BURNS

PRESENTED BY: SUPRIYA KADARIYA

BSC. NURSING 3RD YEAR
 Introduction
Burns are common and serious childhood injury causing
prolonged effect on growing child with various complications and
fetal prognosis.
- Children are at higher risk of burn injury than adults.

- Approximately one fourth of burn cases are below 10 years of age

and about 65% of burns children are below 5 years of age.

- Over 80% of burn accidents occur in the child’s own home.

Cont…
 Burns are the tissue injury caused by the contact with heat, flame ,
chemicals , electricity and radiation.
 The effects of burn injury are not limited to the burnt area , but can cause
serious systemic effects depending upon the extend and depth of burns.
 In children burns are described as-serious with the following condition:
- Second degree burns with 10% or more body surface are injuries.
- Burns of face , hands, feet, perineum and joints.
- Burns with presence of other injuries.
- Burns due to electrical injuries.
Cont…

 Burns in children have higher mortality because they have:

-thin and more sensitive skin
-large body surface area
-immature immune system and
-increased fluid requirement.
TYPES
OF
BURN
INJURY
 1. Thermal burn: Majority of burns results from contact with
thermal agents such as flames, hot surfaces, or hot liquids.
●Flame burns are common during playing with lighter,
candles, matches or open fire in winter seasons or from
fireworks during festivals.
●Scalds are burn injury caused by contact with hot liquids
(water or oil) and steam. The most common hot liquids are
liquid foods such as hot water, tea, coffee, milk. It is common
in children below 3 years of age.
Cont…
2. Electrical burns: These burn injuries are common in
young children, who insert conductive objects into
electrical outlets, and bite and suck on connected electrical
cords.
● These are also common in toddler and adolescent,
specially associated with risk taking behavior of the boys,
i.e., when playing with electrical out let, extension cords,
touching high tension wires and using electrical appliance.
Cont…

● This type of burn injuries may lead to cardiac

arrhythmias, cardiac arrest and unexpected falls with
resultant factures.
● Direct contact with high or low voltage current, as
well as lightening strikes, is the most frequent
mechanism of injury
Cont…

3. Chemical burn:
● Most chemical burn are seen in pediatric
population.
● Because of the curious nature, children are
exposed with the different kinds of household
chemical products.
Cont…

● A variety of common household products,

especially cleaning products contains noxious agents
which may cause localized damage as well as
systemic toxicity.
● The severity of the injury is related to the chemical
agent (acid, alkali or organic compound) and duration
of contact.
Cont.…
4. Radiation burns
They are burns due to prolonged exposure to ultraviolet rays
(UV) of the sun or to other sources of radiation, such as x-ray or
gamma radiation therapy for cancer.
● The consequence of this burn is swelling and redness of the
skin. Injury can start within 30 minutes of exposure.
● UVB is more damaging to the skin and is the main cause of
skin cancer.
CLASSIFICATION
OF BURN IN
CHILDREN
According to Depth of Burn injury
1.Superficial Burns(Partial thickness burns)
- Superficial partial thickness burns : Burn injury
involves epidermis and superficial layers of dermis, i.e up to
papillary dermis. The wound usually heals in less than 2
weeks period of burns.
- Superficial deep dermal burns : Burn injury involves
beyond papillary dermis and takes more than 2 weeks time for
healing.
Cont..

2. Full thickness burns : Burn injury involves all layers

of skin and sometimes underlying tissues are also
destroyed . The wound doesn’t heal normally and needs
skin grafting.
Cont..
According to Extend of Burn Injury
 First degree burns : Superficial burns manifested as
pink to red discolored area with slight edema . Pain may
present up to 48 hours and relieved by cooling . Within 5
days epidermis peels off , pink skin may persist for a
week , no scar develops . Healing takes place
spontaneously within 10 to 15 days , if not infected.
Cont…

 Second degree burn: Superficial second

degree burns are presented as pink red
discoloration of the area with blister
formation , weeping and edema. Superficial
skin layers are destroyed. Wound becomes
moist and painful and takes several weeks to
heal. Scaring may develop.
Cont…

