it consist definition, types of burn, its cause, scales to measure degree of burn, first aid management and supportive management along with rehabilitation therapy.

1. MS. BHARTI SHARMA
NURSING TUTOR
BECON, JAMMU.

2. BURNS
 Injuries that result from direct contact
with or exposure to any thermal,
chemical or radiation sources.
 Burns occurs when energy from heat
source is transferred to the tissues of
the body.

3. ETIOLOGY
 Thermal burns
 Chemicals
 Electricity
 Radiations
 Inhalation injuries

4. THERMAL BURNS
 These are caused by exposure to or
contact with flame, hot liquids, semi
liquids (steam), semi-solid (tar) or hot
objects.
CHEMICAL BURNS
 It is caused by contact of tissue to any
strong acids, alkalis or organic
compounds.

5. ELECTRICAL BURNS
 These are the injuries caused by heat
that is generated by the electrical energy
as it passes through the body.
 It can result from contact with exposed
or faulty electrical wiring or high voltage
power lines.
 People struck by lightening also sustain
electrical injury.

6. RADIATION BURNS
 These are caused by exposure to
radioactive source.
 E.g.
 Nuclear- radiation accidents.
 Use of ionizing radiation in industries
 Therapeutic radiations
 Sunburns from prolonged exposure to
ultraviolet rays.

7. INHALATION INJURIES
 It may result from exposure to asphyxiants
and smoke, if the victim was trapped in
closed, smoke – filled area.
 It results in pulmonary pathophysiologic
changes.

8. BURN DEPTH
 Tissue damage due to burns is determined
by:
 Extent of burn
 Depth of burn

9. EXTENT OF BURNS
 The total body surface area (TBSA), can be
determined by :
 Rule of nines

10. RULE OF NINES
 The rule of nines assesses the percentage of
burn.
 It is used to help guide treatment decisions
including fluid resuscitation and becomes
part of the guidelines to determine transfer to
a burn unit.

11. Measuring extent of burns according
to Rule on nines
ANTERIOR POSTERIOR TOTAL
(anterior +
posterior)
Head and neck 4.5% Head and neck 4.5% 9%
Upper limbs 9% Upper limbs 9% 18%
Trunk 18% Trunk 18% 36%
Lower limbs 18% Lower limbs 18% 36%
Perineum 1%

12. RULE OF NINES

13. DEPTH OF BURN
 1st degree burns
 2nd degree burns
 3rd degree burns
 4th degree burns

15. Names
Layers
involved
Appearance Texture Sensation
Time to
healing
Complication
s
Example
First degree Epidermis
Redness
(erythema)
Dry Painful 1wk or less
Increased
risk to
develop skin
cancer later
in life
Second
degree
(superficial
partial
thickness)
Extends into
superficial
(papillary) d
ermis
Red with
clear blister.
Blanches
with
pressure
Moist Painful 2-3wks
Local
infection/cell
ulitis
Second
degree
(deep partial
thickness)
Extends into
deep
(reticular)
dermis
Red-and-
white with
bloody
blisters.
Moist Painful
Weeks -
may
progress to
third
degree
Scarring,
contractures
(may require
excision
and skin
grafting)
Third degree
(full
thickness)
Extends
through
entire
dermis
Stiff and
white/brown
Dry, leathery Painless
Requires
excision
Scarring,
contractures,
amputation
Fourth
degree
Extends
through
skin, subcut
aneous
tissue and
into
underlying
muscle and
bone
Black;
charred
with eschar
Dry Painless
Requires
excision
Amputation,
significant
functional
impairment,
possible gang
rene, and in
some cases
death.

16. 1st degree burns
 It involves epidermal layers of skin.
 The skin remains intact.
 Patient may have local pain and
erythema.
 Blisters may form in first 24 hours.

17.  C/M :
 Headache,
 pain,
 nausea and vomiting.
It heals in 3 – 5 days.

18. 2nd degree burns
 It can be classified into :
1. Superficial burns
2. Deep or partial - thickness burns

19.  SUPERFICIAL BURNS:
 It involves epidermal or dermal layer.
 It is red in color.
 Blisters forms immediately.
 Pain is present at the site of injury.
 It heals in 21 – 28 days.

20.  DEEP BURNS:
 In deep burns there is destruction of entire
dermal layer of skin.
 A flat dry blisters forms.
 Pain is absent or dull.
 It heals in one month.
 Wound excision or skin grafting may be needed.

