This document provides information on burns, including: - Burns account for approximately 180,000 deaths annually worldwide and most occur in low- and middle-income countries. - The most common causes of burns are fire/flame, scalds, hot objects, electricity, and chemicals. Burns can range from superficial to full thickness. - Management of burns involves reviving the patient, restoring fluid and electrolyte balance, repairing the burn wound, and rehabilitating the patient. The parkland formula is used to guide initial fluid resuscitation.

1. Burn

2. Introduction
 Burns are a global public health problem, accounting for an
estimated 180 000 deaths annually.
 The majority of these occur in low- and middle-income
countries and almost two thirds occur in the WHO African and
South-East Asia regions.
 In many high-income countries, burn death rates have been
decreasing, and the rate of child deaths from burns is currently
over 7 times higher in low- and middle-income countries than
in high-income countries.

3. Introduction cont’d..
 About 90% of burns occur in the developing world. This has
been attributed partly to overcrowding and an unsafe cooking
situation.
 large burns can be fatal, treatments developed since 1960 have
improved outcomes, especially in children and young adults

4. Introduction cont’d..
 Burns exert a catastrophic influence on people in terms of
human life, suffering, disability, and financial loss.
 Burns are estimated to cause approximately 180,000 deaths
annually worldwide, mostly in low- to middle-income countries.

6. Definition
The term “burn” means more than the burning
sensation associated with this injury. Burns are
characterized by severe skin damage that causes the
affected skin cells to die.

7. Risk factors
 codiagnosis of intoxication. The investigators also determined
that within this age group, burn-related visits with a
codiagnosis of intoxication were 1.34 times more likely to be
associated with flame burns.
 risk factors for scald injuries in young children include the
presence of hot drinks within reach of these youngsters and a
lack of education for these children concerning “rules about
climbing on kitchen objects,”

8. Cause
 Burns are caused by a variety of external sources classified as
thermal (heat-related), chemical, electrical, and radiation
 the most common causes of burns are:
 fire or flame (44%),
 scalds (33%),
 hot objects (9%),
 electricity (4%), and
 chemicals (3%).

9. Cause cont’d…
 Most (69%) burn injuries occur at home or at work (9%), and
most are accidental, with 2% due to assault by another, and 1–
2% resulting from a suicide attempt.
 These sources can cause inhalation injury to the airway
and/or lungs, occurring in about 6%.

10. Pathophysiology
 Proteins has a three-dimensional shape; at a temperature
greater than 44 °C, this shape start to breaking down and the
outcome is cell and tissue damage.
 The effect of burn is secondary to disruption in the normal
function of the skin such as loss of skin sensation, disruption
of the ability to prevent water loss through evaporation, lost
the ability to control temperature and destruction of cell
membrane.

11. Pathophysiology cont’d..
 Large percentage of burn (over 30% of the total body surface
area), there is inflammatory response; and the resulting effect is
increase leakage of fluid from the capillaries and subsequent
tissue edema.
 It also cause loss of blood and plasma volume making the
remaining blood more concentrated.
 There is poor blood flow to organs like the kidney and
gastrointestinal tract may result in kidney failure and stomach
ulcers.
 Catecholamines and cortisol level increased, this result to

12. Signs and Symptoms
 Pain lasting two or three days
 Peeling of the skin over the next few days
 Discomfort or complain of feeling pressure rather than pain
 Full-thickness burns may be entirely insensitive to light touch
or puncture
 Superficial burns are typically red in color, severe burns may be
pink, white or black
 Shortness of breath, hoarseness, and stridor or wheezing.
 Itchiness is common during the healing process,

13. Classification of Burns Injury
First Degree Burn:
 Involve the epidemic only, the skin is reddened but is intact
and no blistered. The injury ranges from mildly irritation or
even pruritic to exquisitely painful. Minor edema may be
noted. Causes include ultraviolet light, but healing ventually
occurs with no scaring.