- Second degree deep dermal burns are manifested as

mottled white and red area become pale on pressure.
The area may or may not be sensitive to touch but
sensitive to cold air. Hair does not pull out easily.
Wound takes several weeks to heal and scar may
develop.
Cont…
 Third degree burns: It includes destruction of epithelial cells
even fat , muscles and bone. Reddened areas do not blanch with
pressure.
- It is not painful , inelastic and discoloration may vary from waxy
white to brown. Eschar develops as leathery devitalized tissue ,
which must be removed.
- Granulation tissue develops and grafting is required if the burnt
area is larger than 3 to 5 cm. Grafting is done after wound
debridement.
Firstdegree and second degree burns are
included in partial thickness burns. The third
thickness burns is considered as full thickness
burns.
Cont…

According to Severity of Burn Injury:

Severity of burn injury depends upon total area injured ,
depth of injury , location of injury , age , general health of the
child presence of additional injury or chronic diseases and
level of consciousness.
Cont…

Minor burns:

- 10 % of total body surface area burnt with 1 st and

2nd degree burns.
Cont…

Moderate burns : 10 to 20% TBSA burnt

and 2nd degree burns.
- 2 to 5% TBSA burnt and 3rd
degree burn , but not involving eyes , ears , face ,
genitals , hands , feet or circumferential
burns(over chest or abdomen).
 Cont…
Major burns:
- 20% or more TBSA burnt and 2nd degree burns.
- All 3rd degree burns greater than 10% TBSA burnt.
- All burns involving face , eyes, ears, feet ,hands
and /or genitals.
- Complicated burns with trauma , fracture , head
injury ,cancer , diabetes mellitus , pulmonary diseases
and all at-risk patients.
Estimation of Extent of Burns
Surface Area
 The extent of burns is expressed as the amount of surface area
burnt in relation to total body surface area . Various methods
are used to calculate the burnt area.
 The easiest way to calculate the extend of burns is the ‘rule of
hand’. One hand surface(child’s own hand) with closed
fingers , amount to 1% of body surface area and this can be
used for calculation of extend of burns.
 A Convenient ,easy and quick method of estimation of surface
area in pediatric burns is ‘Rule of Five’.(Fig 1.1 ,Fig 1.2)
 Cont (Fig:1.1)
Area Age 0-5 years Age 5-10 years Age 10 years onwards

Head and Neck 20% 15% 10%

Trunk-front 20% 20% 20%

Trunk-back 20% 20% 20%

Upper Limbs 10 x 2=20% 10 x 2=20% 10 x 2=20%

Lower Limbs 10 x2=20% 15 x 2=30% 15 x 2=30%

100% (20 x5) 105%*(20 x5)=(105- 100%(20 x5)

5)=100%
* : 5% to be deducted from trunk
Cont…(Fig 1.2)
 Cont
• The most accurate estimation of extent of burns surface area
can be done by using Lund and Browder chart , which gives the
exact percentage at different age groups in different parts of the
body.
It is time consuming and laborsome to children.
• The ‘Rule of Nine’ is applicable for children above 10 years of
age , same as like adults.
Lund and Browder
Cont…

