BURNS

PRESENTED BY: SHILPA S

CRITICAL CARE NURSING
 PHYSIOLOGY OF SKIN
1. Regulates body temperature.
2. Prevents loss of essential body fluids, and penetration of
toxic substances.
3. Protection of the body from harmful effects of the sun and
radiation.
4. Excretes toxic substances with sweat.
5. Mechanical support.
6. Sensory organ for touch, heat, cold, socio-sexual and
emotional sensations.
7. Vitamin D synthesis from its precursors under the effect of
sunlight and introversion of steroids.
 INTRODUCTION
Burn injury is defined as an area of
tissue damage caused by the effects of
heat.
It may result directly from the transfer
of thermal energy or indirectly when
some other form of energy is
converted into thermal energy
The skin burn seen in
electrocution (electrical
energy)
Burns occurring as a result of
friction (physical energy)
Thermal energy resulting from a
chemical reaction (chemical
burns).
Traditionally injuries resulting
from wet heat sources, such as
hot water and steam, are
known as scalds.
Majority of burns in children
are SCALDS.
 Burns and scalds tend to be seen at the extremes of
age3–5 and have highest incidence in those less than
two years old.
 Twenty percent of burns occur in children aged up
to four years and of these 70% are scalds.
 Sixty percent of burns occur in patients aged 15 to
64 mostly as a result of contact with flames.
 About 10% occur in people aged over 65.
 As with most forms of trauma, burns are commoner
in males than females and are often associated with
intoxication by alcohol.
 ETIOLOGY OF BURNS
 Dry heat
 Flames
 Electric contact
 Chemical
 Frost bite
 Ionizing radiation
 TYPES OF BURN INJURY
FRICTION
BURNS CHEMICAL
RADIATION
BURNS
BURNS

TYPES

ELECTRICAL THERMAL
BURNS BURNS
COLD
BURNS
FRICTION BURNS
RADIATION BURNS
CHEMICAL BURNS
COLD BURNS
ELECTRICAL BURNS
THERMAL BURNS
CLASSIFICATION OF BURNS
MECHANISM OR CAUSE

THERMAL

INHALATION
Thermal burns involve the
skin and may present as:
 scalds
contact burns
flame burns
 chemical burns
electrical burns
Inhalational burns are the result
of breathing in superheated gases, steam, hot
liquids or noxious products of incomplete
combustion.
 They cause thermal or chemical injury to the
airways and lungs and accompany a skin burn
in approximately 20% to 35% of cases.
 Inhalational burns are the most common cause
of death among people suffering fire-related
burn.
DEGREE AND DEPTH
1ST DEGREE OR SUPERFICIAL BURNS

2nd DEGREE OR PARTIAL THICKNESS BURNS

3RD DEGREE OR FULL THICKNESS BURNS

 First-degree or superficial
burns
 burns to the epidermis that result in a simple
inflammatory response.
 caused by exposure of the unprotected skin to
solar radiation (sunburn) or to brief contact
with hot substances, liquids or flash flames
(scalds).
 heal within a week with no permanent changes
in skin colour, texture, or thickness.
 Second-degree or partial-
thickness burns
 damage to the skin extends beneath the epidermis
into the dermis.
 The damage does not lead to the destruction of all
elements of the skin.
 – Superficial second-degree take less than three
weeks to heal.
 – Deep second-degree take more than three
weeks to close and are likely to form hypertrophic
scars.
 Third-degree or full-thickness
burns
 those where there is damage to all epidermal
elements – including epidermis, dermis,
subcutaneous tissue layer and deep hair follicles.
 As a result of the extensive destruction of the skin
layers, third-degree burn wounds cannot
regenerate themselves without grafting.
In adults, a full-thickness burn will occur
within 60 seconds if the skin is exposed
to hot water at a temperature of 53° C.
If, the temperature is increased to 61° C,
then only 5 seconds are needed for such
a burn.
In children, burns occur in around a
quarter to a half of the time needed for
an adult to burn.
Fourth- degree burn
PATHOPHYSIOLOGY
OF BURNS
ASSESSMENT
OF BURNS
THREE BURN ZONES
  PALMAR METHOD

