this chapter belongs to Medical surgical nursing subject for 3rd year BSc & first yr PbBSc students. this ppt helps the students to learn & understand regarding burn injury, classification, assessment, pathophysiology & management.

1. MANAGEMENT
OF
PATIENTS
WITH BURN
INJURY

2. REVIEW ON SKIN ANATOMY

3. MAJOR GOALS RELATED TO BURNS
1. PREVENTION
2. INSTITUTION OF LIFE SAVING MEASURES FOR
THE SEVERELY BURNED PERSON
3. PREVENTION OF DISABILITY & DISFIGUREMENT
THROUGH EARLY, SPECIALISED &
INDIVIDUALIZED TREATMENT
4. REHABILITATION THROUGH RECONSTRUCTIVE
SURGERY & REHABILITATIVE PROGRAMS

4. CLASSIFICATION OF BURN
INJURY
1. ACCORDING TO DEPTH OF BURN INJURY
2. ACCORDING TO EXTENT OF BURN INJURY
3. ACCORDING TO SEVERITY OF BURN INJURY

5. 1. According To Depth Of Burn Injury
● Superficial Partial Thickness Burns - involves epidermis &
superficial layers of dermis, upto papillary dermis. Wound
heals in less than 2 weeks.
● Superficial Deep Dermal Burns - involves beyond papillary
dermis takes more than 2 weeks for healing.
● Full Thickness Burns - Involves all layers of skin & sometimes
underlying tissues are also affected.

7. 2. According To Extent Of Burn Injury
FIRST DEGREE BURNS
Superficial burns manifests as pink to red discoloration with
slight edema associated with pain which relieves on cooling.
Within 5 days epidermis peels off, healing within 10 -15 days.
SECOND DEGREE BURNS
a) Superficial 2nd degree burns - presented as pink or red
discoloration with blister formation., weeping & edema.
Superficial skin layers are destroyed. Wound becomes painful &
moist & takes several time to heal.

8. b) Second degree deep dermal burns - manifested as mottled
white & red area become pale on pressure.hair does not pull
out easily. Wound takes several weeks to heal & scar may
develop.
THIRD DEGREE BURNS
Destruction of epithelial cells, fat cells, muscles & bones. It is
not painful, inelastic & discoloration may vary from waxy
white to brown. Eschar & granulation tissue develops. Grafting
is required.

10. 3. ACCORDING TO SEVERITY OF BURN INJURY
Depends upon total area injured, depth of injury, location of injury, age,
general health of the patient, presence of additional injury.
MINOR BURNS
● 15% total body surface area ( TBSA) burnt with first & 2nd degree
burns.
● Third degree burns of <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.

11. MODERATE BURNS
● 2nd degree burns of 15 -25% TBSA .
● 3rd degree burns of <10% TBSA but not involving special care areas.
● Excludes electrical injury, inhalation injury, concurrent trauma, all poor
risk patients.
MAJOR BURNS
● 2nd degree burns exceeding 25% TBSA.
● All 3rd degree burns exceeding 10% TBSA
● All burns including special care areas.
● All electrical injury, inhalation injury, concurrent trauma, all poor risk
patients.

12. PATHOPHYSIOLOGY OF BURNS
● Burns are categorized as THERMAL, RADIATION OR
CHEMICAL.
● Burns are caused by a transfer of energy from a heat
source to the body through conduction or
electromagnetic radiation.
● Tissue destruction results from coagulation, protein
denaturation or ionization of cellular contents.

14. ZONES OF
BURN
INJURY

15. 1. THE INNER ZONE / ZONE OF
COAGULATION : Sustains the most damage
& where the cellular death occurs.
2. THE MIDDLE AREA / ZONE OF STASIS :
Compromised blood supply, inflammation &
tissue injury.
3. THE OUTER ZONE / ZONE OF
HYPEREMIA : Sustains the least damage.

16. EXTENT OF
BODY SURFACE
AREA INJURED
1. RULE OF NINES
2. LUND & BROWDER
METHOD
3. PALM METHOD

17. RULE OF NINES
● A quick way to calculate the extent of burns.
● The system assigns percentages in multiples of nine to
major body surface area.

