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1. Burn
Logman Mohammed Alshaikh
BSc N- Gezira university
MSc in MSN- alneelain university

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Definition:
is physical trauma due to effect of heat resulting
in various degrees of coagulation of tissue
proteins.
the high risk:
(1)-Young children and elderly peoples.
(2)- Most burn injury occur at home (kitchen,
bathroom).
(3)- Work place.

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Causes of Burn Injury
 Sun leads to sun tan i.e. brown skin
discolouration due to exposture to direct
sunlight on the white skin people.
 Sclads :burn by boilong liquids like water
,milk,tea…etc
 flames
 Chemical: strong Acids, alkalis usualy
deep burn.

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cont
 Electrical
 Usually deep burn leading to coagulation and
thrombosis of main blood vesseles ending in
gangrene.
 Radiation
 Usually deep and may be associated with bone
marrow depression or cancer

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pathophysiology
 Hemodynamic Changes
 Lessened circulating blood volume results in
decreased cardiac output initially and increased
pulse rate.
 There is a decreased stroke volume as well as a
marked rise in peripheral resistance (due to
constriction of arterioles and increased
hemoviscosity).
 This results in inadequate tissue perfusion, which
may in turn cause acidosis, renal failure, and
irreversible burn shock.

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 Electrolyte imbalance may also occur.
 Hyponatremia usually occurs during the
3rd to 10th day due to fluid shift.
 The burn injury also causes
hyperkalemia initially due to cell
destruction, followed by hypokalemia as
fluid shifts occur and potassium is not
replaced.

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renal system :
 decrease blood flow to the kidney result in
decrease GFR result in oliguria and renal
failure .
 Hemoglobin and myoglobin, present in the
urine due to deep muscle damage commonly
in electrical injury because it causes acute
tubular necrosis

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 Pulmonary Changes
 The majority of deaths from fire are due to
smoke inhalation.
 cause pulmonary edema, contributing to
decreased alveolar exchange.

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Hematologic Changes
 Thrombocytopenia,
 Anemia results from the direct effect of
destruction of RBCs due to burn injury, or
blood loss.

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GI Impact
 As a result of sympathetic nervous system
response to trauma, peristalsis decreases and
gastric distention, nausea, vomiting, and
paralytic ileus may occur.
 Ischemia of the gastric mucosa and histamine
risk for duodenal and gastric ulcers, s/s : occult
bleeding or life-threatening hemorrhage
 Decrase blood flow to the mesenteric artery lead
GIT desfunction

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Immune system :
 Decrease in immuno system componenets
this lead to increase risk of infection .
 The loss of the skin barrier and presence of
eschar favor bacterial growth.

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Summary of

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SEVERITY OF BURNS
 Factor affecting Severity of burns is
determined by:
 Depth : first, second , third degree .
 Extent : percentage of TBSA.
 Age : the very young and very old have a
poor prognosis.

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SEVERITY OF BURNS
 Area of the body burned : face, hands,
feet, perineum, and circumferential burns
need escharotomy.
 Comorbid condition (DM , malnutrition, low
immunity )
 Inhalation injury

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Classifications of burn :
 Burn injuries are described according to :
(1) the depth of the injury
(2)the extent of body surface area injured.

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Burn Depth

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Burn Depth
 Burns are classified according to the depth
of tissue destruction as :
1. Superficial (First degree )
2. Partial thickness (second degree )
3. deep partial-thickness (third degree)
4. or full-thickness injuries

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 First degree ( superficial ) :
 is burn of epiderm , its very painful
 Pink to red: slight edema, which subsides
quickly.
 Pain may last up to 48 hours; relieved by
cooling. No scarring.
 heals spontaneously if not infected

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second degree (partial thickness) :
it is burn until derm that Pink or red;
blisters , edematous, and elastic,
painful.
Takes several weeks to heal.
Scarring may occur

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third degree (full thickness) :
Include , all layers of the skin, muscles, and bone
Its serious need hospitalization
Not painful
coloration varies from waxy white to brown to
black charcoal
pt heal with contracture , scar and deformity
Area requires debridement, and grafting.

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(2) the extent of body surface area
injured.
 Extent of Body Surface Area Injured
 Various methods are used to estimate the total body
surface area (TBSA) affected by burns; among
them are :
1. the rule of nines,
2. the Lund and Browder method,
3. and the palm method

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THE RULE OF NINE
 Rule of nine :
 IS easy and most widely
used:
 The human body divided in
to in (8)parts , head and neck
9%, back 18%, thorax &
abdomen 18%,hand 9%, leg
18% and perinuim1%

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 Palm Method
 In patients with scattered burns, the palm
method may be used to estimate the extent of
the burns. The size of the patient's palm is
approximately 1% of the TBSA.

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Management :
 There are three phases of management :
1. emergent/resuscitative phase,
2. acute/intermediate phase,
3. and rehabilitation phase.