 WALLACE RULE OF NINE

 LUND AND BROWDER

METHOD
PALMAR METHOD
 Burn size should be assessed in a controlled
environment to avoid hypothermia.
 In smaller burns, cut a piece of clean paper the size
of patient’s whole hand (digit and palm) which
present 1% TBSA and match this to the area.
 Another accurate way of measuring the size of burns
is to draw the burn on LUND AND BROWDER
CHART
 RULE OF 9
 The “Rule of 9’s” is commonly used to estimate the
burned surface area in adults.
 The body is divided into anatomical regions that
represent 9% (or multiples of 9%) of the total
body surface.
 The outstretched palm and fingers approximates
to 1% of the body surface area.
 If the burned area is small, assess how many times
your hand covers the area.
WALLACE RULE OF NINE
 ASSESSING
DEPTH FROM
HISTORY
Burning of human skin is temperature
and time dependent.
It takes 6 hours for skin to be
maintained at 45 degree Celsius for
irreversible damage to occur.
A surface temperature of 70 degree
Celsius for 1 sec produces epidermal
destructions.
 SUPERFICIAL PARTIAL THICKNESS
BURN
 No deeper than Papillary dermis.
 Blister formation
 Loss of epidermis
 Capillary return visible when blanched
 Dermis is pink and moist
 Pin prick sensation is normal
 Heal without scaring in 2 weeks
 Treatment is non surgical
 DEEP PARTIAL THICKNESS
BURN
 Damage to deeper parts of dermis
 Epidermis is usually lost
 Fixed capillary staining
 Colour does not blanch with pressure
 Sensation is reduced
 Patient is unable to distinguish sharp and blunt pressure
 Takes 3 or more weeks to heal without surgery
 Leads to hypertrophic scarring
 FULL THICKNESS BURN
Whole of the dermis is destroyed
Hard and leathery feel
No capillary return
Often thrombosed vessels can be seen
under the skin
Patients are completely anesthetized
No pain and no bleeding
CAUSES OF DEATH
IN BURNS
Hypovolaemia and shock
Renal Failure
Pulmonary oedema and ARDS
Septicaemia
Multiorgan failure
 SYSTEMIC
CHANGES DUE
TO BURNS
 Once the burn covers more than 30% of TBSA,
the injury has a systemic effect due to
Molecular structural alterations
 Release of toxic metabolites
 Release of antigen and immunomodulatory
agents Histamine, Serotonin, Bradykinin,
Nitric oxide, etc.
 Causes systemic shock, cardiovascular,
respiratory and renal failure,
immunosuppression and hypermetabolism.
 Cardiovascular Changes
 Myocardial depression : Myocardial contractility
decreased
 Oedema formation : Capillary permeability is increased
leads to loss of intravascular proteins and fluids to the
interstitial compartment
 Hypovolemia : Secondary to oedema and rapid fluid loss
from surface of wound
 Peripheral vasoconstriction occurs : May cause renal
failure
These changes may lead to systemic hypotension and end
organ hypo-perfusion
Respiratory Changes
Inflammatory mediators cause
bronchoconstriction and pulmonary
oedema
 Severely burnt adults acute respiratory
distress syndrome (ARDS) can occur
 Exacerbated in the case of inhalation
injury.
 Metabolic Changes
 Hypermetabolism begins approximately five days post
burn
 Metabolic state is initially suppressed by the effects of
acute shock
 Can persist for up to two years post injury Inflammatory,
hormonal and cytokine milieu cause:
 Increased body temperature
 Increased oxygen and glucose consumption
 Increased CO2 and minute ventilation
 Increased heart rate for up to 2 years post burn
 Gastrointestinal Changes
 Impaired gastrointestinal motility
 Impaired digestion and absorption
 Increased intra-gastric pH
 Feeding difficulties exacerbate effects of hyper metabolism

Immunological Changes
 Immune deficiency occurs despite the activation of the
immune system.
 High risk of infection, particularly while wounds are open.
Location of burn
 Burns to face, neck ,chest and back may inhibit
respiratory function due to mechanical
obstruction secondary to edema, eschar
formation
 Burns to the ear, nose are susceptible to
infection because of poor blood supply
 Burns to buttocks, genitalia are susceptible to
infection because of contamination
 Burns on extremities cause circulatory
compromise and neurologic impairment.
F • FIRST AID

