Management of burn
1. First aid for minor burn (first degree burns)
a. If skin not broken, run cool water over burned area or soak in cool water bath.
(Not ice water)
If burn occurs in cold environment, clean, cold, wet towel help to reduce pain
2. After cover burn with sterile non-adhesive bandage or clean clothes.
3. Protect burn from friction and pressure.
4. Pain medication; relieve pain, reduce inflammation and swelling.
2. First aid treatment for severe burn (second and third degree burn)
1. Don't remove burn clothing unless easily come off.
2. Ensure victim not contact with burning material.
3. Don't apply any ointment and avoid breaking blister.
4. Don't use blanket/towel, use sheets best for large wound.
5. Cover burn with cool moist sterile bandage or clean cloths
6. If victim is not breathing, present respiratory block, open the airway, if necessary begin CPR.
7. If finger or toe burn; separate them with dry sterile non-adhesive dressings.
8. Protect from friction and pressure
9. Continue to monitor vital signs.
10. Steps to prevent shock
Lay victim flat, elevates feet about 12 inches.
Management of Burn according to Burn Phase
1. Immediate management of Burn
1. First aid
2. Prevention of shock
3. Prevention of respiratory distress
4. Detection and treatment of injuries
5. Wound assessment and wound care
a. Airway management
Observed laryngeal edema and airway obstruction.
b. O2 therapy
c. Endotracheal intubation
d. Mechanical ventilation
e. Elevation of head and chest; reduce neck and chest wall edema by 20-30 degrees.
For Second and third degree burn
Escharotomy
Emergency surgical procedure involving incision through area of burnt skin to release eschar and allow ventilation of patient.
2. Hyperbaric oxygen therapy (HBOT)
Hpoxia prevent the wound healing.
Non-invasive mode, patient entirely enclosed in pressure chamber filled with oxygen at pressure greater than one atmosphere.
HBOT support wound healing. HBOT is used in treatment of smoke inhalation; COHb (carboxyhemoglobin) lead to hypoxia and decrease oxygen delivery to tissue.
3. Fluid management
Losses fluid through burn wound and adjacent tissues in form of edema.
1. Replacing body fluid
Fluid therapy started within hours after severe burn; to prevent hypovolemic shock.
Fluid administered during first 48 hours; given to maintain circulating blood volume.
a. Colloids, plasma and plasma expanders
b. Electrolytes; Nacl, RL
c. Distilled water with 5% glucose
Fluid calculation for burn patient's
1. Parkland/ Baxter formula
4ml X Kg body weight X % body surface are (BSA) burned
Administered in first 24 hours;
a. Give half of solution in first 8 hours.
b. Remaining half for next 16 hours.
IV maintenance fluid; 4:2:1 rule
2. Brooke formula
In first 24 hours;
Electrolytes;
1.5 ml X Kg body weight X % body surface area (BSA) burned
Colloids; 0.5ml X Kg body weight X % body surface area (BSA) burned
Non Electrolytes fluids; Glucose 5% in distilled water (2000ml glucose in distilled water)
a. Half given in first 8 hours
b. Remaining half next 16 hours
3. Evans formula
In first 24 hours
Electrolytes;
0.5ml X Kg body weight X % body surface area (BSA) burned
Colloids; 1ml X Kg body weight X % BSA burned
Non Electrolytes; 2000ml glucose in distilled water.
a. Half to given first 8 hours
b. Remaining half to given next 16 hours.
4. Consenus formula
In first 24 hours;
Lactate ringer solution
(2-4) ml X Kg body weight X % BSA burned
a. Half of fluid given first 8 hours.
b. Half of fluid given next 16 hours
5. Hypertonic solution
Reduce edema and pulmonary complications.
Burn Wound Management
1. Cleanase wound to eliminate or decrease dead tissue and debris; source as media for bacterial growth.
2. Prevent distraction of skin
3. Determine burn area depth and then debridement ( remove necrotizing tissue and contamination), cleaning and then dressing.
4. Circumferential burns of digits, limbs or chest, need surgical release of burnt skin, Escharotomy; to prevent problem with circulation and ventilation.
Analgesics and sedation; ibuprofen/acetaminophen and narcotics.
2. Intermediate phase
a. Infection prevention and treatment of complication
b. Burn wound care;
Wound cleaning
Topical antibiotic therapy
Wound dressing
Dressing changes
Wound debridement
Wound grafting
c. Pain management
d. Nutritional support
c. Clean burn area and change bandages.
d. Skin graft need to cover burns
Topical Antibiotics
1. 0.5% silver nitrate
2. Silver sulfadiazine
3. Mycostatin
4. Bacitracin/ polymyxin B
5. Mefenide acetate
6. Mupirocin
7. Povidone-iodine (betadine) ointment (10%)
8. Gentamicin
Note - Mycostatin not combined with mefenide; both became inactived.
