CHAPTER I

PRELIMINARY

A. Background
Burns are a fairly common injury often faced by doctors and nurses.
Heavy types exhibit relatively high morbidity and degree of defect
compared with other causes of injury. Costs needed in handling high.
Causes of burns other than direct or indirect fire burning, as well as
exposure to high temperatures from sun, electricity, and chemicals.
Statistics show that 60% of burns occur due to domestic accidents, 20%
due to occupational accidents, and the remaining 20% for other reasons,
such as burning buses, bomb explosions, and volcanoes. Handling and
treatment of burns (especially severe burns) require complex treatment and
is still a challenge because of high morbidity and mortality rates.1 In the
United States, it is reported that about 2 - 3 million sufferers each year with
a mortality rate of about 5 to 6 thousand deaths per year. In Indonesia until
now there has been no written report on the number of burns and the
number of deaths caused. In the RSCM burn unit of Jakarta, in 2008
reported as many as 107 cases of burns treated with 37.38% death rate.
Some characteristics of burns that occur require different special
actions. These characteristics include the extent, causes (etiology) and
anatomy of burns. Burns involving large body surfaces or expanding into
deeper tissues require more intensive action than smaller and superficial
burns. Burns caused by hot fluid (scald burn) have a difference in prognosis
and complications from the same burns caused by fire or exposure to
ionizing radiation. Burns due to chemicals require different treatments as
opposed to electric shock (electric) or sparks. Genetal burns cause greater
risk of nifeksi than elsewhere of the same size. Burns on the feet or hands
can affect the ability of the client's work function and require different
treatment techniques from other body locations. The nurse's general
 knowledge of the anatomy of skin physiology, the pathophysiology of burns
is necessary to recognize the difference and degree of certain burns and is
useful to anticipate life expectancy and the occurrence of the accompanying
multi-organ complications.
The prognosis of a client suffering from a burn is directly related to the
location and size of the burn. Other factors such as age, previous health
status and inhalation of smoke can affect the severity of burns and other
accompanying effects. Burn clients often experience adverse incidental
events, such as injuries or deaths of other family members, homelessness
and others. Clients of burns should be referred for better care facilities to
deal with immediate and long-term problems that accompany certain burns.
(Elizabeth, 2009)
B. Purpose
1. General objectives
Students can understand Nursing Care of Client with Emergency of
Burn Injuries.
2. Specific objectives
Students can explain again:
a. Understanding burns.
b. Causes of burns.
c. Phase of burns
d. Classification of burns.
e. How to calculate the area of burns.
f. Severity of burns.
g. Pathophysiology of burns.
h. Indication of inpatient burn patient.
i. Management of burns.
3. Benefits
a. Benefits for students
 Through this paper the students can apply the knowledge gained
during the learning, especially about the students' knowledge and
give nursing care to burn patients in a comprehensive manner.
b. Benefits to the nursing profession
Through this paper is expected to add science in nursing, especially
nursing emergency lung injuries. So that students apply in daily life.
c. Other benefits
This paper can be used as an ingredient in continuing research
related to the relationship between knowledge about burns.
 CHAPTER II
CONTENT

A. Description
Burn is a form of trauma or injury to body tissues, either localize in a
certain body part or massive. It is caused by thermal, chemical, electrical, or
radioactive substances. It is classified as partial-thickness or full thickness.
Partial-thickness burns involve the epidermis and upper portion of the
dermis. Full-thickness burns involve all layers of the skin, sometimes with
some of the underlying organs or bones.
Burns are caused by a transfer of energy from a heat source to the body.
The depth of the injury depends on the temperature of the burning agent and
the duration of contact with it.
Burns disrupt the skin, which leads to increased uid loss; infection;
hypothermia; scarring; compromised immunity; and changes in function,
appearance, and body image. Young children and the elderly continue to
have increased morbidity and mortality when compared to other age groups
with similar injuries. Inhalation injuries in addition to cutaneous burns
worsen the prognosis.
Burns are the most severe injuries that lead to complex problems, not
only causing skin damage but also the entire body system (Nina, 2008).
Burns are a trauma caused by heat, chemicals, electrical currents, and
lightning that affect the skin, mucosa and deeper tissues. The surface area of
the burning body will affect the metabolism and function of body cells and
disrupt all systems, especially the cardiovascular system (Rahayuningsih,
2012).
Burns are a skin response and subcutaneous tissue against thermal
trauma. There are two types of burns according to their thickness. Burns
with partial thickness are burns that do not damage the epithelium or
damage some of the epithelium, whereas full-thickness burns damage all
 sources of skin epithelial retreat and if the wounded skin surface will require
extensive excision and skin grafts (Grace & Borley , 2006).
Burns are conditions of burns caused by high heat, chemical
compounds, districts and excessive sun exposure. Treatment of burns should
be distinguished by extent. On the principle of rule of nine burns are divided
into several parts, namely the head 9%, chest 18%, back 18%, limb above
18%, thigh 18% and limb down 18%, perineum and genitalia 1% (Hidayat,
2008 ).
The presence of burns on the body will damage the function of the skin
that protects the body from dirt and infection. If many of the surface of the
body is burned, it can threaten the life of a person due to blood vessel
damage, electrolyte imbalance and body temperature, respiratory
disturbances and nerve function (Adibah & Winasis, 2014 in Sari, 2015).
Widespread burns can cause shock. This happens because the body
fluids are mostly sent to the burned area so that the blood volume that
flowed into the brain and heart is reduced. Shock in children can occur if
burns area of 10%, while in adults as wide as 20% (Mohamad, 2005).
B. Characteristics of Burn
The depth of a burn injury depends on the type of injury, causative
agent, temperature of the burn agent, duration of contact with the agent, and
the skin thickness. Burns are classied according to the depth of tissue
 destruction:

1. Supercial partial thickness burns (similar to rstdegree), such as

sunburn: The epidermis and possibly a portion of the dermis are
destroyed.
2. Deep partial thickness burns (similar to seconddegree), such as a scald:
The epidermis and upper to deeper portions of the dermis are injured.
3. Fullthickness burns (thirddegree), such as a burn from a ame or electric
current: The epidermis, entire dermis, and sometimes the underlying
tissue, muscle, and bone are destroyed.

C. Extent of Body Surface Area Burned

How much total body surface area is burned is determined by one of the
following methods:
 1. Rule of Nines: an estimation of the total body surface area burned by
assigning percentages in multiples of nine to major body surfaces.

2. Lund and Browder method: a more precise method of estimating the

extent of the burn; takes into account that the percentage of the surface
area represented by various anatomic parts (head and legs) changes with
growth.
3. Palm method: used to estimate percentage of scattered burns, using the
size of the patients palm (about 1% of body surface area) to assess the
extent of burn injury.

D. Causes
Most burns result from preventable accidents. Thermal burns, which are
the most common type,occur because of fires from motor vehicle crashes,
accidents in residences, and arson or electrical malfunctions. Children may
be burned when they play with matches or firecrackers or because of a
kitchen accident. Chemical burns occur as a result of contact with, ingestion
of, or inhalation of acids, alkalis, or vesicants (blistering gases). The
percentage of burns actually caused by abuse is fairly small, but they are
some of the most difficult to manage. Neglect or inadequate supervision of
children is fairly common. Effective prevention and educational efforts such
as smoke detectors, flame-retardant clothing, child-resistant cigarette
 lighters, and the Stop Drop and Roll program have decreased the number
and severity of injuries.
E. Etiology