A • ANALGESIA

C • CLEAN
A • ASSESS

D • DRESSING

E • ELEVATE
MANAGEMENT
Prehospital care

Hospital care
 WHAT TO DO?
 Stop the burning process by removing clothing and
irrigating the wounds.
 Apply cold water or allow the burnt area to remain in
contact with cold water for some time.
 In flame injuries, extinguish the flames by allowing the
patient to roll on the ground, or by applying a blanket, or
using water or other fire extinguishing liquids.
 In chemical burns, remove or dilute the chemical agent by
copiously irrigating the wound with water.
 Obtain medical care.
WHAT NOT TO DO?
 Do not commence first aid before ensuring your own
safety (switch off electrical current, wear gloves for
chemicals, etc.).
 Do not apply paste, oil, kumkum (a paste made from
turmeric) – or raw cotton to the burned area.
 Do not apply ice.
 Do not open the blisters with a needle or pin.
 Do not apply any material directly to the wound as it
might become infected.
 Avoid application of topical medication until the patient
has been placed under appropriate medical care.
PHASES OF MANAGEMENT
EMERGENT/
RESUSCITATIVE

INTERMEDIATE/ACUTE

REHABILITATIVE
 EMERGENT PHASE
 Knowledge of circumstances surrounding the burn
injury.
 Obtain client’s pre-burn weight (dry weight) to
calculate fluid rates.
 Height is important in determining body surface are
(BSA) which is used to calculate nutritional needs.
 Know client’s health history because the physiologic
stress seen with a burn can make a latent disease
process develop symptoms.
 Immediate problem is fluid loss, edema, reduced
blood flow (fluid and electrolyte shifts)
GOALS:
1. Secure airway
2. Support circulation by fluid replacement
3. Keep the client comfortable with analgesics
4. Prevent infection through wound care
5. Maintain body temperature
6. Provide emotional support
 ACUTE PHASE
 Lasts until wound closure is complete.
 Care is directed towards continued assessment and
maintenance of the cardiovascular and respiratory system.
 Pneumonia is the concern which can result in respiratory
failure requiring medical ventilation.
 Give topical antibiotics for infection.
 Tetanus toxoid administered
 Weight the patient daily wihtout dressing or splints ad
compare to pre-burn weight.
 Monitor for signs of infection
 REHABILITATIVE
PHASE
 Started at the time of admission.
 Technically begins with wound closure and ends when the
client returns to the highest possible level of functioning
 Provide psychosocial support
 Assess home environment, financial resources, medical
equipment, prosthetic rehabilitation
 Health teaching should include symptoms of infection,
drugs regimens, follow up appointments, comfort
measures to reduce pruritis
 HOSPITAL CARE
 Admit the patient
 Airway control
 Breathing and ventilation
 Circulation
 Disability
 Exposure with environmental control
 Fluid resuscitation
 Assess the percentage , degree and type of burn
 Keep the patient in clean environment
 Sedation and proper analgesia
 AIRWAY
 HISTORY  EXAMINATION
 Fire in an enclosed space 1. Confusion/ altered
 Eg: House fire consciousness
Car fire 2. Burns to face/
Oropharynx
Toxic industrial fumes
3. Hoarseness/ stridor/
Expiratory rhonchi
4. Soot in nostrils or sputum
5. Dysphagia/ drooling
 Burned airway swell
rapidly

