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is an injury to body tissue

caused by excessive heat OC) (>40

A. Assessment
1. Assess airway, breathing, circulation, disability, exposure (prevent hypothermia) and the need for fluid resuscitation. Also assess severity of burns and conscious level. 2. Identify the cause 3. Assess for associated injuries: associated injuries may be sustained while the victim attempts to escape the fire. Explosions may throw the patient some distance and result in internal injuries or fractures.

4. Burns sustained within an enclosed space suggest possible inhalation injury. 5. Pre-existing illnesses, drug therapy, allergies and drug sensitivities 6. Body surface area: Rule of Nines 7. Depth of burn 8. Circumferential extremity burns: assess status of distal circulation, checking for cyanosis, impaired capillary refilling or progressive neurological signs. Assessment of peripheral pulses in burn patients is best performed with a Doppler ultrasound.

B. Characteristics of Burns

Mechanism of Burn injury

Scald -the most common type of burn injury caused by hot liquids or gases Contact burns- this type result from contact of the skin with hot items, including flames Chemical burns- this is the result from contact of the skin with chemicals, or by ingestion of chemicals

Electrical burns- this type of burns result when a person comes into contact with a source of electrical energy; includes burns caused by electrocution and lightning strike Radiation burns- it is the result from contact with a source of radiation; may include overexposure Inhalation Injury- refers to injury due to inhalation or exposure to hot gaseous products of combustion

Superficial burn (1st degree burn) Superficial partial thickness burn (Superficial 2nd degree burns) Deep partial thickness burn (Deep 2nd degree burns)

Ultraviolet light, very short flash (flame exposure) Scald (spill or splash),short flash

Dry and red; blanches with pressure Blisters; moist, red and weeping; blanches with pressure Blisters (easily unroofed); wet or waxy dry; variable color (patchy to cheesy white to red); does not blanch with pressure Waxy white to leathery gray to charred and black; dry and inelastic; does not blanch with pressure


3 to 6 days

Painful to air and temperature

7 to 20 days

Scald (spill), flame, oil, grease

Perceptive of pressure only

More than 21 days

Full thickness (3rd degree burns)

Scald (immersion), flame, steam, oil, grease, chemical, high-voltage electricity

Deep pressure only Never (if the burn affects more than 2 percent of the total surface area of the body)


Depth of the burn: Determined by the depth of tissue involved, the greater the depth, the more severe the burn The extent of the burn: Determined from the Rule of Nines or other calculation methods. The larger the extent, the more severe the burn The location of the burn: Burns of the face, hands, neck, perineum, and feet, even if small burns, can become debilitating

The age of the patient: The age of the patient is important in determining the outcome, infant children, and the elderly are seriously affected by severe burn injuries. The patient's general health: The underlying health of the patient plays a major role. Diabetes, hypertension, cardiac or pulmonary diseases can often increase mortality rates or complicates the condition of the burn patient. Any associated injuries (i.e. trauma etc.): Fractures or internal injuries can complicate a burn injury; this type of complication could be caused by an explosion, Motor Vehicle Accident or from fires associated with falls.

Rule of Nines
Head & Neck 18% Trunk (Front) - 18% Trunk (Back) - 18% Whole Arm - 9% Whole Leg - 14% Groin - 1%

Classification of Burn based on Severity

Type of burn

<10% TBSA Full thickness <2%TBSA

10-20% TBSA Full thickness <10%TBSA(noncritical areas)



Outpatient management

>20%TBSA Full-thickness >10%TBSA (Burns in critical areas) Hospital admission Referral to burn center

Classification of Burn based on Severity

Type of burn

<10% TBSA Full thickness <2%TBSA

10-20% TBSA Full thickness <10%TBSA(non -critical areas)

>20%TBSA Full-thickness >10%TBSA (Burns in critical areas)

*Critical areas: face, hands, feet, perineum

C. Pathophysiology
Burn Injury results from the energy transfer from a heat source (chemical, flame, electrical, etc.) The three zones of a burn:

1. Zone of coagulationthis occurs at the point of maximum damage. In this zone there is irreversible tissue loss due to coagulation of the constituent proteins.

2. Zone of stasisthe surrounding zone of stasis is characterized by decreased tissue perfusion. The tissue in this zone is potentially salvageable. The main aim of burns resuscitation is to increase tissue perfusion here and prevent any damage becoming irreversible. Additional insultssuch as prolonged hypotension, infection, or edemacan convert this zone into an area of complete tissue loss. 3. Zone of hyperemiain this outermost zone tissue perfusion is increased. The tissue here will invariably recover unless there is severe sepsis or prolonged hypoperfusion.