19. LUND & BROWDER METHOD
● It is analyzed by dividing the body into very small
areas & providing an estimate of the proportion of
TBSA accounted for by such body parts.
PALM METHOD
● The size of the patient’s palm is approximately 1%
of TBSA.

20. PATHOPHYSIOLOGIC
CHANGES AFTER
MAJOR BURN

22. MANAGEMENT OF
PATIENT WITH BURN
INJURY
PHASES OF BURN CARE

24. EMERGENT/RESUSCITATIV
E PHASE

25. ON THE SCENE CARE
● Airway
● Breathing
● Circulation: Cervical spine immobilization for patients
with high voltage electrical injuries, cardiac monitoring
for all patients with electrical injuries.
● Assess Apical pulse, BP frequently
● Assess neurologic status for patients with extensive
burns.

26. Contd….
● Transfer to the burn care centre.
Management of fluid loss & shock
FLUID REPLACEMENT THERAPY
● The total volume & rate of IV fluid replacement are gauged by the
patient’s response.
● The adequacy of fluid resuscitation is determined by following
urine output totals, an index of renal perfusion.
● Output totals of 30-50 ml/hr have been used as goals.
● Other indicators are a Systolic BP exceeding 100 mm Hg & or a PR
< 110/mn.

28. EXAMPLE..
A 30 yr old man with a 50% TBSA burns presented to the
emergency department. Calculate the fluid requirement
for this patient using Consensus formula. (Weight of the
patient-70Kg)
● CONSENSUS FORMULA = 2-4 ml x Kg body weight x % TBSA
● Fluid requirement = 2 x 70 x 50 = 7,000ml/24 hrs

29. Plan to administer:
● First 8 hours = 3,500ml, or 437 ml/hour
● Next 16 hrs = 3,500ml, or 219 ml/hour

30. How to make IV PLAN???
1. Amount of time required for each pint
= TOTAL NO. OF HOURS ÷ TOTAL NO. OF PINTS
1. Number of drops per minute
= 500 × NO. OF PINTS × DROP FACTOR
TOTAL NO. OF TIME × 60
Drop factor = 15
For blood transfusion, drop factor = 20

32. PREVENT ASPIRATION -
● Insertion of NG tube
● NPO status
MINIMIZE PAIN & ANXIETY
● Administration of IV opioids, typically Morphine Sulphate or
Fentanyl. Small doses are repeated in 5-10 minute intervals.
PREVENTION OF TETANUS
● Patients who didn't receive a TT booster within past 5 years,
should receive a TT booster.

33. CLINICAL
MANIFESTATIONS
OF BURN INJURY
● HYPOTHERMIA
● FLUID & ELECTROLYTE
IMBALANCE
● ALTERATIONS IN
RESPIRATION
● DECREASED CARDIAC
OUTPUT
● PAIN RESPONSES
● ALTERED LOC
● PSYCHOLOGICAL
ALTERATIONS

34. NURSING Mx in EMERGENT PHASE
1. Impaired gas exchange related to CO poisoning, smoke
inhalation & upper airway obstruction.
● Provide humidified Oxygen
● Assess breath sounds, RR, rhythm, depth & symmetry.
Monitor for signs of hypoxia
● Observe for erythema or blistering of lips or buccal
mucosa, singed nostrils, burns of face,neck or chest &
soot in sputum or tracheal tissue in respiratory
secretions.
● Monitor ABG

35. ● Report laboured respirations, decreased depth of respirations
● Prepare to assist with intubation & mechanical ventilation.
2. Ineffective airway clearance related to edema & effects of
smoke inhalation.
3. Fluid volume deficit related to increased capillary permeability
& evaporative losses from the burn wound.
4. Hypothermia related to loss of skin microcirculation & open
wounds.
5. Pain related to tissue & nerve injury.
6. Anxiety related to fear & the emotional impact of burn injury.

