The document discusses burns, including definitions, causes, classifications, assessment, and management. Burns are injuries caused by heat, chemicals, electricity, or radiation. They can range from superficial to full thickness. Assessment involves determining burn severity and extent using methods like the Rule of Nine. Management consists of three phases - emergent, acute, and rehabilitation. The emergent phase focuses on fluid resuscitation to prevent shock based on established formulas.

2.  Burns is defined as the injuries
that results from direct contact
with or exposure to any chemical,
thermal or radiation source.
OR
 Burns is defined as injury to the
tissues of the body caused by
heat, chemicals, electric current
or radiation.

3.  Burns can occur at all age groups and socio
economic groups.
 Common in low socio economic groups as
well.
 Burns are the second most common injury
in rural Nepal, accounting for 5% of
disabilities.
 An estimated 1 million Americans and 100,000
Canadians seek medical care each year for
burns.

4. • Approximately, 100,000 are hospitalised and
70,000 people required extensive care
services and an estimated 12,000 of these
people die annually as a direct result of burns.

5. Chemical
burns
Thermal
burns
Electrical
burns
Radiation
burns
Smoke and
inhalation
burns

6.  Chemical burns are caused by contact
with strong acids, alkalis or organic
compound.
 It can be result from contact with certain
household cleansing agents and various
chemical used in industry and agriculture.

8.  Thermal burns are caused by exposure to
or contact with flame, hot liquids, semi
liquids (e.g steam),semisolids (e.g tar) or
hot objects.
 E.g residential fires, explosive
automobile accidents, cooking
accident.

10.  It is caused by heat, that is generated by
the electrical energy as it passess
through the body.
 Direct damage to nerve and vessels
causing tissue anoxia and death can
also occur.
 It can result from contact with exposed
or faulty wiring or high voltage power
lines.

11. ELECTRICALBURNS

13.  This are least common types of burn injury
and are caused by exposure to a radiation
source.
 This types of injuries have been
associated with nuclear radiation
accidents, the use of ionising radiation in
industry and therapeutic irradiation.
 Sun burn from prolonged exposure to UV
rays is also considered to be a radiation
burns.

15.  It results from the inhalation of hot air,
flame or noxious chemical and cause
damage to the tissues of the respiratory
tract.
 A) carbon monoxide poisoning : CO
poisoning and asphyxiation account for
the majority of death at a fire scene.
 It is produced by the incomplete
combustion of burning material

16.  It is subsequently inhaled and displaced
oxygen on the hemoglobin molecule,
causing hypoxia, carboxyhemoglobinemia
and ultimately death.
 Risk of mortality increases 7 times than
cutaneous burns injury.

17. • Contact with flame occurs more than 60%
burn injuries.
• Ignition from cigarettes
• 40% of residential deaths due to alcohol
and drug intoxication
• Children playing with matches, fire
• Synthetic fabric ignition during cooking
• Scald injuries during bathing and cooking

18. Heat from the external
source is
conducted into the skin
Direct injury to the skin
Destroys tissue
At sustained temperature of 54 to 60
degree Celsius various cellular enzyme
system and cellular system fails


19. The sodium potassium fails
and cellular edema will
occur
Cell necrosis occurs
Cell damage
Following a burns injury, vasoactive substance
(Catecholamine,histamine, serotonin, leukotrines, kinins and
prostaglandins) are released from the injured tissue

21. Degree of Injury Based on skin Layers
1 Superficial burns
2 Partial thickness
3 Full thickness
4 Full thickness

23. • Superficial (Partial-
Thickness )/First Degree
burn) :
• cause-Sunburn
• Low-intensity flash
Skin involvement- Epidermis
Symptoms- Reddened, Tingling,
Pain that is soothed by cooling

24. DEEP PARTIAL-
THICKNESS (SECOND
DEGREE)
Cause
• Scalds
• Flash flame
• Contact burns
• chemical
Skin involvement- Epidermis,
upper dermis,
portion of
deeper dermis

25. MANIFESTATIONS:
• Blisters that are red,
shiny.
• Severe pain caused by
nerve injury
• mild to moderate edema
• Recovery in 2 to 4
weeks, some scarring and
depigmentation
contractures