 Intubation is necessary
before airway swelling
as soon as possible
 BREATHING
 A progressive increase in respiratory rate and efforts,
anxiety
 Rising pulse and confusion with decreasing oxygen
saturation
 These symptoms take 24 hours to 5 days to appear.
 Treatment starts as soon as possible including
1. Physiotherapy
2. Nebulisers
3. Warm humidified oxygen
 FLUID RESUSCITATION
 IV volume must be maintained in order to
provide sufficient circulation to perfuse the
organs but also the peripheral tissues,
especially damaged skin.
 Appropriate for any child with a burn
greater than 10% and 15% for TBSA for
adults.
 Give oral rehydration such as DIORALYTE
 Most common fluid used is RINGER
LACTATE
 FLUIDS USED
 CRYSTALLOID RESUSCITATION
1. Ringer lactate is the most common
2. As effective as colloids for maintaining intravascular volume
3. Less expensive
IN CHILDREN
1. Dextrose saline is given for maintainence
HYPERTONIC SALINE
1. Produces hyperosmolarity and hypernatremia
2. Reduces shift of intercellular water to extracellular space
3. Induce less tissue oedema
 MONITORING
RESUSCITATION
 The key is to monitor urinary output
 Output should be between 0.5ml and 1.0
ml/kg/hour
 If urine output is below this infusion rate
should increase by 50%
 If output is still inadequate then a bolus of
10ml/kg is given.
 HAEMATOCRIT MEASUREMENT is a
useful tool in confirming suspected under
or overhydration
 SURGICAL
MANAGEMENT
 WOUND CARE
First aid
 If the patient arrives at the health facility without
first aid having been given, drench the burn
thoroughly with cool water to prevent further
damage and remove all burned clothing.
 If the burn area is limited, immerse the site in cold
water for 30 minutes to reduce pain and oedema
and to minimize tissue damage
. If the area of the burn is large, after it has
been doused with cool water, apply clean
wraps about the burned area (or the whole
patient) to prevent systemic heat loss and
hypothermia.
 Hypothermia is a particular risk in young
children.
 First 6 hours following injury are critical
 Initial treatment
 Initially, burns are sterile. Focus the treatment
on speedy healing and prevention of infection.
 In all cases, administer tetanus prophylaxis
 Except in very small burns, debride all bullae.
 Excise adherent necrotic (dead) tissue initially
and debride all necrotic tissue over the first
several days.
 After debridement, gently cleanse the burn with
0.25% (2.5 g/litre) chlorhexidine solution, 0.1% (1
g/litre) cetrimide solution, or another mild
waterbased antiseptic.
 Do not use alcohol-based solutions.
 Gentle scrubbing will remove the loose necrotic
tissue. Apply a thin layer of antibiotic cream (silver
sulfadiazine).
 Dress the burn with petroleum gauze and dry gauze
thick enough to prevent seepage to the outer layers.
 TYPES OF
DRESSING FOR
DIFFERENT
DEGREES OF
BURNS
SUPERFICIAL BURNS
 Protect the wound and encourage Re-
epithelialization
 Topical analgesics cream
 Moisturising cream
 Eg: Polyurethrane semipermeable membrane
Hydrocolloids
Retention dressings
PARTIAL THICKNESS
BURN
 Hydrocolloids
 Polyurethane films
 Biological dressings
 Alginates
 Foams
 ANTIMICROBIAL PRODUCTS such as products
containing silver.
 FULL THICKNESS
BURNS
 Antimicrobial dressings
 Eg: Silver Sulphadiazine
cream and silver nitrate
solution
 ENZYMATIC
DEBRIDEMENT
 Uses naturally occurring proteolytic enzymes for
eliminating devitalized tissue.
 Topical application of exogenous enzymes to the
wound surface breaks down necrotic tissue.
 To allow maximum enzymatic function, a good
delivery system, a prolonged period of enzyme
activity, and the correct wound environment are
required.
Collagenase-based products
Papain-based products.
Papain-urea-chlorophyllin copper
complex.
 DEBRIDEMENT
EXCISION

ESCHAROTOMY
 EXCISSION OF BURN
WOUND
Excision is continued until a plane of
well-vascularized tissue, with punctate
bleeding, is reached and necrotic
material or debris is removed.
 TANGENTIAL
EXCISION
 Tangential excision
involves repeated
removing of very
thin slices (0.5 mm
thick) of burned
tissue from the
zones of statis and
coagulation
Can be done within 48 hours in
patients with less than 25% of
burns.
Usually done in deep dermal
burns
Dead dermis is removed layer by
layer until fresh bleeding occur.
Later skin grafting is done.
 • Good cosmesis
ADVANTAGES • More wound
coverage methods

• High blood loss

DISADVANTAGES
• Difficult burn
method depth
evaluation
 FASCIAL EXCISION
 Best used when excising large flat areas
 When excision of the burn wounds has to be
done with minimum blood loss
 Less bloody than tangential excission, but with
cosmetic effect defect.
 Limited use in extremity due to problems of
edema distal to the area of excision, presence of
avascular fascia and presence of superficial nerves
 Removes all the
layers of eschar
and underlying
tissue to the level
of fascia.
 Excision to this
plane minimizes
bleeding and
provides a
reliable, clean,
vascular bed.
 • Easy burn depth
evaluation
ADVANTAGES
• Low blood loss

• Fewer grafting
possibilities
DISADVANTAGES
• Injury to nerve and
joints
 ESCHAROTOMY
 ESCHAR:
The tough leathery tissue remaining after a full-thickness

ESCHAROTOMY is a surgical procedure used to treat

full-thickness (third-degree) circumferential burns.
 Done to release the constriction, thereby restoring distal
circulation and allowing for adequate ventilation.
 Escharotomy is usually done within the first 2 to 6 hours
of a burn injury.
 LIMB
ESCHAROTOMY
 Indicated when the
circulation is
compromised due
to increased
pressure in the
burned limb and
can not be relieved
by simple elevation
CHEST ESCHAROTOMY
 Considered when a
circumferential burn of the chest
wall results in respiratory
compromise by restricting
normal chest wall movement.
 Circumferential burns of the
abdomen may also caused
respiratory compromise by
restricting diaphragmatic
movements
Eg: Infants under 12 months
 FASCIOTOMY
 Fasciotomy or fasciectomy is a surgical
procedure where the fascia is cut to relieve
tension or pressure commonly to treat the
resulting loss of ciculation to an area to
tissue or muscle.
 Done in patients with electrical burns.
 WOUND CLOSURE
 After excision the wound, there is wound closure.

