INTRODUCTION:

 Burns are one of the most common household injuries, especially among children. The term “burn”
means more than the burning sensation associated with this injury. Burns are characterized by severe
skin damage that causes the affected skin cells to die.
 Most people can recover from burns without serious health consequences, depending on the cause and
degree of injury. More serious burns require immediate emergency medical care to prevent
complications and death.

DEFINITION:
According to Sabiston: –“Injury that result from direct contact with the exposure to any thermal, chemical or
radiation source are termed as Burn”

CLASSIFICATION:
 According to level of severity or depth :-
1) First degree burn :- A first-degree burn is the most common and least serious burn which affects the top
layer of skin i.e. epidermis. It causes local inflammation of the skin & this inflammation is characterized by
pain,redness and a mild amount of swelling.The skin may be very tender to touch.
2) Second degree burn :-It involve the epidermis and the dermis.There are the same symptoms of pain and
swelling but the skin color is usually a bright red and blisters are produced. Usually second-degree burns
produce scarring.
3) Third degree burn :-The 3rd degree burn may appear patches which appear white,brown or black.Both the
dermis and epidermis are destroyed and other organs, tissues and bones may also be involved.Third-degree
burns are considered the most serious.
 According to the etiological factor :-
1. THERMAL BURN INJURY:- A thermal burn is a type of burn resulting from making contact with
heated objects, such as boiling water, steam, hot cooking oil, fire, and hot objects.
2. CHEMICAL BURN INJURY:- A chemical burn occurs when your skin or eyes come into contact with
an irritant, such as an acid or a base. Bases are described as alkaline. Chemical burns are also known as
caustic burns. They may cause a reaction on your skin or within your body.
3. ELECTRICAL BURN:- An electrical burn is a burn that results from electricity passing through the
body causing rapid injury.
4. RADIATION BURN:- A radiation burn is damage to the skin or other biological tissue caused by
exposure to radiation. The radiation types of greatest concern are thermal radiation, radio frequency
energy, ultraviolet light and ionizing radiation. The most common type of radiation burn is a sunburn
caused by UV radiation.
 According to the extent of body surface area injured
1. Rule of nine (system assigns percentages in multiples of nine to major body surface)
2. Lund & Browder method (By dividing the body into very small areas & providing an estimate of the
proportion of TBSA accounted for by such body parts).
3. Palm method (The size of the pt’s palm is approximately 1% of TBSA)
PATHOPHYSIOLOGY:
Major burns

Increased capilary permiability

Na, H2O and protein shift from intravascular to interstitial spaces

Circulating blood volume

Burn shock

Massive stress response SNS activation

Perepheral Tracheyacardia Hyperglycemia ncreased

Vasoconstriction catabolism and metabolism

Tissue perfusion

Decreased renal Decreased Anaerobic Tissue Cellular

Blood flow blood flow metabolism damage dysfunction

ARF Metabolic Peritoneal Cell

Acidosis tissue perfusion swelling

CLINICAL MANIFESTATION:
S.N. BURN SKIN AREA INVOLVEMENT CLINICAL PICTURE
1 First degree Epidermis layer only. Red,dry,painful,
(Superficial moist,pink skin,blisters.
Epidermis with some dermis
partial thickness)
2 Second degree Destruction of epidermis with most of the Pale,pearly white,mostly
(Deep partial dermis,epidermal cells,lining hair follicles & sweat dry,difficult to
 thickness) glands remain intact,may convert to full thickness differentiate full
injury. thickness burn.
3 Third degree (Full Destruction of all layers of skin down to or pass the Thick,dry leathargy
thickness) subcutaneous fat,sometime involving fascia,muscles eschar,white cherry red
& bone.The nerves are also destroyed. or brown/black in
color,blood vessles
thrombosed.

ASSESSMENT & DIAGNOSTIC EVALUATION:

1. Survey,including assessment of airway,breathing & circulation as well as vital signs is done.
2. Severity of burns is determined by :
 Depth :-First,Second & Third degree burn injury
 Extent :- % of total body surface area (TBSA)
 Age :- The very young & very old have a poor prognosis.
 Area of the body burned :- face,hands,feet,perineum & circumferential burns require special care.
 Medical history.
 Inhalation injury.
3. Obtain arterial blood gas & carboxyhemoglobin

MANAGEMENT:
1. First aid treatment in burn:-
 Immerse the burned area immediately in cold running water,then dry the area gently with a clean towel
and dress it with a sterile or clean,dry cloth.
 Do not prick blisters.
 Do not remove clothing adhering to the wound.
 Remove any watches,bracelets,rings,belts or constricting clothing from the affected area before it begins
to swell.
 Do not apply butter,oil or creams.
 Do not press

2. Airway, breathing and circulation:-

 The circulatory system must also be assessed quickly.
 Apical pulse & Blood pressure are monitores.
 The neurologic status is assessed quickly in pt with extensive burns.
 A head to toe survey of the pt is carried out to identify other potentially life threatening injuries.
 Usually,rescue workers will cool the wound,establish an airway,supply O2 & insert at least one large-
bore intravenous line.

