Republic of the Philippines

Department of Health
BAGUIO GENERAL HOSPITAL AND MEDICAL CENTER
Baguio City
Professional Education & Training Office Doc. No.: TM-PETO-LD-008
Rev. No. Ø
TRAINING DESIGN Effectivity Date: October 1, 2016

CONTENT
Part 1

I. Introduction
According to WHO in its report in 2018, about 180,000 deaths yearly is caused by burn injuries,
worldwide, and most of those victims come from low to middle-income regions. On the other
hand, the principal reasons for burn injuries include scalds, contact with hot objects, electrical
and chemical injuries and flame burns (American Burn Association, 2018).

Burn treatment differ from one region to another, but they all agree that rapid assessment and
management of burns should be done to minimize serious scarring, life-long physical
disabilities, and adjustment difficulties, and treatment within 24 hours also directly correlates
to morbidity and mortality rate of patients. For the medical team to render appropriate and
effective treatment, one should understand the pathophysiology of the disease, proper
assessment of injuries, and the various updated treatment in burn science.

It is important to have burn training module in our hospital because the cost to the
organization is significant. Being able to know and master handling patients especially those
critical burn patients will save and help many lives and restore them from their functionality
and help them live life after a traumatic experience.

II. Objectives
A. General
1. After the completion of this module, the participant will be able to familiarize
with the pathophysiology of burn, learn the proper assessment and diagnostics
tools, treatment modalities and surgical procedures for burn patients.
2. Participants will be able to help perform their skills to preserve patient’s
functional ability and range of movements in the burned areas.
3. Participant will be able to render their best skills and knowledge to help return
of the patient to an independent way of living and the integration back into the
society, how to compensate for any loss of function in different areas body
affected by burns
B. Specifics
1. Familiarize with the Pathophysiology of Burn
2. Assess burn size and depth using the Rule of nine
3. Demonstrate accurate computations of fluids for resuscitation using the
Parkland Formula
4. Demonstrate proper insertion of Foley Catheter for fluid monitoring
5. Familiarize with the various types of wound dressing and how to apply them
6. Identify and prepare various solutions for wound dressing
7. Familiarize with various types of topical medications and their indications.
8. Demonstrate proper use of vacuum machine.

Organizational Structure
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 Republic of the Philippines
Department of Health
BAGUIO GENERAL HOSPITAL AND MEDICAL CENTER
Baguio City
Professional Education & Training Office Doc. No.: TM-PETO-LD-008
Rev. No. Ø
TRAINING DESIGN Effectivity Date: October 1, 2016

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 Republic of the Philippines
Department of Health
BAGUIO GENERAL HOSPITAL AND MEDICAL CENTER
Baguio City
Professional Education & Training Office Doc. No.: TM-PETO-LD-008
Rev. No. Ø
TRAINING DESIGN Effectivity Date: October 1, 2016
Unit Leaders
Chief Consultant – Dr. Gene Estandian, MD
Ward Supervisor – Ms. Gabriela Daniel, RN
Head Nurse – Ms. Mirasol Licupa, RN

- Unit Staff
Aura Apilado, RN
Maria Theresa Tomas, RN
Vera Angelica Requillo, RN
Anja Guttierez, RN
Lourvey Aoas, RN
Nikki Flores, RN
Kennedy Locloc, RN
Christine Joy Eban, RN
Adrian Paul Valera, RN

Nursing Attendants:
Juvycel Pahunang
Benjamin Reblora
Edeen Lopez
Michelle Manayan

Population:
Adult, Pediatric and Geriatric burn patients with burn injuries

Services:
Burn Unit caters for Burn Patient Populations

Bed Capacity:
4 Beds ++ Critical and regular beds combined

Demographics:
Averaging 4-5 patients per month

Critical Department Coordination:

Burn patients needing multidisciplinary care shall be referred to all specialization concerned and thus shall
jointly manage the patient or shall be on board the patient’s case.

Key Challenges in the Unit:

Due to the unavailability of ideal burn unit isolation and lack of formally trained personnel and equipment to
cater for appropriate burn care, quality of services rendered to burn patients are sometimes at risk to be
compromised.

Factors Affecting Client Satisfaction:

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 Republic of the Philippines
Department of Health
BAGUIO GENERAL HOSPITAL AND MEDICAL CENTER
Baguio City
Professional Education & Training Office Doc. No.: TM-PETO-LD-008
Rev. No. Ø
TRAINING DESIGN Effectivity Date: October 1, 2016
Part 2
Nursing Roles and Responsibilities
1. Nurse III
a. Oversees the ward: Staffing, patients, ward supplies and articles.
b. Monitor and evaluate staff
c. Plans and supervises nursing activities
2. Nurse II
a. Guidance and Support to staff
b. Quality patient care
c. Monitor and evaluate professional and non-professional staff
3. Nurse I
a. Assessment skills and techniques
b. Quality bedside care
c. Promote safety of patients and watchers
d. Health Promotion
e. Patient Advocate
4. Nursing Attendants
a. Clerical and logistic needs
b. Housekeeping
c. Bedside care

Pertinent Policies and Guidelines

A. Policies and Procedures for Watcher:
1. Implementing Guidelines
a. Watchers – one per patient
b. Visitors – not allowed
c. Reminders for watchers
B. Medication Management Policy
1. Implementing Guidelines
a. Handling and storage of essential drugs/medicines
b. Ordering of Essential Drugs/ Medicines
c. Prescription of Essential Drugs/ Medicines
d. Dispensing of Essential Drugs/ Medicines
e. Preparation and Administration of Essential Medicines
f. The 10 rights of Drug Administration
g. Documentation of Medications
h. Monitoring of Medications

Part 3
Admission, Transfer, and Discharge Procedure

Admission Procedures
The Emergency room shall be open 24 hous a day even during weekends and holidays.

1. SCREENING AND TRIAGE

a. All patients presenting at the Emergency Room with burn injuries should follow the
hospital protocol for patient triaging and screening
b. If available and indicated, routine screening of burn patients according to the
guidelines of the hospital should be done, keeping in mind the delay in the turn around
time for results.
c. Hemodynamically stable patients should undergo routine screening using
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 Republic of the Philippines
Department of Health
BAGUIO GENERAL HOSPITAL AND MEDICAL CENTER
Baguio City
Professional Education & Training Office Doc. No.: TM-PETO-LD-008
Rev. No. Ø
TRAINING DESIGN Effectivity Date: October 1, 2016
significant signs and symptoms, age, comorbidities.
d. For hemodynamically unstable patients unable to be screened, resuscitation and
stabilization should be prioritized.
e. Appropriate assessment and management according to the Algorithm for Burn ER
Patient Triage should be followed.
f. Strict asepsis and infection control measures should still be observed in treating burn
injuries.
g. Registration of patients may be done later after rendition of life saving measures for
Emergency cases.

2. Initial Burns Assessment and Management by ER Officer / Surgeon on Duty

● All burn patients presenting at the ER should undergo an initial, methodical and
systematic evaluation using a PRIMARY and SECONDARY SURVEY with a subsequent
definitive care plan addressing referrals and transport. These should be done using
appropriate PPE depending on the risk of the procedure to be performed
● PRIMARY SURVEY consists of the following burn assessment and
management:
o A – Airway management & cervical spine control
o B – Breathing and ventilation
o C – Circulation, cardiac status & compartment syndrome
o D – Disability & deformity
o E – Exposure & environment
o F – Fluid resuscitation

● Emergency procedures such as the ones below should be done by the emergency
room physician, or anesthesiologist on duty depending on their capability and
qualifications:
o Intubation for burn patients with suspicion of inhalation injury (based on
history and physical examination); or with massive burns >50% TBSA
(securing airway prior to airway edema)
o Aggressive early fluid resuscitation for patients with hemodynamic
instability or with significant burns (>20% TBSA)18
▪ It is recommended to use the Parkland Formula when doing
aggressive fluid resuscitation, using Plain Lactated Ringers
solution, computed at 4 ml/kg/%TBSA over a 24-hour period. The
first half should be given within the first 8 hours from injury, and
the succeeding half given in the remaining 16 hours from injury.
▪ For children (<30 kg), it is advised to use D5LR as the fluid of
choice, as they are more prone to hypoglycemia during the first
hours of injury. Also, for children, add their maintenance fluid
(computed via the Holiday-Segar method) to the computed
Parkland formula resuscitation requirements.
▪ NOTE: These formulas only serve as a GUIDE with the goal of
titrating fluids to obtain a urine output of:
● ADULTS: 0.5 ml/kg/hr
● PEDIA: 1ml/kg/hr

