BURNS

BURN
• A burn is necrosis of the skin that results from when the skin comes in contact with intense heat
• Burns are categorized according to the type of injury
• You want to find out how they were burned
• Teach about safety in the home (electrical)

TYPES OF BURNS
• Thermal
o Most Common
o An injury when the body part has direct contact with something
o Caused by dry or moist heat
 Heating pads
 Hot water - Steam
 Radiators
 Stove / Oven - Autoclave
 Tar / Wax
• Chemical
o Acids, Organic materials
o Alkaline – not as common
 Battery acids
 Cleaning supplies and Paint products
• Must use in a well ventilated area
 Fertilized factors, Farmers at risk
• Electrical
o Faulty electric wiring – high voltage power lines (loggers)
o Look for the entrance and exit point
o Lightning
 Electrical outlets
• Radiation
o X-rays
o Radium implants
o UV Lights – Sunburns
o Sun tanning and tanning beds

CLASSIFIACTION OF A BURN
• Depth of burns
• Size of the burn (BSA involved)
• Age
• Body part – head or lower extremities
• Mechanism of injury
o How did the burn occur
• History of other disease disorders (HTN, CHF, DM)

SUPERFICIAL - PARTIAL THICKNESS - 1O

• Skin Involvement
o Epidermis
o Will remain intact with no blister formation (may or may not blister)
o Possible a portion of dermis is affected
• Possible Causes
o Sunburn
 o Low intensity flash
• Symptoms
o Tingling
o Hyperesthesia – Supersensitivity
o Pain that is soothed by cooling
o Pain (very painful because nerve endings are intact)
 Exposed nerve endings sensitive to cool, moving air
• Wound Appearance
o Redness and painful
o Blanches with pressure
o Dry
o Minimal or no edema in region burned
o Possible blisters that appear in 24 hrs or maybe no blisters
o Minimal but causes some discomfort
• Recuperative Course
o Heals in 3-5 days
o Possible mild scaring or no scaring
o Peeling – Regeneration of skin in 3-4 days

DEEP PARTIAL THICKNESS - 2O

• Causes
o Scalds or flash flame
• Skin Involvement
o Epidermis, Upper dermis, portion of deeper dermis
• Symptoms
o Pain
o Sensitive to cold air - Air moving over the area will generate pain for the individual
• Wound Appearance
o Wet, shiny, weeping wound (serous drainage)
 They are loosing fluid
o Red and the wound will blanche under pressure
o Blistered, mottled red base
o Broken epidermis - Edema
o Very Painful
o Hair follicles remain intact
• Recuperative Course
o Recovery in 2-4 weeks to months - depends on depth may be longer than 21 days
o Grafting may be required
o Some scarring and depigmentation
o May develop contractures (feet, hands) neck with head burns
o Place 4x4 between digits to insure healing individually
FULL THICKNESS - 3O
• Cause
o Flame Prolonged exposure to hot liquids
o Electric current Chemical
• Skin Involvement
o Epidermis, entire dermis and sometimes subcutaneous tissue
o May involve connective tissue, muscle and bone
o Extends to top layer of fat
• Symptoms
o NO Pain due to nerve endings being destroyed. BUT WILL have pain in surrounding region.
o Shock - Heamturia and possible hemolysis
• Wound Appearance
o Hair follicles destroyed, sweat glands destroyed
o Skin color may be charred, leathery, brown, or pale white
o Broken skin with fat exposed
o Edema
o NO blisters present
• Recuperative Course
o Grafting is required for any individual that has a full thickness burn
o Scarring and loss of contour and function; contractures – limited movement
o Loss of digits or extremity possible
o Eschar sloughs – dark leathery, scab like
 Will not break like a scab and they may develop compartment syndrome because
they have a tight band of old skin(eschar) around the extremity and they will not have
blood flow – MD will have to do a Escardotomy or Fasciotomy.
 May put in whirlpools to get the Escar to loosen to create blood flow to the area.
4o BURN
• Burn extension into muscle and to the bone
• No Pain
• Grafting required
• Amputation may be required for healing