3. Intravenous fluid therapy:-

 Immediate I.V. fluid resuscitation is indicated for:
 Adults with burns involving more than 18-20% of TBSA % Children with more than 12-15% of
TBSA. -
 Generally a crystalloid solution (Ringer’s lactate) is used initially.
 Colloid is used during the second day (5% albumin,Plasmanate or hetastarch)
 One of several formulas may be used to determine the amount of fluid to be given in the first 48 hrs.
A. The parkland formula
B. The brook and evans formula
 A.the parkland formula:-
(i) First 24 hrs. :- 4 ml of ringer’s lactate × Wt.in kg × % TBSA burned.
(ii) One half amount of fluid is given in the first 8 hrs.,calculated from the time of injury.If the starting of
fluid is delayed,then the same amount of fluid is given over the remaining time.
(iii) The remaining half of the fluid is given over the next 16 hrs.
Example :- Patient’s weight :- 70 kg, %TBSA burn :- 80%
4 ml × 70 kg ×80% TBSA = 22,400 ml of Ringer’s lactate
First 8 hrs. :- 11,200 ml or 1,400 ml/hr.
Second 16 hrs. :- 11,200 ml or 700 ml/hr
(iv) Second 24 hrs. :- 0.5 ml colloid × wt. in kg × % TBSA + 2000 ml dextrose 5% (D5 W) in water run
concurrently over the 24 hrs period.
Example :- 0.5 ml × 70 kg × 80% = 2,800 ml colloid + 2000ml, = D5 W yields 116 ml colloid/hr & 83 ml
D5 W per hour.
B.The brook and evans formula:-
Crystalloid 1ml/kg/%BSA. PLUS albumin at 1ml/kg/%burn + 2000ml of 5%dextrose.

Formulae to Estimate Fluid Resuscitation Requirements in Adult Burns:-

Formula First 24 hours Next 24 hours

Choice of Volume Choice of fluid Volume

fluid

Parkland Ringer's 4ml/kg/% Colloids only. 20–60% of

Lactate first half in 8 No more calculated
hrs crystalloids. plasma volume.
second half in
16 hr

Modified Ringer's 4ml/kg/% 5% albumin 0.3–1 ml/kg/%

Parkland Lactate first half in 8 burn/16 per
hrs hour
second half in
16 hr

Brooke Ringer's 1.5 ml/kg/% Ringer's Lactate 1.5 ml/kg/%

Lactate

Colloids 0.5 ml/kg/% Colloids 0.25 ml/kg/%

Dextrose 2000ml Dextrose 5% 2000ml

5%

Modified Ringer's 2 ml/kg/% Colloids 0.3–0.5

Brooke Lactate ml/kg/%

Evans Crystalloid 1 ml/kg/% Crystalloid 0.5 ml/kg/%

burn

Colloid 1 ml/kg/% Colloid 0.5 ml/kg/%

 burn

Dextrose 2000ml
5%

Monafo 250 mEq titrate to u/o 250 mEq Na titrate to u/o

Na 150 mEq lactate
150 mEq 100 mEq Cl.
lactate
100 mEq 1/3 saline titrate to u/o
Cl.

4. Emergency medical management :-

 A large bore intravenous catheter should be inserted.
 Most pts have a central venous catheter inserted so that large amounts of I V fluids can be given
quickly.
 Pt. to protect the area from contamination.
 Burns are contaminated wounds,tetanus prophylaxis is administered.
 Only intravenous pain medication usually morphine is given.
 Topical antimicrobial agents includes silver sulfadiazine,silver nitrate(0.5% solution),mafenide acetate
(10% cream or 5% solution) etc.
 Dressing may take may form of commercial multilayered pads,standard 4×4 gauze pads.

5. Wound cleansing and debridement:-

 Daily or twice daily wound cleansing with debridement or hydrotherapy & dressing changes.
 Early excision of deep second & third degree burns is the goal.
 Burn wounds must be cleansed initially & usually daily with a mild antibacterial cleansing agent &
saline solution or water.

6. Surgical management:-
The basic goal is the early excision & grafting.
1. Tangential Excision :-A special blade is used to slice off thin layers of damaged skin until live tissue is
evidenced by capillary bleeding.Commonly used with deep partial thickness burns & followed with
immediate dressing.
2. Fascial (Primary) Excision :- The skin,lymphatics & subcutaneous tissue are removed down to fascia with
either immediate autografting or temporary coverage with biologic dressings.

7. Nursing management:-
Assessment:
1. Obtain a thorough history, including-
a) Causative agent
b) Duration of exposure
c) Circumstances of injury, including whether in closed or open space, accidental or intentional, or
self-inflicted.
d) Initial treatment,including first aid, prefacility emergency care, or care rendered in another facility.
e) Patient’s age and preexisting medical problems.
f) Current medications
g) Concomitant injuries
h) Medication and food allergies, tetanus immunization status.
i) Evidence of inhalation injuries
j) Height and weight
2. Perform ongoing assessment of hemodynamic and respiratory status, condition of wounds, and signs of
infection.