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 Republic of the Philippines
Department of Health
BAGUIO GENERAL HOSPITAL AND MEDICAL CENTER
Baguio City
Professional Education & Training Office Doc. No.: TM-PETO-LD-008
Rev. No. Ø
TRAINING DESIGN Effectivity Date: October 1, 2016
o Other emergent measures are recommended for burn injuries:
▪ Assess burn size and depth
▪ Establishment of good intravenous access
▪ Provide adequate analgesia
▪ Insertion of Foley catheter for fluid monitoring
▪ Taking of baseline blood samples for investigation
▪ Dressing of wounds
▪ Performance of secondary survey, reassessment, and exclusion or
treatment of associated injuries (fractures, lacerations, etc)
▪ Arrangement of safe transfer to specialist burns facility
● For more specialized surgical interventions such as Emergent Escharotomies /
Fasciotomies for Acute Compartment Syndrome, it is important to seek the help and
guidance of a trained plastic surgeon or general surgeon with special training in burn
surgery20.
● Check tetanus prophylaxis status and administer, if needed.18
o For stable, minor/moderate burns not requiring ICU admission, they
should be referred to an available Burn / Plastic Surgery specialist for
definitive management of the burn injury

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 Republic of the Philippines
Department of Health
BAGUIO GENERAL HOSPITAL AND MEDICAL CENTER
Baguio City
Professional Education & Training Office Doc. No.: TM-PETO-LD-008
Rev. No. Ø
TRAINING DESIGN Effectivity Date: October 1, 2016

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 Republic of the Philippines
Department of Health
BAGUIO GENERAL HOSPITAL AND MEDICAL CENTER
Baguio City
Professional Education & Training Office Doc. No.: TM-PETO-LD-008
Rev. No. Ø
TRAINING DESIGN Effectivity Date: October 1, 2016
Admission to Burn Unit
- Admission of patients to the Burn unit shall be determined by the admitting physician, keeping in mind
the proper cohorting of patients.
- If the patient needs admission, the physician shall make the necessary arrangement for such, Explain
the management plan, financial requirements and other related hospital policies and ensure that
patient’s consent is obtained. The physician shall fill up the admission slip, physicians’ orders and
necessary diagnostic requests and prescriptions. The NOD shall carry out orders accordingly and
accomplish nurse’s notes.
- All health care staff involved shall observe proper endorsement during turnover of patient’s care.
Forms
1. Consent/ Dissent for care
- Proper consent must be secured from the patient or his/her representatives before commencing the
treatment plans except in emergency cases where life saving measures must be rendered first prior to
obtaining consent for further care.
2. PHER

Admission Criteria:
Critical Care Admission
- Adult patients with burns >20% TBSA
- Pediatric patients <5 year old with burns >10% TBSA
- All pediatric patients with burns >15% TBSA
- All intubated burn patients
- Any patient requiring close monitoring of extremity perfusion (Ex: Full thickness circumferential burns
requiring Q 1 hour neurovascular exam)
- Any patient requiring respiratory monitoring with concerns for inhalation injury
- Any hemodynamically abnormal burn patient (hypotension, cardiac arrhythmias)
- High Voltage Electrical Injury.

Ward Admission:
- Any burn patient with:
a. > 5% TBSA partial thickness burns
b. Full thickness burn requiring operative intervention within 24 hours
c. Infected burns
d. Concern for non-accidental Trauma
e. Uncontrolled pain

- Elderly burn patients

- Patients requiring initiation of rehabilitative therapy, or those unable to perform stretches.
- Patients with medical comorbidities that will significantly alter their ability to recover from a burn injury.

Admission from ACLS providers’ manual:

- 2nd and 3rd degree burns greater than 10% TBSA, patients younger than 10 or older than 50 years of age.
- 2nd and 3rd degree burns to greater than 20 % TBSA in all other ages
- 3rd degree burns greater than 5 % TBSA in patients of any age
- All 2nd and 3rd degree burns with the threat of functional cosmetic impairment to the face, hands, feet,
genitalia, perineum, or major joints.
- All electrical burns including lightning injuries.
- Chemical burns
- Burns involving inhalation injury
- Circumferential burns of the extremities and/or chest
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 Republic of the Philippines
Department of Health
BAGUIO GENERAL HOSPITAL AND MEDICAL CENTER
Baguio City
Professional Education & Training Office Doc. No.: TM-PETO-LD-008
Rev. No. Ø
TRAINING DESIGN Effectivity Date: October 1, 2016
- Burns involving concomitant trauma among which the burn injury poses the greatest risk of morbidity or
mortality.
- Burns in patients with pre-existing medical conditions that may complicate management and/or prolong
recovery, such as coronary artery disease, lung disease or diabetes.

Discharge Criteria:
1. Pain controlled with oral medications
2. Wound care can be performed by the patient or a designee
3. Burn therapy (PT and OT) has recommended discharge to home and patient has demonstrated ability
to perform their home exercise program.

Discharge Procedure
- The Attending Physician shall determine when the patient Is ready for discharge or not.
- If the patient is for discharge, the physician in charge shall make discharge orders.
- The Nurse Supervisor/ NOD checks the completeness of health records and other needed documents
then brings charts to the chart analysis unit for final checking. The HIMO personnel shall do final
analysis of patient’s health records before endorsing them to the billing section.
- The billing clerk shall compute the bills and generate a statement of account. He/she shall inform the
ward NOD once statements of accounts are available.
- The NOD shall direct the patient/patients’ representative to settle their financial obligations.
- The NOD shall discharge the patient and counsel him/her on Home Instructions and Follow up.

- Patient Rights
1. Right to Appropriate Medical care and Humane treatment
2. Right to Informed Consent
3. Right to Privacy and Confidentiality
4. Right to Information
5. Right to choose healthcare provider and facility
6. Right to self determination
7. Right to Religious belief
8. Right to Medical Records
9. Right to Leave
10. Right to Refuse Participation in Medical Research
11. Right to Correspondence and to receive visitors
12. Right to Express Grievances
13. Right to be informed of his rights and Obligations as a patient

- Patients’ Responsibilities
1. Patients have the responsibility to read and understand all permits and/or consent before signing. If the
patient does not understand, it is the patients’ responsibility to ask the nurse or physician for clarification.
2. Patient have the responsibility to provide truthful, accurate and complete information about his/her present
complains, medical history, past illness, hospitalizations, medications, allergies and other matters relating to
their health.
3. Patient are responsible for making it known to their physician/ nurse whether they clearly comprehend the
course of medical treatment and what is expected of them.
4. Patients are responsible for following the treatment plan recommended by his/her attending physician
responsible for their care, including following the instructions of nurses and other health professionals.
5. Patients have the responsibility to inform their physician or nurse if they have any complications, complaints,
or adverse reaction in the course of their treatment.
6. Patients are responsible for their actions if they refuse treatment or do not follow their physician’s
instructions.
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 Republic of the Philippines
Department of Health
BAGUIO GENERAL HOSPITAL AND MEDICAL CENTER
Baguio City
Professional Education & Training Office Doc. No.: TM-PETO-LD-008
Rev. No. Ø
TRAINING DESIGN Effectivity Date: October 1, 2016
7. Patients are responsible in following hospital rules and regulations affecting patient care and conduct.
8. Patients are responsible to be considerate of the rights of other patients and hospital personnel. They should
also observe silence, prohibition of smoking, control of visitors, maintenance and cleanliness.
9. Patients are responsible for being respectful of the property of other persons and of the hospital.
10. Patients are responsible to fulfill promptly their financial obligations regarding their health care, regardless
of whatever insurance coverage they may have.
11. Patients are responsible to attend schedule of appointments with the physician and hospital. The proper
notification shall be done by the patients when unable to come as scheduled.

Part 4
BURN CLINICAL PRACTICE GUIDELINES

Treatment Protocol Considerations

All burn injuries are treated by initially following the guidelines for Advanced Trauma Life Support to ensure
that life threatening injuries are addressed immediately giving emphasis on ABCD’s first. After addressing the
ABCDs of life support, focus turns to burn injuries. Replacing fluid lost from burns is critical, and an accurate
assessment of the severity and extent of the burns is needed to calculate the amount of fluid to provide.
Wound care and pain management are addressed next. Psychosocial and Spiritual support may be provided
throughout the assessment, treatment and stabilization process.

