CLIENTS WITH

BURN

By: CHARLEMAGNE B. PULGAN, RN

 BURN
• Is an injury from exposure to heat, chemicals, radiation or
electric current leading to sequence of physiologic events.
• For severe burn cases if untreated it can lead to irreversible
tissue damage.
• Injuries result from direct contact with or exposure to any of
heat source and the heat energy from the source is transferred
to the tissues of the body
4 Major goals relating to burns
Prevention
Institution Of Life-Saving Measures For The Severely
Burned Person
Prevention Of Disability And Disfigurement Through Early
Specialized Individual Treatment
Rehabilitation Through Constructive Surgery And
Rehabilitative Programs
 REVIEW OF THE SKIN ANATOMY AND
PHYSIOLOGY
• the skin is the largest organ of the body
• having a surface area of 15 -20 square feet.
• It provides covering for the body thereby protecting the body’s organ
and tissues from the external environment.

Layers of the skin:

1. EPIDERMIS
The epidermis is the outer-thin layer of the skin; protecting the
internal structures from bacteria, viruses, fungi and trauma.
It is compose of keratinocyte and melanocyte cells
 REVIEW OF THE SKIN ANATOMY AND
PHYSIOLOGY
2. DERMIS

 is the middle layer of the skin and is considered as the “TRUE SKIN”
compose of thick layer of fibrous and elastic tissue.
 It is composed of collagen fibers consisting mast cells responsible for
phagocytosis and release histamine in burn injury.
 The dermal layer also serve as supporting and nutritional bed because
most of the blood vessels, nerves, sweat and sebaceous glands, hair
follicles are located
 REVIEW OF THE SKIN ANATOMY AND
PHYSIOLOGY
3. HYPODERMIS
 the bottom layer of skin in your body
 It has many important functions, including storing energy,
connecting the dermis layer of your skin to your muscles and bones
 insulating your body and protecting your body from harm
(subcutaneous layer or superficial fascia) lies between the dermis and
underlying tissues and organs.
 It consists of mostly adipose tissue and is the storage site of most
body fat
 Function Of The Skin
1. Protection of the internal
structures against infection
and trauma
2. Sensation
3. Fluid Balance
4. Temperature Regulation
 
5. Vitamin D Production
 
Mechanism
It covers the internal structures of the body from the
external environment
Receptor endings of nerves senses temperature, pain, light
touch, pressure
Prevents H20 loss and extra H20 release through
perspiration ; serves as water repellent
Body continuously produces heat as result of food
metabolism and this heat is primarily dissipated in the
skin
Skin expose to UV light can convert cholesterol
molecules to vit. D
Physiologic Response to Burn Injury
• Burns are cause by a transfer of energy from a heat source to the body through
conduction and electromagnetic radiation leading to skin disruption causing increase
fluid loss, massive infection, hypothermia, scarring, compromised immunity ,change in
body function ,appearance and body image .
• In severe cases, fluid and electrolyte imbalance ensue.
• If a person inhales products of combustion, respiratory function is compromised.
• Cardiac dysrhythmia and circulatory failure, profound catabolic state increasing
caloric expenditure and nutritional deficiencies are also manifestations in serious burn
injury.
• Gastrointestinal motility if altered , leads to ulcer and paralytic ileus.
• If dehydration is severe , it slows down the glomerular filtration rate, renal clearance of
toxic wastes may lead to tubular necrosis and acute renal failure.
 CLASSIFICATION OF BURN
A. Thermal Burn

This can be caused by

flame, scald or contact
with hot objects
B. Chemical Burns
 This results from tissue injury and destruction
from acids, alkalis and organic compound
1. Acids are found in many household cleaners
like hydrochloric, oxalic, hydrofluoric acid
2. Alkalis are found in oven and drain cleaners,
fertilizers and heavy industrial cleaners
3. Organic compound include phenols and
petroleum products: phenols are found in
chemical disinfectants while petroleum
products are found in creosote and gasoline
C. Smoke and Inhalation Injury