14. Classification of Burns Injury cont’d..
Second Degree Burn:
 Involve the entire epidemic and extend into the dermis to
include sweat glands and hairs follicles superficial thickness
burns involve only the papillary dermis.
 There is pink, moist and extremely painful. Or blister’s
present or the skin may slough.
 Mild to moderate edema is common usual cause are scalds,
contact with list object or exposure to chemicals.

15. Classification of Burns Injury cont’d.
Third Degree Burn:
 Are full thickness burn that destroyed both epidemics and
dermis. The capillary network of the dermis is completely
destroyed.
 The burned skin has a white or leathery appearance with
underlying.
 Unless a third degree burn is small enough to heal by
contraction, skin grafting is always necessary to surface the
injure area.
 The third degree burns are cause by immersion scald, flame
burns, chemical and high voltage electrical inuring.

16. Classification of Burns Injury cont’d.
Fourth Degree Burn
 Involve full thickness destruction of the skin and subcutaneous
tissue, with involvement of the underlying fascia muscle, bone
or other structure.
 These injury require extensive debridement and complex
reconstruction of specialized tissue and invariable from
prolonged disability.
 Fourth degree burns result from prolonged exposure to the
usual causes of third degree burns.

17. Wallace Rules of Nine
 The "Rule of Nines" is a method of estimating the extent of
body surface that has been burned in an adult. This
method divides the body into sections of 9%, or in
multiples of 9%. It assigns 9% to the head, each arm, 18%
to each leg, anterior/posterior trunk, and 1% to the
perineum.
 This method can be used to estimate the volume of fluids
lost by determining how much of the body surface is
burned.

18. Wallace Rules of Nine cont’d..
 The rules of nines are adequate about
adults but limits for differences in percentage in children,
for that the Lund and Browder classification is generally used.

20. Rules of Nine Burns in Child
 The ‘Rule of 9’s’ approach is very imprecise for estimating the
burnt area in young children simply because the infant or
young child’s head, as well as lower extremities, signify
different percentages of the area as compared to a fully
grown.
 Burns above 15% in an adult, over 10% in the child, or even
any specific burn taking place in the still very young or older
are dangerous.

22. Estimation of the Total Body Surface Area Burn
(TBSA)
 The small difference between the BSA of the adult and infant
reflects the size of the infant’s head (18%) which is
proportionally larger than that of the adult and the lower
extremities (14%) which are proportionately smaller than those
of the adult.
Severity of Burns Injury
 Burns can be classified into severity using the TBSA, burns and
the degree of burns into.

23. Severity of Burns Injury cont’d..
 Minor Burns:
Less than 15% TBSA burns in adults or less than 10% TBSA
burns in child or elderly with less than 2% full thickness burns.
 Moderate Burns
Partial and full thickness burns of 15-20% TBSA in young adult,
10-20% in children younger than 10 and adults older than 40
years. Full thickness burns less than 10% TBSA not involving
special care area.

24. Severity of Burns Injury cont’d..
Major Burns
 Greater than 23% TBSA burns in young adults or greater 20%
TBSA in children younger than 10 years and adults older than
40 years.
 Full-thickness burns of 10% or greater. All burns of special care
areas that are likely to result in either functional or cosmetic in
perineum i.e face, hands ear and perineum.

25. Management of Moderate to Severe Burns
Management of burn entails a multidisciplinary approach.
 The Principle of Management are
 Revive
 Restore
 Repair
 Rehabilitate

26. The management of burns at the scene of accident
burns site with
First aid
Basic guidance on first aid for burns is provided below.
 What to do
 Stop the burning process by removing clothing and irrigating
the burns.
 Extinguish flames by allowing the patient to roll on the
ground, or by applying a blanket, or by using water or other
fire-extinguishing liquids.
 Use cool running water to reduce the temperature of the burn.

27. First aid
 In chemical burns, remove or dilute the chemical agent by
irrigating with large volumes of water.
 Wrap the patient in a clean cloth or sheet and transport to the
nearest appropriate facility for medical care.
What not to do
 Do not start first aid before ensuring your own safety (switch
off electrical current, wear gloves for chemicals etc.)

