Burn management

1. (part-2)
MANAGEMENT
OF
BURN

2. MANAGEMENT OF BURN:
The burning agent must be stopped from
further damage, example: fires are extinguished.
Hospitalization is necessary for optimal
care of burns.
Example: elevated a severely burned arm or
leg above the level of the heart to prevent
swelling is more easily accommodated in a
hospital.

4. First aid for Burn injury:
A person with a burn is to stop the burning
process at the source, & cool the burn wound.
1. First aid for Minor burn: (first-degree)
 If skin is not broken, run cool water over
burned area or soak in a cool water (not ice
water) bath, if burn occur in cool environment
water should be applied, a cold, wet towel will
reduce pain

5.  Burns can be painful, reassure the victim &
keep them clean
 After flushing or soaking the burn for few
minutes, cover the burn with a sterile non-
adhesive bandage or clean cloth
 Protect burn from friction & pressure

6. 2. First aid for severe Burns: (second & third degree)
 Do not remove burnt clothing
 Check breathing, if breathing has stopped or
victim’s airway is blocked, open airway & begin
CPR
 If patient is breathing, cover burn with cool moist
sterile bandage or clean cloth
 Do not use blanket/towel. Sheet can be used.
 Do not apply ointments & avoid breaking blisters
 If fingers/toes are burned, separate them with
dry sterile, non-adhesive dressing

7.  Elevate burned area & protect it from
pressure or friction
 To prevent shock, lay victim flat elevates
the feet about 12 inches, & cover victim with a
coat or blanket, do not placed victim in shock
position if a head, back, leg injured is suspected
or if it makes victim uncomfortable
 Monitor victim’s vital sign’s continously

8. Do Not:
 Do not apply ointment, butter, ice,
medications, fluffy cotton dressing, adhesive
bandages, cream, oil spray or household remedy
to a burn.
.

9.  Avoid breathing or coughing on burned area
to avoid contamination
 Don’t apply cold compress & do not
immerse a severe burn in cold water, can cause
shock
 Do not placed a pillow under victim’s head
if there is an airway burn & they are lying down.

10. Management of Burn According to Burn Phase:
a. Immediate Management of Burn:
Emergent period of burn management
refers to first 48-72 hours post burn when patient
is admitted to the hospital, it includes:
1. Airway Management:
For mild pulmonary injury, inspired air is
humidified & patient is encourage to cough so
that secretions can be removed by suctioning, in
more severe situations, secretions to be removed
by bronchial suctioning & administer
bronchodilators.

11. Endotracheal intubation & mechanical
ventilation may be required, head & chest to be
elevated by 20 degree to 30 degree to reduce
neck & chest wall edema.
If a full thickness burn of chest wall leads
to severe restriction of chest wall motion, chest
wall escharotomy may be required (burn incised
into subcutaneous fat & underlying soft tissue)

12. • (Escharotomy is the surgical division of the
nonviable eschar, the tough, inelastic mass of
burnt tissue that results from full-thickness
circumferential and near-circumferential skin
burns.
• An escharotomy is an emergency medical
procedure that involves the removal of the full-
thickness burn (eschar) down to the
subcutaneous fat to release it and prevent further
complications. It restores blood flow and allows
adequate ventilation).

15. 2. Hyperbaric oxygen therapy (HBOT):
It is a non-invasive mode of treatment.
Here patient is entirely enclosed in a pressure
chamber filled with oxygen at a pressure greater
than one atmosphere, it can also be done in a
mono place chamber (one patient), multiplace
chamber (two patient).
Chamber is pressurized with 100% pure
oxygen, it delivers 100% O2 to an open, moist
wound through special devices.

17. 3. Fluid Management:
Burn cause fluid loss through wound as
well as into the burn wound & adjacent tissues in
the form of edema, fluid loss is replaced through
2 large caliber peripheral intravenous catheters
Adults with more than 15% burn or a child
with 10% burn of the body surface area require
fluid resuscitation.
Foley’s catheter is inserted to maintain
intake & output chart.

18. Replacing body fluid: Guidelines & formulas
for fluid replacement in burn patients:
Consensus formula:
• Lactated ringer’s solution (or other balanced
saline solution): 2-4ml × kg body weight × %
body surface area (BSA) burned.
• Half of fluid is to be given in first 8 hours &
remaining half to be given over 16 hours.

20. Evans formula:
Colloids: 1ml ×kg body weight ×% body
surface area (BSA) burned.
Electrolytes (saline) : 1ml ×body weight × %
body surface area (BSA) burned.
Glucose: (5% in water): 2000 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 days colloids &
electrolytes all of insensible fluid replacement
Maximum of 10,000 ml is given over 24 hours

21. Brooke army formula:
Colloids: 0.5 ml × kg body weight × % body
surface area (BSA) burned.
Electrolytes (saline): 1.5 ml × kg body
weight × body surface area (BSA) burned.
Glucose: (5% in water): 2000 ml for
insensible loss
Day 1: Half to be given in first 8 hours. Remaining
half over 16 hours.
Day 2: Half of colloids, half of electrolytes, all of
insensible fluid replacement.