36. COMPLICATIONS…….
● ACUTE RESPIRATORY
FAILURE
● DISTRIBUTIVE SHOCK
● ACUTE RENAL FAILURE
● COMPARTMENT
SYNDROME
● PARALYTIC ILEUS
● CURLING’S ULCER

37. ACUTE /
INTERMEDIATE PHASE

38. PRIORITIES...
● Continued assessment & maintenance of RESPIRATORY,
CIRCULATORY STATUS, FLUID & ELECTROLYTE BALANCE &
GI FUNCTION.
● Infection Prevention
● Pain Mx
● Nutritional Support
● Burn Wound Care ( wound cleaning, wound debridement
& wound grafting).

40. Clinical Manifestations in Acute Phase
● DIURESIS
● SYMPTOMS OF FLUID OVERLOAD & CCF in elderly or
patients with existing cardiac diseases.
● FEVER

41. 1. INFECTION PREVENTION
● Burn wound is an excellent medium for bacterial growth
& proliferation.
● The burn eschar is non viable crust with no blood supply,
therefore neither polymorphonuclear leukocytes or
antibodies nor systemic antibodies can reach the area.
● Microbes can be Staphylococcus, Proteus, Pseudomonas,
Escheria coli, Klebsiella.
● Staphylococci & Enterococci are responsible for > 50% of
nosocomial bloodstream infections.

42. CHARACTERISTICS OF BURN WOUND SEPSIS
● 105 bacteria per gram tissue
● Inflammation
● Sludging & thrombosis of dermal blood vessels

43. ● The primary source of infection is patient’s GI tract itself.
● Secondary source of infection is the environment.
● Use of clean aseptic techniques & PPE is must for the burn
care.
● Tissue specimens ( swab, surface or tissue biopsy
cultures) to monitor colonization of wound by microbes.
● Invasive wound biopsy cultures may require.
● Prophylactic administration of antibiotics.
● Systemic antibiotics in case of sepsis. (sensitivity test
should be done prior).

44. 2. WOUND CLEANING
● HYDROTHERAPY in the form of shower carts, individual
showers & bed baths can be used for cleaning wounds.
● Tap water alone can be used for cleaning.
● Temperature of the water is maintained at 37.8 degree C (100
degree F).
● Temperature of the room is maintained at 26.6 degree C &
29.4 degree C (80- 85 degree F).
● Hydrotherapy should be limited to 20-30 minutes to prevent
chilling of the patient & additional metabolic stress.

45. GOAL OF WOUND CLEANING
Protect the wound from overwhelming proliferation of
pathogenic organisms & invasion of deeper tissues until
either spontaneous healing or skin grafting can be achieved.

46. Assess for signs of:-
1. CHILLING
2. FATIGUE
3. CHANGES IN HEMODYNAMIC STATUS
4. PAIN UNRELIEVED BY ANALGESIC MEDICATIONS or
RELAXATION TECHNIQUES.

47. 3. TOPICAL ANTIBACTERIAL THERAPY
● Topical antibacterial therapy does not sterilize the
wound; it simply reduces the number of bacteria.
● It promotes conversion of the open, dirty wound to a
closed, clean one.
● The three most commonly used topical agents are SILVER
SULFADIAZINE, SILVER NITRATE & MAFENIDE ACETATE.
● Others are POVIDONE-IODINE OINTMENT 10%,
GENTAMICIN SULPHATE, NITROFURAZONE, DAKIN’S
SOLUTION, ACETIC ACID, MICONAZOLE &
CHLORTRIMAZOLE.

48. CRITERIA FOR USING TOPICAL AGENTS
● It is effective against gram negative organisms,
Pseudomonas aeruginosa, Staphylococcus aureus & even
Fungi.
● It is clinically effective.
● It penetrates the eschar but is not systemically toxic.
● It doesn't lose its effectiveness, allowing another
infection to develop.
● It is cost effective, available & acceptable to the patient.
● It is easy to apply, minimizing nursing care time.

49. ● A newer product available is ACTICOAT ANTIMICROBIAL
BARRIER DRESSING.
● ACTICOAT is a silver coated dressing approved for the
treatment of burn wounds & DONOR SITES.

51. 4. WOUND DRESSING
When the wound is clean, the burned areas are patted dry &
the prescribed topical agent is applied; the wound is then
covered with several layers of dressings.

