BURNS

1. RATHEESH R L

2. Definition
• A burn is a type of injury to the flesh or skin which can
be caused by heat, electricity, chemicals, friction or
radiation

3. • Human skin can tolerate temperatures up to 42-440 C
(107-1110 F) but above these, the higher the
temperature the more severe the tissue destruction
• Below 450 C (1130 F), resulting changes are
reversible but >450 C, protein damage exceeds the
capacity of the cell to repair

4. Incidence
• About 2.4 million people suffer burns annually
• Account for an estimated 700,000 cases visits per year and
45,000 require hospitalizations
• Between 8,000-12,000 burn patients die, and approximately
one million will sustain substantial or permanent disabilities

5. Etiology
 Thermal injury
Electrical injury
 Chemical burns—acid/alkali
 Cold injury—frost bite
 Ionising radiation
 Sun burns

6. CLASSIFICATION OF BURNS

7. CLASSIFICATION OF BURNS BY
CAUSATIVE AGENTS
Thermal Burns
–Caused by flame, flash, scald, or contact
with hot objects
–It is the most common type of burn
Chemical Burns
• Result from tissue injury and destruction
from necrotizing substances (chemicals)
• Most commonly caused by acids

8. Smoke Inhalation Injuries
 Result from inhalation of hot air or noxious chemicals
 Cause damage to respiratory tract
 Important determinant of mortality in fire victims
Eg :Carbon monoxide (CO) poisoning
– CO is produced by the incomplete combustion of burning
materials
– Inhaled CO displaces oxygen 200 x more powerful than
oxygen
– CO is colorless, odorless and tasteless

9. Signs and Symptoms
Presence of facial burns
Singed nasal hair
Hoarseness,
painful swallowing
Darkened oral and nasal membranes
Wheezing on auscultation
Edema is the nose and airways
Flushing
Nausea/vomiting
Syncope, coma, death

10. Electrical Burns
• Intense heat generated from an electrical
current
• May result from direct damage to nerves and
vessels causing tissue anoxia and death
• Severity of injury depends on the amount of
voltage, tissue resistance, current pathways,
surface area, and on the length of time of the
flow

11. Electrical burns in hands

12. Cold Thermal Injury (Frostbite)
– Usually affects fingers, toes, nose, and ears
– Numbness, pallor, severe pain, swelling,
edema
• resulting from prolonged exposure to
freezing or subfreezing temperatures.

13. Classification according to the depth of
tissue destruction
1. Superficial partial-thickness injuries (first
degree burn):
In a superficial partial-thickness burn,
the epidermis is destroyed or injured and
a portion of the dermis may be injured.
The damaged skin may be painful and
appear red and dry, as in sunburn, or it may
blister (very minimal).

14. Typical Characteristics for Superficial
thickness burn
–Mild to severe erythema (pink to red)
–NO BLISTERS
–Skin blanches
–Painful, tingling
–Pain responds well to cooling
–Lasts about 48 hours; healing in 3-7 days

15. 2. Deep partial-thickness injuries (second
degree burn):
• A deep partial-thickness burn involves
destruction of the epidermis and upper layers
of the dermis and injury to deeper portions of
the dermis.
• The wound is painful, appears red, and exudes
fluid.
• Capillary refill follows tissue blanching. Hair
follicles remain intact.
• Deep partial-thickness burns take longer to
heal and are more likely to result in
hypertrophic scars.

16. Typical Characteristics for deep partial
thickness burn
–Large blisters over an extensive area
–Edema
–Red base with broken epidermis
–Wet, shiny and weeping
–Sensitive to cold air
–Healing in 2-3 weeks
–Grafts MAY be needed

17. Partial thickness burn in hand

18. 3. Ful-thickness injuries (third degree burn):
• A full-thickness burn involves total destruction of
epidermis and dermis and, in some cases,
underlying tissue as well.
• Wound color ranges widely from white to red,
brown, or black. The burned area is painless
because nerve fibers are destroyed.
• The wound appears leathery; hair follicles and
sweat glands are destroyed

19. Typical Characteristics for Full-thickness burn
• Deep, red, black, white, yellow, or brown area
• Edema
• Tissue open with fat exposed
• Little to no pain
• Requires removal of eschar and skin grafting
• Scarring and contractures are likely
• Takes weeks to months to heal

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

22. RULE OF NINES
• An estimation of the TBSA involved in a burn
is simplified by using the rule of nines.
• The rule of nines is a quick way to calculate
the extent of burns.
• The system assigns percentages in multiples of
nine to major body surfaces.

