pulmonary artery and wedge pressures, and crackles;
report promptly. Position comfortably with head elevated unless contraindicated. Administer
medications and oxygen as prescribed and assess response.
• Sepsis: Assess for increased temperature, increased pulse, widened pulse pressure, and flushed, dry
skin in unburned areas (early signs), and note trends in the data. Perform wound and blood cultures
as prescribed. Give scheduled antibiotics on time.
• Acute respiratory failure and acute respiratory distress syndrome (ARDS): Monitor respiratory
status for dyspnea, change in respiratory pattern, and onset of adventitious sounds. Assess for
decrease in tidal volume and lung compliance in patients on mechanical ventilation. The hallmark of
onset of ARDS is hypoxemia on 100% oxygen, decreased lung compliance, and significant shunting;
notify physician of deteriorating respiratory status.
• Visceral damage (from electrical burns): Monitor electrocardiogram (ECG) and report
dysrhythmias; pay attention to pain related to deep muscle ischemia and report. Early detection
may minimize severity of this complication. Fasciotomies may be necessary to relieve swelling and
 ischemia in the muscles and fascia; monitor patient for excessive blood loss and hypovolemia after
fasciotomy.
• Contractures: Provide early and aggressive physical and occupational therapy; support patient
if surgery is needed to achieve full range of motion.
• Impaired psychological adaptation to the burn injury:
• Obtain psychological or psychiatric referral as soon as evidence of major coping problems appears

FLUID RESUSCITATION
• Is vital in burn injury especially for burns > 20% TBSA to maintain adequate organ perfusion
• Baseline weight and laboratory result are very important prior to initiation and must be closely monitored
to avoid under or over resuscitation with fluids.
• Shock, ischemic complication and multiple organ dysfunction syndrome occur with under-resuscitation.
• Over-resuscitation can cause heart failure, and pulmonary edema.
• To initiate, it is recommended to establish a peripheral IV line using a large bore needle to facilitate ease of
fluid administration.
• For large volume of fluid, a central venous line is recommended.
• Parkland (Baxter) formula
o Widely used formula for initial fluid resuscitation of burn victims
o 4 ml of Lactated Ringer's solution per Kg of body weight per %TBSA burned. Half of this has to be given
during the first 8 hours after injury and the remaining be delivered in the next 16 hours.
• E.G. patient weight 75 kg with 20% TBSA burned
4x75x20 = 6,000 mL fluid replacement within 24 hours.
• Bedside observation and clinical evaluations are useful to judge the adequacy of resuscitation.
• Closely monitor the following:
o LOC
o Vital signs
o Urine output - should be 30-50 mL/hour

SOURCE: https://www.sciencedirect.com/topics/medicine-and-dentistry/parkland-
formula#:~:text=The%20widely%20quoted%20Baxter%20(Parkland,in%20the%20next%2016%20hours.