BURNS

Sonny M. Moreno, RN
 Coverage
• Prevention
• Safety
• Immediate Care
• Assessment

• Emergency Management
• 1st Phase
• 2nd Phase
• 3rd Phase
• Rehabilitation
 PREVENTION

MAJORITY OF BURN
CASES
ARE DUE TO
NEGLIGENCE
SO HAZARD
PRECAUTIONS
MUST BE OBSERVED.
 MNEMONIC IN THE EVENT OF
FIRE
 R ESCUE remove
client
 A LARM activate
fire alarm, report
 C ONFINE close
doors and
windows
 E XTINGUISH fire
 Safety
 Don’t panic
 Drop to the floor
 Look for the exit
 Cover face with wet cloth
 Immerse into cool water or running water
immediately if you get burned to prevent
further injury.
 Extinguish any remaining fire by dropping
and rolling onto the floor.
 INHALATION INJURIES
 Heat Inhalation-
HOT AIR OR FLAMES

 Systemic Toxins-
ENCLOSED FIRE-CO
IS INHALED

 Smoke Inhalations-
FREQUENTLY HIDDEN
BY MORE VISIBLE
INJURIES (60-80%
FATALITIES)
 Indications of Inhalation Injury
 Usually appears within 2-48 hours after
burn occurred.
 Indications may include:
• The patient faints
• Fire or smoke present in a closed area
• Evidence of respiratory distress or upper
airway obstruction
• Soot around the mouth or nose
• Nasal hairs, eyebrows, eyelashes have been
singed
• Burns around the face or neck
 ASSESSMENT
 A IRWAY
 B REATHING
 C IRCULATION
 D ISABILITIES
 E XPOSE
 A airway - check nose, face and neck
(priority) singed and sooty hair of
the nose
 B breathing – rise and fall of chest
 C circulation - if there is no breathing
and circulation start CPR
 D check for disability and manage
accordingly
 E expose to determine extent of
injury
 Types of Burns
 Thermal – dry flames, moist and
heat
 Mechanical – friction or abrasion
 Chemical – acid or alkali
 Electrical – most fatal
 Radiation – sunlight
 Classifications
 1st degree – partial
thickness
painful, no blisters, pink
and red, epidermis
 2nd degree – deep partial
thickness
painless, with blister, (+)
blanch and refill epidermis
and dermis
 3rd degree – full thickness
painless, leathery, fascia
and muscle, F&E imbalance
 4th degree – bones and
visceral organs are affected
Layers of Skin
Extent of Injury
Sunburn, 1 degree
st
Epidermis Only
All Skin Layers
Skin, SQ, Fascia, Muscles
4 Degree
th
 Emergency Room
 ABCDE assessment
 Airway and fluid resuscitation
(priority)
 Strict I and O monitoring
 Give TIG/TAT and TT
 Prophylactic antibiotic
 Sterile dressing for wound
 EXPOSE
 To check other injuries
 Determine TBSA
 Rule of Nines “Berker Formula”
Parkland Formula
(4ml x TBSA x BWkg)
1st 8H give ½,
2nd 8H give ¼ and for the
3rd 8H give the last part
 Repeat ABCDE assessment
 Parkland Formula
 (4ml x TBSA x BWkg)

1st 8H give ½

2nd 8H give ¼

3rd 8H give ¼
 TBSA
 Entire trunk = A1
 Both upper extremities = A2
 Face = A3
 Entire back = B1
 Anterior left upper extremity = B2
 Right and left lower extremities = B3
 Parkland Formula
 A1+A2+A3 = A4
 Total Volume of Infusion = A5
 1st 8 hours = A6
 2nd 8 hours = A7
 3rd 8 hours = A8
 B1+B2+B3 = B4
 Total Volume of Infusion =B5
 1st 8 hours = B6
 2nd 8 hours = B7
 3rd 8 hours = B8
 Questions
 Most common type of burns = A9
 Fatal type of burns = B9
 s/sx of head injury = A10
 s/sx of spinal cord injury = B10
 1st Phase
Fluid Accumulation
IV to IT and IC
 most critical period
 36-48H post burn, FVD or
hypovolemia
 3rd fluid shift
 edema on the injured area (IV to IT)
fatal form is circumferential edema
from chest injury
 1 Phase Con’t
st

 hyponatremia (IV to outside from it)

 hyperkalemia (cell injury)
 1 Phase Con’t
st

 ↓ urine output to RF (dec. BV)

 myoglobinuria destroys the kidney to
RF (muscle destruction)
rhabdomyolysis
 ↓BV - ↓TP - ↑H - ↓pH – Acidosis
 1 Phase Con’t
st

