Burns burns depends on the depth and extent of the

burns on the area of the body tissues.

Definition
Etiology
Refers to an injury to the tissues of the body
caused by either heat, chemicals, electric 1. Hot liquids
current, or radiation. 2. Flash flame
3. Open flame
There are four types of burn injury
4. Steam
1. Thermal burn 5. Hot surface
2. Chemical burn 6. Ultraviolet rays
3. Smoke and inhalation burn
Symptomatology (significant
4. Electrical burns
features/manifestations)
The burn injuries are classified into depth of the
Clinical Features
burns, extent of burns which is calculated to
the body surface area, location of the burn, and 1st degree burn
patient risk factors.
1. Redness
2. inflammation
3. pain at burn site
4. Blanching with pressure
2nd degree burn
1. inflammation
2. blisters
3. pain with sensitivity to touch
4. paleness
5. blanching with pressure at superficial
partial burn and absence of blanching at
deep partial burn.
3rd degree burn
1. necrosis or leathery eschar
2. charred appearance
3. absence of sensation of pain
Anatomy & physiology (only for the major
4. strong odor of pain
organ
Manifestation
When it comes to burns, the integumentary are
one of the most common organ systems that is Emergent phase (onset – 3 days)
affected. The integumentary system has 3
1. oedema
layers of epithelium: the (1) epidermis is a non-
2. pallor
vascularized body tissue consisting of a
3. cool clammy skin
keratinized stratified squamous epithelium, (2)
dermis is a vascularized body tissue consisting General pathophysiology (simplified)
of a dense connective tissue, and lastly (3)
one of the most detectable aspect of burn is
hypodermis which consist of layers of fat cells
the loss of intravascular fluid volume and fluid
and connective tissues. The severity of the
shifting which leads to hypovolemia. Prior to
hypovolemia, it starts with burn injury which
activates proinflammatory cytokines by 4. Obtain laboratory results of the patient
activating the mast cells and macrophages including the CBC, Blood culture,
once activated, it will result to vasodilation and Electrolytes and ECG.
increase capillary permeability which also leads 5. Administer analgesics as per physician’s
to fluid shifting thus producing a symptom of order.
interstitial oedema and “third spacing”. When 6. Weight patient daily if possible and
there is less fluid flowing to the body tissues determine signs for hypovolemia or fluid
leading to irreversible shock. overload.
7. Provide a dry and clean environment to
Laboratory & diagnostic test
the patient’s quarters or ward.
1. physical assessment 8. Facilitate wound healing through
2. rule of nines or lund & browder’s method administration of wound care and
3. CBC performing aseptic technique.
4. Urinalysis 9. Assess for signs of infection and
5. Blood chemistry administer antibiotics to prevent
6. ECG infection.
7. Chest X-ray (if inhalation of chemicals 10. Promote physical mobility through
occur) frequent turn of patient if not
contraindicative for every 2 hours.
Medical management
Priority nursing diagnosis (5)
1. Drug therapy
a. Analgesics (e.g. Morphine 1. Risk for fluid volume deficiency
through IV). 2. Acute pain
b. Anticoagulant (e.g. Heparin) 3. Risk for infection
2. Nutritional Support 4. Impaired skin integrity
a. Vitamins (A,C,E) and 5. Ineffective tissue perfusion
multivitamins
prognosis
b. Minerals (Zinc and Iron)
3. Wound debridment or Grafting if not treated properly, it may result to
4. Wound Care hypovolemic shock and death.
Surgical Management
1. Wound Debridement and Grafting
 Surgical procedures (if
applicable)
 Nursing interventions (post-op
care)
Nursing Management (10)
1. Monitor Vital signs every hour specially
the cardiac rate and blood pressure.
2. Establish Intravenous line as prescribed
by the physician and maintain its
patency.
3. Monitor the urine output and
functionality of the kidneys hourly.