Management of Patients

with Burn Injury

 Burn Injuries

§ Approximately 450,000 people require medical

attention of burns every year, and about 14 % of
them die from burns and associated inhalation
injuries every year.
§ Most burns occur in the home.
§ Young children and the older adults are at high
risk for burn injuries.
§ Nurses must play an active role in the prevention
of burn injuries by education regarding prevention
concepts and promoting safety legislation.
 Goals Related to Burns

§ Prevention

§ Institution of lifesaving measures for the

severely burned person.

§ Prevention of disability and disfigurement

through early specialized and individualized
care.

§ Rehabilitation through reconstructive surgery

and rehabilitation programs.
 Severity of Burns

q Severity of each burn is determined by:

• Age of patients

• Depth of the burn

• Amount of surface area that is burned

• The presence of inhalation injury

• Location of the injury

• Presence of other injuries

• Presence of a past medical history

 Classification of Burns

q Burns Classified According to:

A. The depth of tissue destruction:
§ First-degree: Superficial
§ Second –degree: Partial thickness
§ Third-degree: Full thickness
§ Fourth-degree: Deep burn necrosis
B. The extent of body surface area injured:
§ Minor burn
§ Moderate, uncomplicated burn
§ Major burn
 Classification of Burns

q A: Burn Depth:
1- First Degree Burns (Superficial):
• Involve the epidermis , possibly a portion of dermis
• Erythematous, but the epidermis is intact.
• Causes: Sunburn, low intensity flash & superficial
burn.
• S&S: tingling, hyperesthesia (hypersensitivity),
pain soothed by cooling.
• Appearance: reddened, dry, minimal or no edema
• Treatment: complete recovery within a few days,
oral pain medications, cool compresses, skin
lubricants.
 Classification of Burns

2- Second Degree Burns (Partial thickness):

• Involve the epidermis , & varying portion of
dermis.
• They are painful & typically associated with blister
formation.
• Causes: Scalds, flash flame & contact.
• S&S: pain, hyperesthesia, sensitive to air currents
• Appearance: blistered, mottled red base,
disrupted epidermis, edema, hair follicles remain
intact.
• Treatment: recovery in 2-3 weeks, may be
require grafting.
Classification of Burns
 Classification of Burns

3- Third Degree (Full thickness):

• Involve the epidermis, dermis, & sometimes
subcutsneous tissue, may involve connective tissue
& muscles.
• Causes: flame, prolonged exposure to hot liquids,
electrical current, chemical & contact.
• S&S: lacks sensation, no pain, shock,
myoglobinuria (presence of myoglobin protein in the urine)
• Appearance: dry; color pale white to red brown,
or charred, coagulated vessels may be visible &
edema.
• Treatment: grafting necessary, scarring & loss of
contour & function.
Third degree (Full thickness) Burns
 Classification of Burns

4- Fourth Degree-deep burn necrosis (Full-

thickness that includes fat, muscle & bone):
• Involve deep tissue, muscles & bone.
• Causes: prolonged exposure to high voltage
electrical injury.
• S&S: shock, myoglobinuria (red pigment in
urine).
• Appearance: Charred
• Treatment: Amputation likely, grafting for no
benefit.
 Classification of Burns

q B: Extent of Total Body Surface Area Injured

• Methods to estimate (TBSA) burned:
§ Lund & Browder Chart: is more precise method
which recognize that the percentage of TBSA of
various anatomic parts, especially the head and
legs. By dividing the body into very small areas &
estimate of TBSA for each body part.
§ The palm method:

• The size of the patients hand, including the

fingers, is approximately 1% of TBSA.
Lund & Browder Chart
 Rules of Nines

§ Rule of Nines:

• The most commonly used method

• This system is based on dividing anatomic

regions, each representing approximately 9%
of the TBSA.

