BURNS AND ITS
MANAGEMENT
-BY SHWETA SHARMA
MSC. NURSING Ist YEAR

INTRODUCTION TO BURNS
• A burn is a type of injury to skin, or other tissues, caused by heat,
cold, electricity, chemicals, friction, or radiation.
• Burns are the fourth most common type of trauma worldwide,
following traffic accidents, falls, and interpersonal violence.
• An estimated 1,80,000 deaths every year are caused by burns – the
vast majority occur in low- and middle-income countries.
• Burns are preventable.
• Burns occur mainly in the home and workplace.

ANATOMY OF SKIN

PHYSIOLOGY OF SKIN
1. Regulates body temperature.
2. Prevents loss of essential body fluids, and penetration of toxic
substances.
3. Protection of the body from harmful effects of the sun and radiation.
4. Excretes toxic substances with sweat.
5. Mechanical support.
6. Sensory organ for touch, heat, cold, socio-sexual and emotional
sensations.
7. Vitamin D synthesis from its precursors under the effect of sunlight
and introversion of steroids.

SOURCES OF BURN INJURY

TYPES OF BURN INJURY
TYPES
FRICTION
BURNS CHEMICAL
BURNS
THERMAL
BURNS
RADIATION
BURNS
COLD
BURNS
ELECTRICAL
BURNS

FRICTION BURNS

CHEMICAL BURNS

RADIATION BURNS

THERMAL BURNS

COLD BURNS

ELECTRICAL BURNS

CLASSIFICATION OF BURN
• First- degree (superficial) burn
• Second- degree (partial thickness) burn
• Third- degree (full thickness) burn
• Fourth degree burn

First- degree (superficial) burn

Second- degree (partial thickness) and third
degree burn

Fourth- degree burn

PATHOPHYSIOLOGY
• Local response

LAB INVESTIGATIONS
•COMPLETE BLOOD COUNT
•SERUM ELECTROLYTE –
Potassium level initially elevated due to injured / RBC
destruction renal function.
Hypokalemia when diuresis start.
Magnesium level may be decreased.
Sodium level initially decreased with body water loss.
Hypernatremia occurs later as renal conservation occurs.

• ALKALINE PHOSPHATE – elevated due to interstitial fluid
shift / impairment of sodium.
• SERUM ALBUMIN – albumin / globulin ratio may reserve
as result of loss of protein in edema fluid.
• SERUM GLUCOSE – elevation reflects stress response.
• BUN / CR – elevation (decrease renal perfusion / tissue
injury)
• URINE – presence of albumin, hemoglobin & myoglobin
indicates deep tissue damage.

• RADIOLOGIC EXAMINATION
 CHEST X-RAY – inhalation injury
 FIBEROPTIC BRONCHOSCOPE - in inhalation injury
findings -edema & hemorrhage.
 LUNG SCAN
 ELECTROCARDIOGRAM (MI)

ASSESSMENT OF BURNS
•PALMAR METHOD
•WALLACE RULE OF NINES
•LUND AND BROWDER METHOD

PALMAR METHOD

WALLACE RULE OF NINE

FIRST AID FOR BURNS

MEDICAL MANAGEMENT
There are three phases of burn injury, each
requiring various levels of client care. The
three phases are:
• Emergent
• Intermediate
• Rehabilitative

EMERGENT PHASE
•This phase begins immediately at the time of
injury and ends with the restoration
of capillary permeability.
•The main goal of this phase is to prevent
hypovolemic shock and preserve vital organ
functioning.
•Methods used during this time are pre hospital
care and emergency room care.

Formulas to calculate fluid requirement
• Although there are a number of acceptable formulas
for calculating fluid requirements, the Parkland
formula is most often used.
• The Parkland Formula
• The Parkland formula for the total fluid requirement in
24 hours is as follows:
• 4ml RL x TBSA (%) x body weight (kg)
• 50% given in first eight hours and 50% given in next 16
hours.