21. 3rd degree burns
 These are also known as full thickness
burns.
 It involves all layers of skin and
subcutaneous tissues.
 The wound appears white, cherry red or
black in color.

22.  Skin looses its elasticity and results in
leathery appearance.
 It is painless.
 Superficial thrombosed blood vessels
are evident.

23. 4th degree burns
 It involves all layers of underlying
tissues including bones, blood vessels,
muscle and nerves.
 It requires skin grafting.
 Takes long time for healing.

24. SEVERITY OF BURN
INJURY
 The American burn association has
established severity classification schedule for
burn:
 Major burn injury:
 25 % TBSA in adult < 40 years of age.
 20% TBSA in adults > 40 years of age
 20 % TBSA in children < 10 years of age.
(TBSA – total body surface area)

25. OR
 Burn involving the face, eye, ears, hands ,
feet and perineum.
OR
 High voltage electric burn injury.

26. Moderate burn injury
 15%-25% TBSA in adult < 40 yrs of age
 10%-20% TBSA in adults> 40 yrs of age
 10%-20% TBSA in children < 10 yrs of age

27. Minor burn injury
 Less than 15% TBSA in adults < 40 yrs
 Less than 10% TBSA in adults > 40 yrs
 Less than 10% TBSA in children < 10 yrs

28. CLINICAL MANIFESTATIONS
OF BURNS
1. Fluid and electrolyte imbalance like
hyperkalaemia, Hyponatraemia occurs
immediately after burns.
 Generalized body edema is seen in patients
with greater than 25% burns.

29.  Increased hematocrit level.
 After 18 – 36 hours capillary membrane
integrity begins to be restored.
 The body begins to reabsorb edema,
fluid and excess fluid is excreted.

30. 2. Alteration in respiration
 It depends upon type of burns.
 Manifested by dyspnea, rapid breathing ,
cyanosis, stridor.
 Thermal burns to the upper airway (mouth,
nasopharynx and larynx) leads to mucosal
edema, blisters, ulceration leading to upper
airway obstruction.

31. 3. Cardiac alterations
 Hypovlemia occurs immediately after the
burns.
 Cardiac output decreases.
 Decrease in blood pressure.
 Anemia may occur as a result of
damage to RBC’s.

32. 4. Pain
 Burn patients experiences two types of pain.
 Background pain and procedural pain.
 Background pain is experienced when
patient is at rest.
 Procedural pain is experienced during the
performance of therapeutic procedures like
dressing, cleaning, etc.

33. 5. Thermoregulatory alterations:
 Loss of skin results in an inability to
regulate body temperature.
 Patients may exhibit low body
temperatures in the early hours after
injury.

34. 6. Loss of consciousness due to neurological
trauma.

35.  Psychological trauma:
Period of impact:
It begins immediately after injury
characterized by shock, disbelief, feeling
of being overwhelmed.
Retreat phase:
Characterized by repression, withdrawal,
denial ,suppression.

36.  Acknowledgement phase:
Client accepts the injury and the
changes in the body image.
 Reconstructive phase:
It begins when the patient and family
accepts the limitations imposed by the
injury and begins to plan realistically for
the future.

37. PRE- HOSPITAL CARE
 THERMAL BURNS:
 Lavage with water.
 Assist the patient to drop and roll.
 Cover body to prevent hypothermia.

38.  CHEMICAL BURNS:
 Remove cloths.
 Use shower to lavage the involved area.

39.  ELECTRIC BURNS:
 Disconnect the source of electric
current.
 Monitor cardio pulmonary arrest.
 Begin CPR if patient is unresponsive.
 Place patient on spinal board and apply
cervical collar and transport.

40. MEDICAL MANAGEMENT
 There are three phases of treatment in
care of the burn patients.
 These are:
 Emergent / Resuscitative phase
 Acute phase
 Rehabilitation phase

41.  EMERGENT / RESUSCITATIVE PHASE:
This phase lasts for 36 - 48 hours from the
onset of injury.
 ACUTE PHASE: This phase begins with
diuresis and ends with closure of the burn
wound.
 REHABILITATION PHASE: This phase
begins with wound closure and ends when
client returns to the highest level of health.

42. EMERGENT PHASE
 It lasts for 36– 48 hours after the onset
on the burn injury.
 It ends when fluid resuscitation is
complete.
 The management of burn patient begins
at the scene of accident.