Local Effects
1.Tissue damage 2. Inflammation 3. Infection

Systemic Effect
1. Fluid loss 2. Multiple organ failure 3. Inhalation Injury

D. Nursing Diagnoses

Impaired Skin Integrity related to burns, Thrombocytopenia purpura, and Anaphylaxis High risk for infection related to impaired skin integrity, damage to respiratory mucosa, presence of dead skin, and Poor nutrition High Risk for Fluid Volume Deficit related to Inflammatory response to burn with protein and fluid shifts, Massive fluid shifting and circulating volume loss, Hemorrhage; stress ulcer High Risk for Ineffective Breathing Pattern related to Burns to head/neck, Massive edema, Inhalation of smoke/heated air High Risk for Altered Peripheral Tissue Perfusion related to Blockage of microcirculation, Blood loss, Compartment syndrome (edema restricting circulation)

High Risk for Altered Nutrition related to prolonged

interference in ability to ingest or digest food, increased basal metabolic rate, Loss of protein from dermal wounds Acute pain related to burn wound High Risk for Impaired Home Maintenance Management related to altered body image, self-concept related to deformity, disfigurement, or change in role capabilities, Need for long-term rehabilitation, follow up care, Need for assistance with daily care, and Unavailability/exhaustion of family members Decreased cardiac output related to fluid loss and hypermetabolic state Impaired Gas exchange related to inhalation injury, pain, and immobility

Impaired Physical Mobility related to dressings, pain, and

contractures Disturbed body Image related to pain, scarring, and disfigurement Fear and anxiety related to pain, treatments, procedures and hospitalization

Impaired Parenting related to crisis situation, prolonged

hospitalization, and disfigurement

E. Nursing Interventions
1. Support cardiac output a. be alert to the symptoms of shock that occur shortly after a severe burn-tachycardia, hypothermia, hypotension, pallor, prostration, shallow respiration, anuria b. monitor the administration of IV fluids (R: Major burns are followed by a reduction in blood volume due to outflow of plasma to tissues) c. maintain and record intake and output to provide an accurate measurement of volume d. with severe burn injuries, insert and indwelling catheter e. weigh the patient daily to help evaluate fluid balance f. provide oxygen mask, if necessary g. maintain a warm, humidified ambient environment to maintain body temperature and decrease fluid needs

2. Prevent infection a. provide skin care to prevent infection and promote healing b. prevent child from scratching by administering antipruritics and apply protective devices to hands c. assess drainage for color, odor, and amount d. administer topical antimicrobials and systemic antibiotics as ordered e. observe signs of toxemia, such as, fever, prostration, tachycardia, vomiting, and oliguria, report immediately 3. Optimizing Gas exchange a. be alert and report symptoms of respiratory distressdyspnea, stridor, tachypnea,, restlessness, cyanosis, coughing, increasing hoarseness, drooling b. provide oxygenation c. monitor arterial blood gas levels as necessary

4. Ensure adequate nutrition a. be aware that hypernutrition is important because of hypermetabolism related to large burn injury b. maintain ambient room temperature to minimize metabolic expenditure c. monitor dietary compliance with dietary goals and adjust as needed d. administer total parenteral nutrition if necessary e. monitor nutritional status through weight gain 5. Preserve mobility a. encourage range-of-motion exercises, ambulation, position changes to minimize joint and skin complications b. apply pressure garments to aid circulation and protect newly healed skin as long as 12-18 months after injury, until the healed skin has matured c. medicate for pain before exercise or therapy to reduce discomfort

6. Alleviate pain a. assess signs of pain such as irritability, crying, elevated BP, tachycardia and inability to sleep b. administer analgesics or sedatives relieve pain c. maintain warmth and prevent chilling d. provide diversional activities appropriate to age to distract from focus on pain 7. Prevent negative body image a. encourage child to express about the way he feels and looks b. provide emotional support to child most especially his parents

8. Reduce fear and anxiety a. explain surgeries, procedures and treatments to child based on age and level of understanding b. allow child to express fears through puppet, dolls, water play, clay and drawings

F. Medications
Thermal Burn Medications
1. Analgesics-for severe pain

Morphine sulfate Demerol Vicodin

2. Nonsteroidal Anti-inflammatory Agents

Ibuprofen (Advil, Motrin) Naproxen Ansaid Anaprox

3.Topical Antibiotics
Neosporin Silvadene

Chemical Burn Medications

Silvadene Erythromycin ointment (Bacitracin)

Morphine Acetaminophen.

3.Nonsteroidal Anti-inflammatory Agents

Advil Motrin Ansaid Naprosyn Anaprox

Electrical Injuries
Lactated ringers are used for fluid resuscitation

2.Osmotic Diuretics

3.Scar Treatment Medications

Mederma Cica-Care gel sheets

G. Surgical Procedures
1. Dermabrasion is a surgical procedure to improve or minimize the appearance of scars, restore function and correct disfigurement resulting from an injury. 2. Skin graft is surgical procedure in which a piece of skin from one area of the patient's body is transplanted to another area of the body.

3. Escharotomy is a surgical procedure used to treat full thickness burns. Since full thickness burns are characterized by tough, leathery eschar, an escharotomy is used primarily to combat compartment syndrome. 4. Debridement is the removal of unhealthy tissue from a wound to promote healing. It can be done by surgical, chemical, mechanical, or autolytic (using your body's own processes) removal of the tissue.

H. Evaluation
Absence of shock, stabilization of vital signs Absence of infection Adequate nutritional status: weight gain and wound healing Absence of shock, stabilization of vital signs Absence of infection

Adequate nutritional status: weight gain and wound healing Improved mobility Minimal discomfort Positive body image: verbalization, socialization and ability to look self in mirror