burn

1. ‫التمريض‬ ‫كلية‬
–
‫معتمدة‬ ‫كلية‬
Burn
Prepared by
Dr/ Ahmed Abozeid
Lecturer At Medical-surgical Nursing Department
Faculty of Nursing – Ain Shams University

2. Objectives
After studying this lecture, the student should be able to:
• Identify the anatomy and physiology of the skin.
• Enumerate the different types of burn injury.
• List the classifications of the Burn injury.
• List the factors that influence the severity of the burn injury.
• Identify the complications of burn injury
• List the first aids of the different degrees of burn injury.
• Discuss the Nursing care of the victims with severe Burn injury.

3. Out lines
• 1. Introduction
• 2. Anatomy and physiology of skin
• 3. Types of burn injury.
• 4. Classifications and degrees of burn injury.
• 5. Factors that influence the severity of the burn injury.
• 6. Complications of burn injury
• 7. First aids of the different degrees of burn injury.
• 8. Nursing care of the victims with severe burn injury according
nursing process

4. Introduction
 The skin is the largest organ in the body. It is accounting for about
16% of the total body weight.
 Anatomy of the skin
 It is composed 3 layers:-
 (1)- Epidermis:
It is the surface layer of the skin.

5. (2)- Dermis:
It is the inner surface and it is thicker than the epidermis. It is
consisting of:
- Blood vessels - Sweat glands
- Nerve ending - Hair follicles
It is tough matrix of connective tissue that supports and provides
nutrition to the epidermis.
(3)- Subcutaneous layer:
It is the deepest part of the skin. It is consisting of connective
tissue and fat.

7. ➢ Physiology and Functions of the skin:-
1. It is covering the entire body so it is influence in body
image and self esteem
2. Perception of external stimuli
3. Responsible for regulation of body temperature
4. Protect the body against bacterial invasion
5. Conserves and balances bodily fluids
6. Excretion of waste products.

8. Definition of Burn:
It is an injury to the skin that results from contact with
heat, chemical agent, radiation, or electrical currents.
Types of burn injury:-
(1)- Thermal burn Injury:
• Dry burn injury as flame and flash injuries. It is caused by fires.
• Moist burn injury as scald injury. It is caused by steam or hot
fluids.
Contact burn injury. It is caused by steam or hot fluids.

9. (2)- Chemical Burn Injury:
It is caused by a strong acid or strong alkali.
(3)- Electrical Burn Injury;
The passage of the currents through the body may cause
cardiac arrest at the time of the injury.
(4)- Radiation Burn Injury:
It is less critical than the other types of the burn injury.
The sun burn it considered as a type of the radiation burn
injury.

10. Classification and Degrees of the Burn Injury:
I- Classification according to depth
II- Classification according to Total Body Surface
Area (TBSA)
III- Classification according to the Severity.

11. I- Classification according to Depth:
1. First Degree Burn Injury (Superficial Burn Injury).
2. Second Degree Burn Injury (Partial and deep
thickness Burn Injury).
3. Third Degree Burn Injury (Full Thickness Burn
Injury).
4. Fourth degree burn injury.

13. (1)- First Degree Burn Injury (Superficial Burn Injury):
It is characterized by:
• The epidermis is destroyed.
• Dry skin surface
• Reddening of the epidermis without blister formation
• Painful sensation
• It is healed without difficulty.
• Regeneration of the epidermis from 3-7 days

14. (1)- First Degree Burn Injury
(Superficial Burn Injury):

15. (2)- Second Degree Burn Injury
A- Partial Thickness Burn Injury: It is characterized by:
• The epidermis is destroyed and part of the dermis
• Moist skin surface.
• Deep reddening with blister formation
• Blanches with pressure
• It is very painful sensation
• It is sensitive to the air currents
• Loss of the body fluids (Plasma & Electrolyte)
• The healing and regeneration is from 7-14 days and deep
injury needs graft to avoid infection

16. B- Deep Partial Thickness Burn Injury:
It is characterized by:
• Extends into deep dermis
• Dry skin surface and
less blanching
• Yellow or white.
• May be blistering
• The healing and regeneration is
from 3-8 weeks

