Nursing management of burn patient

NURSING MANAGMENT OF
BURN PATIENT

Submitted to:
Mrs. Mamta Toppo
(Subject coordinator,Medical
Surgical nursing )
Submitted by:
Priti kumari
Basic bsc nursing 3rd year
College of nursing
RIMS ,Ranchi

CONTENT
1. Introduction
2. Definition
3. Classification of burn injury
4. Clinical manifestation
5. Assessment of burn injury
6. Management phases of burn injury
7. Burn intensive care unit
8. Arrival to the hospital
9. Pre hospital management
10. Other managements

12. Nusring management
13. Post burn exercises
14. Research work
15. summary
16. Evaluation
17. Referances
18 . Bibliography

INTRODUCTION
 Burn injuries occur when energy from a heat source is
transferred through conduction or electromagnetic radiation.

Definition
 A burn is an injury to the skin or other organic tissue primarily
caused by heat or due to radiation ,radioactivity, electricity,
friction ,or contact with chemicals.
-WHO(World health organization)

Classification
Burn are classified according to the depth of tissue
destruction as:
1.superficial partial thickness
2.Deep partial thickness
3.Full thickness

Based on causes
 Thermal
 Electrical
 Chemical
 Radiation
 Inhalation

Classification according to extent
Mild(10%)
Moderate (10-30%)
severe(>30%)

Clinical manifestation
The changes that occur in burn include the following:
 Hypovolemia
 Decreased cardiac output
 Edema
 Decreased circulating blood volume
 Hyponatremia
 Hyperkalemia
 Hypothermia

Assessment
 Various methods are used to determine the TBSA(total body surface
area) affected by burn:
1. Rule of nine : a common method ,the rule of nine is a quick way to
estimate the extent of burn .
2. Lund and browder method : this method recognize the percentage
of surface area of various anatomic parts especially the head and neck.
3. Palmer method : In patient with scattered burn a method to
estimate the percentage of burn is the palm method. The size of the
patient’s palm is approximately 1%of total body surface area (TBSA).

Rule of nine method
Lund and browder method

MANAGEMENT PHASES
 Emergent or resuscitative phase
 Acute or intermediate phase
 Rehabilitation phase

Burn intensive care unit
The Burn Intensive Care Unit is a highly specialized surgical ward often catering to
patients with extensive tissue damage and multi-disciplinary demands.
Indication of admission for burn patient:
 Partial thickness burn more than 10%in age less than 10 and 50years .
 Partial thickness burn more than 20%in adults.
 Partial thickness burn of face ,head ,feet ,perineum .
 Full thickness burn more than 5% TBSA.
 Chemical burn,inhalational burns, electric burn.

Arrival to the burn center
 Room should be warmed
 Adult :minimum of 80 degrees.
 Childern: minimum of 85 degrees.
 Provide warm IV fluids and blood product.
 Minimize exposure.
 Cool guard should be provided.
 Lighting

Management
 Per hospital management
 Remove the person from the source and burning process must be stopped.
 Addressing inhalation injury with 100% oxygen.
 Remove heated source like ring ,bracelet, chain, watches etc.
 Pouring water with room temperature advisable only up to 15 min beyond which it can
lead to hypothermia.
 Remove cloths and assess for size and depth of burn according to “Rule of nine”.

Maintaining hemodynamic stability
 Early fluid resuscitation is required for burn exceeding 20% of body surface.
 The following formulas are used for resuscitation:
PARKLAND FORMULA :
RL : 4 ml x kg body weight x %body surface area
burned.
DAY 1 : ½ to be given in first 8 hours and rest in next
16 hours
DAY 2 : varies colloid is aided

Consensus formula : RL : 2-4mlxbody weight in kg x % body surface area
burned . Half fluid is to be given in first 8 hours and remaining half over next
16 hours.
• EVANS FORMULA :
• Colloids : 1ml x kg body weight x % body surface area [BSA]burned
• Electrolytes :1ml x body weight [kg] x% body surface area burned
• Glucose :2000ml for insensible loss
• DAY 1 :1/2 to be given in first 8hrs, remaining half in next 16 hours
• DAY 2 : ½ of previous days colloids and electrolytes all for insensible fluid
loss
• Maximum :1000 ml is given in first 24 hours.