22. Second & third degree (partial & full
thickness) burns exceeding 50% of BSA are
calculated on the basis of 50% BSA
Parkland/Baxter formula:
Lactated ringer’s solution (or other balanced
saline solution): 4 ml × kg body weight × %
body surface area (BSA) burned.
Hypertonic saline solution:
Concentrated solutions of sodium chloride
(NACL) & lactate with concentration of 250-300
meq of sodium per liter, administered at a rate
sufficient to maintain a desire volume of urinary
output.

23. 4. Wound Management:
Assessment to be done to determine burn
area & depth, then debridement (removing
devitalized tissue & contamination), cleaning
than dressing.

24. • (Debridement is a procedure for treating a
wound in the skin. It involves thoroughly
cleaning the wound and removing all
hyperkeratotic (thickened skin or callus),
infected, and nonviable (necrotic or dead) tissue,
foreign debris, and residual material from
dressings).

25. Circumferential burns of digits, limbs or
chest may need urgent surgical release of burnt
skin (escharotomy) to prevent problems with
distal circulation or ventilation.
Early excision & skin grafting of full
thickness & deep dermal burn wounds.

26. 5. Analgesics & Sedation:
Severely burned patient are restless &
anxious from hypoxemia or hypovolemia rather
than pain.
Simple analgesics such as ibuprofen &
acetaminophen, and Narcotics are used.
A local anesthetic helps reduce pain in
minor first degree & second degree burns.
The patient then responds better to oxygen or
increased fluid administration rather than to
narcotic analgesics or sedatives may mask signs
of hypoxemia & hypovolemia

27. B. Acute period or intermediate phase
It begins at the end of emergent period &
lasts until burn wound is healed. If burn is partial-
thickness injury, acute period extends 10-20 days,
if burn injury is a full thickness injury over a
large percentage of body requiring surgery for
skin grafting, the acute period can lasts for
months.

28. • During acute period, 2 main principle of
management are:
Treatment of burn wound & avoidance, detection
& treatment of complications.

29. a. Infection prevention:
Burned area is cleaned regularly. Wounds
are cleaned & bandages changed 1-3 times per
day.
Infection is promoted by loss of epithelial
barrier, by malnutrition induced by
hypermetabolic response, post burn
immunosuppression.

30. • Tissue specimens are obtained for culture by
swab, tissue biopsy, to monitor colonization of
wound by microbial organisms.

31. Systemic antibiotics are administered
when there documentation of burn wound sepsis
or other positive cultures such as urine, sputum
or blood.
Infection control is a major role of burn
team in providing appropriate burn wound care.
Cap. Gown, mask & gloves are worn while
caring for patient with open burn wounds.

32. b. Topical antimicrobials
Application of topical agents to burn wound
can help decrease infection & hasten healing.
Topical agent includes:
Silver sulfadiazine:
Most commonly used topical
antimicrobial agent in burn, its antimicrobial
properties are derived from dual mechanism of
its silver & sulfa moieties & has broad spectrum
of microbial coverage.
It is painless on application, has high
patient acceptance, easy to use with or without
dressing.

33.  Allergic sensitivity can develop where
patient will develop transient leukopenia 3 to 5
days following its continued use secondary to
margination of circulating WBCs. If WBC count
drops below 3000, medication to be withheld
until WBC counts returns to >4000-5000

34. Mafenide:
Broad spectrum of antimicrobial activity,
unlike other topical agents, mafenide has good
penetration through eschar, it is used on dirty or
infected burn wounds or electrical burns and burn
ears.
after application, mafenide produces a
manful sensation for several minutes, therefore it
is called “white lightning’
Sites of mafenide application can be rotated
every 2 hours until entire burn has been treated.

36. Silver Nitrate 0.5% solution:
Broad spectrum, non penetrating , painless
antimicrobial agent, requires multiple daily
application on burn dressing & is messy &
staining.
This dressing is used in treatment of toxic
epidermal necrolysis syndrome & in rare patient
allergic to silver sulfadiazine or mafenide.
The solution is hypotonic, so electrolyte
leeching, hyponatremia & hypokalemia are
common side effects.

37. Povidone iodine (betadine) ointment:
Reddish brown germicidal preparation of
10% povidone iodine with broad spectrum
microbial action, applied 3 times daily.
Can be applied by spreading it with sterile
gloved hand on to burned surface.
Petroleum based antimicrobial ointments:
Such as bacitracin or polymyxin B are clear
on application, painless, allow easy wound
observation.
used for facial burns, grafts sites, healing
donor sites & small partial thickness burns.

