Saint Marys

University
School of Health
and Natural Sciences

BURNS
Prepared By: Mrs. Mary Antoinette B. Aseron, RN, MAN

Heat
Source
Conduction
Radiation
Classification of Burn accdg. to Depth:
Partial- Thickness
Superficial
1st o
Deep
2nd o
Full-
Thickness
3rd and 4th o
Figure 1:
Epidermis,
Heat is transferred from a heat source to the body through
Epidermis, at dermis,
conduction and radiation. Epidermis +
times with subcutaneous
Conduction- exchange of heat bet. Objects in direct Area upper layers
portion of and may affect
of dermis
contact with each other (Thermal and Chemical Burns) dermis underlying
tissues
Categories: Mottled red, White to red,
1. Thermal- direct heat (eg. flames, steam, molten liquid, blistered, fluid brown or black
red, dry
hot object) and electricity exudates Broken skin
sunburnt- like
Wound with fat
2. Radiation- gain or loss of heat bet. 2 objects not in or worse, with
When a blister exposed
physical contact with each other (eg. UV light, hot blister
breaks, what , waxy, pearly
coal, hot sand) happens after? grey
3. Chemical- chemical agents (eg. alcohol) x
Why is there no
Pain , Tingling
Classifications: pain?
Hint: PNS
Soothed by Sensitive to
Hyperesthesia -
cooling cold air
Edema Min or x
Hair - Intact x
Sweat glands x
Weeks to
months
Recovery 1 wk 2-6 wks
Eschar
sloughing

Eschar x
Hard, Leathery
Can be, if
healing is
Grafts x prolonged, to
reduce healing
time
1. Accdg. To Depth X contour
X function
FYIs
What will X digits,
Epidermis- nonvascular
happen if there extremity,
Dermis- contains BV, hair follicles, nerve endings and Others - is an infection in Skin does not
sweat glands a DPT Burn? blanch after
- Thicker than epidermis Hint: EVOLVE being pressed
- Made out of collagen, fibrous connective tissue, and Possibly X
collagen. bleeding
- When burn injury occurs, skin can REGROW as long as,
parts of dermis are present. FYIs
Subcutaneous Tissue- contains major vascular Mottled- with colored spots or blotches
networks, nerves, fat, and lymphatics. Heat insulator Hyperesthesia- pathologic sensitivity of skin
for underlying structures. Eschar- scab formed after burn, from coagulated
What are the s/sx when nerve endings are damaged? particles of destroyed skin
 Scab- hard covering of dried blood that forms over - Full- Thickness: wound edges transmit sensation, dull
wound and serves as protection or pressure type of pain
Blister- raised area on skin containing clear liquid Sweat Excretion
caused by injury - Destruction of sweat glands= X excretory ability
Vit D activation through sunlight exposure
Classification of Burn accdg. to BSA injured: - or x Vit D activation in alteration of skin integrity
Altered body temp maintenance
Change in appearance= altered self- image

Cardiovascular
- BV thrombosis, further causing necrosis
- Causes of DVT in burns ( TBSA, length of hosp stay,
burn wound infection, transfusion > 4 PRBC)
- Burnt area causes vasodilation, leaking blood and fluids
into interstitial space; Third- spacing, capillary leak
syndrome continuous leak of plasma from vascular
space to interstitial space
- Immediate consequence of fluid loss= Hypovolemia
- Fluid volume leak:
Greatest: 24- 48 hrs. post- burn
Peak: 6- 8 hrs.
a. Rule of Nines - Compensatory mechanisms:
a. Macrophages in damaged tissues release chemicals=
Adult: vasoconstriction
b. Catecholamines released through SNS=
PVR, vasoconstriction, PR
- CO first before BP

Pedia:

6.7 or 7

b. Lund and Browder

- precise method
- recognizes percentage of TBSA in anatomic
parts esp. head and legs
- Evaluation:
1st ax upon arrival of pt.
2nd ax 2nd and 3rd post- burn days
c. Palm Method
- used for small scattered burns
- palm= 0.5% TBSA
- palm + fingers= 1% TBSA

Bodys Response to Burn: (s/ sx)

Burned area <25% TBSA- local effect
Burned area >25% TBSA- both local and systemic effect,
considered major burn injury