25. LUND AND BROWDER METHOD
A more precise method of estimating the
extent of a burn is the Lund and Browder
method,
It recognizes that the percentage of TBSA of
various anatomic parts, especially the head and
legs, and changes with growth.

27. PALM METHOD
• In patients with scattered burns, a method to
estimate the percentage of burn is the palm
method.
• The size of the patient’s palm is approximately
1% of TBSA.

28. Criteria for Classifying the Extent of Burn
Injury(American Burn Association)
Minor Burn Injury
• Second-degree burn of less than 15% total body
surface area(TBSA) in adults or less than 10%
TBSA in children
• Third-degree burn of less than 2% TBSA not
involving special care areas (eyes, ears, face,
hands, feet, perineum, joints)
• Excludes electrical injury, inhalation injury,
concurrent trauma, all poor-risk patients (eg,
extremes of age, concurrent disease)

29. Moderate, Uncomplicated Burn Injury
• Second-degree burns of 15%–25% TBSA in
adults or10%–20% in children
• Third-degree burns of less than 10% TBSA not
involving special care areas
• Excludes electrical injury, inhalation injury,
concurrent trauma, all poor-risk patients (eg,
extremes of age, concurrent disease)

30. Major Burn Injury
• Second-degree burns exceeding 25% TBSA in
adults or 20% in children
• All third-degree burns exceeding 10% TBSA
• All burns involving eyes, ears, face, hands,
feet, perineum, joints
• All inhalation injury, electrical injury,
concurrent trauma, all poor-risk patients

32. 32
Blister may ↑size because continuous
exudation and collection of tissue fluid

33. 33
Eschar:composed of
denatured protein

34. Burn Photos
Chemical (Acid) Burns
Radiation (Flash) Burns

35. Burn Photos
Electrical Burns
Entrance Wounds
Electrical Burns
Exit Wounds
Entrance wound of electrical
burns from an overheated tool
Severe swelling
peaks 24-72 hrs after
Electrical burns mummified
1st 2 fingers later removed

36. Chemical Burn

38. Pathologic Features
• Zone of coagulation (necrosis): Superficial area of
coagulation necrosis and cell death on exposure to
temperatures >450 (primary injury)
• Zone of stasis (vascular thrombosis): Local capillary
circulation is sluggish, depending on the adequacy of the
resuscitation, can either remain viable or proceed to cell
death (secondary injury)
• Zone of hyperemia (increased capillary permeability)

40. Zone of injury
40

41. PATHOPHYSIOLOGY

42. LOCAL AND SYSTEMIC RESPONSES
TO BURNS
• Burns that do not exceed 25% TBSA produce a
primarily local response.
• Burns that exceed 25% TBSA may produce
both a local and a systemic response and are
considered major burn injuries.
• These systemic responses are due to the
release of cytokines and other mediators into
the systemic circulation and include the
following:

43. Effects of a severe burn
1. Local response include tissue edema
effects on fluid, electrolytes and blood volume
2. Cardiovascular
3. Respiratory
4. Immune
5. Integumentary
6. Gastrointestinal
7. Urinary
43

44. Cardiovascular system
• Blood pressure falls-fluid leaks from intravascular
to interstitial (sodium and protein)
• Hypotension
• tachycardia
• Blood flow in intravascular is concentrated and
cause static.
• Cardiac output ↓,
• Due to that tissue perfusion ↓,

45. Hematologic changes
• Thrombocytopenia, abnormal platelet function,
depressed fibrinogen levels, deficit plasma
clotting factors.
• Life span ↓RBC.
• Blood loss during diagnostic and therapeutic
procedure.

46. Respiration system
• Majority of deaths from fire are due to smoke
inhalation.
• Pulmonary damage can be from direct inhalation
injury or systemic respond to the injury.
• Damage to cilia and cell in the airway-
inflammation.
• Mucociliary transport mechanism not
functioning-bronchial congestion and infection.
• Pulmonary edema, fluids escape to interstitial.
• Airway obstruction

48. Gastrointestinal
• Burn >20% experience ↓peristalsis, gastric
distention and ↑risk of aspiration.
• Paralytic ileus due to secondary to burn trauma.
• Stress ulcer (stomach/duodenum) due to burn
injury.
• Indication of stress ulcer-malena stool or
hematemesis.
• These signs suggest gastric or duodenal erosion
(Curling`s ulcer)
• Gastric distention and nausea may lead to
vomiting.