17. (3)- Third Degree Burn Injury (Full thickness Burn Injury)
It is characterized by:
• All layers of the skin are destroyed
• There is no pain due to destroyed the
nerve endings
• The surface may vary in appearance
from white, gray, waxy, or black in severe
case and no blanching.
• The victim is susceptible to shock and
infection
• Prolonged (months) and incomplete
healing
• The wound is needed to graft to avoid
infection

18. (4)- Fourth Degree Burn Injury
It is characterized by:
•The damage is the most severe in a fourth-
degree burn.
•All layers of skin are completely destroyed,
muscle, fat, bone and tendons are often
affected.
•Dry skin surface and no pain.
•Even amputation is common with these
injuries.
•The victim is usually left with functional
impairment.
•Extensive skin grafting.
•Requires excision.

19. Full thickness
3rd degree
Partial thickness
2n degree
Superficial 1st
degree
Characteristics
Epidermis , dermis, and underling
tissue
Epidermis and dermis
Epidermis
Skin layers lost
Waxy white , dry, leathery, charred
Fluid-filled blisters, bright pink,
may appear waxy white with deep
partial thickness burn
Red, may have
local edema
Skin appearance over
burn
Absent
Absent
Present
Skin function
Absent
Present
Present
Pain sensation
Little pain , edema
Severe pain, edema
Pain , local
edema
Manifestation of the
burn site
Regular cleaning
Topical
agents
Skin grafting
Regular cleaning
Topical agents
My require skin grafting
Regular
cleaning
Topical agents
Mild analgesics
Treatment
Occurs in grafted area
May occur in deep burn
Non
Scarring
Requires skin grafting to heal
7-14 days
3-7 days
Time to heal

20. Classification according Total Body
Surface Area (TBSA) The injured part
is assessed by using the following:
• Rule of Nine ( See Fig. 2)
• Lund and Browder burn assessment Chart (See Fig. 3).
Rule of Palm (Rule of Five). (See Fig. 4).

21. • Rule of Nine

22. Lund and Browder Assessment Chart

23. Rule of Palm

24. III- Classification according to the Severity of
the burn injury:
Minor Burns
• Less than 15% body surface area in the low-risk group (Age 10-50 yrs).
• Less than 10% body surface area in the high-risk group (Age <10 or >50).
• Full-thickness burns that are less than 2% body surface area in others.
Moderate Burns
• Partial-thickness burns of 15 to 25% body surface area in the low-risk
group (Age 10-50 yrs).
• Partial-thickness burns of 10-20% body surface area in the higher-risk
group (Age <10 or >50).
• Full-thickness burns of at least 10% body surface area or less in others.

25. Major Burns
• Any burns in infants or the elderly.
• Any burns involving the hands, face, feet or perineum.
• Burns complicated by fractures or other trauma.
• Burns complicated by inhalation injury.
• Burns crossing major joints.
• Burns extending completely around the circumference of
a limb.
• Electrical burns.
• Full-thickness burns of greater than 10% body surface
area in any risk group.
• Partial-thickness burns more than 20% body surface area
in the high- risk group (Age <10 or >50).
• Partial-thickness burns more than 25% of the body
surface area in the low-risk group (Age 10-50 yrs).

26. Factors that determining the severity of the burn injury: -
1. Mechanism of the burn injury (electrical burn is more danger).
2. Location of burn injury (head, chest, feet, hands, perineum,
and circumferential burn injury are more danger).
3. Age of the victim (high mortality among children and old age).
4. General health status of the victim (the victim with history of
cardiovascular, pulmonary, renal, or neurological problem more
danger).
5. Percentage of total Body Surface Area (TBSA).

27. Patho-physiology of the major burn injury

28. Complications of Burn Injury
1- Fluids and electrolyte imbalance
2- Hypovolemic shock
3- Anemia
4- Impairment of immune system
5- Respiratory Problems as:
(a)- Inhalation Injury as smoke inhalation which is characterized by:
• Singed hairs, nasal hair, bread, eyelids or eyelashes.
• Hoarseness
• Copious sputum production
• Smell of smoke on victim's cloths
(b)- Respiratory distress
6- Oliguria and may lead to renal failure.

