BURN

INJURY
NCMB312 LEC
DR. POTENCIANA A. MAROMA
LEARNING OBJECTIVES:

1. Describe the factors that affect the severity of burn

injury.
2. Describe the local and systemic effects of a major
burn injury.
3. Compare and contrast the potential fluid and
electrolyte alterations of the emergent/resuscitative
and acute phases of burn management.
4. Describe the goals of burn care and the nurse’s role
in wound assessment, wound cleansing, topical
antibacterial therapy, wound dressing, and
débridement.
 BURN

Traumatic injury to the skin and underlying

tissues caused by heat, chemical, &
electrical injuries (most severe!!!)
degree of tissue damage is related to:
• What agent caused the burn
• Temperature of the burning agent
• Duration of contact with the agent
• Thickness of the skin
PATHOPHYSIOLOGY

Immediate initial cause of cell

damage is HEAT
• Coagulation of CHONs in the cells
• Tissue liquefaction
• Electrical burn: internal damage
(cardiac dysrhythmias, CNS
complications)
PATHOPHYSIOLOGY
Serious burns cause various neuro-
endocrine changes within the 1st 24hr
• ACTH & ADH (released in response to
hypovolemia)
• Mineralocorticoid (aldosterone) = Na+
retention, peripheral edema, oliguria
• Glucocorticoids = causes hyperglycemia
Client eventually enters
hypermetabolic state to compensate
for the accelerated tissue catabolism
(increased O2 & nutrition demand)
PATHOPHYSIOLOGY

Intravascular fluid deficit:

• After a burn, fluid from the body moves
toward the burned area = edema at the
burn site
• Fluid lost (water vapor & seepage)

BP  SHOCK
PATHOPHYSIOLOGY

Affects fluid & electrolyte status

• Fluid shifting, electrolyte deficit, loss of
extracellular CHONs
Anemia (RBC destruction)
Hemoconcentration inadequate
nutrition to healthy body cells &
organs
Risk for Mortality: 90%
• >60y/o
• >40% of TBSA
• presence of inhalation injury
DEPTH OF BURN INJURY
DEPTH OF BURN INJURY

Superficial-thickness wounds
• epidermis is the only part injured;
• desquamation occurs for 2-3 days after
the burn & heals in 3-5 days without a
scar or complications
• e.g., sunburn, short (flash) exposure
to a high intensity heat
Superficial burns on the trunk and right arm of a young child.
Typically, these are red burns that blanch with pressure.
DEPTH OF BURN
INJURY

Partial-thickness wound
• entire epidermis & varying depths of the
dermis
• 2 types:
•Superficial partial thickness
•Deep partial thickness
DEPTH OF BURN INJURY
Superficial partial-thickness wound
• There is involvement of the upper 3rd of the dermis leaving a good blood
supply; wounds are red, moist & blanch (whiten) when pressure is applied
• Blister formation (leakage of large amount of plasma from the injured
small vessels lifting off the destroyed epidermis)
• Intense pain due to exposed nerve endings especially when stimulated by
touch & temperature changes
• with standard care, heals in 10-21 days with no scar, but some minor
pigment changes may occur
Superficial partial-thickness burn on a man's right knee.
Blistering wounds that blanch with pressure are
characteristic of superficial partial-thickness burns. These
wounds are also typically moist and weeping.
 DEPTH OF BURN INJURY

Deep partial-thickness wound

• wounds that extend deeper into the skin, dermis and fewer healthy cells
remain; wounds are red & dry (because fewer BV are patent) with white
areas in deeper parts
• due to ischemia, hypoxia & even infection it can progress to full-thickness
wounds
• No Blister formation because dead tissue layer is so thick & sticks to
underlying viable dermis that it does not readily lift off the surface
• Lesser degree of pain (more nerve endings have been destroyed),
moderate edema is present
• generally heals in 3-6 weeks with scar formation
DEPTH OF BURN INJURY

Full-thickness wound
• destruction of the entire epidermis & dermis, leaving no residual
epidermal cells to repopulate; wound may be waxy, white, deep red, yellow,
brown or black, hard, dry, leathery eschar (burn crust) [eschar is a dead
tissue; it must slough off or be removed from the burn wound before
healing can occur]
• avascular, no sensation, healing can take from weeks to months
depending on the establishment of a good blood supply to the injured areas
Full-thickness burn on a woman's left flank. Burn areas of this type
are characteristically insensate and waxy white or leathery gray in
color.
DEPTH OF BURN INJURY
Deep full-thickness wound