49. CURLING’S ULCER
• Acute ulcerative gastro duodenal disease
• Occur within 24 hours after burn
• Due to reduced GI blood flow and
mucosal damage
• Treat clients with H2 blockers,
mucoprotectants, and early enteral
nutrition
• Watch for sudden drop in hemoglobin
4/1/2011 49

50. Immunologic changes
• Skin barrier to invading organisms s destroyed,
circulating levels of immunoglobulins are ↓
• Changes in WBC both quantitative and
qualitative.
• Depression of neutrophil, phagocytic and
bactericidal activity is found after burn injury.
• All this changes in the immune system can
make the burn patient more susceptible to
infection

51. SUMMARY

52. Diagnosis
• A detailed history and physical
examination is the first step. The
physician will evaluate the type, duration, and
timing of the burn; the burn location and
severity; and associated dehydration,
disfigurement, and infection.
• Fires in enclosed spaces should raise the
suspicion for smoke–inhalation injury.

53. Lab Tests
• Routine blood work for
a patient with a burn
injury includes a complete
blood count, platelet
count, clotting studies,
liver function studies, and
carboxyhemoglobin,
electrolyte, blood urea
nitrogen, glucose and
creatinine levels.
• Urinalysis may reveal
myoglobinuria and
hemoglobinuria.
• If pt. is 35 or older,
he’ll also need an
electrocardiogram.
• Chest x-rays and
arterial blood gas levels
allow the evaluation of
alveolar function.

54. MANAGEMENT OF THE BURN INJURY
Phases of Management
• Burn care then proceeds through three phases:
– Emergent/resuscitative phase (on-the-scene care),
– Acute/intermediate phase, and
– Rehabilitation phase.

55. Phase Duration Priorities
Emergent or
immediate
resuscitative
From onset of injury to
completion
of fluid resuscitation
 First aid
 Prevention of shock
 Prevention of respiratory distress
 Detection and treatment of
concomitant injuries
 Wound assessment and initial care
Acute From beginning of diuresis
to near
completion of wound
closure
 Wound care and closure
 Prevention or treatment of
complications, including infection
 Nutritional support
Rehabilitation From major wound closure
to return
to individual’s optimal level
of physical
and psychosocial
adjustment
 Prevention of scars and
contractures
 Physical, occupational, and
vocational rehabilitation
 Functional and cosmetic
reconstruction
 Psychosocial counseling

56. EMERGENT/RESUSCITATIVE PHASE
MGT
Emergent phase
- begins at the time of injury and ends with the
restoration of capillary permeability, usually at
48-72 hours after the injury

57. • Emergency Procedures at the Burn Scene
–Extinguish the flames
–Cool the burn
–Remove restrictive objectives
–Cover the wound
–Irrigate chemical burns

58. • Emergency Medical Management
• The patient is transported to the nearest
emergency department.
• The hospital nurses (staff) and physician are
alerted that the patient is in route to the
emergency department so that life-saving
measures can be initiated immediately by a
trained team.
• Initial priorities in the emergency department
remain airway, breathing, and circulation.

59. • For mild pulmonary injury, inspired air is
humidified and the patient is encouraged to cough
so that secretions can be removed by suctioning.
• For more severe situations, it is necessary to
remove secretions by bronchial suctioning and to
administer bronchodilators and mucolytic agents.
• If edema of the airway develops, endotracheal
intubation may be necessary.

60. • Continuous positive airway pressure and
mechanical ventilation may also be required to
achieve adequate oxygenation.
• A large-bore (16- or 18-gauge) intravenous
catheter should be inserted in a non-burned
area (if not inserted earlier).

61. Management of fluid loss and shock
Fluid Replacement Therapy:
• The total volume and rate of intravenous fluid
replacement are gauged by the patient’s response.
• The adequacy of fluid resuscitation is determined
by:
– Output totals of 30 to 50 mL/hour
– systolic blood pressure exceeding 100 mm Hg
and/or
– pulse rate less than 110/minute.

