Our Lady of Fatima University

C O L L E G E OF N U R S I N G

BURN INJURY
In Partial Fulfillment of the Requirements for NCM 105 RLE

A case study presented to:

Ma’am Potenciana A. Maroma, RN, PhD

Submitted By:
Andrea Patrice F. Custodio
Introduction
Burns are one of the most common household injuries, especially among children.
The term “burn” means more than the burning sensation associated with this injury.
Burns are characterized by severe skin damage that causes the affected skin cells to die.
Most people can recover from burns without serious health consequences, depending on
the cause and degree of injury. More serious burns require immediate emergency medical
care to prevent complications and death.

Burn levels

There are three primary types of burns: first-, second-, and third-degree. Each degree is
based on the severity of damage to the skin, with first-degree being the most minor and
third-degree being the most severe. Damage includes:

 first-degree burns: red, non blistered skin

 second-degree burns: blisters and some thickening of the skin
 third-degree burns: widespread thickness with a white, leathery appearance
There are also fourth-degree burns. This type of burn includes all of the symptoms of a
third-degree burn and also extends beyond the skin into tendons and bones.

Burns have a variety of causes, including:

 scalding from hot, boiling liquids

 chemical burns
 electrical burns
 fires, including flames from matches, candles, and lighters
 excessive sun exposure

The type of burn is not based on the cause of it. Scalding, for example, can cause all three
burns, depending on how hot the liquid is and how long it stays in contact with the skin.

Chemical and electrical burns warrant immediate medical attention because they can
affect the inside of the body, even if skin damage is minor.
First-degree burn - cause minimal skin damage. They are also called “superficial burns”
because they affect the outermost layer of skin. Signs of a first-degree burn include:

 redness
 minor inflammation, or swelling
 pain
 dry, peeling skin occurs as the burn heals

Since this burn affects the top layer of skin, the signs and symptoms disappear once the
skin cells shed. First-degree burns usually heal within 7 to 10 days without scarring.

You should still see your doctor if the burn affects a large area of skin, more than three
inches, and if it’s on your face or a major joint, which include:

 knee
 ankle
  foot
 spine
 shoulder
 elbow
 forearm

Second-degree burn - are more serious because the damage extends beyond the top
layer of skin. This type burn causes the skin to blister and become extremely red and
sore. Some blisters pop open, giving the burn a wet or weeping appearance. Over time,
thick, soft, scab-like tissue called fibrinous exudate may develop over the wound. Some
second-degree burns take longer than three weeks to heal, but most heal within two to
three weeks without scarring, but often with pigment changes to the skin.
Third-degree burn - excluding fourth-degree burns, third-degree burns are the most
severe. They cause the most damage, extending through every layer of skin. There is a
misconception that third-degree burns are the most painful. However, with this type of
burn the damage is so extensive that there may not be any pain because of nerve damage.
Depending on the cause, the symptoms third-degree burns can exhibit include:

 waxy and white color

 char
 dark brown color
 raised and leathery texture
 blisters that do not develop

Without surgery, these wounds heal with severe scarring and contracture.

ANATOMY AND PHYSIOLOGY

Integumentary System
SKIN - the skin is made up of two tissue layer: epidermis and dermis. The epidermis is
the most superstitial layer of skin. It is a layer of epithelial tissue that rest on the dermis, a
layer of dense connective tissue. The thickness of epidermis and dermis varies, depending
on location, but on average the dermis is 10 to 20 times thicker than the epidermis. The
epidermis prevents water loss and resists abrasion. The dermis is responsible for most of
the skin’s structural strength. The skin rest on the subcutaneous tissue, which is a layer of
connective tissue. The subcutaneous tissue is not part of the skin, but it does connect the
skin to underlying muscle or bone.

PHYSIOLOGY OF THE INTEGUMENTARY SYSTEM

For Protection - the integumentary system performs many protective functions:
1. The intact skin plays an important role in reducing water loss because its lipids acts as
a barrier to the diffusion of water from the deeper tissues of the body to the surface of the
epidermis.
2. The skin acts as a barrier that prevents microorganisms and other foreign substances
from entering the body. Secretions from skin glands also produce an environment
unsuitable for some microorganisms.
3. The stratified squamous epithelium of the skin protects underlying structures against
abrasion.
4. Melanin absorbs ultraviolet light and protects underlying structures from its damaging
effects.
5. Hair provides protection in several ways: the hair on the head acts as a heat insulator,
eyebrows keep sweat out of the eyes, eyelashes protect the eyes from foreign objects, and
hair in the nose and ears prevents the entry of dust and other materials.
6. The nails protects the ends of the fingers and toes from damage and can be used in
defense.
For Sensation - many sensory receptors are associated with the skin. Receptors in the
epidermis and dermis can detect pain, heat, cold, and pressure. Although hair does not
have a nerve supply, sensory receptors around the hair follicle can detect the movement
of a hair.