28. First aid cont’d…
 Do not open blisters until topical antimicrobials can be
applied, such as by a health-care provider.
 Do not apply any material directly to the wound as it might
become infected.
 Avoid application of topical medication until the patient has
been placed under appropriate medical care.

29. First aid cont’d…
 Do not apply paste, oil, haldi (turmeric) or raw cotton to the
burn.
 Do not apply ice because it deepens the injury.
 Avoid prolonged cooling with water because it will lead to
hypothermia.

30. Resuscitation
 ABCD of resuscitation and Primary and Secondary Survey.
 Take quick history
 Expose the patient
 Evaluate airway breathing and circulate
 Set-up IV access using wide bore cannula

31. Initial fluid resuscitation
 Initial fluid resuscitation should proceed wound care. The
parkland formula is used as a guide to give initial fluid
resuscitation during the 1st 24 hr.
 Adult =2-4ml/kg body wit/% TBSA Burn (ringer lactate)
 child = 3mlkg body wt % TBSA burn.
 Estimate the amount of fluid to give in 24 hours and give half
of the fluid in the 1st shire counting from when the injuring
occurred. The 2nd half is given over the next 16 hours.

32. Worked example of burns resuscitation
Fluid resuscitation regimen for adult
A 25 years old man weighty 70 Kg with a 30% flame
burn was admitted at 4pm. His burn occurred at
3pm.
Total fluid requirement for first 24 hours.
4ml x (30% total burn surface area) x (70kg) =
8400ml in 24 hours
Half to be given in first 8 hours and 4200ml during 8

33. input-output
 Catheterize the patient monitor urine input-output of
0.3ml/Kg/hr is aimed at or 50ml/hr.
 Pass NG tube
 After completing the primary and secondary survey, priority
should be given to pain management
 Give ATS or T.T
 Measure Vital signs every30mins
 Record all the measures taken

34. Care of the wound
Thus follow resuscitation
Exposure method
Wound dressing
Excision and skin grafting

35. Nutritional Support
Adult = 100j/kg body wt plus 160jl% surface burn
Children = 240jlKg body wt plus 140jl% surface burn
The protein intake should be 2-3glkg body wt
Antibiotic

36. Management of Inhalational Injuries
Early bronchoscopy
Maintain open airway (O2 therapy)
Suction
Early physiotherapy

37. Burn complications
 Minor burns should heal without causing any lasting problems.
Deeper and more severe burns can cause scars, as well as the
following complications:
Infection
 Like any wounds, burns create an opening that can allow
bacteria and other germs to sneak in.
 Some infections are minor and treatable. If bacteria get into
the bloodstream, they can cause an infection called sepsis,
which is life-threatening.

38. Burn complications cont’d..
Dehydration
 Burns make the body lose fluid. If the body lose too much
fluid, blood volume became low that the individual don’t
have enough blood to supply to the entire body.
Low body temperature
 Skin helps regulate the body temperature. When it’s
damaged from a burn, the individual can lose heat too
quickly. This can lead to hypothermia, a dangerous drop in
body temperature.

39. Burn complications cont’d..
Contractures
 When scar tissue forms over a burn, it can tighten the skin
so much that the part affect can’t move bones or joints.
Muscle and tissue damage
 If the burn goes through the layers of your skin, it can
damage the structures underneath.
Emotional problems
 Large scars can be disfiguring, especially if they’re on the
face or other visible areas. This may lead to emotional

40. Burn scars
 Burns cause skin cells to die. Damaged skin produces a protein
called collagen to repair itself.
 As the skin heals, thickened, discolored areas called scars form.
 Some scars are temporary and fade over time. Others are
permanent.
 Scars can be small or large. Burn scars that cover a wide
surface of the face or body can affect the appearance.

41. Burn scars cont’d…
Burns can cause one of these types of scars:
 Hypertrophic scars are red or purple, and raised. They may
feel warm to the touch and itchy.
 Contracture scars tighten the skin, muscles, and tendons, and
make it harder for you to move.
 Keloid scars form shiny, hairless bumps.