 For the adult, it allots 9% of the TBSA to the head

and neck and to each upper extremity, 18% each to
the anterior and posterior portions of the trunk, 18%
to each lower extremity, and 1% to the perineum and
genitalia. The patient's palm area represents
approximately 1% of TBSA and can be helpful in
calculating scattered areas of involvement
Clinical Manifestation
 Itdepends upon the degree of burns . The child may present
with shock along with varied depth and extent of body surface
area burnt.
 Symptoms of shock appear soon after burns.
-pallor
-cyanosis
-prostration
- poor muscle tone(may become flaccid)
-rapid pulse , low blood pressure and subnormal temperature
-failure to recognize familiar people.
 Cont…
 Inhalation injury causes inflammation of edema of the glottis , vocal
cords and upper trachea leading to upper airway obstruction.
 The child usually presents with,
- Dyspnea
- tachypnea
- Hoarseness
- Stridor
- Chest retractions
- Nasal flaring
- Restlessness
- Cough and drooling
Cont…
 Smoke inhalation initially may produce no
symptoms or mild bronchial obstruction , but
suddenly within 48 hours , may develop pulmonary
edema , severe airway obstruction and bronchiolitis.
 Symptoms of toxemia may develop after burns
within one to two days . The patient usually
manifested with fever , vomiting , edema , decreased
urinary output , prostration , rapid pulse , glycosuria
and unconsciousness.
Management
The burns patient has the same priorities as all
other trauma patients. Assess:
● Airway
● Breathing: beware of inhalation and rapid airway
compromise
● Circulation: fluid replacement
● Disability: compartment syndrome (edema pressure,
tissue damage, loss of body function).
● Exposure: percentage area of burn.
Essential management points:
● Stop the burning
● ABCDE
●Determine the percentage area of burn (Rule of
9’s)
●Good IV access and early fluid replacement.
The severity of the burn is determined by:
● - Burned surface area
● - Depth of burn
● Morbidity and mortality rises with increasing
burned surface area . It also rises with increasing
age so that even small burns may be fatal in
elderly people (slow recover, immune).
Acute Care
●Extinguish flames by rolling on the ground;
cover the child with a blanket, coat, or carpet.
●After determining that the airway is patent,
remove clothing.
●Jewelry, particularly rings and bracelets, should
be removed or cut away to prevent constriction
and vascular compromise during the edema phase
in the first 24-72 hr post burn.
- In cases of chemical injury, brush off any
remaining chemical if powdered or solid; then
use copious irrigation or wash the affected area
with water.
- Cover the burned area with clean, dry sheeting
and apply cold (not iced) wet compresses to small
injuries. Significant large burn surface area injury
(>15-20% BSA) contraindicates the use of cold
compress dressings.
Outpatient Management of Minor Burn
● First- and second-degree burns less than 10% BSA
may be treated on an outpatient basis.

