1. Nursing Care of
Patients with Burns
Dr. Karim Shaarawy, MD

2. Types and Causative Agents of Burns
Thermal: open flame, steam, hot liquids
Chemical: acids, strong alkalis, organic compounds
Electrical: direct current, alternating current, lightening
Radiation: solar, x-rays, radioactive agents
Dr.Karim Shaarawy, MD

3. Factors Affecting Burn Classification
Characteristics of Burns by Depth
Superficial (epidermis): skin may pink to red and dry, painful
Partial thickness (epidermis and dermis): skin bright pink and blisters, painful
Full thickness (epidermis, dermis, underlying tissues): skin appears waxy, dry, leathery, charred, no pain
Dr.Karim Shaarawy, MD

4. Classification by Burn Depth
Dr. K. Shaarawy
Dr. K. Shaarawy
Figure 17–1 Burn injury classification according to the depth of the burn.
Dr.Karim Shaarawy, MD

5. Zones of Injury Dr. K. Shaarawy Dr.Karim Shaarawy, MD
Figure 17–8 The zones of injury.
Dr.Karim Shaarawy, MD

6. Extent of Burn - TBSA Dr.Karim Shaarawy, MD
Figure 17–5 The “rule of nines” is one method for quickly estimating the percentage of TBSA affected by a burn injury. Although useful in emergency care situations, the rule of nines is not accurate for estimating TBSA for adults who are short, obese, or very thin.
Dr.Karim Shaarawy, MD

7. Lund & Browder Burn Chart
Figure 17–6 The Lund and Browder burn assessment chart. This method of estimating TBSA affected by a burn injury is more accurate than the “rule of nines” because it accounts for changes in body surface area across the life span.
Dr.Karim Shaarawy, MD

8. Minor Burns Sunburn Scald burn Superficial burns less than 15% of TBSA
Exposure to ultraviolet light
More commonly seen in light skinned clients
Redness, pain, nausea/vomiting, chills
Scald burn
Exposure to moist heat
Involves superficial and partial thickness
Superficial burns less than 15% of TBSA
Dr.Karim Shaarawy, MD

9. Classification – Minor Burns
Classification of Burn Injuries
Minor Burn Injuries
Excludes electrical, inhalation, and complicated injures such as trauma
Partial thickness burn of less than 15% of total body surface area
Full thickness burn of less than 2% of total body surface
Dr.Karim Shaarawy, MD

10. Classification - Moderate
Moderate Burn Injuries
Excludes electrical, inhalation, and complicated injures such as trauma
Partial thickness burns of 15-25% of the total body surface
Full thickness burns of less than 10% of total body surface
Dr.Karim Shaarawy, MD

11. Partial Thickness Burn
Figure 17–2 Partial-thickness burn injury.
Dr.Karim Shaarawy, MD

12. Major Burn Event Dr.Karim Shaarawy, MD
Figure 17–7 Effects of a severe burn on major body systems and metabolism.
Dr.Karim Shaarawy, MD

13. Cardiovascular System
Hypovolemic shock (Burn shock) – massive fluid shift from intracellular & intravascular into the interstitium
24 to 36 hours of injury
Direct loss of cell wall integrity
BP falls as cardiac output diminishes
Proteins and sodium escape into interstitium
Potassium increases then will decrease as burn shock resolves
Dr.Karim Shaarawy, MD

14. Cardiovascular System
Myocardial dysfunction – ventricular fibrillation, cardiac arrest, & vascular compromise
Peripheral vascular compromise – edema, compartment syndrome
Dr.Karim Shaarawy, MD

15. Classification - Major
Major Burn Injuries
Includes all burns of the hands, face, eyes, ears, feet, and perineum, all electrical injuries, multiple traumas, and all clients that are considered high risk
Partial thickness burns of greater than 25% of the total body surface
Full thickness burns of 10% or greater of the total body surface area
Dr.Karim Shaarawy, MD