42. Treatment of burn scars
Treatment will depend on the degree and size of the burn.
Don’t try any home treatment
For second-degree burns:
 Apply a thin layer of antibiotic ointment to the burn to help it
heal.
 Cover burn with sterile, nonstick gauze to protect the area,
prevent infection, and help the skin recover.

43. Treatment of burn scars
For third-degree burns
 Wear tight, supportive clothing called compression garments
over the burn to help the skin heal. The individual may have to
wear compression garments all day, every day for several
months.
 The individual may need a skin graft. This surgery takes healthy
skin from another area of the body or from a donor to cover
the damaged skin.

44. Treatment of burn scars cont’d..
 The client can also have surgery to release areas of the body
that have been tightened by contractures, and help him/her
move again.
 A physical therapist can teach you exercises to help you regain
motion in areas that have been tightened by contractures.

45. Prevention
 Cooking should be at a higher level so children cannot reach
 Houses should be better designed
 Epileptic children and infants should not be left alone near
fire
 Proper storage of Kerosene, petrol and gas
 Put out candles, off all electrical appliances
 Teach people how to use fire extinguisher at homes and
public places.

46. Pressure Injuries (Pressure Ulcers)
and Wound Care

47. Introduction
 The terms decubitus ulcer (from Latin decumbere, “to lie
down”), pressure sore, and pressure ulcer have often been
used interchangeably in the medical community.
 However, as the name suggests, decubitus ulcer occurs at
sites overlying bony structures that are prominent when a
person is recumbent.
 Hence, it is not an accurate term for ulcers occurring in other
positions, such as prolonged sitting (eg, ischial tuberosity
ulcer).

48. Introduction cont’d…
 Because the common denominator of all such ulcerations is
pressure, pressure ulcer came to be considered the best term to
use.
 The National Pressure Ulcer Advisory Panel (NPUAP) was
formed in 1987 and dedicated to the prevention, management,
treatment, and research of pressure ulcers.
 In April 2016, the NPUAP announced that it was changing its
preferred terminology from pressure ulcer to pressure injury,
on the grounds that the latter term better described this injury
process in both intact and ulcerated skin

49. Definition
 In November 2019, the NPUAP changed its name to the
National Pressure Injury Advisory Panel (NPIAP).
 Currently, the NPIAP defines a pressure injury as localized
damage to the skin and underlying soft tissue, usually over
a bony prominence or related to a medical or other device.
 Such injury can present either as intact skin or an open ulcer
and may be painful.

50. Epidemiology
 Pressure injuries are common among patients hospitalized in
acute- and chronic-care facilities.
 Reported incidences of pressure injuries in hospitalized
patients range from 2.7% to 29%, and reported prevalence in
hospitalized patients range from 3.5% to 69%.
 Patients in critical care units have an increased risk of
pressure injuries, as evidenced by a 33% incidence and a 41%
prevalence.

51. Epidemiology cont’d…
 Of the various hospital settings, intensive care units (ICUs)
had the highest prevalence, at 21.5%. The largest single age
group of patients with pressure injuries consisted of patients
aged 71-80 years (29%).
 Elderly patients admitted to acute care hospitals for non-
elective orthopedic procedures are at even greater risk for
pressure injuries than other hospitalized patients are, with a
66% incidence.
 Among patients with neurologic impairments, pressure
injuries occur with an incidence of 7-8% annually, [41] with a
lifetime risk estimated to be 25-85%.

52. Causes
 Pressure or the compression of tissues and/or destruction of
muscles cell. In most cases, this compression is caused by
the force of bone against a surface, as when a patient
remains in a single decubitus position for a lengthy period.
After an extended amount of time within tissue perfusion,
ischemia occurs and can lead to tissue necrosis if left
untreated.
 Pressure can also be exerted by external devices, such as
medical devices, traces, wheel chairs, etc.

53. Causes cont’d..
 Shearing a force created when the skin of a patient stays in
one place as a deep facial and skeletal muscle slide down with
gravity, can also cause the pinching off of blood vessels which
may lead to ischemia and tissue necrosis.
 Friction is related to sheer but is considered less important in
causing pressure ulcers.

