This document discusses the management and nursing care of burn injuries. It covers the pathophysiology of local and systemic effects of burns, classification of burns by depth, determining burn size and extent, and management approaches. It also details fluid therapy using the Parkland formula and the nursing care plan, including assessing risks like infection, impaired mobility, and nutrition imbalances.

1. BURN INJURIES:
MANAGEMENT AND NURSING CARE
DR EVAVELIKOSHI-INDONGO
(DIP NURSING/MIDWIFERY, RN/RM/RT, BNSc
(HSM), NED (NDP), MNSc, DNSc (UNAM),
MBChB (ZAMBIA)
15/07/2019 1

2. Outline
1) Introduction
2) Pathophysiology- local and systemic effects of
a burn injury
3) Classification of burns
4) Determining burn size and extent
5) Management and nursing care of burns
6) Fluid therapy- the Parkland formula
2

3. 1. Introduction
• Burn injury: damage/injury to an epithelial surface
or other tissues caused by flames, heat, chemicals
radiation or electricity.
• Morbidity and mortality depends on the total body
surface area (TBSA) involved, depth of the injury
and age of patient.
• Duration of exposure also matters.
3

4. • Globally, 10-20 thousand deaths annually
• Survival best at ages 15-45 (youth)
• Children, elderly, and diabetics high risk
• Good prognosis if burns cover less than 20% of
TBSA
4

5. 2. Pathophysiology of burn injury
Local effects : 3 zones- Coagulative necrosis, stasis
(cell death) and hyperemia
1. Coagulative necrosis to the epidermis and the
underlying tissues  irreversible tissue damage
• 2. Zone of stasis  Moderate damage,
decreased perfusion to the burnt area, ends in
ischemia
5

6. 3. Zone of hyperemia- increased tissue perfusion,
site where healing begins
6

7. Systemic effects
Significant burns: immune response, inflammatory
mediators release ( e.g. vasoconstrictors and
vasodilators, histamine, kinins, prostaglandins and
oxygen free radicals).
vasoconstriction and vasodilatation,
 increased capillary permeability
 edema locally and distant organs
7

8. • Respiratory system changes:
- Thermal injury to upper airway may result in
mucosal swelling and obstruction
• Cardiovascular system:
• - ↓ fluid volume  low cardiac output , shock
• Psychological
- stress, depression
• Hematologic system
- anemia Haemolysis due to micro-vessels
breakdown 8

9. • Gastrointestinal system
- Ulceration (stress ulcers), Ileus, Bacterial
translocation, Liver dysfunction (deranged
enzymes, decreased synthesis of clotting factors
and proteins)
• Renal system:
-Renal blood flow GFR, ADH production;
aldosteroneNa+ + H20 retention 
generalised oedema, myoglobinuria
9

10. 3. Classification of burns
• According to burn depth
- May be classified as first degree, second
degree, third degree, and fourth degree
- May also be classified as superficial and deep
burns
10

11. 3.1. Superficial (First degree) burns
- localized to the epidermis
• No blisters, but reddish
• heals in 1week with no scar
• Include hot water scalds,
• skin tanning
11

12. 3.2. Partial thickness (2nd degree) burns
• divided into superficial partial thickness and deep
partial thickness.
1. Superficial partial thickness (superficial 2nd degree
burns)
- Epidermis plus part of dermis (papillary dermis)
- Red, painful ruptured and un-ruptured blisters
- Heals in 2-3 weeks, with minimal or no scaring, but
may leave discoloration
- Blanching on pressure
12

13. • Superficial partial thickness burns
13

14. • 2. Deep partial thickness burns (Deep 2nd
degree burns)
• Involves epidermis, upper dermis and part of the
lower dermis (Reticular dermis)
• Appears pale/mottled
• Pain might be present/absent
• Takes weeks to heal with significant scaring and
contracture formation, may need grafting
• No blanching
14

15. 15
Deep partial thickness burns

16. 3.3. Full thickness (Third degree) burns
• Both epidermis , whole dermis and subcutaneous
tissue is burnt
• Skin appendages also burned
• No blisters, no pain
• Waxy, white, leathery, black charred
• Takes long to heal, contractures formation
16

17. • Full thickness burns
17

18. • Full thickness burns
18

19. • 3.4. Fourth degree burns
• Full-thickness, extends to muscle or bone
• Commonly seen with electric injury or severe
thermal burns
• Surgical amputation of the affected extremity
may be required
19