• A quick way to calculate the extent of burns

§ In the adult, most areas of the body can be
divided roughly into portions of 9%, or
multiples of 9.
Rules of Nines
 Pathophysiology of Burns

§ Burns are caused by a transfer of energy from a

heat source (Thermal (includes electrical),
Radiation, Chemical) to the body.
§ Burns causing tissue destruction through
coagulation, protein denaturation, or ionization
of cellular contents.
§ Tissue necrosis occurs at the center of the injury

§ The central area of the wound is termed the zone

of coagulation.
Zones of Burn Injury
 Pathophysiology of Burns

§ The surrounding zone, zone of stasis, an area of

injured cells that may remain viable, but will
undergo necrosis within 24 to 48 hours.
§ The outer most zone, zone of hyperemia, may
fully recover over time.
§ The skin & the mucosa of the upper airways
are the most common site of tissue destruction.
§ Deep tissues can be damaged by electrical
burns or through prolonged contact with a heat
or chemical source.
 Pathophysiology of Burn Injury

§ Burns less than 25% TBSA produce primarily a

local response.
§ Burns more than 25% (major burn) may
produce a local & systemic response.
§ Systemic response includes release of cytokines
and other mediators into systemic circulation.
§ Major burn injuries characterized by burn
wound edema, generalized edema formation,
altered cardiovascular function, & impaired
organ perfusion.
§ Fluid shifts & shock result in tissue
hypoperfusion & organ hypofunction.
 Effects of Major Burn Injury

§ Fluid and electrolyte shifts from intravascular to

interstitial space producing hypovolemic shock.
§ Cardiovascular effects
§ Pulmonary injury
n Upper airway
n Inhalation below the glottis
n Carbon monoxide poisoning
n Restrictive defects
§ Renal and GI alterations
§ Immunologic alterations
§ Effect on thermoregulation
Management of the Patient with a
Burn Injury
Management of patient with a burn injury

q Burn care proceeds through Three Phases:

Ø Emergent/ Resuscitative Phase
• Onset of injury to completion of fluid
resuscitation.
Ø Acute/ Intermediate Phase
• From beginning of diuresis to wound closure.
Ø Rehabilitation Phase
• From wound closure to return to optimal
physical and psychosocial adjustment.
 Emergent or Resuscitative Phase

§ The first step in management is to remove

patients from the source of injury.
§ Stop burn injury: extinguish flames, cool the
burn, irrigate chemical burns.
§ ABCDEs: Establish airway, breathing, and
circulation, disability & expose & examine.
§ Start oxygen and large-bore Ivs
§ Remove restrictive objects and cover the wound
§ Do assessment surveying all body systems and
obtain a history of the incident and pertinent
patient history.
 Emergent or Resuscitative Phase
Medical Management

§ Patient is transported to emergency department.

§ Fluid resuscitation is begun.
§ Foley catheter is inserted.
§ Patient with burns exceeding 20% to 25% should
have an Ng tube inserted and placed to suction.
§ Patient is stabilized and condition is continually
monitored.
§ Patients with electrical burns should have ECG.
§ Address pain; only IV medication should be
administered.
§ Psychosocial consideration and emotional support
should be given to patient and family.
 Emergent or Resuscitative Phase
Medical Management

§ Baseline weight & laboratory test are obtained.

§ TBSA is calculated.
§ Assessed patient for cervical spine & head injuries
if involved in a traumatic or electrical injury.
§ All clothing & jewelry are removed.
§ Remove contact lenses immediately if chemical or
facial burn have occurred.
§ Monitor V/S particularly body temperature.
§ Strict monitoring of fluid intake & output.
§ Clean sheets are placed under & over patient to
prevent contamination & maintain bord
temperature.
 Nursing Process in the Care of the Patient in
the Emergent Phase of Burn Care—Diagnoses

§ Impaired gas exchange

§ Ineffective airway clearance

§ Fluid volume deficit

§ Hypothermia

§ Acute pain

§ Anxiety
 Emergent Phase of Burn Care—Potential
Complications and Collaborative Problems

§ Acute respiratory failure

§ Distributive shock

§ Acute renal failure

§ Compartment syndrome

§ Paralytic ileus
§ Curling’s ulcer (acute gastric erosion):
resulting as a complication from severe burns when reduced
plasma volume leads to ischemia and cell necrosis
(sloughing) of the gastric mucosa
 Management of Shock—Fluid Resuscitation

§ 1 or 2 large bore IV replacement lines (may need

jugular or Subclavian).
§ Maintain blood pressure of greater than 100 mm
Hg systolic & urine output of 30 to 50 mL/hr;
maintain serum sodium at near-normal levels.
§ There are formula’s for replacement based on
TBSA & patient weight:
§ Consensus formula, Evans formula, Brooke Army
formula, Parkland Baxter formula, & Hypertonic
saline formula.
§ Note: Adjust formulas to reflect initiation of fluids
at the time of injury.
n Consensus formula (parkland); Evans formula; Brooke Army
formula

n Note: Adjust formulas to reflect initiation of fluids at the time of

injury.

