3. Three Types of Burn Classifications
➢Thermal -93 % of all burns
○ Cell injury occurs by coagulation from a source of significant heat.
○ Can occur from:
■ Flame
■ Scalding liquids
■ Steam
■ Direct contact with a heat source
○ The severity is related to heat intensity and duration of contact
5. Burn Classification Cont’d
➢ Chemical
○ Caused by contact, inhalation of fumes, ingestion, or injection.
○ Can have both local and systemic effects.
○ Tissue damage continues until chemical is completely removed or neutralized.
➢ Categories of chemical agents
○ Alkalies
■ Oven cleaners, lye, wet cement, and fertilizers
○ Acids
■ Bathroom cleaners, rust removers, swimming pool chemicals.
7. Burn Classification Cont’d
➢Electrical
○ Frequently work related
○ AC- most commercial applications
■ Can create cardiopulmonary arrest by V-
Fib
■ Tetanic muscle contraction can freeze
patient to source of electricity
○ DC- lightning, car batteries
○ Tissue damage occurs during the process of
electricity turning into heat.
8. Inhalation Injury
➢Smoke exposure causes an airway inflammatory response with changes in
biochemical mediators and cells.
➢Systemic
○ Carbon Monoxide (burning wood or coal)
■ Binds to hemoglobin more rapidly than oxygen
■ Tissue hypoxia
○ Cyanide (smoke byproducts)
■ Binds to respiratory enzymes in the mitochondria
■ Inhibits cellular metabolism and utilization of oxygen
9. Inhalation Injury Cont’d
➢ Subglottic (lower airway injury)
○ Chemical
■ Impaired ciliary activity, erythema, hypersecretion, edema, ulceration of mucosa, increased
blood flow, spasm of bronchi and bronchioles.
■ ARDS may develop
● Xray may show Atelectasis, edema, infiltrates,
■ Respiratory mucosal sloughing
■ Carbonaceous sputum
● Soot or carbon particles in sputum
➢ Clinical indications of inhalation injury
10. Burn Classification and Severity
➢Depth
○ superficial-epidermis -first layer of skin
■ Heals in 3-5 days without treatment
○ Partial-thickness-dermal layer-second layer
■ Second degree injury- heals in 2-4 weeks
○ Full thickness-epidermis, dermis, subcutaneous
■ Third degree- does not heal requires skin grafting
➢Extent of injury is the total body surface area (%TBSA)
11. Physiological Response
➢The entire body responds to major burns.
➢Hemodynamic, metabolic and immunologic effects
○ Systemic and local as a result of cellular damage
○ Relates to %TBSA
12. Burns - Medical Management
Stop the burning and identify life threatening
injuries!
Thermal: Smother flames.
Chemical: Flush with water.
Electrical: Stop the current.
Assess
Airway
Breathing
13. Initial Assessment: Airway
Secure the airway first.
Look for soot or singed nasal hairs.
Severe upper body and facial burns
May need to intubate quickly d/t edema.
Get history as much as possible before
intubation.
14. Initial Assessment: Breathing
High flow oxygen: reduces CO.
Impaired ventilation: Assess for escharotomy.
Listen: verify breath sounds.
Assess rate and depth.
15. Initial Assessment: Circulation
Monitor blood pressure, pulse, and skin
color.
Fluid Resuscitation: Establish IV access; two
large bores.
Remove jewelry and constricted clothing.
Monitor peripheral pulses in circumferential
burns.
18. Nursing Management: Assessment
Emergent Phase:
Assess the injury:
What time did it occur?
What type of burn?
Can you classify it?
Rule of 9’s
Possibility of inhalation injury?
Stop the burning process!
● Initiate Cardiac
Monitoring
● Conduct patient
interview as
appropriate
AIRWAY
BREATHING
CIRCULATION
19. Nursing Management: Diagnosis
Ineffective Tissue Perfusion R/T
hypovolemia AEB diminished or lack of
peripheral pulses/capillary refill time
Risk for Infection R/T inadequate primary
defenses (destruction of skin barrier) AEB
Second degree burn, 15% TBSA
Risk for Ineffective Airway Clearance R/T
fluid shifts, pulmonary edema and
decreased lung compliance AEB
tachypnea, diminished breath sounds
20. Nursing Management: Planning
Prioritize:
focus on severity and high-risk
factors
Create clear, measurable goals for
expected beneficial outcomes.
Where is closest burn center?
Collaborate with the center
What mode of transportation?
Treatment necessary to stabilize the
patient for transport
21. Nursing Management: Implementing
Actions taken by the nurse to achieve defined
& planned goals
Spinal Immobilization
IV access, 14-16 gauge (Labs)
Obtain pt. Weight
Calculate fluids
Intubation?
Elevated HOB (reduce facial and airway
edema)
22. Nursing Management: Evaluation
ALWAYS reassess the patient as you go!
The patient's status may change
suddenly forcing you to reprioritize
interventions & goals!
Evaluate the effectiveness of the
interventions completed
Anticipate patient's needs
Collaborate with all team members
23. NCLEX Question
The newly admitted client has burns on both legs. The burned areas appear white
and leather-like. No blisters or bleeding are present, and the client states that he
or she has little pain. How should this injury be categorized?
A.Superficial
B.Partial-thickness superficial
C.Partial-thickness deep
D.Full thickness
24. NCLEX Answer:
The newly admitted client has burns on both legs. The burned areas appear white
and leather-like. No blisters or bleeding are present, and the client states that he
or she has little pain. How should this injury be categorized?
A.Superficial
B.Partial-thickness superficial
C.Partial-thickness deep
D.Full thickness
The characteristic of the wound meets the criteria for a full-thickness injury (Color
that is black, brown, yellow, white or red; no blisters; pain minimal; outer layer firm
25. NCLEX Question
At what point after a burn injury should the nurse be most alert for the
complication of hypokalemia?
a. Immediately following the injury
b. During the fluid shift
c. During fluid remobilization
d. During the late acute phase
26. NCLEX Answer:
At what point after a burn injury should the nurse be most alert for the
complication of hypokalemia?
a. Immediately following the injury
b. During the fluid shift
c. During fluid remobilization
d. During the late acute phase
Hypokalemia is most likely to occur during the fluid remobilization period as a result
of dilution, potassium, movement back into the cells, and increased potassium
excreted into the urine with the greatly increased urine output.
27. Reference
Sole, M. L., Klein, D. G., & Moseley, M. J. (2009). Introduction to critical care
nursing. St. Louis, MO: Saunders.
Editor's Notes
Ineffective airway clearance and Impaired gas exchange related to tracheal edema or interstitial edema secondary to inhalation injury and/or circumferential torso eschar manifested by hypoxemia and hypercapnia
Deficient fluid volume secondary to fluid shifts into the interstitium and evaporative loss of fluids from the injured skin