1. carbon monoxide poisoning

2. Inhalation injury above the glottis (due to inhalation of hot air,
steam or smoke) thus, mucosal burn and mechanical obstruction
of the airway can occur
3. Inhalation injury below the glottis this is related to the exposure
to smoke or toxic fumes. Clinical manifestations of pulmonary
edema, ARDS appear 12 to 24 hours after the burn
D. Electrical Burn

 Due to intense heat generated from electric current (contacts with

electric current can cause muscle contractions strong enough to
fracture long bones and vertebrae)
 All patients with electrical burn should be considered at risk for a
potential cervical spine injury
 Electrical injury puts the patient at risk for dysrhythmias or cardiac
arrest, severe metabolic acidosis, and myoglobinuria which cause
immediate cardiac standstill or fibrillation (CPR should be initiated
immediately)
D. Radiation Burns

Due to excessive exposure to sunlight or from exposure to

ionizing radiation as cancer treatment

E. Cold Thermal Injury

 also called frostbite

 exposed to freezing temperatures for too long
 COMMON PLACES AND CAUSES OF BURN
INJURY
1. Occupational Hazards 2. Home and recreational: (kitchen
 Tar and bathroom)
 Chemicals  Pressure Cookers

 Hot metals  Microwave Oven

 Steam Pipes  Gas Stoves
 Combustible fuels  Hot water heater
 Fertilizers, Pesticides  Hot grease or liquid from
 Electricity from cooking
powerlines
 Sparks from live electric
source
3. General Home
 Gas Fireplace
 Open space Heaters
 Frayed or defective wiring
 Radiators (home, automobile)
 Improper use of outdoor grills
 Multiple extension cords per outlet
 Carelessness with cigarettes or
matches
 Improper use/ storage of flammables
(Gasoline , Kerosene)
 TYPES OF BURN INJURY AND RISK REDUCTION
STRATEGIES
1. FLAME
 Never leave candles unattended or near open windows and
curtains
 Encourage used of child-resistant lighters
 Install smoke / carbon monoxide detectors
 Encourage use of home fire exits drills
 Never use gasoline or other flammable liquids as accelerants
of fire
 Never leave hot oil unattended while cooking
 Do not smoke in bed or if very tired and likely to fall asleep
2. ELECTRICAL
 Avoid repair frayed wiring
4. CHEMICAL
 Store
chemicals safely
 Ensure electrical power source is shut off before
commencing repair in approved containers
and label appropriately
 Ensure safety of
3. SCALD workers handling
 Lower hot water temperature to the “lowest point”
chemicals (education,
or 40’C protective eyewear,
 Utilize “anti-scald” devices with showerhead or gloves , masks,
faucet fixtures clothing)
 Supervise bathing with small children, older
adults, or anyone with impaired physical
movement/ physical sensation/ judgment
 After running bath water, check temperature with
hand or bath temperature
 Cause /Type Causative Agent Priority Treatment
open flame Extinguish flame (stop, drop, and roll)
Thermal
steam Flush with cool water
  hot liquids (water, grease, tar, Consult fire department
metal)
Acids Neutralize or dilute chemical
Chemical
Strong alkalis Remove clothing
Organic compounds Consult poison control center

Direct current Disconnect source of current

Electrical
Alternating current Initiate CPR if necessary
Lightning Move to area of safety
Consult electrical experts
Solar Shield the skin appropriately
Radiation
X-rays Limit time of exposure
Radioactive agents Move the patient away from the radiation source
Consult a radiation expert
 BURNS MAY BE CLASSIFIED ACCORDING TO
DEPTH OF SKIN INVOLVED AS FOLLOWS:
1. FIRST DEGREE
 involves the epidermis; reddish, intact skin , painful
2. SECOND DEGREE
 involves the dermis; moist surface, with blisters, more painful
3. THIRD DEGREE
 involves the subcutaneous layer; pearly white, no pain
4. FOURTH DEGREE
 involves the muscles and bones; blackish or charred, no pain