1. Thermal burns
Thermal burns are caused by exposure or contact with fire, liquids or hot
gases and solids (solid). Burns are most often caused by exposure to hot
temperatures such as direct fire burning or exposure to hot metal (Borley &
Grace, 2006; Rahayuningsih, 2012).
2. Chemical burn
Chemical burns are caused by skin tissue contact with acids or strong bases.
The degree of burns due to chemicals is directly related to contact length,
chemical concentration and the number of tissues exposed. All affected
clothing should be removed and skin examined to see the wound area. Since
the depth of the wound is also determined by the concentration of agents
present on the skin, dilution with many water rinses becomes the stage in
the management of burns patients due to strong bases is more damaging
than the effects of strong acids (Sabiston, 1995; Borley & Grace, 2006;
Rahayuningsih, 2012 ).
4. Electrical burns
Electrical burns are damage that occurs when an electric current flows into
the human body and burns tissue or causes disruption of the function of an
internal organ. The human body is a good electric conductor. Electric
current that flows into the human body will produce heat that can burn and
destroy body tissues. Although electric burns appear mild, but there may
have been serious internal organ damage, especially in the heart, muscles or
brain. The severity of the wound is influenced by the length of contact, the
high voltage, and the way the electric wave about the body (Borley &
Grace, 2006; Rahayuningsih, 2012).
Electric current can cause injury in 3 ways:
a. Cardiac arrest (cardiac arrest) due to electrical effects on the heart
 b. Damage to muscles, nerves and tissues by an electric current passing
through the body
c. Thermal burn due to contact with power source.
4. Radiation burns
Radiation burns are caused by exposure to radioactive sources. This relates
to the use of ionizing radiation in industry or from radiation sources for
therapeutic purposes in the medical world. Exposure to sun exposure for too
long is also a type of radiation burn. Initially this wound with partial depth,
but can lead to deeper trauma (Borley & Grace, 2006; Rahayuningsih,
2012).
F. Patofisiology
Burns are caused by the transfer of energy from the heat source to the
body. The heat may be transferred through conduction or skin irradiation with
burns damaged in the epidermis, dermis, or subcutaneous tissue depending on
the duration of contact with the heat source.
Burn injuries affect all organ systems. The magnitude of this
pathophysiological response is closely related to the extent of burns and
reaches a stable period when burns account for approximately 60% of the
entire body surface.The level of nursing changes depends on the extent and
depth of the burn that caused damage starting from the occurrence of burns and
lasted 24 - 72 hours first. The condition is characterized by a fluid shift from
the vascular component to the interstitial space. When the tissue is burning,
vasodilatsi increases capillary permeability and changes in cell permeability
occur in burns and surrounding cells. The impact is the amount of fluid that is
in the extra cells, sodium chloride and proteins passing through the areas that
burn and form bubbles and edema or out through open wounds. Due to the
presence of edema burns, the skin environment is damaged. The skin as a
mechanical barrier serves as an important self-defense mechanism of the
incoming organism. The occurrence of damage to the skin environment will
allow micro organisms enter the body and cause wound infections that can
slow the wound healing process. With the edema will also affect the increase in
stretching of blood vessels and nerves that can cause pain. Pain can disrupt the
patient's mobility.
When there is loss of fluid in the vascular system, homo concentration
and hematocrit rise, the blood fluid becomes substandard in the burn area and
less nutrients. The presence of burn injuries causes peripheral vascular
resistance to increase as a result of neurohomoral stress response. It may
increase cardiac afterload and result in further decrease in cardiac output. Due
to the decrease in cardiac output, cause anaerobic metabolism and the end
result of acid products are retained due to impaired kidney function.
Subsequent metabolic acidosis results in tissue perfusion that occurs not
perfect.
Following the period of fluid shift, the patient remains in acute condition.
This period is characterized by anemia and malnutrition. Anemia will develop
as a result of much loss of erythrocytes. Negative nitrogen balance begins to
occur in the event of burns caused by tissue loss of protein and due to stress
response. This will take place during the acute period due to the continuous
loss of protein through the wound.
Timothy respiratory disorders due to upper airway obstruction or due to
hypovolemic shock effects. Upper airway obstruction is caused by inhalation
of harmful substances or overheated air, irritation of the airways, laryngeal
edema and potential obstruction.Body temperature burns occur either because
of direct heat conditions or electromagnetic radiation. The cells can withstand
temperatures up to 440C without significant damage, the rate of tissue damage
multiples for each temperature rise. Nerves and blood vessels are less resistant
structures with heat conduction. Damage to these blood vessels results in
intravascular fluid coming out of the lumen of the blood vessels, in this case
not just fluid but plasma proteins and electrolytes. In extensive burns with
altered permeability changes, the accumulation of massive tissue in the
intersitial causes hypovolemic conditions. Intravascular fluid volume is deficit,
there is an inability to organize transportation process to network, this
condition known as shock (Moenajat, 2001).
G. Gender, Ethnic/Racial, and Life Span Considerations
Preschool children account for over two-thirds of all burn fatalities.
Clinicians use a special chart (Lund-Browder Chart) for children that
provides a picture and a graph to account for the difference in body surface
area by age. Serious burn injuries occur most commonly in males, and in
particular, young adult males ages 20 to 29 years of age, followed by children
under 9 years of age. Individuals older than 50 years sustain the fewest
number of serious burn injuries.The younger child is the most common victim
of burns that have been caused by liquids. Preschoolers, school-aged children,
and teenagers are more frequently the victims of flame burns. Young children
playing with lighters or matches are at risk, as are teenagers because of
carelessness or risk-taking behaviors around fires. Toddlers incur electrical
burns from biting electrical cords or putting objects in outlets.
Most adults are victims of house fires or workrelated accidents that
involve chemicals or electricity. The elderly are also prone to scald injuries
because their skin tends to be extremely thin and sensitive to heat. Because of
the severe impact of this injury, the very young and the very old are less able
to respond to therapy and have a higher incidence of mortality. In addition,
when a child Burns 167 experiences a burn, multiple surgeries are required to
release contractures that occur as normal growth pulls at the scar tissue of
their healed burns. Adolescents are particularly prone to psychological
difficulties because of sensitivity regarding body image issues. No specific
gender and ethnic/racial considerations exist in burns.
H. Gerontologic Considerations
1. Elderly people are at higher risk for burn injury because of reduced
coordination, strength, and sensation and changes in vision.
2. Predisposing factors and the health history in the older adult inuence
the complexity of care for the patient.
3. Pulmonary function is limited in the older adult and therefore airway
exchange, lung elasticity, and ventilation can be affected.
 4. This can be further affected by a history of smoking.
5. Decreased cardiac function and coronary artery disease increase the risk
of complications in elderly patients with burn injuries. Malnutrition and
presence of diabetes mellitus orother endocrine disorders present
nutritional challenges and require close monitoring.
6. Varying degrees of orientation may present themselves on admission or
through the course of care making assessment of pain and anxiety a
challenge for the burn team.
7. The skin of the elderly is thinner and less elastic, which affects the
depth of injury and its ability to heal.
I. Burn Center Referral
There are 90 to 100 hospitals with burn centers in the United States.
Verified burn centers have specially trained staff and resources. The ABA
and the American College of Surgeons perform rigorous criteria-driven
evaluations to ensure that verified burn centers are able to provide burn care
throughout the continuum of care, from acute injury to rehabilitation. The
ABA also describes patients who should be referred to a verified burn center
for definitive care. As a nurse, you should familiarize yourself with these
criteria. (See Burn center referral criteria). Burn center referral criteria:
1. Partial thickness burns comprising greater than 10% of total body
surface area.
2. Burns involving face, hands, feet, genitalia, perineum, or major joints.
3. Any third degree burn.
4. Electrical burns, including lightning injuries.
5. Chemical burns.
6. Inhalation injury.
7. Burn injury with preexisting medical conditions.
8. Burns in conjunction with traumatic injuries.
9. Burned children in geographic areas without resources dedicated to
pediatric patients.
 10. Burn injuries in people with special social, emotional, or rehabilitation
needs.
Source: American Burn Association. (2011). Advanced Burn Life
Support Course Provider Manual. Chicago, IL: American Burn Association.

