• Burns are traumatic injuries that result

in tissue loss or damage. A burn

destroys cells by increasing capillary
permeability and damaging cellular
proteins
• Burns may be classified according to
the mechanism of injury and according
to depth and size of the injury
CLASSIFICATION

Mechanism of Injury
Thermal
Electrical
Chemical
Radiation
• Thermal – caused by steam, hot water
scalds, flames and direct contact with heat
source
• Electrical – caused by electric shocks due
to exposure to electricity or lightning
• Chemical – caused by exposure to acids,
alkalis or other organic substances
• Radiation – result from exposure to
radioactive sources coming from either
industrial, therapeutic or natural.
Sunburn is a form of radiation burn
CLASSES OF BURNS

• First Degree Burns

• Second Degree Burns

• Third Degree Burns

First Degree Burns

A first degree burn is caused by brief

exposure to heat. In a first degree burn, the
skin is intact, dry but red and the burned
area is painful. (Fig. 1) Sunburn is a type of
first degree burn.
CLASSES OF BURNS
First Degree Burns
Second Degree Burns

• A second degree burn is caused by prolonged

exposure to heat or very high temperatures. In
a second degree burn, the skin may be intact or
it may appear to be partially peeling. It may
also appear moist or have a mottled
appearance. Any burn with blisters is second
degree. The burned area is very painful in a
second-degree burn.
Second Degree Burns
Second Degree Burns
Third Degree Burns
• A third degree burn is the most serious type
of burn and is caused by prolonged
exposure to very high temperatures. In a
third-degree burn, the skin is burned
through its full thickness. The tissues
underneath the skin may show through. The
edges of the burn are frequently charred.
(Fig. 3) The center of the burned area may
not be painful because the pain receptors in
the skin have been destroyed along with the
skin.
Third Degree Burns
 Characteristics of Burns of Various
Depth

I – Partial thickness
a. superficial (first degree)
b. superficial moderate(second degree)
c. deep dermal (second degree)
II – Full thickness (third degree)
 Partial Thickness
a. Superficial (first degree)
- Minimal epithelial damage
- Dry, blisters after 24 hrs, pinkish-red
in color, blanch with pressure
- Painful
- Cause – sun
 Partial Thickness (2)

b. Superficial (second-degree) (moderate)

- Epidermis and minimal dermis
involvement
- Moist, blisters, pinkish or mottled-red,
some blanching
- Painful, hyperesthetic (very sensitive)
- Sensitive to pressure
- Caused by flash burns or hot liquids
 Partial Thickness (2)

c. Deep Dermal – (second degree)

- Entire epidermis and part of dermis
are involved with hair and sweat
glands intact
- Dry, pale, waxy, no blanching
- Sensitive to pressure
- Flash burns, hot liquids, hot solids,
flame, intense radiant injury
 FULL THICKNESS
(third degree)

• Whole skin and subcutaneous fat

possibly involving muscle and bone
• Leathery, cracked, avascular, white
cherry red or black
• Little or minimal pain
• Sustained flame, electrical, chemical
and steam
Burn Classification as to Extent of
Injury

a. Mild or Minor

b. Moderate

c. Severe or Major
 Burn Classification as to Extent of Injury
(American Burn Association) : Minor Burns

• 2nd degree burn of < 15 % TBSA in adults

• 2nd degree burn of < 10 % TBSA in children
• 3rd degree burn of < 2 % not involving special
care areas (eyes, ears, face, hands, feet,
perineum, joints)
Excludes electrical injury, inhalation injury,
concurrent trauma, all high risk patients
(extremes of age and concurrent disease)
 Burn Classification as to Extent
of Injury: Moderate Burns

• Also called uncomplicated burn injury

2nd degree burns of 15-25 % TBSA adult
2nd degree burns 10-20 % TBSA children
3rd degree burns <10 % TBSA, not
involving special care areas
Excludes electrical injury, inhalation injury,
concurrent trauma, all high risk patients
(extremes of age and concurrent disease)
 Burn Classification as to Extent of
Injury: Severe or Major Burns
• 2nd degree burns of >25% TBSA adults
• 2nd degree burns of >20% TBSA children
• All 3rd degree of > 10% TBSA
• All burns involving eyes, ears, face, hands, feet,
perineum, joints
• All inhalation or electrical injury, concurrent
trauma, high risk clients
• Should be admitted to an ICU
 CALCULATION OF BURNED BODY
SURFACE AREA

• Calculation of Burned Body

Surface Area

4/1/2011 24
 TOTAL BODY SURFACE AREA (TBSA)
• Superficial burns are not involved in the
calculation
• Lund and Browder Chart is the most
accurate because it adjusts for age
• Rule of nines divides the body – adequate
for initial assessment for adult burns

4/1/2011 25
Lund Browder Chart used for determining BSA

4/1/2011 26
Evans, 18.1,
 RULES OF NINES
• Head & Neck = 9%
• Each upper extremity (Arms) = 9%
• Each lower extremity (Legs) = 18%
• Anterior trunk= 18%
• Posterior trunk = 18%
• Genitalia (perineum) = 1%