Skin
Sensation of pain, pressure, temperature and touch
- Partial- thickness: exposure of nerve endings,
sensitivity and pain
 - Burn shock pd: - Tourniquet- like effect
Bld vol, BP, CVP - Circumferential Burn + Edema= pressure on BV and
CVP even after adequate fluid resuscitation, during nerves, bld flow, ischemia Compartment Syndrome
burn shock period Mgmt:
RBC damage= RBC/ Erythrocytopenia, Hgb, Anemia (+) Compartment syndrome Escharotomy
(+ surgical procedures, wound care, diagnostic studies, Escharotomy: surgical incision into eschar, relieve
ongoing hemolysis) constricting effect of burned tissue
Hct= plasma loss
Platelets/ Thrombocytopenia Effects of circumferential burn on specific body parts:
Clotting time, Prothrombin Time 1. Face
- Burn shock resolves: - Corneal abrasion
Capillaries regain integrity 2. Neck and thorax (chest)
Fluid returns intravascularly, reabsorbed from - Pulmo insufficiency, chest excursion, tidal
interstitial tissue volume
Bld vol What is chest excursion?
What is tidal volume?
UO, only if renal and fn is still adequate
Diuresis (days to 2 wks)
Fluids and Electrolytes
- Open wound= Evaporative fluid loss > 3-5 L in 24 hrs.
- Covered burn wound= x evaporative fluid loss
FYIs
- Burn shock pd:
CVP (Central Venous Pressure)
Na (Hyponatremia), even at 1st wk of acute phase
- pressure in SVC or RA
Massive cell destruction= K (Hyperkalemia)
- measures:
- Burn shock resolves:
a. RV function- RV pump blood to system
K (Hypokalemia), may also be caused by inadequate
b. venous return to right side of
K+ replacement
- normal CVP= 2-12 mmHg, 4-10 cm H2O
BP= CO x PVR
Pulmonary
Where,
- Leading cause: Inhalation injury (toxic fumes and
BP- blood pressure
smoke)
CO- Cardiac output
- S/ Sx not immediately apparent. Observe 24 hrs post-
PVR- peripheral vascular resistance, resistance in the
burn for respi complications
peripheral blood vessels.
- WOF airway obstruction!
S/Sx of airway obstruction?
PVR= vasoconstriction
- Below lvl of bronchus= usually X direct heat injury due
PVR= vasodilation
to cooling effect of rapid vaporization of pulmo tract
Main Catecholamines:
- Diagnostics:
- Dopamine
serum carboxyhemoglobin lvl, ABG, bronchoscopy, VP
- Norepinephrine (Noradrenaline)
scan, pulmo fn studies
- Epinephrine (Adrenaline)
- 1st 5 days post burn:
Catecholamines
lung compliance
- Secreted by the
PaCO2 (Respi acidosis)
Hint: Somewhere above the kidney. It is from the INSIDE part.
- Where: burn occurred in an enclosed area. Why?
- Diet that increases Cathecolamine levels:
Face and neck
Caffeinated drinks (Tea, coffe, choco)
Singed nasal/ facial hair
Banana
Hoarse voice and other voice changes
Citrus fruit
Stridor, wheezing
Vanilla
Dry cough
Sooty or bloody sputum. Define sooty
Edema
Flaring nostrils
- Presence of fluid in interstitial spaces or tissues
Dyspnea, RR, hypoxemia
- Forms rapidly after injury
Erythema, blisters, swelling of oral, nasal & pharyngeal
- <25%= local edema
mucosa
>25%= generalized edema
Agitation, anxiety
- Maximal 24 hrs. post- burn
- Complications:
- Resolves 1-2 days post- burn
ARDS, AResF
- Completely resolved 7- 10 days post- burn
- Controlled fluid intake during early post- burn pd.
Categories:
a. Upper Airway
Circumferential Burn
- Above the glottis
- Burn injury that goes all the way around a body part
 - Direct heat
- Mechanical obstruction
Vomiting
b. Lower Airway
- Below the glottis Mgmt:
- Inhalation of products of incomplete combustion, gastric decompression X vomiting
noxious gases (CO, SO, NO, aldehyde, cyanide, NH4, Cl,
phosgene, benzene, halogens) b. Curlings Ulcer= gastric or duodenal erosion
- Chemical irritation
- X ciliary action Gastric bleeding- 2o massive physiologic
secretions stress
Mucosal edema
Histamine, serotonin and thromboxane release=
Bronchospasm/ bronchoconstriction Occult blood in stool
Circumferential burn= Chest constriction Regurgitation of coffee- ground material
O2= Hypoxia from stomach
surfactant= Atelectasis Bloody vomitus
Cardinal sign: expectoration of C particles
Fluid Replacement Therapy
Carbon Monoxide Poisoning
- Colorless, odorless, tasteless gas - Goal: Urine output of 30- 50mL/ hr
- CO: leading cause of inhalation injury, byproduct of Normal serum Na levels and other electrolytes also
combustion - Urine output of 30- 50mL/ hr
- Oxyhemoglobin Carboxyhemoglobin Systolic BP > 100mmHg
- CO + Hgb= Carboxyhemoglobin (CO vs. O2 Hgb PR < 110bpm
binding site) = Adequate fluid resuscitation indicators
- Carboxyhemoglobin: O2 displaced by CO2 and - Guideline/s:
reversibly binds with Hgb Parkland/ Baxter Formula
- Affinity of Hgb for CO ( 200x)> Affinity of Hgb for O2 PLR: 4mL x Wt (kg) x TBSA burned
Mgmt: (Parkland formula is the most commonly discussed. More formulas/
O2 therapy- 100% O2, to accelerate removal of CO guidelines on Brunner & Suddarths book, 10th edition, page 1713)