J. Medical Management
a. Minor Burn Care
Minor burn wounds are cared for by using the principles of
comfort, cleanliness, and infection control. A gentle cleansing of the
wound with soap and water 2 or 3 times a day, followed with a topical
agent such as silver sulfadiazine or mafenide, prevents infection. Minor
burns should heal in 7 to 10 days; however, if they take longer than 14
days, excision of the wound and a small graft may be needed. Oral
analgesics may be prescribed to manage discomfort, and as do all burn
patients, the patient needs to receive tetanus toxoid to prevent infection.
b. Major Burn Care
For patients with a major injury, effective treatment is provided by
a multidisciplinary team with special training in burn care.
In addition to the physician and nurse, the team includes specialists
in physical and occupational therapy, respiratory therapy, social
work, nutrition, psychology, and child life for children. The course of
recovery is divided into four phases: emergent-resuscitative, acute-
wound coverage, convalescent-rehabilitative, and reorganization-
reintegration.
The emergent-resuscitative phase lasts from 48 to 72 hours after
injury or until diuresis takes place. In addition to managing airway,
breathing, and circulation, the patient receives fluid resuscitation,
maintenance of electrolytes, aggressive pain management, and early
nutrition.Wounds are cleansed with chlorhexidine gluconate and care
consists of silver sulfadiazine ormafenide and surgical management as
needed. To prevent infection, continued care includes further
 dbridement by washing the surface of the wounds with mild soap or
aseptic solutions. Then the physician dbrides devitalized tissue, and
often the wound is covered with antibacterial agents such as silver
sulfadiazine and occlusive cotton gauze.
The acute-wound coverage phase, which varies depending on the
extent of injury, lasts until the wounds have been covered, through
either the normal healing process or grafting. The risk for infection is
high during this phase; the physician follows wound and blood cultures
and prescribes antibiotics as needed. Wound management includes
excision of devitalized tissue, surgical grafting of donor skin, or
placement of synthetic membranes. Inpatient rehabilitation takes place
during the convalescent-rehabilitative phase. Although principles of
rehabilitation are included in the plan of care from the day of
admission, during this time, home exercises and wound care are taught.
In addition, pressure appliances to reduce scarring, or braces to prevent
contractures, are fitted. The reorganization phase is the long period of
time that it may take after the injury for physical and emotional healing
to take place.
K. Complication
1. Congestive heart failure and pulmonary edema.
2. Compartment syndrome
Compartment syndrome is a process of restoration of capillary integrity,
shock burns will disappear and fluid flows back into the vascular
compartment, blood volume will increase. Because edema gets worse on a
circular burn. Pressure against small blood vessels and nerves in the distal
extremities causes blood flow obstruction resulting in ischemia.
3. Adult Respiratory Distress Syndrome, due to respiratory failure occurs
when the degree of disturbance of ventilation and gas exchange is already
life-threatening to the patient.
4. Paralytic Ileus and Ulcer Curling
 Reduced intestinal peristaltic and bowel sounds are signs of paralytic ileus
from burns. Gastric distension and nausea can result. Stomach bleeding
secondary to massive physiologic stress (gastric acid hypersecretion) may
be marked by occult blood in stool, regurgitation of vomitus or vomiting,
this is a sign of ulcer curling.
5. Circulatory shock results from fluid overload or even hypovolemic
secondary occurrences due to adequate fluid resuscitation. The signals are
usually shown to be mentally altered, changes in respiratory status,
decreased urine output, changes in blood pressure, bulk janutng, central
cen- tral pressure and increased pulse rate.
6. Acute renal failure
Inadequate urinary blowing may indicate inadequate fluid resusiratsi,
especially hemoglobin or mycogenic deroglobin in the urine.
7. Contractures Burns Photography: Gives a note for healing burns.