INITIAL BURN ASSESSMENT AND MANAGEMENT

1. PRIMARY ASSESSMENT – This includes the assessment of airway patency and cervical spine
protection in cases of spinal cord injuries.
a. AIRWAY – assess and visualize the upper airway for blockages and evidence of burn, such
as soot, singed nasal hairs, eyebrows, facial hairs, raspy voice, and cough.
For unconscious patients – place an OPA or Endotracheal tube as needed if an airway
obstruction is observed.
For patients with suspected spinal injuries – immobilize the neck with cervical collar and
avoid manipulation and flexing and extending the cervical area.
 Auscultate breath sounds and palpate chest walls – start oxygen support as needed
(high flow oxygen at 15L on a non-rebreather mask), and monitor di-oxide level.
 Aide in procedures to improve patient’s breathing. Procedures such as:
Escharotomies to release constrictive eschars, Needle decompression for tension
pneumo-thorax, and CTT insertion for draining of fluid.
b. VITALS SIGNS
 Check pulses in any extremity for circumferential burns – these may lead to
compartment syndrome
 Check heart rate – an elevation of heart rate to 100 to 120 beats per minute is
expected due to increased in catecholamine and hypermetabolism. Cardiac rate of
more than 120 will likely indicate hypovolemia from trauma, desaturations, and
pain
 Baseline blood pressure should be obtained including history of medications for
hypertension
 Arrhythmias may be seen in electrical burn injuries, including electrolyte
imbalances – interventions should be started to avoid further complications.
c. NEUROLOGIC ASSESSMENT
 Assess for alertness, responsive to pain and verbal orders.
 For patients that are not alert and disoriented – consider injury, CO poisoning
intoxication, or pre-existing health conditions.
 Assess Glasgow Coma Scale
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 Republic of the Philippines
Department of Health
BAGUIO GENERAL HOSPITAL AND MEDICAL CENTER
Baguio City
Professional Education & Training Office Doc. No.: TM-PETO-LD-008
Rev. No. Ø
TRAINING DESIGN Effectivity Date: October 1, 2016
d. SKIN EXPOSURE
 Remove any burn agent from the skin and flush the burnt area with water. Do
not use cold water and ice to prevent a rapid decrease in basal body
temperature that may lead to hypothermia.
 Remove clothes, jewelries, shoes, and other items that may develop into
tourniquets when edema develops.
 Cover patient with clean sheets and blankets, use warm IV fluids, and maintain
a warm environment
 Work toward maintaining a normal temperature by removing wet dressings
and covering with dry, sterile dressings.
 Begin re-warming the patient with blankets and warmed fluid. Ambient
temperature should be from 28’ Celcius to 32’ Celcius (82’-90’F). The patients
core temperature must be kept at least above 34’C. Increase the room
temperature if necessary.

e. Determination of Total Body Surface Area.

Total body surface area (TBSA) is an assessed measure of the severity of skin burns.
- In adults, the “Rule of Nines’’ is used to determine the total percentage of the burned
area for each major section of the body. However, this rule cannot be used in pediatric
burns.

- The Lund-Browder chart is one of the most accurate methods to estimate not only
the size of the burn area but also the burn degree in both adult and pediatric burn
patients.

- The rule of palms can be used to measure the extent of small scattered burns. The
patient’s hand including fingers is equal to 1% of TBSA.

Burn Classification or Severity

A. First degree burns – Redness and pain of the affected skin. Minor epithelial damage occurs without
formation of blisters. Typically occurs with sunburns.
B. Superficial Second degree burns (Superficial partial thickness burns) – Complete epithelial damage and
only papillary dermal damage occurs. This degree leaves no neurovascular damage. It causes pain,
bleeds and presents with blisters. Epithelial repair occurs within 14 days, and mostly leaves no scars
after healing. Sometimes discoloration remains.
C. Deep second degree burns (deep partial thickness burns) – Complete epithelial damage of the reticular
dermis are present. Blisters also can be present but are bigger than in superficial second degree burns.
Healing can occur but takes longer than 14 days.
D. Third degree burns (Full thickness burns) – The epidermis, dermis and subcutaneous tissue are
involved. The skin appears white and/or leathery with thrombosed vessels.
E. Fourth degree burns – This classification may be used when a burn involves the underlying fascia,
muscles and even bones.

Brief Categorization of Burns

Correlating with the degree classification are these categories of burns by thickness of damage:
- Superficial burn injury (first degree)
- Superficial partial thickness burns (superficial second degree)
- Deep partial thickness burns (deep second degree)
- Full thickness burns (third degree)
- Full thickness burns involving the underlying fascia, muscles and bones (fourth degree).

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 Republic of the Philippines
Department of Health
BAGUIO GENERAL HOSPITAL AND MEDICAL CENTER
Baguio City
Professional Education & Training Office Doc. No.: TM-PETO-LD-008
Rev. No. Ø
TRAINING DESIGN Effectivity Date: October 1, 2016

f. FLUID RESUSCITATION – fluid shifting that occurs with large TBSA burns are results of
shock, that creates hypovolemia in the first 48 hours. Therefore, rapid fluid resuscitation is
essential to replace fluid losses and maintain organ perfusion.
- Crystalloids such as Lactated Ringers are the preferred IV fluids,
but some patients will further require colloids (such as albumin), to
retain as much fluid as possible)

*BGHMC mostly utilizes a modified Parkland Formula to calculate fluid volume

requirements, and this includes estimation of TBSA and obtaining patient’s weight.

Parkland Burn Center, Dallas

Follow Advanced Burn Life Support recommendations. If available, titrate fluid up or down in response
to urinary output via foley catheter.
- Pediatric:
3 ml LR X patients body weight in kg X TBSA second and third-degree burns
- Pediatric High Voltage Electric Burns:
4 ml LR X patient’s body weight in kg X % TBSA second and third-degree burns
- Adult:
For thermal and chemical burns: 2 ml LR X patient’s body weight in kg X % TBSA 2 nd and 3rd degree
burns
- Adult High Voltage Electrical Burns:
4 ml LR X patient’s body weight in kg X % TBSA 2nd and 3rd degree burns
- Geriatrics:
2 ml LR X patient’s body weight in kg X % TBSA 2nd and 3rd degree burns

 Calculation of total volume

 Half of the computed volume is given in the first 8 hours after the time
of injury
 25% is given the second 8 hours
 Last 25% in the last 8 hours.

* The patient’s vital signs, mental status, capillary refill, and urine output through foley
catheter must be monitored and fluid rates adjusted accordingly. Urine output of 0.5
mL/kg or about 30 – 50 mL/hr in adults and 0.5-1.0 mL/kg/hr in children less than 30kg
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 Republic of the Philippines
Department of Health
BAGUIO GENERAL HOSPITAL AND MEDICAL CENTER
Baguio City
Professional Education & Training Office Doc. No.: TM-PETO-LD-008
Rev. No. Ø
TRAINING DESIGN Effectivity Date: October 1, 2016
is a good target for adequate fluid resuscitation.
*Reassess patient for treatment effectiveness and adjust as needed. Watch out for
fluid overload, rhabdomyolysis, rising lactate levels, acid-base imbalances, and
compartment syndrome resulting from fluid resuscitation.
*Quantify all fluids given and record.

2. SECONDARY ASSESSMENT
a. BURN HISTORY - Once the ABCDs are completed and fluid resuscitation has been initiated,
attention should be focused on obtaining information about how the burn injury occurred.
- Interview patient or family members, friends, or those who were at the scene of the
incident. This includes:
- The patient’s, family members, friends, EMS provider’s or those who were at the
scene the history of the events.
- Time of injury
- Where the injury occurred including if the patient was in an enclosed space
- If there was loss of consciousness
- Causative agent/ mechanism of burn
- How long the patient was exposed to the burn source
- If decontamination occurred
- Suspicion of abuse or intentional injury
- Possibility of carbon monoxide intoxication based on the history of burns in a closed
area as well as the presence of soot in the mouth and nose.
- Presence of facial burns, if applicable
- Examination of the cornea
- Consistency of burn with the history provided
- Allergies and usual medications
- Past medical history including the date of the last tetanus shot
- The patients weight