CLASSIFICATION OF BURNS
PERCENTAGE BODY SURFACE ARE BURNED
o Rule of Nines
 An estimation of the total BSA
 The rule of nines is a quick way to calculate the initial extent of burns. The system
assigns percentages in multiples of 9 to major body surfaces.
 Anterior is 9 and posterior is 9 Anterior chest 18%, Posterior chest 18%, Head 9%,
Perineum is 1%
 Does not allow for the difference in children (Peds use different way)
o Lund and Buowder
 Children mainly – a more precise method
 Recognizes % of BSA of various anatomic parts (especially head and legs) that
change with growth
 Divides body into very small areas
 Initial evaluation made clients arrival to hospital and revised 2nd and 3rd post burn
day. Because demarcation usually not clear until then
 Recognized that the body parts change with age.
o Palm Method
 Clients with scattered burns
 Size of examiners palm approximately 1% BSA
LOCATION OF BURNS
• Upper area of body; such as head, neck, and chest area.
o Could have some pulmonary complications because of the burn area close to lungs
o Respiratory burns will be evident in upper and lower airways
 Pen light to check nares to see if hair is singed or absent
 May look for black drainage from nose or black productive cough
 Black or bloody sputum
 Blisters on lips
 Blisters in oral cavity
 Raspy speech or hoarse
 Labored breathing
 Dry cough
 More restless than other burn patients
 Will do bronchoscopy

• Burn to the face is associated with corneal abrasions

• If an arm was burned was it circumferential type of burn

• If it is circumferential then the person will have problems with circulation and possible compartment
syndrome. The escar serves as a tourniquet for circulation
• Will have a fasciotomy or escardotomy to insure they have good blood flow to the area.

• Burns of the hands, feet, and perineal area require some special attention that would not normally
get for the burns of extremities such as arms, legs, chest because of their general location….whats
goin on with them. (I don’t get it )

• Know the mechanism of the burn

• Age of Client
o Very Young (<4yrs) and very old do not do well with burns
o High risk for mortality
o Metabolic increases

o Children
 Smaller body surface area
 Greater percentage of water content
 Nephrons of kidneys are not as mature
 Greater risk for fluid and electrolyte imbalance
 INFANT: May not have the antibodies to fight infection

o Elderly
 May have other health problems
 Body does not heal as quickly
 Lose number of nephrons of kidneys
LOCAL AND SYSTEMIC RESPONSES TO BURNS
• Burns that do not exceed 25% total BSA produce primarily local response to the burn
o Will not see all the fluid shifts
• Burns exceeding 25% BSA may produce both local and systemic response
o Considered major burn injury with MAJOR FLUID SHIFTS
o Initial systemic event after major burn injury
 Hemodynamic instability R/F loss capillary integrity and subsequent shift of fluid, Na,
Protein from intravascular space into interstitial spaces – LOSING FLUIDS
 The individual cells are damaged and release Potassium K ;  Na
 Pathophysiologic changes refer to major burns during initial burn-shock period
include tissue hypoperfusion, organ hypofunction 2nd to decreased cardiac output
followed by hyperdynamic and hypermetabolic phase
 Major Loss of a lot of fluid (6-8hrs) – Will have a drastic change in F/E – Person will
experience burn shock if they loose 3-5L of fluid.
 Anasarka (Generalized body edema) >25%BSA burned
 Hematocrit is elevated – because they lost fluid and the RBC’s are
hemoconcentrated. Will stay elevated until they are fully hydrated again.
• (may take 3-4 days)
 Can experience thrombocytopenia; where they have a decrease in platelet count.
Cardiovascular System
o  Cardiac Output,  BP,  P
o But with adequate fluid volume replacement there will be a reversal and the BP will go back
up and the P will come back down.
Respiratory System
o Not a lot of changes unless there is INHALATION damage
o A burn in upper part of the body or if they were in a closed in space
o Look at the color of sputum
Gastrointestional System
o Paralytic Ilius – Decreased BS, Sluggish BS
o Blood is shunted away from GI system
o Acid Production
 Develops Curling’s Ulcer (gastric or duodenal erosion) excessive acid production
 S/S of this are vomiting bright red blood, coffee ground material from stomach
 Look at color of stool – If upper GI bleed the stool with dark tarry appearance.
Genitourinary System
o Hourly I’s & O’s
o Olgiuria ( in urine output) to Polyuria
o Urine Specimens are taken
 Myoglobin (muscle damage) Blood in urine – Dark urine
o Could develop urinary retention
 Kidneys usually produce 1cc of urine per minute or (30-60cc/hr)
Neurological System
o Increased anxiety
Immune System
o Becomes Depressed due to burn
o As a result of a depressed immune system they will be imunosupressed and are at risk for
possible Sepsis
o May be placed in isolation
o Must wear gowns, gloves, controlled environment – Sterile sheets and blankets

