2. After the end of the lecture, the
student will understand:
1. What is Burn Injury?
2. Classification
3. Pathophysiology
4. Clinical Manifestations
5. Prevention
6. Complication
7. Assessment and Diagnostic Findings
8. Medical Management
4. What is Burn Injury?
Burn injury is the result of heat transfer from one site to another.
Burns disrupt the skin, which leads to increased fluid
loss; infection; hypothermia; scarring; compromised immunity;
and changes in function, appearance, and body image.
5.
6. Classification
Burns are classified according to the depth of tissue destruction as superficial partial-thickness
injuries, deep partial-thickness injuries, or full-thickness injuries.
8. Deep partial-thickness. A deep partial-thickness burn involves the
destruction of the epidermis and upper layers of the dermis and injury to the
deeper portions of the dermis.
9. Full-thickness. A full-thickness burn involves total destruction of the
epidermis and dermis and, in some cases, the destruction of the
underlying tissue, muscle, and bone.
11. Local response. Burns that do not exceed 20% of TBSA
according to the Rule of Nines produces a local response.
Systemic response. Burns that exceed 20% of TBSA
according to the Rule of Nines produces a systemic response.
The systemic response is caused by the release
of cytokines and other mediators into the systemic circulation.
The release of local mediators and changes in blood flow,
tissue edema, and infection, can cause the progression of the
burn injury.
12. Clinical Manifestations
The changes that occur in burns include the following:
Hypovolemia. This is the immediate consequence of fluid loss and results in
decreased perfusion and oxygen delivery.
Decreased cardiac output. Cardiac output decreases before any significant change in
blood volume is evident.
Edema. Edema forms rapidly after burn injury.
Decreased circulating blood volume. Circulating blood volume decreases
dramatically during burn shock.
Hyponatremia. Hyponatremia is common during the first week of the acute phase, as
water shifts from the interstitial space to the vascular space.
Hyperkalemia. Immediately after burn injury hyperkalemia results from massive cell
destruction.
Hypothermia. Loss of skin results in an inability to regulate body temperature
13.
14. Prevention
To promote safety and avoid burns, the following must be done to prevent burns:
-Advise that matches and lighters be kept out of reach of children.
-Emphasize the importance of never leaving children unattended around fire or in
bathroom/bathtub.
-Caution against smoking in bed, while using home oxygen, or against falling asleep while
smoking.
-Caution against throwing flammable liquids onto an already burning fire.
-Caution against using flammable liquids to start fires.
-Recommend avoidance of overhead electrical wires and underground wires when
working outside.
-Advise that hot irons and curling irons be kept out of reach of children.
-Caution against running an electrical cord under carpets or rugs.
-Advocate caution when cooking, being aware of loose clothing hanging over the stove top.
-Recommend having a working fire extinguisher in the home and knowing how to use it.
15. Complications
There are a lot of consequences involved in burn injuries that may progress
without treatment.
Ischemia. As edema increases, pressure on small blood vessels and nerves in
the distal extremities causes an obstruction of blood flow.
Tissue hypoxia. Tissue hypoxia is the result of carbon monoxide inhalation.
Respiratory failure. Pulmonary complications are secondary to inhalational
injuries.
17. Medical Management
Transport. The hospital and the physician are alerted that the patient is en
route so that life-saving measures can be initiated immediately.
Priorities. Initial priorities in the ED remain airway, breathing, and circulation.
Airway. 100% humidified oxygen is administered and the patient is encouraged
to cough so that secretions can be removed by coughing.
Chemical burns. All clothing and jewelry are removed and chemical burns
should be flushed.
18. Intravenous access. A large bore (16 or 18 gauge) IV catheter is inserted in the non-
burned area.
Gastrointestinal access. If the burn exceeds 20% to 25% TBSA, a nasogastric tube is
inserted and connected to low intermittent suction because there are patients with large
burns that become nauseated.
Clean beddings. Clean sheets are placed over and under the patient to protect the burn
wound from contamination, maintain body temperature, and reduce pain caused by air
currents passing over exposed nerve endings.
Fluid replacement therapy. The total volume and rate of IV fluid replacement is gauged
by the patient’s response and guided by the resuscitation formula.
19. Nursing Management
Nursing management in burn care requires specific
knowledge on burns so that there could be a provision of
appropriate and effective interventions.
20. Nursing Assessment
The nursing assessment focuses on the major priorities for any trauma patient; the burn
wound is a secondary consideration.