•wounds that extend beyond

the skin into underlying fascia
& tissues
•damages the muscle, bone,
and tendons & leave them
exposed
•wound is blackened and
depressed, and sensation is
completely absent
EXTENT OF BURN INJURY

How big an area of the body is

involved
% of burn injury
• Rule of Nines
• Special charts & graph (Berkow
Method)
• Palm method
EXTENT OF BURN INJURY

Quickinitial
method
 Disadvantage:
overestimation
EXTENT OF BURN INJURY

more accurate for evaluating the size

of the injury
uses a diagram of the body divided
into sections, with the representative
% of TBSA for all ages
EXTENT OF BURN INJURY
EXTENT OF BURN INJURY
EXTENT OF BURN INJURY

most practical method employed

in patients with scattered burns
the size of the palm of the
PATIENT (not the examiner’s) is
approximately 1% of the TBSA
ASSESSMENT FINDINGS:
Skin color: light pink to black (depth)
Edema or blistering
Pain in all areas (except full thickness burn)
Hypotension, tachycardia, oliguria or anuria (hypovolemic shock)
Breathing may be compromised (inhalation injury)
• Sore throat, singed nasal hairs, eyebrows, eyelashes, hoarseness,
carbon in sputum, shortness of breath, stridor
Entrance & exit wounds (electrical burns)
MEDICAL
MANAGEMENT

Outcome depends on the initial 1st aid provided and the

subsequent treatment in the hospital or burn center
• Life threatening:

• inhalation injury
• hypovolemic shock
• infection
MEDICAL
MANAGEMENT

Initial 1st Aid

•Prevent further injury (at the
scene of the fire)
•Observed closely for respiratory
difficulty (inhalation injury) during
transport
• O2 is administered, IV fluid
MEDICAL
MANAGEMENT

Acute Care
Quick assessment (extent of burn injury,
additional trauma – fractures, head injuries,
lacerations)
Maintain adequate ventilation
• Bronchoscopy (assess internal airway)
• Warmed humidified O2
• ET should be available for insertion
• Eschar (a hard leathery crust of dehydrated skin) in the neck
area = tracheostomy
MEDICAL
MANAGEMENT
MEDICAL
MANAGEMENT

Acute Care
• Mechanical ventilation
• Hyperbaric O2 treatment (100% O2 3x greater
than atmospheric pressure in a specifically
designed chamber)
Initiating fluid resuscitation
• Goal:
• Restore IVF, Prevention of tissue & cellular ischemia,
maintenance of vital organ function
• UO: 0.3-0.5 ml/kg/hr = SUCCESFUL!!!
• Fluid-replacement regimen is calculated from the time
the burn injury occurred
MEDICAL
MANAGEMENT
Lactated Ringers: alkalinizing sol’n; Na+,
Cl-, K+, Ca++ plus Lactate w/c is converted
to HCO-3 in the Liver (met. acidosis)
MANAGEMENT
MEDICAL
MANAGEMENT

management of extensive burns may require placement of a

large-bore central venous catheter so that massive fluid loads
can be given
peripheral lines are less useful because they become dislodge
or fluid flow is cut off when massive peripheral edema
compresses the IV catheter
MEDICAL
MANAGEMENT

Pain
•Morphine is generally the DOC
•Severe: 50 mg/hr
•If respiratory depression occurs:
naloxone (Narcan)
Tetanus immunization is also
administered
WOUND MANAGEMENT

Wear powder-free sterile gloves

Body hair around the perimeter of the burns is shaved
Blisters that have ruptured are removed with scissors
Clean the burned areas to remove debris

• Open method
• Wound is left uncovered
• Closed method
• Wound is covered
WOUND MANAGEMENT: OPEN
METHOD (EXPOSURE METHOD)

Advantages Disadvantages
Reduces labor- Contributes to wound
intensive care desiccation (dryness)
Promotes loss of water
Causes less pain and body heat
during wound care
Exposes wound to
Facilitates pathogens
inspection Contributes to pain
Decreases expense during repositioning
Compromises modesty
WOUND MANAGEMENT: CLOSED
METHOD (EXPOSURE METHOD)
Advantages Disadvantages
Maintains moist wound Requires more time
Promotes maintenance of Adds to expense
body temperature Enhances growth of
Decreases cross pathogens beneath
contamination of wound dressings
Provides wound Interferes with wound
debridement during assessment
dressing removal Causes more blood loss
Keeps skin fold separated with removal
Reduces pain during Can interfere with
circulation if tightly applied
position changes
WOUND MANAGEMENT
Open method (exposure method)
• Abandoned already (except in face & perineum)
WOUND MANAGEMENT
Closed method – current preferred method
• Covered first with non adherent & absorbent dressings (gauze
impregnated w/ petroleum jelly or ointment-based antimicrobials)
• Occlusive or semi occlusive dressing made of polyvinyl, polyethylene,
polyurethane & hydrocolloid materials as final dressing
ANTIMICROBIAL THERAPY

