2. Objectives
At the end of the session participants will be able to :
• define burn.
• state incidence of burn.
• state aetiology of burn.
• classify burn.
• describe pathophysiology of burn.
• describe therapeutic management of burn.
• describe nursing management of burn.
• list complication of burn.
• state prevention of burn.
4. Introduction
•A burn is a type of injury to tissue caused by heat, electricity,
chemicals, light, radiation or friction.
•Most burns only affect the skin(epidermal tissue and dermis).
•Rarely, deeper tissues, such as muscle, bone and blood vessels can also
be injured.
5. Incidence
• Globally, deaths from burn: 180 000/year and majority occurs in low
and middle-income countries.
• Burns are the second most common injury in rural Nepal, accounting
for 5% of disabilities.
(WHO, 2018)
6. Aetiology
1. Thermal Burn
• Contact with steam, flames and hot surfaces or hot liquids with a
temperature above 115F(e.g boiling water at 212F or 100C).
• Commonly occurs in home while doing ironing, cooking, or touching
hot water.
7. Contd...
2. Chemical Burn
• Strong acids or alkalis.
• Household chemicals : bleach, boric acid, paint thinner.
• common in the workplace in certain industries.
8. Contd...
3. Electrical Burn
• Electric current flowing through tissues or bone.
• It effects on the muscles, veins, arteries, and nerves between the entry
and the exit point of the electrical current.
9. Contd...
4. Radiation Burn
• sunburn caused by UV radiation.
• Radiotherapy
5. Inhalation burn injury:
• Breathing in of harmful gases, vapors, and hot smoke.
10. Classification of Burn
A. Burn Depth
Burns are classified according to the depth of tissue destruction as:
1. Superficial Burn (1st degree Burn):
• The epidermis is destroyed and a portion of the dermis.
• Painful, hyperesthetic and appear red and dry.
• Erythema blanches with pressure.
• Heals in 5-10 days without scarring.
11. Contd...
2. Partial thickness(2nd degree Burn):
Destruction of the epidermis and dermis
In superficial partial thickness burn injury:
• Dermal elements are intact, sweat glands and hair follicles remain
intact that appears thick walled blisters, wet shiny, weeping surface
which is painful.
• Injury heals within 2-3wks if no infection.
12. Contd...
Deep dermal burn injuries:
• Appears mottled, with pink, red or waxy white areas exhibiting
blisters and edema formation.
• The wound is painful
• Deep partial thickness burns take longer time to heal and are more
likely to result in hypertrophic scars.
13. Contd...
3. Full Thickness(3rd Degree ) Burns:
Entire epidermis and dermis and extend into subcutaneous and other
underlying tissue, nerve tissue, sweat glands and hair follicle.
•Wound color ranges widely from waxy white to red, brown or black
and is distinguished by a dry, leathery appearances.
•The wound is painless because nerve fibres are destroyed.
14. Contd...
• Not capable of re-epithelization and require surgical excision and
grafting to close the wound.
4. Fourth Degree Burn:
This burn is full thickness injuries that involve underlying structures
such as muscle, fascia and bone.
16. Contd...
B. Extent of body surface area
• The extent of a burn is expressed as a percentage of the total body
surface area (TBSA).
• Lund and Browder method, palm method, and rule of nine.
20. C. Severity of Burn Injury
Minor Burn Injury Moderate Burn Injury Severe Burn Injury
TBSA and Depth of Burn:
<10yrs: <10%TBSA 2nd
degree burn
>10yrs: <15%TBSA 2nd
degree burn
<2% 3rd degree burn
TBSA and Depth of burn:
<10yrs: 10-20% TBSA 2nd
degree burn
>10yrs: 15-25% TBSA 2nd
degree burn
<10% 3rd degree burn
TBSA and Depth of burn:
<10yrs: > 20% TBSA 2nd
degree burn
>10yrs: > 25% TBSA 2nd
degree burn
All third degree burn
exceeding 10%.
21. Pathophysiology
Local response
A. The three zones of a burn
i. Zone of coagulation-
• This occur at the point of maximum damage.
• In this zone there is irreversible tissue loss due to coagulation of the
constituent proteins.
22. Contd…
ii. Zone of stasis-
•The surrounding zone of stasis is characterized by decreased tissue
perfusion.
•The main aim of burns resuscitation is to increase tissue perfusion here
and prevent any damage becoming irreversible.
23. Contd…
iii. Zone of hyperemia:
•In this outermost zone tissue perfusion is increased.
•The tissue here will invariably recover unless there is severe sepsis or
prolonged hypoperfusion.