20. • Fourth degree burns
20

21. 21

22. 22

23. Complications of burns
23
Early/immediate
complications
Late complications
Airway obstruction
Hypothermia
Fluid and electrolyte
imbalance
Anemia
Paralytic ileus
Compartment syndrome
Wound infection
Multi-organ failure
Skin Contractures
Curling’s ulcer
Depression
Malignant ulcers
Hypertrophic scar
(Keloids)

24. 4. Determining size and extent of burn injury
(TBSA)
- Rule of nines (commonly used)
- Lund Browder Chart
- Rule of the palm
24

25. 4.1. Rule of nines
• Appropriate for initial assessment for adult burns
• Head & Neck = 9%
• Each upper extremity (Arms) = 9%
• Each lower extremity (Legs) = 18%
• Anterior trunk= 18%
• Posterior trunk = 18%
• Genitalia (perineum) = 1%
25

26. 26

27. 4.2. Lund Browder Chart
27

28. 4.3. Rule of palm
• Applicable small burns
• both adults and children
• Use the palm of the patient’s hand (with fingers
extended). This equates to approximately 1% of
the body surface area.
28

29. Referral and admission criteria
• TBSA >10% in children
• TBSA >20% in adults
• TBSA <1% in special areas (face, head, perineum,
joints)
• Electrical burns
• Chemical burns
• Inhalation burns
29

30. • 5. Management and nursing care
5.1. Management
• Three phases of care:
• emergent/resuscitative,
• acute/intermediate
• rehabilitation.
30

31. 5.1.1. Emergent/resusitative
- Remove patient from hazard
- Airway/C-spine, Breathing, Circulation, Disability
(Primary survey).
-  patency of airway, C-spine protection), oxygen, IV
fluids and physical/neurological disability
- Cover victim with dry blanket (hypothermia)
- Cover wound
- Remove all rings, belts, watches and jewelry
- Caregiver to wear protective clothing
31

32. 5.1. 2. Acute-Intermediate phase:
• Secondary survey
-After patient is stabilized
• History taking- circumstances surrounding the
event
• Past medical history
• Drugs history
3
2

33. Diagnosis and Monitoring: Investigations (routine)
Labs: FBC (anemia, infection), electrolytes, Cross-
match (group and save for BT), Pus swab
– Imaging: Chest -ray, C-spine,
• Fluids management- Intravenous fluids
• Wound management –Topical antibiotics/dressing,
Tetanus vaccine
• Pain management- analgesia 33

34. Management cont…
• Surgery- Skin grafting
• Escharotomy
34

35. 5.1.3. Rehabilitative phase
• Psychological support/counselling
• Cosmetic reconstruction
• Prevention of contractures
35

36. • 5.2. Nursing care plan
• Actual problems:
-Acute pain
-Impaired skin integrity
-Anxiety related to fear
36

37. • Risk for:
• Ineffective airway clearance
• Impaired gas exchange
• Ineffective breathing pattern
• Deficient fluid volume
• Hypothermia
• Infection
• Ineffective tissue perfusion
• Imbalanced nutrition 37

38. 1) Acute pain related to burn injury evidenced by
patient verbal and non-verbal expression
• Assess the level of pain
• Ensure patient is positioned comfortably
• Administer intravenous analgesics
• Provide emotional support and reassurance
• Promote rest
38

39. 2) Impaired skin integrity related to destruction of
skin layers (epidermis/dermis).
• Dress wound with prescribes topical antibacterial
agents
• Cover wound
• Wound assessment features include size, color,
odor, presence of eschar and exudate
• Assess that donor and recipient site
• Keep skin free from pressure
• Nurse under bed cradle 39

40. • 3) Anxiety related to burn injury, isolation, fear of
disfigurement and death.
Assess the anxiety level of the client
• Reassure the patient and his family members
• Encourage the family members to give care and
support
• Develop a good interpersonal relationship
• Counsel the client to accept the condition
• Assess mental status, including mood and thoughts
• Identify methods of coping and handling of stressful
situations.
40