 GOALS:
1. Re-establish barrier (epidermis) to prevent
bacterial invasion and evaporative water loss.
2. Re-constitute the dermis to provide durability,
pliability and acceptable cosmetics
CLASSIFICATION OF
GRAFTS
 SPLIT THICKNESS
GRAFT
 Skin graft including the epidermis and part of the
dermis.
 Thickness depends on the donor site and needs of
the patient.
 Can expand upto 9 times.
 Frequently used as they can cover large areas and the
rate of autorejection is low.
 INDICATIONS CONTRAINDICATIONS
1. Immediate coverage of 1. Need to place the graft
clean soft tissue defects. in areas where good
2. Immediate coverage of cosmesis or durability is
burn defects. essential.
3. Prevention of scar 2. Significant wound
contracture. contraction could
compromise functions.
 FULL THICKNESS
GRAFT
 A full thickness graft consists of the epidermis and the
entire thickness of the dermis.
 INDICATION:
1. Deep burn injuries
CONTRAINDICATIONS:
1. Recipient bed cannot sustain the graft.
2. On avascular tissues
3. Uncontrolled bleeding in recipients bed.
 MESHED VS SHEET GRAFTS
 Sheet grafts are those which are not altered once
they have been taken from the donor site.
 Meshed grafts are those which are passed
through a machine that places fenestrations (small
holes) in the graft.
 Meshed grafts have advantages over sheet grafts of :
1) allowing the leakage of serum and blood which
prevents haematomas and seromas
2) they can be expanded to cover a larger surface
area.
CRITERIA FOR GRAFTING
Diagnosis of DEEP tissue loss
 Patient is systemically fit for surgery
 Patient has no coagulation
abnormalities
 Sufficient donor sites available
 Would clear of streptococcus
 DONOR SITE
 The donor site should just be left with a
superficial or a superficial partial thickness
wound which will heal in 10-14 days and may
be reused if necessary.
 Often, the donor site can be more painful than
the recipient due to exposure of nerve endings
 STSG : thigh
 FTSG: groin
 SKIN SUBSTITUTES
“Skin Substitutes are defined as a
heterogeneous group of wound
cover materials that aid in wound
closure and replace the functions
of the skin either temporarily or
permanently”
 Cellular Allogenic skin Cellular autologous skin
Acellular skin substitute substitute substitute

• BIOBRANE • TRANSCYTE • EPIDERMAL

• INTEGRA • APLIGRAF AUTOGRAFT
• ALLODERM • DERMAGRAFT • SKIN SUBSTITUTE
 RECIPIENT SITE
 The graft should take within 5 days and will
provide a permanent covering of the injury.
 A graft should always be placed over bleeding,
healthy tissue to ensure it is vascularised for
survival.
 The body part is immobilised in an anti-
deformity position at first in order to prevent
shearing forces that could disrupt the graft.
 REASONS FOR GRAFT
FAILURE
 Inadequate blood supply to wound bed
 Graft movement
 Collection of fluid beneath graft (e.g.
haematoma)
 Infection (e.g. streptococcus)
 The grafts properties (e.g. vascularity of donor
site)
 SKIN FLAP
 A skin flap contains its own vasculature and
therefore can be used to take over a wound
bed that is avascular.

A skin graft does not have this ability.

 GRAFT VS FLAP
 GRAFT  FLAP
Does not maintain original Maintains original blood
blood supply. supply
 CATEGORIZATION OF
FLAPS
Based on three factors:
1. Vascularity
2. Anatomical composition
3. Method of relocation
 VASCULARITY
Random pattern flaps are not raised on
any particular major blood vessel, but
instead are raised on smaller branches of
these blood vessels.
Axial flaps, on the other hand, are raised
upon a specific blood vessel
 ANATOMICAL
COMPOSITION
 Skin Flap- epidermis, dermis and superficial fascia
 Fasciocutaneous Flap- epidermis, dermis and both
superficial and deep fascia
 Muscle Flap-muscle belly without overlying structures
 Myocutaneous Flap-muscle belly with the overlying skin
 Osseous Flap- bone
 Osseomyocutaneous Flap-bone, muscle, skin
 Composite Flap- Contains a no. Of different tissues such
as skin, fascia, muscle and bone.
 DAILY WOUND
TREATMENT
Change the dressing daily (twice daily
if possible) or as often as necessary to
prevent seepage through the dressing.
 On each dressing change, remove any
loose tissue.
Inspect the wounds for discoloration or
haemorrhage, which indicate developing
infection.