\
 CHAPTER III

NURSING MANAGEMENT

A. Nursing Management: Emergent/Resuscitative Phase

1. Assessment
a. Focus on the major priorities of any trauma patient; the burn wound
is a secondary consideration, although aseptic management of the
burn wounds and invasive lines continues.
b. Assess circumstances surrounding the injury: time of
injury, mechanism of burn, whether the burn occurred in a
closed space, the possibility of inhalation of noxious chemicals,
and any related trauma.
c. Monitor vital signs frequently; monitor respiratory status closely;
and evaluate apical, carotid, and femoral pulses particularly in areas
of circumferential burn injury to an extremity.
d. Start cardiac monitoring if indicated (eg, history of cardiac or
respiratory problems, electrical injury).
e. Check peripheral pulses on burned extremities hourly; use Doppler
as needed.
f. Monitor uid intake (IV uids) and output (urinary catheter) and
measure hourly. Note amount of urine obtained when catheter is
inserted (indicates preburn renal function and uid status).
g. Assess body temperature, body weight, history of preburn weight,
allergies, tetanus immunization, past medicalsurgical problems,
current illnesses, and use of medications.
h. Arrange for patients with facial burns to be assessed for corneal
injury.
i. Continue to assess the extent of the burn; assess depth of wound, and
identify areas of full and partialthickness injury.
j. Assess neurologic status: consciousness, psychological status, pain
and anxiety levels, and behavior.
 k. Assess patients and familys understanding of injury and treatment.
Assess patients support system and coping skills.