41. 4) Risk for fluid volume deficit related to increased
capillary leak and large fluid shift from
intravascular to interstitial space as characterized by
altered mental status and edema
-Assess Blood pressure 1-4hly
-Monitor intake and output strictly- fluids balance chart
-Monitor urine output at least hourly (catheterize)
- Maintain patent IV lines and regulate fluids at
prescribed rates
-Weigh patient daily
-Elevate head of patient’s bed and elevate burned
extremity
41

42. 5. Risk for related ineffective airway clearance to
airway obstruction and inability to clear secretions.
• assess the patient’s airway and breathing.
• Look out for signs of smoke inhalation-
smoky/dusky nasal hairs, mucosal burns, voice
changes, wheezing, coughing
• Monitor respiratory rate, rhythm, depth
• Assess for cyanosis and pink-tinged sputum
(edema)
• Suction (PRN) with extreme care
• Administer humidified oxygen
42

43. • Assess for cyanosis and pink-tinged sputum
(edema)
• Suction (PRN) with extreme care
• Administer humidified oxygen
43

44. 6) Risk for infection related to loss of skin barrier
and impaired immune response
• Nurse in isolation room (ideal situation: burn care
room)
• Monitor temperature every 4-6 hrs
• Aseptic handwashing before handling patient
• Use sterile dressing materials and techniques
• Assess wound for color, discharges, smell
• Wound debridement of dead tissues
44

45. • Administer antibiotics as prescribed by physician
• Monitor the total leukocyte count
• Observe and report signs of infection
45

46. 7) Risk of imbalance nutrition related to hyper-
metabolic state, anorexia and restricted oral intake.
• Assist with feeds
• High protein, high calorie diet
• Provide small, frequent meals and snacks.
• Encourage the client to take liquid diet or soft diet
if cannot tolerate normal diet
• NGT feeds as per patient condition
• Provide oral hygiene before meals
• Administer IV fluids as need
46

47. 8) Risk for ineffective tissue perfusion resulting in
hypoxia to the tissues.
• Assess color, peripheral pulses, and capillary
refill of affected extremities
• Elevate affected extremities as required
• Monitor blood pressure
• Fluid balance chart- intake and output
• Encourage passive exercises/range of movement
exercises
47

48. 9) Impaired physical mobility neuromuscular
impairment, pain/discomfort, limb immobilization
and/or contractures.
• Maintain proper body alignment with supports or
splints for burns over joints
• Position change as tolerated
• Perform ROM exercises- passive, then active
• Analgesia before activity or exercise
• Encourage patient participation in activities as
individually able
• Keep patient dry, assist with excretion
48

49. 6. Fluids replacement therapy: Parkland’s formula
- Prevents fluid overload, applicable to first 24hrs
- Body weight (kgs)xTBSAx 2-4 mls = Xmls
- Give 1st half of Xmls in the first 8hrs from time of
burnask what time was patient burnt
- Give 2nd half of Xmls in the next 16 hrs
- Total hours (8+16=24 hrs)
- N/Saline, Ringers, DNS fluids 49

50. • Example: Child 10 kg, 10%TBSA, burnt at 05hrs
today, and now is 8h00.
• ** burnt 3 hours ago
Fluids to give: 10kgx10x2mls= 400mls
THEREFORE: in the remaining 5 hours, we give
½ of 400 mls  200mls
Thereafter: the remaining 16 hours, we give
Remaining half (200mls over 16hrs)
50

51. • Example:Adult 87 kgs, 15% burns
Fluids: 87kgx15x4mls = 5220mls in 24 hours (±5,2L)
First 8 hours: ½ of 5220mls (2610 mls)
(326.25mls per hour)
Remaining 16 hours: Give the remaining 2610mls
(163ml/hr)
After 24hrs, patient receive maintance fluids
based on their weight. 51

52. • Summary
2) Pathophysiology- local and systemic effects of a
burn injury
3) Classification of burns: superficial, Partial
thickness burns (superficial/deep), Full thickness,
fourth degree.
4) Determining burn size and extent- rule of 9,
Lund Browder chart, rule of palm
5) Management and nursing care of burns
6) Fluid therapy- the Parkland formula
52

53. • References
• Hinkle, J.L. & Cheever, K.H. (2014). Burner and
Suddarth’sTextbook of Medical-Surgical Nursing.
13th .
• Nursing Care Plans
• Doenges, M. E., Moorhouse, M.F. & Murr, A. C.
(2014). Guidelines for Individualizing Client Care
Across the Life Span. 9th ed.
53

54. THE END…
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