BURNS Mrs.

Hanan AL Majed
MSN, RN
INTRODUCTION
Many people are hospitalized each year for burns.

Burns affect not only the skin but also every major body system.

Smoke inhalation and wound infections complicate care of the patient who
has been burned.
 Pathophysiology And
Signs And Symptoms
Burns are wounds caused by an energy transfer from a
heat source to the body, heating the tissue enough to cause
damage.
Locally, the heat denatures cellular protein and interrupts
the blood supply.
The three zones of tissue damage that occur with burns
are:
The zone of coagulation.

The zone of stasis.

The zone of hyperemia

Pathophysiology And Signs And
Symptoms

The amount of skin damage is related to:

1. The temperature of the burning agent.
2. The burning agent itself.
3. The duration of exposure.
4. The conductivity of tissue.
5. The thickness of the involved dermal structures.
SYSTEMIC RESPONSES
1. Fluid Balance
Following a major burn, increased capillary permeability leads to the leakage of
plasma and proteins into the tissue, resulting in the formation of edema and loss of
intravascular volume.

There is also water loss by evaporation through the burned tissue that can be 4
to 15 times normal.

Increased metabolism leads to further water loss through the respiratory system.
 SYSTEMIC RESPONSES
2. Cardiac Function
A burn is followed by an initial decrease in cardiac output, which is further compromised by the loss of
circulating plasma volume.
Severe hematologic changes resulting from tissue damage and vascular changes occur in patients with major
burns.
Plasma moves into the interstitial space because of increased capillary permeability.
In the first 48 hours after a burn, fluid shifts lead to hypovolemia and, if untreated, hypovolemic shock.
Loss of intravascular fluid causes a relative increase in hematocrit, and red blood cells are destroyed.
The intense heat decreases platelet function.
Leukocyte and platelet aggregation may progress to thrombosis.
 SYSTEMIC RESPONSES
3. Metabolic Changes
A high metabolic rate proportional to the severity of the burn is usually maintained until wound
closure.

This hypermetabolism is further compromised by associated injuries, surgical interventions, and the
stress response.

Severe catabolism also begins early and is associated with a negative nitrogen balance, weight loss,
and decreased wound healing.

Elevated catecholamine (epinephrine, norepinephrine) levels are triggered by the stress response.

This, along with elevated glucagon levels, can stimulate hyperglycemia.

SYSTEMIC RESPONSES
4. Gastrointestinal Problems
A few of the gastrointestinal (GI) problems that can develop with a major
burn include gastric dilation, peptic ulcers, and paralytic ileus.

Most of these problems occur in response to fluid shifting, dehydration,

opioid analgesics, immobility, depressed gastric motility, and the stress
response.
SYSTEMIC RESPONSES

5. Renal Function
Acute renal insufficiency can occur as a result of hypovolemia and
decreased cardiac output.
Fluid loss and inadequate fluid replacement can lead to decreased renal
blood flow and glomerular filtration rate.
Extensive burns can cause destruction of muscle, creating myoglobin
casts that can block renal tubules and lead to renal failure.
SYSTEMIC RESPONSES
6. Pulmonary Effects

Pulmonary effects are mostly related to smoke inhalation.

However, hyperventilation may occur with any moderate to major burn

injury, usually proportional to the severity of the burn.

Oxygen consumption increases because of the hypermetabolic state,

fear, anxiety, and pain.

 EVALUATION OF BURN INJURIES
The severity of a burn injury is determined by the depth of tissue destruction,

percentage of body surface area injured, cause of the burn, age of the patient,

additional injuries, medical history (e.g., heart disease, diabetes), and location of the

burn wound.
 CLASSIFICATION OF BURN DEPTH
Classification Formerly Areas Involved Appearance Sensitivity Healing Time
Partial First to second Epidermis Bright red to pink, Sensitive to air, 7–10 days
thickness degree Papillae of dermis Blanches to touch, Serum- temperature, and
(superficial) filled blisters touch
Glistening, moist
Partial Second degree Epidermis, half to Blisters may be present. Pressure may be 14–21 days; may
thickness seven-eighths Pink to light red to white. painful because need grafting
(deep) of dermis Soft and pliable. of exposed nerve to decrease
Blanching present. endings. scarring
Full thickness Third to fourth Epidermis Snowy white, gray, or No pain because Grafting necessary
degree Dermis brown nerve endings are to complete
Tissue Texture is firm and destroyed, unless healing
Muscle leathery surrounded by
Bone Inelastic areas of
partialthickness
burns
Classification Example
Partial thickness
(superficial)