b. LAB WORKS AND TESTS

 CBC, Serum electrolytes BUN, Creatinine, Glucose level
 Prothrombin time (PT), Partial Thrombin Time (PTT), International Normalized
Ration (INR) should be considered if the patient is on anticoagulants.
 Urine drug test
 Human Chorionic Gonadotropin (B-HCG) if the patient is female.
 For burns that occurred in an enclosed space: Arterial blood gas,
carboxyhemoglobin levels
 For inhalation injury suspect: ABG’s
 Other tests:
1. ECG – done before fluid resuscitation because cardiac arrhythmias may
occur during the early stages of resuscitation of large burns
2. CXR – to detect fluid accumulation, ET tube placement if intubated,
atelectasis for fluid overload
3. Serum Lactate – detects acid-base imbalance
4. Cyanide Level – done in the presence of unexplained lactic acidosis; may
also be present with smoke inhalation
5. Blood type and crossmatch – for possible blood transfusion
6. Urine Myoglobin, Serum Creatinine Kinase – helps detect kidney or muscle
injuries, detects rhabdomyolysis that can occur with electrical or in third
degree burns
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 Republic of the Philippines
Department of Health
BAGUIO GENERAL HOSPITAL AND MEDICAL CENTER
Baguio City
Professional Education & Training Office Doc. No.: TM-PETO-LD-008
Rev. No. Ø
TRAINING DESIGN Effectivity Date: October 1, 2016

c. WOUND CARE – Note that wound care is a low priority in the initial care of a severely
burned patient unless covering of the burn with sterile, dry dressing reduces the pain and
increases the comfort level of the burn injured patient. It should be noted that wound care
should not be attempted until well after the patient’s airway, breathing and circulatory
status have been addressed.

1. If more than 10 percent of the patient’s TBSA is affected, cover with a

clean, dry sheet or dressings.
2. If more than 20% of the patient’s TBSA is injured, cover with a clean dry
sheet or dressings, and remember to keep the patient warm with
blankets or by increasing the room temperature to 90 degrees.
3. If less than 10% percent of the patient’s TBSA is affected, saline
moistened sterile dressings may be applied.

 Usually done after primary and secondary assessment and after any life
threatening conditions are treated
 Pre-medicate with analgesia
 Thoroughly wash the area with water and disinfectants or antibacterial soaps
 Clean away debris on the wound and debride ruptured blisters
 Apply antibacterial ointment and non-adherent gauze to open areas
 Keep the gauze loose and secure with tapes
 Additional interventions for infection control:
1. Daily baths with antimicrobial soaps
2. Perform change of dressing and wound care aseptically
3. Implement strict handwashing policy
4. Minimize interventions in non-intact skin
If high fever develops, wound culture can be done and patient will be prescribed with
broad-spectrum antibiotics until a specific organism is identified.

e. PAIN AND ANXIETY – pain varies based on extent of injury and nerve involvement, and there are
several pharmacologic and nonpharmacologic treatments that can reduce pain:
 If no contraindications, elevate head of bed to at least 30 degrees
 Elevate affected extremities above the level of the heart to decrease edema and
swelling
 Perform change of dressing with only exposing one area at a time, since exposure to air
is painful in those with partial thickness and superficial burns.
 Premedicating the patient prior to wound care

Anxiety
 Provide emotional support during the treatment process.
 Engage in therapeutic communication and build rapport.
 Explain procedures to be done and refrain from giving unsolicited advice.
 Acknowledge concerns and avoid trivializing extreme emotions such as depression,
guilt, fear, or anger.
 Advocate for psychiatric support including close family and relatives.

*Anxiety is different from pain and may be controlled with benzodiazepines.

Intramuscular and subcutaneous routes should not be used due to fluid volume changes and unpredictable
blood flow/absorption. Tetanus is the only medication given intramuscularly in burn patients. Intravenous pain
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 Republic of the Philippines
Department of Health
BAGUIO GENERAL HOSPITAL AND MEDICAL CENTER
Baguio City
Professional Education & Training Office Doc. No.: TM-PETO-LD-008
Rev. No. Ø
TRAINING DESIGN Effectivity Date: October 1, 2016
medication should be measured and adjusted to provide relief to the patient, although careful monitoring of
the patient’s respiratory status is required.

Consider Special Circumstances

Patient characteristics as well as the cause of the burn injury may require special considerations in the
assessment as well as the treatment of the patient. Age of the burn patient should be taken into account in
assessment and treatments. For example: Children maybe the victim of abuse, and elderly burn patients need
to be managed aggressively due to their overall health conditions and co-morbidities. Specific types of burn
injuries – such as electrical and chemical burns – also require special interventions.

Pediatric Considerations
If the patient is a child, look for signs of abuse. Specific things to consider include the following:
- Is the pattern of burn consistent with the story?
- Does the story change?
- Observe the caregivers behavior and be suspicious if the individual seems disinterested in the child’s
care.
- Observe interactions – if possible – between the child and caregiver, strange behavior may indicate an
unhealthy relationship.
- Scald burns with circumferential demarcation line often indicate and intention action.
- Accidental burns usually have splatter marks and inconsistent edges.
-
Additional Pediatric Considerations
Appreciating the major differences between burn management in children and adults is important. With nearly
three times the body surface area (BSA) to body mass ratio of adults, fluid losses are proportionately higher in
children than adults and predispose the child to hypothermia which must be aggressively avoided. Be sure to
address appropriate fluid resuscitation, hypothermia, pain control and blood glucose level.
- Fluid resuscitation in a child must be more precise. Urinary Output is the most sensitive indicator of
fluid resuscitation.
- Hypothermia is a continued high risk in this patient population due to the high surface-to-volume ratio
and low fat mass. Hypothermia can increase the depth of the burn.
- Monitor the pediatric patient’s blood glucose level. In this patient population, temperature regulation
is partially based on non-shivering thermogenesis, which further increases metabolic rate.
- Thrashing, resisting care and dislodging important treatment adjuncts such as catheters, endotracheal
tubes etc, may indicate pain in children who are not able to express pain. Begin with small doses 0.1
mg/kg of morphine intravenously initially and increase as long as patient remains hemodynamically
stable and shows no evidence of respiratory depression.
-
Geriatric Considerations
With patients 65 years of age and older, the risk of mortality is increased, so early and aggressive management
of burns are needed. Thinner skin, poorer circulation, pre-existing conditions, fewer reserves and higher
complication rates increase morbidity and mortality. Because of age, thoughtful consideration should be given
to treatment such as:
- Early surgical intervention is recommended
- Use care in fluid resuscitation so as not to cause fluid overload. Be aware that it may require more fluid
to resuscitate the same burn size than expected to avoid hypovolemia, possibly due to the decreased
skin turgor.
- Implement aggressive respiratory therapy. Inhalation injury tends to be more prevalent in elderly
patients because they are generally less mobile. Inhalation injury is a significant predictor of mortality
and is an important comorbidity factor.
- For optimum outcomes, aggressive rehabilitation is needed.
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 Republic of the Philippines
Department of Health
BAGUIO GENERAL HOSPITAL AND MEDICAL CENTER
Baguio City
Professional Education & Training Office Doc. No.: TM-PETO-LD-008
Rev. No. Ø
TRAINING DESIGN Effectivity Date: October 1, 2016
-
Electrical injury considerations
When the patient’s burns were caused by an electrical injury, circumstances dictate special care consideration,
including the following:
- Assess cardiac rhythm as life-threatening arrhythmias may be present.
- Assess contact points (it is possible to have more than two).
- Be aware that significant underlying tissue and muscle injury may be present in electrical injuries. If this
happens, muscle fibers and chemicals may be released into the blood stream, causing electrolyte
imbalances.
- Assess for myobloginuria; the presence of these muscles fragments in the urine can cause electrolyte
disturbances and kidney failure.
-
Chemical Injury Considerations
Every Chemical and the appropriate care for an exposure should be included in the Material Safety Data Sheet.
This reference should define the appropriate type of emergency care for each chemical in the region that could
cause a burn.
With chemical burns, it is important to determine that the patient has undergone decontamination for an
appropriate length of time based on the specific recommendations in the MSDS, at least 20 minutes or until the
burning process has stopped. If the burn was caused by a chemical agent, providers should take appropriate
precautions to protect themselves and the immediate environment from exposure to the chemical agent.