● These outpatients do not require a tetanus booster or

prophylactic penicillin therapy.
●Children who are not current with
immunizations should have their immunizations
updated.
●Blisters should be left intact and dressed with
bacitracin or silver sulfadiazine cream
(Silvadene).
● Dressings should be changed once daily, after
the wound is washed with lukewarm water to
remove any cream left from the previous
application.
● Very small wounds, especially those on the
face, may be treated with bacitracin ointment and
left open.
● Burns to the palm with large blisters usually heal
beneath the blisters, with close follow-up on an
outpatient basis.
● Pain control should be accomplished by using
acetaminophen with codeine 1 hour before dressing
changes.
● Wounds that appear deeper than at initial
assessment or that have not healed by 21 days may
require a short hospital admission for grafting.
Outline of major Burn Management
● Ascertain the adequacy of airway, and provide oxygen,
intubation and ventilatory support as indicated.
● Insert a large borehole intravenous, preferably, through
unburned skin, to deliver fluids at a sufficiently rapid rate
to affect resuscitation.
● Remove clothing and jewelry, and examine for
secondary trauma.
●Obtain an admission weight
●Insert a nasogastric tube to empty stomach
contents and maintain gastric decompression.
Insert a indwelling Foley catheter to obtain
specimen and monitor hourly output.
●Evaluate the born wound and determine the
extent and depth of injury.
● Calculate fluid requirements and establish the
appropriate regimen.
● provide iv medication for control of pain and anxiety
only after adequate oxygenation is ensured and fluid
resuscitation is initiated.
● Obtain baseline laboratory studies.
● Perform escharotomy to the chest and extermities for
constricting circumferential eschar and for impaired
circulation
●Apply topical antimicrobials and dressings to the burn
wounds.
●Obtain a history regarding the injury and other
pertinent data.
●Administer appropriate tetanus prophylaxis
Management of major born cont…
1. Establishment of adequate airway :
● The first priority of care is airway maintenance.
● Examination of an oral and nasal membranes that
reveals edema, hyperemia and blister or evidence of
trauma to the upper respiratory passages all suggest
inhalation of noxious agents or respiratory burns, if there
is evidence of respiratory involvement , 100% o2 is
administered and blood gas values including carbon
monoxide( toxic) levels are determined.
● If the child exhibits sign of respiratory distress, an ET
tube is to maintain the airway.
● When severe edema of the face and neck is
anticipated, intubation is performed before swelling
make tube placement difficult or impossible.
● When full thickness burn encircle the chest,
constricting eschar may limit chest wall excursion. The
child becomes increasingly difficult to ventilate.
Esharotomy of the chest relieves this pressures and
improves ventilations.
2. Fluid replacement therapy:
● The objectives of fluid therapy are compensation for
water and sodium losses to traumatized area and the
interstitial space, replenishment of sodium deficits,
restoration of circulation volume, provision of adequate
perfusion, correction of acidosis, and improvement of
renal function.
● Parkland formula is an appropriate starting
guideline for fluid resuscitation (4 mL lactated
Ringer *kg *% BSA burned).
● One half of the fluid is given over the first 8 hr
calculated from the time of onset of injury.
● The remaining half is given at an even rate
over the next 16 hr.
●The rate of infusion is adjusted according to the
patient's response to therapy.
●Pulse and blood pressure should return to normal, and
an adequate urine output (1 mL/kg/hr) should be
accomplished by varying the intravenous infusion rate.
● Because of interstitial edema and sequestration of
fluid in muscle cells, patients may gain up to 20% over
baseline pre-burn body weight.
● Patients with burns of 30% BSA require a large
venous access (central venous line) to deliver the fluid
required over the critical first 24 hr.
● Patients with burns greater than 60% BSA may require
a multilumen central venous catheter; these patients are
best cared for in a specialized burn unit.
● Adequacy of resuscitation should be constantly
assessed using vital signs, blood gases, hematocrit, and
protein levels.
●Some patients require arterial and central venous
lines, particularly if undergoing multiple excision and
grafting procedures as needed, for monitoring and
replacement purposes.
●Femoral vein cannulation is a safe access for
fluid resuscitation especially in infants and
children.
●Burn patients who require frequent blood gas
monitoring benefit from radial or femoral
arterial catheterization.
● Five per cent albumin infusions may be used to
maintain the serum albumin levels at a desired 2 g/dL.
The following rates are effective:
● for total BSA burns of 30-50%, 0.3 mL of 5%
albumin/kg/% BSA burn is infused over a 24hr period;
● for total BSA burns of 50-70%, 0.4 mL/kg/% BSA
burn is infused over 24 hr; and
● for total BSA burns of 70-100%, 0.5 mL/kg/ % BSA
burn is infused over 24 hrs.
● Packed red cell infusion is recommended if the
hematocrit falls below 24% (hemoglobin ≤8
g/dL).
● Sodium supplementation may be required for
children having burns greater than 20% BSA, if
0.5% silver nitrate solution is used as the topical
antibacterial burn dressing.
● Oral sodium chloride supplement of 4 g/ m2
