Burns- 

are tissue damage that results from heat, overexposure to the sun or other radiation, or chemical or
electrical contact
What Are Common Causes of Burns?
The first step in helping to protect kids from burns is to understand how common burns happen:
 Thermal burns: These burns raise the temperature of the skin and tissue underneath. Thermal burns
happen from steam, hot bath water, tipped-over coffee cups, hot foods, cooking fluids, etc.
  Radiation burns: These happen from exposure to the sun's ultraviolet rays (a sunburn because skin
isn't well-protected in the sun) or from radiation such as during an X-ray.
  Chemical burns: These happen from swallowing strong acids (like drain cleaner or button batteries)
or spilling chemicals (like bleach) onto the skin or eyes.
  Electrical burns: These are from contact with electrical current and can happen from things like biting
on electrical cords or sticking fingers or objects in electrical outlets, etc.
Types of Burns
1. First-Degree (Superficial) Burns
- Superficial (shallow) burns are the mildest type of burns. They're limited to the top layer of skin:
* Signs and symptoms: These burns cause redness, pain, and minor swelling. The skin is dry without blisters.
* Healing time: Healing time is about 3–6 days; the superficial skin layer over the burn may peel off in 1 or 2
days.
2. Second-Degree (Partial Thickness) Burns
- These burns are more serious and involve the top layer of skin and part of the layer below it. 
* Signs and symptoms: The burned area is red and blistered, and can swell and be painful. The blisters
sometimes break open and the area is wet looking with a bright pink to cherry red color.
* Healing time: Healing time varies depending on the severity of the burn. It can take up to 3 weeks or longer.
3. Full Thickness Burns
- These burns (also called third-degree burns or fourth-degree burns) are the most serious type of burn. They
involve all layers of the skin and the nerve endings there, and may  go into underlying tissue.
* Signs and symptoms: The surface appears dry and can look waxy white, leathery, brown, or charred. There
may be little or no pain or the area may feel numb at first because of nerve damage.
* Healing time: Healing time depends on the severity of the burn. Most need to be treated with skin grafts, in
which healthy skin is taken from another part of the body and surgically placed over the burn wound to help the
area heal
Risk factors
Greatest number of pediatric burn patients are infants and toddlers younger than 3 years of age burned by
scalding liquids. Male children are at increased risk, often due to fire play and risk-taking behaviors. Female
children are at increased risk, with most burns occurring in the kitchen or bathroom
Burn Management in Children
The ‘Rule of 9’s’ method is too imprecise for estimating the burned surface area in children because the infant
or young child’s head and lower extremities represent different proportions of surface area than in an adult 
 •  Burns greater than 15% in an adult, greater than 10% in a child, or any burn occurring in the very young or
elderly are serious.

Wound care - First aid 

• If the patient arrives at the health facility without first aid having been given, drench the burn thoroughly with
cool water to prevent further damage and remove all burned clothing. 
• If the burn area is limited, immerse the site in cold water for 30 minutes to reduce pain and edema and to
minimize tissue damage. 
• If the area of the burn is large, after it has been doused with cool water, apply clean wraps about the burned
area (or the whole patient) to prevent systemic heat loss and hypothermia.
• Hypothermia is a particular risk in young children.
• First 6 hours following injury are critical; transport the patient with severe burns to a hospital as soon as
possible.
  
Initial treatment 
Initially, burns are sterile. Focus the treatment on speedy healing and prevention of infection. 
1. In all cases, administer tetanus prophylaxis. Except in very small burns, debride all bullae.
2. Excise adherent necrotic (dead) tissue initially and debride all necrotic tissue over the first several days.
3. After debridement, gently cleanse the burn with 0.25% (2.5 g/litre) chlorhexidine solution, 0.1% (1 g/litre)
cetrimide solution, or another mild waterbased antiseptic. 
4. Do not use alcohol-based solutions. 
5. Gentle scrubbing will remove the loose necrotic tissue. Apply a thin layer of antibiotic cream (silver
sulfadiazine). 
6. Dress the burn with petroleum gauze and dry gauze thick enough to prevent seepage.to the.outer layers. 