26. FULL-THICKNESS (THIRD
DEGREE)
Cause-
• Flame
• Prolonged exposure to:
hot liquids
Electric current
Chemical

27. • Skin involvement- Epidermis, entire dermis,
and sometimes subcutaneous tissue;
• may involve connective tissue, muscle and
bone

28. MANIFESTATIONS-
Dry; pale white, Leathery, visible
thrombosed blood vessels
• Pain free, all skin elements and local nerve
endings are destroyed, surgical intervention
required for healing

29. 4TH DEGREE/ FULL THICKNESS
BURNS
E+D+S+muscles, tendons & bone
 It involves total destruction of the
epidermis and dermis, subcutaneous layer.
 The burnt area is painless.
 Prolonged exposure or high voltage
electrical injury
 Deep tissue ,muscle and bone

32. • Loss of heat from through the burn wound
• Leads to shivering
• vasoconstriction

33. • Low BP
• Decreased urine output
• Hyponatremia
• Hypernatremia
• Hyperkalemia
• Generalized body edema
• Hypovolemic shock
• Decreased GI motility

34. • Tachypnea
• pO2 decreased in ABG
• CO poisoning
• Dyspnea
• Cyanosis
• Use of respiratory accessory muscles
• Bronchospasm

36. 7. RENALALTERATION
 Destruction of RBC result in free
hemoglobin in urine
 Decreased in urine output
 Acute tubular necrosis
 Increased in urea level
 Renal failure

37. 8. IMMUNOLOGICALTERATION
 Sepsis
 Impaired neutrophil function
 Reduction in lymphocyte
 Resulting in
immunosuppression

38. 9. GASTROINTESTINALALTERATION
 Decreased or absence of bowel sound
stool or flatus
 Nausea, vomiting and abdominal
distention
 Paralytic ileus and curling ulcers( gastric
erosion/necrosis)

39. 10. PSYCHOLOGICAL ALTERATIONS
 Psychological and emotional response
 Body image and ineffective coping
abilities
 Isolation
 Disbelief
 Anxiety
 Grief
 Depression

40. 11. PAIN RESPONSES
 Pain
 Clinical response to pain may include
an increased in BP, heart rate,
respiratory rate with dilated pupils and
rigid muscle tone

41. DIAGNOSTICEVALUATIONS
 History collection
 Physical examination
 ABG analysis
 Na, K, Cl
 CBC
 Prothrombin time
 Bleeding time and clotting time
 RBS, urea and creatinine , ECG,chest
Xray etc

42. • Assess burn severity

43. EXTENT OF TBSA INJURED:
 Rule of nine
 Palm method
 The Lund and Browder
method

44. RULE OFNINE
 It is the quick way to estimate the extent of
burns.
 The system assigns percentages in
multiples of nine to major body surfaces.

48. CRITERIA FOR CLASSIFYING THE EXTENT OF
BURN INJURY(AMERICAN BURN ASSOCIATION)
• Minor Burn Injury:
• Second-degree burn of less than 15% total body
surface area(TBSA) in adults or less than 10%
TBSA in children
• Third-degree burn of less than 2% TBSA not
involving special care areas (eyes, ears, face,
hands, feet, perineum, joints)
• Excludes electrical injury, inhalation injury,
concurrent trauma, all poor-risk patients (eg,
extremes of age, concurrent disease)

49. • Moderate, Uncomplicated Burn Injury:
• Second-degree burns of 15%–25% TBSA in
adults or 10%–20% in children
• Third-degree burns of less than 10% TBSA not
involving special care areas
• Excludes electrical injury, inhalation injury,
concurrent trauma, all poor-risk patients (eg,
extremes of age, concurrent disease)

50. CRITERIA FOR CLASSIFYING THE EXTENT
OF BURN INJURY(AMERICAN BURN
ASSOCIATION)…….
• Major Burn Injury:
• Second-degree burns exceeding 25% TBSA
in adults or 20% in children
• All third-degree burns exceeding 10% TBSA
• All burns involving eyes, ears, face, hands,
feet, perineum, joints
• All inhalation injury, electrical injury,
concurrent trauma, all poor-risk patients

