King Saud University

College of Nursing

Burn
Hatem Alsrour
Layers of the Skin

Brunner, 2008, Figure 55.1. anatomic structures of the skin

Epidermis
Outermost layer, composed of cornified
.epithelial cells

.Outer surface cells are dead and sloughed off

Dermis
Middle layer, composed primarily of connective
.tissue

Contains capillaries that nourish the skin, nerve

endings and hair follices
Hypodermis
Layer of adipose and connective tissue
.between the skin and underlying tissues
Function of Skin

 Protection from infection & injury

 Prevention of loss of body fluid
 Regulation of body temperature
 Sensory contact with environment
?What is a Burn
 An injury to tissue from:

–Exposure to flames or hot liquids

–Contact with hot objects
–Exposure to caustic chemicals or
radiation
–Contact with an electrical current
Types (Causes) of Burn Injury
Thermal
Open flame, steam, hot liquids
Chemical
Acids, strong alkalis, organic compounds
Electrical
Direct or alternating current, lightning
Radiation
Radioactive agents
Pathophysiology of Burn Injury
 Zone of Coagulation:
 Irreversible damage
 Zone of Stasis:
 Impairment of blood flow
 Recovery variable
 Zone of Hyperemia:
 Prominent vasodilation
 Usually recovers
Severity of a Burn
Depends on:
 Depth of burn

 Extent of burn

 Location of injury

 Patient’s age
 First degree burn
: Superficial Partial Thickness
 Involves only the epidermis

 Skin pink to red

 Outer layers of skin damaged
(epidermis )
 Painful
 Heals without grafting
Second degree burn
 Deep partial thickness
 Involve the epidermis and
portions of the dermis
 Skin red to white
 Blisters
 Weeping surface
 Edema
 All epidermis and much of
dermis damaged
 Painful
 Heals without grafting
Partial thickness 
Superficial (first- 
(second-degree) degree) burns
burns
Third degree burn

 Referred to as full-thickness burns

 Charred appearance(black, brown, leathery)
 Waxy, white
 Edema
 All layers of skin destroyed
 Nerves, muscle tissue, and bone may be
destroyed
 Grafting preferred
Full thickness (third-degree) burns
Depth of burn injury
Depth of a Burn

First Degree

Superficial Second

Deep Second

Third Degree
Extent of a Burn
 “Rule of Nines”

 Most universal guide

for initial estimate

 Deviates in children
due to larger head
surface area
Rule of Nine
”Robyn’s Rule of 4s“
Carbon Monoxide Poisoning
 Colorless, odorless gas
 Binds to hemoglobin 200 times more than oxygen
 Most immediate threat to life in survivors with
severe inhalation injury
 Toxicity related directly to percentage of
hemoglobin it saturates
Carbon Monoxide Poisoning
Signs & Symptoms of Carbon Monoxide Toxicity
Carboxyhemoglobin (%) Signs/Symptoms
0-10 None
10-30 Headache
30-50 Headache, nausea,
dizziness, tachycardia
50-60 CNS dysfunction,
coma
60+ Death
CO Poisoning: Treatment
 100% oxygen until carboxyhemoglobin levels
less than 15
Shock & Fluid Resuscitation
Goal:

 To maintain vital organ function while avoiding

the complications of inadequate or excessive
therapy
Resuscitation Fluid Needs
 Related to:
 extent of burn (rule of nines)
 body size (pre-injury weight estimate)
 Delivered through large bore peripheral IV
 Attempt to avoid overlying burned skin
 Can use venous cut down or central line
 Parkland Formula:
 Adults : 2-4 ml RL x Kg body weight x % burn
 Children: 3-4 ml RL x Kg body weight x %
burn
Monitoring of Resuscitation
 Urinary output is a reliable guide to end organ
perfusion
 Adults: 30-50 ml per hour
 Children (less than 30 Kg): 1 ml/Kg per hour
Chemical Burns
 Occur whenever a toxic substance contacts
the body
 Eyes are particularly vulnerable.
 Fumes can cause burns.
 To prevent exposure, wear appropriate gloves
and eye protection.
Care for Chemical Burns
 Remove the chemical from the patient.
 If it is a powder chemical, brush off first.
 Remove all contaminated clothing.
 Flush burned area with large amounts of
water for about 15 to 20 minutes.
Electrical Burns
 Make sure the power is off before touching
the patient.
 There will be two wounds (an entrance and an
exit wound) to bandage.
 Arrange for prompt transport and be prepared
to administer CPR.
Pre-hospital Care
Stop the burning process
Thermal – smother; stop, drop, and roll
Chemical– remove clothing and flush /
irrigate skin / eyes
Electrical – shut off electrical current or
separate person from source with a
nonconducting implement (such as wooden
(broomstick
Radiation – limit exposure
 Emerncy impelementation :
Stop the burning process, if still active-1