 Fever is not a useful sign as it may persist

until the burn wound is closed.

 Cellulitis in the surrounding tissue is a

better indicator of infection.
 TOPICAL ANTIBIOTIC
CHEMOTHERAPY
 Silver nitrate (0.5% aqueous) is the cheapest, is applied
with occlusive dressings but does not penetrate eschar. It
depletes electrolytes and stains the local environment.
 Use silver sulfadiazine (1% miscible ointment) with a
single layer dressing. It has limited eschar penetration and
may cause neutropenia. •
 Mafenide acetate (11% in a miscible ointment) is used
without dressings. It penetrates eschar but causes acidosis.
Alternating these agents is an appropriate strategy.
 Treat burned hands with special care to preserve
function.
− Cover the hands with silver sulfadiazine and place them in
loose polythene gloves or bags secured at the wrist with a
crepe bandage.
− Elevate the hands for the first 48 hours, and then start hand
exercises
− At least once a day, remove the gloves, bathe the hands,
inspect the burn and then reapply silver sulfadiazine and the
gloves
− If skin grafting is necessary, consider treatment by a
specialist after healthy granulation tissue appears.
 GOALS OF
REHABILITATION
• Return to pre-injury
OVERALL level of function with
GOAL best possible cosmoses.

SHORT • Assist wound healing

• Prevent
TERM musculoskeletal
GOAL complications.
REHABILITATION
SPLINTING AND POSITIONING

SCAR MANAGEMENT
 SPLINTING AND
POSITIONING
 Done to prevent contractures.
 Positioning is vital to bring the best
functional outcomes in rehabilitative phases.
 Begin immediately after the injury occur.
 Design position for specific individual needs.
 Should not compromise mobility and
functions.
TYPES OF SPLINTING
PRIMARY POSTURAL
SPLINT SPLINT
Acute phase and pre Immediate post graft
grafting period phase

Used to position the

Worn continously for 5 to
involved joints during
14 days until graft is
sleep, inactivity or
secure
unresponsiveness.
 POSITIONING
 Reduces edema
 Maintains joint alignment
 Maintains tissue elongation
 Prevents contracture formation
 Promotes wound healing
 Relieves pressure
 Protects joints, exposed tendons and new
grafts and flaps.
SCAR MANAGEMENT
 Pressure therapy
 Silicone gel sheet
 Intra lesion injection
 Split skin graft
 Laser therapy
 Cryotherapy
 Radio therapy
 Combination therapy
 Elevation
 Itching
 Redness
 ADDITIONAL
ASPECTS IN
TREATING BURN
INJURIES
BURN ASSOCIATED PAIN
84% of major burn patients suffer “severe
or excruciating pain”
100% suffer daily pain
 92% are woken at night with pain
 TYPES OF PAIN IN
BURNS
Procedural Pain
Procedural pain and associated
pain anxiety
Background pain
Breakthrough pain
 ANALGESIA
Oral form of paracetamol and NSAIDS in
superficial burns.
IV Opiates for large burns.
IM should not be given over 10% of TBSA
as absorption is unpredictable.
Short acting analgesia should be given
before dressing,
 • 2-5 mg morphine IV
repeated every 5 min
ADULTS