51. PALMMETHOD
 In patient with scattered burns, the palm
method may be used to estimate the
extent of the burns.
 The size of the patient palm is
approximately 1% of the TBSA

52. LUND AND BROWDER METHOD
 The more precise method of estimating the
extent of a burn in the Lund and Browder
method'
 which recognise that the percentage of the
surface area of various anatomical parts
especially the head and legs, changes with
growth

53. LUND AND BROWDERMETHOD

55. MANAGEMENT OF THE PATIENT WITH A
BURN INJURY46
 Burn care must be planned according to
the burn depth and local response, the
extent of the injury, and the presence of
a systemic response.

56. Burn care then proceeds
through three phases:
•Emergent/resuscitative phase (on-the-
scene care),
•Acute/intermediate phase, and
•Rehabilitation phase.

57. • Although priorities exist for each of the
phases, the phases overlap, and
assessment and management of
specific problems and complications are
not limited to these phases but take
place throughout burn care.

58. Phase Duration Priorities
Emergent or
immediate
resuscitative
From onset of injury to
completion
of fluid resuscitation
 First aid
 Prevention of shock
 Prevention of respiratory distress
 Detection and treatment of concomitant
injuries
 Wound assessment and initial care
Acute From beginning of diuresis
to near
completion of wound
closure
 Wound care and closure
 Prevention or treatment of
complications, including infection
 Nutritional support
Rehabilitati
on
From major wound closure
to return
to individual’s optimal level
of physical
and psychosocial
adjustment
 Prevention of scars and contractures
 Physical, occupational, and vocational
rehabilitation
 Functional and cosmetic reconstruction
 Psychosocial counseling

59. EMERGENT/RESUSCITATIVE PHASE
MGT
(MEDICAL MANAGEMENT):
1. First Aid:
 Emergency Procedures at the Burn
Scene
Extinguish the flames
Cool the burn
Remove restrictive objects
Cover the wound
Irrigate chemical burns

60. EMERGENT/RESUSCITATIVE PHASE MGT
2. Emergency Medical Management
 The patient is transported to the nearest
emergency department.
 The hospital nurses (staff) and physician are
alerted that the patient is in route to the
emergency department so that life-saving
measures can be initiated immediately by a
trained team.
 Initial priorities in the emergency
department remain airway, breathing,
and circulation.

61. EMERGENT/RESUSCITATIVE PHASE MGT
Emergency Medical Management cont’d
 For mild pulmonary injury, inspired air is
humidified and the patient is encouraged to
cough so that secretions can be removed by
suctioning.
 For more severe situations, it is necessary to
remove secretions by bronchial suctioning
and to administer bronchodilators and
mucolytic agents.
 If edema of the airway develops,
endotracheal intubation may be
necessary.

62. EMERGENT/RESUSCITATIVE PHASE MGT
Emergency Medical Management cont’d
 Continuous positive airway pressure and
mechanical ventilation may also be required to
achieve adequate oxygenation.
 A large-bore (16- or 18-gauge) intravenous
catheter should be inserted in a non-burned area
(if not inserted earlier).

63. EMERGENT/RESUSCITATIVE PHASE MGT
Emergency Medical Management cont’d
 Assessment of both the TBSA burned and the
depth of the burn is completed after soot and
debris have been gently cleansed from the
burn wound.
 An indwelling urinary catheter is inserted to
permit more accurate monitoring of urine
output and renal function for patients with
moderate to severe burns.

64. 3. MANAGEMENT OF FLUID LOSS AND SHOCK
Fluid Replacement Therapy:
 The total volume and rate of intravenous
fluid replacement are gauged by the
patient’s response.
 The adequacy of fluid resuscitation is
determined by:
Output totals of 30 to 50 mL/hour
systolic blood pressure exceeding 100
mm Hg and/or
 pulse rate less than 110/minute.

