BURN

INTRODUCTION TO BURN
Burn this can be defined as the tissue damage brought on by
heat, chemicals, electricity, radiations or by the sun rays. A
burn can occur when those heat, chemicals, electricity,
radiations and sun rays damage the tissue and this most occur
accidentally
PATHOYPYSIOLOGY OF BURN

1. Local response
2. Systemic response
LOCAL RESPONSE

This is characterized by three concentric zones which are

coagulation zone, stasis zone and hyperemia zone.
The zone of coagulation occurs at the point of maximum
damage, it is characterized by irreversible tissue death due to
coagulation of structure protein. During this phase the platelets
plug acts like bricks and the fibrin acts like mortar which together
they form a solid and stable clot.
Events which occurs during coagulation phase includes
constriction of blood vessels, formation of a temporary platelet
plug and activation of the coagulation cascade
LOCAL RESPONSE…..

• The stasis zone is characterized by decreased blood perfusion to the

tissue, in this zone may be rescued if the blood flow can be restored
nevertheless extended perfusion or infection may still cause tissue
death.
LOCAL…….
 In the outer most zone of hyperemia it contains viable
tissue and has no risk of necrosis it is characterized by
vasodilation due to effect from zone of stasis.
 also, perfusion, edema and inflammation are frequently
sign of full recovery.
 These three zones of burn are three dimensional and loss of
tissue in the zone of stasis will lead to wound deepening and
widening
SYSTEMIC RESPONSE

The release of inflammatory mediators and cytokines at the

site of injury has a systemic effect when the burn reaches
about 30% of total cardiovascular alteration, respiratory
changes, metabolic changes and immunological changes.
Cardiovascular changes include permeability leading to loss
of intravascular protein and fluid into interstitial space,
decreased myocardial contractility also patient may
experience hypotension and organ hypofusion
Systemic………
 respiratory changes include bronchoconstriction due to release of
inflammatory mediator leading to respiratory distress.
 Metabolic changes include increase in basal metabolic rate thus may
place the patient into persistent catabolic state that decrease the rate
of recovery.
 Immunological changes include non-specific down
regulation of the immune response occurs affecting both
cells mediated and humoral pathway.
CLASSIFICATION OF BURNS

I. According to types of burn or causes of burn

a) Thermal burns
b) Electrical burns
c) Chemical burns
d) Friction burns
II. Classification according to depth
a) Superficial or epidermal burns (First degree)
b) Partial thickness burns (second degree)
c) Full thickness burns (third degree)
d) Deep, full thickness burns (fourth degree)
CLASSIFICATION OF BURNS
III Classification of burns according to size/extent
a) Palmar Method.
b) Rule of nine Method.
c) Lund- Browder method.
IV According to severity
d) Minor burns
e) Moderate burns
f) Major burns
According to types of burn
Thermal burns
They are caused by direct contact with an open heat source,
such as fire, steam, or a boiling liquid. Sunburns are also a
type of thermal burn.
Burns due to external heat sources that raise the temperature
of the skin and tissues. These burns also cause tissue cell
death or black charring. Hot metals, scalding liquids, steam,
and flames, when coming in contact with the skin, can cause
thermal burns.
According to types………
Electrical burns
can happen if a victim interferes with an electric current by
gripping an exposed wire, swimming in electrified water, or
mishandling machinery. can cause superficial tissue damage.
Chemical burns
When a synthetic, corrosive substance comes into contact with
soft tissue—such as skin, eyes, and internal organs—it can
result in chemical burns. Certain acids, bases, oxidizers,
solvents, thinning agents, and alkylating agents can all have
damaging effects on the human body.
According to types of burn………
Friction burns.
Burns from direct damage to the cells and from the heat
generated by friction. Examples include children falling on or
touching a treadmill in motion. Or a rope burns from a rope
sliding through the hands.
ACCORDING TO DEPTH
according to depth………..

Superficial or epidermal burns involve only the epidermal

layer of the skin and are classified as first degree,
 Partial thickness burns involve the epidermis and portions
of dermis and are classified as second degree,
 Full thickness burns extend through and destroy all layers of
the dermis are classified as third and fourth degree.
according to depth………..

FIRST DEGREE
This class of burns involves the epidermis tissue only.
They may be caused by the sun, hot objects or hot water. The
wound appears with mild edema, dry and no blistering or
vesicles initially, the patient may experience
pain/hypersensitivity to touch.
according to depth………..