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Emergency phase :
 From time of the burn until 48
to 72hours
 Begin at the time of the injury

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 Pre hospital care (FIRST AIDS ):
 Remove a victim from the source of burn injury
 SECURE ABC
 Covering body heat with sterile dressing and
leave the blister intact .
 Burning clothes should be removed as quickly
as possible. If they adherent to the skin
should be left

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 cooling the area of burn (not ICE ) water .
 Brush off chamical powder , If burns by
liquid Chemicals with copiuos irrigation
 The patient must be transferred to
hospital as quickly as possible.

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In Emergency department
:
 minor burn :
 pain management
 tetanus prophylaxis
 wound care
 teaching about wound care and active
exercise to maintain normal joint function

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major burn management
(1)reevaluation ( history of events &
physical examination )
(2) ABC
(3) I.V Fluid replacement : in
Adults involving more than 18% to 20%
of TBSA.
Children with burns involving 12% to
15% of TBSA.

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 Initially administer crystalloid (Ringer's
lactate) as prescribed . Then lately give
Colloid during the second day (5% albumin,
Plasmanate )
 One of the most commonly formula used is
Parkland

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 (4) Insert urinary catheter to monitor urine
out put
 (5) Vital signs
 (6) Pain management with narcotic
 (7) Tetanus prophylaxis
 (8) Blood grouping and cross matching.

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 (9) Laboratory studies : Serum
electrolytes ,Hematocrit , Hb% , RBG ,
ECG , ABGs And Xray for fracture
 (10) Wound care : cover wound with
sterile guase and dressing under
aseptic technique .
 (11) elevate burned extremities above
the level of the heart to decrease
oedema

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 acute phase : from (48-72hrs) until wound
closed :
 begin when the patient hemodynamic ally
stable after 48 - 72 hours until wound closed :
1. infection control
2. Wound care :
3. Wound closer
4. Nutritional support
5. Pain management
6. Physiotherapy

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(1)infection control
 source of infection for burned patient include :
- auto contamination from oropharyngx ,fecal
flora ,unburned skin
- cross contamination fro staff and visitor
- infection control methods include hand
washing , wearing gloves , mask , gown , cab
and isolate the patient

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2.Burn Wound Care
 Cleanse the wound
 Pain medications as needed; 20-30 minutes
prior to all wound care procedures !!
 Hydrotherapy
• Shower,, bed baths or clear water spray.
• Maintain proper water and room
temperature
• Limit duration to 20-30 minutes

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Burn Wound Care
•Don’t break blister
•Trim hair around wound; expect
eyebrows
•Dry with towel; pat dry don’t rub
•Don’t forget about cleansing unburned
skin and hair

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Burn Wound Care Cont.,
 Apply an Antimicrobial Agent
 Silvadene
Broad spectrum; the most common agent
used
 Sulfamylon
 Betadine
• Drying effect makes debridement of the
eschar easier
 Acticoat (antimicrobal occlusive dressing)

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Burn Wound Care Cont.,
 Cover with a Sterile Dressing
 Most wounds covered with several layers of sterile
gauze dressings.
 Special Considerations:
• Joint area lightly wrapped to allow mobility
• Facial wounds maybe left open to air
Must be kept moist; prevent conversion
to deep wound

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Burn Wound Care Cont.,
• Circumferential burns: wrap distal to proximal
• All fingers and toes should be wrapped
separately
• Splints always applied over dressings
• Functional positions maintained; not always
comfortable
 Debridement of the wound
 May become completed at the bedside with wound care
or as a surgical procedure.

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Burn Wound Care Cont.,
 Types of Debridement:
• Natural
Body & bacterial enzymes dissolve eschar;
takes a longtime
• Mechanical
Sharp (scissors), Wet-to-Dry Dressings or
Enzymatic Agents
• Surgical
Operating room / general anesthesia

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 (3) wound closed:
 autograft : it is surgical remove of thin
layer of client from unburned skin and
application of burned area . the area of the
body where the skin it was removed known
as donor site

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 postoperative nursing of wound closed:
 assessment of bleeding from graft site
 proper positioning and immobilization of
graft site donor site care by dressing .

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(4)nutirnotional support : with high calories
, protein and vitamins to promote healing .
(6)pain management : by analgesic
(7)physiotherapy : exercise and splint to
maintain proper position

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Rehabilitation phase
 physiotherapy
 diet of high calories , high protein
, high vitamin especially vitamin c
 skin care by cream and lotion
 psychosocial support ,
 Occupational & social
preparation

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Complication of burn
 Hypovolemic shock
 Neurogenic shock
 Peptic ulcer
 Wound infection
 Septic shock
 long term complications
 Keloids ( mass of scar tissue)
 Failure to Heal
 Contractures
 hypertrophic scar

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Nursing Diagnoses of Burn
Nursing Care plan for Patient During
the Emergent/Resuscitative Phase
of Burn Injury

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Impaired gas exchange related to carbon
monoxide poisoning, smoke inhalation, and
upper airway obstruction
 Goal: the client will have improve gas exchange
 Nursing Interventions :
 Assess signs and symptoms of respiratory distress
 Place patient in semi-Fowler's position
 Monitor ABG values
 Give humidified oxygen as prescribed .
 Monitor patient for signs of hypoxia
 Observe for Increasing hoarseness , sputum or respiratory
secretions
 Prepare to intubation and escharotomies if ordered
 Monitor mechanically ventilated patient closely

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Nursing Diagnosis: Ineffective airway
clearance related to edema and effects of
smoke inhalation
 Goal: Maintain patent airway and adequate
airway clearance
 Nursing Interventions
 Assess air way clearnce
 Put on semi sitting position
 Suction to removal of secretions,
 insert airway as order .
 Give humidified oxygen.
 Encourage patient to turn, cough, and deep
breathe.