Vitamin D Production - when the skin is exposed to ultraviolet light, precursor molecule
of vitamin D is formed. If exposed to enough ultraviolet light, humans can produced all
the vitamin D they need.

For Temperature Regulation - body temperature normally is maintain at about

37C(98.6F). Regulation of body temperature is important because the rate of chemical
reactions within the body can be increased or decreased by changes in body temperature.
If body temperature begins to drop below normal, heat can be conserved by the
constriction of dermal blood vessels, which reduces blood flow to the skin. Thus, less
heat is transferred from deeper structures to the skin, and heat loss is reduced. However,
with smaller amounts of warm blood flowing through the skin, the skin temperature
decreases. If the skin temperature drops below about 15C(59F), dermal blood vessels
dilate.
For Excretion - the integumentary system plays a minor role in excretion, the removal of
waste products from the body. In addition to water and salts, sweat contains small
amounts of waste products, such as urea, uric acid, and ammonia. Even though the body
can loss large amounts of sweat, the sweat glands do not play a significant role in the
excretion of waste products.

PATHOPHYSIOLOGY
BURN INJURY (SUPERFICIAL)
DAMAGE TO EPIDERMIS AND UPPER DERMIS

DAMAGE KERATINOCYTES

ACTIVATE THE IMMUNE CELLS (MAST AND MACROPHAGES)

SECRETES PROINFLAMMATORY CYTOKINES VASODILATION

PAIN STIMULATES NERVE ENDING WARMTH, BLANCHING, ERYTHEMA

VASCULAR PERMEABILITY BLISTERS

 FLUID SHIFTING

INTERSTITIAL EDEMA, HYPOTENSION

LABORATORY AND DIAGNOSTIC EXAM

Burn patients should be placed on a cardiac monitor, and pulse oximetry should be
assessed and monitored, if indicated. Basic laboratory studies should be obtained in
patients with severe burns or concomitant trauma, including a complete blood count, type
and crossmatch, chemistries, coagulation profiles, arterial blood gas measurement, and a
pregnancy test, when appropriate. All patients with thermal burns should have arterial or
venous blood sent for measurement of the carboxyhemoglobin level to evaluate for
carbon monoxide poisoning.

An initial chest radiograph is warranted in all burned patients when an inhalation

injury is possible. A normal study does not rule out pulmonary injury however, and serial
chest radiographs may show delayed development of pulmonary edema or findings of
pulmonary contusions. Computed tomography scans should be obtained as indicated in
the patient with accompanying traumatic injuries or decreased mental status. In addition,
the history and physical examination should guide radiologic examination of the
extremities and cervical spine.
MEDICATION/TREATMENT
Most minor burns can be treated at home. They usually heal within a couple of weeks.

For serious burns, after appropriate first aid and wound assessment, your treatment may
involve medications, wound dressings, therapy and surgery. The goals of treatment are to
control pain, remove dead tissue, prevent infection, reduce scarring risk and regain
function.

People with severe burns may require treatment at specialized burn centers. They may
need skin grafts to cover large wounds. And they may need emotional support and
months of follow-up care, such as physical therapy.
Rule of nines for burns

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.

Initial Management

Stabilization of the ABCs is essential in managing any medical emergency

The first priority in stabilizing these patients is ensuring a patent airway, which can be
challenging, secondary to oropharyngeal and laryngeal edema. Airway edema may
progress rapidly in a burned patient who has inhaled heated gases or toxic products of
combustion. Signs that indicate the patient may have had a significant inhalational injury
include singed nasal hairs, facial burns, oral burns, sooty sputum, and stridor or wheezes.

Medical treatment
After the patient received first aid for a major burn, medical care may include
medications and products that are intended to encourage healing.

 Water-based treatments. Care team may use techniques such as ultrasound mist

therapy to clean and stimulate the wound tissue.
 Fluids to prevent dehydration. The patient may need intravenous (IV) fluids to
prevent dehydration and organ failure.
 Pain and anxiety medications. Healing burns can be incredibly painful. The patient
may need morphine and anti-anxiety medications, particularly for dressing changes.
 Burn creams and ointments. If the patient is not being transferred to a burn center,
care team may select from a variety of topical products for wound healing, such as
bacitracin and silver sulfadiazine (Silvadene). These help prevent infection and
prepare the wound to close.
 Dressings. Care team may also use various specialty wound dressings to prepare the
wound to heal. If the patient is being transferred to a burn center, wound will likely
be covered in dry gauze only.
 Drugs that fight infection. If the patient develop an infection, patient may need IV
antibiotics.
 Tetanus shot. Doctor might recommend a tetanus shot after a burn injury.

