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Burn Injuries 1. MINOR BURN INJURY
 Second-degree burn of <15% total body
 Young children and the elderly are at high risk
surface area (TBSA) in adults or <10% TBSA
for burn injuries.
in children
 Nurses must play an active role in the
 Third-degree burn of <2% TBSA not
prevention of burn injuries by teaching
involving special care areas (eyes, ears, face,
prevention concepts and promoting safety
hands, feet, perineum, joints)
legislation.
 Excludes all patients with electrical injury,
Nature inhalation injury, or concurrent trauma and
all poor-risk patients (eg, extremes of age,
 40%: flame related intercurrent disease)
 30%: scald injuries: occurs more often in
children particularly the toddlers 2. MODERATE, UNCOMPLICATED BURN INJURY
 4%: electrical  Second-degree burns of 15-25% TBSA in
 3%: chemical adults or 10-20% in children
Goals Related to Burns  Third-degree burn of <10% TBSA not
involving special care areas
 Institution of life-saving measures for the  Excludes electrical injury, inhalation injury,
severely burned person or concurrent trauma and all poor-risk
 Prevention of disability and disfigurement patients (eg, extremes of age, intercurrent
through early specialized and individualized disease)
care 3. MAJOR BURN INJURY
 Rehabilitation through reconstructive surgery • Second-degree burns >25% TBSA in adults
and rehabilitation programs. or >20% in children
• All third-degree burns >10% TBSA
Classification of Burns
• All burns involving eyes, ears, face, hands,
I. Superficial Partial Thickness (1st degree) feet. Perineum, joints
– involves epidermis, reddish, painful • All inhalation injury, electrical injury, or
II. Deep Partial Thickness (2nd degree) concurrent trauma, and all poor-risk
– involves dermis. Moist surface, with vesicles, patients
painful Methods to Estimate Total Body Surface Area (TBSA)
III. Full Thickness (3rd degree) Burned
– involves subcutaneous layer, pearly white, no
pain  Rule of nines – quick way; the system assigns
- Due to damage to the nerve endings percentages in multiples of nine to a major
IV. 4th degree body surface.
– involves the muscles and bones, blackish or  Lund and Browder method – more precise
charred, no pain method; recognizes that the percentage of
surface area of various anatomic parts, esp. the
Zones of Burn Injury head & legs, changes with growth.
 Palm method – scattered burns; 1 size of palm is
Zone of Hyperemia – sustain the least damage
approximately 1% of the TBSA
Zone of Stasis - has a compromised blood supply,
inflammation, and tissue injury
Zone of Coagulation – cellular death occurs.

Classification of Burns by Extent of Injury

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Pathophysiology of Burns

Rule of Nines  Burns are caused by a transfer of energy from a

heat source to the body.
 Thermal – hot objects or substances; due to
fires in the home, auto acidents , playing with
matches, poorly stored gas , faulty electrical
systems, space heaters, fire crackers, kitchen
accidents, scalding.
 Chemical – caused by contact, ingestion,
inhalation, injection of strong acids or alkali
 Electrical – from contact with malfunctioning
electrical appliances, wires, flash electrical arcs
from any high voltage power lines, machine and
lightning.
 Radiation – excessive exposure to sunlight.

Burn related Respiratory Injuries:

1. Smoke Inhalation
 Carbon monoxide CO (most common)
 Released when organic substances are
burned
 Colorless, odorless gas that combines
with Hgb 200x more than O2 causing
Tissue Hypoxia
 Causes headache, dizziness, confusion,
syncope, coma, respiratory failure.
 Treatment: 100% O2 administration;
Hyperbaric O2 chamber to reduce CO
level
2. Smoke Poisoning
 Results from noxious chemicals formed
in the burning process and is prevalent
with nonorganic substances (plastic);
decreases ciliary action in respiratory
tract and mucosal edema,
bronchospasm, carbon-flecked sputum
and then sloughing of the
tracheobronchial mucosa with cough up
Lund and Browder of purulent mucus.
3. Heat Injury
 More precise: recognizes that the percentage of
 Affects the upper airway with edema
TBSA of various anatomic parts, especially the
causing obstruction in the first 24 to 48
head and legs, and changes with growth
hours after burn
 Initial evaluation is made on the patient’s arrival
at the hospital and is revised within the 1st 72 Physiologic Changes
hours
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 Burns less than 20% TBSA produce a  Hyponatremia: Sodium is lost with diuresis and
primarily local response. due to dilution as fluid enters vascular space
 Burns more than 20% may produce a  Metabolic acidosis
local and systemic response and are
Cardiovascular Alterations:
considered major burns.
 Systemic response includes release of  ↓ Cardiac Output even without significant
cytokines and other mediators into the changes in blood volume
systemic circulation.  SNS stimulation due to Burn Shock releases
 Fluid shifts and shock result in tissue Adrenal corticoid hormones and
hypoperfusion and organ hypofunction. Catecholamines leading to vasoconstriction→
further ↓ in CO
Effects of Major Burn Injury
 24-36 hrs (peak at 6-8H) = Fluid Leak
 Fluid and electrolyte shifts ↓
 Cardiovascular effects Increases Blood volume
 Pulmonary Injury ↓
 Upper airway Increased renal perfusion
o Inhalation below the glottis ↓
o Carbon monoxide poisoning DIURESIS (up to 2 weeks)
o Restrictive defects  Anemia due to destruction of RBC (but HCT
 Renal and GI alterations level is increased)
 Immunologic alterations Pulmonary Alterations
 Effect upon thermoregulation
 Bronchoconstriction- Histamine, serotonin,
Fluid and Electrolyte Shifts: Emergent Phase thromboxane
 Generalized DHN evaporative loss, fluid shift  Upper airway-above glottis edema
 Reduced blood volume and hemoconcentration  Inhalation below the glottis-decrease ciliary
 Trauma causes release of potassium into function, Hypersecretion, Severe mucosal
extracellular fluid: hyperkalemia. edema, Bronchospasm, decrease surfactant
 Extensive local edema maximal 24H, begins to leading to Atelectasis → Acute Respiratory
resolve 1- 2days; completely resolved 7-10days Failure
 Decreased urine output o Treatment: Intubation, Mechanical
 Sodium traps in edema fluid and shifts into cells ventilation
as potassium is released: hyponatremia  Carbon monoxide poisoning (headache,
 Metabolic acidosis dizziness, weakness, upset stomach, vomiting,
chest pain, and confusion
Fluid and Electrolyte Shifts: Acute Phase  Restrictive defects – Escharotomy
 Fluid re-enters the vascular space from the Renal Alterations
interstitial space.
 Increased urinary output-Fluid shift into IVC • Due to decreased blood volume, hemolysis (Hgb in the
increases renal blood flow and causes increased urine), and muscle damage (Myoglobin)
urine formation. ↓
 Potential Hypokalemia: Potassium shifts from Occlusion of the renal tubules
extracellular fluid into cells ↓
 Hemodilution (↓HCT)- results as fluid enters Acute tubular necrosis
the IVC; loss of RBCs dt lysis at burn site ↓
RENAL Failure
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 application and soaking with cool water on
burned areas
 no direct application of ice

Immunologic Alterations:
• Diminished resistance to infection 3. Remove restrictive objects
 clothing and jewelry removed to
↓
prevent constriction due to edema
SEPSIS
4. Cover the wound
 immediate covering with sterile
▪ Abnormal inflammatory factors, altered level of IgA, dressings
impaired neutrophil functions, decrease lymphocytes  minimize bacterial contamination
↓  prevent air from contact with burned
Immunosuppression areas
• Loss of skin integrity  no medication/ material applied except
• Release of abnormal inflammatory factors, altered sterile dressings
levels of immunoglobulin and serum complement, 5. Irrigate chemical burns
impaired neutrophil function, lymphocytopenia  rapid, sustained flushing
 brush off chemical agents
 remove clothes immediately
GI Alterations:
Emergent or Resuscitative Phase: On-the Scene Care
 ↓peristalsis and bowel sounds
 Gastric distention and Nausea= vomitting Prevent injury to rescuer
 Gastric bleeding due to massive physiologic
↓
stress= CURLING’s ulcer (acute ulcerative
Stop injury: extinguish flames, cool the burn, irrigate
duodenal disease 24 H post burn)
chemical burns.
Phases of Burn Injury
↓
Emergent or Resuscitative Phase ABCs: Establish airway, breathing, and circulation.

