Burn.pptx for nursing students for AHN

Burn Injuries
Presented by:
Capt Azra Mahmood (Retd)
Lecturer FUCN

Objectives
• At the end of this lecture learners will be able to :
• Define burn injuries
• Classify burn injuries
• Describe its pathophysiology
• Enlist various clinical manifestations of burn
injuries
• Discuss complications of burn injuries
• Apply nursing process on the burn injuries patient

Burn Injury
• Burn injury is the result of heat transfer from
one site to another.
• Burns disrupt the skin, which leads to increased
fluid loss; infection; hypothermia; scarring;
compromised immunity; and changes in
function, appearance, and body image.
• Young children and the elderly continue to have
increased morbidity and mortality when
compared to other age groups with
similar injuries. Inhalation injuries in addition to
cutaneous burns worsen the prognosis.

• The severity of each burn is determined by
multiple factors that when assessed help the
burn team estimate the likelihood that a
patient will survive and plan for the care for
each patient

Classification
• Burns are classified according to the depth of
tissue destruction as superficial partial-
thickness injuries, deep partial-thickness
injuries, or full-thickness injuries.

• First Degree Burn (Superficial Partial Thickness
Burn). In first-degree burn injuries, the skin function
remains intact, and transfer to a burn center is not
required. They do NOT count towards total body
surface area (TBSA) burned. This classification of
burn depth affects the epidermis leading to the
following signs and symptoms:
• Erythema
• Edema
• Pain but without blisters
• Fluid loss is MILD

• Second Degree Burn (Deep Partial Thickness Burn). In
second-degree burn injuries, the skin function is lost.
Deep partial-thickness injuries can easily convert to or
require the same management as full-thickness. An MCI
(mass casualty incident) aims to treat as many 2nd
degree injuries as possible in an outpatient setting. This
classification of burn depth affects the dermis and
epidermis, leading to the following signs and symptoms:
• Erythema
• Edema
• Pain with blisters
• Pink to reddish skin
• Fluid loss is MODERATE

• Third-Degree Burn (Full Thickness Burn). In
third-degree burn injuries, skin function is lost,
and grafting is required for functional healing.
Third-degree burns will almost always require
hospital admission. This classification of burn
depth affects the subcutaneous tissues,
epidermis, and dermis leading to:
• Pearly white or charred appearance of the skin
• Mottled brown, black, or red burn site
• Pain is absent
• Fluid loss is SEVERE

• Fourth-Degree Burn (Deep Fullness Thickness Burn). In fourth-
degree burn injuries, the affected areas go through both layers
of the skin and underlying tissue as well as deeper tissue. This
classification of burn depth involves muscle and bone.
• Burned part is black/charred
• Fluid loss is VERY SEVERE
• Assess the burn size and extent.
• The size of the burn is expressed through percentage according
to the total body surface area (TBSA), Rule of Nines.
• Small Burns (<25%). Response of the body is localized.
• Large Burns (>25%). Response of the body is systemic.
• Assess for the burn location.
• The area of a burn injury usually directs treatment. Burns on
the face, hands, feet, and genitalia, as well as large burns in
other areas of the body and those

Pathophysiology
• Tissue destruction results from coagulation, protein
denaturation, or ionization of cellular components.
• Local response. Burns that do not exceed 20% of TBSA
according to the Rule of Nines produces a local response.
• Systemic response. Burns that exceed 20% of TBSA
according to the Rule of Nines produces a systemic
response.
• The systemic response is caused by the release
of cytokines and other mediators into the systemic
circulation.
• The release of local mediators and changes in blood flow,
tissue edema, and infection, can cause the progression of
the burn injury.

Clinical Manifestations
The changes that occur in burns include the following:
• Hypovolemia. This is the immediate consequence of
fluid loss and results in decreased perfusion and
oxygen delivery.
• Decreased cardiac output. Cardiac output decreases
before any significant change in blood volume is
evident.
• Edema. Edema forms rapidly after burn injury.
• Decreased circulating blood volume. Circulating
blood volume decreases dramatically during burn
shock.

• Hyponatremia. Hyponatremia is common
during the first week of the acute phase, as
water shifts from the interstitial space to the
vascular space.
• Hyperkalemia. Immediately after burn injury
hyperkalemia results from massive cell
destruction.
• Hypothermia. Loss of skin results in an
inability to regulate body temperature

Complications
• There are a lot of consequences involved in
burn injuries that may progress without
treatment.
• Ischemia. As edema increases, pressure on
small blood vessels and nerves in the distal
extremities causes an obstruction of blood flow.
• Tissue hypoxia. Tissue hypoxia is the result of
carbon monoxide inhalation.
• Respiratory failure. Pulmonary complications
are secondary to inhalational injuries

Assessment and Diagnostic Findings
• Various methods are used to determine the TBSA affected
by burns.
• Rule of Nines. A common method, the rule of nines is a
quick way to estimate the extent of burns in adults
through dividing the body into multiples of nine and the
sum total of these parts is equal to the total body surface
area injured.
• Lund and Browder Method. This method recognizes the
percentage of surface area of various anatomic parts,
especially the head and the legs, as it relates to the age of
the patient.