B. Nursing Management: Acute/ Intermediate Phase

The acute or intermediate phase begins 48 to 72 hours after the burn
injury. Burn wound care and pain control are priorities at this stage.
1. Assessment
a. Focus on hemodynamic alterations, wound healing, pain
and psychosocial responses, and early detection of complications.
b. Measure vital signs frequently; respiratory and uid status remains
highest priority.
c. Assess peripheral pulses frequently for rst few days after the burn
for restricted blood ow.
d. Closely observe hourly uid intake and urinary output, as well as
blood pressure and cardiac rhythm; changes should be reported to
the burn surgeon promptly.
e. For patient with inhalation injury, regularly monitor level
of consciousness, pulmonary function, and ability to ventilate; if
patient is intubated and placed on a ventilator, frequent suctioning
and assessment of the airway are priorities.
C. Nursing Assassment
1. Airway maintenance with cervical spine protection
Airway evaluation and maintenance with cervical spine protection
must always be your first priority. It is also important to protect the
cervical spine if there is obvious or suspected traumatic injury. Burn
patients frequently become edematous because of the marked increase
in capillary permeability, which occurs as a response to the burn injury.
Edema is a frequent culprit in compromising the airway of burn
patients. Therefore, once emergency medical services (EMS) have
arrived, intubation will be required if the airway is compromised.
2. Breathing and ventilation
 Breathing and ventilation is the next step. Burns of the chest may
restrict the expansion of the chest wall because of the stiffening of the
dermis in deep burns, which can impact respirations. Inhalation of
smoke impairs gas exchange (oxygen and carbon dioxide) at the
alveolar level. Any patient with suspected smoke inhalation injury must
be started on high-flow oxygen (15 L/min at 100%) using a non-
rebreather oxygen mask. You should suspect an inhalation injury if the
fire occurred in an enclosed space, if the patient has singed nasal hair,
facial hair, or both, or soot around the nose/mouth. Keep in mind,
however, that respiratory distress can also be caused by a condition not
related to the burn, for example, a patient with preexisting diagnoses
such as congestive heart failure or asthma.
3. Circulation and cardiac status with hemorrhage control
Circulation and cardiac status (with hemorrhage control in cases
of trauma) is the third step in the emergency burn care process. In
addition to evaluating the patient for hemodynamic stability, it is
important to remember that edema can impair peripheral circulation.
Your assessment may include evaluation of heart rate, peripheral
pulses, and skin color (of unburned skin). Prehospital personnel will
insert large-bore I.V. catheters for fluid administration. Larger burns
will require high volumes of continuous I.V. fluids to accommodate for
the shift of plasma into the interstitial tissue, which occurs as part of the
physiological response to burn injury.
4. Disability, neurological deficit, and gross deformity
Disability, the fourth priority in the ABCDE evaluation, refers to
neurologic deficit and gross deformity. Once again, keep in mind that a
trauma injury may result in deformities such as open fractures. When
this happens, these traumatic injuries must also be included in your
assessment and treatment. Neurological assessments must be
performed. With the exception of smoke inhalation, burns should not
necessarily affect the level of consciousness. Therefore, if you assess
 altered level of consciousness, consider other problems such as head
trauma, carbon monoxide poisoning, hypoxia, preexisting medical
conditions, or substance abuse.
5. Exposure to Examine for major associated injuries and maintain warm
The fifth and final step in the emergency burn care process is
Exposure to examine for major associated injuries and maintaining a
warm environment. Remove any clothing or jewelry that is restrictive
or covering the body part that was burned. Quickly look for other
injuries and then cover the patient. If the patient is wearing contact
lenses, these should be removed immediately to prevent corneal
damage from edema. You may cool the burn with water for a few
minutes.
Never use ice or cold water because it will restrict peripheral
circulation locally, increasing the depth of the burn, and it may decrease
body temperature. It is imperative to prevent hypothermia in burn
patients, as body temperatures below 97.7 F (36.5 C) in the first 24
hours are associated with increased mortality. Cover the patient with a
clean, dry covering such as a sheet or blanket to prevent evaporative
heat loss. Source: American Burn Association. (2011). Advanced Burn
Life Support course provider manual. Chicago, IL: American Burn
Association.
D. Nursing Process: Rehabilitation Phase
Rehabilitation should begin immediately after the burn has occurred. Wound
healing, psychosocial support, and restoring maximum functional activity
remain priorities. Maintaining uid and electrolyte balance and
improving nutrition status continue to be important.
1. Assessment
a. In early assessment, obtain information about patients educational
level, occupation, leisure activities, cultural background, religion, and
family interactions.
 b. Assess selfconcept, mental status, emotional response to the injury
and hospitalization, level of intellectual functioning, previous
hospitalizations, response to pain and pain relief measures, and sleep
pattern.
c. Perform ongoing assessments relative to rehabilitation goals,
including range of motion of affected joints, functional abilities in
ADLs, early signs of skin breakdown from splints or positioning
devices, evidence of neuropathies (neurologic damage), activity
tolerance, and quality or condition of healing skin.
d. Document participation and selfcare abilities in ambulation, eating,
wound cleaning, and applying pressure wraps.
e. Maintain comprehensive and continuous assessment for early
detection of complications, with specic assessments as needed for
specic treatments, such as postoperative assessment of patient
undergoing primary excision.
E. Primary Nursing Diagnosis
1. Ineffective airway clearance related to airway edema and effect of
smoke inhalation.
a. Outcomes:
1) Respiratory status: Gas exchange;
2) Respiratory status: Ventilation; Symptom control behavior;
3) Treatment behavior: Illness or injury;
4) Comfort level
b. NIC
1) Airway management;
2) Anxiety reduction;
3) Oxygen therapy;
4) Airway suctioning;
5) Airway insertion and stabilization;
6) Cough enhancement;
7) Mechanical ventilation;
 8) Positioning;
9) Respiratory monitoring
c. Interventions
1) Promoting Gas Exchange and Airway Clearance
a) Provide humidied oxygen, and monitor arterial blood
gases (ABGs), pulse oximetry, and carboxyhemoglobin
levels.
b) Assess breath sounds and respiratory rate, rhythm,
depth, and symmetry; monitor for hypoxia.
c) Observe for signs of inhalation injury: blistering of lips
or buccal mucosa; singed nostrils; burns of face, neck, or
chest; increasing hoarseness; or soot in sputum or
respiratory secretions.
d) Report labored respirations, decreased depth of
respirations, or signs of hypoxia to physician immediately;
prepare to assist with intubation and escharotomies.
e) Monitor mechanically ventilated patient closely.
f) Institute aggressive pulmonary care measures:
turning, coughing, deep breathing, periodic forceful
inspiration using spirometry, and tracheal suctioning.
g) Maintain proper positioning to promote removal of
secretions and patent airway and to promote optimal
chest expansion; use articial airway as needed.
h) Fluid volume acid related to increased capillary
permeability and evaporative losses from burn wound.
i) Hypotermia related to loss of skin microcirculation and
open wounds.
j) Pain related to tissue and nerve injury.
k) Anxiety related to fear and the emotional impact of burn
injury.
l) Restoring Fluid and Electrolyte Balance
