Prof.Dr.Chinna Chadayan.N
RN.RM., B.Sc (N)., M.Sc (N)., Ph.D (N).,
Professor,
Adult and Elderly Health Nursing Department,
Enam Nursing College – Savar,
1st yr M.Sc (N)
2nd batch
Unit – 20.3b AEN Specialty
1

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.
Definition
A burn is an injury to the skin or other organic
tissue primarily caused by heat or due to radiation,
radioactivity, electricity, friction or contact with
chemicals. 2

ETIOLOGY
⦿Thermal burns
⦿Chemicals
⦿Electricity
⦿Radiations
⦿ Inhalation injuries
3

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.
CHEMICAL BURNS
THERMAL BURNS
4

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.
ELECTRICAL BURNS
5

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.
RADIATION BURNS
6

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.
7

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

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

ASSESSMENT OF BURNS
•PALMAR METHOD
•WALLACE RULE OF NINES
•LUND AND BROWDER METHOD
10

PALMAR METHOD
11

WALLA
CE
12

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%
13

14

DEPTH OF BURN
⦿ 1st degree burns
⦿ 2nd degree burns
⦿ 3rd degree burns
⦿ 4th degree burns
15

16

Names
Layers
involved
Appearance Texture Sensation
Time to
healing
Complication
s
Example
First degree Epidermis
Redness
(erythema)
Dry Painful
Increased
risk to
1wk or less develop skin
cancer later
in life
Second
degree
(superficial
partial
thickness)
superficial
(papillary) d
ermis
Extends into Red with
with
Blanches
pressure
clear blister.
Moist Painful 2-3wks
Local
infection/cell
ulitis
Second
degree deep
(deep partial (reticular)
thickness) dermis
Extends into Red-and-
white with
bloody
blisters.
Moist Painful
Weeks -
may
third
degre
e
Scarring,
contractures
progress to (may require
excision
and skin
grafting)
(full
thickness)
Third degree 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. 17

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.
18

 C/M :
⦿Headache,
⦿ pain,
⦿nausea and vomiting.
It heals in 3 – 5 days.
19

2nd degree burns
⦿It can be classified into :
1. Superficial burns
2. Deep or partial - thickness burns
20

 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.
21

⦿ 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.
22

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.
23

⦿Skin looses its elasticity and results in
leathery appearance.
⦿It is painless.
⦿Superficial thrombosed blood vessels
are evident.
24

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.
25

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.
⦿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.
26

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.
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.
27

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.
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.
28

PRE- HOSPITAL CARE
⦿THERMAL BURNS:
 Lavage with water.
 Assist the patient to drop and roll.
 Cover body to prevent hypothermia.
⦿CHEMICAL BURNS:
 Remove cloths.
 Use shower to lavage the involved area.
⦿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.
29

MEDICAL MANAGEMENT
⦿There are three phases of treatment in
care of the burn patients.
⦿These are:
⦿ Emergent / Resuscitative phase
⦿Acute phase
⦿Rehabilitation phase
30

⦿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.
31

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.
⦿Remove the patient from the area of danger.
⦿Stop the burning process.
⦿Implement basic life support.
32

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.
33

 Treatment of minor burns:
⦿Wound evaluation and initial care
⦿Tetanus toxoid immunization
⦿Pain management
 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. 34

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.
35

2. Preventing burn shock
⦿In adultswith> 15%burnfluidresuscitation is
required.
⦿2 largeboreneedlesareinsertedintravenously.
⦿Fluidresuscitation is usedto minimizetheharmful
effect of fluid shift.
⦿The main goal is to maintain vital organ
perfusion.
36

⦿ Formula for calculating the fluid:
⦿ CONSENCES FORMULA:
 RL 2-4 ml / Kg / % TBSA
⦿In 1st 8 hrs
⦿ In next 8 hrs
⦿ In next 8 hrs
first half of the amount
¼ of total amount
¼ of the total
37

⦿For example:
70 kg patient with 50% TBSA burn
⦿RL to be administered is…….
7000 ml in 24 hrs.
 2 * 70 * 50 =
⦿In 1st 8 hrs
⦿ Next 8 hrs
⦿ Next 8 hrs
3500 ml
1750 ml
1750 ml
38

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
39

⦿EVAN’S FORMULA:
⦿ Electrolytes or saline- 1ml / kg / % TBSA
⦿Colloids- 1ml / kg / % TBSA + 2000ml
dextrose in H2O.
40

⦿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.
41

⦿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.
42

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.
43

⦿ 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.
44

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.
45

⦿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.
46

⦿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.
47

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.
4. MINIMIZING PAIN
⦿Pain management in moderate or major
burns is achieved through IV
administration of opoids like morphine
sulphate.
48

5. WOUND CARE
⦿Immediate care
⦿Cover the wound with sterile towel and
place on clean dry sheet.
⦿ Wound care for burns consists of :
⦿Cleansing
⦿Debridement
⦿Application of topical agents
⦿dressing
49

6. Preventing tetanus: immunization with tetanus
toxoid.
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.
50

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
⦿ 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.
⦿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
51

ACUTE PHASE /
INTERMEDIATE PHASE
⦿Acute phase begins when the patient is
hemodynamically stable, capillary
permeability is restored and diuresis
begins.
52

⦿ 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.
53

The management includes
⦿Wound cleansing
⦿ Topical antimicrobial therapy
⦿Wound dressing
⦿Wound debridement
⦿Grafting burn wound
⦿Pain management
⦿Infection control
⦿Nutrition therapy
54

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.
55

⦿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.
56

⦿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.
57

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
58

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.
59

⦿Dressing is changed 20 minutes after
giving analgesics.
⦿ All PPE are used while dressing.
60

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.
61

DEBRIDEMENT
NATURAL
MECHANICAL
SURGICAL
62

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.
63

⦿ 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
64

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.
65

TYPES OF GRAFTS
BIOLOGICAL
GRAFTS
BIOSYNTHETIC
AND SYNTHETIC
DERMAL
SUBSTITUTES
AUTOGRAFTS
CULTURED
EPITHELIAL
AUTOGRAFTS
66

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
67

⦿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).
68

⦿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.
69

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.
70

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
71

⦿ 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.
72

⦿ 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.
73

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.
74

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.
75

⦿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.
76

Cultured epithelial autograft
⦿It provides permanent coverage of large
wounds.
⦿Biopsy of patient’s skin is taken from
unburned area.
77

⦿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.
78

6. PAIN MANAGEMENT
⦿Burn patients experiences severe pain.
⦿Morphine sulfate is administered IV.
⦿ Fentanyl may be used in procedural pain.
79

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.
80

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.
81

⦿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)
82

⦿Method for delivering nutritional support
include oral intake, enteral tube feeding ,
TPN and Parenteral nutrition.
⦿ These may be used alone or in combination.
83

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.
84

⦿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.
85

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.
86

⦿Reconstructive surgery may be done to
improve body appearance and function.
⦿Psychological counseling may be done to
promote recovery and quality of life
87

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.
88