Focus on the major priorities of any trauma patient. the burn wound is a
secondary consideration, although aseptic management of the burn wounds
and invasive lines continues.
Assess circumstances surrounding the injury. Time of injury, mechanism of
burn, whether the burn occurred in a closed space, the possibility of inhalation
of noxious chemicals, and any related trauma.
Monitor vital signs frequently. Monitor respiratory status closely; and
evaluate apical, carotid, and femoral pulses particularly in areas of
circumferential burn injury to an extremity.
Start cardiac monitoring if indicated. If patient has history of cardiac or
respiratory problems, electrical injury.
21. Monitor fluid intake (IV fluids) and output (urinary catheter) and measure hourly. Note
amount of urine obtained when catheter is inserted (indicates preburn renal function and fluid
status).
Obtain history. Assess body temperature, body weight, history of preburn weight, allergies,
tetanus immunization, past medical surgical problems, current illnesses, and use of
medications.
Arrange for patients with facial burns to be assessed for corneal injury.
Continue to assess the extent of the burn; assess depth of wound, and identify areas of full
and partial thickness injury.
Assess patient’s and family’s understanding of injury and treatment. Assess patient’s support
system and coping skills.
22. Rehabilitation Phase
Rehabilitation should begin immediately after the burn has occurred.
Wound healing, psychosocial support, and restoring maximum functional
activity remain priorities. Maintaining fluid and electrolyte balance and
improving nutrition status continue to be important.
23. Diagnosis
Nursing diagnoses for burn injuries include
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.
Pain related to tissue and nerve injury.
Anxiety related to fear and the emotional impact of burn injury.
24. Planning & Goals
To implement the plan of care for a burn injury patient effectively, there
should be goals that should be set:
Maintenance of adequate tissue oxygenation.
Maintenance of patent airway and adequate airway clearance.
Restoration of optimal fluid and electrolyte balance and perfusion of vital organs.
Maintenance of adequate body temperature.
Control of pain.
Minimization of patient’s and family’s anxiety.
25. Nursing Priorities
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.
26. Nursing Interventions
Nursing care of a patient with burn injury needs to be precise and
effective.
Promoting Gas Exchange and Airway Clearance
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.
27. Restoring fluid and Electrolyte Balance
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.
28. Maintaining Normal Body Temperature
Provide warm environment: use heat shield, space blanket, heat lights, or blankets.
Assess core body temperature frequently.
Work quickly when wounds must be exposed to minimize heat loss from the wound.
29. Minimizing Pain and Anxiety
Use a pain scale to assess pain level (ie, 1 to 10); differentiate between restlessness
due to pain and restlessness due to hypoxia.
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.
30. Monitoring and Managing Potential Complications
Acute respiratory failure: Assess for increasing dyspnea, stridor, changes in respiratory
patterns; monitor pulse oximetry and ABG values to detect problematic oxygen
saturation and increasing CO2; monitor chest xrays; assess for cerebral hypoxia (eg,
restlessness, confusion); report deteriorating
respiratory status immediately to physician; and assist as needed with intubation or
escharotomy.
31. Restoring Normal fluid Balance
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.
32. Preventing Infection
Provide a clean and safe environment; protect patient from sources of cross
contamination (e.g., visitors, other patients, staff, equipment).
Closely scrutinize wound to detect early signs of infection.
33. Maintaining Adequate Nutrition
Initiate oral fluids slowly when bowel sounds resume; record tolerance—if vomiting and
distention do not occur, fluids
may be increased gradually and the patient may be advanced to a normal diet or to tube
feedings.
Collaborate with dietitian to plan a protein and calorie-rich diet acceptable to patient.
Encourage family to bring nutritious and patient’s favorite foods. Provide nutritional
and vitamin and mineral supplements if prescribed.
34. Evaluation
In a patient with burn injury, the expected outcomes are:
Absence of dyspnea.
Respiratory rate between 12 and 20 breaths/min.
Lungs clear on auscultation,
Arterial oxygen saturation greater than 96% by pulse oximetry.
ABG levels within normal limits.
Patent airway
Respiratory secretions are minimal, colorless, and thin.
Urine output between 0.5 and 1.0 mL/kg/h.
Blood pressure higher than 90/60 mmHg.
Heart rate less than 120 bpm.
Body temperature remains between 36.1ºC and 38.3ºC