 ↓BV – curling’s ulcer or paralytic ileus

(dec. BV), NPO, NGT lavage, TPN
 Infection may set in (isolation)
 2nd Phase
Fluid Remobilization
IT/IC to IV

 May last 48-60H

 FVE (CHF)
 Hypokalemia
 Diuresis phase (oliguria may signifies
RF)
 2 Phase Con’t
nd

 Hyponatremia due to fluid loss from

diuresis phase
 Infection may set in (isolation)
 Anemia may linger up to recovery
period
 Complications from immobility may
set in (Circulo-O-electric bed)
 Anemia may linger
 3rd Phase to Recovery Period
 Infection may set in
(isolation, Sulfadiazine
application)
 Healing process to scar
formation and
contractures
 Surgery (Reconstructive
or Plastic) STSG auto-
graft
 3 Phase Con’t
rd

 Debridement and Escharotomy

 Diet: high caloric high CHON
 Psychological Aspect: dec. self
esteem, stigma, perceived body
changes, isolation, depression, loss
of identity these are all related to
physical disfigurement.
 RECAP
• Prevention
• Safety
• Immediate Care
• Assessment

• Emergency Management
• 1st Phase
• 2nd Phase
• 3rd Phase
• Rehabilitation
 Short Quiz
 1. Fluid accumulation A. FVE
 2. Fluid remobilization B. FVD
 3. Hypokalemia C. 1st Phase
 4. Hyperkalemia D. 2nd Phase
 5. Priority during 1st phase?
A. fluid C. infection
B. I&O D. all of the above
 6. diuresis A. 1st Phase
 7. oliguria B. 2nd Phase
 8. tetany
 9. anemia
 10. infection
 11. T wave elevation
 12. T wave inversion