 Onset of injury to completion of fluid ↓

resuscitation Start oxygen and large-bore IVs.

Acute or intermediate phase ↓

Remove restrictive objects and cover the wound.
• From beginning of diuresis to wound closure
↓
Rehabilitation phase Do assessment, surveying all body systems, and obtain a
• From wound closure to return to optimal history of the incident and pertinent patient history.
physical and psychosocial adjustment ↓
Emergency procedures at the Burn Scene: Note: Treat patients with falls and electrical injuries as
for potential cervical spine injury.
1. Extinguish flames
 victim "drops and rolls" Emergent or Resuscitative Phase
 smother the flames cool  Patient is transported to emergency
 effects on standing and running department.
 disconnect electrical source
 Rapid assessment; v/s q 15mins
2. Cool the burn
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 Maintain ABC; look for signs of inhalation injury
 Fluid resuscitation is begun.
 Foley catheter is inserted.
 Patients with burns exceeding 20-25% should Nursing Management
have an NG tube inserted and placed to suction.
 Monitor v/s closely, (RR, PR, BP)
 Patient is stabilized and condition is continually
 Monitor I&O
monitored.
 Asses frequently urine specific gravity, glucose,
 Patients with electrical burns should have an
protein, hgb; Burgundy colored urine suggests
ECG.
presence of hemochromogen & myoglobin due
 Address pain; only IV medication should be
to muscle damage
administered.
 Elevate burned extremity
 Psychosocial consideration and emotional
 Monitor IV therapy, obtain infusion pump
support should be given to patient and family
Nursing Process: Care of the Patient in the Emergent
Management of Shock: Fluid Resuscitation
Phase of Burn Care Diagnosis
 Maintain BP above 100 mm Hg systolic and
 Impaired gas exchange
urine output of 0.5- 1.0mL/kg/hr. Maintain
 Ineffective airway clearance
serum sodium at near-normal levels.
 Fluid volume deficit
 Consensus formula
 Hypothermia
 Evans formula Brooke
 Acute pain
 Army formula
 Anxiety
 Parkland Baxter formula
 Hypertonic saline formula Acute or Intermediate Phase
 Note: Adjust formulas to reflect initiation of
fluids at the time of injury.  Begins 48-72 hrs. after the burn injury
 Priorities of care: Continued assessment and
CONSENSUS FORMULA maintain respiratory and circulatory support;
F&E balance, prevention of infection, wound
Lactated Ringer’s Solution (or other balanced saline
care, pain management, and nutritional support
solution)
 Cautious administration of fluid because of fluid
2-4 mL x kg body weight x % TBSA burned shifts from the interstitial to the intravascular
compartment, losses of fluid from large burn
Half to be given in 1st 8 hours
wounds
Remaining half to be given over next 16 hours  Fever: caused by bacteremia and septicemia;
treated with acetaminophen and hypothermia
blanket