Circumferential Burns Considerations

Burns that encircle an extremity, the chest or the abdomen require special attention. Edema and swelling in the
tissue under the burn may cause the burnt skin – which is rigid – to act like a tourniquet. In a limb, this can
cause ischemia. In the chest or abdomen, it can restrict chest expansion and diaphragm movement and
interfere with ventilation. A burn center surgeon should be consulted prior to treatment.
Among the interventions that typically may be implemented are the following:
- Checking for pulses; often a Doppler scan is needed.
- Elevating extremities if not contraindicated.
- Performing and escharotomy – full thickness incision of the burn down to the subcutaneous fat, to
release constricting unyielding burned skin. This may be necessary to restore blood flow. However, this
optimally should be performed after appropriate consultation with the burn center surgeon.
-
Additional Considerations for all types of Burn Patients
Regardless of the patient’s age or type of burn, these treatment considerations apply to all burn patients:
- Insert a gastric tube as directed by a physician.
- Monitor urinary output to assess fluid resuscitation by inserting an urinary catheter and monitoring
urine output (UOP) for amount and color, using these guidelines:
a. Adults UOP goal is 30 cc/hr.
b. Pediatric UOP goal is 1 cc/kg/hr.
c. Electrical injuries with myobloginuria UOP goal is 75-100 cc/hr.
- Electrical and inhalation injuries may require additional fluid during resuscitation.
- Elevate the head of bed 30 degrees.
- Elevate affected extremities.
- Administer Tetanus prophylaxis.
Forms and Tools for Documentation
Assessment Charts
- Rule of Nines is recommended
- Lund-Browder chart is recommended after initial burn care and debridement.
Documentation
- Warming efforts documented.
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 Republic of the Philippines
Department of Health
BAGUIO GENERAL HOSPITAL AND MEDICAL CENTER
Baguio City
Professional Education & Training Office Doc. No.: TM-PETO-LD-008
Rev. No. Ø
TRAINING DESIGN Effectivity Date: October 1, 2016
- Serial vitals, including a temperature, documented.
- Volume of resuscitation fluid required for optimal patient response during the first 24 hours

Nursing Diagnosis

1. Impaired Skin Integrity

- Due to loss of skin, which can result in infection, impaired wound healing and delayed recovery.
- Maybe related to : Disruption of the skin surface with the destruction of skin layers (partial-full
thickness burn) requiring grafting.
- As evidenced by: Absence of viable tissue
- Desired Outcomes:
Wound Healing:
a. The Client will demonstrate tissue regeneration
b. The client will achieve timely healing of burned areas.
- Nursing Assessment and rationales
Assess and document the size, color and depth of the wound, noting necrotic tissue and the condition
of the surrounding skin. – this provides baseline information about the need for skin grafting and
possible clues about circulation in the area to support graft.

- Nursing Interventions and Rationales

a. Provide appropriate burn care and Infection Control measures.
b. Maintain wound covering as indicated:
 Synthetic dressing: Douderm
Hydroactive dressing that adheres to the skin to cover small partial thickness burns and that
interacts with wound exudate to form a soft gel that facilitates debridement.
 Opsite, Acuderm
Thin, transparent, elastic, waterproof, occlusive dressing (permeable to moisture and air) that
is used to cover clean partial thickness wounds and clean donor sites; reduces swelling/ limits
risk of graft separation.
c. Elevate grafted area if possible. Maintain desired position and immobility of area when
indicated. – Movement of tissue under graft can dislodge it, interfering with optimal healing.
d. Maintain dressings over newly grafted area and/or donor site as indicated.
e. Keep skin free from pressure. – Promotes circulation and prevents ischemia or necrosis and graft
failure.
f. Wash sites with mild soap, rinse and lubricate with cream several times daily after dressings are
removed and healing is accomplished. Newly grafted skin and healed donor sites require special
care to maintain flexibility.

2. Acute pain
- Due to destruction of skin and tissues which exposes nerve endings and increase sensitivity to pain.
Edema formation and manipulation of injured tissues during wound care further exacerbate pain.
Effective pain management is critical in promoting patient comfort and preventing complications such
as anxiety, depression and delayed wound healing.
- Maybe related to:
Destruction of skin tissue, edema formation,
Manipulation of injured tissues during wound debridement.
- Possibly evidenced by
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 Republic of the Philippines
Department of Health
BAGUIO GENERAL HOSPITAL AND MEDICAL CENTER
Baguio City
Professional Education & Training Office Doc. No.: TM-PETO-LD-008
Rev. No. Ø
TRAINING DESIGN Effectivity Date: October 1, 2016
Reports of pain, Alteration in muscle tone, autonomic responses,
Distraction/ guarding behaviors: Anxiety, fear, restlessness.
- Desired Outcomes
The client will report relief/ control of pain
The client will display relaxed facial expressions/ body posture.
The client will participate in activities and sleep/ rest appropriately.
- Nursing Assessment, Interventions and Rationales:
a. Assess reports of pain, noting location and character, and intensity (0–10 scale).
Pain is nearly always present to some degree because of varying severity of tissue involvement and
destruction but is usually most severe during dressing changes and debridement. Changes in location,
character, and intensity of pain may indicate developing complications (limb ischemia) or herald
improvement and/or return of nerve function and sensation.
b. Cover wounds as soon as possible unless an open-air exposure burn care method is required.
Temperature changes and air movement can cause great pain to exposed nerve endings.
c. Elevate burned extremities periodically.
Elevation may be required initially to reduce edema formation; thereafter, changes in position and
elevation reduce discomfort and the risk of joint contractures.
d. Provide bed cradle as indicated.
Elevation of linens off wounds may help reduce pain.
e. Wrap digits or extremities in the position of function (avoiding the flexed position of affected joints)
using splints and footboards as necessary.
Position of function reduces deformities or contractures and promotes comfort. Although the flexed
position of injured joints may feel more comfortable, it can lead to flexion contractures.
f. Change position frequently and assist with active and passive ROM as indicated.
Movement and exercise reduce joint stiffness and muscle fatigue, but the type of exercise depends on
the location and extent of the injury.
g. Maintain comfortable environmental temperature, provide heat lamps, and heat-retaining body
coverings.
Temperature regulation may be lost with major burns. External heat sources may be necessary to
prevent chilling.
h. Provide medication before performing dressing changes and debridement.
Reduces severe physical and emotional distress associated with dressing changes and debridement.
i. Encourage the expression of feelings about pain.
j. Involve the patient in determining the schedule for activities, treatments, and drug administration.
k. Explain procedures and provide frequent information as appropriate, especially during wound
debridement.
Empathic support can help alleviate pain and/or promote relaxation. Knowing what to expect provides
an opportunity for the patient to prepare self and enhances a sense of control.
l. Provide basic comfort measures: massage of uninjured areas and frequent position changes.
Promotes relaxation; reduces muscle tension and general fatigue.
m. Encourage the use of stress management techniques: progressive relaxation, deep breathing, guided
imagery, and visualization.
Refocuses attention, promotes relaxation, and enhances a sense of control, which may reduce
pharmacological dependency.
n. Provide diversional activities appropriate for age and condition.
Helps lessen concentration on the pain experience and refocus attention.
o. Promote uninterrupted sleep periods.
Sleep deprivation can increase the perception of pain/reduce coping abilities.
p. Administer analgesics as indicated: morphine; fentanyl hydrocodone ; oxycodone.
The burned patient may require around-the-clock medication and dose titration. IV method is often
used initially to maximize drug effect. Concerns of patient addiction or doubts regarding the degree of
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 Republic of the Philippines
Department of Health
BAGUIO GENERAL HOSPITAL AND MEDICAL CENTER
Baguio City
Professional Education & Training Office Doc. No.: TM-PETO-LD-008
Rev. No. Ø
TRAINING DESIGN Effectivity Date: October 1, 2016
pain experienced are not valid during the emergent/acute phase of care, but narcotics should be
decreased as soon as feasible and alternative methods for pain relief initiated.

3. Risk for deficient fluid volume

Patients with burn injuries are at risk for deficient fluid volume due to the loss of fluids and
electrolytes through the damaged skin, resulting in dehydration and electrolyte imbalances.
Additionally, the inflammatory response caused by the burn injury can increase capillary permeability
and cause fluid to leak into the surrounding tissues, further exacerbating the risk of 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
- Desired Outcomes:
The client will demonstrate improved fluid balance as evidenced by individually adequate urinary
output with normal specific gravity, stable vital signs, and moist mucous membranes.