n The following example illustrates use of the consensus formula in

a 70-kg (154-lb) patient with a 50% TBSA burn:
n Consensus formula: 2 to 4 mL/kg/% TBSA
n 2 × 70 × 50 = 7000 mL/24 hours
n Plan to administer: first 8 hours = 3500 mL, or 437
mL/hour; next 16 hours = 3500 mL, or 219 mL/hour

29
Fluid and Electrotype Shifts—Emergent Phase

§ Generalized dehydration

§ Reduced blood volume & hemoconcentration

§ Decreased urine output

§ Trauma causes release of Potassium (K) into

extracellular fluid: Hyperkalemia

§ Sodium traps in edema fluid and shifts into

cells as Potassium is released: Hyponatremia

§ Metabolic acidosis.
 Acute or Intermediate Phase

§ Begins 48 to 72 hours after burn injury.

§ Attention is directed toward continue
assessment & maintain respiratory &
circulatory support, fluid & electrolyte balance,
GI & kidney function.
§ Prevention of infection, wound care (cleaning &
debridement, topical Antibacterial therapy,
dressing & wound grafting), pain management,
& nutritional support are priorities in this stage.
§ 48 hr after burn, fluid moves from interstitial to
intravascular compartment, fluid overload may
occur.
Fluid and Electrolyte Shifts—Acute Phase

§ Fluid reenters the vascular space from the

interstitial space.

§ Hemodilution

§ Increased urinary output .

§ Sodium is lost with diuresis & due to dilution
as fluid enter vascular space: Hyponatremia
§ Potassium shifts from extracellular fluid into
cells: potential Hypokalemia

§ Metabolic acidosis
Nursing Process in the Care of the Patient in
the Acute Phase of Burn Care—Diagnoses

§ Excessive fluid volume

§ Risk for infection

§ Imbalanced nutrition

§ Acute pain

§ Impaired physical mobility

§ Ineffective coping

§ Interrupted family processes

§ Deficient knowledge
 Nursing Process -Acute of Burn Care
Collaborative Problems & Potential
Complications

§ Heart Failure (HF) and Pulmonary Edema

§ Sepsis

§ Acute Respiratory Failure

§ Visceral damage (Electrical burns)

 Infection Prevention

§ Source of contamination from burn unit

equipment, health care workers hand,
environmental surfaces, patient’s own flora
from GI tract.
§ Use of barrier techniques (gown, gloves)
§ Environmental cleaning
§ Application of topical & systemic Antimicrobial
agents.
§ Early & excision & closure of burn wound
§ Control of hyperglycemia
§ Aseptic precaution
 Wound Cleaning

§ The goal of wound care is debridement of

nonviable tissue, removal of previously
applied topical agents.
§ Hydrotherapy (use of bath & shower) with
disinfectant or cleansing agent.

§ Can be done in tank, shower, or bed

§ Gentle cleaning with mild soap, water can
prevent infection.
§ Hair around the burn area is clipped short
§ Water temperature is maintained at 37.8 C
 Wound Dressing

§ After topical agents are applied, the wound is

covered with several layers of dressing.
§ Burns to the face may be left open to air.
§ A light dressing can be applied to the face.
§ Occlusive dressing, gauze & a topical
Antimicrobial agent may be used over areas
with new skin grafts to protect the new graft.
§ Ideally these surgical dressing remain in place
for 3 to 5 days.
§ Dressing that adhere to wound may be
removed by moistening the dressing with water.
 Wound Debridement

§ Natural Debridement: take weeks to months.

§ Mechanical Debridement: use of surgical tools
to separate & remove the eschar.
• Done with daily dressing changes.
• Chemical Debridement: topical Enzyme agents
§ Surgical Debridement:
• Carried out before the natural separation of
eschar is occur.
• Involves either excision of the skin down or
shaving of burned skin layers.
 Rehabilitation Phase

§ Rehabilitation is begun as early as possible in

the emergent phase & extends for a long period
after the injury.
§ Focus is on wound healing, psychosocial
support, self-image, lifestyle, and restoring
maximal functional abilities so the patient can
have the best quality life, both personally &
socially.
§ The patient may need reconstructive surgery to
improve function & appearance.
§ Vocational counseling & support groups may
assist the patient.