Escharotomy
An Escaharotomy is a surgical procedure used to treat full thickness
(third degree) burn. This can be performed as to release pressure
,facilitate circulation and it also allow healing.

Skin grafting
Skin grafting is a surgical procedure that involve removing skin from one area of
the body and moving it or transplanting it to different area of the body.
Healthy skin is taken from a place on our body called donor site .
Types of graft:

Nursing managment
Nursing management in emergent phase
 Nursing assessment
 Focus on the major priorities of any trauma patient.
 Assess circumstances surrounding the injury.
 Monitor vital signs frequently.
 Start cardiac monitoring if indicated.
 Check peripheral pulses on burned extremities hourly
 Monitor fluid intake (IV FLUID) and output (urinary
catheter) and measure hourly.

 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.

Nursing process
Nursing diagnosis
Impaired gas exchange related to carbon monoxide poisoning,
smoke inhalation, and upper airway obstruction.
Goal: Maintenance of adequate tissue oxygenation.
Intervention:
 Provide humidified oxygen.
 Assess breath sound, respiratory rate, rhythm,depth.monitor
patient for sign of hypoxia.
 Monitor ABG and pulse oximetry.

Nursing diagnosis
Ineffective airway clearance related to edema and effects of smoke
inhalation.
Goal: Maintenance of patent airway and adequate airway clearance.
Intervention:
 Maintain patent airway through proper positioning, removal of
secretions, and artificial airway if needed.
 Provide humidified oxygen.
 Encourage patient to turn, cough ,deep breathe.
 Encourage patient to use incentive spirometry.
 Suction can be provided as needed.

Nursing diagnosis:
Fluid volume deficit related to increased capillary permeability and
evaporative losses from burn wound as evidence by decreased urine
output.
Goal: Restoration of optimal fluid and electrolyte balance and perfusion of
vital organs.
Intervention:
 Observe vital sign ,urine output, and moniter for sign and symptoms of
hypovolemia or fluid overload.
 Observe for symptoms of deficiency or excess of serum electroyte(sodium
,potassium ,calcium , phosphorus and bicarbonate).
 Maintain iv line and regular fluid at appropriate rate.

Nursing diagnosis:
Acute pain related to destruction of skin or tissue as evidenced by alteration in
muscle tone .
Goal: To control pain.
Intervention:
 Assess the severity of pain using pain scale .
 Administer IV opioid analgescis as prescribed and assess response to medicine .
 Provide emotional support, reassurance, and simple explanations about procedures.

Monitoring and Managing Potential
Complications
1. Acute respiratory failure
1. Assess for increasing dyspnea, stridor, changes in respiratory patterns; monitor
pulse oximetry and ABG values to detect problematic oxygen saturation and
increasing CO2
2. Assess for cerebral hypoxia (eg, restlessness, confusion); report deteriorating
respiratory status immediately to physician; and assist as needed with intubation
or escharotomy.
2. Distributive shock
1. Monitor for early signs of shock (decreased urine output, cardiac output,
pulmonary artery pressure, pulmonary capillary wedge pressure, blood pressure,
or increasing pulse) or progressive edema
2. Administer fluid resuscitation as ordered in response to physical findings;
continue monitoring fluid status.

Cont….
3.Acute renal failure
1. Monitor and report abnormal urine output and quality, blood urea nitrogen
(BUN) and creatinine levels; assess for urine hemoglobin or myoglobin.
2. Administer increased fluids as prescribed.
4. Compartment syndrome
1. Assess peripheral pulses hourly with Doppler; assess neurovascular status
of extremities hourly (warmth, capillary refill, sensation, and movement).
2. remove blood pressure cuff after each reading; elevate burned
extremities; report any extremity pain, loss of peripheral pulses or
sensation; prepare to assist with escharotomies.