Remove all clothing and jewelry, rings, in anticipation -2

. of edema formation

Ensure patent airway. Prepare for early intubation -3

Administer oxygen via a mask at flow rate sufficient -4

enough to keep reservoir bag inflated; usually
requires 12 to 15L\minute

Assist Ventilation, if needed-5

Cannulate two veins with large-bore, 14- or 16-gauge -6
catheters, and initiate infusion of an IV solution

Infuse a crystalloid solution such as lactated Ringer's -7

.solution according to a pre established fluid protocol

Fluid resuscitation is based on the individual patient's -8

response to the injury. Patients who may require
more fluid than predicted are those patients who
:have
An inhalation injury
A high voltage electrical injury
Delayed fluid resuscitation since the time of injury
Administer analgesic medications, e.g., morphine, IV -9

Insert a gastric tube. If patient has TBSA more -10

than 25%, nausea & vomiting are present

Apply cool, saline-moistened, sterile dressings to -11

. TBSA burns less than 10%
Do not use ice *
Keep the area cool will help to relieve pain *
Apply cool dressings within 10 minutes of the *
burn to reduce the heat content of the tissues
and the depth of the burn injury
ABCs of Emergency Burn Care
((Advanced Burn Life Support
 A = Airway (with cervical spine assessment)
 B = Breathing
 C = Circulation
 D = Disability
 E = Exposure and Environmental Control
 F = Fluid Resuscitation based on Burn Size and
Weight Measurement
 Secondary Survey
A: Airway

Assess the patient’s airway

Upper airway edema due to inhalation injury
•
Rapid or delayed progression

Decision to intubate: individualized
B: Breathing
 Look, listen, feel for breath sounds and chest
movement
 Give 100% oxygen to all victims of major
burn beginning in the field
 Pulse oximetry
 Arterial blood gases
• Required for definitive diagnosis of CO
 Baseline chest x-ray
C: Circulation

Who needs fluid resuscitation?
•
All >20% total body surface area burned (TBSA)
•
Young and old with >10% TBSA

2 large bore peripheral IVs
D: Disability

Assess level of consciousness: AVPU
•
Alert
•
Responds to verbal stimuli
•
Responds to painful stimuli
•
Unresponsive

Alteration in mental status is not normal

Moves extremities
E: Exposure and Environment

Remove clothing, jewelry

Keep warm
•
blankets
•
warm I.V. fluids
•
heating lamps
•
heat the room

Keep Patient Dry
F: Fluid Resuscitation
((based on burn size and weight

Determine fluid needs based on burn size and
weight

Burn size: include second and third degree
only
•
Rule of Nines
Nursing Considerations
:Goals
Correct fluid and electrolyte imbalance
Promote wound healing
Support nutrition
Control pain
Prevent complications of immobility
Support patient
Questions
Which nursing intervention holds the highest priority of
a patient with burns to her face and upper
?respiratory tract
A– Elevate the head of the bed to at least 30º
B– Administer six liters of oxygen via nasal
cannula
C– Medicate the patient prior to repositioning
the patient in bed
D– Prevent moving the skin around the burn
site
: Answer
Which nursing intervention holds the highest priority of
a patient with burns to her face and upper
?respiratory tract
A– Elevate the head of the bed to at least 30º
B– Administer six liters of oxygen via nasal
cannula
C– Medicate the patient prior to repositioning
the patient in bed
D– Prevent moving the skin around the burn
site
Questions
What is the highest priority for the nurse when caring
for a patient who has just received an electrical
?burn
Disconnect the patient from the electrical
source
B. Ensure the patients have a cervical collar
.and be placed on a back board prior to care
.C. Monitor for cardiac dysrhythmia
D. Patients may require changes in fluid
resuscitation as compared to patients with
.other types of burns
 : Answer
What is the highest priority for the nurse when caring
for a patient who has just received an electrical
?burn
A. Disconnect the patient from the electrical
source
B. Ensure the patients have a cervical collar
.and be placed on a back board prior to care
.C. Monitor for cardiac dysrhythmia
D. Patients may require changes in fluid
resuscitation as compared to patients with
.other types of burns