Diagnosis:
 Impaired gas exchange related to inhalation injury.
 Ineffective breathing pattern related to circumferential chest burn, upper airway obstruction , or ARDS.
 Decreased cardiac output related to fluid shifts and hypovolumic shock.
 Ineffective tissue perfusion: peripheral related to edema and circumferential burns.
 Risk for imbalanced fluid volume related to fluid resuscitation and subsequent mobilization 3-5
postburn.
 Impaired skin integrity related to burn injury and surgical intervention.

Intervention:
I. Achieving adequate oxygenation and respiratory function
a) Provide humidified 100% oxygen until carbon monoxide level is known.
b) Assess for sign of hypoxaemia and differentiate this from pain.
c) Suspect respiratory injury if burn occurred in an enclosed space.
d) Observe for and report erythema or blistering of buccal mucosa, singed nasal hairs, burns of lips ,
face, or neck, increasing hoarshness.
e) Monitor respiratory rate depth, rhythm, and cough.
f) Auscultate chest and note breathing sounds.
g) Note character and amount of respiratory secretion.
h) Observe for signs of inadequate ventilation and begin serial monitoring ABG levels and oxygen
saturation.
II. Maintaining adequate tidal volume and unrestricted chest movement
a) Observe rate and quality of breathing , report if progressively more rapid and shallow.
b) Assess tidal volume , report decreasing volume to health care provider.
c) Encourage deep breathing and incentive spirometry.
d) Place the patient in semi-fowler’s position to permit maximal chest excursions if there are no
contraindications, such as hypo-tension or trauma.
e) Make sure that chest dressings are not constricting.
III. Supporting cardiac output
a) Position the patient to increase venous return.
b) Give fluid, as prescribed.
c) Monitor vital signs, including apical pulse, respiration, central venous pressure,pulmonary artery
pressures, and urine output at least hourly.
d) Determine cardiac output, as required.
e) Monitor sensorium.
IV. Promoting peripheral circulation
a) Remove all the jewellery and clothing.
b) Elevate extremities.
c) Monitor peripheral pulses hourly, using Doppler as needed.
d) Avoid tight, constrictive dressings.
V. Facilitating fluid balance
a) Titrate fluid intake, as tolerated.
b) Maintain accurate intake and output records.
c) Weigh the patient.
d) Monitor results of serum potassium and other electrolytes.
e) Be alert to signs of fluid overload and heart failure, especially during initial fluid resuscitation and
immediately afterward, when the mobilization is occurring.
f) Administer diuretics, as ordered.
VI. Protecting and reestablishing skin integrity
a) Cleanse wounds and changes dressings twice daily.
b) Perform debridement of dead tissue at this time. May use gauze, scissors, or forceps as appropriate.
Try to limit time to 20-30 minutes depending on the patient’s tolerance. Additional analgesic may
be necessary.
c) Apply topical bacteriostatic agents as directed.
d) Dress wounds, as appropriate , using conventional burn pads, gauze rolls, or any combination.
e) Observe all the wounds daily and document wound status on the patient’s record.
Evaluation:
1. Carboxyhemoglobin level is below 10% ABG levels within normal limits, respiration rate 12-28b/m.
2. Tidal volume within normal limits.
3. Pulse 110-120b/m or below, BP stable.
4. Peripheral pulse stable.
5. Weight stable, no edema, lungs clear.
6. Wounds clean and granulating.

Patient education:
1) Assist the patient in transition from dependence on the health team to independence by assisting the
patient to communicate needs and functional abilities to others.
2) Guide the patient in thinking positively about self.
3) Instruct the patient in measures to lubricate and enhance comfort of healing skin:
a) After cleaning, use moisturizer such as cocoa butter or other nonperfumed hand lotion at-least twice
per day.
b) Wear clean white underwear and clothing free from irritating dyes until wounds are well healed.
c) Take antipruritics, as prescribed.
d) Stay in cool environment if itching occurs.
4) Review with the patient and family common emotional response during convalescence and discuss
usual temporary nature of these as well as effective coping mechanism.
5) Make sure that information has been given about follow up evaluation and home care services, as
needed, in the interin.

SUMMARY:
Burns are one of the most common household injuries, especially among children. The term “burn” means
more than the burning sensation associated with this injury. A first-degree burn is the most common and
least serious burn which affects the top layer of skin i.e. epidermis. Survey,including assessment of
airway,breathing & circulation as well as vital signs can be done.

CONCLUSION:
A burn is a type of injury to skin, or other tissues, caused by heat, cold, electricity, chemicals, friction,
or radiation. Most burns are due to heat from hot liquids (called scalding), solids, or fire. While rates are
similar for males and females the underlying causes often differ. Among women in some areas, risk is related
to use of open cooking fires or unsafe cook stoves. Among men, risk is related to the work environments.

BIBLIOGRAPHY:
 Lippincott,textbook of manual of nursing practice,wolters kluwer publication, 10th edition, page no-
1178-1196.
 Suddarth and brunner’s, textbook of medical surgical nursing, wolters kluwer publication, 13th edition,
page no1704-1742.
 https://www.slideshare.net/OmVerma6/slide-for-burn
 https://www.slideshare.net/specialclass/burns-4065329