62. Burn shock

63. Fluid Requirements:
• The projected fluid requirements for the first 24
hours are calculated by the clinician based on
the extent of the burn injury.
• Some combination of fluid categories may be
used:
–Colloids (whole blood, plasma, and plasma
expanders) and
– Crystalloids/electrolytes (physiologic sodium
chloride or lactated Ringer’s solution).

64. Fluid Requirements:
• Adequate fluid resuscitation results in slightly
decreased blood volume levels during the first
24 post-burn hours and restores plasma levels
to normal by the end of 48 hours.
• Oral resuscitation can be successful in adults
with less than 20% TBSA and children with
less than 10% to 15% TBSA.

65. Guidelines and Formulas for Fluid
Replacement in Burn Patients
Consensus Formula
• Lactated Ringer’s solution (or other balanced
saline solution): 2–4 mL× kg body weight × %
total body surface area (TBSA) burned.
• Half to be given in first 8 hours; remaining
half to be given over next 16 hours.

66. • The following example illustrates use of the
formula in a management of a 70-kg patient
with a 50% TBSA burn:
• Steps
–1, Consensus formula: 2 to 4 mL/kg/% TBSA
–2, 2 × 70 × 50 = 7,000 mL/24 hours
–3, Plan to administer: First 8 hours = 3,500
mL, or 437 mL/ hour; next 16 hours = 3,500
mL, or 219 mL/hour

67. Evans Formula
• 1. Colloids: 1 mL × kg body weight × % TBSA burned
• 2. Electrolytes (saline): 1 mL × body weight × % TBSA
burned
• 3. Glucose (5% in water): 2,000 mL for insensible loss
• Day 1: Half to be given in first 8 hours; remaining half
over next 16 hours
• Day 2: Half of previous day’s colloids and electrolytes;
all of insensible fluid replacement
• Maximum of 10,000 mL over 24 hours. Second- and
third-degree
• (partial- and full-thickness) burns exceeding 50% TBSA
are calculated
• on the basis of 50% TBSA.

68. Brooke Army Formula
• 1. Colloids: 0.5 mL × kg body weight × %
TBSA burned
• 2. Electrolytes (lactated Ringer’s solution): 1.5
mL × kg body weight × % TBSA burned
• 3. Glucose (5% in water): 2,000 mL for
insensible loss

69. Parkland/Baxter Formula
• Lactated Ringer’s solution: 4 mL × kg body
weight × % TBSA burned
• Day 1: Half to be given in first 8 hours; half to
be given over next16 hours
• Day 2: Varies. Colloid is added.

70. Hypertonic Saline Solution
• Concentrated solutions of sodium chloride (NaCl)
and lactate with concentration of 250–300 mEq of
sodium per liter, administered at a rate sufficient
to maintain a desired volume of urinary output.
• Do not increase the infusion rate during the first 8
post burn hours.
• Serum sodium levels must be monitored closely.
• Goal: Increase serum sodium level and osmolality
to reduce edema and prevent pulmonary
complications.

71. Nursing management
Includes:
• infection prevention,
• wound cleansing and
• administering topical antibacterial drugs like:
– Silver sulfadiazine 1% (Silvadene)
– watersoluble cream,
– Silver nitrate 0.5% aqueous solution,
– Mafenide acetate 5% to 10% (Sulfamylon)
hydrophilic-based cream,
– Acticoat, etc

72. ACUTE PHASE
- Begins when the client is hemodynamically
stable, capillary permeability is restored, and
diuresis has begun
- Usually begins 48 - 72 hours after the time of
injury

73. - Emphasis during this phase is placed on
restorative therapy, and the phase continues
until wound closure is achieved
- The focus is on infection control, wound care,
wound closure, nutritional support, pain
management, and physical therapy

74. Pathophysiology
• Diuresis from fluid mobilization occurs, and
the patient is no longer grossly edematous
• Bowel sounds return
• Healing begins
• Formation of granulation tissue
• A partial-thickness burn wound will heal from
the edges
• Full-thickness burns must be covered by skin
grafts

75. • Wound Care
• Daily observation
• Assessment
• Cleansing
• Debridement
• Appropriate coverage of the graft:
– Fine-mesh gauze next to the graft followed by
middle and outer dressings
– Sheet skin grafts must be kept free of
blebs (small blisters)