• Initial dose of IV
morphine 0.1mg/kg
CHILDREN • Repeat acc to Pain
score to max 0.3mg/kg
 ENERGY BALANCE
 Feeding should start within 6 hours of injury to
reduce gut mucosal damage.
 Burn patients need extra feeding and nutrition.
 A nasogastric tube should be used in all patients
with burns over 15% TBSA and 10% TBSA in
children.
 Burn injuries are catabolic in acute episodes.
 Removing the burn and achieving healing stops the
catabolic drive.
 Patient’s energy and protein requirements will
be extremely high due to the catabolism of
trauma, heat loss, infection and demands of
tissue regeneration. If necessary, feed the
patient through a nasogastric tube to ensure an
adequate energy intake (up to 6000 kcal a day).
 Anaemia and malnutrition prevent burn wound
healing and result in failure of skin grafts. Eggs
and peanut oil and locally available
supplements are good.
 INFECTION CONTROL
 Patients with major burns are immuno-compromised.
 Pathogenic and opportunistic bacteria and fungi enter via
the burn wound, catheter or IV line.
 They have compromised local defences in the lungs and gut
due to oedema.
 Sterile precautions must be rigorous.
 Swabs should be taken regularly.
 A rise in WBC , thrombocytosis and increased catabolism
are warnings of infection.
 PHYSIOTHERAPY
“The quality of outcome must be worth the
pain of survival”
 The physiotherapist must be aware of the
importance of an early and adequate assessment of
Burn patients for optimal functional and cosmetic
outcomes to minimise the impact of the trauma long
term.
 Physiotherapy aims
1. Prevent respiratory
complications
2. Control Oedema
3. Maintain Joint ROM
4. Maintain Strength
5. Prevent Excessive Scarring
PSYCHOLOGICAL
SUPPORT
 RESUSCITATIVE OR
CRITICAL STAGE
 The psychological characteristics of this stage
include stressors of the intensive care
environment, uncertainty about outcome, and
a struggle for survival.
 Patients may also be intubated, which greatly
limits direct communication.
Challenges Treatments
• Overstimulation • Protect patient's natural defences
• Understimulation and coping strategies
• Delirium, confusion, • Drug management for pain
and disorientation control and to help with sleep
• Impaired • Non-pharmacological techniques
communication for pain management
• Sleep disturbance • Educate and provide support to
• Pain family members
• Educate and provide support to
staff
 ACUTE STAGE
 The acute phase of recovery focuses on
restorative care, but patients continue to
undergo painful treatments.
 As patients become more alert during this
phase, they face these procedures with less
sedation.
 Also, patients are more aware of the physical
and psychological impact of their injuries.
 Challenges  Treatments
• Pain—both background • Drug management of
and procedural anxiety, pain,
• Anxiety—both acute stress sleeplessness, and
disorder and post- depression
traumatic stress disorder • Brief counselling
• Depressiona • Teach non-drug
• Sleep disturbance approaches to pain
• Premorbid management
psychopathology becomes (relaxation, imagery,
more apparent hypnosis, virtual
reality)
• Grief
 REHABILITATION OR RECOVERY
STAGE
 Begins after discharge from hospital, when patients begin
to reintegrate into society.
 Involve continued outpatient physical rehabilitation,
possibly with continuation of procedures such as dressing
changes and surgery.
 Patients slowly regain a sense of competence while
simultaneously adjusting to the practical limitations of their
injury.
 The first year after hospitalisation is a psychologically
unique period of high distress.
Challenges Treatments
Physical—Itching, • Outpatient
limited endurance, counselling
decrease in function • Social skills training
Social—Changing • Support groups
roles, return to • Peer counselling
work, body image, • Vocational
sexual issues counselling
Psychological—
Anxiety, depression
COMPLICATIONS
OF
BURN INJURY
TOXIC SHOCK
SYNDROME
It is a life-threatening exotoxin mediated
disease caused by Staphylococcusaureus.
It is common in children
Presents with – rashes
- Myalgia
- Diarrhea
- Vomiting
-Multi organ failure with
high mortality
 CURLING’S ULCER
 Acute ulcerative gastro duodenal disease.
 Occur within 24 hours after burn.
 Due to reduced GI blood flow and musocal damage.
 Treat clients with H2 blockers, mucoprotectants and
early enteral nutrition.
 Watch for sudden drop in hemoglobin
CONTRACTURES
A contracture is a fixed tightening of
muscle, tendons, ligaments, or skin. It
prevents normal movement of the
associated body part.
An injury such as a severe burn can
cause contracture of the skin.
The skin becomes scarred and nonelastic
which limits the range of movement of the
affected area.
 FOUR STAGES OF
CONTRACTURE
STAGE 1 • Can develop within a week of suffering
injury. Sometimes as quickly as 4 days

STAGE 2 • Takes another seven to fourteen days

to develop

STAGE 3
• Needs upto year and a hlf to recover

STAGE 4
• Exists when a patient’s muscles and joints
have suffered so much they have folded into
fetal position.
Development of a contracture is a late
problem.