PHASES OF BURN CARE

Emergent or Resuscitative
• At the scene and first at hospital
• ABC’s
• Note if inhalation injury
• First 48-72 hours after the burn
• Continuing to loose fluid and protein from their burn site into the interstitial compartment
• Elevated Hct
• Hyperkalemia and Hyponatremia
• Given fluids that are isotonic and will NOT be given fluids that contain K+
• Monitor K+ level – If low may have Cardiac Arrest

Acute Phase
• Begins 48-72 hours AFTER the injury
• Fluid Shifts back into intravascular compartment
o Fluid remobilization
• Capillary wall is beginning to heal
o Fluid volume excess R/T resumption of capillary integrity and fluid shift from interstitial back
to intravascular compartment
• Increase Hct and Decreased in Urine output
• Hyponatremia continued until completely stabilized
• Hypokalemia begin 4-5 day post burn – because the K+ is no longer oozing out of the cells into the
circulation. The cells are beginning to heal and the K+ is not able to escape from the cells into the
intervascular compartment.
• Risk for Fluid Overload
• Anemia – May get Fe 3 times a day to increase Hct
• Metabolic Acidosis
• Increased capillary permeability

Rehabilitation Phase
• Can take months up to years depending upon the degree of the burn
• Own home or other agency long term care
• Concern with body image related to scars
• Jobst Stocking (Tighter than TED hose) 23 our of 24o
o Compress scar from back out and blend into tissue
• Activity Intolerance
o Muscle Wasting
o Decreased movement
• Knowledge Deficit Client/Family
o Care, Food, Activity
EMERGENCY TREATMENT
• At the scene
• Stop Burning Process
o Apply cool (not cold) H2O to burn or hold burned area under cool running water.
o Flame burns – smother fire
o Place victim in horizontal position
o Roll victim in blanket or similar object (Avoid covering head)
• DO NOT disturb any blisters that form
• DO NOT Apply anything to the wound such as ointment or salve
• Cover with clean cloth if risk of damage or contamination
• Remove burned clothing and jewelry
• If a chemical burn you have to irrigate the burn for 20 minutes!!!
• Assess for an adequate airway and breathing
o If not breathing, begin mouth-to-mouth
• Remove burned clothing and jewelry
• Cover wound with clean cloth
• Transport to medical aid
• Begin IV and O2 therapy as ordered

MEDICAL MANAGEMENT
• Volume Fluid Deficit: IV started with large gauge cath with volume expander, LR
• Monitor urine output from Foley (Urimeter –small measurements). Replacement is based on urine
output, VS, monitor electrolyte, Daily Wt’s,
• Placement of NG or Salem Sump tube – Prevent Paralytic Ulcers
• May or may not be connected to suction
• Pain Management
o Morphine Sulfate IV
o If allergic to Morphine then give Demerol or maybe Dilaudid
• Wound Care
• Hypothermia – IV at room temp – room temp is set comfort
• Infection – hand washing – full isolation
• When was the last time the person received a tetanus shot
• Decreased tissue perfusion