43.  Remove the patient from the area of
danger.
 Stop the burning process.
 Implement basic life support.

44. Medical management of
emergent phase
 Assess the burn severity.
 Assess the burn depth.
 Assess burn extent using rules of nine
 Assess location of burn
 Identify the mechanism of injury.

45.  Treatment of minor burns:
 Wound evaluation and initial care
 Tetanus toxoid immunization
 Pain management

46.  TREATMENT OF MAJOR BURNS:
Initial goals are :
 Saving life
 Maintaining and protecting airway
 Restoring hemodynamic stability
Later goals:
 Replacement of missing skin.
 Promoting healing
 Assessing and correcting complications.

47. 1. Monitor airway and
breathing
 Maintaining patent airway and breathing
are of prime importance.
 Inspect oropharynx for erythema,
blisters, ulcerations and need for
endotracheal intubation.
 In inhalation injury administer 100% O2
via tight fitting mask.

48. 2. Preventing burn shock
 In adults with > 15% burn fluid resuscitation is
required.
 2 large bore needles are inserted intravenously.
 Fluid resuscitation is used to minimize the harmful
effect of fluid shift.
 The main goal is to maintain vital organ
perfusion.

49.  Formula for calculating the fluid:
 CONSENCES FORMULA:
 RL 2-4 ml / Kg / % TBSA
 In 1st 8 hrs first half of the amount
 In next 8 hrs ¼ of total amount
 In next 8 hrs ¼ of the total

50.  For example:
70 kg patient with 50% TBSA burn
 RL to be administered is…….
 2 * 70 * 50 = 7000 ml in 24 hrs.
 In 1st 8 hrs 3500 ml
 Next 8 hrs 1750 ml
 Next 8 hrs 1750 ml

51. Exercise:
 A 45 kg patient comes to emergency
with 25% TBSA burn. Find out the
amount of fluid to be administered using
Consensus formula.
 RL to be administered :
2 * 45 *25 = 2250 ml
 In first 8 hrs – 1125 ml
 In next 8 hrs- 562.5
 In next 8 hrs- 562.5

52.  EVAN’S FORMULA:
 Electrolytes or saline- 1ml / kg / % TBSA
 Colloids- 1ml / kg / % TBSA + 2000ml
dextrose in H2O.

53.  Day 1 – half of the amount to be given in 1st 8
hrs.
 Remaining half over next 16 hours.
 Day 2 – Half of the colloids and electrolytes.

54.  For example:
70 kg patient with 50% TBSA burn
 Electrolytes or saline to be administered:
1 * 70 * 50 = 3500 ml
 Colloids to be administered :
1 * 70 * 50 + 2000
3500 + 2000 = 5500 ml.

55. BROOKE ARMY
FORMULA
 Colloids – 0.5 ml * kg body wt * % TBSA burn
 Electrolytes (RL) 0.5 ml * kg body wt* % TBSA
 GLUCOSE (5% in H2O) ; 2000ml for
insensible loss.

56.  Day 1 – half to be given in 1st 8 hours.
 Remaining half over next 16 hrs.
 Day 2 – half of colloids and half of
electrolytes.

57. PARKLAND / BAXTER
FORMULA
 RL – 4 ml * kg body wt * % TBSA burned
 Day 1 – half to be given in 1st 8 hrs, rest
half to be given over next 16 hours.
 Day 2 – colloids are added 0.3 – 0.5 ml / kg
body wt / % TBSA.

58.  Colloid solutions are not administered in
first 24 hours period. They are
administered after 24 hours.
 Adequacy of fluid resuscitation is assessed
by urine output.
 Indwelling catheter is inserted for keeping
accurate monitoring of output.

59.  Vital signs are monitored frequently.
 Base line laboratory studies, BUN,
Serum creatnine, serum electrolytes and
hematocrit level.
 ECG monitoring , ABG analysis and
chest X- ray.

60. 3.PREVENTING
ASPIRATION
 Nasogastric tube is placed to prevent
vomiting and reduce the risk of
aspiration which occur due to GI
dysfunction resulting from the intestinal
ileus or paralytic ileus.

61. 4. MINIMIZING PAIN
 Pain management in moderate or major
burns is achieved through IV
administration of opoids like morphine
sulphate.

62. 5. WOUND CARE
 Immediate care
 Cover the wound with sterile towel and
place on clean dry sheet.