Daily treatment 
• Change the dressing daily (twice daily if possible) or as often as necessary to prevent seepage through the
dressing. On each dressing change, remove any loose tissue. 
•  Inspect the wounds for discoloration or haemorrhage, which indicate developing infection. 
• Fever is not a useful sign as it may persist until the burn wound is closed. 
• Cellulitis in the surrounding tissue is a better indicator of infection. 
• Give systemic antibiotics in cases of haemolytic streptococcal wound infection or septicaemia.
• Pseudomonas aeruginosa infection often results in septicaemia and death. Treat with systemic
aminoglycosides. 
• Administer topical antibiotic chemotherapy daily. Silver nitrate (0.5% aqueous) is the cheapest, is applied with
occlusive dressings but does not penetrate eschar. It depletes electrolytes and stains the local environment. 
• Use silver sulfadiazine (1% miscible ointment) with a single layer dressing. It has limited eschar penetration
and may cause neutropenia. 
• Mafenide acetate (11% in a miscible ointment) is used without dressings. It penetrates eschar but causes
acidosis. Alternating these agents is an appropriate strategy. 
• Treat burned hands with special care to preserve function. − Cover the hands with silver sulfadiazine and
place them in loose polythene gloves or bags secured at the wrist with a crepe bandage; − Elevate the hands
for the first 48 hours, and then start hand exercises; − At least once a day, remove the gloves, bathe the
hands, inspect the burn and then reapply silver sulfadiazine and the gloves; − If skin grafting is
necessary, consider treatment by a specialist after healthy granulation tissue appears.
Nutrition
• Patient’s energy and protein requirements will be extremely high due to the catabolism of trauma, heat loss,
infection and demands of tissue regeneration. If necessary, feed the patient through a nasogastric tube to
ensure an adequate energy intake (up to 6000 kcal a day).
Anemia and malnutrition
- prevent burn wound healing and result in failure of skin grafts. Eggs and peanut oil and locally available
supplements are good.
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A Nurse who cares for a patient with burn injury should be knowledgeable about the physiologic changes that
occur after a burn, as well as astute assessment skills to detect subtle changes in the patient’s condition.
• Burn injury is the result of heat transfer from one site to another.
• Burns disrupt the skin, which leads to increased fluid loss; infection; hypothermia;
scarring;compromised immunity; and changes in function, appearance, and body image.
• Young children and the elderly continue to have increased morbidity and mortality whencompared to
other age groups with similar injuries. Inhalation injuries in addition to cutaneous burns worsen the
prognosis.
• The severity of each burn is determined by multiple factors that when assessed help the burn team
estimate the likelihood that a patient will survive and plan for the care for each patient.
Classification
Burns are classified according to the depth of tissue destruction as superficial partial-thickness injuries, deep
partial thickness injuries, or full thickness injuries.
 • Superficial partial-thickness. The epidermis is destroyed or injured and a portion of the dermis may
be injured.
• Deep partial thickness. A deep partial thickness burn involves the destruction of the epidermis and
upper layers of the dermis and injury to the deeper portions of the dermis.
• Full thickness. A full thickness burn involves total destruction of the epidermis and dermis and, in
some cases, the destruction of the underlying tissue, muscle, and bone.
Pathophysiology
Tissue destruction results from coagulation, protein denaturation, or ionization of cellular components.
• Local response. Burns that do not exceed 20% of TBSA according to the Rule of Nines produces
alocal response.
• Systemic response. Burns that exceeds 20% of TBSA according to the Rule of Nines produces a
systemic response.
• The systemic response is caused by the release of cytokines and other mediators into the systemic
circulation.
• The release of local mediators and changes in blood flow, tissue edema, and infection, can cause
progression of the burn injury.