Silver sulfadiazine (Silvadene) 1% ointment

Mafenide (Sulfamylon)
Silver nitrate (AgNO3) 0.5% solution
Acticoat (contains a thin, soluble film coat of silver)
Povidone-iodine (Betadine)
Gentamicin (Garamycin) 0.1% cream
Nitrofurazone (Furacin)
Mupirocin (Bactroban)
Clotrimazole (Lotrimin)
Ciclopirox (Loprox)
ANTIMICROBIAL THERAPY
SURGICAL MANAGEMENT

Additional treatment modalities to

promote healing includes:
•Debridement
•Skin grafting
•Application of a skin
substitute
•Application of cultured skin
SURGICAL MANAGEMENT

Debridement - Removal of necrotic tissue

Done in one of four ways:

• Natural (tissue sloughs away)

• Mechanical (tissue adheres to dressings or detached during
cleansing)

• Enzymatic (application of topical enzymes)

• Surgical (use of forceps & scissors)
SURGICAL MANAGEMENT

Skin grafting
• Necessary for deep partial-thickness & full-thickness burns
• Purpose:

• Lessen the potential for infection

• Minimize fluid loss by evaporation
• Hasten recovery
• Reduced scarring
• Prevent loss of function
SURGICAL MANAGEMENT
Sources for skin graft:

• Autograft (client’s own skin)

• Allograft or homograft (from a human cadaver)
• Temporarily covers large areas of tissue (slough
away approx 1 week)
• Short supply; it could be a source of other pathogen
• Heterograft or xenograft (from animals)
• Temporary
• Rejected in days to weeks & must be removed &
replaced at that time
SURGICAL MANAGEMENT
SURGICAL MANAGEMENT
 SURGICAL
MANAGEMENT

Types of Autografts
Split-thickness graft
• Epidermis & a thin layer of dermis are harvested
• Cosmetic appearance is less than desirable, less
elastic, hair does not grow from their surface
Full-thickness graft
• Epidermis, dermis & some subcutaneous tissue
• Comparable appearance to normal skin
• Tolerate more stress once they become permanently
attached to the burn wound
Slit/ lace/ expansile graft
SURGICAL MANAGEMENT

Smooth the grafted

skin, reducing
scarring & the
potential for wound
contractures
SURGICAL MANAGEMENT

Skin substitute
SURGICAL MANAGEMENT
Skin substitute
• Biobrane (nylon silicone membrane coated with a protein derived
from pig tissue)

BioBrane is a nylon material that contains a gelatin that interacts with

clotting factors in the wound. That interaction causes the dressing to
adhere better, forming a more durable protective layer.
SURGICAL MANAGEMENT
PROCESS OF APPLICATION
Identify appropriate wound
Remove the sterile biobrane
sheet from package
Cut to fit and apply under a
moderate stretch,
Attached product to surrounding
unburned skin with steri-strips
BIOBRANE REMOVAL

When healed biobrane turns whitish and

dry in appearance Gently peel off then
that wound with moisturizer If small
area still open, treat with bacitracin or
Neosporin (triple mix).
SURGICAL MANAGEMENT
Skin substitute
• TranCyte (from cultured human fibroblasts from the dermis with a
biosynthetic semipermeable membrane attached to nylon mesh)

TransCyte is stored
and sealed in a
cassette with two
pieces per cassette.
Product is thawed just
prior to use.
SURGICAL MANAGEMENT
SURGICAL MANAGEMENT
Cultured Skin
• Growing the client’s own skin cells in a laboratory culture medium
• Postage stamp-sized skin  entire body (3weeks)
• Disadvantage: pigmentation does not perfectly match the original skin
NURSING
MANAGEMENT
Focus: assessing the wound & how the burn injury has
affected the client’s status
Calculates fluid-replacement requirements & infuses
the prescribed volume according to agency’s protocol
Quickly recognized & efficiently treats signs of shock
Administer prescribed analgesics
Wound care
Helps the client & family to cope with the change in
body image
Health teaching (pressure garments, skin care, etc…)
THANK YOU!
PLEASE PREPARE FOR THE QUIZ!
GOOD LUCK!