Management of Patients with
Burn Injury
Faculty: Rubina Shehzadi
Nursing Lecturer
Lecture outline
Define Burns
Problems of impaired skin integrity
Various types of burns and causative agents
Classify size and depth of a burn
Pathophysiology of a major burn injury
3 phases of Managing burn patient
Burns
• An injury caused by exposure to heat or flame.
• Burns are caused by a transfer of energy from a heat
source to the body.
• Heat may be transferred through conduction or
electromagnetic radiation.
• Note: Temperatures <111°F are tolerated for long
periods without injury.
• 156°F for 2sec …destroys both the epidermis and the
dermis, causing a full thickness (third-degree) injury.
Remember!
Types of burn according to causative agent
1. Friction burns: When a hard object rubs off some of
your skin, you have what's called a friction burn. ...
2. Cold burns: Also called “frostbite,” cold burns cause
damage to your skin by freezing it. ...
3. Thermal burns
4. Radiation burns
5. Chemical burns
6. Electrical burns
Burn and scald burn difference
• Burn which is caused by dry heat like iron, fire.
• Scald burn which is caused by wet heat like
hot water.
Factors determining the depth of the burn
• How the injury occurred
• Causative agent, such as flame or scalding
liquid
• Temperature of the burning agent
• Duration of contact with the agent
• Thickness of the skin
Three zones of burn injury
• The inner zone –zone of coagulation is where
cellular death occurs and sustains the most
damage.
• The middle area-zone of statsis has a
compromised blood supply, inflammation and
tissue injury.
• The outer zone –zone of
hyperemia/hyperthermia sustains the least
damage.
Three Zones of burn
CLASSIFICATION OF
BURNS
• Burn injuries are described accor-
ding to the:
– depth of the injury
– the extent of body surface area (TBSA) injured.
1.Depth of injury
1. Superficial partial-thickness injuries— 1st degree
burn
2. Deep partial-thickness injuries— 2nd degree burn
3. Full-thickness injuries— 3rd degree burn
Conti….
2.Extent of Body Surface Area
• Three methods are used to estimate the
TBSA:
1. The rule of nines(a quick way )
2. The lund and browder method
3. The palm method
1.The Rule of Nines
• The system assigns percentages in
multiples of nine to major body surfaces..
• TBSA percentage is used to calculate
the patient’s fluid replacement needs.
• Head A& P=4.5+4.5=9%
(In child=18% of head)
• Upper extremities A & P=9+9=18%
• Lower extremities A & P=18+18=36%
(In child=28% of legs)
• Upper chest A & P=9+9=18%
• Abdominal region A & P=9+9=18%
• Genital region=1%
Difference b/w TBSA of Adult and child
2.The Lund and Browder method
• A more precise method of estimating the
extent of a burn is the Lund and Browder
method, which recognizes that the percentage
of TBSA of various anatomic parts, especially
the head and legs, and changes with growth.
3.The Palmer method
Pathophysiology of burn injury
• Burns that do not exceed 25% TBSA produce a primarily
local response.
• Burns that exceed 25% TBSA may produce both a local
and a systemic response and are considered major burn
injuries.
• Generally, the greatest volume of fluid leak occurs in the
first 24-36 hours after the burn, peaking by 6 to 8 hours.
• Hemodynamic instability involves cardiovascular, fluid
and electrolyte, blood volume, pulmonary, and other
mechanisms.
Systemic response to burn
• Cardiovascular response: hypovolemia, vasoconstriction, low CO—
>low tissue perfusion to all organs
• Burn edema: Local swelling due to thermal injury is often extensive.
Edema is defined as the presence of excessive fluid in the tissue
spaces.
– As edema increases in circumferential burns, pressure on small blood vessels
and nerves in the distal extremities causes an obstruction of blood flow and
consequent ischemia. This complication is known as compartment syndrome.
• Effects on Fluids, Electrolytes, and Blood Volume: Circulating blood
volume decreases ; , evaporative fluid loss through the burn wound
may reach 3 to 5 L or more over a 24-hour period until the burn
surfaces are covered; hyponatremia and hyperkalemia occur; red
blood cells may be destroyed and others damaged, resulting in anemia
Conti…
• Pulmonary Response: smoke Inhalation injury is the leading cause
of death in fire victims.
– Pulmonary injuries fall into several categories:
1. Upper airway injury ;mechanical obstruction of the upper airway
2. Inhalation injury below the glottis; Carbon monoxide is probably the
most common cause of inhalation.
3. Restrictive defects; when edema develops under full thickness burns
encircling the neck and thorax. Chest excursion may be greatly restricted.
The affinity of hemoglobin for carbon monoxide is 200 times greater than
that for oxygen.
patient with possible inhalation injury must be observed for at least 24
hours for respiratory complications.
ARF and ARDS are the complications of major burn.