Nursing Management: Acute/ Intermediate Phase
Assessment
 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.

Nursing interventions
1. Restoring Normal Fluid Balance
 Monitor IV and oral ﬂuid intake; use IV infusion pumps.
 Measure intake and output and daily weight.
 Report changes (e . g, blood pressure, pulse rate) to physician.
2. Preventing Infection
 Provide a clean and safe environment; protect patient from sources of cross
contamination (e . g, visitors, other patients, staff, equipment).
 Closely scrutinize wound to detect early signs of infection.

3.Maintaining Adequate Nutrition
 Initiate oral ﬂuids slowly when bowel sounds resume; record tolerance—if vomiting and distention do
not occur.
 Fluid may be increased gradually and the patient may be advanced to a normal diet or to tube
feedings.
 Collaborate with dietitian to plan a protein and calorie-rich diet acceptable to patient. Encourage
family to bring nutritious and patient’s favorite foods.
 Weigh patient daily and graph weights.
4. Promoting Skin Integrity
 Assess wound status.
 Support patient during distressing and painful wound care.
 Assess burn for size, color, odor, eschar, exudate, epithelial buds (small pearllike clusters of cells on
the wound surface), bleeding, granulation tissue, the status of graft take, healing of the donor site, and
the condition of the surrounding skin; report any signiﬁcant changes to the physician.

Monitoring and Managing Potential Complications
1.Pulmonary edema
 Assess for increasing CVP, pulmonary artery and wedge pressures, and crackles; report
promptly.
 Position comfortably with head elevated unless contraindicated. Administer medications
and oxygen as prescribed and assess response.
2.Sepsis:
 Assess for increased temperature, increased pulse, widened pulse pressure, and ﬂushed,
dry skin in unburned areas (early signs), and note trends in the data.
 Perform wound dressing and blood cultures as prescribed. Give scheduled antibiotics on
time.

3.Acute respiratory failure and acute respiratory distress syndrome (ARDS)
 Monitor respiratory status for dyspnea, change in respiratory pattern, and onset of
adventitious sounds.
 Assess for decrease in tidal volume and lung compliance in patients on mechanical ventilation.
4.Visceral damage (from electrical burns)
 Monitor electrocardiogram (ECG) and report dysrhythmias; pay attention to pain related to deep
muscle ischemia.
 Fasciotomies may be necessary to relieve swelling and ischemia in the muscles and fascia; monitor
patient for excessive blood loss and hypovolemia after fasciotomy.

NURSING PROCESS :REHABILITAION PHASE
 Nursing assessment
 obtain information about patient’s educational level, occupation, leisure
activities, cultural background, religion, and family interactions.
 Assess selfconcept, mental status, emotional response to the injury and
hospitalization.
 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.

Nursing diagnosis
 Activity intolerance related to pain on exercise, limited joint mobility, muscle
wasting, and limited endurance
 Disturbed body image related to altered appearance and self concept
 Deﬁcient knowledge of post discharge home care and recovery needs

Planning and Goals
 Goals include increased participation in ADLs;
 increased understanding of the injury, treatment, and planned followup care;
 adaptation and adjustment to alterations in body image, selfconcept, and
lifestyle; and absence of complications.

Nursing intervention
 Promoting Activity Tolerance
 allow periods of uninterrupted sleep. Administer hypnotic agents, as
prescribed, to promote sleep.
 Reduce metabolic stress by relieving pain, preventing chilling or fever, and
promoting integrity of all body systems to help conserve energy. Monitor
fatigue, pain, and fever to determine amount of activity to be encouraged daily.
 Physical therapy exercises to prevent muscular atrophy and maintain mobility
required for daily activities.