38.  In severely burned patients (>40% BSA),
combination of mycostatin ointment or powder with
other topical agents reduces incidence of fungal
superinfection & improves antimicrobial action.
Mycostatin 5-15 ml given orally 3 times daily
reduces alimentary fungal overgrowth.
 Topical antimicrobial creams are used with
closed dressings.
 Dressing to be change every 8-12 hours
 In contaminated area, wounds are washed with
an antimicrobial soap or phosphate buffered 0.25%
hypochlorite solution

39. Wound care:
Untill complete re-epithelization occurs, burn
dressing helps in protection against micro-organisms
invasions, minimize metabolic losses
Wound covering:
1. Dressing:
Wet dressing may be used with silver nitrate or
normal saline applications.
Normal saline applied to clean granulation
tissue or to new graft to maintain moisture
Single layer of fine mesh gauze placed over the
wound, covered with thick gauze pads to maintain
moisture, & held in place with a gauze wrapping

41. a. Open or exposure method:
Patient is washed daily & kept of clean dry
sheets with another sheet to reduce contamination
from the environment.
Exudates of partial thickness burn dry in 48-
72 hours, & forms a crust that protects the wound,
epitheliazation occurs beneath this crust in 14-21
days & crust falls off.
Dead skin of a full thickness burn is
dehydrated & converted to black, leathery eschar in
48-72 hours. Exposure is less painful for full-
thickness burn.

42. Loose eschar may be removed with the
use of hydrotherapy & debridement,
Lights & heat lamps to use with caution to
provide warmth, Ambient temperature control is
important to maintain normothermia.
Advantages: Wound is easily inspected &
patient has maximal freedom to perform
exercises for prevention of contractures &
improvement of circulation

43. b. Closed Method or occlusive method:
In this wounds are washed & dressings are
changed at least once a day.
An occlusive dressing is thin gauze that is
applied after topical antimicrobial application,
pressure wrappings or elastic bandages may be
applied. This dressings are used over areas with
new skin grafts to protect the graft, this dressings
remains in place for 3-5 days.
Nursing observation includes: Monitoring for signs
of impaired circulation

44. Nursing observation includes: Monitoring for
signs of impaired circulation (numbness, pain,
tingling) & signs of infection.
C. Bland dressing:
These provides a clean, moist wound
healing environment, absorb exudates, protect
from contamination & provide comfort at a
fraction of cost of antibiotic dressings, paraffin
gauze can be used.

45. Dressing guidelines for minor & moderate burns:
 Ensure that the patient is not allergic to any
dressing.
 Use a dressing that both the patient & staff
find acceptable & with which both will comply.
 Use a dressing that is cost effective ie, do not
use expensive dressing if burn requires frequent
dressing changes.
 Consider changing type of dressing as burn
character changes in particular exudates control

46.  Decrease the dressing bulk as soon as the
wound will allow for greater freedom of
movement as well as reducing “sick role” effect
of bulky dressings on patients.

47. (Under wound care)
2. Biological Dressing:
Biological dressing have no direct toxins
or antmicrobial properties, however, it creates a
wound environment that prevents dessication,
diminishes bacterial proliferation, reduces loss of
water, protein & red blood cells, promotes rapid
wound healing, reduces burn pain.
These materials may be organic or synthetic in
origin.

48. Skin grafts:
Skin grafts are applied to cover burn
wound & speed healing, to prevent contractures
& to shorten convalescence, successful grafting
reduces patient’s vulnerability to infection &
prevent loss of body heat & water vapor from the
open wound.

49. Synthetic dressings:
Helps increase rate of wound healing, reduce
discomfort.
Biobrane is a nylon material that contains a
gelatin that interacts with clotting factors in the
wound, it is a synthetic, bilaminate membrane with
an outer semi-permeable silicone layer bonded to an
inner collagen nylon matrix, its elasticity &
transparency allows easy drape ability, fuller range
of motion, easy wound inspection.
It is suited to use on donor sites superficial partial
thickness burns, & clean excised wounds prior to
grafting.

50. Skin substitutes:
Skin substitutes becomes incorporated
permanently, in parts or as a whole, into the
wound closure. An artificial skin developed by
Burke, is composed of an outer silastic
‘epidermis’ (0.1mm thick), and an inner
biodegradable bovine collagen
glycosaminoglycan (GAG) based dermal analog,
Inner surface provides good wound
adherence while the outer layer prevents
exogenous bacterial contamination

51. Surgical Treatment:
Partial thickness burns should heal without
surgical intervention, but full thickness requires
surgical management.
There are 2 alternatives treatment for deep burns:
 One can wait for spontaneous desloughing &
apply split thickness skin graft at 3 weeks, this
policy has the advantage that early operation can be
avoided, but had disadvantage of slow healing &
greater scarring.
 Early excision of burn is carried out with the
application of skin cover by a skin graft or a flap,
has advantage of rapid healing & early restoration of
function.