52. ● A light dressing is used over joint areas to allow for range
of motion (unless the particular area has a graft & motion
is contraindicated).
● Circumferential dressings should be applied distal to
proximally.
● Burns to the face may be left open to air once they have
been cleaned & the topical agent has been applied.

53. OCCLUSIVE DRESSINGS
● An occlusive dressing is a thin gauze that is impregnated
with a topical antimicrobial agent or that is applied for
topical antimicrobial application.
● They are most often used over areas with new skin grafts.
● Their purpose is to protect the graft, promoting an
optimal condition for its adherence to the recipient site.
● The dressings remain in place for 3 - 5 days, at which time
they are removed for examination of the skin graft.

54. DRESSING CHANGES
● Dressings are changed in the patient’s unit, hydrotherapy
room, or treatment area approximately 20 minutes after
administering analgesics.
● Health care professionals should wear all PPE while
removing the dressings.
● The outer dressings are slit with blunt scissors, & the
soiled dressings are removed & disposed.
● Dressings that are adhere to the wound can be removed
more comfortably if they are moistened with tap water or
if the patient is allowed to soak for a few minutes in the
tub.

55. ● The wounds are then cleaned & debrided to remove
debris, any remaining topical agent, exudate & dead
skin.
● Sterile scissors & forceps may be used to trim loose eschar
& encourage separation of devitalized skin.
● Assess for the COLOR, ODOR, SIZE, EXUDATE, SIGNS OF
RE-EPITHELIALIZATION & OTHER CHARACTERISTICS OF
THE WOUND & THE ESCHAR & ANY CHANGES FROM THE
PREVIOUS DRESSING CHANGE ARE NOTED.

56. 5. WOUND DEBRIDEMENT
● A debris accumulates on the wound surface, it can retard
keratinocyte migration, thus delaying the
epithelialization process.
GOALS OF WOUND DEBRIDEMENT
1. To remove tissue contaminated by bacteria & foreign
bodies, thereby protecting the patient from invasion of
bacteria.
2. To remove devitalized tissue or burn eschar in
preparation for grafting & wound healing.

57. 3 TYPES OF
WOUND
DEBRIDEMENT
1. NATURAL
DEBRIDEMENT
2. MECHANICAL
DEBRIDEMENT
3. SURGICAL
DEBRIDEMENT

58. 6. GRAFTING OF BURN WOUND
● If wounds are deep or extensive, spontaneous re-
epithelialization is not possible.
● Therefore coverage of the burn wound is necessary until
coverage with a graft of the patient’s own skin
(AUTOGRAFT) is possible.

59. PURPOSES OF WOUND COVERAGE
● To decrease the risk of infection.
● Prevent further loss of protein, fluid & electrolytes
through the wound
● Minimize heat loss through evaporation
● Grafting permits earlier functional ability & reduces
contractures.

60. TYPES OF GRAFTING
● BIOLOGIC
● BIOSYNTHETIC
● SYNTHETIC
● AUTOLOGOUS
● COMBINATION METHODS

61. ● The main areas for skin grafting include the face ( for
cosmetic & psychological reasons)
● Functional areas such as hands & feet
● Areas that involve joints.
● When the burns are very extensive, the chest &
abdomen may be grafted first to reduce the burn
surface.

62. CHARACTERISTICS OF GRANULATION
TISSUE
● PINK
● FIRM
● SHINY
● FREE OF EXUDATE & DEBRIS
● Should have a bacterial count of < 100,000 per tissue.

63. 1. BIOLOGIC DRESSINGS
USES
● In extensive burns, they provides temporary wound
closure & protects the granulation tissue until
autografting is possible.
● It is commonly used in patients with large areas of burn &
little remaining normal skin donor sites.
● It is also used to debride wounds after eschar separation.

64. ● It also provide temporary immediate coverage for clean,
superficial burns & decrease the wound’s evaporative
water & protein loss.
● They decrease pain by protecting nerve endings.
● They act as an effective barrier against entry of bacteria.
● When applied to superficial partial thickness burns, it
increases the speed of healing.