 13. STSG?
 14. type of dressing? (debridement)
 15. diet? (recovery)
 Full thickness, circumferential chest
burns cause difficulty breathing.
Which of the following surgical
intervention can correct this?
A. intubation
B. thoracentesis
C. escharotomy
D. chest tube insertion
 An adult woman arrives in the ER 20
minutes after sustaining a major burn
injury. IV line was inserted, which of the
following intervention would the nurse do
next?
A. insert an indwelling catheter
B. apply silvadene cream
C. shave the hair around the burn wound
D. obtain culture from the deepest burned
area
 During the fluid accumulation phase
of major burn injury, fluids shift from
the:
A. intravascular to outside from it
B. intracellular to intravascular
C. interstitial to intracellular
D. any of the above
 When the nurse is completing an
assessment of a burned client, second
degree burns (deep partial thickness)
would appear as:
A. injury is extended to the muscles and
bones
B. with edema and redness no vesicle
C. thickness involving the epidermis and
dermis showing edema and vesicles
D. full thickness with dry, waxy or leathery
appearance
 Hypervolemia can occur during the fluid
remobilization phase as a result of:
A. giving too much fluid
B. fluids shifting back into the intracellular
space
C. fluids shifting back into the interstitial
D. none of the above
 Using Berker Formula or Rule of
Nines, an injury affecting the
anterior chest, anterior abdomen and
entire right arm would be estimated
at how many percent?
A. 18% C. 27%
B. 45% D. 50%
 During the fluid accumulation phase
the nurse would expect to see signs
of which electrolyte imbalance?
A. hyperkalemia C.
hypercalcemia
B. hypernatremia D. hypokalemia
 What is your parameter in assessing the
degree of burn?
A. count the presence of blisters or
vesicles
B. observe presence of soot and singed
hair of the nose
C. Check the location of injury
D. assess the rate and extent of burned
area
 Using Berker Formula, which has the
largest percent of burns?
A. face and neck C. upper trunk
B. both thighs D. all limbs
 In relation to post burn injury, you
would expect that doctor will order:
A. foley catheter insertion
B. intermittent catheterization
C. straight catherterization
D. none of the above
 During the initial phase of burn
management, the type of fluid that
would be given is:
A. hypotonic C. hypotonic
B. isotonic D. whole blood
 Which of the following would be
appropriate in managing post burn?
A. Circul-O-electric bed
B. Stryker frame bed
C. Cradle bed
D. Bed with egg crate mattress
 Priority nursing action 16 hours after
major burn injury would be:
A. watchout for infection
B. hourly urine output
C. ROM every 3 hours
D. give high caloric diet
 Burn clients require continuous emotional
support. The nurse will know that he will
receive therapeutic support by which of
the following nursing actions?
A. keeping his room neat and clean
B. reacting to him as individual by
spending time
C. keeping family members aware of his
conditions
D. rotate the staff nurse so he could have
varied interactions
 An electrical worker has come in contact
with a live power line. He is unconscious
and is lying across the power line, the best
initial action is to:
A. flush him with water
B. grab him and pull away
C. cover him with blanket
D. use a wooden pole and pull him away
 Nursing intervention during the
emergent phase would be, except;
A. obtain an IV line
B. assess the degree and type
C. administer antacids
D. maintain an open airway
END
 SCAR
 Scar tissue forms as skin heals after an
injury (such as an accident) or surgery.
The amount of scarring may be
determined by the size, depth, and
location of the wound; the age of the
person; heredity; and skin
characteristics including color
(pigmentation).
 SURGERY
 Surgery to revise scars is done while
the patient is awake, sleeping
(sedated), or deep asleep and pain-
free (local anesthesia or general
anesthesia).
 MEDICATIONS
 Medications (topical corticosteroids,
anesthetic ointments, and antihistamine
creams) can reduce the symptoms of itching
and tenderness. Scars shrink and become
less noticeable as they age, therefore,
immediate surgical revision is delayed until
the scar lightens in color, which is usually
several months or even a year after a wound
has healed.
 KELOID
 A keloid is an abnormal scar that is thicker, different color
and texture, extends beyond the edge of the wound, and
has a tendency to recur. It often creates a thick, puckered
effect simulating a tumor. Keloids are removed at the point
where they meet normal tissue.
Massive injuries (such as burns) can cause loss of a large
area of skin and may form hypertrophic scars. A
hypertrophic scar can cause restricted movement of
muscles, joints, and tendons (contracture). Surgical repair
includes removing excessive scar tissue and a series of
small incisions on both sides of the scar site, which creates
V-shaped skin flaps (Z-plasty) may be used. The result is a
thin, less noticeable scar because the wound closure
following a Z-plasty more closely follows the natural skin
folds.
 GRAFTING
• Skin grafting involves the taking a thin (split
thickness) layer of skin from another part of
the body and placing it over the injured area.
Skin flap surgery involves moving an entire
thickness (full thickness) of skin, fat, nerves,
blood vessels, and muscle from a healthy part
of the body to the injured site. These
techniques are planned when a considerable
amount of skin has been lost in the original
injury, when a thin scar will not heal, and
when improved function (rather than aesthetic
reasons) are the primary concern. Secondary
procedures may later be necessary to achieve
appropriate aesthetic results.
 First Aid for Minor Burns
 If the skin is not broken, run cool water over the burned
area or soak it in a cool water (NOT ICE WATER) bath.
Keep the area in the bath for five minutes. If the burn
occurred in a cold environment, DO NOT apply water. A
clean, cold, wet towel will also help reduce pain.
 Burns can be extremely painful, reassure the victim and
keep them calm.
 After flushing or soaking the burn for several minutes,
cover the burn with a sterile non-adhesive bandage or
clean cloth.
 Protect the burn from friction and pressure.
 Over-the-counter pain medications may be used to help
relieve pain; they may also help reduce inflammation and
swelling.
 Minor burns will usually heal without further treatment.
 First Aid for Severe Burns
 DO NOT remove burnt clothing (unless it comes off easily), but do ensure
that the victim is not in contact with burning or smoldering materials.
 Make sure the victim is breathing. If breathing has stopped or the victim's
airway is blocked then open the airway and if necessary begin CPR.
 If the victim is breathing, cover the burn with a cool moist sterile bandage
or clean cloth. DO NOT use a blanket or towel; a sheet is best for large
burns. DO NOT apply any ointments and avoid breaking blisters.
 If fingers or toes have been burned, separate them with dry sterile, non-
adhesive dressings.
 Elevate the burned area and protect it from pressure or friction.
 Take steps to prevent shock. Lay the victim flat elevate the feet about 12
inches, and cover the victim with a coat or blanket. DO NOT place the
victim in the shock position if a head, neck, back, or leg injury is suspected
or if it makes the victim uncomfortable.
 Continue to monitor the victim's vital signs (breathing, pulse, blood
pressure).
 DO NOT
 DO NOT apply ointment, butter, ice, medications,
fluffy cotton dressing, adhesive bandages, cream,
oil spray, or any household remedy to a burn.
This can interfere with proper healing.
 DO NOT allow the burn to become contaminated.
Avoid breathing or coughing on the burned area.
 DO NOT disturb blisters or dead skin.
 DO NOT apply cold compresses and DO NOT
immerse a severe burn in cold water. This can
cause shock.
 DO NOT place a pillow under the victim's head if
there is an airway burn and they are lying down.
This can close the airway.