76. Excision and Grafting
• Eschar is removed down to the subcutaneous
tissue or fascia
• Cultured Epithelial Autographs (CEA): CEA is
grown from biopsies obtained from the
patient’s own skin
• Artificial Skin: used when life-threatening full-
thickness or deep partial-thickness wounds
where conventional autograft is not available
or advisable

77. Pain Management
• Opioid every 1 to 3 hours for pain
• Several drugs in combination
• Morphine with haloperidol
• Nonpharmacologic strategies
• Relaxation tapes
• Visualization, guided imagery
• Meditation

78. Acute Phase management
Debriding Full-Thickness Burn
78

79. Acute Phase management
Surgeon Harvesting Skin
79

80. Acute Phase management
Donor Site After Harvesting
80

81. Acute Phase management
Application of Cultured Epithelial Autograft
81

82. REHABILITATION PHASE
• The rehabilitation phase is defined as
beginning when the patient’s burn wounds are
covered with skin or healed and the patient is
able to resume a level of self-care activity
• Complications
– Skin and joint contractures
– Hypertrophic scarring
82

83. Rehabilitation Phase
• Both patient and family actively learn how to
care for healing wounds
• Cosmetic surgery is often needed following
major burns
• Role of exercise cannot be overemphasized
• Constant encouragement and reassurance
• Address spiritual and cultural needs
• Maintain a high-calorie, high-protein diet
• Occupational therapy 83

85. Definitions
Graft
• A skin graft is a tissue of epidermis and varying
amounts of dermis that is detached from its own
blood supply and placed in a new area with a new
blood supply.
• Skin graft is a segment of skin separated from the
donor site and transplanted to the recipient site
devoid of its blood supply

86. Indications for Grafts
• Extensive wounds.
• Burns.
• Specific surgeries that may require skin grafts
for healing to occur.
• Areas of prior infection with extensive skin
loss.
• Cosmetic reasons in reconstructive surgeries.

87. Classification of Grafts
1. Autografts – A tissue transferred from one
part of the body to another.
2. Homografts/Allograft – tissue transferred
from a genetically different individual of the
same species.
3. Iso grafts: genetically identical donor-twins
4. Xenografts – a graft transferred from an
individual of one species to an individual of
another species.

88. Types of Grafts
Grafts are typically described in terms of thickness or
depth.
Split Thickness(Partial): Contains 100% of the epidermis
and a portion of the dermis. Split thickness grafts are
further classified as thin or thick.
Full Thickness: Contains 100% of the epidermis and
dermis.

89. Split Thickness
Used when cosmetic appearance is not a
primary issue or when the size of the wound
is too large to use a full thickness graft.
1. Chronic Ulcers
2. Temporary coverage
3. Correction of pigmentation disorders
4. Burns

90. Split thickness Skin Graft
• Advantages
– Can tolerate less than ideal conditions for survival
– Used to resurface large wounds, line cavities,
resurface mucosal deficits, close donor sites of
flaps, and resurface muscle flaps
– Can be used to achieve temporary closure
– Donor sites heal spontaneously
– Donor sites may be reharvested

91. Split thickness Skin Graft
• Disadvantages
– More fragile, especially over areas with little underlying
bulk
– They contract more during healing
– Do not grow with the individual
– Tend to be smoother, thinner & shinier than normal skin
– They tend to be abnormally pigmented & lack hair
growth
– more functional than cosmetic.
– produce an undesirable masklike appearance on the face
– The wound created at the donor site is often more
painful than the recipient site

92. Full Thickness
Indications for full thickness skin grafts include:
1. If adjacent tissue has premalignant or malignant
lesions and precludes the use of a flap.
2. Specific locations that lend themselves well to
FTSGs include the nasal tip, forehead, eyelids,
medial canthus, concha, and digits.

