Managem

ent of a
Burn
Patient
Objectives
At the end of the lecture, students should be able to
• Define burn
• Identify the classification of burn
• Assess the severity of burn
• Describe the critical management of a burn patient
• Apply nursing care plan for a burn patient
Critical care and Burns
• Burns is one of the commonest cause that bring severe damage to
patients all over the world

• Despite of the medical advancement as well as the development of burn

units, the deaths due to burns are rising at an alarming rate

• Emergency management is necessary to save burn patients’ lives

• Knowledge about pathophysiology and physiological changes are very

important when managing a burn patient
Definition
• Burns can be defined as any injury that results from
direct exposure to a thermal, chemical, electrical or
radiation source
Anatomy of the skin
 Anatomy of the Skin
• Epidermis • Dermis Hypodermis
• The outermost layer of the • The second, thicker layer, the The hypodermis is beneath the dermis
epidermis is 0.07 to 0.12 mm thick, dermis, is 1 to 2 mm thick and lies and contains fat, smooth
• with the deepest layer found on the below the epidermis and muscle, and areolar tissues.
soles of the feet and the palms regenerates continuously. The hypodermis acts as a heat
of the hands. • The dermis contains blood vessels; insulator, shock absorber, and nutrition
• The epidermis is composed of sweat and sebaceous glands; hair depot.
dead, cornified cells that act as a follicles; nerves to the skin and
tough protective barrier against the capillaries that nourish the
environment. avascular epidermis; and sensory
• It serves as a barrier to bacteria and fibers that detect pain, touch, and
moisture loss. temperature.
• The epidermis regenerates every 2 • Mast cells in the connective tissue
to 3 weeks perform the functions of secretion,
phagocytosis, and production of
fibroblasts.
Functions of the skin
1. Protection against
• invasion by microbes
• chemicals
• physical agents, e.g. mild trauma, ultraviolet light
• dehydration
2. Regulation of body temperature
3. Formation of vitamin D
4. Sensation
5. Absorption
6. Excretion
Incidence of Burn
• Burn injuries that are the fourth leading cause of traumatic injury
worldwide remains a significant, preventable cause of morbidity and
mortality in Sri Lanka
Types of Burns
1. Thermal burns
• Most common type of burn
• Burns due to direct contact with heat source
• Sources can be hot water, fire, flammable liquids, greases, Explosions etc.
• The length of time the hot object is in contact with the skin
determines the depth of injury.
• Children have thinner skin and will sustain a deeper burn at
any temperature

• Two main types

1. Wet burns – hot water or steam (scald) - Toddlers
2. Dry burns – direct contact with heat source
 Types of burns cont.
2. Chemical Burns
Alkali burns commonly result in more severe injuries compared with acid burns.

• Tissue damage or destruction occurs due to

 chemical coagulation of proteins
 Precipitation of chemical compounds in the cell
 Severe cellular dehydration

• The extent of the damage depends on

 Concentration of the chemical
 Duration of exposure
 Extent of tissue perfusion
 Mode of action of the chemical
 Heat generates on neutralization
Types of burns cont.
• Types of chemical agents that cause burns
Type of Chemical Examples

Oxidising agents Sodium hypochlorite, potassium

permanganate

Reducing agents Nitric acid,

Protoplasmic poisons Fluoric acid, Oxalic acid, Hydrofluoric acid

Vesicants Dimethyl sulfoxide

Desiccants Sulfuric acid

3. Electrical burns

• Electrocution may cause severe thermal injuries that may even cause
death
• Result from the conversion of electrical energy into heat. Extent of
injury depends on the type of current, the pathway of flow, local
tissue resistance, and duration of contact
• Children have the highest incidence of electrical injury. These
accidents occur as a result of insertion of an object into an outlet or
by biting or sucking on an electrical cord
• Lead to tissue destruction and contracture formation
Types of burns cont.
4. Radiation Burns
Result from radiant energy being transferred to the body resulting in
production of cellular toxins
Sources – UV Rays , X- Rays, External Beam Radiation
Phases of care of burn injuries