SECOND DEGREE
• This class of burns involves the outer layer of skin and part of
inner layer of skin (epidermis and deep layer of dermis).
• They may be caused by very hot water, open flames, hot
objects, sun, chemicals or electricity.
• The wound is characterized by mottled (red, pink to white
surface), moist, moderate edema and severe painful.
• Hospitalization is required if about 25% of the body surface
involved.
according to depth………..

THIRD DEGREE
This class of burns are deep, severe burns that completely damage the
skin (involves the entire epidermis and dermis).
They may be caused by exposure to flames, explosions or strong
chemicals.
The wound is characterized by dry, leathery and rigid, red, white, yellow,
brown or black in colour, severe edema, painless and insensitive to
palpation.
Patients with third degree burns needs immediate medical attention
from a special burn unit so as to prevent serious complications such as
infection or shock.
according to depth………..

FOURTH DEGREE
This class of burns extend beyond skin to include muscle, tendons
and possibly bone.
They may be caused by flames and chemicals, some of possibilities
includes a hot stove or oven and hot irons.
The wound is characterized by black (dry, dull and charred), no
edema, painless and insensitive to palpation.
ACCORDING TO SIZE/EXTENT

Calculation of burns according to the size or extent is based

much on calculating the total body surface area burned
(TBSA). The aim of calculating the total body surface area is
 to enable the practioners to determine the amount of fluid
required by the patient to be resuscitated
it used in prioritizing the patient either to be hospitalized or
not and furthermore it is needed so as to know how
prognosis can be determined.
ACCORDING TO SIZE/EXTENT……..

Palmar Method.
• By using the Palmar Method in estimating the total body
surface area of the burn, the patient's hand (palm) is used. It
involves positioning the patient’s hand fingers together.
Commonly, the method is used for small and scattered burns,
under this method it describes that the area represented by
the palm is 1% of Total Body Surface Area (TBSA). But some
literature shows different finding as the palm with digits
counts 0.8% and palm without digits counts about 0.5% of
Total Body Surface Area (TBSA
ACCORDING TO SIZE/EXTENT……..

Rule of nine Method.

• This method involves calculation of the area burned by
dividing the body into percentage of 9. It involves assigning
percentage to different areas of the body. It is only applicable
for the burn involving the Full-time thickness and partial-
thickness burn, no consideration of superficial burns
ACCORDING TO SIZE/EXTENT……..

Lund- Browder method.

• Under this method, burning size/extent is calculated
considering the variation in the body shapes with the age,
extra knowledge and skills on the depth of burn are required
so as to accomplish well the task. The method does not
include the estimation of burned area in superficial burn as
well. Mostly used for both adults and children.
ACCORDING TO SEVERITY

According to severity burn is mainly grouped under here

categories that includes
• Minor burns
• Moderate burns
• Major burns
ACCORDING TO SEVERITY
ACCORDING TO SEVERITY
Minor burns
• They include all burns that covers only a small surface area of
the body and surface area is usually less than 2% of the total
body surface area. It can be due to the result of touching hot
object or a burning little amount of hot water on a localized
body part. This kind of burn can heal without the need of
hospitalization and hence cause little or no complications.
ACCORDING TO SEVERITY
Moderate burn
• These are burns that tend to cover about 10% of the total
body surface. It may include burns in the different body parts
like the hands, feet or on the genitals. Close monitoring of
this kind of burns
ACCORDING TO SEVERITY
Major burns
• Include all large burn that covers almost greater than 10% of
the total body surface area. They can be due the various
cause like electrical accidents, lightning or chemical burns.
This kind of burns contribute to high mortality as they cause
major changes in the physiological conditions of the body
hence very close monitoring and management is required for
the survival of the patient
COMPLICATION OF BURN
• Infection. Burns can leave skin vulnerable to bacterial
infection and increase your risk of sepsis, a life-threatening
infection that travels through bloodstream and affects whole
body. Sepsis is a rapidly progressing, life-threatening
condition that can cause shock and organ failure
• Low blood volume (hypovolemia). Burns can damage blood
vessels and cause fluid loss. This may result in low blood
volume (hypovolemia). Severe blood and fluid loss prevent
the heart from pumping enough blood to the body.
COMPL…….
• Dangerously low body temperature (hypothermia). The skin
helps control the body's temperature, so when a large
portion of the skin is injured, the body lose heat.
• Breathing (respiratory) problems. Breathing hot air or
smoke can burn airways and cause breathing difficulties.
Smoke inhalation damages the lungs and can cause
respiratory failure.
COMPL…..
• Bone and joint problems. Deep burns can limit movement of
the bones and joints. Scar tissue can form and cause
contractures, when skin, muscles or tendons shorten and
tighten, permanently pulling joints out of position.
• Scarring. Burns can cause scars and keloids — ridged areas
caused by an overgrowth of scar tissue.
 PHASES OF PATIENT WITH BURN
• EMERGENT PHASE
• The emergent phase begins on the onset of the injury and complete
until the fluids resuscitation or the period of about the range of 48
hours. In this phase the major priority is to maintain the air ways and
treating a patient from the hypovolemic shock together with edema
formation.
EMERGENT PHASE....