Physical and occupational therapy

If the burned area is large, especially if it covers any joints, the patient may need physical
therapy exercises. These can help stretch the skin so that the joints can remain flexible.
Other types of exercises can improve muscle strength and coordination. And occupational
therapy may help if the patient have difficulty doing their normal daily activities.

Surgical and other procedures

Patient may need one or more of the following procedures:

 Breathing assistance. If the patient has been burned on the face or neck, patient
throat may swell shut. If that appears likely, doctor may insert a tube down to
windpipe (trachea) to keep oxygen supplied to the lungs.
 Feeding tube. People with extensive burns or who are undernourished may need
nutritional support. The doctor may thread a feeding tube through his/her nose to
their stomach.
 Easing blood flow around the wound. If a burn scab (eschar) goes completely
around a limb, it can tighten and cut off the blood circulation. An eschar that goes
completely around the chest can make it difficult to breathe. The doctor may cut the
eschar to relieve this pressure.
 Skin grafts. A skin graft is a surgical procedure in which sections of patient’s own
healthy skin are used to replace the scar tissue caused by deep burns. Donor skin
from deceased donors or pigs can be used as a temporary solution.
  Plastic surgery. Plastic surgery (reconstruction) can improve the appearance of burn
scars and increase the flexibility of joints affected by scarring.

NURSING CARE PLAN FOR BURN INJURY

ASSESSMENT NURSING BACKGROUND PLAN OF INTERVENTION RATIONALE EVALUATION
DIAGNOSIS KNOWLEDGE CARE
Subjective: Ineffective Burn Short Term Independent: 1.To gain Short Term
tissue Goal: patient trust Goal:
“Parang wala perfusion Damage to cells 1.Establish and
ng pakiramdam related to and muscles Within rapport to the confidence. After 48hours
dito sa paa ko” decrease 48hours of client and of continuous
as verbalized by blood flow continuous nursing care, the
Triggered significant
the patient. secondary to nursing care, goal was met as
circumferentia inflammatory others.
the patient evidenced by:
l burns of response 2.To provide a
will be able
lower to: baseline data -The patient
Objective: extremities. Release of 2. Monitor and for future verbalize
chemical -Verbalize record vital signs. comparison. understanding
Vital signs mediators understandin of condition,
taken as g of 3.To assess therapy regimen
follows: condition, increasing and side effects
Increased blood
BP: 130/90 vessel therapy 3. Assess color of edema because of medications
permeability regimen and the skin, edema
Temp:36C side effects movement of the formation -Good capillary
of hands and readily refill: 1-2secs
Fluid shift from
PR: 125bpm medications
IV to interstitial peripheral pulses compresses
-Skin warm and
space and capillary blood vessels.
RR:30 -With good dry
capillary
refill on
Edema refill: 1-2secs extremities. 4. To promote
With ptting -Lab values:
edema on the systemic
burn area Decrease blood -Skin warm 4. Encourage circulation/ven Hct:40-54%
volume and dry active ROM ous return.
Cold clammy exercise for HgB:14-18
skin on -Lab values unaffected body To maximize
Decrease
unburned area within parts. circulating
venous return normal volume and
Skin color: red range: systemic Long Term
to brown Decrease CO Goal:
circulation.
Hct:40-54%
Capillary refill: Decrease tissue After a week of
3secs perfusion HgB:14-18
5.Elevate the hospitalization,
affected the goal was
Weak in met as
extremities.
appearance evidenced by
Long Term
Lab values: Goal: -Absence of
Dependent: edema on lower
Hct:-66% Within a Dependent: extremities
week of 1. To maintain
hospitalizatio fluid -VS within
 replacement
HgB-10 n, the patient 1. IV Fluid and to improve normal range:
will be able tissue
to perfusion. PR:60-100
demonstrate
oincreased RR:12-20
perfusion as
evidenced BP:120/80
.
by:

-Absence of
edema on
lower
extremities

-VS within
normal
range:

PR:60-100

RR:12-20

BP:120/80
RECOMMENDATIONS
Medications Instruct the patient about the importance of
compliance in medications and the side effects.

Exercise Instruct the patient to do ROM exercise of unburned

areas to promote good circulation.

Treatment Instruct and remind the patient to

Health Teaching Instruct and remind the patient to track his/her own
fluid intake.

Out Patient Follow Up Instruct the patient to be sure to make and go to all
appointments, and call the doctor if he/she having
problems.

Diet Instruct the patient to eat high protein foods and

drinking milkshake/smoothies may also help meet the
calorie and protein needs.

Spiritual Support Always pray continually and give thanks in all

circumstances.