• Palmer Method. The size of the patient’s
palm, not including the surface area of the
digits, is approximately 1% of the TBSA, and
the patient’s palm without the fingers is
equivalent to 0.5% TBSA and serves as a
general measurement for all age groups.

Medical Management
• Burn care is a delicate task any nurse can have
and being knowledgeable in the proper
sequencing of the interventions is very
essential.
• Transport. The hospital and the physician are
alerted that the patient is en route so that life-
saving measures can be initiated immediately.
• Priorities. Initial priorities in the ED remain
airway, breathing, and circulation.

• Airway. 100% humidified oxygen is
administered and the patient is encouraged
to cough so that secretions can be removed by
coughing.
• Chemical burns. All clothing and jewelry are
removed and chemical burns should be
flushed.
• Intravenous access. A large bore (16 or 18
gauge) IV catheter is inserted in the non-
burned area

• Gastrointestinal access. If the burn exceeds 20% to
25% TBSA, a nasogastric tube is inserted and
connected to low intermittent suction because there
are patients with large burns that become nauseated.
• Clean beddings. Clean sheets are placed over and
under the patient to protect the burn wound from
contamination, maintain body temperature, and
reduce pain caused by air currents passing over
exposed nerve endings.
• Fluid replacement therapy. The total volume and rate
of IV fluid replacement is gauged by the patient’s
response and guided by the resuscitation formula.

Wound Care
• Prescribed topical agents are administered before the
wound is covered with layers of dry dressings.
• Use ointments. Antibiotic ointments or creams are
frequently used to fight or treat infections in patients
with second-degree burns. Using these ointments
may require the use of bandages.
• Regularly change dressings. Dressings may need to be
changed regularly. The skin and the burn wound
should be washed gently with mild soap and rinsed
well with tap water. Use a soft wash cloth or piece of
gauze to gently remove old medications.

Nursing Assessment
• The nursing assessment focuses on the major
priorities for any trauma patient; the burn wound is a
secondary consideration.
• Focus on the major priorities of any trauma
patient. the burn wound is a secondary consideration,
although aseptic management of the burn wounds
and invasive lines continues.
• Assess circumstances surrounding the injury. Time of
injury, mechanism of burn, whether the burn occurred
in a closed space, the possibility of inhalation of
noxious chemicals, and any related trauma.
• .

• Monitor vital signs frequently. Monitor
respiratory status closely; and evaluate apical,
carotid, and femoral pulses particularly in
areas of circumferential burn injury to
an extremity.
• Start cardiac monitoring if indicated. If patient
has history of cardiac or respiratory problems,
electrical injury

• Check peripheral pulses on burned extremities
hourly; use Doppler as needed.
• Monitor fluid intake (IV fluids) and output
(urinary catheter) and measure hourly. Note
amount of urine obtained when catheter is
inserted (indicates preburn renal function and fluid
status).
• Obtain history. Assess body temperature, body
weight, history of preburn weight, allergies,
tetanus immunization, past medical surgical
problems, current illnesses, and use of
medications.
• Arrange for patients with facial burns to be
assessed for corneal injury.

• Continue to assess the extent of the burn;
assess depth of wound, and identify areas of
full and partial thickness injury.
• Assess neurologic status: consciousness,
psychological status, pain and anxiety levels,
and behavior.
• Assess patient’s and family’s understanding of
injury and treatment. Assess patient’s support
system and coping skills.

• Fluid Resuscitation
• Fluid Resuscitation refers to replacing fluids in burn patients
to prevent hypovolemia and hypo perfusion that can result
from the body’s systemic response to burn injury.
• Initiate fluid administration. Peripheral IV access may initially
be used though in larger and more severe cases of burns, a
central venous access is recommended as a large volume of
fluid is required.
• Use American Burn Association (ABA) guidelines for fluid
resuscitation. The formula for the total fluid requirement in
24 hours is as follows: 4ml x TBSA (%) x body weight
(kg). [Example: Patient weighs 80 kg with TSBA of 20% = 4mL
x 80 kg = 320 x 20 = 6,400 mL]
• First half of the solution is given in the first 8 hours (3,200
mL)

• One quarter of the solution is given in the second
8 hours (1,600 mL)
• Another quarter of the solution is given in the
third 8 hours (1,600 mL)
• Avoid colloid-containing solution for the first 24
hours because it may aggravate edema due to an
increase in capillary permeability.
• The amount of fluid in the second 24 hours will
depend on the patient’s urine output and
hemodynamic studies (Hct, CVP, and
BUN/Creatanin)

Emergent Phase
• The emergent phase starts from the time of burn injury
and ends when the patient is hemodynamically stable,
capillary permeability has been restored, and fluid
resuscitation has been completed. Usually 48-72 hours
from the time of injury. The emergent phase is also known
as the resuscitative phase, and the goals of this phase
include prevention of hypovolemic shock and preservation
of vital organ functioning.
• Asses for the burn depth.
• Burn depth is assessed 24 hours after injury as blisters and
other injuries may evolve.