Emergency care at the site of injury.

This can be applied to the minor burn injury.
• Soaking a burn with cool water for the purpose of pain relief and
limiting local tissue edema
• Removing all the jewelry and all the non-adherent clothing
• water
EMERGENT PHASE….

• Covering the wound with sterile or the clean dressing to reduce

bacteria contamination
• Brushing chemical contaminants
• Flushing the area with running water
EMERGENT PHASE…
• Also, if the burn is classified and determined to be the major injury
the following assessment should be done.
• Air way
• Breathing
• Circulation
EMERGENT PHASE….
• At this point tracing the presence f stridor indicate the respiratory
damage as it shows that upper air ways is 85% narrowed , blisters in
the roof of the mouth , soot [carbon ] in the mouth, Edema of the lips
and oral cavity ,.
EMERGENT PHASE….
• coughing, Hoarse voice and circumferential neck burn indicates the
patient has respiratory damage , therefore endotracheal intubation
with assisted ventilation might be required to achieve adequate
oxygenation
EMERGENT PHASE….
• -Air way Management
• Hoarse voice and circumferential neck burn indicates the patient has
respiratory damage , therefore endotracheal intubation with assisted
ventilation might be required to achieve adequate oxygenation.
EMERGENT PHASE….
• -Breathing
• Involve the assessment of breath sound, chest movement, rate and
depth of breathing and take the intervention of each accordingly,
Example position of a patient in high semi fowlers position, encourage
deep breathing and coughing every hour, suctioning and chest
physiotherapy.
EMERGENT PHASE….
- Circulation
• Compromised circulation is evidenced by the following, slowed
capillary refill, drop in blood pressure and decreased urine output
which all this may lead to shock, the following can be done monitor
blood pressure, pulse rate, establishment of IV access and monitor
peripheral pulses in circumferential burn
EMERGENT PHASE….
• THE NEXT INTERVATION
• Insertion of a large bore catheter for administering IV fluids
• The fluids therapy aims to prevent shock by maintaining the adequate
circulating blood fluid volume for normal cardiac output., In severe
burn require large fluids loads in short time to maintain blood flow to
a vital organ. Although there are a number of acceptable formulas for
calculating fluid requirements, the Parkland formula is most often
used
EMERGENT PHASE….
• Parkland formula
• Ringer’s Lactate 4 ml × kg body weight × % TBSA
• Half of the amount is to be infused in the first 8 hours.
• The remainder is to be infused over the next 16 hours.
• Calculation of the TBSA using the Rule of Nines
EMERGENT PHASE….
EMERGENT PHASE….
• Example: A client receives full thickness burns of the arms, chest,
back, and head at 0600 hours. The client weighs 82 kg. Using the
Parkland formula, how much fluid should the client receive by 1400?
EMERGENT PHASE….
• Steps involved.
• Calculate the TBSA using the Rule of Nines:
• arms (9% each arm) = 18% + chest (18%) + back (18%) + head (9%) =
63%
• Calculate using the Parkland formula for fluid resuscitation:
• 4 ml × 82 kg × 63 = 20,664 ml in 24 hours
EMERGENT PHASE….
• According parkland formula a half of calculated volume of lactated
ringers’ solution is to infuse in the first 28 hours, one fourth is to
infuse in the second eight hours and one fourth is to infuse in the
remaining eight hours
EMERGENT PHASE….
• 20664/2=10332ml therefore this will be given in the first 8 hours of
resuscitation and the remaining half will be given in the next sixteen
hours.
ACUTE PHASE