54. Causes cont’d..
 Microclimates, the temperature and moisture of the skin in
contact with the surface of the bed or wheelchair.
 Moisture on the skin causes the skin to lose the dry outer layer
and reduces the tolerance of the skin for pressure and sheer.
 The satisfaction may be aggregated by other conditions such
excess moisture from incontinence, perspiration, or exudates.

55. Causes cont’d..
 Overtime, this excess moisture may cause the bonds between
epithetical cells to weaken, thus resulting in the maceration of
the epidermis. Temperature is also a very important factor.
 The cutaneous metabolic demand rises by 13% for every 1oc
rise in cutaneous temperature when supply can’t meet
demand, ischemia then occurs.

56. Risk
 People who are immobile are at highest risk of developing
pressure ulcers.
 The risk of developing bedsores can be predicted using the
Braden scale for predicting pressure ulcer.
 The scale contains 6 areas of risk: sensory-perception,
immobility, inactivity, moisture, nutrition, and friction/shear.

57. Pathophysiology
 Pressure injuries result from constant pressure sufficient to
impair local blood flow to soft tissue for an extended period.
 This external pressure must be greater than the arterial capillary
pressure (32 mm Hg) to impair inflow and greater than the
venous capillary closing pressure (8-12 mm Hg) to impede the
return of flow for an extended time.

58. Pathophysiology cont’d..
 Tissues are capable withstanding enormous pressures for
brief periods, but prolonged exposure to pressures just
slightly above capillary filling pressure initiates a downward
spiral toward tissue necrosis and ulceration.
 The inciting event is compression of the tissues against an
external object such as a mattress, wheelchair pad, bed rail, or
other surface.

59. Example of Pressure Injury

60. Sites
 Back of the hand
 Ear
 Shoulder
 Scapula
 Sacrum
 Hip

61. Sites cont’d…
Knee
Heels
Ankle
Toe
Elbows

62. Classification
 The categories specified in the current NPIAP staging system
are as follows
 Stage 1 pressure injury - Intact skin with a localized area of
nonblanchable erythema, which may appear differently in
darkly pigmented skin; presence of bleachable erythema or
changes in sensation, temperature, or firmness may precede
visual changes; color changes do not include purple or maroon
discoloration, which may indicate deep tissue pressure injury

63. Classification cont’d…
 Stage 2 pressure injury - Partial-thickness skin loss with
exposed dermis; the wound bed is viable, pink or red, moist,
and may also present as an intact or ruptured serum-filled
blister; adipose (fat) and deeper tissues are not visible, and
granulation tissue, slough and eschar are not present; these
injuries commonly result from adverse microclimate and
shear in the skin over the pelvis and shear in the heel

64. Classification cont’d…
 Stage 3 pressure injury - Full-thickness skin loss, in which
adipose (fat) is visible in the ulcer and granulation tissue and
epibole (rolled wound edges) are often present; slough or
eschar may be visible; the depth of tissue damage varies by
anatomic location; areas of significant adiposity can develop
deep wounds; undermining and tunneling may occur; fascia,
muscle, tendon, ligament, cartilage, and bone are not
exposed

65. Classification cont’d…
 Stage 4 pressure injury - Full-thickness skin and tissue loss
with exposed or directly palpable fascia, muscle, tendon,
ligament, cartilage or bone in the ulcer; slough or eschar
may be visible; epibole (rolled edges), undermining, and
tunneling often occur; depth varies by anatomic location

66. Classification cont’d…
 Unstageable pressure injury - Full-thickness skin and tissue
loss in which the extent of tissue damage within the ulcer
cannot be confirmed because it is obscured by slough or
eschar; if slough or eschar is removed, a stage 3 or 4 pressure
injury will be revealed

67. Classification cont’d…
 Deep tissue pressure injury - Intact or nonintact skin with
localized area of persistent nonblanchable deep red, maroon,
purple discoloration or epidermal separation revealing a dark
wound bed or blood-filled blister; pain and temperature
change often precede skin color changes; discoloration may
appear differently in darkly pigmented skin; the injury results
from intense and/or prolonged pressure and shear forces at
the bone-muscle interface

69. Sign and Symptoms
 Most patients experience pain of the site. A report of pain
requires continual assessment, documentation and treatment.
 A wound may contain a mixture of black, yellow and red
colors. Neurotic wounds are the worst because they contain
dead tissue.
 Beefy red wounds are desired because they are healing
wounds. It is important to consider treating the worst color
present first or healing will be delayed.