Clinical Manifestations
The changes that occur in burns include the following:
• Hypovolemia. This is the immediate consequence of fluid loss and results in decreased perfusion and
oxygen delivery.
• Decreased cardiac output. Cardiac output decreases before any significant change in blood volume is
evident.
• Edema. Edema forms rapidly after burn injury.
• Decreased circulating blood volume. Circulating blood volume decreases dramatically during burn
shock.
 • Hyponatremia. Hyponatremia is common during the first week of the acute phase, as water shifts
from the interstitial space to the vascular space.
• Hyperkalemia. Immediately after burn injury hyperkalemia results from massive cell destruction.
• Hypothermia. Loss of skin results in an inability to regulate body temperature.
Prevention
To promote safety and avoid burns, the following must be done to prevent burns:
• Advise that matches and lighters be kept out of reach of children.
• Emphasize the importance of never leaving children unattended around fire or in bathroom/bathtub.
• Advise that hot irons and curling irons be kept out of reach of children.
• Caution against running an electrical cord under carpets or rugs.
• Advocate caution when cooking, being aware of loose clothing hanging over the stove top.
• Recommend having a working fire extinguisher in the home and knowing how to use it.
Complications
There are a lot of consequences involved in burn injuries that may progress without treatment.
• Ischemia. As edema increases, pressure on small blood vessels and nerves in the distal
extremities causes an obstruction of blood flow.
• Tissue hypoxia. Tissue hypoxia is the result of carbon monoxide inhalation.
• Respiratory failure. Pulmonary complications are secondary to inhalational injuries.
Assessment and Diagnostic Findings
Various methods are used to determine the TBSA affected by burns.