16. Burn Injuries Dr.Karim Shaarawy, MD
Figure 17–4 Full-thickness burn injury.
Dr.Karim Shaarawy, MD

17. Pathophysiologic Effects of a Major Burn
Can involve all body systems
Extensive loss of skin can result in massive infection, fluid and electrolyte imbalances, and hypothermia
Cardiac dysrhythmias and circulatory failure
Profound catabolic state & dehydration
Alteration in gastrointestinal motility – Curling’s ulcer
Overall body metabolism is profoundly altered
Dr.Karim Shaarawy, MD

18. Pathophysiologic Effects of a Major Burn
Burn wound healing
Inflammation, Proliferation, Remodeling
Burn wound infection
Increased sloughing of burn tissue
Increased edema around wound edges
Partial-thickness wound converting to full- thickness wound
Black or brown areas of discoloration
Dr.Karim Shaarawy, MD

19. Stages of Progression Dr. K. Shaarawy Dr.Karim Shaarawy, MD
Figure 17–9 The client’s progression through the healthcare system during the emergent, acute, and rehabilitative stages of burn injury.
Dr. K. Shaarawy
Dr.Karim Shaarawy, MD

20. Burn Stages Emergent/Resuscitative Stage
From onset of injury through successful fluid resuscitation
Estimate extent of burn injury
Institute first aid measures
Client may be intubated
Nursing diagnosis – Impaired Skin Integrity, Deficient Fluid Volume, Acute Pain, Powerlessness, Risk for Infection
Dr.Karim Shaarawy, MD

21. Burn Stages Acute Stage Rehabilitative Stage
Begins with start of diuresis and ends with closure of the wound, either by natural healing or by using skin grafts
Rehabilitative Stage
Begins with wound closure and ends when client returns to highest level of health restoration, which may take years
Dr.Karim Shaarawy, MD

22. Fluid Resuscition Necessary in all burns >20%TBSA
Warmed Ringer’s lactate using Parkland formula 4mLxkgx&TBSA through two large bore (14 to 16 gauge) catheters for 1st 24 hours
Hourly urine 30 to 50 mL/hr
HR <120 beats/min
Changed to 5% dextrose to maintain urine output
Dr.Karim Shaarawy, MD

23. Respiratory Management
Maintain head of bed 30 degrees
TCDB every 2 hours
Maintain adequate tissue oxygenation with least amount of inspired oxygen necessary
Arterial line for continuous assessment of ABGS
Pulmonary artery pressure catheter
Dr.Karim Shaarawy, MD

24. Medications Morphine 3 to 5mg every 5 to 10 minutes
Anxiolytic agents – midazolan (Versed)andlorazepan (Ativan)
Antiulcer meds – dec.intestinal motility
Topical antimicrobial therapy
Mafenide acetate (Sulfamylon) cream – face and neck edema
Silver nitrate 0.5% soaks – blackens skin
Sulfadiazine(Silvadene) cream- leukopenia
Dr.Karim Shaarawy, MD

25. Closed Dressing Method
Figure 17–14 Closed method of dressing a burn.
Dr.Karim Shaarawy, MD

26. Surgery
Escharotomy - prevent circumferential constriction, removal of eschar facilitates healing
Surgical Debridement – remove burn wound to level of viable tissue, should bleed briskly before coagulation
Autografting – permanent skin coverage
Homograft/allograft – human skin
Heterograft/xenograft – animal usually pig
Biologic dressings – Biobrane, Intregra
Dr.Karim Shaarawy, MD

27. Escharotomy Dr.Karim Shaarawy, MD
Figure 17–10 Escharotomy. The surgical procedure consists of removing the eschar formed on the skin and underlying tissue following severe burns. The procedure is particularly helpful in restoring circulation to the extremities of clients when scar tissue forms a tight, constrictive band around the circumference of a limb.
Dr.Karim Shaarawy, MD

28. Autograft Dr.Karim Shaarawy, MD
Figure 17–12 Skin graft for burn injury (autograft).
Dr.Karim Shaarawy, MD

29. Skin Grafting Dr.Karim Shaarawy, MD
Figure 17–11 Skin grafting procedure.
Dr.Karim Shaarawy, MD

30. Burn Contracture
Figure 17–3 Burn contracture.
Dr.Karim Shaarawy, MD