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Fluid volume deficit related to increased
capillary permeability and evaporative
losses from the burn wound
 Goal: Restoration of optimal fluid and electrolyte
balance and perfusion of vital organs
 Nursing Interventions
 Assess for hypovolemic shock in 48 hrs
 Observe vital signs and Monitor urine output at least
hourly
 weigh patient at admission and daily.
 Administer IV fluids & electrolytes as order

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 be alert for signs of fluid overload
 Monitor serum electrolytes & hematocrite
 Semi fowler position and elevate burned
extremities.
 Notify physician immediately of decreased urine
output, blood pressure increased pulse rate.

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Hypothermia related to skin loss
 Goal: Maintain normal body temperature
 Nursing Interventions
 Assess client temperature
 Cover the patient with clean gauze
 Limit the amount of body surfaces area exposed
during wound care
 .

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Alter peripheral tissue perfusion
R/T decrease blood flow
 P.E.O.C : client will have adequate tissue
perfusion
 Nursing intervention :
 Remove all constricted clothes , jewellary
 Donot use B.P cuff in affected part
 Monitor arterial pulses
 Elevate affected limb above the level of
the heart
 Encourage active exercise

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 Anxiety related to fear and the emotional impact of
burn injury
 Goal: Minimization of patient's and family's anxiety
 Nursing Interventions
– Assess patient's and family's understanding of burn injury,
coping skills .
– to the patient and the family in clear, simple terms.
– Psychological support
 Pain related to burn injury
 Goal: Control of pain
 Nursing Interventions
– Assess characteristics of the pain
– Administer analgesics as orders
– Provide emotional support and reassurance.

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 Collaborative Problems: Acute respiratory failure, distributive
shock, acute renal failure, compartment syndrome, paralytic
ileus, Curling's ulcer
 Goal: Absence of complications
 Nursing Interventions
 Acute Respiratory Failure
 Assess for increasing dyspnea, stridor, changes in
respiratory patterns.
 Monitor pulse oximetry, arterial blood gas values
 Monitor chest x-ray results.
 Assess s/s of hypoxia (restlessness, confusion)
 Prepare to assist with intubation or escharotomies as
indicated.

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 Distributive Shock
 Assess vital signs ( hypotension , tachycradia )
 Assess for decreasing urine output
 Assess for progressive edema
 Give I,V fliuds as prescribed
 Acute Renal Failure
 Insert urinary catheter to monitor urine output hourly
 Monitor renal fuction test (BUN and serum creatinine
levels.
 Report decreased urine output to doctor
 Assess urine for hemoglobin or myoglobin.
 Administer I.V fluids as prescribed

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 Paralytic Ileus
 Assess bowel function
 Auscultate for bowel sounds, abdominal distention
4hrly
 If it occur nasogastric tube for suction until bowel
sounds resume.
 Curling's Ulcer
 Assess gastric aspirate for pH and blood.
 Assess stools for occult blood.
 Administer histamine blockers and antacids as
prescribed

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 Impaired Skin Integrity related to burn injury and
surgical interventions (donor sites)
 PEOC : to maintain Skin Integrity intact
 dressings wound twice daily under aseptic technique.
 Use an antimicrobial solution as order
 Perform debridement of dead tissue using gauze,
scissors, or forceps as appropriate.
 give analgesia as order
 if there is grafted area observe for purulent drainage and
report
 Observe all wounds status daily and document
 Check history of tetanus immunization and provide
passive or active tetanus prophylaxis as prescribed.

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Impaired physical mobility R/T
edema , pain and dressing
 PEOC The client will improve physical mobility
 Asses joint mobility & joint strength
 Maitain burned area in good anatomical position
 Encourage active every 2 hours to perform active ROM
exercises throughout the day.
 Provide passive exercise if client unable to active
exercise
 Consultation with physical and occupational therapists,

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nutritional alter less than body requirement
R/T increase metabolic rate for wound
healing
 P.E.O.C : Maintain Nutritional balance
 Assess nutritional status by HB%
 Assess eating habits
 Provide oral hygiene
 Provide clean environment
 Weigh the patient daily
 Encourage high intake protein & vitamins and
mineral supplements as prescribed.
 Provide nasogastric (NG) tube feedings if unable
per oral

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Thank you