!!! NOTE:
 First and Second degree burns are partial-thickness burns
 Third and Fourth degree burns are full-thickness burns
 STAGES OF BURN
1. SHOCK PHASE or FLUID ACCUMULATION or EMERGENT PHASE

 first stage of burn

 It occurs during the first 48 hours post-burns
 Fluid shifts from intravascular compartment to interstitial
compartment (IVC to ISC). This leads to generalized dehydration
increased capillary pressure, increased capillary permeability, decreased
interstitial hydrostatic pressure, chemical inflammatory mediators, and
increased interstitial protein retention
 STAGES OF BURN

 Hypovolemia occurs due to plasma loss (this causes

decreased cardiac output and fall of Blood Pressure)
 Hemoconcentration: increased hematocrit. Plasma is
lost into the interstitial compartment (ISC)
 Oliguria: due to decreased renal tissue perfusion,
decreased release of ADH and aldosterone
 STAGES OF BURN
Why do burns have blisters?

A burn blister is a covering of skin that forms over a burnt area of

the body to protect it from infection
body's way of protecting the underlying skin while it heals, so
popping it can cause infection and slow down the healing process.
If a blister does break, gently clean the area with water and apply
an antibiotic ointment
Fluid in the blister is ultrafiltrate of the plasma, which is rich in
proteins such as immunoglobulins, various cytokines,
prostaglandins, and interleukins
 STAGES OF BURN
Hyperkalemia and hyponatremia: results from release of potassium
from damaged cells, sodium is trapped in the edema fluids
(interstitial compartment)
metabolic Acidosis: results from accumulation of metabolites,
hyponatremia and hyperkalemia.
 Primarily, it is due to hyponatremia. Since sodium is
unavailable because it is trapped in the edema fluids. Bicarbonate
produced by kidneys will be excreted.
The goal in this phase is to preserve vital functions and prevent
hypovolemic shock
• Pre -Hospital Care
Remove person from source of burn
Assess ABC and trauma
Cover burn with sterile or clean cloth
Remove constricting clothes and jewelry
Transport immediately
• Emergency Care for • Emergency Care for Major Burns
Minor Burn
Evaluate degree and extent of burn
Administer pain
medication
Established patent airway and
Administer Tetanus administer oxygen for burn victims in
prophylaxis enclosed area
Wound care Venoclysis and assess for hypovolemia
Apply topical Maintain NPO and insert NGT
antibiotics
Insert foley catheter
Tetanus prophylaxis and give pain
medication
Fluid management is one approach to treat burn patients

Within minutes of burn injury, a massive amount of fluid shifts

from the intracellular and intravascular compartments into the
interstitium (interstitial space) (third spacing).

This kind of shift is called burn shock and it continues until

capillary integrity is restored within 24-36 hours of the injury.
Fluid resuscitation is indicated for if :

a. burns greater than 20% TBSA in adults

b. greater than 10% BSA in children, patients older than 65 or
younger than 2 years of age
c. patient with pre-existing disease that would reduce normal
compensatory responses to minor hypovolemia (Cardiac,
pulmonary, renal, hepatic , diabetes).
Computation of Body Surface Area Burn
• The extent of the burn injury size is expressed as percentage of the
total body surface area (TBSA).
• Several methods are use to determine the extent of the injury. The
“Rule of Nines” is a rapid method of estimation of the burn size.
• This method divides the body into 5 surface areas- head, trunk, arms,
legs and perineum and percentage that equal or total to the sum of
nines are assigned except the perineum which is only one percent.
 PERCENTAGE OF
BURNS

 Head, Face, Neck = 9%

 Anterior Trunk = 18%
 Posterior Trunk = 18%
 Upper Extremities = 9%
 Lower Extremities = 18%
 Genital = 1%
Common Formula for Fluid Resuscitation
Fluid resuscitation is the administration of the intravenous fluids to
restore the circulating blood volume during the acute period of capillary
permeability in order to prevent burn shock .
Crystalloids are administered during the first 24 hours after burn injury
(Lactated Ringer/ Hartmann’s Solution) – effective volume expanders
The commonly used formula is the Parkland Formula
This formula specify to infuse the 50% volume of fluid during the first 8 hours
and the remaining 50% to be infused over the next 16 hours.

