BURNS

By: Annabelle P. Flores, RN; MAN

Learning outcome
1. Describe the factors that affect the severity of burn injury.
2. Describe the local and systemic effects of a major burn injury.
3. Compare and contrast the potential fluid and electrolyte alterations of the
emergent/resuscitative and acute phases of burn management.
4. Describe the goals of burn care and the nurse’s role in wound assessment,
wound cleansing, topical antibacterial therapy, wound dressing, and
débridement.
 Introduction
◦ Skin is the human body’s largest organ, covering a surface area of about 2
sqm in an average adult.
◦ It consists of the epidermis and the dermis, deep within which are
important skin appendage structures (including hair follicles, sweat glands
and sebaceous glands)
◦ These deep structures are a source of proliferating epithelial cells
(keratinocytes), which migrate into the clot and wound bed, playing an
important role in the wound healing process.
◦ The loss of the physical barrier function of the skin opens the door to
invasion by harmful microorganisms, which can lead to infection, and
ultimately even to the development of sepsis.
Burns
◦ Traumatic injury to the skin and underlying tissues caused
by heat, chemical, & electrical injuries (most severe!!!)
◦ degree of tissue damage is related to:
◦ What agent caused the burn
◦ Temperature of the burning agent
◦ Duration of contact with the agent
◦ Thickness of the skin
Incidence
◦ Severity The severity of each burn injury is determined by multiple factors
◦ age of the patient;
◦ depth of the burn;
◦ amount of surface area of the body that is burned; the presence of inhalation
injury; presence of other injuries;
◦ location of the injury in areas such as the face, the perineum, hands, or feet; and
the presence of comorbid conditions
◦ . Age
◦ Young children and older adults continue to have increased morbidity and mortality
◦ Burn Depth
◦ Burns are classified according to the depth of tissue destructio
 Classification of Burns
◦ Thermal Injuries - Injuries caused by
hot liquids (scalds)—the most common
type of burn injury, accounting for
nearly 70% of burns in children, but
also common in the elderly
◦ Flame—Flame burns comprise 50% of
adult burns. They are often associated
with inhalational injury and other
concomitant trauma. Flame burns tend
to be deep dermal or full thickness.
◦ Electrical injuries

◦ Some 3-4% of burn unit admissions are

caused by electrocution injuries. An
electric current will travel through the
body from one point to another, creating
“entry” and “exit” points.

◦ They are most common in children and

male manual workers.

◦ The severity of injury is determined by

the voltage and amperage, the type of
current, duration of contact, and the
pathway of the current through the body.
◦ Chemical injuries
◦ are usually as a result of
industrial accidents but may
occur with household chemical
products. These burns tend to be
deep, as the corrosive agent
continues to cause coagulative
necrosis until completely
removed
◦ Alkalis tend to penetrate deeper
and cause worse burns than
acids. Cement is a common
cause of alkali burns.
◦ Radiation
• Gamma rays from X-rays and the
natural decay of radioisotopes,
such as (cobalt) can travel several
metres in the air and penetrate
deep into tissues.
• gamma rays can cause very deep
damage involving vital structures
such as the bone marrow and
lungs
Local Effects of Burn Injuries
Systemic Effects of Burns

◦ Burns involving more than 30% of

total body surface area (TBSA) result
in considerable hypovolemia - Burn
Shock
◦ Circulatory and microcirculatory
impairment,
◦ Plasma extravasation
◦ Edema forms rapidly after a burn • Inhalation injury is caused by
injury. A superficial burn will cause
inhalation of thermal and/or
edema to form within 4 hours,
chemical irritants.
◦ Immediately after burn injury, • Upper airway injury is obstructive
hyperkalemia (excessive potassium)
and is caused by severe upper
may result from massive cell
destruction. airway edema
• Smoke inhalation injuries cause
◦ Hypokalemia (potassium depletion)
loss of ciliary action,
may occur later with fluid shifts and
inadequate potassium replacement.
◦ Hyponatremia (serum sodium
depletion) may be present as a result
of plasma loss
Complications

◦ Kidney function may be altered as a result of decreased blood

volume post-burn injury due to the compensatory response to
intravascular volume loss.
◦ The immunologic defenses of the body are greatly altered by a
burn injury
◦ Integumentary loss also results in an inability to regulate body
temperature.
◦ Patients who are critically ill, including those with burns, are
predisposed to altered GI motility
Phases of Burn Injury
◦ The emergent phase starts with the onset of burn injury and lasts
until the completion of fluid resuscitation or a period of about the
first 24 hours.
◦ The intermediate phase of burn care starts about 48–72 hours after
the burn injury. Alterations in capillary permeability and a return of
osmotic pressure bring about diuresis or increased urinary output
◦ This Rehabilitative stage starts with the closure of the burn and
ends when the patient has reached the optimal level of functioning.
Various methods are used to estimate the TBSA
• Rule of Nines
◦ This system is based on anatomic regions, each representing approximately 9% of
the TBSA, allowing clinicians to quickly obtain an estimate of burn size
• Lund and Browder Method
• more precise method of estimating the extent of a burn
• which recognizes the percentage of surface area of various anatomic parts,
especially the head and legs, as it relates to the age of the patien
• By dividing the body into very small areas and providing an estimate of the
proportion of TBSA accounted for by each body part, clinicians can obtain a
reliable estimate of TBSA burned.
• Palmer Method
• In patients with scattered burns, the Palmer method may be used to estimate the
extent of the burns. The size of the patient’s hand, including the fingers, is
approximately 1% of that patient’s TBSA
 Assessment Findings