70. Assessment and Diagnosis
The risk of developing bedsores can be predicted using
the Braden scale for predicting pressure ulcer.
 The scale contains 6 areas of risk: sensory-perception,
immobility, inactivity, moisture, nutrition, and
friction/shear.

71. Assessment and Diagnosis cont’d…
Swab cultures and culture and sensitivity tests may be
done to identify the causative organism in suspected
infected site.
If the wound does not demonstrate signs of healing
wound biopsies may be performed for large extensive
wounds.

72. Physical Examination
 A thorough physical examination is necessary to evaluate the
patient’s overall state of health, comorbidities, nutritional
status, and mental status.
 The patient’s level of comprehension and extent of
cooperation dictate the intensity of nursing care that will be
required.
 The presence of contractures or spasticity is important to
note and may help identify additional areas at risk for
pressure ulceration.

73. Physical Examination cont’d..
Adequate examination of the wound may
necessitate the administration of intravenous
(IV) or oral pain medications to ensure patient
comfort.
Chronic pain may be present among these
patients and may be exacerbated by
examination ulcer.

74. Complications of chronic injury
 Malignant transformation
 Autonomic dysreflexia
 Osteomyelitis
 Pyarthrosis
 Sepsis
 Urethral fistula
 Amyloidosis
 Anemia

75. Treatment
 Treatment varies according to the size, depth, and stage, of
the pressure ulcer as well as special need of the patient and
healthcare ponder preference.
 All pressure must be removed from the affected area for
health occur. Cleanliness must be maintained.
 Basic treatment includes debridement, cleansing and dressing
of the wound to provide a moist and healing environment.

76. Treatment cont’d..
Debridement
 Debridement is the removal of dead or nonviable tissue from a
wound to help clean up the wound and facilitate formation or
granulation tissue.
 It may be done surgically or nonsurgically. Nonsurgical
debridement includes mechanical, enzymatic, and autolytic
methods. Surgical is used only if the patient has sepsis or
cellulitis, or to remove extensive eschar.

77. Treatment cont’d..
 scar is a blank or brown hard scab or dry crust that forms from
necrotic tissue, it may hide the true depth of the wound and
must be removed for the wound to heal.
Wound Cleansing
 The ulcer should be thoroughly cleansed via whirlpool, hand-
held shower head, irrigating system with a pressure between
1.81kg and 6.8kg per square inch, such a s30ml syringe with 18-
guage needle.

78. Treatment cont’d..
 Pressure less than 1.8kg per square inch does not adequately
cleanse the wound and greater than 6.8kg per square inch may
damage tissue.
 If an irrigating system is used, 250ml of normal saline. (or
sometimes tap water for home wound care) should be used to
thoroughly cleanse the wound.
 If the wound is red, gentle irrigation with a needle-less 30 to
60ml syringe should be used to prevent trauma and bleeding.

79. Treatment cont’d..
 When bleeding occurs wound healing has been impaired.
However, if the wound has been diagnosed as being infected,
pressure flushing with a 30 to 60ml syringe and an 18 gauge
needle is needed to help remove bacteria.
 Wound Dressing
 Dressing vary according to sizes, location, depth, stage of ulcer
and preference of the ordering practitioner.
 Commonly used dressing materials include hydrogel dressing,
polyurethane films, hydrocolloid waters, biological dressings,
alginates and cotton guaze.

80. Medication
 Antibiotic to treat infection depending on the culture and
sensitivity test.

81. Nursing care plan.

82. Thank you