• In Parkland formula, lactated Ringer solution is administered 4 ml X kg

X % TSBA burn.
• Hartmann's (or Lactated Ringer's) solution is the preferred first-line fluid recommended by the
British Burns Association.
• Its composition and osmolality closely resemble normal bodily physiological fluids and it also
contains lactate which may buffer metabolic acidosis in the early post- burn phase.
2. DIURETIC or FLUID REMOBILIZATION or ACUTE
PHASE
 The second stage of Burn
 This occurs after 48 hours post burns
 Fluid shifts from interstitial compartment to intravascular
compartment (ISC to IVC)
 Hypervolemia, hemodilution and decreased hematocrit occur due to
fluid shifting from ISC to IVC
 Diuresis: this is due to increased renal tissue perfusion, decreased
anti-diuretic hormone and aldosterone secretion
 Hypokalemia, hyponatremia: potassium moves back into the cells;
sodium still trapped in the edema fluids
 Metabolic acidosis: decreased sodium levels cause excretion of
bicarbonate by the kidneys
Restorative therapy to wound closure and infection control are the
primary concern

Aseptic technique
tetanus immunization
IV antibiotics , topical anti-bacteria therapy wound care are the
basic management
adequate debridement of wound
Escharotomy
Fasciotomy
Hydrotherapy
Wound dressing
• ESCHAROTOMY is an
emergency surgical procedure
involving incising through areas of
burnt skin to release the eschar and
its constrictive effects, restore distal
circulation, and allow adequate
ventilation

• Escharotomy incisions must be

made in the inelastic skin eschar
that is typical of circumferential
third-degree burns.
• Later, the necrotic tissue must be
debrided and substituted with a
skin graft
• Fasciotomy is an incision
through skin, fat, and muscle
fascia, exposing the underlying
muscle compartment
• HYDROTHERAPY
through shower, bed bath and total
immersion
If total immersion is use, the tank is
lined with plastic liners and
decontamination every after use is
done to prevent cross infection,
the temperature of the water to be
use is 37 degrees Celsius and the
immersion process should not
exceed more than 30 minutes to
prevent chilling.
• WOUND DRESSING
For wound dressing , it may
open or close dressing depending
on the burn area involve in order
to maintain circulation, and
allows motion.
 For Joints , light dressing is
required to allow movement,
face dressings should be open
type of dressing
 for finger and toes, it should be
wrapped individually.
• Tilapia skin grafts have been used successfully for management of
various types of wounds in human medicine including burn wounds,
diabetic ulcers, and traumatic wounds sustained in combat (4,6–8). In
human studies, tilapia skin grafts have been shown to be superior
to other wound dressings