◦ Skin color: light pink to black (depth)

◦ Edema or blistering
◦ Pain in all areas (except full thickness
burn)
◦ Hypotension, tachycardia, oliguria or
anuria (hypovolemic shock)
◦ Breathing may be compromised (inhalation
injury)
◦ Sore throat, singed nasal hairs,
eyebrows, eyelashes, hoarseness,
carbon in sputum, shortness of breath,
stridor
◦ Entrance & exit wounds (electrical burns)
 Management
◦ Serum creatinine kinase levels are useful in determining the degree of
muscle injury in the early phases of care
◦ Myoglobinuria, common with muscle damage, may cause kidney failure if not
treated.
◦ IV fluid administration titrated to a higher target of urine output per hou
◦ To add 50 mEq of sodium bicarbonate per liter of IV fluid in an effort to assist
in alkalinizing the urine
◦ Surgical treatment of an electrical injury is as complex as the injury itself.
Vasculature is commonly affected; thus, progressive tissue necrosis occurs
over time. Sequential surgical debridement may be necessary
 Medical Management
◦ Outcome depends on the
initial 1st aid provided and the
subsequent treatment in the
hospital or burn center
◦ Life threatening:
◦ inhalation injury
◦ hypovolemic shock
◦ infection
Initial 1st Aid
• Prevent further injury (at the
scene of the fire)
• Observed closely for
respiratory difficulty
(inhalation injury) during
transport
• O2 is administered, IV fluid
◦ Parkland Formula = 4ml x Bwin kg x TBSA
◦ BW = 55
◦ TBSA = 35
◦ ANSWER 7700 ML
◦ 4X 55X35
◦ Computation 7700/2 = 3850
◦ First half = 3850 to be given for 8 hours = compute for cc/her= 481
cc/hr
◦ Second half= 3850 to run for 16 hours = 240 cc/hr
Maintenance Fluid Dose
◦ 4: 2: 1
◦ 4 ml/kg for first 10 kg 4x10 = 40
◦ 2ml/for 10-20 kg 2x 20 = 40
◦ 1 ml/ 20 kg and above 1x 25 = 25
◦ Total 105cc/hr

◦ ;2:1
 Medical Management
Acute Care
◦ Quick assessment (extent of burn injury,
additional trauma – fractures, head
injuries, lacerations)
◦ Maintain adequate ventilation
◦ Bronchoscopy (assess internal airway)
◦ Warmed humidified O2
◦ ET should be available for insertion
◦ Eschar (a hard leathery crust of
dehydrated skin) in the neck area =
tracheostomy
Management
◦Pain
◦Morphine is generally the DOC
◦Severe: 50 mg/hr
◦If respiratory depression occurs: naloxone
(Narcan)
◦Tetanus immunization is also administered
 Wound Management – Open Method
Advantages
◦ Reduces labor-intensive care
◦ Causes less pain during
wound care
◦ Facilitates inspection
◦ Decreases expense
Disadvantages
• Contributes to wound
desiccation (dryness)
• Promotes loss of water and
body heat
• Exposes wound to
pathogens
• Contributes to pain during
repositioning
• Compromises modesty
Wound Management – closed method

Advantages Disadvantages
◦ Maintains moist wound • Requires more time
◦ Promotes maintenance of body • Adds to expense
temperature • Enhances growth of pathogens
◦ Decreases cross contamination of beneath dressings
wound • Interferes with wound assessment
◦ Provides wound debridement during • Causes more blood loss with
dressing removal removal
◦ Keeps skin fold separated • Can interfere with circulation if
tightly applied
◦ Reduces pain during position changes
Pharmacologic Management
◦ Silver sulfadiazine
(Silvadene) 1% ointment
◦ Mafenide (Sulfamylon)
◦ Silver nitrate (AgNO3) 0.5%
solution
◦ Acticoat (contains a thin,
soluble film coat of silver)
◦ Povidone-iodine (Betadine)
• Gentamicin (Garamycin)
0.1% cream
• Nitrofurazone (Furacin)
• Mupirocin (Bactroban)
• Clotrimazole (Lotrimin)
• Ciclopirox (Loprox)
 Surgical Management
◦ Additional treatment modalities to
promote healing includes:
◦ Debridement
◦ Skin grafting
◦ Application of a skin substitute
◦ Application of cultured skin
 Surgical Management

