Burns

• Functions of the Skin

  • Protects against injury
  • Keeps germs out
  • Fluids and electrolyte balance
  • Excretory organ
  • Pain perception
  • Vitamin D absorption
  • Maintains body temp
• Tissue destruction


  • Can have local and systemic effects
  • Sepsis, shock, death
  • Infection prevention is key
  • Closure of burn wound
• Systems affected by burns

  • Endocrine
  • Cardiac
  • Respiratory
  • Hematologic
  • Immune
• Layers of the skin

  • Epidermis -outer layer, it can grow back. No blood vessels and has to get resources from the second layer of skin.
  • Dermis -has collagen, connective tissue, elastic fibers, blood vessels, nerves, hair, lymph vessels, and glands.
  • Subcutaneous tissue - has a basement membrane separating it from dermis
• Dermis


  • Skin regrowth can occur as long as parts of the dermis remains
  • No skin regrowth if the entire dermal layer is burned and the cells and dermal appendages are destroyed
• Feet and hand have deeper dermal appendages which allows for healing of deep burns
• Nerves


  • Epidermis burn is painful
  • Dermis is painful
  • If a full thickness burn occurs the nerves may be destroyed, and pain may only be at the wound edges
  • May feel only dull or pressure-like pain
• Burn classification by depth

  • Superficial-thickness- only the epidermis (heals 3-6 days)
  • Partial-thickness-loss of epidermis and part of dermis
  • Superficial partial thickness- upper third of the dermis
  • Deep partial thickness- deeper in the dermis, very few healthy cells remain
  • Full-thickness- entire dermis and epidermis
  • Deep full-thickness-beyond the skin into muscles bones and tendons
• Type of Burn


  • Superficial
  • Superficial partial thickness
  • Deep partial thickness
  • Full thickness
  • Deep full thickness
  • Electrical Burn (A=entrance; B=exit)

  
• Burn classification by injury

  • Mild- treat and street
  • Moderate- may need to go to burn center
  • Major- need to go to a burn center
• Rule of 9's Fig
• Vascular changes from burns

  • Excessive weight gain w/i first 12 hours and continues 24-36 hours
  • Increased macrophages
  • Blood vessel thrombosis
  • Fluid shift
  • Fluid remobilization- starts about 24 hours after burn
  • Hypokalemia and hyponatremia
  • Anemia
  • Continue to lose protein at wound site
  • Metabolic acidosis
• Cardiac changes from burns

  • Hypovolemia
  • Dysrhythmia
• Pulmonary changes from burns

  • Airway edema
  • Pulmonary capillary leak
  • Chest burns that restrict movement of chest
  • Carbon monoxide poisoning
• GI changes from burns

  • Decreased perfusion to GI tract
  • Sympathetic nervous system causes decreased motility and even greater decrease in blood flow
  • Curling's ulcer
• Metabolic changes from burns

  • Greatly increased
  • Hypoglycemia
  • Increased body temp
• Always our jobs to educate patients ways to prevent burns
• Risk factors for death from burns

  • > 60 years old
  • > 40% TBSA
  • Presence of inhalation injury
• Goals of management in the 1st Resuscitation/Emergent Phase of Burn Injury

  • Secure airway
  • Support circulation — fluid replacement
  • Prevent infection
  • Maintain body temp
  • Provide emotional support

  
• General Management in Resuscitation phase

  • Airway patency
  • O2 as needed
  • Keep warm
  • NPO
  • Elevate extremities if no other obvious injuries
  • IV with fluid replacement
  • Tetanus toxoid
  • Head to toe
• Respiratory Assessment


  • Fire source, temp, environment, toxic, enclosed space?
  • Was burn to face, lips, ears, neck, eyes
  • Inspect nose, mouth, pharnyx
  • Auscultate lungs, bronchi, trachea
  • Inspect chest for eschar from circumferential burn
  • Review carbon monoxide poisoning
• Cardiovascular assessment


  • Monitor for hypovolemia shock s/s
  • ECG because of electrolyte imbalance or if electrical burn
• Renal assessment


  • Urine output, color and consistency, debris
  • BUN/Crea, NA
• GI assessment


  • Motility/ bowel sounds/ occult blood in any stool or vomit
  • > 25% TBSA get NG tubes
• Skin Assessment


  • Size and depth of injury
  • BSA affected
  • Laser Doppler image to determine depth
• Lab values to review

  • H/H
  • BUN
  • GLU
  • Electrolytes
  • T.protein,alb
  • ABG
  • Xrays
  • CT, US, Bronchoscopy, MRI
• Nursing diagnosis
• Interventions to support pulmonary functioning

  • Airway maintenance
  • Positioning, deep breathing
  • Promote ventilation
  • Monitor for gas exchange
  • O2 therapy
  • Antibiotics, diuretics, lol's, paralytics
• Preventing hypovolemic shock


  1. Rapid fluid infusion- Parkland formula 4ml X kg X TBSA (This is times not divided by.)

  2. 1st 24 hour dosing give ½ the first 8 hours and then the 2nd ½ over next 16 hours

  3. Monitor for s/s of shock
• Surgical Management of Burns in Emergent Phase

  • Escharotomy
  • Fasciotomy (Done when burnt to the bone)
• Pain management


  • Opioids- know what route is best to administer and why
  • Complementary and alternative options
  • Environmental changes
  • Surgical excision
• Preventing respiratory distress
• Wound care nonsurgical management

  • Remove exudates and necrotic tissue (debridement)
  • Clean
  • Stimulate granulation and revascularization
  • Dressing
• Silver Nitrate


  • Apply with a gauze dressing
  • Reduces fluid evaporation
  • Bacteriostatic
  • Inexpensive
  • But it does penetrate the eschar and it can deplete Na and K
• Silver sulfadiazine


  • Apply with a clean glove
  • Effective against both gram neg/pos and yeast
  • But it can cause neutropenia, decreases granulocyte formation
  • Penetrates eschar some
  • Discoloration a gray or blue-green
• Mafenide acetate


  • BID
  • Penetrates eschar and bacteriostatic
  • But it is painful to apply and remove
  • Can cause metabolic acidosis
• Nonsurgical debridement


  • Mechanical: use scissors and forceps to cut away the dead tissue during hydrotherapy
  • Chemical: Apply a topical enzyme (collagenase) to the wound during daily dressing changes
• Dressing the Burn Wound

  • Standard wound dressings- distal to proximal
  • Biologic dressings- temporary
  • Biosynthetic dressings- commonly used on partial thickness burns
  • Synthetic dressings-clear, decrease pain, low infection rate, reduced cost
• Surgical management


  • Grafting- autografting
  • Xenograph
• Nursing care of grafts

  • Maintain immobilization of graft sites
  • Elevate extremities
  • Monitor the graft for infection