25. Contd…
B. Edema formation:
Thermal injury in the tissue results in increased capillary permeability
and vasodilation.
So, loss of water, protein and electrolytes from the circulating volume in
to the interstitial spaces occur leading to edema.
26. Contd…
C. Fluid Loss:
Burn-injured skin is more permeable to evaporative water loss(
approximately 4000ml/m2 total surface area).
D. Circulatory Status:
Reduced blood flow in the burned area
In full thickness burn the vascular supply is completely occluded.
28. Contd…
Cardiovascular changes
Capillary permeability is increased, leading to loss of intravascular
proteins, fluids and electrolytes into the interstitial compartment.
Peripheral and splanchnic(organ) vasoconstriction occurs.
Myocardial contractility is decreased.
Systemic hypotension and organ hypoperfusion.
29. Contd…
Hematological Changes
A significant loss of circulating red cell mass
Respiratory Changes
Inflammatory mediators cause bronchoconstriction and in severe burns
respiratory distress syndrome can occur.
30. Contd…
Renal Changes
• Renal vasoconstriction.
• Reduced renal plasma flow and depressed glomerular filtration.
• Oliguria and acute renal failure.
• Blood urea(BUN) and creatinine levels are elevated from tissue
breakdown and oliguria.
31. Contd…
Metabolic changes
• The basal metabolic rate increases up to three times to its original rate.
Neuro-endocrine change
• It stimulates various target organs of the neuroendocrine system.
• Increased amounts of the catecholamines; epinephrine and
nonepinephrin
• Aldosterone secretion is elevated
• There is release of antidiuretic hormone
32. Therapeutic Management
A. Resuscitative Phase (First aid management)
• Remove the child from burn area.
• Extinguish the flames.
• Maintain A, B and C(airway, breathing, circulation)
• Cool the burn area.
• Remove restrictive clothes, objects.
33. Contd…
• Cover the wound with clean cloth/dress.
• Irrigate/wash out in running water if chemical burn.
• Place the victim in comfortable position.
• Reassure the victim.
• Refer the patient to health facilities with burn care facilities.
34. Contd…
B. Emergency Medical Management
Airway, breathing
• Assess breathing, maintain patent airway.
• Administer 100% humidified oxygen.
• Endotracheal intubation and manual ventilation may be needed.
• NPO to prevent aspiration.
35. Contd…
Circulation
• Assess circulatory status quickly: monitor pulse, BP, frequently.
• Careful watch for features of shock and prevent it.
Assessment of the total body surface area affected(TBSA) and degree
of burn.
36. Contd…
Fluid Resuscitation
• Keep IV canula of large bore.
• Administer fluids and electrolytes according to depth of burn and
TBSA affected.
• Assess vital signs (pulse:<110/m, BP: >100mmhg), tissue
perfusion.
• Central venous catheter may be needed for fluid administration
and fluid balance monitoring.
37. Contd…
• Monitor urine output (30-40ml/hr).
• If burn<20%, oral fluid replacement can be done.
Keep the child warm.
• Assess body temperature frequently.
• Less exposure of wound, and keep warm.
38. Contd...
Management of the pain usually pharmacologic management in
this situation.
Dressing of the wound.
Administer tetanus prophylaxis.
Insert Foleys catheter to facilitate urination and for accurate
measurement of the urine output.
N/G tube in continous drainage if abdominal area affected /
abdominal distension present.
39. Contd...
C. Guidelines and Formulas for Fluid Replacement in Burn
Patient
Consensus Formula
• Ringer Lactate (RL) or normal saline(NS): 2-4ml×Kg body
weight×TBSA%
• Half amount in first 8hrs.
• Remaining half in next 16 hrs.
40. Contd...
Parkland and Baxter Formula :
RL : 4ml × Kg body weight ×TBSA%
• Day 1st: Half amount in 1st 8hrs, remaining ½ in next 16hrs.
• Day 2nd : Varies, colloids are added.
41. Contd...
Intermediate Management of Burn
Continous assessment of the condition and acute complication of the
burn injury such as hypovolemic shock, signs of CHF, renal failure.
Administration of fluid: colloids including blood, albumin, and
electrolytes according to patient’s condition and response to therapy.
Pain management: Pharmacological and non pharmacological
42. Contd...
Maintain thermoregulation.
Infection Prevention.
Wound care
• Wound cleaning(tub bath, cleaning with warm NS)
• Topical antibacterial application(more effective than systemic)
• Wound dressing: exposure or occlusive method and frequency usually
daily).