•Practice question:-
•A patient is brought to the Emergency after
having sustained burns to 27% of their body. The
patient weighs 98 kgs. What must be the total
amount of fluid to be given in the first 8 hours?
Ans. = 4ml RL x TBSA (%) x body weight (kg)
=4ml RL x 27 (%) x 98(kg)=10,584 ml in 24
hours
In first 8 hours, 50% i.e. 5,292 ml will be given

Evans formula:
First 24 hours:
Crystalloid 1 ml/kg/% BSA+ albumin at 1 ml/kg/% burn+2000 ml of 5%
dextrose(Half over the first 8 hours and remaining half over second 16 hours)
Next 24 hours:
Crystalloid at 0.5 ml/kg/% burn+ albumin at 0.5 ml/kg/% burn+2000 ml of 5%
dextrose
The Brooke formula:
First 24 hours:
Hartmann’s (or Ringer's lactate). No colloids.
2 ml/kg/% BSA
Next 24 hours:
Albumin infusion at 0.3–0.5 ml/kg/% burn. No more crystalloid.

INTERMEDIATE PHASE
• It begins about 48–72 hours following the burn injury.
• During this time, the emphasis is placed on restoration of the
patient’s capillary permeability and the phase continues until
the wound is totally closed.
• During the intermediate phase, attention is given to
removing the eschar and other cellular debris from the
burned area. Debridement, the process of removing eschar,
can be done placing the client in a tub or shower and gently
washing the burned tissue away with mild soap and water or
by the use of enzymes, substances that digest the burned
tissue. Santyl (collagenase) is an important debriding agent
for burn wounds.

HYDROTHERAPY CART
SHOWER
ESCHAROTOMY

DRESSINGS FOR BURN INJURY

BIOLOGIC DRESSINGS
FISH GRAFT
AMNIOTIC MEMBRANE
GRAFT

REHABILITATIVE PHASE
• This stage begins with closure of the burn and
ends when the client has reached the optimal
level of functioning.
• In actuality, it begins the day the client enters the
hospital and can continue for a lifetime.
• In the rehabilitative phase, the focus is on helping
the client return to preinjury life.

SURGICAL MANAGEMENT OF BURNS
•SKIN GRAFTS- 1. Split-thickness grafts
2. Full-thickness grafts
•MICROSURGERY
•FREE FLAP PROCEDURE
•TISSUE EXPANSION

TISSUE EXPANSION

Types of balloon used for tissue expansion

NURSING MANAGEMENT OF BURNS
• NURSING ASSESSMENT
PRIMARY ASSESSMENT SECONDARY ASSESSMENT
• Airway
• Vital signs
• Neurologic
assessment
• Skin exposure
• Transport
• History
• Lab investigations
• Wound care
• Pain and anxiety
• Fluid resuscitation

NURSING DIAGNOSIS
• 1. Ineffective airway clearance related to edema and effects of
smoke inhalation as evidenced by abnormal breath sounds,
dyspnea, etc.
• Goal- Maintain patent airway and adequate airway clearance.
• 2. Impaired gas exchange related to carbon monoxide poisoning,
smoke inhalation and upper airway obstruction as evidenced by
cyanosis, abnormal arterial pH, etc.
• Goal- Maintain patent airway and adequate airway clearance.
• 3. Deficient fluid volume related to increased capillary
permeability and evaporative loss from the burn wound as
evidenced by concentrated urine, decreased skin turgor, etc.
• Goal- Restoration of optimal fluid and electrolyte balance and
perfusion of vital organs.

• 4.Hypothermia related to loss of skin microcirculation
and open wounds as evidenced by body temperature
below normal range, cool pale skin, etc..
• Goal- Maintenance of adequate body temperature.
• 5.Acute pain related to tissue and nerve injury as
evidenced by verbal explanation of patient, pain scale
score, etc.
• Goal- Control of pain.
• 6. Anxiety related to fear and the emotional impact of
burn injury as evidenced by irritability, feelings of
inadequacy, etc.
• Goal- Minimization of patient’s and family’s anxiety.

• Four major goals relating to burn management are prevention,
institution of lifesaving measures for the severely burned person,
prevention of disability and disfigurement, and rehabilitation.
Nursing Priorities
•Maintain patent airway/respiratory function.
•Restore hemodynamic stability/circulating volume.
•Alleviate pain.
•Prevent infection.
•Wound care.
•Prevent complications.
•Provide emotional support for patient/significant other (SO).
•Provide information about condition, prognosis, and treatment.