Partial thickness (deep)

Full thickness
 Percentage of
Body Surface Area
Injured.
Rule of Nines
Lund And Browder
Chart
Common Causes of Burns
Flame House fire is a common cause.
Usually associated with an inhalation injury. Flash injury occurs from a sudden ignition or explosion.
Contact Hot tar, hot metals, or hot grease produce a full-thickness injury on contact.
Scald A burn from hot liquid.
More common in children younger than age 5 and adults older than age 65.
With an immersion scald, there are usually no splash marks; usually involves lower regions of body.
Chemical Usually occurs in an industrial setting.
Extent and depth of injury are directly proportional to concentration and quantity of agent, duration of
contact, and chemical activity and penetrability of agent.
Electrical One of the most serious types of burn injury; can be full thickness with possible loss of limbs, as well as cause
internal injuries.
Entry wound is usually ischemic, charred, and depressed. Exit wound may have an explosive appearance.
Extent of injury depends on voltage, resistance of body, type of current, amperage, pathway of current, and
duration of contact.
Bones offer greatest resistance to the current; resulting in great damage.
Tissue fluid, blood, and nerves offer least resistance; therefore, the current travels this path.
Radiation Can occur in an industrial setting, as a result of treatment of disease, or from ultraviolet light (sun or tanning
salons). Severity depends on type of radiation, duration of exposure, depth of penetration, distance from
source, and absorbed dose.
COMPLICATIONS
PULMONARY INJURY
Damage usually occurs within 24 to 48
hours.

An inhalation injury is a major cause of

morbidity and mortality associated with
burn injuries.

Carbon monoxide toxicity.

INFECTION
Infection is the most common cause of death in patients with burns after the first
7 days.

Immune system is compromised by severe burn injury.

The health care provider must:

Handle all catheters with clean technique.

Make proper Hand hygiene

Sterile gloves when dressings are removed and wounds exposed

Monitor for signs of septic shock

 TRAUMA
Burn wounds may mask some of the classic signs
of underlying injuries, such as ecchymosis or
swelling.
Look for concomitant injuries like fractures and
head trauma.
Ensuring adequate airway, breathing, and
circulation
Cervical spine injuries should be stabilized and
cleared.
CT scan if head trauma is suspected
DIAGNOSTIC TESTS
Burns are diagnosed by physical assessment.

Common laboratory tests include complete blood cell count (CBC) and differential,
blood urea nitrogen (BUN), serum glucose and electrolytes, serum protein and
albumin levels, urinalysis, urine cultures, and clotting studies.

If an inhalation injury is suspected, arterial blood gases, bronchoscopy, and

carboxy-hemoglobin levels are done.

X-rays, electrocardiogram, and wound cultures are completed if indicated.

 Therapeutic Measures
Stages of Burn Care
Stage Duration

I (Emergent) From onset of injury to completion of fluid resuscitation

II (Acute) From start of diuresis to near completion of wound

closure

III (Rehabilitation) From wound closure to return of optimal level of physical

and psycho - social function
Stages of Burn Care, I (EMERGENT)
Primary Survey Secondary Survey
1. Airway maintenance with cervical 1. Complete blood count (CBC)
spine protection 2. Comprehensive chemistry panel,
including blood urea nitrogen
2. Breathing and ventilation
3. Creatinine level
3. Circulation with hemorrhage control
4. Urinalysis
4. Disability (assess neurological deficit) 5. ABG values to include
carboxyhemoglobin
5. Exposure (completely undress the
patient, but maintain temperature) 6. Electrocardiogram
7. Chest radiograph
Stages of Burn Care, I (EMERGENT)
Providing Hemodynamic Support
Correct fluid, electrolyte, and protein deficits.

Replace continuing losses and maintain fluid balance.

Prevent excessive edema formation.

Maintain an hourly urinary output of 30 to 50 mL/h (approximately 0.5

mL/kg/h) in adults.
 FLUID RESUSCITATION
ABA recommendations for
resuscitation:
– 2 to 4 mL/kg/%TBSA of LR
– ½ given in the first 8 hours
(starting from the time of the
burn injury)
– ¼ given over the next 8 hours
– ¼ given over the next 8 hours
CASE STUDY.
Mrs. Rivera is admitted to the emergency department after sustaining injuries from a
house fire. Both arms and hands are burned, she has a right leg fracture and a
possible neck fracture, her lips are swollen, her face is sooty, and she is spitting up
grayish, blackish sputum.
1. What is your priority concern with all of these injuries?
2. An IV is ordered at 1 L over 6 hours. How many milliliters per hour should be set
on the controller?
3. Approximately what percent of her body is burned?
4. What members of the health team will collaborate on Mrs. Rivera’s care?
1. What is your priority concern with all of these injuries?