• Rule of Nines. A common method, the rule of nines is a quick way to estimate the extent of burns in
adults through dividing the body into multiples of nine and the sum total of these parts is equal to the
total body surface area injured.
• Lund and Browder Method. This method recognizes the percentage of surface area of various
anatomic parts, especially the head and the legs, as it relates to the age of the patient.
• Palmer Method. The size of the patient’s palm, not including the surface area of the digits, is
approximately 1% of the TBSA, and the patient’s palm without the fingers is equivalent to 0.5% TBSA
and serves as a general measurement for all age groups.
Medical Management
Burn care is a delicate task any nurse can have and being knowledgeable in the proper sequencing of the
interventions is very essential.
• Transport. The hospital and the physician are alerted that the patient is en route so that life-saving
measures can be initiated immediately.
• Priorities. Initial priorities in the ED remain airway, breathing, and circulation.
• Airway. 100% humidified oxygen is administered and the patient is encouraged to cough so that
secretions can be removed by coughing.
 • Chemical burns. All clothing and jewelry are removed and chemical burns should be flushed.
• Intravenous access. A large bore (16 or 18 gauge) IV catheter is inserted in the non-burned area.
• Gastrointestinal access. If the burn exceeds 20% to 25% TBSA, a nasogastric tube is inserted and
connected to low intermittent suction because there are patients with large burns that become
nauseated.
• Clean beddings. Clean sheets are placed over and under the patient to protect the burn wound from
contamination, maintain body temperature, and reduce pain caused by air currents passing over
exposed nerve endings.
• Fluid replacement therapy. The total volume and rate of IV fluid replacement is gauged by the
patient’s response and guided by the resuscitation formula.
Nursing Management
Nursing management in burn care requires specific knowledge on burns so that there could be a provisionof
appropriate and effective interventions.
Nursing Assessment
The nursing assessment focuses on the major priorities for any trauma patient; the burn wound is a secondary
consideration.
• Focus on the major priorities of any trauma patient. the burn wound is a secondary
consideration, although aseptic management of the burn wounds and invasive lines continues.
• Assess circumstances surrounding the injury. Time of injury, mechanism of burn, whether the burn
occurred in a closed space, the possibility of inhalation of noxious chemicals, and any related trauma.
• Monitor vital signs frequently. Monitor respiratory status closely; and evaluate apical, carotid, and
femoral pulses particularly in areas of circumferential burn injury to an extremity.
• Start cardiac monitoring if indicated. If patient has history of cardiac or respiratory problems,
electrical injury.
• Check peripheral pulses on burned extremities hourly; use Doppler as needed.
• Monitor fluid intake (IV fluids) and output (urinary catheter) and measure hourly. Note amount of
urine obtained when catheter is inserted (indicates preburn renal function and fluid status).
• Obtain history. Assess body temperature, body weight, history of preburn weight, allergies, tetanus
immunization, past medical surgical problems, current illnesses, and use of medications.
• Arrange for patients with facial burns to be assessed for corneal injury.
• Continue to assess the extent of the burn; assess depth of wound, and identify areas of full and partial
thickness injury.
• Assess neurologic status: consciousness, psychological status, pain and anxiety levels, and behavior.
• Assess patient’s and family’s understanding of injury and treatment. Assess patient’s supportsystem
and coping skills.
Acute Phase
The acute or intermediate phase begins 48 to 72 hours after the burn injury. Burn wound care and pain
control are priorities at this stage.
Acute or intermediate phase begins 48 to 72 hours after the burn injury.
• Focus on hemodynamic alterations, wound healing, pain and psychosocial responses, and early
detection of complications.
• Measure vital signs frequently. Respiratory and fluid status remains highest priority.
• Assess peripheral pulses frequently for first few days after the burn for restricted blood flow.
• Closely observe hourly fluid intake and urinary output, as well as blood pressure and cardiac rhythm;
changes should be reported to the burn surgeon promptly.
• For patient with inhalation injury, regularly monitor level of consciousness, pulmonary function, and
ability to ventilate; if patient is intubated and placed on a ventilator, frequent suctioning and assessment
of the airway are priorities.
Rehabilitation Phase
Rehabilitation should begin immediately after the burn has occurred. Wound healing, psychosocial
support, and restoring maximum functional activity remain priorities. Maintaining fluid and electrolyte balance
and improving nutrition status continue to be important.
• In early assessment, obtain information about patient’s educational level, occupation, leisure activities,
cultural background, religion, and family interactions.
• Assess self concept, mental status, emotional response to the injury and hospitalization, level of
intellectual functioning, previous hospitalizations, response to pain and pain relief measures, and sleep
pattern.
• Perform ongoing assessments relative to rehabilitation goals, including range of motion of affected
joints, functional abilities in ADLs, early signs of skin breakdown from splints or positioning devices,
evidence of neuropathies (neurologic damage), activity tolerance, and quality or condition of healing
skin.
• Document participation and self care abilities in ambulation, eating, wound cleaning, and applying
pressure wraps.
• Maintain comprehensive and continuous assessment for early detection of complications, with specific
assessments as needed for specific treatments, such as postoperative assessment of patient
undergoing primary excision.
Diagnosis
• Impaired gas exchange related to carbon monoxide poisoning, smoke inhalation, and upper airway
obstruction.
• Ineffective airway clearance related to edema and effects of smoke inhalation.
• Fluid volume deficit related to increased capillary permeability and evaporative losses from burn
wound.
• Hypothermia related to loss of skin microcirculation and open wounds.
• Pain related to tissue and nerve injury.
• Anxiety related to fear and the emotional impact of burn injury.
Planning & Goals
To implement the plan of care for a burn injury patient effectively, there should be goals that should be set:
• Maintenance of adequate tissue oxygenation.
• Maintenance of patent airway and adequate airway clearance.
• Restoration of optimal fluid and electrolyte balance and perfusion of vital organs.
• Maintenance of adequate body temperature.
• Control of pain.
• Minimization of patient’s and family’s anxiety
Nursing Priorities
1. Maintain patent airway/respiratory function.
2. Restore hemodynamic stability/circulating volume.
3. Alleviate pain.
4. Prevent complications.
5. Provide emotional support for patient/significant other (SO).
6. Provide information about condition, prognosis, and treatment
Nursing Interventions
Nursing care of a patient with burn injury needs to be precise and effective.