63.  Wound care for burns consists of :
 Cleansing
 Debridement
 Application of topical agents
 dressing

64. 6. Preventing tetanus: immunization with
tetanus toxoid.

65. 7. Preventing tissue ischemia:
 Elevate the injured extremity above the
level of heart and perform active
exercises to reduce dependent edema
formation.
 Immediately assess the distal extremity
perfusion.

66. Nursing diagnosis in emergent
phase
 Impaired gas exchange related to carbon
mono oxide intoxication, smoke inhalation
and upper airway obstruction.
GOAL: Maintenance of adequate tissue
oxygenation

67.  Ineffective airway clearance related to edema
and effect of smoke inhalation.
GOAL: Maintain patent airway.
 Fluid volume deficit related to increased
capillary permeability and evaporation losses
from the burn wound.
GOAL: Restoration of optimal fluid and
electrolyte balance and perfusion of vital
organs.

68.  Hypothermia related to loss of skin
microcirculation and open wound.
GOAL: Maintenance of adequate body
temperature.
 Pain related to tissue and nerve injury and
emotional impact of injury.
GOAL: Control of pain

69. ACUTE PHASE /
INTERMEDIATE PHASE
 Acute phase begins when the patient is
hemodynamically stable, capillary
permeability is restored and diuresis
begins.

70.  This is generally considered to be at 48
– 72 hours after the time of burn injury.
 This phase continues until the wound
closure is achieved.

71. The management includes
 Wound cleansing
 Topical antimicrobial therapy
 Wound dressing
 Wound debridement
 Grafting burn wound
 Pain management
 Infection control
 Nutrition therapy

72. 1. Wound cleansing
 It is done with the help of hydrotherapy.
 Hydrotherapy is a form of shower carts.
 Individual showers and bed baths can
be used to clean the wounds.

73.  The temperature of the water is
maintained at 37.8 0 C.
 The temperature of the room should be
maintained between 26.6 0 C to 29.4 0 C.
 Hydrotherapy should be limited to 20 – 30
minutes period to prevent chilling of the
patient.

74.  Patient is encouraged to perform active
exercises of extremities during
hydrotherapy.
 Cross infection should be prevented by
changing the plastic lining place inside the
bathtub.
 Vital signs are monitored before and after
hydrotherapy.

75. 2. TOPICAL ANTIBACTERIAL
THERAPY
 It reduces the number of bacteria on the
burn wound.
 It promotes conversion of open, dirty
wound to a closed, clean wounds.
 E.g.
 Silver Nitrate
 Mafenide acetate
 Silver sulfadiazine

76. 3. WOUND DRESSING
 When the wound is cleaned the burned
areas are patted dry and the topical
agent is applied, the wound is covered
with the several layers of dressings.
 A light dressing is used over joint areas
to allow for motions.

77.  Dressing is changed 20 minutes after
giving analgesics.
 All PPE are used while dressing.

78. 4. WOUND DEBRIDEMENT
 It is done to….
 Remove tissues contaminated by
bacteria and foreign bodies.
 To remove devitalized tissue or burn
eschar in preparation for grafting and
wound healing.

79. DEBRIDEMENT
NATURAL
MECHANICAL
SURGICAL

80. 5. GRAFTING OF THE
WOUND
 Grafting is done when wounds are deep
or extensive or re- epithelialization is not
possible.
 Patient’s own skin is used for graft.

81.  The purpose is to……..
Decrease the risk for infection
To prevent the loss of proteins,
fluids and electrolytes through
the wound
To minimize heat loss

82. ADVANTAGE
 It permits earlier functional ability and
reduces contractures.
 It fills the space created by the wound,
creates a barrier to bacteria and serves
as a bed for epithelial cell growth.

83. TYPES OF GRAFTS
BIOLOGICAL
GRAFTS
BIOSYNTHETIC
AND SYNTHETIC
DERMAL
SUBSTITUTES
AUTOGRAFTS
CULTURED
EPITHELIAL
AUTOGRAFTS

84. BIOLOGICAL GRAFTS
 Provides temporary wound closure.
 Protects granulation tissue until auto grafting is
possible.
 Used in patients with extensive burns.
 It is of two types:
 Homograft (Allograft)
 Heterograft

85.  Homograft : These are obtained from
skin of any living or recently dead
humans.
 Amniotic membrane of placenta may
also be used for homograft.
 Heterografts : These consists of skin
taken form animals (pigs).

