Republic of the Philippines

Mindanao State University -Sulu

Master of Science in Nursing
Major in Nursing Administration

Burns

Presented By:
Nursia Albin-Ammad,RN.

Presented To:

Prof.Kamala Sangkula-Elam,RN,MPA,MAN,DNM(CAR)
 Burns
 Heat or chemical injury to tissue

Causes
 Radiation
 Mechanical
 Chemical
 Electrical
 Thermal

Superficial partial thickness

 The epidermis and portion of dermis is destroyed
 Slightly painful
 Appears red and dry(sunburn)
 Healing period is 3-5days
Deep partial thickness burn
 Destruction of epidermis and deeper layers of dermis.
 Burn wound is painfulWound appears red(blister and exudes fluid)
 Result to hypertrophic scar
 Healing period is 14-21days

Full thickness burn

 Involves total destruction of epidermis,dermis and underlying tissue.
 Wound color:white,red,brown or black.
 Painless
 Grafting is needed

Pathophysiology
 Due to Etiological Factor
 Heat causes coagulation necrosis to skin and subcutaneous tissue
 Release of vasoactive peptides
 Altered capillary permeability
 Fluid plasma leak into interstitial space
 Edema and dehydration
 Hypovolemic shock,decrease cardiac output,cellular shock,pulmonary edema
 Assessment Findings

First Degree
 Erythema
 Edema
 Pain
 Blanching
Second-degree
 Pain
 Oozing fluid-Filled vesicles
 Erythema
 Shiny,wet subcutaneous layer after vesicles rupture

Third-degree
 Eschar
 Edema
 Little or no pain

Rule of Nines
Diagnostic test
 Blood chemistry
 ABG Analysis
 24 hour urine collection
 Hematology
 Urine chemistry

Medical Management
 Morphine sulfate and Fentanyl
 Silver sulfadiazine 1%
 Mafenide acetate
 Silver Nitrate 0.5%
 ATS
 TT
 Anxiolytics

Pre hospital Nursing Care

 Remove from source of burns
 Apply cool water,Never Apply ice directly
 Cover the wound with sterile dressing
 Do not Apply ointments
 Assess ABC,s
 Conserve body heat
  Transport

Nursing Management

Emergent phase
 Onset of injury-24-36 hours.
 Priorities:
 First Aid
 prevention of shock
 respiratory distress
 wound assessment and initial care.
Acute Phase
 48-72 hours after burn injury.
 Priorities:
 Maintain ABC,Fluid and electrolytes.
 prevent infection
 Wound Care
 Manage pain
 Provide adequate Nutrition
Rehabilitation phase
  Begins Immediately after burns and extends for years
 Priorities:
 Wound Healing
 Psychological support
 Restore maximal functional activities
 Maintain fluid and electrolytes balance
 Maintain nutritional intake
Nursing Management
 Administer oxygen and maintain patent airway
 Administer I.V fluids as directed
 Assess for signs of hypovolemia
 Assess respiratory status and fluid balance
 Assess pain level and neurovascular status
 Administer analgesics as prescribed and evaluate response
 Monitor V/S,I/O
 Maintain patient’s diet;withhold food and fluids as ordered
 Provide suctioning,Turning,coughing deep breathing exercises
 Provide tracheostomy care and ET care as indicated
 Administer TPN
 Encourage verbalization of feelings
 Allay patient’s anxiety
 Provide emotional support
 Elevate affected extremities
 Provide ROM exercises
 Maintain warm environment
 Provide skin and mouth care

Surgical Interventions
 Skin grafting
 Tissue debridement
 Escharotomy
Complications
 Hypovolemic shock
 Septicemia
 Acute respiratory failure
 Multiple organ dysfunction

Clinical Decision Making Study Guide

 Encourage Health care professionals to focus on individual patients perceptions of disease
impact and disease activity Measures.
 Maintain Aseptic/sterile technique during wound care
 Adherence to diet, medication and treatment regimen
 Avoid wearing restrictive clothing
 Observe for signs of complications
 Emphasize the importance of follow up check up.