29. Complications of Burn Injury
7- Contracture and limited range of
motion.
8- Hypertrophic scaring.
9- Curling's Ulcer (Ulceration of
duodenum and stomach).

30. Burn care Management
The aims of burn management are
 Reduced mortality and morbidity
 Reducing the degree of pain
 Reducing the rate of infection
 Reducing the degree of scarring
 Increased healing rate

31. Nursing Management
1- First Aids of burn injury:
First Degree Burn Injury (Superficial Burn Injury)
Do------
- Apply cold water
- Mild local analgesic
Don't---------
- Apply butter or oleomargarine

32. Nursing Management
Second Degree Burn Injury (Partial thickness Burn Injury)
Do------
- Immerse in cold water
- Loosen or remove of constricting clothes, shoes, or jewelry
- Treat for shock
- Obtain medical attention if severe
- Cover the wound
Don't---------
- Break blisters
- Remove Shreds tissue
- Use ointment home remedy

33. Nursing Management
Third and Fourth Degree Burn Injury (Full Thickness Burn Injury)
Do------
-Cover burn with sterile cloth to protect it
-Treat victim for shock
-Watch for breathing difficulty
-Obtain medical attention quickly
Don't---------
- Remove charred clothing that is stuck to the skin
- Apply ice
- Use home medication

34. Nursing Management
Chemical Burn injury
Do------
- Remove chemical powder if present at first
- Flushing the burn part by large amount of water at least
20 minutes or longer
- Remove surrounding clothes

35. Nursing Management
Chemical injury in the eyes
Do------
- Flush the eye with water or milk immediately
- Loosely bandage both eyes with cold wet dressing
- Seek immediate medical attention

36. 2- Nursing Care during Emergent Phase
(A)- General Assessment:
1. Assessment of the air way, breathing, and circulation (ABC).
2. Assess the presence of hypovolemia.
3. Insert indwelling urinary catheter and I.V. lines.
4. Assess the total body surface area injured by using rule of nine
5. Assess the respiratory condition.
6. Assess the weight of the victims
7. Assess the temperature of the victims.
8. Assess the educational level and cultural background, religion,
and occupational history to help the nurse during providing the
care.

37. Nursing Diagnosis:
1. Impaired in gas exchange related to inhalation injury
2. Fluid volume deficit related to increased capillary permeability
3. High risk for hypothermia related to open wound
4. Altered in nutritional status related to altered in gastro-intestinal
function
5. Impaired in physical mobility related to low immunity
6. Pain related to treatment procedure
7. High risk for infection related to low immunity
8. Body image disturbance related to disfigurements

38. (C) Nursing planning and nursing intervention:
(1) Maintain patent airway:
• The nurse reports the doctor about any
respiratory problem
• Oxygen mask according doctor ordered
• Endo tracheal intubation may be used in severe
cases
• Aggressive Pulmonary care as, deep breathing,
coughing, and tracheal suction

39. (C) Nursing planning and nursing intervention:
(2)- Maintain fluids and electrolyte balance:
- Monitor intake and output.
- I.V. fluids are used according the following formula (Parkland
formula):
4ml. L.R. x Weight kg. x TBSA of Burn
L.R. = Lactated Ringer (Na + K + Ca )
TBSA= Total body surface area

40. Fluids administrated during the 1st 24 hours according
the following:
• One half of the total amount is given in the 1st 8 hours
• One fourth of the solution is given in the 2nd 8 hours
• The remaining one fourth is given in the 3rd 8 hours.
- The fluids administrated during the 2nd 24 hours according the
following:
• One half to two thirds of the initial 24 hours volume is
required.
• Begin to give victim colloid and plasma.

41. (3)- Maintain normal body temperature:
• Limit wound exposure time during dressing
changes.
• Maintain room temperature.
• Limit hydrotherapy treatment sessions to 30
minutes or less with water temperature 37.2 c to
39.3 c .
• Keep procedure rooms and surgical suits warm.

