Let us know move on to the Classification of Burn Injuries

Burns are classified according to the depth of tissue destruction as depicted in the table. So there
are two classification of burn injury depth: The Partial thickness skin destruction and Full
thickness skin destruction. For Partial thickness skin destruction, we have here the Superficial
burn or the first degree burn. First-degree burns are superficial injuries that involve only the
outermost layer of skin. The appearance of this burn would be erythematous but the epidermis
is intact; there would also blanching on pressure, pain and mild swelling, no vesicles or blisters
(although after 24 hrs, skin may blister and peel. Possible causes are superficial sunburn and quick
heat flash.
Next is the deep burn or the second degree burn. This type of burn are uh fluid-filled vesicles that
are red, shiny and wet if vesicles have ruptured. Also, there would be severe pain cause by nerve
injury and mild to moderate edema. Possible causes include flame, flash, scald, contact burns,
chemical, tar and electric current. Second-degree burns involve the entire epidermis and varying
portions of the dermis. Healing time depends on the depth of dermal injury and typically ranges
from 2 to 3 weeks.
For Full thickness skin destruction, we have the third and fourth degree burns. Third-degree
burns involve total destruction of the epidermis, dermis, and, in some cases, damage of
underlying tissue. The burned area lacks sensation because nerve fibers are damaged. Fourth-
degree burns are those injuries that extend into deep tissue, muscle, or bone. Appearance would
be dry, waxy white, leathery, or hard skin; and thrombosed vessels may be visible. Insensitivity
to pain because of nerve destruction. and Possible causes are flame, scald, chemical tar and
electric current.
- For this type of burn, surgical intervention is required for healing.
Burn Injuries are also classified by determining the extent of body surface area injured
Various methods are used to estimate the Total Body Surface Area affected by burns; among
them are the rule of nines and the Lund and Browder method.
The right side of the picture is the rule of nines chart and on the left side is the lund and browder
chart.
Rule of Nines
The most common method used to estimate the extent of burns in adults is the rule of nines.
This system is based on anatomic regions, each representing approximately 9% of the TBSA,
allowing clinicians to quickly obtain an estimate of burn size. If a portion of an anatomic area is
burned, the TBSA is calculated accordingly. —for example, if approximately half of one arm were
burned, the TBSA burned would be 4.5%.
Lund and Browder Method
A more precise method of estimating the extent of a burn which recognizes the percentage of
surface area of various anatomic parts, especially the head and legs, as it relates to the age of the
patient.
Now let me give you an overview about thermal injury before we will proceed to our case
scenario.
Thermal burns are skin injuries caused by excessive heat, typically from contact with hot surfaces,
hot liquids, steam, or flame.
Causes include --------------
Now let us move on to our case presentation. *Read case and legend.
Again, these are the risk factors or etiology of thermal injury.
For our case, the cause of the thermal injury is flash flame.

So now let us proceed to the pathophysiology.

Pathophysiology
Thermal burn pathophysiology can be broken into local and systemic responses. First, I will be
talking about the local response. When excessive heat is transferred to the skin, it radiates
outward from the point of initial contact and forms a local response with three zones in all
directions. The zone of coagulation is the central contact point of maximal damage in which cell
death, denaturation of proteins in the extracellular matrix, and damage to the circulation occur.
Damaged circulation near the zone of coagulation results in a second surrounding zone of stasis.
The third peripheral zone of hyperemia results from increased circulation as the body responds
to injury. The zone of stasis can recover with a proper resuscitation and adequate wound care.
On the contrary, prolonged periods of hypotension and inadequate wound care can convert the
zone of stasis and even the zone of hyperemia into wider and deeper tissue damage.
Nursing Management
Pain related to burn trauma and destruction of skin/tissues
Nursing Interventions:
1. Monitor physiological responses to pain, such as increased blood pressure increased
heart rate, restlessness and nonverbal cues. Use validated tools in each patient to assess
pain and anxiety.
2. Assess reports of pain, noting location and character and intensity (0–10 scale).
 - Pain is nearly always present to some degree because of varying severity of tissue
involvement and destruction but is usually most severe during dressing changes and
debridement. Changes in location, character, intensity of pain may indicate developing
complications or herald improvement and/or return of nerve function and sensation.
3. Elevate burned extremities periodically.
- Elevation may be required initially to reduce edema formation; thereafter, changes in
position and elevation reduce discomfort and risk of joint contractures.
4. Use nonpharmacological pain-reducing methods as appropriate.
- Refocuses attention, promotes relaxation, and enhances sense of control, which may
reduce pharmacological dependency.
5. Medicate patient before bathing, dressing changes and major procedures as needed.
- Assist patient to perform at higher level as needed of the function
6. Administer analgesic and/or anxiolytic medication as ordered.

Impaired physical mobility related to burn injury, therapeutic splinting and immobilization
requirements after reconstructive surgery and/or contractures
Nursing interventions:
1. Perform active and passive range of motion exercises to extremities every 2 hours while
awake. Increase activity as tolerated. Reinforce importance of maintaining proper joint
movement/function, alignment with splints.
- Prevents progressively tightening scar tissue and contractures; enhances maintenance
of muscle and joint functioning and reduces loss of calcium from the bone.
2. Elevate extremities
- Decreases edema and promote range of motion and mobility
3. Provide pain relief measures before self-care activities and occupational and physical
therapy
- Facilitate mobility; assist performance at a higher level of function enabling patient to
be more active.
4. Explain procedures, interventions, and tests in clear, simple, age-appropriate language
- Patient more likely to participate and adhere if understands purpose
5. Promote use of adaptive devices as needed to assist in self-care and mobility.
- This would decrease the dependency of the patient
6. Encourage family/SO support and assistance with ROM exercises.
- Enables family/SO to be active in patient care and provides more consistent therapy

Risk for ineffective individual coping and disabled family coping related to acute stress of critical
injury and potential life-threatening crisis

Nursing interventions:
1. Orient patient and family to unit guidelines and support services; provide written
information and reinforce frequently; Involve in plan of care. Support adaptive and
functional coping mechanisms.
 - Decreases patient’s fear and anxiety
2. Use interventions to reduce fatigue and pain
- Adequate pain control and rest facilitate patient coping
3. Use social worker for assistance in discharge planning
4. Consult psychiatric services for inadequate coping skills
- Provides expert consultation and intervention
5. Promote use of group support sessions
- Assists patient and family in understanding experiences, reactions, and methods of
coping

Post op care:

3. These types of diet are important for patients with burn injury because the patient’s
energy and protein requirements will be extremely high due to the catabolism of
trauma, heat loss, infection and demands of tissue regeneration.
Follow-up care- Patients should be advised to contact their primary care provider with
any concerns including inadequate pain management, signs or symptoms of infection, or
any problems with their wound care.