• Wound debridement(natural, mechanical, surgical).
43. Contd...
• Grafting the burn wound.
auto graft(own body skin)
allograft(skin of others)
synthetic graft material
• Care of the donor site
Nutritional support: High protein, vitamins and minerals
Parenteral or enteral feeding if oral intake inadequate.
44. Contd...
Physical mobility and exercises to promote physical functioning and
minimize scarring.
Use splint and exercise device to maintain proper position of joints.
Strengthening coping strategies
Home care teaching
Refer them to social services or other support groups
45. Rehabilitative Care
The goals of rehabilitation are:
• To promote wound healing.
• To promote psychological support.
• To restore maximal function.
• To reconstruct the contracture.
46. Nursing Management
Nursing Assessment
• Assess the child for extent of burned surface, aetiology of burn,
hypovolemic shock etc.
Nursing Diagnosis
• Impaired physical mobility related to open burn wound, contracture,
anxiety
• Deficient knowledge related to child condition and treatment
• Disturbed body Image related to burn wound
• Fear/Anxiety related to chlid’s physical condition, treatment procedure
• Impaired skin integrity related to burn wound
47. Contd…
Nursing Diagnosis
• Imbalanced nutrition less than body requirements related to lack of
knowledge
• Risk for ineffective tissue perfusion related to complication of burn
• Acute pain related to burn wound
• Risk for infection related to burn, invasive procedure
• Risk for deficient fluid volume related to loss of fluid from burn
wound
• Risk for ineffective airway clearance related to immobilization
48. Contd…
Nursing Intervention
• Promoting physical mobility of child
• Improve knowledge of child and parents
• Increasing acceptance of body image
• Providing emotional support
• Providing Skin Care
• Providing balanced nutrition
• Increasing tissue perfusion
• Decreasing pain
49. Contd…
• Prevention from infection
• Maintenance of fluid volume
• Increase airway clearance
Evaluation
• Maintained strength and function of affected body part.
• Absence of contractures.
• Demonstrated techniques/behaviors that enable resumption of activities.
• Acceptance of body image and setting future goals.
51. Contd...
Long term complications
• Growth retardation
• Different types of contracture
• Body image disturbance
• Lowered self esteem, depression
52. Prevention
• Enclose fires and limit the height of open flames in domestic
environments.
• Promote safer cookstoves and less hazardous fuels, and educate
regarding loose clothing.
• Apply safety regulations to housing designs and materials, and
encourage home inspections.
• Lower the temperature in hot water taps.
• Promote fire safety education and the use of smoke detectors, fire
sprinklers, and fire-escape systems in homes.
• Use of fire-retardant fabrics for children’s sleepwear.
53. Summary
• A burn is a type of injury to tissue caused by heat, electricity,
chemicals, light, radiation or friction.
• Globally, deaths from burn: 180 000/year and majority occurs in low
and middle-income countries.
• Aetiology of burn includes thermal burn, chemical burn, electrical
burn, radiation burn, inhalation burn.
• Burn is classified as 1st degree, 2nd degree, 3rd degree and 4th degree.
• The extent of burn surface is calculated through lund and browder
method, palm method and rule of nine.
54. Contd…
• Management includes first aid management, emergency medical
management, intermediate management and rehabilitation.
• Fluid resuscitation through consensus formula, parkland and baxtar
formula.
• Wound care includes bathing, dressing, prevention of contracture,
physiotherapy, grafting; autograft, allograft and synthetic materials,
prevention of infection etc.
• Nursing management includes supportive care: Pain management,
fluid volume maintenance, nutrition, infection prevention, range of
motion exercise, emotional support.
55. Assignment
• Define Burn. State aetiology of burn and write emergency medical
management of burn. (2+3+5)
56. References
Hockenberry, M.J., Wilson, D. and Rodgers,C.C. (2018). Wong’s Essentials of Pediatric Nursing.
2nd ed. India: Reed Elsevier.
Uprety, K. (2018).Essential of Child Health Nursing. 1st edition. Kathmandu: Akshav Publication.
Shrestha, T. (2016). Essential Child Health Nursing. 2nd edition. Kathmandu: Medhavi
Publication.
Kyle, T. and Carman, S.(2013). Essentials of Pediatric Nursing.2nd edition. Philadelphia:Wolters
Kluwer Health.
Ball, J., Bindler, R., Cowen, K., Shaw, M.(2017). Principles of Pediatric Nursing. 7th edition.
America: Pearson Education.
WHO.(2018). Retrived on 21/8/2020 from https://www.who.int/news-room/fact-
sheets/detail/burns