93. Full Thickness Skin Graft
• Advantages
– Nearly all qualities of normal skin (color, texture and
thickness)
– Resistant to trauma
– Sensation is good
– Esthetically is good
• Ideal for visible areas of the face
– Undergo less contraction while healing
• This is important on the face as well as on the hands and
over mobile joint surfaces.
– In children are more likely to grow with the individual

94. Full Thickness Skin Graft
• Disadvantages
– limited to relatively small, uncontaminated, well-
vascularized wounds
– Do not have as wide a range of application as
split-thickness grafts
– Donor sites must be closed primarily or resurfaced
with a split-thickness graft from another site

95. Type of Graft Advantages Disadvantages
Thin Split
Thickness
-Best Survival
-Heals Rapidly
-Least resembles original skin.
-Least resistance to trauma.
-Poor Sensation
-Maximal Secondary
Contraction
Thick Split
Thickness
-More qualities of normal
skin.
-Less Contraction
-Looks better
-Fair Sensation
-Lower graft survival
-Slower healing.
Full
Thickness
-Most resembles normal
skin.
-Minimal Secondary
contraction
-Resistant to trauma
-Good Sensation
-Aesthetically pleasing
-Poorest survival.
-Donor site must be closed
surgically.
-Donor sites are limited.

96. Donor Sites selection
The ideal donor site would provide skin that is
identical to the skin surrounding the recipient area.
- Colour
- Thickness
- Hair
- Texture
Acute phase of burns-- STSG

97. Donor site selection
• Split-thickness skin grafts
– are commonly harvested from the thigh, buttocks,
abdominal wall, or scalp
– The method of harvesting the split-thickness skin graft
depends primarily on the size and thickness needed for
coverage
• Full-thickness skin grafts
– taken from the supraclavicular pre- or postauricular areas
provide a suitable color match for defects of the face
– Taken from body creases allowing primary closure and
hidden scars

98. Harvesting Tools
• Razor Blades
• Grafting Knives (Blair, Ferris, Smith, Humbly, Goulian)
• Manual Drum Dermatomes (Padgett, Reese)
• **Electric/Air Powered Dermatomes (Brown,
Padgett, Hall)
Electric & Air Powered tools are most commonly used.

99. Padgett Dermatome

100. Goulian Blade

101. STSG Harvesting
• Dermatome
– Uniform thickness (set width
and thickness)
– Fast
– Must be familiar with
equipment
– 15 blade scalpel simulates
0.015 inches
• Free hand with scalpel
– Variable thickness
– Irregular edges

102. STSG

103. FTSG

104. Meshing of grafts

105. Grafting…..,
• Preparation of the wound
• Fixation of the graft
• Vascularization of the graft

106. NURSING MANAGEMENT
• Maintain patent airway/respiratory function.
• Restore hemodynamic stability/circulating
volume.
• Alleviate pain.
• Prevent complications.
• Provide emotional support for patient/significant
other (SO).
• Provide information about condition, prognosis,
and treatment.

107. • Provide humidified oxygen, and monitor
arterial blood gases (ABGs), pulse oximetry,
and carboxyhemoglobin levels.
• Assess breath sounds and respiratory rate,
rhythm, depth, and symmetry; monitor for
hypoxia.

108. • Monitor vital signs and urinary output (hourly),
central venous pressure (CVP), pulmonary artery
pressure, and cardiac output.
• Note and report signs of hypovolemia or fluid
overload.
• Maintain IV lines and regular fluids at appropriate
rates, as prescribed. Document intake, output,
and daily weight.
• Elevate the head of bed and burned extremities.

109. • Administer IV opioid analgesics as prescribed,
and assess response to medication; observe
for respiratory depression in patient who is
not mechanically ventilated.
• Provide emotional support, reassurance, and
simple explanations about procedures.

110. • Assess wound status.
• Support patient during distressing and painful
wound care.
• Monitor IV and oral fluid intake; use IV
infusion pumps.
• Measure intake and output and daily weight.
• Report changes (e.g., blood pressure, pulse
rate) to physician.

111. • Support and address the verbal and nonverbal
concerns of the patient and family.
• Instruct family in ways to support patient.
• Make psychological or social work referrals as
needed.

112. NURSING DIAGNOSIS
• Impaired gas exchange related to carbon
monoxide poisoning, smoke inhalation, and
upper airway obstruction.
• Ineffective airway clearance related to edema
and effects of smoke inhalation.
• Fluid volume deficit related to increased capillary
permeability and evaporative losses from burn
wound.
• Hypothermia related to loss of skin
microcirculation and open wounds.

113. • Pain related to tissue and nerve injury.
• Anxiety related to fear and the emotional
impact of burn injury.