Acute Phase
• The acute or intermediate phase begins 48 to
72 hours after the burn injury. Burn wound
care and pain control are priorities at this
stage.
• Focus on hemodynamic alterations, wound
healing, pain and psychosocial responses, and
early detection of complications.

• Measure vital signs frequently. Respiratory and fluid
status remains highest priority.
• Assess peripheral pulses frequently for first few days after
the burn for restricted blood flow.
• Closely observe hourly fluid intake and urinary output,
as well as blood pressure and cardiac rhythm; changes
should be reported to the burn surgeon promptly.
• For patient with inhalation injury, regularly monitor level
of consciousness, pulmonary function, and ability to
ventilate; if patient is intubated and placed on a ventilator,
frequent suctioning and assessment of the airway are
priorities.

Pain Management
• Pain due to burns can range from mild to severe to
excruciating. Pain management, which includes
pharmacologic and nonpharmacologic approaches, is a
central component of the complex issues involved in
treating patients with burns.
• NO intramuscular or subcutaneous administration because
the patient is hypovolemic.
• Intravenous analgesics: Morphine, Demerol
• Oral administration is NOT considered due to GI dysfunction.
• Minor burns: Per oral
• Nonpharmacological: Deep breathing exercises, guided
imagery

Rehabilitation Phase
• Rehabilitation should begin immediately after the
burn has occurred.
• Wound healing, psychosocial support, and restoring
maximum functional activity remain priorities.
• Maintaining fluid and electrolyte balance and
improving nutrition status continue to be important.
• In early assessment, obtain information about
patient’s educational level, occupation, leisure
activities, cultural background, religion, and family
interactions.

• Assess self concept, mental status, emotional
response to the injury and hospitalization, level
of intellectual functioning, previous
hospitalizations, response to pain and pain relief
measures, and sleep pattern
• Perform ongoing assessments relative to
rehabilitation goals, including range of motion of
affected joints, functional abilities in ADLs, early
signs of skin breakdown from splints
or positioning devices, evidence of neuropathies
(neurologic damage), activity tolerance,
and quality or condition of healing skin.

Nursing Diagnoses
Nursing Diagnosis for burn injuries include:
• Impaired gas exchange related to carbon monoxide
poisoning, smoke inhalation, and upper airway obstruction.
• Ineffective airway clearance related to edema and effects of
smoke inhalation.
• Fluid volume deficit related to increased capillary
permeability and evaporative losses from burn wound.
• Hypothermia related to loss of skin microcirculation and
open wounds.
• Pain related to tissue and nerve injury.
• Anxiety related to fear and the emotional impact of burn
injury.

Planning & Goals
• To implement the plan of care for a burn injury patient
effectively, there should be goals that should be set:
• Maintenance of adequate tissue oxygenation.
• Maintenance of patent airway and adequate airway
clearance.
• Restoration of optimal fluid and electrolyte balance and
perfusion of vital organs.
• Maintenance of adequate body temperature.
• Control of pain.
• Minimization of patient’s and family’s anxiety.

Nursing Priorities
• Maintain patent airway/respiratory function.
• Restore hemodynamic stability/circulating volume.
• Alleviate pain.
• Prevent complications.
• Provide emotional support for patient/significant
other (SO).
• Provide information about condition, prognosis,
and treatment.

Nursing Interventions
• Nursing care of a patient with burn injury
needs to be precise and effective.
• Promoting Gas Exchange and Airway
Clearance
• Provide humidified oxygen, and monitor
arterial blood gases (ABGs), pulse oximetry,
and carboxyhemoglobin levels.
• Assess breath sounds and respiratory rate,
rhythm, depth, and symmetry; monitor for
hypoxia.

• Observe for signs of inhalation injury: blistering
of lips or buccal mucosa; singed nostrils; burns
of face, neck, or chest; increasing hoarseness;
or soot in sputum or respiratory secretions.
• Report labored respirations, decreased depth
of respirations, or signs of hypoxia to physician
immediately; prepare to assist with intubation
and escharotomies.
• Monitor mechanically ventilated patient closely

• Institute aggressive pulmonary care measures:
turning, coughing, deep breathing, periodic
forceful inspiration using spirometery, and
tracheal suctioning.
• Maintain proper positioning to promote
removal of secretions and patent airway and
to promote optimal chest expansion; use
artificial airway as needed.

Burn.pptx for nursing students for AHN

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Burn.pptx for nursing students for AHN