Conti…
• GI response: paralytic ileus (absence of intestinal
peristalsis) and Curling’s ulcer(gastric or duodenal
erosion )
• Skin response: inability to regulate body temperature;
initially hypothermia; later--hyperthermia
• Renal Response: inadequate blood flow through the
kidneys, the hemoglobin and myoglobin occlude the
renal tubules, resulting in acute tubular necrosis and
renal failure
• Immunological response: resistance to infection
Pathophysiology of burn
Management of the Patient With a Burn
Injury
• Burn care categorized into three phases:
1. Emergent/ resuscitative phase
2. Acute/intermediate phase
3. Rehabilitation phase
• Although priorities exist for each of the
phases, the phases overlap
Emergent/ resuscitative phase
Emergency procedures at the burn scene:
• Extinguish the flames/remove from source— stop,
drop & roll; stop, sit & pat, don’t run and don’t stand
• Cool the burn--- soak clothe in water and apply to
burn site, never apply ice
directlyhypothermiatissue damage
• Remove restrictive objects— remove adherent
clothing and jewelry
• Cover the wound— with clean clothe, no ointment
on burn scene
• Irrigate chemical burns— rinsing with water
How to treat minor chemical burn
Immediate primary survey
• An immediate primary survey of the patient is
carried out to assess ABCDEs:
• A=Airway
• B=breathing
• C=circulatory and cardiac status
• D=Disability
• E=expose and examine in warm environment
• If airway is compromised then:
• Humidified 100% oxygen administered to patient.
• No food or fluid is given by mouth
Secondary Survey
• Taking history
• Total body system assessment
• Initial fluid resuscitation
• Psychosocial support
Medical Management
• Transported to nearest burn center/early referrals
• Mild pulmonary injury—100%oxygen;encourged to
cough; suctioning
• Fluid resuscitation started—if burn 20% of TBSA(Total
body surface area)
• Lactated ringers (LRs) given IV by using ABA formula for
first 24hours.
– For thermal and chemical burn:30-50ml/hr urine output
– For electrical burn: 75—100ml/hr urine output
• Baseline weight and blood test
• Assess for cervical/spine or head injury. remove contact
lens/jewelary if wear.
• Taking all history including 5 Ws
• Indwelling catheter is inserted
• NF tube inserted
• Clean sheets used
• Maintain temperature
• Reduce pain
• Blood test,ECG
• Inj Tetanus prophylactically
• Bp can be measured from burned extremity if necessary
American burn association ABA
• ABA Formula: for 2nd ,3rd and 4th burn
• For thermal and chemical burn
Total fluid in first 24hrs =2ml(LR)*pt wt(kg)* TBSA (%)
• For electrical burn
=4ml*pt wt(kg)*TBSA(%)
Half fluid (50% will given in first 8hrs remaining half in
next 16hrs
Maintenance fluid
For next 24 hrs = 0.3-0.5ml crystalloid/colloid* wt(kg)*
%TBSA
Nursing Diagnoses in burn patient
1. Impaired gas exchange related to carbon monoxide poisoning, smoke
inhalation, and upper airway obstruction
2. Ineffective airway clearance related to edema and effects of smoke
inhalation goal: maintain patent airway and adequate airway clearance
3. Fluid volume deficit related to increased capillary permeability and
evaporative losses from the burn wound
4. Hypothermia related to loss of skin microcirculation and open wounds
goal: maintenance of adequate body temperature
5. Pain related to tissue and nerve injury and emotional impact of injury
6. Fluid volume deficit related to loss of water from the body sec ondary to
burn
7. Anxiety related to fear and the emotional impact of burn injury
8. Impaired skin integrity related to skin damage
9. Risk for infection related to open burn wound
2. Acute/Intermediate phase
• Begins from 48-72hrs
• During this phase, attention is directed toward
continued assessment and maintenance of
respiratory and circulatory status, fluid and
electrolyte balance, and gastrointestinal function.
Infection prevention, burn wound care (ie, wound
cleaning, topical antibacterial therapy, wound
dressing, dressing changes, wound débridement,
and wound grafting), pain management, and
nutritional support are priorities at this stage.
complications
• Pulmonary complications are common in burn
injury.
• Stridor and dyspnea are the late signs of airway
obstruction
• Ventilator associated pneumonia can occur.
• As capillary regain integrity, fluid overload risk
increases which can lead to CHF.
• Hyperthermia occur which shows
sepiticemia/bacteremia
Nursing management
• Infection prevention
• Wound cleaning
• Topical antibacterial therapy
• Wound dressing
• Wound debridement(removal of devitalized
tissues)
• Wound grafting(autograft,allograft,xenograft)
• Pain management
Rehabilitation phase
It begins immediately after the burn has occurred and
often extends for years.
Complications in this phase:
• Neuropathies and nerve entrapment
• Wound breakdown or ulcer formation
• Hypertrophic scarring
• Contractures
• Joint instability
• Complex pain
Nursing management
• Psychological support
• Prevention and treatment of hypertrophic
scars
• Promoting activity tolerance
• Improving body image and self concept
• Monitoring and managing potential
complications (PTSD,grief
• High calorie,high protein diet
Burn prevention tips
Keep matches and lighters out of the reach of children.
Never leave children unattended around fire or in bathroom/bathtub.
Install and maintain smoke detectors in the home.
Develop and practice a home exit fire drill with all members of the household.
Set the water heater temperature no higher than 120°F.
Do not smoke in bed. Do not fall asleep while smoking.
Do not throw flammable liquids onto an already burning fire.
Do not use flammable liquids to start fires.
Do not remove radiator cap from a hot engine.
Watch for overhead electrical wires and underground wires when working outside.
Never store flammable liquids near a fire source, such as a pilot light.
Use caution when cooking.
Keep a working fire extinguisher in your home.
Thank you