65. BIOLOGIC
DRESSINGS
CONSISTS OF:- 1. HOMOGRAFTS
2. HETEROGRAFTS

66. HOMOGRAFTS
● They are skin obtained from living or recently deceased
humans.
● The amniotic membrane (amnion) from the human
placenta may also be used as biologic dressing.
● It is very expensive.
● They are available in from skin banks in fresh &
cryopreserved (frozen) forms.

67. ● It provides the best infection control of all the biologic or
biosynthetic dressings available.
● Revascularization occurs within 48 hrs, & the graft may
be left in place for several weeks.
● Cost, availability & transmission of disease limits the use
of homografts.

68. HETEROGRAFTS
● It consists of skin taken from animals (usually pigs).
● Pigskin available from commercial suppliers are in fresh,
frozen or lyophilized (freeze-dried) forms for longer shelf
life.
● Pigskin impregnated with a topical antibacterial agent
such as silver nitrate is also available.
● It is used for temporary covering of clean wounds such as
superficial partial thickness wounds & donor sites.

69. 2. BIOSYNTHETIC & SYNTHETIC
DRESSINGS
Problems with the availability, sterility & cost have
prompted the search for biosynthetic & synthetic skin
substitutes, which may eventually replace biologic dressings
as temporary wound coverage.

70. BIOBRANE
● Most widely used synthetic dressing.
● It is composed of a nylon, Silastic membrane combined
with a collagen derivative.
● The material is semitransparent & sterile.
● It has an indefinite shelf life & is less costly than
homograft or pigskin.
● It protect the wound from fluid loss & bacterial invasion.

71. ● Biobrane adheres to the wound fibrin, which binds to the
nylon-collagen material.
● Within 5 days cells migrate in to the nylon mesh.
● When biobrane dressings adheres to the wound, the
wound remains stable & it can remain in place for 3-4
weeks.
● It can readily adhere to donor sites & meticulously clean
debrided partial thickness wounds & they will remain
until spontaneous epithelialization & wound healing
occur.

74. ● As the biobrane gradually separates, it is trimmed,
leaving a healed wound.
● It is also useful for intermediate or long term closure of a
surgically excised wound until an autograft becomes
available.
● It should not be used over grossly contaminated or
necrotic wounds.

75. BCG Matrix
● This dressing combines a beta glucan, a complex
carbohydrate, with collagen in a meshed reinforced
wound dressing.
● Beta glucan is known to stimulate macrophages, which
are vital in the inflammatory process of healing.
● It is a temporary wound covering intended for use with
partial thickness burns & donor sites.
● It is applied immediately after cleaning & debridement.

76. OTHER EXAMPLES…….
1. OP-SITE
2. TEGADERM
3. N-TERFACE
4. DUODERM
5. TRANCYTE

77. 3. DERMAL SUBSTITUTES
Dermal substitutes are created in attempt to develop an
ideal wound covering product. Two such products are:-
1. INTEGRA ARTIFICIAL SKIN
2. ALLODERM

78. INTEGRA ARTIFICIAL SKIN
● It is the newest type of dermal substitute.
● It is composed of two layers; EPIDERMAL & DERMAL
● The epidermal layer, consisting of SILASTIC, acts as a
bacterial barrier & prevents water loss from the dermis.
● The dermal layer is composed of animal collagen.
● It interferes with the open wound surface & allows
migration of fibroblasts & capillaries in to the material.

79. ● This forms the NEODERMIS & becomes a permanent
structure.
● The integra is biodegraded & reabsorbed.
● The outer silicone membrane is removed 2-3 weeks after
application & is replaced with the patient’s own skin in
the form of a thin epidermal skin graft.
● The graft is very pliable, almost eliminating the need for
repeated cosmetic surgery.

80. ● Integra has resulted in less hypertrophic scarring, thus
eliminating the need for compression devices once burn
wound has healed.
● Use of integra is ;
1. Increasing the survivability of burns
2. Improves the functional & cosmetic qualities the healed
burn.
● Long term effects of integra include MINIMAL
CONTRACTURE FORMATION.

83. ALLODERM
● It is processed dermis from human cadaver skin, which
can be used as dermal layer of the skin graft.
● It provides a permanent dermal layer replacement.
● It’s use allows burn surgeon to harvest a thinner skin
graft consisting of epidermal layer only.
● The patient’s epidermal layer is placed directly over the
dermal base (Alloderm).