- Nursing Assessment and Rationales:

a. Monitor vital signs, and central venous pressure (CVP). Note capillary refill and strength of peripheral
pulses.
Serves as a guide to fluid replacement needs and assesses cardiovascular response. Note: Invasive
monitoring is indicated for patients with major burns, smoke inhalation, or preexisting cardiac disease,
although there is an associated increased risk of infection, necessitating careful monitoring and care of the
insertion site.
b. Monitor urinary output and specific gravity. Observe urine color and Hematest as indicated.
Generally, fluid replacement should be titrated to ensure average urinary output of 30–50 mL/hr (in the
adult). Urine can appear red to black (with massive muscle destruction) because of the presence of blood
and the release of myoglobin. If gross myoglobinuria is present, the minimum urinary output should be 75–
100 mL/hr to reduce the risk of tubular damage and renal failure.
c. Estimate wound drainage and insensible losses.
Increased capillary permeability, protein shifts, inflammatory process, and evaporative losses greatly affect
circulating volume and urinary output, especially during the initial 24–72 hr after burn injury.
d. Weigh daily.
Fluid replacement formulas partly depend on admission weight and subsequent changes. A 15%–20%
weight gain can be anticipated in the first 72 hr during fluid replacement, with a return to pre-burn weight
approximately 10 days after the burn.
e. Evaluate changes in mentation.
Deterioration in the level of consciousness may indicate inadequate circulating volume and reduced
cerebral perfusion.
f. Measure the circumference of burned extremities as indicated.
May be helpful in estimating the extent of edema and fluid shifts affecting circulating volume and urinary
output.
g. Observe for gastric distension, hematemesis, and tarry stools.
Stress (Curling’s) ulcer occurs in up to half of all severely burned patients and can occur as early as the first
week. Patients with burns more than 20% TBSA is at risk for mucosal bleeding in the gastrointestinal (GI)
tract during the acute phase because of decreased splanchnic blood flow and reflex paralytic ileus.
h. Monitor laboratory studies: Hb/Hct, electrolytes, random urine sodium.
Identifies blood loss or RBC destruction and fluid and electrolyte replacement needs. Urine sodium of less
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 Republic of the Philippines
Department of Health
BAGUIO GENERAL HOSPITAL AND MEDICAL CENTER
Baguio City
Professional Education & Training Office Doc. No.: TM-PETO-LD-008
Rev. No. Ø
TRAINING DESIGN Effectivity Date: October 1, 2016
than 10 mEq/L suggests inadequate fluid resuscitation. Note: During the first 24 hr after the burn,
hemoconcentration is common because fluid shifts into the interstitial space.

- Nursing Interventions and Rationales:

a. Maintain a cumulative record of the amount and types of fluid intake.
Massive or rapid replacement with different types of fluids and fluctuations in the rate of administration
require close tabulation to prevent constituent imbalances or fluid overload.
b. Insert and maintain an indwelling urinary catheter.
Allows for close observation of renal function and prevents urinary retention. Retention of urine with its
by-products of tissue-cell destruction can lead to renal dysfunction and infection.
c. Insert and maintain large-bore IV catheter(s).
Accommodates rapid infusion of fluids.
d. Administer calculated IV replacement of fluids, electrolytes, plasma, and albumin.
Fluid resuscitation replaces lost fluids and electrolytes and helps prevent complications (shock, acute
tubular necrosis). Replacement formulas vary but are based on the extent of injury, amount of urinary
output, and weight. Note: Once initial fluid resuscitation has been accomplished, a steady rate of fluid
administration is preferred to boluses, which may increase interstitial fluid shifts and cardiopulmonary
congestion.
e. Administer medications as indicated:
5.1. Diuretics: mannitol (Osmitrol)
May be indicated to enhance urinary output and clear tubules of debris and prevent necrosis if acute renal
failure (ARF) is present.
5.2. Potassium
Although hyperkalemia often occurs during the first 24–48 hr (tissue destruction), subsequent replacement
may be necessary because of large urinary losses.
5.3. Antacids: calcium carbonate
Antacids may reduce gastric acidity;
5.4. histamine inhibitors: cimetidine (Tagamet) and ranitidine (Zantac).
Histamine inhibitors decrease the production of hydrochloric acid to reduce the risk of gastric irritation
and bleeding.

4. Risk for Ineffective Tissue Perfusion

Patients with burn injuries are at risk for ineffective tissue perfusion due to the loss of skin and other
tissues, which can result in decreased blood flow to the affected area. This can lead to impaired wound
healing, tissue necrosis, and other complications.
- Risk factors may include:
 Reduction/interruption of arterial/venous blood flow, e.g., circumferential burns of extremities
with resultant edema
 Hypovolemia
- Desired outcomes
The client will maintain palpable peripheral pulses.
- Nursing Assessment and Rationales:
a. Assess color, sensation, movement, peripheral pulses, and capillary refill on extremities with
circumferential burns. Compare with findings of unaffected limb.
Edema formation can readily compress blood vessels, thereby impeding circulation and increasing
venous stasis or edema. Comparisons with unaffected limbs aid in differentiating localized versus
systemic problems (hypovolemia or decreased cardiac output).

b. Obtain BP in unburned extremities when possible. Remove the BP cuff after each reading, as
indicated.
If BP readings must be obtained on an injured extremity, leaving the cuff in place may increase edema
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 Republic of the Philippines
Department of Health
BAGUIO GENERAL HOSPITAL AND MEDICAL CENTER
Baguio City
Professional Education & Training Office Doc. No.: TM-PETO-LD-008
Rev. No. Ø
TRAINING DESIGN Effectivity Date: October 1, 2016
formation and reduce perfusion, and convert partial thickness burn to a more serious injury.

c. Check for irregular pulses

Cardiac dysrhythmias can occur as a result of electrolyte shifts, electrical injury, or release of
myocardial depressant factor, compromising cardiac output.

d. Investigate reports of deep or throbbing ache and numbness.

Indicators of decreased perfusion and/or increased pressure within enclosed space, such as may occur
with a circumferential burn of an extremity (compartment syndrome).

e. Monitor electrolytes, especially sodium, potassium, and calcium. Administer replacement therapy
as indicated.
Losses or shifts of these electrolytes affect cellular membrane potential and excitability, thereby
altering myocardial conductivity, potentiating the risk of dysrhythmias, and reducing cardiac output
and tissue perfusion.

f. Measure intracompartmental pressures as indicated.

Ischemic myositis may develop because of decreased perfusion.

- Nursing Interventions and Rationales:

a. Elevate affected extremities, as appropriate. Remove jewelry or arm bands Avoid taping around a
burned area.
Promotes systemic circulation and venous return that may reduce edema or other deleterious effects
of constriction of edematous tissues. Prolonged elevation can impair arterial perfusion if blood
pressure (BP) falls or tissue pressures rise excessively.

b. Encourage active ROM exercises of unaffected body parts.

Promotes local and systemic circulation.

c. Maintain fluid replacement per protocol.

Maximizes circulating volume and tissue perfusion.

d. Avoid the use of IM/SC injections.

Altered tissue perfusion and edema formation impair drug absorption. Injections into potential donor
sites may render them unusable because of hematoma formation.

e. Assist and prepare for escharotomy or fasciotomy, as indicated.

Enhances circulation by relieving constriction caused by rigid, nonviable tissue (eschar) or edema
formation.

5. Risk for infection

Patients with burn injuries are at risk for infection due to the loss of their skin barrier, which normally protects
the body from pathogens. Additionally, the tissues surrounding the burn site are traumatized, there is a
decrease in hemoglobin levels, and the inflammatory response is suppressed, making it easier for pathogens to
infect the body. Environmental exposure and invasive procedures can also increase the risk of infection.

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 Republic of the Philippines
Department of Health
BAGUIO GENERAL HOSPITAL AND MEDICAL CENTER
Baguio City
Professional Education & Training Office Doc. No.: TM-PETO-LD-008
Rev. No. Ø
TRAINING DESIGN Effectivity Date: October 1, 2016
- Risk Factors may include:
Inadequate primary defenses: the destruction of the skin barrier, traumatized tissues
Inadequate secondary defenses: decreased Hb, suppressed inflammatory response
Environmental exposure, invasive procedures
- Desired Outcomes:
The client will achieve timely wound healing free of purulent exudate and be afebrile.
- Nursing Assessment and Rationales:
a. Examine wounds daily, and note and document changes in appearance, odor, or quantity of
drainage.
Indicators of sepsis (often occurs with full-thickness burn) requiring prompt evaluation and
intervention. Note: Changes in sensorium, bowel habits, and the respiratory rate usually precede fever
and alteration of laboratory studies.

b. Examine unburned areas (such as the groin, neck creases, and mucous membranes) and vaginal
discharge routinely.
Eyes may be swollen shut and/or become infected by drainage from surrounding burns. If lids are
burned, eye covers may be needed to prevent corneal damage.

c. Monitor vital signs for fever, increased respiratory rate, and depth in association with changes in
sensorium, presence of diarrhea, decreased platelet count, and hyperglycemia with glycosuria.
Water softens and aids in the removal of dressings and eschar (slough layer of dead skin or tissue).
Sources vary as to whether a bath or shower is best. Bath has the advantage of water providing support
for exercising extremities but may promote cross-contamination of wounds. Showering enhances
wound inspection and prevents contamination from floating debris.

d. Photograph the wound initially and at periodic intervals.