This phase of wound care follows after emergent phase and it start
48hrs to 72hrs (2 to 3 days) post burn injury
ACUTE PHASE…
• From 48hrs post burn injury blood capillaries regain ability to retain
fluids due to this fluid there will be shifting of fluids from interstitial to
intravascular compartment this will lead to increase of urine secretion
and for individuals with inadequate renal and cardiac function fluid
overload may occur and may results to congestive heart failure
ACUTE PHASE…
• In this phase of burn caring focuses is directed toward the following;
• Continued assessment, respiratory and circulatory system
maintenance
• Body fluids and electrolytes balance
• Gastrointestinal tract function
• Infection prevention
ACUTE PHASE…
• INFECTION PREVENTION
• Burn wound has the favorable condition for bacterial growth,
bacterial such astaphylococcus, Proteus, pseudomonas, E. coli and
klebsiella can infect and colonies the burn wound.
• About 50% of nosocomial blood stream infection in patients with
burn injury are associated with staphylococci and enterococci. Fungi
such as Candida albicans can grow on wound
ACUTE PHASE…
• WOUND CLEANING
• Different measures such as hydrotherapy in form of shower carts,
personal shower and bed bath are used to clean wound, tape water
alone can also be used in wound cleaning.
• During bath a patient is emphasized to be active as much as possible,
this will help to provide exercise of extremities and for cleaning of the
whole body
ACUTE PHASE…
• TOPICAL ANTI-BACTERIAL THERAPY.
• Topical antibacterial are drugs which are applied directly on the
wound they are not applied sterilize the wound instead are applied to
reduce an overall number of microbial populations so as a patient's
defensive mechanism can fight against microbes.
ACUTE PHASE…
The following are three commonly applied topical agents
• Silver sulfadiazine
• Mefidine acetate
• Silver nitrate
ACUTE PHASE…
• WOUND DRESSING
• After a wound is cleaned, burned area is patted dry and prescribed
topical agent is applied, the wound is then covered with several layers
of dressings, joints are covered by light dressing to allow motion. If
hand and foot are burned fingers and toes should be covered
individually to promote adequate healing.
ACUTE PHASE…
• Burns on the face may be left open after they have been cleaned and
topical agent has been applied. Caution should be taken to the burns
which are left opens in order to prevent them from dry up and
convert to a deeper burn
ACUTE PHASE…
ACUTE PHASE…
• DEBRIDEMENT
• Debridement is done to remove tissue contaminated by microbes
and foreign bodies so as to protect the patient from invasion of
bacteria, also debridement is done to prepare burn wound for healing
and grafting.
ACUTE PHASE…
• WOUND GRAFTING
• Is a surgical procedure in which a shaving of healthy skin is completely
removed from another part of the body (donor site) and placed over
the wound where the lesson was present (grafting site). The graft skin
may be a thin layer or thick layer in accordance to the site where has
been taken and the graft site involved
ACUTE PHASE………..
• Alternatives of skin grafting
• Biological dressings (homograft and heterograft
•Biosynthetic and synthetic dressing
• Skin substitutes
ACUTE PHASE…

Figure Biological dressings (homograft and

heterograft)
ACUTE PHASE…
• NUTRITIONAL SUPPORT
• Nutritional support and intervention are required to provide energy
and nutrients for infection prevention and also to promote wound
healing process. A patient must get enough protein, vitamins and
minerals for wound healing but also carbohydrates and fats for energy
requirements.
ACUTE PHASE…
• PAIN MANAGEMENT
• Burn injury is the most painful type of trauma that a patient
experience. Depth of the burn wound influence the severity of pain
ACUTE PHASE…
• Management is done by measuring the extent of pain followed by
administration of opioids, nonsteroidal ant-inflammatory drugs
(NSAIDs), and anesthetics. To make patient free from anxiety
benzodiazepines are used along with opioids
REHABILITATION PHASE

• This is the phase when the burn wound completely healing

or it has healed, and begins as early as 2 weeks or 7-8
months (In case of larger burn) after occasion of injury and
may extend to years.
• During this phase, management is done in order to;
• Return the patient into normal physical and functional role to
the family and society.
• Rehabilitate from physiological and postburn effects like
performing reconstructive surgery if crucial.
MANAGEMENT OF REHABILITATION
PHASE
A: EMOTIONAL AND PSYCHOLOGICAL MANAGEMENT
• After person got burn injury during and after recovery, he/she
may experience problems in his/her mindset that partially or
completely distort emotional and psychological status. The
contributing factors to this health problems are;
• Fear about the wound injury and it's healing
• Anxiety when comes to lack control
• Anger by himself or about the situation and injury status
• depression by himself on society around.
MANAGEMENT…………