4/1/2011 27
The Rule of
Nines
 Burn Injury Management
• The chief nursing concerns in treating
burns are combating shock, alleviating pain
and restoring fluid and electrolyte balance.
Secondary interventions include the
prevention of infection and contractures
and the reconstruction or repair of damage.
Treatment of burn is long term. Pressure
garments are frequently used to prevent
contractures and scarring
The seriousness of a burn is determined by its
depth, percentage of area burned, location,
age and any underlying complications

Special Considerations:
1. A burn that involves more than 10 % of
the TBSA is serious
2. Any 2nd or 3rd degree burn is serious
3. Full thickness circumferential burns to
the limbs or chest are special problems
because they can restrict circulation and
breathing
Special Considerations: (cont’n)
4. Diabetics of any age have more difficulty
recovering from burns because their bodies
heal more slowly. They may also have
underlying circulatory or other difficulties
5. Any underlying injury can affect a person’s
recovery after burn
6. A person with a compromised immune
system is at a particular high risk for infection
following a burn
Associated Problems
These often cause more harm than the burn itself
(inhalation injury, broken bones or other
injuries)
Signs of possible inhalation injury
a. Burned or singed nasal hairs or burns in or
around the mouth
b. Decrease the patient’s saliva
c. Smell of smoke on the client’s breath
Nursing alert !
If a burned person was trapped in a
confined space and exposed to chemicals
or smoke, suspect smoke or heat
inhalation injury especially if the patient
is coughing and has difficulty of
breathing.
The gases in smoke replaces the air in
the lungs rendering the person unable to
oxygenate the blood.
Emergency first aid for Burns
1. Stop the burning process by removing the heat
source. Don’t remove burning clothing
unless they fall off. Removing the clothing
could tear the person’s skin and damage it
further.
2. If rescuers arrive within a few minutes of the
incident, flood the area with cool water. Do
not apply ice. The goal is to cool the area to
stop the burning and to reduce the incidence
of scarring. Ice may further irritate the
burned area by cooling it too quickly.
3. Continue to flood the area with cool water.
Cool water helps to control pain and
discontinuation may increase pain temporarily
due to damaged nerve endings.
4. Flood most chemical burns with gentle,
continuous flow of plain water until
emergency help arrives. Flooding with water
will help stop the burning process and cool the
area. It will also help to dilute and wash away
caustic chemicals.
5. Always check a chemical container for
directions on emergency treatment. Some
chemicals react adversely when in contact
with water.
6. Watch for shivering if you are using water to
cool a burn covering more than 10% of the
body. Change to dry sterile dressing if
shivering occurs. Too much exposure too cold
may cause hypothermia.
7. Do not put anything other than water of a
specifically prescribed substance on a burn.
Materials such as salves, ointments, butter
occlude the burn so that it becomes difficult to
examine. These substances promote infection
and pain on removal.
8. Remove the injured person’s jewelry. It can remain
hot and continue the burning process. Swelling
usually occurs later making it impossible to remove
rings or other jewelry. If left on, jewelry can cut off
circulation.
9. Monitor the person’s airway, breathing and
circulation. Be prepared to initiate CPR. Respiratory
or cardiac arrest or both can occur from the shock.
10. If the burn is extensive, cover it with a dry, non-stick
sterile dressing. Do not use gauze. Gauze will peel off
additional tissue and cause additional damage. For
all large burn, use only a dry sterile dressing,
following removal or the heat source and cooling
down period. The dressing will help to prevent
infection.
11. Keep dressings cool and wet. Be sure to keep
person warm and monitor for hypothermia.
Wet dressing may promote hypothermia.
12. Prevent contamination of the wound as much
as possible. Infection is a major hazard with
burns
13. Treat for shock. Pain, loss of body fluids and
anxiety contribute to shock
14. Determine what first aid measures others
have already given. Some of these measures
may be dangerous . Emergency and medical
personnel need to be aware of what has been
done.
 Phases of Burn Injury Management
The immediate or emergency response to a burn
is to stop the burning process and cold water to
the affected area.
Care Priorities:
A – airway
B – breathing
C – circulation
Resuscitative Phase: The goal of this phase is to
achieve physiologic stability. Wear sterile
gloves and use aseptic technique when
preparing and handling supplies.
Resuscitative Phase: (cont’n)
Vital Signs: record vital signs frequently as
patient is subject to shock
Fluid and Electrolyte Balance: Parkland
formula and others are available for
resuscitation.
Renal Function: Monitor urine output
closely because renal function commonly
slows or stops after the body undergoes
severe shock. If the output is too low (less
than 30 ml/hour) , dialysis may be needed.
Resuscitative Phase: (cont’n)
Infection: This is the leading cause of death in
patients with burns. They are highly
susceptible to infection because of the
lowered body resistance and the many open
wounds acting as portal of entry for
infectious agents.
Pain management: Patients with superficial
burns experience a great deal of pain. Those
with full-thickness burn are not in as much
pain, because their nerve endings have been
destroyed. Narcotic administration via PCA
is the standard for pain relief.
Morphine is often given to relieve pain. Be alert
for CNS and respiratory depression.
Pain medication is usually given prior to
any painful procedure such as debridement
Acute Phase:
Dressings: Several types of solutions and
substances are used as dressings. Synthetic
dressings such as Duoderm, Opsite, Vigilon and
Biobrane promote wound healing or
temporarily cover the wound. Pressure
dressing is used to prevent the development of
keloid (scar) tissue
Topical Agents:
Mafenide: Bacteriostatic cream against gm-
and gm+ bacteria. Associated with
complaints of burning after application and
development of metabolic acidosis
Silver sulfadiazine: Bactericidal against gm-
and gm+ bacteria. Associated with
leukopenia; monitor patient’s CBC. May
have resistance with gm- bacteria
Bacitracin – Used in superficial and facial
burn, applied 2-3x per day
Silver nitrate – Will blacken anything it comes
in contact with.
Applying Burn Dressings
1. Explain procedure to patient
2. Give prn analgesic and anxiolytic about ½
hour before a dressing change for pain
relief and relaxation.
3. Use aseptic technique throughout the
procedure
4. Wear goggles and sterile gloves when
changing dressings. Wear gown and mask if
splashing is likely.
5. Loosen dressing by moistening them with
warmed, sterile, normal saline if ordered
Applying Burn Dressings (cont’n)
6. Assess the burns condition:
- extra dry indicates dehydration
- wet and oozing with strong odor indicates
infection
- redness and swelling at the edge f the wound
indicate cellulitis
- clean, pink and shiny indicates healthy
healing
7. Dispose of all dressings and packs according
to the institutions policy as these are
considered contaminated.
Skin Grafting: Usually done on patients with full
thickness burn to replace tissue that cannot
heal by itself and to limit the amount of
scarring.
Autograft – a graft using the clients own skin
Homograft or allograft – using a cadaver skin
or another persons skin
Heterograft or xenograft – use of pigskin
which is rejected in approximately 1 week
• Cultured Epithelial Autograft (CEA) – The
patients own skin is biopsied and grown
which is used in covering extensive burns