 m) Monitor vital signs and urinary output (hourly), central
venous pressure (CVP), pulmonary artery pressure, and
cardiac output.
n) Note and report signs of hypovolemia or uid overload.
o) Maintain IV lines and regular uids at appropriate rates,
as prescribed. Document intake, output, and daily weight.
p) Elevate the head of bed and burned extremities.
q) Monitor serum electrolyte levels (eg, sodium, potassium,
calcium, phosphorus, bicarbonate); recognize developing
electrolyte imbalances.
r) Notify physician immediately of decreased urine
output; blood pressure; central venous, pulmonary artery, or
pulmonary artery wedge pressures; or increased pulse rate.
2) Maintaining Normal Body Temperature
a) Provide warm environment: use heat shield, space
blanket, heat lights, or blankets.
b) ssess core body temperature frequently.
c) Work quickly when wounds must be exposed to
minimize heat
d) loss from the wound.
3) Minimizing Pain and Anxiety
a) Use a pain scale to assess pain level (ie, 1 to 10);
differentiate between restlessness due to pain and
restlessness due to hypoxia.
b) Administer IV opioid analgesics as prescribed, and
assess response to medication; observe for respiratory
depression in patient who is not mechanically ventilated.
c) Provide emotional support, reassurance, and simple
explanations about procedures.
d) Assess patient and family understanding of burn injury,
coping strategies, family dynamics, and anxiety levels.
 Provide individualized responses to support patient and
family coping; explain all procedures in clear, simple terms.
e) Provide pain relief, and give antianxiety medications
if patient remains highly anxious and agitated after
psychological interventions.
4) Monitoring and Managing Potential Complications
a) Acute respiratory failure: Assess for increasing dyspnea,
stridor, changes in respiratory patterns; monitor pulse
oximetry and ABG values to detect problematic oxygen
saturation and increasing CO2; monitor chest xrays; assess
for cerebral hypoxia (eg, restlessness, confusion); report
deteriorating
b) respiratory status immediately to physician; and assist
as needed with intubation or escharotomy.
c) Distributive shock: Monitor for early signs of shock
(decreased urine output, cardiac output, pulmonary artery
pressure, pulmonary capillary wedge pressure, blood
pressure, or increasing pulse) or progressive edema.
Administer uid resuscitation as ordered in response to
physical ndings; continue monitoring uid status.
d) Acute renal failure: Monitor and report abnormal urine
output and quality, blood urea nitrogen (BUN) and
creatinine levels; assess for urine hemoglobin or myoglobin;
administer increased uids as prescribed.
e) Compartment syndrome: Assess peripheral pulses
hourly with Doppler; assess neurovascular status of
extremities hourly (warmth, capillary refill, sensation, and
movement); remove blood pressure cuff after each reading;
elevate burned extremities; report any extremity pain, loss
of peripheral pulses or sensation; prepare to assist
with escharotomies.
 f) Paralytic ileus: Maintain nasogastric tube on low
intermittent suction until bowel sounds resume; auscultate
abdomen regularly for distention and bowel sounds.
g) Curlings ulcer: Assess gastric aspirate for blood and
pH; assess stools for occult blood; administer antacids and
histamine blockers (eg, ranitidine [Zantac]) as prescribed.
5) Restoring Normal Fluid Balance
a) Monitor IV and oral uid intake; use IV infusion pumps.
b) Measure intake and output and daily weight.
c) Report changes (eg, blood pressure, pulse rate) to physician.
6) Preventing Infection
a) Provide a clean and safe environment; protect patient
from sources of crosscontamination (eg, visitors, other
patients, staff, equipment).
b) Closely scrutinize wound to detect early signs of infection
7) Monitor culture results and white blood cell counts.
a) Practice clean technique for wound care procedures and
aseptic technique for any invasive procedures. Use
meticulous hand hygiene before and after contact with
patient.
b) Caution patient to avoid touching wounds or dressings; wash
unburned areas and change linens regularly.
8) Maintaining Adequate Nutrition
a) Initiate oral uids slowly when bowel sounds resume;
record toleranceif vomiting and distention do not occur,
uids
b) may be increased gradually and the patient may be
advanced to a normal diet or to tube feedings.
c) Collaborate with dietitian to plan a protein and calorie-
rich diet acceptable to patient. Encourage family to bring
 nutritious and patients favorite foods. Provide nutritional
and vitamin and mineral supplements if prescribed.
d) Document caloric intake. Insert feeding tube if caloric
goals cannot be met by oral feeding (for continuous or bolus
feedings); note residual volumes
e) Weigh patient daily and graph weights.
9) Promoting Skin Integrity
a) Assess wound status.
b) Support patient during distressing and painful wound care.
c) Coordinate complex aspects of wound care and
dressing changes.
d) Assess burn for size, color, odor, eschar, exudate,
epithelial buds (small pearllike clusters of cells on the wound
surface), bleeding, granulation tissue, the status of graft take,
healing of the donor site, and the condition of the
surrounding skin; report any signicant changes to the
physician.
e) Inform all members of the health care team of latest
wound care procedures in use for the patient.
f) Assist, instruct, support, and encourage patient and family to
take part in dressing changes and wound care.
g) Early on, assess strengths of patient and family in
preparing for discharge and home care.
10) Relieving Pain and Discomfort
a) Frequently assess pain and discomfort; administer
analgesic agents and anxiolytic medications, as prescribed,
before the pain becomes severe. Assess and document the
patients response to medication and any other interventions.
b) Teach patient relaxation techniques. Give some control
over wound care and analgesia. Provide frequent reassurance.
 c) Use guided imagery and distraction to alter patients
perceptions and responses to pain; hypnosis, music therapy,
and virtual reality are also useful.
d) Assess the patients sleep patterns daily; administer
sedatives, if prescribed.
e) Work quickly to complete treatments and dressing changes.
11) Encourage patient to use analgesic medications before painful
procedures.
a) Promote comfort during healing phase with the following:
b) oral antipruritic agents, a cool environment, frequent
lubrication of the skin with water or a silicabased lotion,
exercise and splinting to prevent skin contracture, and
diversional activities.
12) Promoting Physical Mobility
a) Prevent complications of immobility (atelectasis, pneumonia,
edema, pressure ulcers, and contractures) by deep breathing,
turning, and proper repositioning.
b) Modify interventions to meet patients needs.
Encourage early sitting and ambulation. When legs are
involved, apply elastic pressure bandages before assisting
patient to upright position.
c) Make aggressive efforts to prevent contractures and
hypertrophic scarring of the wound area after wound closure
for a year or more.
d) Initiate passive and active range-of-motion exercises
from admission until after grafting, within prescribed
limitations.
e) Apply splints or functional devices to extremities for
contracture control; monitor for signs of vascular
insufciency, nerve compression, and skin breakdown.
F. Nursing Diagnosis
1. Damage to gas exchange is associated with carbon monoxide poisoning,
inhalation of smoke and upper respiratory tract obstruction
2. Effective airway clearance is associated with edema and the effects of
smoke inhalation
3. The fluid volume deficit is associated with increased capillary
permeability and loss through evaporation of burns
4. Ineffective tissue perfusion disorders are associated with decreased or
interrupted arterial / venous blood flow
5. Damage to skin integrity is associated with inflammation, lesions
6. Pain associated with skin / tissue damage
G. Intervention