◦ Skin grafting
◦ Necessary for deep partial-thickness
& full-thickness burns
◦ Purpose:
◦ Lessen the potential for infection
◦ Minimize fluid loss by evaporation
◦ Hasten recovery
◦ Reduced scarring
◦ Prevent loss of function
Sources for skin graft:
Autograft (client’s own skin)
Allograft or homograft (from a
human cadaver)
Temporarily covers large areas of
tissue (slough away approx 1
week)
Short supply; it could be a source
of other pathogen
Heterograft or xenograft (from
animals)
Temporary
Rejected in days to weeks & must
be removed & replaced at that
time
 Surgical Management
Types of Autografts
◦ Split-thickness graft
◦ Epidermis & a thin layer of dermis are harvested
◦ Cosmetic appearance is less than desirable,
less elastic, hair does not grow from their
surface
◦ Full-thickness graft
◦ Epidermis, dermis & some subcutaneous tissue
◦ Comparable appearance to normal skin
◦ Tolerate more stress once they become
permanently attached to the burn wound
◦ Slit/ lace/ expansile graft
Smooth the grafted skin, reducing scarring & the
potential for wound contractures
Skin substitute
• Biobrane (nylon silicone membrane
coated with a protein derived from pig
tissue)
• Borane is a nylon material that contains
a gelatin that interacts with clotting
factors in the wound. That interaction
causes the dressing to adhere better,
forming a more durable protective layer.
PROCESS OF APPLICATION
◦ Identify appropriate wound
◦ Remove the sterile biobrane sheet
from package
◦ Cut to fit and apply under a
moderate stretch,
◦ Attached product to surrounding
unburned skin with steri-strips

BIOBRANE REMOVAL
When healed biobrane turns whitish
and dry in appearance Gently peel off
then that wound with moisturizer If
small area still open, treat with
bacitracin or Neosporin (triple mix).
◦ Skin substitute

◦ TranCyte (from cultured human

fibroblasts from the dermis with a
biosynthetic semipermeable membrane
attached to nylon mesh)

TransCyte is stored and sealed in a

cassette with two pieces per
cassette. Product is thawed just
prior to use.
◦ Cultured Skin
◦ Growing the client’s own skin cells in a
laboratory culture medium
◦ Postage stamp-sized skin  entire body
(3weeks)
◦ Disadvantage: pigmentation does not
perfectly match the original skin
Nursing Management
◦ Focus: assessing the wound & how the burn injury has affected the
client’s status
◦ Calculates fluid-replacement requirements & infuses the prescribed
volume according to agency’s protocol
◦ Quickly recognized & efficiently treats signs of shock
◦ Administer prescribed analgesics
◦ Wound care
◦ Helps the client & family to cope with the change in body image
◦ Health teaching (pressure garments, skin care, etc…)
Nursing Interventions and Actions

◦ Improving Physical Mobility

◦ Circulation, motion, and sensation of digits frequently.
◦ Maintain proper body alignment with supports or splints, especially for
burns over joints.
◦ Perform ROM exercises consistently, initially passive, then active.
◦ Encourage patient participation in all activities as individually able.
◦ Encourage family/SO support and assistance with ROM exercises.
◦ Medicate for pain before activity or exercise.
◦ Incorporate ADLs with physical therapy, hydrotherapy, and nursing care.
Improving Body Image and Self-Esteem

◦ Assess the meaning of loss or change to the patient and SO, including future
expectations and the impact of cultural or religious beliefs.
◦ Acknowledge and accept the expression of feelings of frustration, dependency,
anger, grief, and hostility.
◦ Set limits on maladaptive behavior. Maintain a nonjudgmental attitude while
giving care, and help the patient identify positive behaviors that will aid in
recovery.
◦ Provide hope within the parameters of the individual situation; do not give
false reassurance.
◦ Helps begin the process of looking to the future and how life will be different.
Improving Airway Clearance

◦ Assess the patient’s airway, breathing, and circulation. Be especially alert for
signs of smoke inhalation, and pulmonary damage:
◦ Obtain a history of injury. Note the presence of preexisting respiratory
conditions, and a history of smoking.
◦ Assess gag and swallow reflexes; note drooling, inability to swallow, hoarseness,
and wheezy cough.
◦ Assess for tachypnea, use of accessory muscles, presence of cyanosis, and
changes in sputum suggest developing respiratory distress or pulmonary edema
and the need for medical intervention.
◦ Auscultate lungs, noting stridor, wheezing or crackles, diminished breath sounds,
and brassy cough.
◦ Note the presence of pallor or cherry-red color of unburned skin. Suggests the
presence of hypoxemia or carbon monoxide.
• Minimizing Fear and Anxiety
- patients may use denial and repression to reduce and filter information
that might be overwhelming
◦ Providing Wound Care and Improving Skin Integrity
◦ Assess and document the size, color, and depth of the wound, noting
necrotic tissue and the condition of the surrounding skin.
◦ Evaluate the color of grafted and donor site(s); note the presence or
absence of healing
◦ Provide appropriate burn care and infection control measures.
◦ Keep skin free from pressure
◦ Maintaining Adequate Nutrition
◦ Provide a diet high in calories or protein with trace elements and
vitamin supplements.
Thanks for Listening
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Quiz!!!
GOOD LUCK!