• Emergent phase

• Acute/intermediate phase

• Rehabilitative/long term phase

Phase I - Emergent phase
• The emergent phase begins with the onset of burn injury and lasts
until the completion of fluid resuscitation or a period of about the first
24 hours
• During the emergent phase, the priority of client care involves
maintaining an adequate airway and treating the client for burn shock
• Immediate problems are fluid loss, oedema, reduced blood flow (fluid and electrolyte
shifts)
• Goals:
1. Secure airway
2. Support circulation by fluid replacement
3. Keep the client comfortable with analgesics
4. Prevent infection through wound care
5. Maintain body temperature
6. Provide emotional support
Systemic effect of burn
• Hemodynamic instability (burn shock)
• Cardiac output decreased
• Decrease Pulse pressure
• Increased pulse rate
• Decreased BP
• Fluid leak within 24 to 36 hours and peak in 12 hours
• Decreased UOP
Systemic effect of burn Cont.
• Evaporate fluid 3 to 5 L /24 hours
• hypernatremia
• Hyperkalaemia
• Weight loss
• Anaemia
• Pulmonary complication
Other systemic changes of burn
• Alter renal function due decreased blood volume
• Destruction of RBCs – Hemoglobin urea
• Reduce blood flow to kidney- tubular necrosis
• Altered immunologic defense – infection
• Loss of skin – reduce thermoregulation
• Burn trauma- paralytic ileus, gastric distention ,vomiting occult blood,
hematemesis coffee ground gastric content
 GI system - Curling’s ulcer
• A condition happen – body is undergoing extreme physical stress
• Acute ulcerative gastro duodenal disease
• Result of complication from severe burns (reduced plasma volume
leads ischemia and necrosis of gastric mucosa)
• Occur within 24 hours after burn
• Due to reduced GI blood flow and mucosal damage
• Treat clients with H2 receptor antagonists, mucoprotective drugs and
early enteral nutrition and Proton pump inhibitors
• Watch for sudden drop in haemoglobin
Vascular changes resulting from
burn injuries
• Circulatory disruption occurs at the burn site immediately after a burn
injury
• Blood flow decreases or cease due to occluded blood vessels
• Damaged macrophages within the tissues release chemicals that
cause constriction of vessel
• Blood vessel thrombosis may occur causing necrosis
Fluid shift – Burn Shock
• Occurs after initial vasoconstriction, then dilation
• Blood vessels dilate and leak fluid into the interstitial space
• Known as third spacing or capillary leak syndrome
• Causes decreased blood volume and blood pressure
• Occurs within the first 12 hours after the burn and can continue to up
to 36 hours
Fluid remobilization
• Occurs after 24 hours
• Capillary leak stops
• See diuretic stage where edema fluid shifts from the interstitial spaces
into the vascular space
• Blood volume increases leading to increased renal blood flow and
diuresis
• Body weight returns to normal
• Hypokalaemia can be seen
Skin assessment

• Assess the skin to determine the size and depth of burn injury

• The size of the injury is first estimated in comparison to the total body
surface area (TBSA). For example, a burn that involves 40% of the
TBSA is a 40% burn

• Use the rule of nines for clients whose weights are in normal
proportion to their heights
Estimation of Burn size

1. Wallace’s Rule of nine

• The body is divided into parts

that is approximately 9% of the
total surface area
Estimation of Burn size cont
2. Lund Browder chart

Accurately determine the surface area

of the each body part

3. Palm method

Patient’s palmer size is approximately

1% of the body surface area
Lund Browder chart
Estimation of the burn depth
1. Superficial Burns / First Degree Burns

• Caused due to prolong extension to low intensity heat

• Skin appears red and painful
• Only epidermis is burned
• Local oedema present
• Need only comfort measures
• Heal in 3 – 5 days without a scar
e.g. Sunburn
Estimation of the burn depth cont.
2. Partial Thickness Burns / Second Degree Burns

• Epidermis and part of the dermis are damaged

• Epidermal appendages are preserved
• Fluid filled blisters appear immediately after injury
• Appearance is pink and mottled
• Healing takes place between 10 – 14 days after injury with minimal
scarring
• Burns are painful as nerve endings are exposed
Estimation of the burn depth cont.
3. Full Thickness Burns / Third Degree Burns

• Epidermis, dermis and dermal appendages are destroyed

• Burn may extend to subcutaneous fat, Muscle or even bones
• Thick and leathery escher can be seen
• Wound is not painful as the as nerve endings are damaged
• Healing may take one to several months depending on the severity of
injury
• Skin grafts are applied to promote function and stability
IV fluid therapy
• Infusion of IV fluids is needed to maintain sufficient blood volume for
normal CO
• Clients with burns involving 15% to 20% of the TBSA require IV fluid
• Purpose is to prevent shock by maintaining adequate circulating blood
volume
• Severe burn requires large fluid loads in a short time to maintain
blood flow to vital organs
• Fluid replacement formulas are calculated from the time of injury and
not from the time of arrival at the hospital
Fluid volume calculation formula
1. Consensus formula