• Stress on consideration of the injury and destruction on

compare to normal body status.
• So, during this phase a care giver must be careful and spend
more time in assisting the patient on the needs and
encouraging self-care process to victim. Also counselling and
teachings must be provided concerning the injury and on
how to deal with situation when comes an absence of an
assistant.
MANAGEMENT…………
B: CONTROLLING AND PREVENTING THE ABNORMALITIES OF
WOUND HEALING
• It is experienced that during burn wound healing especially
the type of deep partial thickness and full thickness wounds
that involves dermis and subcutaneous tissues varies in
healing process and forming scars. Normal scars form within
7-10 days while abnormal scars are those long-time forming
scars at about 2-12 months after the injury. The abnormal
scars can be categorized as; Hypertrophic and Keloid scars.
•.
MANAGEMENT…………
• - Keloid scar that lack definite form(irregularity). This can
extend beyond the initial wound and observed large sized,
modular and sometimes tender.
• Their prevention and control involve;
• Using Compression method
• On this method, elastic bandages and pressure garments are
used, these are worn for about 23hours a day. These help to
compress the region of the healing wound helping softening
collagens and prevent hypervascularity hence the raisings
and nodular forms wouldn't form.
MANAGEMENT…………
• Using topical silicone and steroid injections
• This is pharmacologically control and prevention of scar
formation.
• Surgical procedure
• This is the technical correction of scar formed on the skin
involving surgery Processes. This is done usually after Long
time from injury, and aim to return the cosmetics, normal
appearance and functional of body parts example during
correction of contractures.
COMPLICATIONS IN REHABILITATION PHASE

 Contractures;
due to scars
formed on the
skin after
healing
COMPLICATIONS IN REHABILITATION PHASE

• Wound breakdown; due to shearing, pressure, and poor nutrition

during recovery.
• Neural problems; due to larger and deep burning wounds that
affect nerves.
• Joint inflexibility; due to formation of scars and contractures may
affect normal mobility ranges of some body parts when involved.
• Pruritus and itching; its common to healed wound from burn the
victim experience this disturbance and to deal with this
moisturizers, massages, oral/topical antihistamines, bath, and
Topical compressors can help to relieve this issue.
NURSING PROCESS IN
REHABILITATION PHASE
• Assessment
• During assessment of patient subjective information’s are
obtained from the patient or family member, where personal
and health history of patient's information’s are obtained.
• After that, healthy personnel in concern will observe, measure,
and take concerning data of the patient's in relation to the
wound status example basing in Range of motion (ROM),
activities and functional of body parts in concern, wound
breakdown, sensory function and quality of healing wound.
NURSING PROCESS…………

Diagnosis
• This part can comprise the;
• Activity intolerance related to pain on exercise
• - Disturbed body image and physical features
• - Contractures presences and its complication
• - Poor adaptation to health status emotionally (acceptance of injury)
• Planning
• - To make sure patient is able to assume self-care by himself
• - To return to normal health status of patient
• - Patient achieve and perform all physical activities without disturbances
NURSING PROCESS…………
Interventions
• - Exercise comply to Health status of patient at that time.
• - Enough rest and sleep.
• - Ensuring charming and providing psychological advices to patient.
• - Providing medications as prescribed by Physician.
• - Providing teachings and instructions on self-care and directives on wound
caring all these given to patient and family member who are taking care of
the patient. These should be of verbal and written form for easy memory.
• - Follow up care after discharge, example patient may be required to come
back to hospital for wound recheck up.
CONCLUSION
• Generally, burn injuries can be reduced/prevented through
various methods including the following:
• avoid smoking on bed
• Children should restrict from playing with fire sources.
• lower hot water temperature to the lowest point at 40
degrees.
CONCL……
• children, older adults, people with impaired movement and
people with mental disabilities should be supervised when
bathing, cooking or playing
• chemicals should be stored in safe and clearly labeled
containers
• careful handling and use of electrical appliances
• turning off electricity before electrical repairs
• Fire extinguishers should be kept in public buildings