86.  Most biologic dressings are used as
temporary coverings of burn wounds
and are eventually rejected by the
body’s immune reaction to them as
foreign.

87. BIOSYNTHETIC AND SYNTHETIC
DRESSINGS
 Biobrane is most commonly used.
 It is composed of nylon, siliastic membrane
with collagen derivative.
 It protects wound from fluid loss and
bacterial invasion.

88. DERMAL SUBSTITUTES
 They enhance the healing process of an
open wound when autologous skin is
unavailable or limited for use.
 Examples of dermal substitutes are:
 Integra (artificial skin)
 Alloderm

89.  INTEGRA / ARTIFICIAL SKIN
 It is composed of two layers….
 The epidermal layer made up of silicon
which acts as a bacterial barrier and
prevents water loss from the skin.
 The dermal layer which is made up of
animal collagen. It is adhered to the wound
surface and helps in epithelialization.

90.  Alloderm:
 It is processed dermis from human cadaver
skin, which can be used as the dermal layer for
skin grafts.
 Its use allows the surgeon to harvest a thinner
skin graft from patient’s own body, consisting
the epidermal layer only.
 The patient’s epidermal later is placed directly
over the alloderm base.

91. AUTOGRAFTS
 Autografts are the preferred material for
definitive burn wound closure.
 Patient’s own skin is taken for closing the
burn wound.
 The main advantage is that they are not
rejected by the patient’s immune system.

92. Care of the graft site
 Dressings are applied over the grafts to
immobilize.
 Splints may be used for immobilization.
 The first dressing is usually performed 2 – 5
days after surgery or earliest in the case of
purulent drainage or foul odor.

93.  Patient should be positioned and turned
carefully to avoid disturbing the graft or
putting pressure on the graft site.
 If an extremity has been grafted, it is
elevated to minimize edema.
 Patient is advised to exercise the grafted
area 5 – 7 days after grafting.

94. Cultured epithelial autograft
 It provides permanent coverage of large
wounds.
 Biopsy of patient’s skin is taken from
unburned area.

95.  Epithelial cells are cultured in the
laboratory.
 Epithelial cells multiplies to 10,000 times in
30 days.
 These cells are then attached to the burn
wounds.

96. 6. PAIN MANAGEMENT
 Burn patients experiences severe pain.
 Morphine sulfate is administered IV.
 Fentanyl may be used in procedural pain.

97. 7. INFECTION CONTROL
 Strict sterile technique is used for wound
care procedures.
 Provide safe and clean environment to
the patient.
 Use of PPE.
 Invasive lines and tubing must be
routinely changed.
 Regular changing of linen.

98. 8. NUTRITIONAL
SUPPORT
 Burn injuries produce profound metabolic
abnormalities.
 Patient’s metabolic demands vary with the
extent of burns.
 The goal of nutritional support is to
promote a state of positive nitrogen
balance.

99.  High protein, lipid and carbohydrate diet
should be given to the patient.
 Curreri formula can be used to estimate
energy requirement.
 Energy requirement =
(25 kcal * kg body weight) + (40 kcal * %
TBSA burn)

100.  Method for delivering nutritional support
include oral intake, enteral tube feeding ,
TPN and Parenteral nutrition.
 These may be used alone or in combination.

101. NURSING DIAGNOSIS
 Excessive fluid volume related to
resumption of capillary integrity and fluid
shift form the interstitial tot eh
intravascular compartment.
 Risk of infection related to loss of skin
barrier and impaired immune response.

102.  Imbalanced nutrition, less than body
requirements related to hyper
metabolism and wound healing needs.
 Impaired skin integrity related to open
burn wounds.
 Acute pain related to burn wounds and
procedures.

103. REHABILITATION PHASE
 Rehabilitation should begin immediately
after the burn has occurred.
 Wound healing, psychosocial support
and restoration of maximal functional
activity remain priorities so that the
patient can have the best quality of life
both personally and socially.

104.  Reconstructive surgery may be done to
improve body appearance and function.
 Psychological counseling may be done to
promote recovery and quality of life

105. NURSING DIAGNOSIS
 Disturbed body image related to altered
physical appearance and self concept.
 Activity intolerance related to pain on
exercise, limited joint mobility.
 Deficient knowledge about post discharge
home care and follow up.