Promoting Gas Exchange and Airway Clearance

• Provide humidified oxygen, and monitor arterial blood gases (ABGs), pulse oximetry, and
carboxyhemoglobin levels.
• Assess breath sounds and respiratory rate, rhythm, depth, and symmetry; monitor for hypoxia.
 • Observe for signs of inhalation injury: blistering of lips or buccal mucosa; singed nostrils; burnsof face,
neck, or chest; increasing hoarseness; or soot in sputum or respiratory secretions.
• Report labored respirations, decreased depth of respirations, or signs of hypoxia to physician
immediately; prepare to assist with intubation and escharotomies.
• Monitor mechanically ventilated patient closely.
• Institute aggressive pulmonary care measures: turning, coughing, deep breathing, periodic forceful
inspiration using spirometry, and tracheal suctioning.
• Maintain proper positioning to promote removal of secretions and patent airway and to
promote optimal chest expansion; use artificial airway as needed.
Restoring fluid and Electrolyte Balance
• Monitor vital signs and urinary output (hourly), central venous pressure (CVP), pulmonary artery
pressure, and cardiac output.
• Note and report signs of hypovolemia or fluid overload.
• Maintain IV lines and regular fluids at appropriate rates, as prescribed. Document intake, output, and
daily weight.
• Elevate the head of bed and burned extremities.
• Monitor serum electrolyte levels (eg, sodium, potassium, calcium, phosphorus, bicarbonate); recognize
developing electrolyte imbalances.
• Notify physician immediately of decreased urine output; blood pressure; central venous, pulmonary
artery, or pulmonary artery wedge pressures; or increased pulse rate.
Maintaining Normal Body Temperature
• Provide warm environment: use heat shield, space blanket, heat lights, or blankets.
• Assess core body temperature frequently.
• Work quickly when wounds must be exposed to minimize heat loss from the wound.
Minimizing Pain and anxiety
• Use a pain scale to assess pain level (ie, 1 to 10); differentiate between restlessness due to pain and
restlessness due to hypoxia.
• Administer IV opioid analgesics as prescribed, and assess response to medication; observe for
respiratory depression in patient who is not mechanically ventilated.
• Provide emotional support, reassurance, and simple explanations about procedures.
• Assess patient and family understanding of burn injury, coping strategies, family dynamics, and anxiety
levels. Provide individualized responses to support patient and family coping; explain all procedures in
clear, simple terms.
• Provide pain relief, and give antianxiety medications if patient remains highly anxious and agitated after
psychological interventions.
Monitoring and Managing Potential Complications
• Acute respiratory failure: Assess for increasing dyspnea, stridor, changes in respiratory patterns;
monitor pulse oximetry and ABG values to detect problematic oxygen saturation and increasing CO2;
monitor chest xrays; assess for cerebral hypoxia (eg, restlessness, confusion); report deteriorating
respiratory status immediately to physician; and assist as needed with intubation or escharotomy.
• Distributive shock: Monitor for early signs of shock (decreased urine output, cardiac output,
pulmonary artery pressure, pulmonary capillary wedge pressure, blood pressure, or increasing pulse)
or progressive edema. Administer fluid resuscitation as ordered in response to physical findings;
continue monitoring fluid status.
• Acute renal failure: Monitor and report abnormal urine output and quality, blood urea nitrogen (BUN)
and creatinine levels; assess for urine hemoglobin or myoglobin; administer increased fluids as
prescribed.
• Compartment syndrome: Assess peripheral pulses hourly with Doppler; assess neurovascular status
of extremities hourly (warmth, capillary refill, sensation, and movement); remove blood pressure cuff
 after each reading; elevate burned extremities; report any extremity pain, loss of peripheral pulses or
sensation; prepare to assist with escharotomies.
• Paralytic ileus: Maintain nasogastric tube on low intermittent suction until bowel sounds
resume; auscultate abdomen regularly for distention and bowel sounds.
• Curling’s ulcer: Assess gastric aspirate for blood and pH; assess stools for occult blood;
administer antacids and histamine blockers (eg, ranitidine [Zantac]) as prescribed.
Restoring Normal fluid Balance
• Monitor IV and oral fluid intake; use IV infusion pumps.
• Measure intake and output and daily weight.
• Report changes (e.g., blood pressure, pulse rate) to physician.
Preventing Infection
• Provide a clean and safe environment; protect patient from sources of cross contamination (e.g.,
visitors, other patients, staff, equipment).
• Closely scrutinize wound to detect early signs of infection.
Monitor culture results and white blood cell counts.
• Practice clean technique for wound care procedures and aseptic technique for any invasive
procedures. Use meticulous hand hygiene before and after contact with patient.
• Caution patient to avoid touching wounds or dressings; wash unburned areas and change linens
regularly.
Maintaining Adequate Nutrition
• Initiate oral fluids slowly when bowel sounds resume; record tolerance—if vomiting and
distention do not occur, fluids may be increased gradually and the patient may be advanced to a normal
diet or to tube feedings.
• Collaborate with dietitian to plan a protein and calorie-rich diet acceptable to patient. Encourage family
to bring nutritious and patient’s favorite foods. Provide nutritional and vitamin and mineral supplements
if prescribed.
• Document caloric intake. Insert feeding tube if caloric goals cannot be met by oral feeding (for
continuous or bolus feedings); note residual volumes.
• Weigh patient daily and graph weights.
Promoting Skin Integrity
• Assess wound status.
• Support patient during distressing and painful wound care.
• Coordinate complex aspects of wound care and dressing changes.
• Assess burn for size, color, odor, eschar, exudate, epithelial buds (small pearl-like clusters of cells on
the wound surface), bleeding, granulation tissue, the status of graft take, healing of the donor site, and
the condition of the surrounding skin; report any significant changes to the physician.
• Inform all members of the health care team of latest wound care procedures in use for the patient.
• Assist, instruct, support, and encourage patient and family to take part in dressing changes and wound
care.
• Early on, assess strengths of patient and family in preparing for discharge and home care.