from Hgb molecule

Early intubation and mech vent with 100% O2 Remember: Formulas are only guide estimation of fluid
requirements. Fluid resuscitation/ therapy should
Renal always be determined primarily by clinical parameters/
- Possible damage due to: patients response.
bld vol
Hgb and myoglobin occlusion in tubulues,
What is the mechanism of this? Phases of Burn:
- renal fn, ATN, RF Characteristics and Managements per burn phase

Immunologic defense A. Emergent/ Resuscitative Phase

- resistance to infxn, immunosuppression
- X skin integrity= X neutrophil fn, Lymphocytopenia ( - From onset of burn injury to complete fluid
lymphocytes), X T- helper cell lymphocytes, X prod and resuscitation
rel of granulocytes & macrophages from bone marrow - Nsg. ax. focuses on major priorities
If all extremities are burned, apply sterile dressing
Temperature Regulation under BP cuff is placed (dressing in between cuff and
- Hypothermia ( temp), early hrs post- burn pts burnt extremity= to X wound contamination)
- Hypermetabolism= resets core temp Burnt extremitys peripheral pulses are checked hourly
- Hyperthermia ( temp), much of post- burn pd, even if Elevate burnt part= edema
X infxn - Priorities: Generally, Physical stabilization
- First aid
Gastrointestinal Prevent hypovolemic shock- through fluid
- Complications: replacement
a. Paralytic Ileus= /X peristaltic movt and BS - Use of Large- bore IV catheter (16 or 18- gauge) in a
non- burned area or central venous cath.= for
Gastric distention immediate large amt of fluid replacement, CVP
Nausea monitoring
 - An indicator of renal perfusion that is measured hourly
in this phase (UO)
- Burgundy/ tea- colored urine= hemochromagen and
myoglobin form ms. damage assoc. with deep burns
What is hemochromagen?

- Glucosuria= release of glucose from liver due to stress

(Stress/ Stimuli Sympa NS glucose release from liver energy)
- Humidified O2= provide moisture for injured tissues
(esp. with inhalation injuries), liquefy secretions and
facilitate expectoration
- Turn, cough, deep breathe, incentive spirometry=
mobilization and secretion removal
- Maintain patent airway= crucial (ABCs of life)
- Hypovolemic shock= major risk immediately at post-
burn pd
- WOF rapid shifting of fluid and electrolyte status=
detect FVD, prevent distributive shock
- Monitor UO hourly, weigh pt daily
- Elevate affected extremity= edema
- Warm envt= heat loss through evaporation
- Minimize wound exposure= heat loss
- IV route= necessary d/t altered tissue perfusion
- Pain relief= pain increases anxiety
- Pulmonary affectation:
Intubation= for mech vent, if airway edema develops
Escharotomy= improve chest excursion with
respirations
Encourage coughing= remove secretions
Suctioning
Bronchodialtors, mucolytics
- Progressive edema= fluid shifting from intravascular
to interstitial, tissue perfusion
- NPO= paralytic ileus
- NGT= connected to suction, primarily for gastric
decompression and X aspiration d/t vomiting
Ax gastric aspirate and blood= (+) bld indicates gastric
bleeding
- Position SF to HF= prevent aspiration of vomitus d/t
Paralytic Ileus
- Clean sheets placed under and over burnt area= X
contamination
- Tetanus prophylaxis= burns are contaminated wounds
- Ax peripheral perfusion, compare affected with
unaffected extremity= WOF compartment syndrome

PLEASE READ ASSESSMENT AND NURSING CARE FOR THE

OTHER 2 PHASES OF BURN. THIS MODULE IS JUST FOR
SUPPLEMENTARY INFORMATION REGARDING THIS TOPIC.
MOST OF THE INFO HERE ARE FROM THE BRUNNER &
SUDDHARTHS AS WELL AND IS SUMMARIZED TO HIGHLIGHT
IMPORTANT DETAILS. GOOD LUCK ON YOUR QUIZ ON FRIDAY