84. ● Use of Alloderm has also resulted in less scarring &
contractures with healed grafts.
● Donor sites heal much more quickly than conventional
donor sites because only the epidermal layer has been
harvested.

85. 4. AUTOGRAFTS
● It remained the preferred material for definitive burn
wound closure following excision.
● It is the ideal method of covering the wound because the
grafts are the patient’s own skin & thus are not rejected
by the patient’s immune system.
● They can be split thickness, full-thickness, pedicle flaps or
epithelial grafts.

86. ● Full thickness & pedicle flap are commonly used for
reconstructive surgery, months or years after the initial
injury.
● Split thickness autografts can be applied in sheets or in
postage stamp like pieces, or they can be expanded by
meshing so that they can cover 1.5 to 9 times more than a
given donor site area.
● Use of Cultured Epithelial Autografts (CEA) is common
now, as it involves a biopsy of the patient’s skin in an
unburned area.

87. ● Keratinocytes are the isolated & epithelial cells are
cultured in a laboratory.
● The quality of burn scar is better, but needs longer
hospital stay & higher hospital costs & require more
surgical procedures than those treated by traditional
methods.

88. Care of the patient with an Autograft
● Occlusive dressings are needed initially to immobilize the
grafts.
● Need of occupational therapy in constructing splints to
immobilize the newly grafted areas to prevent the
dislodging of grafts.
● Homografts, heterografts or synthetic dressings may also
be used to protect the graft.

89. ● The graft may be left open with skin staples to immobilize
it, which allows close observation of progress.
● The first dressing change is performed 3-5 days after
surgery, or earlier in case of purulent drainage or a foul
odor.
● If the graft is dislodged , sterile saline compress will help
prevent drying the graft until it is reapplied.
● Position & turn patient carefully to avoid disturbing the
graft or putting pressure on the skin graft.

90. ● Elevate the extremity if it is grafted to minimize the
edema.
● The patient begins exercising the grafted area 5-7 days
after grafting.

91. Care of Donor site
● A moist gauze dressing is applied at the time of surgery to
maintain pressure & to stop any oozing.
● A thrombo-static agent such as THROMBIN or
EPINEPHRINE may be applied directly to the site.
● The donor site can be treated with single layer gauze
impregnated with petrolatum, scarlet red, or bismuth to
new biosynthetic dressings such as biobrane or BCG
matrix.

92. ● The site must remain clean, dry & free from pressure.
● It will heal within 7-14 days with proper care.
● Donor sites are painful & additional pain management
must be a part of patient’s care.

93. DISORDERS OF WOUND HEALING
1. SCARS
2. KELOIDS
3. FAILURE TO HEAL
4. CONTRACTURES

94. POTENTIAL Cx IN ACUTE PHASE
1. HEART FAILURE
2. PULMONARY EDEMA
3. SEPSIS
4. ACUTE RESPIRATORY FAILURE
5. ACUTE RESPIRATORY DISTRESS SYNDROME
6. VISCERAL DAMAGE ( Electrical burns)

95. NURSING Mx IN ACUTE PHASE OF
BURN CARE

96. ● Fluid volume excess
● Risk for infection
● Altered nutrition less than body requirements
● Impaired skin integrity
● Pain
● Impaired physical mobility
● Ineffective individual coping
● Altered family process
● Knowledge deficit
● Complications

97. REHABILITATIVE
PHASE

98. ● Rehabilitation begins immediately after the burn has
occurred- as early as the emergent period & often extends
for years after injury.
● Focus is on self image, lifestyle modifications,
maintaining fluid & electrolyte balance & improving
nutritional status.
● Priorities are WOUND HEALING, PSYCHOSOCIAL SUPPORT
& RESTORING MAXIMAL FUNCTIONAL ACTIVITY.

99. ● Importance of psychological & vocational counselling &
referral may be helpful to promote recovery & quality of
life.
● Support & guidance is also required for family members in
assisting the patient to return to optimal health.

100. NURSING MANAGEMENT

101. ● Promoting activity tolerance
● Improving body image & self concept
● Monitoring and managing potential complications
● Promoting home & community based care