Relieving Pain and Discomfort

• Frequently assess pain and discomfort; administer analgesic agents and anxiolytic medications, as
prescribed, before the pain becomes severe. Assess and document the patient’s response to
medication and any other interventions.
• Teach patient relaxation techniques. Give some control over wound care and analgesia. Provide
frequent reassurance.
 • Use guided imagery and distraction to alter patient’s perceptions and responses to pain; hypnosis,
music therapy, and virtual reality are also useful.
• Assess the patient’s sleep patterns daily; administer sedatives, if prescribed.
• Work quickly to complete treatments and dressing changes.
Encourage patient to use analgesic medications before painful procedures.
• Promote comfort during healing phase with the following:
• oral antipruritic agents, a cool environment, frequent lubrication of the skin with water or a silica-based
lotion, exercise and splinting to prevent skin contracture, and diversional activities.
Promoting Physical Mobility
• Modify interventions to meet patient’s needs. Encourage early sitting and ambulation. When legs are
involved, apply elastic pressure bandages before assisting patient to upright position.
• Make aggressive efforts to prevent contractures and hypertrophic scarring of the wound area after
wound closure for a year or more.
• Initiate passive and active range-of-motion exercises from admission until after grafting, within
prescribed limitations.
• Apply splints or functional devices to extremities for contracture control; monitor for signs of vascular
insufficiency, nerve compression, and skin breakdown.
Promoting Activity Tolerance
• Schedule care to allow periods of uninterrupted sleep. Administer hypnotic agents, as
prescribed, to promote sleep.
• Communicate plan of care to family and other caregivers.
• Reduce metabolic stress by relieving pain, preventing chilling or fever, and promoting integrity of all
body systems to help conserve energy. Monitor fatigue, pain, and fever to determine amount of activity
to be encouraged daily.
• Incorporate physical therapy exercises to prevent muscular atrophy and maintain mobility required for
daily activities.
• Support positive outlook, and increase tolerance for activity by scheduling diversion activities in periods
of increasing duration.
Evaluation:
In a patient with burn injury, the expected outcomes are:
• Absence of dyspnea.
• Respiratory rate between 12 and 20 breaths/min.
• Lungs clear on auscultation,
• Arterial oxygen saturation greater than 96% by pulse oximetry.
• ABG levels within normal limits.
• Patent airway
• Respiratory secretions are minimal, colorless, and thin.
• Urine output between 0.5 and 1.0 mL/kg/h.
• Blood pressure higher than 90/60 mmHg.
• Heart rate less than 120 bpm.
• Body temperature remains between 36.1oC and 38.3oC