52. Early excision of skin grafting is the technique used for
deep dermal burns, preferred within 48 hours, the
layers of burned tissue are shaved with a split skin
grafting knife until a healthy bleeding bed is reached,
upon which partial thickness skin graft is applied.
Surgical reconstruction of burn injury:
Major complication of burn injury is scarring,
hypertrophic scar or keloid scar can be prevented by
application of pressure, & by giving routine Lycra
pressure garments to wear for 14 months. When burn
scar crosses a joint, contractures occur.

53. 3. Rehabilitation period or Long term phase:
Rehabilitation care should commence on
the day of injury.
Goals are:
Limit or prevent loss of motion
Prevent or minimize anatomic deformities
Prevent loss of lean muscles mass
Return the patient to work or normal activities as
soon & completely as possible

54. BARRIER NURSING CARE OF THE BURNS
1. Restoring normal fluid balance:
 Nurse closely monitors patient’s IV & oral
fluid intake, maintain intake & output chart,
daily weight are obtained
 Changes in blood pressure, pulse rate to be
observed & report to physician if any
 Administer medication as prescribed.

55. 2. Preventing infection:
 Detection & prevention of infection
 Aseptic technique used for wound care
procedure & any invasive procedure
 Nurse protects patient from source of
contamination.
3. Maintaining adequate nutrition:
 Nurse collaborate with the dietician to plan a
protien & calorie-rich diet
 Family members to be encouraged to bring
nutritious & favoured foods for patient

56.  Feeding tube is inserted & used for continous or
bolus feeding of specific formulas
 check patient weight daily to monitor weight loss
& gain
4.Promoting skin integrity:
 Nurse serves as coordinator of complex aspect of
wound care & dressing changes for patient
 Nurse must be aware & of the rationale &
nursing implications for various wound management
approaches.
 Nurse assists patient & family by instruction,
support & encouragement to take an active part in
dressing changes & wound care.

57. 5. Relieving pain & discomfort:
 Assessment of pain & discomfort,
intervention to be made to relieve pain
 Analgesics & anti-anxiety medications as
prescribed.
 Dressing change & complete treatment to be
done to reduce pain & discomfort
6. Promoting physical mobility:
 Deep breathing, turning & proper
repositioning are essential nursing practices to
prevent atelectasis, pneumonia, edema, pressure
ulcers & contractures.

58. Both passive & active exercise to be done from
admission & to be continued after grafting,
within prescribed limitations.
7. Strengthening coping strategies:
 Assist patients in developing effective
coping strategies by promoting truthful
communications to build trust, giving positive
reinforcement when appropriate
 Helps patients set realistic expectations for
self care, self feeding, assistance with wound
care procedures, exercise.

59. COMPLICATIONS:
Infections:
Burn leaves skin vulnerable to bacterial
infection & increase rick of infections, sepsis is a
life-treatening infection that travels through
bloodstream & affects whole body, progresses
rapidly & can cause shock & organ failure
Low blood volume:
Burn can damage blood vessels & cause fluid
loss, results in low blood volume

60. Hypothermia:
Skin helps control body’s temperature so,
when a large portion of skin is injured, patient
lose body heat, it increases risk of hypothermia.
Breathing problems:
Breathing hot air or smoke can burn airways
& cause respiratory difficulties, smoke inhalation
damages lungs & cause respiratory failure.
Scarring:
Burns can cause scars & ridge areas caused
by an overgrowth of scar tissue (keloids)

61. Musculoskeletal problems:
Deep burns can limit movement of bones &
joints , scar tissue can form & cause shortening &
tightening of skin, muscles or tendons
(contractures), this conditions can permanently
pull joints out of position.

62. Prevention & Health education:
To reduce risk of common household burns:
1. Never leave items cooking on the stove
unattented
2. Turn pot handles towards the rear of the stove
3. Keep hot liquids out of reach of children & pets
4. Keep electrical appliances away from water
5. Test food temperature before serving a child,
don’t heat a baby’s bottle in the microwave
6. Never cook while wearing loose fitting clothes
that could catch fire over the stove

63. 7. In presence of a small child, block his or
her access to heat sources such as stove, outdoor
grill, fireplace & space heater
8. Before placing a child in a car seat, check
for hot straps or buckles.
9. Unplug irons & similar devices when not in
use, store them out of reach of small children
10. Cover unused electrical outlets with safety
caps, keep electrical cords & wires out of the
way so that children don’t chew on them.

64. 11. Avoid smoking in the house & never smoke
in bed
12. Keep fire extinguisher on every floor of your
house.
13. Set water heater’s thermostat below 120 F
(48.9 C) to prevent scalding, test bath water
before placing a child in it.