SCAR MANAGEMENT

PRESSURE GARMENTS

SILICON GEL

COMPLICATIONS OF BURNS
• Infection
• Low blood volume
• Dangerously low body temperature
• Compartment syndrome
• Breathing problems [Inhalation injury]
• Scarring
• Bone and joint problems
• Shock
• Heat exhaustion and heatstroke

PREVENTION OF BURNS

NEW TECHNOLOGY
• ReCell

Strata graft

Research Articles
• 1.Stem cells in burn wound healing: A systematic review of the
literature.
Stem cell therapy appears to exert a positive effect in burn wound
healing. There is, therefore, justification for continued efforts to
evaluate the use of stem cells as an adjunct to first-line therapies in
burns.
• 2.Burn intensive care treatment over the last 30 years: Improved
survival and shift in case-mix.
After correction for case-mix, survival improved, mainly in the major
burn group. Case-mix shifted towards inhalation injury and watchful
waiting. Growth of the watchful waiting group is not necessarily
harmful. However, the increase of mechanical ventilation could be. We
suggest raising awareness for risks and consequences of mechanical
ventilation.

Conclusion
• As discussed throughout the presentation, learning about burns
and its management will help nurses to care for a burn injury
patient.
• Nurses can do burn wound assessment ,classify the degree of
burn , observe the sign and symptoms , provide the necessary
nursing care and support the patient psychologically.
• Nurses can also counsel the patients and their family for various
options available in burn treatment and rehabilitation.

RECAPITULATION
• WHAT ARE THE TYPES OF BURNS???
• WHAT ARE THE DEGREES OF BURN???
• METHODS OF BURN ASSESSMENT???
• THREE PHASES OF BURN MANAGEMENT???
• NEW TECHNOLOGY???

References
• 1.Gerard J. Tortora, Bryan Derrickson. Principles of Anatomy and Physiology.
2011. Asia. John Wiley and Sons Pte Ltd. Volume I. 13th Edition. Pg. no. 154-
159, 167-169.
• 2.Janice L. Hinkle, Kerry H. Cheever. Brunner and Suddarth’s Textbook of
Medical Surgical Nursing. 2015. New Delhi. Wolters Kluwer.13th Edition.
Volume 2. Pg. no. 1805-1833.
• 3.Lewis. Medical Surgical Nursing Assessment and Management of clinical
problems.2015. New Delhi. Elsevier. 2nd Edition. Volume I. Pg no. 470-493.
• 4.Joyce M. Black, Jane Hokanson Hawks. Medical Surgical Nursing Clinical
Management of positive outcomes.2015. New Delhi. Reed Elsevier India Private
Limited. Volume II. Pg. no. 1239-1268.
• 5.Nayana Ambardekar. Plastic Surgery for Burns and other wounds. Available
from
• https://www.webmd.com/skin-problems-and-treatments/plastic-surgery-
burns#2 [cited16 aug 2019]

6.American academy of Pediatrics. Burn treatment and prevention tips for families. Available
from https://www.healthychildren.org/English/health-issues/injuries-
emergencies/Pages/Treating-and-Preventing-Burns.aspx [cited 19 aug 2019]
7. Mayo clinic. Burns. Available from https://www.mayoclinic.org/diseases-
conditions/burns/symptoms-causes/syc-20370539 [cited 16 aug 2019]
8. Federal Practitioner. Exciting new technology for burn treatment. Available from
https://www.mdedge.com/fedprac/article/103531/dermatology/exciting-new-technology-burn-
treatment [cited 21 aug 2019]
9.ScienceDirect. Stem cells in burn wound healing: A systematic review of the literature.
Available from https://www.sciencedirect.com/science/article/abs/pii/S0305417918302663
[cited 22 aug 2019]
10.ScienceDirect. Burn intensive care treatment over the last 30 years: Improved survival and
shift in case-mix. Available from
https://www.sciencedirect.com/science/article/abs/pii/S030541791830857X [cited 22 aug 2019]