42. (4)- Maintain optimal nutritional status:
• Insert naso-gastric tube to prevent vomiting and aspiration of
gastric content into the lungs.
• Maintain daily calories counts and weight according the
following formula ( Currari Formula):
(25 Kcal X Kg of body weight ) + (40 Kcal X % TBSA of
burn)
• Provide high calories, high protein diet with supplements.
• Consult dietitian in diet planning.
• Involve the victim in choice of preferable diet.
• Avoid painful procedure near meal time.
• Provide relaxed and calm environment.

43. (5)- Achievement of optimal physical mobility:
•Proper position of the victim to prevent pressure ulcer.
•Both active and passive range of motion exercise is
initiated from the day of admission.
•Splints may be applied to extremities to prevent contracture.
(6) Reduction of pain and discomfort:
•Minimize wound exposure time.
•Analgesics are given 30 minutes before dressing change.
•Instruct the victim to follow the relaxation techniques.
•Reassure the victim about his condition.

44. (7)- Absence of infection and wound healing begin:
• Follow aseptic technique during wound care
procedures.
• The nurse protects the victim from across infection
from the other victims.
• Monitor for signs of infection.
• Establish isolation techniques.

45. Wound Care:
(1)-Hydrotherapy:
It is accomplished by:
• Immersion
• Showering
• Spraying
N.B: A hydrotherapy session should be done through 30 minutes or
less to avoid hypothermia and fluid & electrolyte loss.
(2) : Debridement:
It is mean removal of the eschar to promote wound healing. It is
may be:
• Mechanical debridement
• Enzematic debridement
• Surgical debridement

48. Topical antimicrobial Ointment and
dressing:
(a)- Open dressing:
The antimicrobial cream is applied and
then left open to air without gauze
dressings.
(b)- Closed dressing:
The antimicrobial cream is applied and
then the wound wrapped by gauze
dressings.

50. Quiz
A client who is admitted after a thermal burn injury has the
following vital signs: blood pressure, 70/40; heart rate, 140
beats/min; respiratory rate, 25/min. He is pale in color and it is
difficult to find pedal pulses. Which action will the nurse take
first?
A. Start intravenous fluids.
B. Check the pulses using a Doppler device
C. Obtain a complete blood count (CBC)
D. Obtain an electrocardiogram (ECG)

51. A 40-year-old male client who was burned was
admitted under your care. Assessment reveals he has
crackles, respiratory rate of 40/min, and is coughing
up blood-tinged sputum. What action will the nurse
take first?
A. Administer digoxin
B. Perform chest physiotherapy
C. Monitor urine output
D. Place the client in an upright position.

52. The client has burns on both legs. These areas appear
white and leather-like. No blisters or bleeding are
present, and there is no pain.” How will the nurse
categorize this injury?
A. Full-thickness.
B. Partial-thickness superficial
C. Partial-thickness deep
D. Superficial

53. The nurse provides wound care for a client 48 hours
after a burn injury. To achieve the desired outcome of
the procedure, which nursing action will be carried
out first?
A. Applies silver sulfadiazine (Silvadene) ointment
B. Covers the area with an elastic wrap
C. Places a synthetic dressing over the area
D. Removes loose nonviable tissue.

54. What intervention will the nurse implement to reduce a
client’s pain after a burn injury?
A. Administering morphine 4 mg intravenously.
B. Administering antihistamines intramuscularly
C. Applying ice to the burned area
D. Avoiding tactile stimulation

55. When providing care for a client with an acute burn injury, which
nursing intervention is most important to prevent infection by
auto contamination?
A. Avoiding sharing equipment such as blood pressure cuffs
between clients
B. Changing gloves between wound care on different parts of the
client's body.
C. Using the closed method of burn wound management
D. Using proper and consistent handwashing

56. Which assessment finding assists the nurse in confirming
inhalation injury?
A. Cough.
B. Decreased blood pressure
C. Nausea
D. Headache

57. Which finding indicates that fluid resuscitation has been
successful for a client with a burn injury?
A. Hematocrit = 60%
B. Heart rate = 130 beats/min
C. Increased peripheral edema
D. Urine output = 50 mL/hr.

58. What are the main causes of death among people who
initially survive a severe burn?
A. Fever
B. diarrhea
C. Severe dehydration.
D. abdominal pain