Mrs. Rivera has an inhalation injury. This takes precedence over the burn and other injuries.

2. An IV is ordered at 1 L over 6 hours. How many milliliters per hour should be set on the
controller?

167 mL/hr

3. Approximately what percent of her body is burned?

Approximately 18%.

4. What members of the health team will collaborate on Mrs. Rivera’s care?

Burn care requires a true interdisciplinary approach.

She has a major burn, so the burn nurse will collaborate with a burn physician, plastic surgeon,
pulmonary physician, orthopedic surgeon, physician assistant or nurse practitioner, physical
therapist, occupational therapist and dietitian.
PROVIDING PULMONARY SUPPORT
Inhalation injury increases the mortality rate
by 20%.
Goals: improve oxygenation, decrease
interstitial edema, and airway occlusion.
Humidified oxygen
Fowler’s position
Administering aerosolized racemic
epinephrine
Severe upper airway obstruction may
require endotracheal intubation.
High Fowler’s position, coughing and deep
breathing, chest physiotherapy, repositioning,
frequent tracheal suctioning, and incentive
spirometry
Frequent suctioning, and bronchoscopic
removal of debris, may require endotracheal
intubation and mechanical ventilatory
support.
Escharotomy
Circumferential burn to an arm or leg may
mimic compartment syndrome.
Remove rings, watch, and other jewelry.
Elevation and range of motion of the injured
extremity
Assess hourly—skin color, sensation, capillary
refill, and peripheral pulses
Escharotomy at the bedside
Narcotics and benzodiazepines for comfort
Stages of Burn Care, II (ACUTE)
Once stabilized, promote healing and prevent infection.

Ensure optimal nutrition.

Providing musculoskeletal support

 Physical and occupational therapy begins on day 1.( to prevent
contractures)
 Managing pain
 Narcotics intravenously; absorption of the drug is unpredictable.
 Stages of Burn Care, II (ACUTE)
Caring for the Wound:
Cleansing
 Clean with water and chlorhexidine or normal saline solution and povidone-iodine (Betadine) with each
dressing change.
 Observe for signs of infection and rate of healing.

 The first step in this process is removing exudates and necrotic tissue.

Hydrotherapy

Topical antimicrobial medications

 General Principles for Dressings
1. Limit the bulk of the dressing to facilitate range of motion.
2. Never wrap skin-to-skin surfaces (e.g., wrap fingers or toes separately; place a
donut gauze dressing around the ear).
3. Base dressings on the size of wounds, absorption, protection, and type of
debridement.
4. Wrap extremities from distal to proximal to promote venous return.
5. Do not wrap dressings too tightly.
6. Check peripheral pulses often.
7. Elevate affected extremities.
Common Topical Broad-spectrum Antibiotic Agents
DÉBRIDEMENT
Mechanical débridement
 Forceps and scissors to gently lift and trim loose necrotic tissue
 Wet-to-dry or wet-to-wet dressings
Enzymatic débridement
 Application of a proteolytic substance to burn wounds to shorten the time of
eschar separation
Surgical débridement
 Excised to viable bleeding points while minimizing the loss of viable tissue
 GRAFTS
Auto- graft of similar color, texture, and thickness
from a close location on the body

Sheet graft—the harvested skin is applied to the

surgically excised area

Mesh graft—the harvested skin is slit, and the graft

is then placed on the burn site.

Dressings immobilize the grafted area and prevent

shearing and dislodging of the graft.
 Providing Psychological And
Familial Support
Explain what to expect and escort them to the bedside.
Counseling for the patient/family begins on the day of admission.
Weekly family meetings
Establish trust.
Encourage self-care for family and patient.
Work with a psychiatric liaison nurse.
Hallucinations, confusion, and combativeness are common in burned patients.
Honest and open approach
Stages of Burn Care, III (REHABILITATION)

1. Physical rehabilitation

2. High-protein diet

3. Prevention of scarring and contractures

4. Psychological rehabilitation