• Fluid volume = 2 to 4 ml of ringer lactate * body weight * TBSA %

• Give half of the calculated fluid volume within first 8 hours

• The rest half is given within the next 16 hours

Fluid volume calculation formula
cont.
2. Evans formula
Give this within first 24 hours (1st 8 hours – ½ cal fluid & ½ cal fluid in 16
hrs)
• Crystalloids (NS) = 1ml * body weight * TBSA %
• Colloids (blood, plasma) = 1 ml * body weight * TBSA %
• Glucose (5% In water) = 2000 ml for insensible losses
• For the next 24 hours half of the calculated (Crystalloids + Colloids)
fluid volume (glucose remain same)
• Maximum 10000 ml/24 hrs
Fluid volume calculation formula
cont.
3. Parkland formula

• Fluid volume = 4 ml * body weight * TBSA %

• Give half of the calculated fluid volume within first 8 hours

• The rest half is given within the next 16 hours (1/4 in next 8 hours and
remaining ¼ in next 8 hours)
Fluid volume calculation formula
cont.
4. The brooke army hospital formula

• Electrolytes = 0.5 ml NS * body weight * TBSA %

• Colloids (blood, plasma) = 1.5 ml * body weight * TBSA %
• Glucose = 2000 ml
Phase II – Acute
phase/Intermediate phase
• Begins after 48 – 72 hrs. following burn injury
• Observe diuresis and increased urinary output (capillary permeability
changes and correction of osmotic pressure)
• Can observe symptoms of congestive heart failure (renal and cardiac
functions not normal)
• Assessment of CVP (5-12mmH2o) – elevated – volume overload
• Curling’s ulcer, Paralytic ileus, Anemia, DIC and Acute Respiratory
Failure
Phase II – Acute phase
• Pneumonia is a concern which can result in respiratory failure requiring
mechanical ventilation
• Infection (Topical antibiotics) - Staphylococcus, proteus,
pseudomonas, escherichia coli, and klebsiella)
• Tetanus toxoid
• Weight daily without dressings or splints and compare to pre-burn weight
• A 2% loss of body weight indicates a mild deficit
• A 10% or greater weight loss requires modification of calorie intake
• Monitor for signs of infection
Local and systemic signs of infection
• May led to septic shock
• Conversion of a partial-thickness injury to a full-thickness injury
• Ulceration of healthy skin at the burn site
• Erythematous, nodular lesions in uninvolved skin
• Excessive burn wound drainage
• Odor
• Sloughing of grafts
• Altered level of consciousness
• Changes in vital signs
• Oliguria
• GI dysfunction such as diarrhea, vomiting
Other important concerns
• Pain management
Patient controlled anelgesia
• Diet
High protein, high caloric diet
If paralytic ileus present, TPN indicated
• Skin grafting
Facilitates wound healing
Full and partial thickness burns
Other important concerns
• Removing eschar and other cellular debris (gently washing the
wound under a shower,
• Treating with topical antibiotics and dressing (Silver Sulfadiazine)
Acticote
• Wound dressing – standard WD (sterile gauze)
Biologic or synthetic dressings (human tissue -
homograft, animal tissue - heterograft)
Phase III - Rehabilitative phase

• Begins with wound closure and ends when the client returns to the highest
possible level of functioning

• Provide psychosocial support

• Assess home environment, financial resources, medical equipment,

prosthetic rehab

• Health teaching should include symptoms of infection, drugs regimens,

comfort measures etc
Phase III - Rehabilitative phase
• Diagnostic Tests for review – CBC, Serum electrolytes, urinalysis, chest
X-Ray
 Prevention of contractures

A permanent tightening of the muscles, tendons, skin, and nearby

tissues that causes the joints to shorten and become very stiff

• Physiotherapy

• Positioning

• Splinting

• Skeletal traction of necessary

Psychosocial issues

• Help with the process of emotional recovery

• May need support of a social workers

• Not only the patient, consider about the family

What are the frequent psychological responses of a burn patient?

Nursing diagnoses
• Ineffective airway clearance related to inhalation injury
• Fluid volume deficit related to discharges from burns
• Pain related to the burn wound
• Risk for infection related to the burn wound
• Altered nutrition less than body requirement related to poor oral food
intake
• Anxiety related to the traumatic exposure
• Impaired mobility related to burn wound
• Body image disturbances related to disfigurement