burn area per 24 hr is usually well tolerated,
divided into four to six equal doses to avoid
osmotic diarrhea.
●The aim is to maintain serum sodium levels
over 130 mEq/L and urinary sodium
concentration over 30 mEq/L.
●Intravenouspotassium supplementation is
supplied to maintain serum potassium level
over 3 mEq/dL.
● Oral supplementation may start as early as 48 hr post
burn. Milk formula, artificial feedings, can be given by
bolus or constant infusion through a nasogastric or
small bowel feeding tube.
● As oral fluids are tolerated, intravenous fluids are
decreased proportionately in an effort to keep the total
fluid intake constant.
Medicine
● Antiboitic are usually not administerd
prophylactically .
● Surveillance culture and monitoring of the clinical
course provide the most reliable indicators of
developing infection.
● Appropriate antibiotics can then be instituted to treat
the identified organism.
● Some form of sedation and analgesia is required.
● Morphine sulphate is the drug of choice for severe
burn injuries.
● Continues infusion and frequent administration is
needed for pain management in burn. (before
procedure)
● combined with midazolam provides excellent
analgesia for procedural pain.
●Anesthetic agents such as nitrous oxide,
propofol, and ketamine also are used to control
procedural pain.
Management of Burn Wound
● The objective of wound management include
prevention of infection, removal of devitalized tissue,
and closure of the wound.
1.Primary excision- large full thickness burn wounds,
excision is performed as soon as patient is
hemodynamically(blood pressure, heart rate) stable after
initial resuscitation.
Early wound excision has significantly decreased the
incidence of infection, which can lead to sepsis and death
Debridement
● Partial thickness of wound require debridement of
devitalized tissue to promote healing.
● Its very painful and require some type of analgesia
before the procedures.
● Hydrotherapy is used to cleanse the wound and
involves soaking in a tub or showering once or twice a
day, for no more than 20 minutes.
● The water acts to loosen and remove sloughing tissue,
exudate and topical medications.
●Mesh gauze entraps the exudative slough and is
readily removed during hydrotherapy.
●Any loose tissue is carefully trimmed away before
the wound is redressed.
Topical antibiotic agent :
●Silver nitrate 0.5%
●Silver sulfadiazine1%
●Mafenide acetate 10%
●Bacitracin
●Some topical agents are packaged and prepared on a
fine mesh gauze, which allows ease of application.
●Daily dressing changes of the burn wound are
recommended to allow for inspection.
● Biological skin coverings- allograft ( hemograft) skin
is obtained from human cadavers (dead human body)
and processed by comercial skin bank.
● Donors are screened for communicable diseases, and
skin is tracked much like blood transfusions.
● Xenograft – from variety of species (pigs).
Permanent skin coverings
 ●Permanent coverage of deep partial thickness
burns is usually accomplished with a split thickness
skin graft.
 ●This graft consist of epidermis and a portion of
dermis removed from an intact area of skin by
special instrument- dermatome.
Nursing Considerations
Assess
◦ Airway
◦ Breathing: beware of inhalation and rapid airway
compromise (look, feel and listen)
◦ Circulation: (look, feel, check)
◦ Disability: (AVPU)
◦ Exposure: percentage area of burn
Airway
● Assess for airway patency.
Breathing
● Look-respiratory movement, respiratory rate,
presence of cyanosis.
Feel-Perform palpation and percussion
Listen-Auscultation for normal air entry and breathing
sounds equal bilaterally, absence or addition of noises.
Circulation
Look-Inspect for pallor and capillary refill time
Feel
●Palpate pulse presence.
●Palpate pulse rate
●Palpate peripheral temperature
●Check-Blood pressure
Disability
●Determine level of patient’s consciousness using AVPU
assessment.
●A-Alert (confused/disoriented)
●V-Response to vocal stimuli
●P-Responds to painful stimuli
●U-Unresponsive
Exposure:
percentage area of burn /depth of burn
● percentage area of burn should be calculated.
Depth of burn
● It is important to estimate the depth of the burn to
assess its severity and to plan future wound care.
● Burns can be divided into three types, first degree,
second degree and third degree.
Nursing diagnosis
● Alteration in airway patency related to burn(inhalation burn)
● Ineffective breathing pattern related to circumferential chest
burn, upper airway obstruction
● Impaired tissue perfusion related to arrested blood circulation
secondary to decreased intravascular fluid volume
● Fluid volume deficit related to shift of fluid from intravascular
to interstitial tissues.
● Pain related to burn and therapeutic modalities.
● Impaired skin integrity related to thermal injury.
● Altered nutrition: less than body requirements related to
increased body metabolic need.
● Impaired physical mobility related to pain; impaired joint
movement.
● Ineffective individual coping related to fear and anxiety
● Body image disturbance related to cosmetics and functional
sequelae of burn wound
● Prone to infection related to loss of integrity of skin/injured skin
and decreased immunity
● Prone to develop contractures related to scarring of tissue.
Achieving adequate oxygenation and respiratory function
• Provide humidified 100% oxygen
• Assess the signs of hypoxemia (anxiousness, tachypnea, and
tachycardia).
• Monitor respiratory rate, depth, rhythm.
• Note character and amount of respiratory secretions, report