65. CONDITIONS LEADING TO BURN SHOCK
5
4

66. MANAGEMENT OF FLUID LOSS AND SHOCK
Fluid Requirements:
 The projected fluid requirements for the first
24 hours are calculated by the clinician
based on the extent of the burn injury.
 Some combination of fluid categories
may be used:
Colloids (whole blood, plasma, and
plasma expanders) and
 Crystalloids/electrolytes (physiologic
sodium chloride or lactated Ringer’s
solution).

67. MANAGEMENT OF FLUID LOSS AND SHOCK
Fluid Requirements:
 Adequate fluid resuscitation results in
slightly decreased blood volume levels
during the first 24 post-burn hours and
restores plasma levels to normal by the end
of 48 hours.
 Oral resuscitation can be successful in
adults with less than 20% TBSA and
children with less than 10% to 15% TBSA.

68. GUIDELINES AND FORMULAS FOR FLUID REPLACEMENT IN
BURN PATIENTS
i. Consensus Formula
 Lactated Ringer’s solution (or other
balanced saline solution): 2–4 mL× kg
body weight × % total body surface area
(TBSA) burned.
 Half to be given in first 8 hours; remaining
half to be given over next 16 hours.

69.  The following example illustrates use of
the formula in a management of a 70-kg
patient with a 50% TBSA burn:
 Steps
1, Consensus formula: 2 to 4 mL/kg/%
TBSA
2, 2 × 70 × 50 = 7,000 mL/24 hours
3, Plan to administer: First 8 hours = 3,500
mL, or 437 mL/ hour; next 16 hours =
3,500 mL, or 219 mL/hour

70. ii. Evans Formula
 1. Colloids: 1 mL × kg body weight × % TBSA
burned
 2. Electrolytes (saline): 1 mL × body weight × %
TBSA burned
 3. Glucose (5% in water): 2,000 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 day’s colloids and
electrolytes; all of insensible fluid replacement

71. iii. Brooke Army Formula
 1. Colloids: 0.5 mL × kg body weight × %
TBSA burned
 2. Electrolytes (lactated Ringer’s solution): 1.5
mL × kg body weight × % TBSA burned
 3. Glucose (5% in water): 2,000 mL for
insensible loss

72. Brooke Army Formula cont’d
 Day 1: Half to be given in first 8
hours; remaining half over next16
hours
 Day 2: Half of colloids; half of electrolytes;
all of insensible fluid replacement.
 Second- and third-degree (partial- and
full- thickness) burns exceeding 50%
TBSA are calculated on the basis of
50% TBSA.

73. iv. Parkland/Baxter Formula
 Lactated Ringer’s solution: 4 mL × kg
body weight × % TBSA burned
 Day 1: Half to be given in first 8 hours;
half to be given over next16 hours
 Day 2: Varies. Colloid is added.

74. Hypertonic Saline Solution
 Concentrated solutions of sodium chloride
(NaCl) and lactate with concentration of 250–
300 mEq of sodium per liter, administered at a
rate sufficient to maintain a desired volume of
urinary output.
 Do not increase the infusion rate during the
first 8 post burn hours.
 Serum sodium levels must be monitored closely.
 Goal: Increase serum sodium level and
osmolality to reduce edema and prevent
pulmonary complications.

75. • 4. prevent aspiration
• 5. minimize pain and anxiety
• Wound care:
• Stop the burning process
• Prevent tetanus
• Prevent tissue ischemia- escharotomy,
Fasciotomy
• Transport to burn facility

76. ESCHAROTOMY

77. FASCIOTOMY

78. NURSING MANAGEMENT
• Includes Assessment:
• infection prevention,
 wound cleansing and
 administering topical antibacterial drugs
like:
 Silver sulfadiazine 1% (Silvadene)
 watersoluble cream,
 Silver nitrate 0.5% aqueous solution,
 Mafenide acetate 5% to 10% (Sulfamylon)
hydrophilic- based cream,
 Acticoat, etc

79. AIRWAYMANAGEMENT
 Airway management frequently involves
endotracheal intubation
 Early intubation eliminates the necessity for
emergency tracheostomy after respiratory
problems have become apparent
 After intubation, the patient may be placed on
ventilatory assistance and the delivered
oxygen is determined by assessing ABG
values

80.  When intubation is not performed,
supplemental oxygen is given/provided.
 Fowlers position should be provided unless
contraindicated by a possible spinal injury.