 Improving Body Image and Self-Concept
 Take time to listen to patient’s concerns and provide realistic support; refer
patient to a support group to develop coping strategies to deal with losses.
 Assess patient’s psychosocial reactions; provide support and develop a plan to
help the patient handle feelings.
 Teach patient ways to direct attention away from a disﬁgured body to the self
within.
 Coordinate communications of consultants, such as psychologists, social
workers, vocational counselors, and teachers, during rehabilitation.


Monitoring and Managing Potential Complications
Contractures:
 Provide early and aggressive physical and occupational therapy; support patient if
surgery is needed to achieve full range of motion.
 Impaired psychological adaptation to the burn injury:
 Obtain psychological or psychiatric referral as soon as evidence of major coping
problems appears.

Post burn exercises
1. Stretching exercises
The exercise are done for different parts of the body:
 Face : Look in mirror and make facial expression such as smiling,close eye tightly and massage
skin around eyes.
 Neck: stretch your neck with facial stretching and in opposite direction of tightness
 Chest: Lie on your back with a ball or cushion in middle of the back.
 Shoulder: Hold a stretch band with each hand .Use one arm at the point of pull .Repeat to stretch the
other shoulder.
 Elbow: sit your elbow all the way straight and your plams facing forward or up.
 Hands: stretch each finger at the knuckle to help get the hand into a fist .
 Knees: To help get the knees straight ,sit with your legs propped up.
 Ankle: Standing helps to stretch ankles to get your feet flatter on the ground.
 Toes: First massage the scar then use your hand to stretch the toes.

Evaluation
 Expected Patient Outcomes
 Demonstrates activity tolerance required for desired daily activities
 Adapts to altered body image
 Demonstrates knowledge of required selfcare and followup care
 Exhibits no complications

Teaching Self-care
 Provide verbal and written instructions about wound care, prevention of
complications, pain management, and nutrition.
 Inform and review with patient speciﬁc exercises and use of elastic pressure
garments and splints; provide written instructions.
 Teach patient and family to recognize abnormal signs and report them to the
physician.
 Encourage and support followup wound care.
 Evaluate patient status periodically for modiﬁcation of home care instructions
and planning for reconstructive surgery.

Summary
Burn injuries occur when energy from a heat source is transferred
through conduction or electromagnetic radiation , and is classified
according to depth, causes , and extent of burn .For the assessment of
burn area three methods are used that are, rule of nine , lund and
browder and palmer method . There are three phases for management
of burn ; emergent phase , acute phase , and rehabiltative phase.

Evalution
1. A full thickness burn is:
A. Classified by the appearance of blisters.
B. Identified by the destruction of the dermis and epidermis.
C. Not associated with edema formation.
D. Usually very painful because of exposed nerve endings.
2. As the first priority of care, a patient with burn injury will initially need:
A. A patent airway established.
B. An indwelling catheter inserted.
C. Fluids replaced.
D. Pain medication administered.

3.Which of the following is not an indication for admission in case of burn:
A. Full thickness burns more than 5%of total body surface area.
B. Partial thickness burns more than 10%in adults
C. Partial thickness burns more than 10% in childern.
D. Inhlation burns.
4Which statement made by the client with facial burns who has been prescribed to wear a
facial mask pressure garment indicates a correct understanding of the purpose of this
treatment?
A“After this treatment, my ears will not stick out.”
B “The mask will help protect my skin from sun damage.”
C“Using this mask will prevent scars from being permanent.”
D “My facial scars should be less severe with the use of this mask.”

Reference
 Book
 Internet
 Teachers

Biblography
1.Javed ansari;A textbook of medical surgical nursing-II;PV
publication;page no.-609-625.
2.Bunner and suddarth’s;textbook of medical surgical nursing;13th
edition;page no.-1703-1739.
3.www.nurseslab.com
4.www.slideshare.com
5.www.researchgate.net

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