Burns

Burns
Anatomy of the Skin
Three Types of Burn Classifications

Thermal -93 % of all burns
Cell injury occurs by coagulation from a source of significant heat.
Can occur from:
Flame
Scalding liquids
Steam
Direct contact with a heat source
The severity is related to heat intensity and duration of contact
UP TO 104 degree F does not cause damage; anything above combined
Thermal Burn
Burn Classification Contd

Chemical
Caused by contact, inhalation of fumes, ingestion, or injection.
Can have both local and systemic effects.
Tissue damage continues until chemical is completely removed or neutralized.
Categories of chemical agents
Alkalies
Oven cleaners, lye, wet cement, and fertilizers
Acids
Bathroom cleaners, rust removers, swimming pool chemicals.
Chemical Burn
Burn Classification Contd

Electrical
Frequently work related
AC- most commercial applications
Can create cardiopulmonary arrest by VFib
Tetanic muscle contraction can freeze
patient to source of electricity
DC- lightning, car batteries
Tissue damage occurs during the process of
electricity turning into heat.
Inhalation Injury
Smoke exposure causes an airway inflammatory response with changes in
biochemical mediators and cells.
Systemic
Carbon Monoxide (burning wood or coal)
Binds to hemoglobin more rapidly than oxygen
Tissue hypoxia
Cyanide (smoke byproducts)
Binds to respiratory enzymes in the mitochondria
Inhibits cellular metabolism and utilization of oxygen
Inhalation Injury Contd

Subglottic (lower airway injury)
Chemical
Impaired ciliary activity, erythema, hypersecretion, edema, ulceration of mucosa,
increased blood flow, spasm of bronchi and bronchioles.
ARDS may develop
Xray may show Atelectasis, edema, infiltrates,
Respiratory mucosal sloughing
Carbonaceous sputum
Soot or carbon particles in sputum
Clinical indications of inhalation injury

Facial burns
Burn Classification and Severity

Depth
superficial-epidermis -first layer of skin
Heals in 3-5 days without treatment
Partial-thickness-dermal layer-second layer
Second degree injury- heals in 2-4 weeks
Full thickness-epidermis, dermis, subcutaneous
Third degree- does not heal requires skin grafting
Extent of injury is the total body surface area (%TBSA)
Rule of nines
Physiological Response
The entire body responds to major burns.
Hemodynamic, metabolic and immunologic effects
Systemic and local as a result of cellular damage
Relates to %TBSA
Burns - Medical Management

Stop the burning and identify life
threatening injuries!
Thermal: Smother flames.
Chemical: Flush with water.
Electrical: Stop the current.
Assess
Airway
Breathing
Initial Assessment: Airway

Secure the airway first.
Look for soot or singed nasal hairs.
Severe upper body and facial burns
May need to intubate quickly d/t
edema.
Get history as much as possible before
intubation.
Initial Assessment: Breathing

High flow oxygen: reduces CO.
Impaired ventilation: Assess for
escharotomy.
Listen: verify breath sounds.
Assess rate and depth.
Initial Assessment: Circulation

Monitor blood pressure, pulse, and skin
color.
Fluid Resuscitation: Establish IV access;
two large bores.
Remove jewelry and constricted
clothing.
Monitor peripheral pulses in
circumferential burns.
Thermoregulation
Cover with clean dry blanket
Warm IV fluids
Warm humidified oxygen
Warm ambient air
Fluid Resuscitation
Determine TBSA
Recommended
for adults
>15% TBSA or
children >10%
TBSA.
GOAL: Prevent
hypovolemic
shock!
Nursing Management: Assessment

AIRWAY
Emergent Phase:
Assess the injury:
What time did it occur?
What type of burn?
Can you classify it?
Rule of 9s
Possibility of inhalation injury?
Stop the burning process!
Vital Signs:
Initiate Cardiac
Monitoring
Conduct patient
interview as
appropriate
BREATHING
CIRCULATION
Nursing Management: Diagnosis

Ineffective Tissue Perfusion R/T
hypovolemia AEB diminished or lack
of peripheral pulses/capillary refill
time
Risk for Infection R/T inadequate
primary defenses (destruction of
skin barrier) AEB Second degree
burn, 15% TBSA
Risk for Ineffective Airway Clearance
R/T fluid shifts, pulmonary edema
and decreased lung compliance AEB
tachypnea, diminished breath
sounds
Nursing Management: Planning

Prioritize:
focus on severity and high-risk
factors
Create clear, measurable goals for
expected beneficial outcomes.
Where is closest burn center?
Collaborate with the center
What mode of transportation?
Treatment necessary to stabilize the
patient for transport
Nursing Management: Implementing

Actions taken by the nurse to achieve defined
& planned goals
Spinal Immobilization
IV access, 14-16 gauge (Labs)
Obtain pt. Weight
Calculate fluids
Intubation?
Elevated HOB (reduce facial and airway
edema)
Prevent hypothermia - blanket
Nursing Management: Evaluation

ALWAYS reassess the patient as you go!
The patient's status may change
suddenly forcing you to reprioritize
interventions & goals!
Evaluate the effectiveness of the
interventions completed
Anticipate patient's needs
Collaborate with all team members
NCLEX Question
The newly admitted client has burns on both legs. The burned areas appear white
and leather-like. No blisters or bleeding are present, and the client states that he
or she has little pain. How should this injury be categorized?
A.Superficial
B.Partial-thickness superficial
C.Partial-thickness deep
D.Full thickness
NCLEX Answer:
The newly admitted client has burns on both legs. The burned areas appear white
and leather-like. No blisters or bleeding are present, and the client states that he
or she has little pain. How should this injury be categorized?
A.Superficial
B.Partial-thickness superficial
C.Partial-thickness deep
D.Full thickness
The characteristic of the wound meets the criteria for a full-thickness injury (Color that
is black, brown, yellow, white or red; no blisters; pain minimal; outer layer firm and
inelastic)
NCLEX Question
At what point after a burn injury should the nurse be most alert for the complication
of hypokalemia?
a. Immediately following the injury
b. During the fluid shift
c. During fluid remobilization
d. During the late acute phase
NCLEX Answer:
At what point after a burn injury should the nurse be most alert for the complication
of hypokalemia?
a. Immediately following the injury
b. During the fluid shift
c. During fluid remobilization
d. During the late acute phase
Hypokalemia is most likely to occur during the fluid remobilization period as a result
of dilution, potassium, movement back into the cells, and increased potassium
excreted into the urine with the greatly increased urine output.
Reference
Sole, M. L., Klein, D. G., & Moseley, M. J. (2009). Introduction to critical
care nursing. St. Louis, MO: Saunders.

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Burns

Anatomy of the Skin

Three Types of Burn Classifications

Burn Classification Contd

Caused by contact, inhalation of fumes, ingestion, or injection.

Can have both local and systemic effects.

Tissue damage continues until chemical is completely removed or neutralized.

Categories of chemical agents

Oven cleaners, lye, wet cement, and fertilizers

Bathroom cleaners, rust removers, swimming pool chemicals.

Burn Classification Contd

Inhalation Injury Contd

Clinical indications of inhalation injury

Burn Classification and Severity

Burns - Medical Management

Initial Assessment: Airway

Initial Assessment: Breathing

Initial Assessment: Circulation

Nursing Management: Assessment

Nursing Management: Diagnosis

Nursing Management: Planning

Nursing Management: Implementing

Nursing Management: Evaluation

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