NURSING MANAGEMENT

 Continued Assessment of Circulatory Status,

F&E:
 Hemodilution
 Increased UO
 Hyponatremia
 Hypokalemia
 Acidosis
 Continuous and monitored fluid resuscitation
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• Pseudoeschar formation
2. Mafenide Acetate 5%-10% (Sulfamylon)
✓ Effective against gram – or + microorganism
Burn Wound Care ✓ Diffuses rapidly through the eschar
✓ In 10% strength, it is the agent of choice for
 Wound cleaning
electrical burns because of its ability to
 Hydrotherapy-cleaning of wounds &
penetrate the eschar
exercising the extrimities.
 The temperature of the water ✓ Apply thin layer with sterile glove 2x daily and
is maintained at 37.8 C (100 F) leave open as prescribed; if the wound is
 The temperature of the room dressed, change q6h as prescribed
should be maintained between Nursing Implications:
26.6 C and 29.4 C (80 oF to 85
oF) ▪ Monitor ABG levels because it causes
 Limited to a 20-30 minutes metabolic acidosis with its effect on renal
period to prevent chilling and buffering
additional metabolic stress. ▪ Analgesic for pain mgt- may cause pain
 Wound débridement- the removal of foreign
material and devitalized tissue until surrounding 3. Silver Nitrate- Bacteriostatic and fungicidal
healthy tissue is exposed; two goals: ✓ Does not penetrate the eschar
• To remove tissue contaminated by ✓ Apply to gauze dressing, place over wound.
bacteria and foreign bodies, thereby Keep dressing wet but covered w/ dry gauze &
protecting the patient from invasion of blankets to prevent vaporization. Re-moisten
bacteria. q2h; redress wound 2x daily
• To remove devitalized tissue or burn
Nursing Implications:
eschar in preparation for grafting and
wound healing. ▪ Monitor Na & K serum levels because of its
hypotonicity
Escharotomy
▪ Protect bed linen/clothing in contact as it
 Treat full thickness (third-degree) causes black staining
circumferential burns
 Used primarily to combat compartment 4. Acticoat- Effective against gram – or +
syndrome microorganism and some yeasts and molds
 Performed by making an incision ✓ Delivers a uniform, antimicrobial
through the eschar to expose the fatty concentration of silver to the burn wound
tissue in order to lessen its pull on the ✓ Moisten w/sterile water only; Apply directly
surrounding tissue. to wound.
✓ Cover with absorbent secondary dressing.
Topical Antibacterial Agents for Burns
Remoisten w/ sterile water q3-4h.
1. Silver Sulfadiazine 1%(Silvadene)- bactericidal
agent Nursing Implications:
• Minimal penetration of the eschar ▪ No oil-based products or topical antimicrobials
• Apply 1/16 in. layer of cream with sterile glove ▪ Keep moist
1-3x/day ▪ Left in place 3-5 days