Provides baseline and documentation of the healing process.

e. Obtain routine cultures and sensitivities of wounds and/or drainage.

Allows early recognition and specific treatment of wound infection.

- Nursing Interventions and Rationales:

a. Implement appropriate isolation techniques as indicated.

Dependent on the type or extent of wounds and the choice of wound treatment (open versus closed),
isolation may range from simple wound and/or skin to complete or reverse to reduce the risk of cross-
contamination and exposure to multiple bacterial flora.

b. Emphasize and model good handwashing techniques for all individuals coming in contact with
patient.
Prevents cross contamination; reduces the risk of acquired infection.

c. Use gowns, gloves, masks, and strict aseptic technique during direct wound care and provide
sterile or freshly laundered bed linens or gowns.
Prevents exposure to infectious organisms.

d. Monitor and/or limit visitors, if necessary. If isolation is used, explain the procedure to visitors.
Supervise visitor adherence to the protocol as indicated.
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 Republic of the Philippines
Department of Health
BAGUIO GENERAL HOSPITAL AND MEDICAL CENTER
Baguio City
Professional Education & Training Office Doc. No.: TM-PETO-LD-008
Rev. No. Ø
TRAINING DESIGN Effectivity Date: October 1, 2016
Prevents cross-contamination from visitors. Concern for the risk of infection should be balanced against
the patient’s need for family support and socialization.

e. Shave or clip all hair from around burned areas to include a 1-in border (excluding eyebrows).
Shave facial hair (men) and shampoo head daily.
Opportunistic infections (yeast) frequently occur because of depression of the immune system and/or
the proliferation of normal body flora during systemic antibiotic therapy.

f. Provide special care for eyes: use eye covers and tear formulas as appropriate.
Prevents adherence to surface it may be touching and encourages proper healing. Note: Ear cartilage
has limited circulation and is prone to pressure necrosis.

g. Prevent skin-to-skin surface contact (wrap each burned finger or toe separately; do not allow the
burned ear to touch the scalp).
Identifies the presence of healing (granulation tissue) and provides for early detection of burn-wound
infection. Infection in a partial-thickness burn may cause conversion of burn to full-thickness injury.
Note: A strong sweet, musty smell at a graft site is indicative of Pseudomonas.

h. Remove dressings and cleanse burned areas in a hydrotherapy or whirlpool tub or in a shower stall
with a handheld shower head. Maintain the temperature of water at 100°F (37.8°C). Wash areas with
a mild cleansing agent or surgical soap.
Early excision is known to reduce scarring and the risk of infection, thereby facilitating healing.

i. Debride necrotic or loose tissue (including ruptured blisters) with scissors and forceps. Do not
disturb intact blisters if they are smaller than 1–2 cm, do not interfere with joint function, and do not
appear infected.
Promotes healing. Prevents autocontamination. Small, intact blisters help protect the skin and increase
the rate of re-epithelialization unless the burn injury is the result of chemicals (in which case fluid
contained in blisters may continue to cause tissue destruction).

j. Administer topical agents as indicated.

Topical agents help control bacterial growth and prevent the drying of wounds, which can cause further
tissue destruction. Some ointments also promotes wound healing.

k. Administer other medications as appropriate: Subeschar clysis or systemic antibiotics; Tetanus

toxoid or clostridial antitoxin, as appropriate.
Tissue destruction and altered defense mechanisms increase the risk of developing tetanus or gas
gangrene, especially in deep burns such as those caused by electricity.

l. Place IV and/or invasive lines in the non-burned areas.

Decreased risk of infection at the insertion site with the possibility of progression to septicemia.

Part 5
Common Medications Encountered during burn care

1. Tramadol
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 Republic of the Philippines
Department of Health
BAGUIO GENERAL HOSPITAL AND MEDICAL CENTER
Baguio City
Professional Education & Training Office Doc. No.: TM-PETO-LD-008
Rev. No. Ø
TRAINING DESIGN Effectivity Date: October 1, 2016
Belongs to the group of medicines called opioid analgesics. It acts in the central
nervous system (CNS) to relieve pain.
2. Ketorolac
It belongs to the group of medicines called nonsteroidal anti-inflammatory drugs
(NSAIDs).
3. Douderm/ Hydrocolloid Dressing (HCD)
Promotes self-debridement and provides faster re-epithilialization than
allografts or SSD.
4. Mebo cream
Moist exposed burn ointment (MEBO) is an oil-based herbal paste, purported to be
efficacious in managing burn wounds. It helps clear away toxic material and promotes
the natural repair and regeneration of new skin (re-epithilialization).
5. Silver sulfadiazine (Silvadene)
Broad-spectrum antimicrobial that is relatively painless but has intermediate,
somewhat delayed eschar penetration. It is previously a mainstay of topical burn
treatment but is no longer recommended because it is no better than other topical
antibiotic preparations and is proven to impair wound healing. May cause rash or
depression of WBCs.
6. Mafenide acetate (Sulfamylon)
Antibiotic of choice with confirmed invasive burn-wound infection. Useful against
Gram-negative or Gram-positive organisms. Causes burning or pain on application and
for 30 min thereafter. Can cause rash, metabolic acidosis, and decreased Paco2.
7. Silver nitrate
Effective against Staphylococcus aureus, Escherichia coli, and Pseudomonas
aeruginosa, but has poor eschar penetration, is painful, and may cause electrolyte
imbalance. Dressings must be constantly saturated. Product stains skin/surfaces black.
8. Bacitracin
Effective against Gram-positive organisms and is generally used for superficial and
facial burns.
9. Povidone-iodine (Betadine)
Broad-spectrum antimicrobial, but is painful on application, may cause metabolic
acidosis or increased iodine absorption, and damage fragile tissues.

Part 6
Common Procedures Encountered at Ward:
1. Total Body Surface Area Determination
a. Rule of Nine
- for Adults
- used to determine the total percentage of the burned area for each major section of the body.
b. Lund-Browder chart
- is one of the most accurate methods to
estimate not only the size of the burn
area but also the burn degree in both
adult and pediatric burn patients.
c. The rule of palms can be used to measure the extent of small scattered burns. The patient’s hand
including fingers is equal to 1% of TBSA.

2. Fluid Resuscitation
Parkland Burn Center, Dallas
- Fluid Resuscitation
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 Republic of the Philippines
Department of Health
BAGUIO GENERAL HOSPITAL AND MEDICAL CENTER
Baguio City
Professional Education & Training Office Doc. No.: TM-PETO-LD-008
Rev. No. Ø
TRAINING DESIGN Effectivity Date: October 1, 2016
Follow Advanced Burn Life Support recommendations. If available, titrate fluid up or down in response
to urinary output via foley catheter.
- Pediatric:
3 ml LR X patients body weight in kg X TBSA second and third-degree burns
- Pediatric High Voltage Electric Burns:
4 ml LR X patient’s body weight in kg X % TBSA second and third-degree burns
- Adult:
For thermal and chemical burns: 2 ml LR X patient’s body weight in kg X % TBSA 2 nd and 3rd degree
burns
- Adult High Voltage Electrical Burns:
4 ml LR X patient’s body weight in kg X % TBSA 2nd and 3rd degree burns
- Geriatrics:
2 ml LR X patient’s body weight in kg X % TBSA 2nd and 3rd degree burns

3. Wound Debridement and Change of dressing

-During the first 30 minutes after injury, use room temperature or cold water for irrigation, immersion or
compresses to limit the extent of the burn and provide significant pain relief.
- Treat pain before doing anything to the burn wound. IV opioids for severe burns, NSAIDS and acetamenophen
for minor burns.
- Check patient’s Tetanus Vaccination history. Provide Tetanus Prophylaxis for incompletely immunized
patients.
- Reinforce and Observe infection control measures at all times.
A. Cleanse the burned area gently with a clean gauze with a mild antibacterial wound cleanser such as
chlorhexidine. Irrigate the wound with saline or water.
B. Devitalized and nonviable tissues ( loose skin and broken blisters) should be debrided by peeling from the
wound and sniping with scissors close to the border with viable, attached epidermis.
C. Apply sterile burn dressing, with or without topical agent. Consider applying a layer of antibiotic cream or
ointment directly to all wounds except first degree or superficial burns.
D. Cover the wound surface with available dressings. A fine-mesh gauze or commercial non adherent gauze is
appropriate.
E. If fingers and toes are involved, pad the web spaces and the digits individually and separate them with strips
of gauze.
F. Wrap the entire dressing with and absorbent, slightly elastic material.
G. Manage pain post procedure.