It leads to ECTROPIAN,

MICROSTOMIA, disability of different
joints, defective hand functions, growth
retardation causing shortening.
 COMPLICATION OF BURN
CONTRACTURE
Ectropion of eyelids causing keratitis and
corneal ulcers.
Disfigurement of face.
Narrowing of mouth – Microstomia
Contracture in the neck causing
restrictive neck movements.
Disability and non functioning of joints
due to contractures.
Hypertropic scar and keliod formation.
A keloid is an abnormal proliferation
of scar tissue that forms at the site of
cutaneous injury
MARJOLIN’S ULCER
 It is a very well-differentiated squamous cell carcinoma occuring in a
scar ulcer due to repeated breakdown (ulstable scar of long duration).
 It is locally malignant
 As there are no lymphatics in the scar, so there is no spread to lymph
nodes.
 As there are no nerves in the scar it is painless.
TREATMENT:
1. Radiotherapy is not recommended.
2. Treatment is either wide excision or amputation.
Once it spreads out the scar tissue it can spread to regional lymph nodes
 TREATMENT OF BURN
CONTRACTURE
 Release of contracture surgically and use of skin
graft or different flaps.
 Proper physiotherapy and rehabilitation is essential.
 Pressure garments to prevent hypertrophic scars.
 Management of itching in the scar using aloe vera,
antihistamines and moisturizing creams.
 NURSING
RESPONSIBILTIES
Impaired Physical Mobility
 May be related to
 Neuromuscular impairment, pain/discomfort,
decreased strength and endurance
 Restrictive therapies, limb immobilization;
contractures
 Possibly evidenced by
 Reluctance to move/inability to purposefully move
 Limited ROM, decreased muscle strength control
and/or mass
 Disturbed Body Image
 May be related to
 Situational crisis: traumatic event, dependent patient role;
disfigurement, pain
 Possibly evidenced by
 Negative feelings about body/self, fear of
rejection/reaction by others
 Focus on past appearance, abilities; preoccupation with
change/loss
 Change in physical capacity to resume role; change in
social involvement
 Fear and Anxiety
 May be related to
 Situational crises: hospitalization/isolation procedures,
interpersonal transmission and contagion, memory of the trauma
experience, threat of death and/or disfigurement
 Possibly evidenced by
 Expressed concern regarding changes in life, fear of unspecified
consequences
 Apprehension; increased tension
 Feelings of helplessness, uncertainty, decreased self-assurance
 Sympathetic stimulation, extraneous movements, restlessness,
insomnia
 Impaired Skin Integrity
May be related to
Disruption of skin surface with
destruction of skin layers (partial-/full-
thickness burn) requiring grafting
Possibly evidenced by
Absence of viable tissue
Imbalanced Nutrition: Less
Than Body Requirements
 May be related to
 Hypermetabolic state (can be as much as 50%–60% higher
than normal proportional to the severity of injury)
 Protein catabolism
 Anorexia, restricted oral intake
 Possibly evidenced by
 Decrease in total body weight, loss of muscle
mass/subcutaneous fat, and development of negative
nitrogen balance
 Acute Pain
 May be related to
 Destruction of skin/tissues; edema formation
 Manipulation of injured tissues, e.g., wound
debridement
 Possibly evidenced by
 Reports of pain
 Narrowed focus, facial mask of pain
 Alteration in muscle tone; autonomic responses
 Distraction/guarding behaviors; anxiety/fear,
restlessness
 Deficient Knowledge
 May be related to
 Lack of exposure/recall
 Information misinterpretation; unfamiliarity with
resources
 Possibly evidenced by
 Questions/request for information, statement of
misconception
 Inaccurate follow-through of instructions,
development of preventable complications
 Risk for Ineffective Tissue Perfusion
 Risk factors may include
 Reduction/interruption of arterial/venous blood flow, e.g.,
circumferential burns of extremities with resultant edema
 Hypovolemia

Risk for Infection

 Risk factors may include
 Inadequate primary defenses: destruction of skin barrier,
traumatized tissues
 Inadequate secondary defenses: decreased Hb, suppressed
inflammatory response
 Environmental exposure, invasive procedures
 Risk for Fluid Volume Deficit
 Risk factors may include
 Loss of fluid through abnormal routes, e.g.,
burn wounds
 Increased need: hypermetabolic state,
insufficient intake
 Hemorrhagic losses
 Risk for Ineffective Airway
Clearance
 Risk factors may include
 Tracheobronchial obstruction: mucosal edema and loss of
ciliary action (smoke inhalation); circumferential full-
thickness burns of the neck, thorax, and chest, with
compression of the airway or limited chest excursion
 Trauma: direct upper-airway injury by flame, steam, hot
air, and chemicals/gases
 Fluid shifts, pulmonary edema, decreased lung compliance