carbonaceous sputum (carbon), tracheal tissue.
• Observe for signs of inadequate ventilationMonitor of ABGs
and oxygen saturation.
• Keep intubations equipment, nearby and be alert for signs of
respiratory obstruction
In mild inhalation Injury
●Provide humidification of inspired air.
●Encourage coughing and deep breathing
●Maintain pulmonary toilet. (Brochoscopy suctioning)
In moderate to severe inhalation Injury
● Initiate more frequent bronchial suctioning.
● Closely monitor vital signs, urinary output and ABGs.
● Administer bronchodilator treatments as ordered.
● For additional respiratory problems:
● Necessary incubated and
● Placed on Mechanical ventilation.
Maintaining Adequate tidal Volume and unrestricted
Chest Movement.
● Observe rate and quality of breathing.
● Encourage deep breathing and incentive spirometry.
● Place patient in Semi-Fowler’s position to permit
maximum chest excursions (movement) if there are no
contra indicatory such as hypotension or trauma.
● Ensure that chest dressings are not constricting.
Supporting Cardiac Output
●Give fluids as prescribed
●Monitor vital signs-including apical pulse , central
venous pressures , pulmonary artery Pressures.
●Monitor Sensorium
Maintaining Fluid and Electrolyte balance
● Replace the lost fluid. The half of the calculated fluid
should be given within 8 hours and the remaining fluid
within 16 hours.
● Maintain intake and output strictly.
● Prevent from dehydration.
● Sodium and potassium level in the blood should be
monitored.
● Hyperkalemia and hyponatremia should be managed
in time.
Provide wound care
●Provide wound care according to the protocol of the
hospital.
●Apply silver sulfadiazine and T-bact.
●Masking, gloving, capping, hand washing should be
done for wound care.
●Eschar should be removed.
●Excise adherent necrotic (dead) tissue initially and
debride all necrotic tissue over the first several days.
Management of Pain
● It is one of the most essential component to be
managed.
● Regular Paracetamol 15mg/kg every 6hourly and
● Either regular Ibuprofen 5mg/kg every 6 hours OR
Diclofenac 1mg/kg every 8 hours with food.
● Give injection morphine 0.1mg/kg 4hourly if required.
● Syrup morphine sulphate can also be given.
Prevent Complications
● Infection: Initially the burn wounds are sterile but with
contamination it gets infected with different organisms.
● Prevent different sources of infection through proper
handwashing , gowning, capping and prevent overcrowding of
persons.
● Maintain sterile techniques during dressing.
● Provide appropriate antibiotics as prescribed.
● Prevent overcrowding.
● Encourage adequate nutrition.
●Inspect the wounds for discoloration or haemorrhage,
which indicate developing infection.
●Provide food rich in vitamins, proteins, iron etc.
●In all cases, administer tetanus prophylaxis.
● High wash of the ward should be performed on
interval basis.
Prevent Contracture
● The scars cannot expand to keep pace with the growth
of the child and may lead to contractures.
● Arrange for early surgical release of contractures before
they interfere with growth.
● Burn scars on the face lead to cosmetic deformity,
ectropion and contractures about the lips.
●Ectropion can lead to exposure keratitis and
blindness and lip deformity restricts eating and
mouth care.
●Consider specialized care for these patients as
skin grafting is often not sufficient to correct
facial deformity.
Provide adequate nutrition
● Patient’s energy and protein requirements will be
extremely high due to the catabolism of trauma, heat loss,
infection and demands of tissue regeneration.
● If necessary, feed the patient through a nasogastric tube
to ensure an adequate energy intake.
● Anaemia and malnutrition prevent burn wound healing
and result in failure of skin grafts. Eggs and peanut oil
and locally available supplements are good.
●Maintain nutritional status by providing calories
need according to TBSA burned
●Calorie need=60kcal/kg+35kcal/TBSA%
●Protein need should be equally taken into
account.
●Protein need=3g/kg+1g/TBSA%
●Weigh the patient regularly.
Preserving Positive Body Image
●Encourage the patient to express concerns regarding
changes in self image or life- style that may result from
burn injury.
●Positively reinforce appropriate, effective coping
mechanisms.
Discharge Teaching
● The home care needs of the family should be addressed long before the
child is ready for discharge. Discharge teaching focus on;
● Nutrition and diet requirements.
● Daily dressing changes and skin care
● Application of splint.
● Daily range of motion exercises to prevent from contractures.
● Safety in the home.
● Protection of the burned area
● Signs of infection and action take
Complication of Burn
● Depend on severity of burn injury; commonly occur, especially with
severe injury;
Acute
● Infection: burn wound sepsis, Pneumonia , urinary tract infection ,
phlebitis
● Paralytic illus: paralytic ileus occurs especially in child younger than
2 years of age with greater than 20% injury and develops early in post
burn period lasting 2 to 3 days
● Renal failure
Respiratory failure: Severe inhalation injury most likely to cause death.
●Post burn seizures
●Hypertension
●Central nervous system dysfunction
●Vascular ischemia
●Anaemia and malnutrition
●Depression secondary to hospitalization and changing
body image.
Long Term
● Growth and development delays secondary to
malnutrition. ●Scaring, disfigurement, and
contractures, marjolin’s ulcer ●Psychological
trauma and cosmetic problems.
References