Nursing Implications:
Other agents:
• Leucopenia 2-3days  Aquacel,
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 Siversorb,  Use of occlusive dressings to immobilize the
 Silverlon, graft.
 Povidoneiodine ointment 10%;  First dressing change is performed 2-5 days
 gentamicin sulfate; after surgery.
 nitofurazone;  Sterile saline to prevent drying of the graft.
 Dakin’s solution;  Patient positioned and tuned carefully to avoid
 acetic acid; disturbing the graft
 miconazole;  Elevate grafted extremity to minimize edema.
 clotrimazole Bacitracin is used for facial burns  Patient to exercise the grafted area 5-7 days
 Wound dressing, dressing changes after grafting.
 light dressing for joints areas (allow motion);
areas with splint (maintain body contour); on Care of the Donor Site (area from which skin is taken)
face (absorb exudates going into the eyes)  Moist gauze dressing applied after surgery to
 circumferential dressings applied from distal to maintain pressure and stop bleeding.
proximal; fingers and toes wrapped individually  Thrombostatic agents applied to the site.
 burns on face left open to air  Covering of donor sites with biosynthetic
 occlusive dressings are used over areas with dressings.
new skin, graft; this thin gauze with  Pain relievers.
antimicrobial agent remains in place for 3-5  A donor site heals within 7-14 days with proper
days care
 changing of dressings is done 20 minutes after
analgesic agent is prescribed Pain Management
 note for color, odor, size, exudates, signs of re-  Burn pain has been described as one of the
epithelialization, eschar and other changes most severe forms of acute pain.
 peripheral extremities must be checked  Pain accompanies care and treatments such as
frequently and burned areas elevated on 2 wound cleaning and dressing changes.
pillows  Types of burn pain
o Background or resting: exists on 24 hour
Wound Grafting basis
• Purposes: to decrease risk of infection o Procedural: caused by manipulation of
• to prevent further loss of protein, fluids wound bed during dressing changes or
&electrolytes ROM exercises.
• to minimize heat loss through o Breakthrough: occurs when blood levels
evaporation of analgesic agents decreased below
• permits earlier functional ability the level required
• reduces wound contractures  Analgesics
• temporary grafting is done before o IV use during emergent and acute
patient’s own skin is possible phases
• main areas for grafting are the face,  Morphine
hands and feet, and areas that involve  Fentanyl
joint
• granulation process to take place first Nutritional Support
before grafting  Burn injuries produce profound metabolic
abnormalities. Patients with burns have great
Care of the Graft Site nutritional needs related to stress response,
Increased catabolic hormones (cortisol and
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catechols), hypermetabolism, and wound parallel orientation of the collagen to
healing. the skin surface
 Goal of nutritional support is to promote a state • Worn 23 hours a day
of nitrogen balance and match nutrient 2. Silicone Sheets: for small troublesome areas
utilization.  Gentle superficial scar massage w/
 Nutritional support is based on patient’s moisturizer: smaller areas
preburn status and % of TBSA burned.  Steroid injections
 Enteral route is preferred. Jejunal feedings are 3. Keliod: irregularly formed scar, extends
frequently used to maintain nutritional status beyond the margins of the original wound
with lower risk of aspiration in a patient with  Large, nodular, ropelike
poor appetite, weakness, or other problems.  Itchy, tenderness
 Calories: 4. Contractures: burn wound tissue shortens
o High Protein (15%-25%): 2-3g/kg because of the force exerted by the fibroblasts
BW/every 24 hours • the flexion of muscles in natural wound
o High Carbohydrates (55%-85%) healing
o Low fat (3%-20%) • Tx: splints, traction, and purposeful
 Vitamin supplementation: movement and positioning: counteract
o A: skin & mucous membrane integrity deformity in burns affecting joint.
o B: enhances metabolism
o C: ↑ resistance to stress & infection Care of the Patient During Acute Phase:
 Oral fluids must be initiated slowly 1. Assessment:
 High protein and high vitamin food  Focuses on hemodynamic alterations,
 High calorie nutritional supplements wound healing, pain and psychosocial
 Vitamins and Mineral supplements responses, early detection of complications.
 Enteral feeding of bolus formula if not possible  Frequent assessment on vital signs,
by mouth peripheral pulses, edema, dysrhythmias,
electrolyte imbalance, residual gastric
 Parenteral nutrition if GI function is
volumes, and pH.
compromised
 Weigh patient daily and record  Assess burn wounds as to size, color, odor,
eschar, exudates, abscess formation,
epithelial buds bleeding, granulation, status
Disorders of wound healing:
of grafts and donor sites, and quality of
1. Hypertrophic scars: form within the boundaries
surrounding skin.
of the initial wound and push outward on the
perimeter of the wound.  Focus on pan and psychosocial responses,