IMPORTANT:
Skin grafts are very delicate. Take care not to
disturb them so that they can grow and attach
to the live tissue underneath. Assess the graft
and report if it seems to be a detaching.
Rehabilitative Phase:
Services: Physiotherapy (whirlpool), helps
clean the body and assists in removing
eschar. Counseling, occupational
therapy, financial, others
Complications: Curling’s ulcer, develops
about 1 week after the injury causing
significant GI bleeding manifested by
bloody emesis or tarry stool.
Contractures esp. if burn is near a joint is the
most serious long term complication of burns.
May be prevented by passive and active ROM
exercises. Splinting the extremities in anti-
deformity positions is essential in preventing
contractures.
Premedicate patients with analgesics
before exercise in order to reduce pain
Fluid and Electrolyte Balance
Parkland Formula
4 ml Lactated Ringer’s Solution x kg BW x
body surface area burned = volume in 24
hours
Half of this fluid is given for the first 8 hours
and the remaining half is given over the next
16 hours.
The patient is placed on:
- an indwelling catheter and an NGT
Fluid and Electrolyte Balance
(cont’n)
• Record I & O accurately:
Urinary output is measured every hour on
the hour and must have:
1. 0.5 – 1.0 ml per kg BW per hour
2. Heart rate < 120 bpm
3. SBP > 100 mmHg
• Hypo-hyperkalemia, hyponatremia may
occur
Fluid Resuscitation:

Mr. E.C. weighs 200 lbs., with burns of the

entire back.
Formula:
4 ml Lactated Ringer’s solution
x Kg BW
x % TBSA burned
Nursing Considerations
Severe burns are often obvious and distressing
but be sure to take note for other concomitant
injuries such as spinal cord injury and
fractures.
Circumferential burns of the extremities or chest
may compromise circulation or breathing.
Assess perfusion or distal extremities and
respiratory status. An escharotomy may be
needed to restore tissue perfusion or ease
beathing
Nursing Considerations (cont’n)
Never apply ointments or salves to an extensive
burn because removing them causes further
discomfort and their presence makes
determining the extent of the burn difficult.
Salves may also introduce pathogens into
wounds.
Report the presence of cough and note the
amount and character of any sputum. Black or
gray sputum indicates smoke inhalation.
 Nursing Considerations (cont’n)
Burns disrupt the integumentary system and
place the individual at increased risk for
infection. Note for early signs and symptoms
of a developing infection.
Silver nitrate will blacken anything it comes in
contact with. Take measures to prevent
staining of clothes, linens and walls.
Offer the patient a prn pain or anxiolytic about
one half hour before any painful procedure
such as debridement.
Nursing Considerations (cont’n)
The burned patient may need as many as
6,000 calories per day. The diet should be
high in calories, nitrogen and protein.
Administer electrolyte replacement as ordered
Patient may be placed on tube feedings or
Total Parenteral Nutrition (TPN)