IV Consensus Formula
o 2-4ml IV Fluid X kg body weight X % body surface area involved
 Example: A person weighs 70kg and ordered is 2ml of LR- 70X2=140
 140 X 70% of their body = 9800cc of fluid in a 24 hr period
 in the first 8 hours they will be given 4900cc ( ½ of the fluid)
 Which is 613cc of fluid per hour
o ½ the amount 1st 8 hour
o Next 16 hr remaining fluid
o CHECK URINE OUTPUT every hour
o LISTEN TO BREATH SOUNDS
o 3-5L lost first 24o

Goals of Fluid Volume Replacement

o Systolic BP >100mmHg
o Pulse Rate <110 bpm
o Urine output 30-50ml/hr Most reliable factor
o Lung sounds; Listen for Pulmonary Edema (frothy sputum)
WOUND CARE

DEBREIDMENT
• To remove tissue contaminated by bacteria and foreign bodies, thereby protecting the patient from
invasion of bacteria
• Painful process; med 20-30o before process; reach relaxation technique
• Morphine 2mg or 25mg Demerol, Ativan or Versed

Mechanical
• Using surgical scissors and forceps to separate and remove the eschar
• Wet to dry dressing
• Topical Enzymatic agents – Travase-you would rub in wound to help remove the necrotic tissue

Hydrotherapy
• Helps to loosen skin QD or BID
• Water temp 100oF – 37.8oC
• Room temp 80-85oF – 26.6-29.4oC
• Limited 20-30 min period to prevent chilling and added metabolic stress
• May add betadine to help disinfect skin

Surgical
• Cutting away with scissors to good tissue until you have bleeding
• Requires there to be good tissue

SITE CARE
• Medicated cream on the area to reduce the likelihood of them developing infection or escar tissue
o Silvadene
 Still used some 1-3 times a day
o Sulfamylon
 Penetrates thick escar tissue to let it fall off on its own and aid in debredment
 Wear gloves – because can cause metabolic acidosis
 2 times a day, Diffuses through eschar
o Silver Nitrate – Not used much
Premedicate before procedures

GRAFTING
• Done once all old necrotic tissue is removed from the body

• Auto Graft
o Permanent graft with the persons own skin (Best)
 Donor Site - The area from the tissue was removed
 Be sure to assess donor site also
• Homograft
o Same Species; skin banks
• Heterograft
o Graft from a pig (temporary graft)
• Aminograft
o Placenta tissue (temporary)

NURSING DIAGNOSIS
• #1 Fluid volume deficit
 o Take priority over all
o LR
o Strict I&O’s
• Impaired Skin integrity
o Change dressing – Sterile Technique
o Isolation
• R/F Infection
o Isolation
o Antibiotics
o Hand washing***
o Gowns, Mask, Gloves
o Bacteria: Screen visitors, hand washing, Disinfect tank before and after use.
o Topical Antibiotic
o Sterile Dsg Change and monitor WBC
• Altered nutrition: Less than body requirements
o Increase calorie intake 5000-6000/day
o Vitamins and minerals
o Protein / Calorie rich diet and high in Vitamin C
o Snacks: Milkshakes, Meats, Peanut Butter, Cheese, Ensure or Resource
o If they don’t like hospital foods, they family may bring foods to eat.
o Daily weights and Possible TPN
• Pain (1o or 2o more pain)
o IV Morphine
• Anxiety
o Burn support group
o Discuss reality of situation
o Let you know body image, fear of dying
• Hypothermia
o Set temp control at comfortable level
o Linen Cradle - Tent
 Protects skin
 Has small wattage bulb

NURSING INTERVENTIONS
• Protein / Calorie rich diet
• Restore fluids and electrolyte balance
• Maintain body temp
• Control Pain and Anxiety
• Monitor Complications
• Monitor respiratory status HOME CARE
• Daily Wts P. 1532
• VS Q2-4o
• INFECTION CONTROL
• Prevent atelectasis and pneumonia
• Deep breathing, turning, with proper repositioning
• Control edema
• Prevent pressure ulcers and contractures
• Lower Extremities
o Elastic Pressure bandage before placed upright position
o ***Promote venous return and minimize swelling