o Areas over joints daily weights, caloric intake, general
hydration, serum electrolytes, Hgb and Hct
o Hypopigmented/hyperpigmented
levels.
2. Scars: red, raised and hard
2. Diagnosis
 Excessive fluid volume
Prevention and Treatment of Scars
 Risk for infection
1. Compression: early in burn wound treatment
 Imbalanced nutrition
 Elastic Bandage wraps: desensitize the
patient’s skin, protect healing areas,  Acute pain
apply pressure, and promote venous  Impaired physical mobility
return  Ineffective coping
• Elastic pressure garments: loosens  Interrupted family processes
collagen bundles and encourages  Deficient knowledge
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Nursing Diagnosis:
1. Activity intolerance r/t pain on exercise, limited Other Major Care Issues
joint mobility, muscle wasting, and limited  Pulmonary care
endurance  Psychological support of patient and family
NI: Promoting Activity Tolerance  Patient and family education
 ▪Insomnia due to frequent nightmares  Restoration of function
(listening; prescribed hypnotic agents)
 Metabolic stress (relieve pain; Potential Complications/Collaborative Problems
preventing chilling or fever)  Acute respiratory failure
 Muscle atrophy (therapy exercises)  Distributive shock
 Low endurance (play therapy)  Acute renal failure
EO: Obtains adequate sleep daily  Compartment syndrome
 Reports absence of nightmares or sleep  Paralytic ileus
disturbance  Curling’s ulcer
 Shows gradually increasing tolerance
and endurance in physical activities Rehabilitation Phase
 Can concentrate during conversations  Rehabilitation is begun as early as possible in
 Has energy available to sustain desired the emergent phase and extends for a long
daily activities period after the injury.
2. Disturbed body image r/t altered physical  Focus is upon wound healing, psychosocial
appearance and self-concept or Impaired coping support, self-image, lifestyle, and restoring
NI: Improving Body Image and Self-concept maximal functional abilities so the patient can
 Refer patient to support group have the best-quality life, both personally and
 Meet others with same experience and socially.
learn coping strategies  The patient may need reconstructive surgery to
 Constantly assess the patient’s improve function and appearance.
psychological reactions  Vocational counseling and support groups may
EO: Verbalizes alterations in body image assist the patient.
and accepts physical appearance
 Demonstrates interest in resources Complications
 Use cosmetic; wigs; and prostheses; 1. Neuropathies, nerve entrapment
 Socialize with others - Electrical injury, large deep burns, improper
 Seeks and achieve family and societal positioning, edema, scar tissue
roles Nursing Interventions:
3. Deficient knowledge about post-discharge  Assess peripheral pulses and sensation.
home care and follow-up needs  Prevent edema and pressure by
NI: Demonstrate knowledge of required self- elevation, positioning, prevention of
care and follow-up care constricting dressings.
EO: Describes surgical procedures and Tx  Assess splints for proper fit and
accurately application.
• Verbalizes detailed plan for follow-up  Consult OT and PT for positioning.
care 2. Heterotophic ossification – Prolonged
• Demonstrate ability to perform wound immobility
care and prescribed exercises ▪ abnormal formation of true bone within
• Returns for follow up appointments extraskeletal soft tissues
• Identifies resource people and agencies Nursing Interventions:
to contact for specific problem
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• Perform gentle range-of-motion  Mental health
exercises  Skin and wound care
3. Hypertrophic scarring  Exercise and activity
- Partial and full thickness burns  Nutrition
Nursing Interventions:  Pain management
• Keep skin pliable and soft.  Thermoregulation and clothing
• Apply pressure garments as prescribed.  Sexual issues
• Massage.
4. Contractures Collaborative Problems/Potential Complications
- Partial and full-thickness burns  Heart failure and pulmonary edema
Nursing Interventions:  Sepsis
 Maintain position of joints in alignment.  Acute respiratory failure
 Perform gentle range-of-motion  Visceral damage (electrical burns)
exercises.
 Consult OT and PT for exercises and
positioning recommendations.
5. Wound breakdown
-sheer, pressure, inadequate nutrition
Nursing Interventions:
 Teach patient about importance of
good nutrition.
 Protect wound from pressure and
shearing forces.
6. Gait deviations
- Pain; burn wound; donor site, scarring of
joints, electrical injury of the brain
Nursing Interventions:
 Provide adequate pain management.
 Consult OT and PT.
 Promote ambulation and mobility
training.
7. Complex regional pain syndrome
- Trauma and burns
Nursing Interventions:
 Provide adequate pain management.
 Consult OT and PT for exercises.
 Promote gentle motion of affected
extremities
8. Joint instability
- Burn wound, burn scar, and contractures
Nursing Interventions:
 Maintain joint through appropriate
application of splints.
 Monitor joint pinning if indicated.
 Consult OT and PT

Home Care Instructions