• Before it can be used on a patient, tilapia skin must go through a

sterilization process that removes germs and smells. The skin can
then be applied directly to the burn site like a bandage. It helps to
soothe pain and reduce healing time by several days
3. RECOVERY/REHABILITATIVE PHASE
 The 3rd stage of burn
 This occurs on the 5th day onwards
 The following problems occurs this time:
Hypocalcemia: this results from loss of calcium in the exudates. It is
also due to utilization of calcium in the granulation tissue (scar)
formation in the areas of burns
 Negative Nitrogen balance: in stress like burns, there is increased
protein catabolism, protein demands are increased for healing and
protein intake may be inadequate
 Hypokalemia: potassium has shifted back in the cells, serum levels are
decreased
Categories of Burn Injury B. MODERATE
 Partial thickness burn 15 to 25 % adult
A. MILD
TBSA
 Partial thickness < 15% adult  Full thickness 2% to 10 % adult TBSA
 Full thickness burns < 2% adult  Plus other mild category criteria
• OTHER MILD CRITERIA C. SEVERE
 Does not involve eyes ,ears, nose,  Partial thickness > 25% adult TBSA
hands, face , feet , perineum  Full thickness burns are > 10% adult
 No electrical burns / inhalation injuries TBSA
 Adult younger than 60 yrs. Old  Burns are accompanied by other injuries
 No pre existing disease and other injury  Presence of other criteria in the
with the burn previous categories
 FIRST AID INTERVENTION FOR
BURNS
A.STOP THE BURNING PROCESS
1. Immerse the affected part in cold water
2. “Drop and Roll” –Advise the client to drop and roll on the ground if
clothing is in flame (to smother the flame)
3. Throw blanket over the client to extinguish the flame.
 This cuts the source of oxygen from environment and the flame will
spontaneously be extinguished
4. If the hands are involved, remove jewelry.
Metals may be superheated causing further tissue damage. They may serve
as torniquet once edema of the hands and fingers occur
IN CASE OF FIRE USE THIS FOUR ESSENTIAL
STEPS
 COLLABORATIVE
MANAGEMENT
1. PROMOTE RESPIRATORY FUNCTION

Assess for sooty (charcoal looking) sputum and singed

hair in the nose and eye brows (singed hair are stiff and
burnt hair)
 Establish open airway
 Administer oxygen therapy as ordered
2. PROMOTE FLUID-ELECTROLYTE AND ACID-BASE
BALANCE

 Assess the following parameters:

Vital signs : elevated body temperature, increased pulse rate,
rapid respiratory rate, low blood pressure ( due to decreased
plasma volume)
 Urine Output: decreased
 Level of consciousness
 Weight Loss
 Percentage of Burns
3. RELIEVE PAIN
 Administer morphine Sulfate per IV as prescribed.
Monitor client for respiratory depression
Have Narcan (Naloxone) readily available (antidote of narcotics, if
respiratory depression occurs)
 Initially, medications are given IV because of sluggish blood
flow (increased hematocrit) during the first 48 hours post-burns
 Used bed cradle to relieve pressure from the top sheet and to
prevent sticking on exudates to the top sheet
 Avoid exposure of affected areas
Sudden gush of wind causes hypersensitivity of exposed nerve
endings. Close the door of the client’s room.
4. PREVENT INFECTION

 Practice asepsis
Handwashing is the most important practice to prevent spread of
microorganisms
 Implement reverse or protective isolation
 Administer tetanus immunization.
There is high risk of tetanus infection in burns.
If history of tetanus immunization cannot be obtained or the client
had not received booster dose for the last five years, administer
Immune Globulin
 Irrigate affected area with normal saline (NS) solution .
5. Maintain Adequate Nutrition
 Do not give oral fluids for the first 48 years.
To prevent paralytic ileus, gastric dilatation and water intoxication. SNS
stimulation causes decreased gastric motility that results to paralytic ileus.
Increased ADH secretion causes water retention.
 Provide High Calorie, High Carbohydrate, High Protein Diet – High
Calorie, High Carbohydrate provides adequate source of energy. High
Protein Diet promotes healing and tissue repair.
 Provide Diet Rich in Vitamins A, B, C
 Vitamin A- maintains skin and mucous membrane integrity
 Vitamin B- enhances metabolism
 Vitamin C- increases resistance to stress and infection
6. PROVIDE WOUND CARE

 The different methods of wound care are as follows:

a. Open Method- After application of the topical antibiotic, the area is
left exposed. This is applicable in extensive body burns

b. Semi-open Method – The wound is covered with thin layer of sterile

gauze after application of topical antibiotic.
c. Closed Method –
The wound is covered with thick layer of sterile gauze or with
occlusive dressings after application of topical antibiotic.
 No two burn surfaces should be allowed to touch; touching can
promote webbing of digits, contractures and poor cosmetic outcome.
(this is indicated with burns on hand)
 Apply dressings with the fingers separate from each other to prevent
contracture deformities
 Apply splint on the hand with the fingers curbed to allow flexion-
extension exercises of the fingers (this will also prevent nerve
damage in the fingers and prevent hyperextension deformity of the
fingers)
The Antimicrobials used in burns are as follows:

A.FURACIN (Nitrofurazone)
 Apply 1/16 inch film directly to the burn area
 Side effects: rash, contact dermatitis
B.SULFAMYLON (Mafenide Acetate)
 Apply 1/16 inch film directly to the burn area
 Administer analgesic prior to application of the medication. It causes
local pain.
 the medication may cause metabolic acidosis (usually manifested by
hyperventilation)
 Other side effects may include rash, bone marrow depression, and
hemolytic anemia
C. Silvadene (Silver Sulfadiazine)
 Apply 1/16 inch film
It does not cause acidosis
 Side effects: rash, leukopenia, nephritis
 Monitor CBC, especially WBC

D. Silver Nitrate
Apply silver nitrate to the dressing; do not apply directly to wounds,
cuts or broken skin (it stains anything with which it comes in contact.
Discoloration is not usually permanent.
7. HYDROTHERAPY

 It
is done to remove debris, improve circulation, relieve pain,
promote healing, improve muscle tone and prevent contractures
 Administer analgesic 15 to 30 minutes before hydrotherapy to
promote comfort. Immersion into the water may initially cause pain
8. DEBRIDEMENT
 To remove necrotic tissues from the area of burns. It may be surgical or
mechanical debridement
 Mechanical debridement is done by wet-to-dry dressings.
1. Wash hands
2. Wear clean gloves and confine soiled dressing within the gloves
3. Remove Gloves and confine soiled dressing within the gloves
4. Wear sterile gloves, apply sterile dressings over the area, pour sterile
Normal Saline solution over the dressing
5. Cover the moist dressing with dry dressings (gauze, sponges or absorbent
pads) to maintain moisture of the wet dressing
6. Change the dressing as it becomes dry to remove debris. As drying occurs,
wound debris and necrotic tissues are absorbed into the gauze dressing.
9. SKIN GRAFTING

 To improve appearance of the affected area

1. Isograft or syngeneic graft. The donor site comes form an
identical twin
2. Autograft. The donor site comes from the self
3. Homograft or allograft. The donor site comes from another
human being
4. Heterograft or xenograft. The donor site comes from an animal
(e.g pigskin, tilapia ).
Care of the Graft Site
 elevate and immobilize the graft site
 Keep site free from pressure
 Avoid weight bearing
 Cleanse the graft from exudates to prevent infection and prevent graft
adherence
 Monitor the graft site for signs and symptoms of infection like foul-
smelling drainage, fever, elevated WBC, hematoma or edema in the area
 Instruct the client on the following:
 Lubricate healing skin with cocoa butter lotion
 Protect affected area from sunlight
 Use splints and support garments as prescribed
10. PROMOTE GI SUPPORT TO PREVENT
STRESS ULCER (CURLING’S ULCER)

Insert NGT as ordered

 Administer antacids (histamine receptor blockers as
prescribed)
11. FLUID REPLACEMENT
 To prevent hypovolemic shock
 Types of Fluid Replacement
a. Colloids: blood, plasma expanders (Hetastarch)
b. Electrolytes: Lactated Ringer Solution (LR)
c. Non-Electrolyte: Dextrose 5% in Water (D5W)
 PARKLAND FORMULA ( Crystallized Resuscitation)
 Volume of Lactated Ringer
= 4ml x weight in kilogram x % of TBSA (total body surface area with burn)

 Allocation of fluid replacement for the first 24 hours

 1st 8 hours: 50 %
 2nd 8 hours: 25 %
 3rd 8 hours: 25
12. REHABILITATION
 The priority goal rehabilitation among burns clients is to
prevent or minimize scarring
 The client may wear anti-scar garment for 6 months
 Prevent contractures
 Promote activity tolerance and improve body image and
self-concept