Wound Care
Prevent from infection
Limiting pain of exposed burn surface
1. Wound Covering
Cover wound with dressing or graft.
Wet dressing used with silver nitrate or normal saline application.
A single layer of fine mesh gauze placed over the wound, coverd with thick gauze pads to maintain moisture. Dressing must kept wet.
Types of scar
1. Keloid scar
Overgrowth of scar tissue.
2. Hypertrophic scars
Red, thick and raised scars.
3. Contractures
Permanent tightening of skin. Elastic connective tissue replaced by inelastic fiberous tissue.
Make tissue resistant to stretching and prevent normal movement of affected area.
Management for Burn Patient
1. Medical management
1. Topical Antibiotics
a. Neosporin
b. Silvadene
2. Analgesics
Ibuprofen (advil), acetaminophen
For severe pain; morphine sulfate, vicodin, Demerol, anaprox
Drug used in Reconstructive and cosmetic surgery
1. Bacterial protein synthesis inhibitors; topical
Altabax (Retapamulin)
2. Immunosuppressants
Amevive (Alefacept)
3. Avita gel
Topic form of retinoic acid
4. Topical Antibiotics
Bactroban 2% Ointment
5. Benzamycin (erythromycin 3% / benzoyl peroxide 5%); topical gel
6. Botox cosmetic (injection)
Directly given into effected area.
Blocking nerve impulse and relax contraction.
Nursing management of Burns
Nursing assessment
1. Assess ABCDE (airway, breathing, circulation, disability, exposure; prevent hypothermia) and need for fluid resuscitation.
2. Assess severity of burn and conscious level.
3. Establish tha cause
4. Assess associated factor; injury, fracture and internal injury.
5. Asses the possible inhalation injury.
6. Assess any pre-existing illness, any drug therapy, allergy and drug sensitivities.
7. Establish patient tetanus immunization.
8. Body surface area; rule of nine
9. Palmer surface of patient's hand including finger.
10. Depth of burn (first degree burn, second degree burn, third degree burn)
11. Assess pain, redness of area, absence or presence of blister, swelling, capillary refill time, reduced or absence sensation according to degree of burn.
12. Circumferential extremity burn
Assess circulation, checking for cyanosis, impaired capillary refilling.
13. Assessment of peripheral pulses.
14. Assess Neurological signs
Nursing Diagnose
1. Impaired gas exchange related to carbon monoxide poisoning, smoke inhalation and upper airway obstruction.
2. Ineffective airway clearance related to edema and effect of smoke inhalation.
3. Fluid volume deficit related to increased capillary permeability and evaporation losses from burn wound.
4. Hypothermia related to loss of skin and open wounds.
5. Pain related to tissue injury
6. Risk of infection related to loss of skin barrier and altered immune response.
7. Impaired nutrition; less than body requirement related to hypermetabolic response to burn injury.
8. Impaired skin integrity related to open burn wounds and surgical interventions.
9. Impaired physical mobility related to edema, pain, skin and joint contractures.
10. Anxiety related to fear and emotional impact of burn injury.
Role of nurse in burn Management
1. Restoring normal fluid balance
IV therapy, oral intake, infusion pump
Monitor changes in fluid status
2. Preventing infection
Burn wound care
Aseptic technique used for wound care procedures.
Protect patient from source of infection or contamination.
3. Maintaining adequate nutrition
Dietician plan; protein and colorie rich diet
Home made food
NG feeding tube inserted; continuous or bolus feeding of specific formula.
Patient weight
4. Promoting skin integrity
Wound care and dressing changes
Wound Management
Teach the patient and family by instruction, encourage to active part in dressing changes and wound care.
5. Relieving pain and discomfort
Assessment of pain (scale and intensity)
Analgesics and antianxiety medication
Dressing changes to reduce pain and discomfort
Teach patient and family; wound care relaxation technique
6. Promoting physical mobility
a. Prevent complication resulting from immobility.
b. Deep breathing, turning, changing position
Prevent; atelectasis, pneumonia
Control edema
Prevent pressure ulcer and contractures
c. Initiate both active and passive ROM within prescribed limitation.
7. Strengthening coping strategies
Effective coping strategy
Self care, self feeding, assistance with wound care procedures, excercise, relaxation techniques.
Assess tha ability of patient, cope with information.
8. Educate the patient and family
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