81. • Maintaining effective gas exchange
• Maintaining adequate fluid volume
• Maintaining effective tissue perfusion Renal
& peripheral.
• Pain management
• Preventing risk for infection

82. ACUTE PHASE MANAGEMENT
(MEDICAL MANAGEMENT):
 Hemodynamically stable through diuresis
 Capillary permeability is restored
 48-72 hours after injury
 Goal is restorative therapy
 Focus on infection control, wound care and
closure, nutritional support, pain
management, PT
 Concluded when the burned area is
completely covered by skin grafts or
when the wounds are healed

83. ACUTE PHASE MANAGEMENT
Pathophysiology
 Diuresis from fluid mobilization occurs,
and the patient is no longer grossly
edematous
 Bowel sounds return
 Healing begins
 Formation of granulation tissue
 A partial-thickness burn wound will heal
from the edges
 Full-thickness burns must be covered by
skin grafts

84. ACUTE PHASE MANAGEMENT
• Wound Care
 Daily observation
 Assessment
 Cleansing
 Debridement
 Appropriate coverage of the graft:
 Fine-mesh gauze next to the graft followed by
middle and outer dressings
 Sheet skin grafts must be kept
free of blebs (small blisters)

85. ACUTE PHASE MANAGEMENT
Excision and Grafting
 Eschar is removed down to the
subcutaneous tissue or fascia
 Cultured Epithelial Autographs (CEA): CEA
is grown from biopsies obtained from the
patient’s own skin
 Artificial Skin: used when life-threatening
full- thickness or deep partial-thickness
wounds where conventional autograft is not
available or advisable

86. ACUTE PHASE MANAGEMENT
Pain Management
 Opioid every 1 to 3 hours for
pain
 Several drugs in combination
 Morphine with haloperidol
 Nonpharmacologic strategies
• Relaxation tapes
• Visualization, guided
imagery
• Meditation

87. ACUTE PHASE MANAGEMENT DEBRIDING FULL-
THICKNESS BURN
7
0

89. NURSING MANAGEMENT DURING ACUTE PHASE OF
BURN INJURY
• Maintaining effective gas exchange
• Maintaining effective airway
• Maintaining core body temperature.
• Pain management
• Preventing risk for infection, stress ulcers,
• Improve physical mobility

90. SURGICAL MANAGEMENT DURING ACUTE
PHASE:
• Auto grafting/ split thickness graft
• Full thickness graft

91. ACUTE PHASE MANAGEMENT
SURGEON HARVESTING SKIN
7
1

92. ACUTE PHASE MANAGEMENT DONOR
SITE AFTER HARVESTING
7
2

93. ACUTE PHASE MANAGEMENT HEALED SPLIT-
THICKNESS SKIN GRAFT
7
3

94. ACUTE PHASE MANAGEMENT
APPLICATION OF CULTURED EPITHELIAL AUTOGRAFT
7
4

95. NURSING MANAGEMENT DURING:
• Pre operative care:
• Assessment
• Proper prior information
• Same as other pre
operative orders
• Post operative care:
• Same as other.
• Assessment of bleeding, pain
control
• Dressing
• Immobilize the grafted site
• Elevate the grafted site
• Bed rest.

96. REHABILITATION PHASE
 The rehabilitation phase is defined as
beginning when the patient’s burn wounds
are covered with skin or healed and the
patient is able to resume a level of self-care
activity
 Complications
 Skin and joint contractures
 Hypertrophic scarring

97. CONTRACTURE OF THE AXILLA
7
6

98. REHABILITATION PHASE
 Both patient and family actively learn how to
care for healing wounds
 Cosmetic surgery is often needed following major
burns
 Role of exercise cannot be overemphasized
 Constant encouragement and reassurance
 Address spiritual and cultural needs
 Maintain a high-calorie, high-protein diet
 Occupational therapy

99. BED CRADLE

100. THANK YOU