Part 7
Additional Readings

BURN PATIENT WITH SUSPICIOUS INHALATION

Patients with inhalation injuries are at high risk for complications. This includes short-term
complication, such as pneumonia (most common), especially if the patient has underlying lung diseases
(such as COPD and asthma), while long term complications include bronchiectasis, bronchiolitis
obliterans, and the need for artificial airways, but are less common to occur.

Etiology: Smoke inhalation injuries happen is the respiratory system is exposed to direct heat
from fire of toxic chemicals formed by combustion. High-oxygen and high-temperature fires
produces large amount of smoke, while low-oxygen fires give rise to more toxic chemicals, such
as carbon monoxide. Other common toxic chemicals include: ammonia, CO2, hydrogen
cyanide, aldehydes, sulfur dioxides, and nitrogen dioxide. Inhalation of those chemicals causes
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 Republic of the Philippines
Department of Health
BAGUIO GENERAL HOSPITAL AND MEDICAL CENTER
Baguio City
Professional Education & Training Office Doc. No.: TM-PETO-LD-008
Rev. No. Ø
TRAINING DESIGN Effectivity Date: October 1, 2016

both upper and lower airway injuries

Pathophysiology:

Inhalation of toxins leading to thermal injury (to the level of the larynx) and chemical toxins
(damage to just the airways, alveoli, or both). More water soluble chemicals (ammonia and
sulfur dioxide) will often damage the moist mucosa of the upper airway without causing
alveolar damage. Due to the damage to the airway tissues, there will be increased mucus
production, edema, denudation of epithelium, and mucosal ulceration and hemorrhage. This
will cause obstruction of airflow. Pseudomembranes may also develop in the trachea or
bronchi causing bronchiolitis obliterans and organizing pneumonia. Epithelial and endothelial
damages will result to pulmonary edema and possibly acute respiratory distress syndrome due
to widespread alveolar-capillary leak.

History and Physical

 Gather information about the duration of exposure, location, any loss of consciousness
 Patients with inhalation injuries usually have burning sensation in the nose or throat, a
cough with increased sputum production, stridor, and dyspnea with rhonchi or
wheezing.
 Assess for symptoms of odynophagia (painful swallowing)
 Assess for systemic symptoms (headache, delirium, hallucinations, comatose)
 Assess for changes in mental status (may be caused by hypoxia, hypercarbia, or
asphyxiant exposure)
 Look for facial burns
 Assess the use of accessory muscles – stridors in the upper airways are often a sign of
impending airway compromise – intubation is strongly considered.
 Delayed onset of symptoms may occur. Advise patient that delayed symptoms may
occur in the lower airways, which may bypass the upper airways. Ex. Nitric Oxide is
highly water-insoluble and its damage onset has been seen up to 72 hours post
exposure

Evaluation

 Chest imaging: Serial Chest radiographs and CT scans

 CBC, Complete metabolic panel, lactate
 Pulse oximetry (may be falsely elevated in CO exposure)
 Arterial blood gas
 Carboxyhemoglobin level
 Cyanide level (often not readily available therefore limited use in the acute
setting)
 Pulmonary function testing: The flow-volume loop is a very sensitive
noninvasive test
 Bronchoscopy and direct laryngoscopy

TREATMENT AND MANAGEMENT

 Limit exposure and remove patient from the area

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 Republic of the Philippines
Department of Health
BAGUIO GENERAL HOSPITAL AND MEDICAL CENTER
Baguio City
Professional Education & Training Office Doc. No.: TM-PETO-LD-008
Rev. No. Ø
TRAINING DESIGN Effectivity Date: October 1, 2016
 Secure and maintain a patent airway (Intubation or tracheostomy may be performed as
needed)
 Aggressive pulmonary hygiene in the presence of obstruction resulting from edema,
hemorrhage and mucosal sloughing:
o Administration of N-Acetylcysteine (mucolytic and have a role in inactivating
reactive oxygen species).
o Consider pre-medicating with a bronchodilator prior to NAC nebulization as
nebulized NAC may irritate the airways that may cause bronchoconstriction.

 Consider the use of Bronchodilators, such as: Beta-2-adrenergic sgonists (Albuterol and
Salbutamol), and muscarinic receptor antagonists (Tiotropium), which has been found
to improve pulmonary functioning in smoke inhalation injuries (Palmieri et al and
Jankam et al).
 Antibiotics should only be started if a diagnosis of pneumonia is made.
 Use of anticoagulants – Nebulized heparin is found to reduce inflammatory response
and fibrin cast formation, which reduces airway obstruction. Usual dosage is 5000 to
10000 units of nebulized heparin every 4 hours (usually given with alternating dose of
NAC and bronchodilators).
 Accurate treatment will require the determination of possible compounds, duration
and concentration of exposure, and solubility of chemicals inhaled
 Specific treatments
o CO treatment: High-oxygen therapy. Hyperbaric oxygen treatment has been
shown to increase clearance rate of CO from the blood. Alternatively, 100%
FiO2 oxygen therapy can also be considered.
o Hydrogen cyanide poisoning – testing results are not readily available, which
makes it difficult to determine.
 Hydroxocobalamin – antidote of hydrogen cyanide; nontoxic and
renally excreted; side effects include reddening of the skin and urine

Part 8

REFERENCES:
1. World Health Organization.(2018, March 06). Burns. Burns (who.int)
2. American Burn Association.(2018, February 4-10).Burn Injury Fact Sheet. nbaw-
factsheet_121417-1.pdf (ameriburn.org)
3. Strauss, S. and Gillespie, G.L. (2018).American Nurse. Initial Assessment and Management of
Burn Patients. Initial assessment and management of burn patients (myamericannurse.com)
4. Schaefer, T.J; Lopez, O.N. (2022, January 31). National Library of Medicine. Burn Resuscitation
and Management. Burn Resuscitation And Management - StatPearls - NCBI Bookshelf (nih.gov)
5. Perez, E.; Fraser, M; Novick, T. (2022, May 01). Nationwide Chidlren’s. Classification of Burns.
https://www.nationwidechildrens.org/conditions/health-library/classification-of-
burns#:~:text=What%20are%20the%20classifications%20of,burn%20immediately%20when
%20it%20occurs.
6. Shubert, J.; Sharma, S. (2021, June 26). National Library of Medicine. Inhalation Injury.
Inhalation Injury - StatPearls - NCBI Bookshelf (nih.gov)
7. The Royal Children’s Hospital Melbourne. (2018, December).Nursing Management of burn

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 Republic of the Philippines
Department of Health
BAGUIO GENERAL HOSPITAL AND MEDICAL CENTER
Baguio City
Professional Education & Training Office Doc. No.: TM-PETO-LD-008
Rev. No. Ø
TRAINING DESIGN Effectivity Date: October 1, 2016

Injuries. Clinical Guidelines (Nursing) : Nursing management of burn injuries (rch.org.au)

8. Browning, J.; Cindass, R. (2022, April 30). National Library of Medicine.Burn Debridewment,
Grafting, and Reconstruction. Burn Debridement, Grafting, and Reconstruction - StatPearls -
NCBI Bookshelf (nih.gov)
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is Burn Surgery: Overview, Benefits, and Expected Results
10. Bittner, E. et.al.(2015, February).Acute and Perioperative Care of the Burn-injured Patient.
Acute and Perioperative Care of the Burn-injured Patient | Anesthesiology | American Society
of Anesthesiologists (asahq.org)
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Prevention and Treatment. Outpatient Burn Care: Prevention and Treatment - PubMed
(nih.gov)
12. Lloyd, E. et.al. (2012, January 01). Outpatient Burns: Prevention and Care. Outpatient Burns:
Prevention and Care (aafp.org)
13. Antoon, A.; Donovan, M. (2016, June 18).Burn Injuries. Burn Injuries | Obgyn Key
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15. Abesamis, G.M.; Bico, J.D. (2021).Proposed Guidelines in the Management og Burn Inuries
During the COVID-19 Pandemic for Baguio General Hsopital and Medical Center. Adapted from
Metro Manila Burn Centers and Units

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