No NOC NIC
Diagnosis

1. Gas exchange After the patient's nursing a. Monitor GDA reports

damage associated action gets adequate and serum carbon
with carbon oxygenation. monoxide levels.
monoxide Results Criteria: b. Give oxygen
poisoning, a. RR 12-24 x / min supplements at a
inhalation of smoke b.Normal skin colorGDA prescribed level.
and upper airway in normal renatng c. Place or aid with an
obstruction No difficulty breathing endotracheal tube and
place the patient on a
mechanical ventilator as
indicated in case of
respiratory insufficiency
(hypoxic dyspnoea,
hypercapnia, rales,
tachypnea and sensory
changes).
d. Suggest deep breathing
with the use of
spirometry during bed
rest.
e. Keep the semi-fowler
position, if there is no
hypotension.
 2. Ineffective airway After a nursing action for Airway Management:
clearance is 3x24 hours of airway the a. Auscultation breath
associated with client returns the patent sounds before and after
edema and the (free from blockage), with exhaled airway, record
effects of smoke the result criteria: the results
inhalation a. Normal RR (12- b. Perform fixation on the
24x / min) head neck region to
b. Regular respiratory minimize the
rhythm occurrence of
c. Normal breath movement
sound c. Manually exempt the
d. No use of the airway with careful jaw
breath aids thrust maneuver
technique to prevent
neck movement
d. Perform airway
clearance with
oropharyngeal airway
if necessary
e. Respiratory monitoring
and client oxygenation
status

3. The fluid volume After being given nursing a. Observation of urinary

deficit is associated care for 3x24 Hour was expenditure, specific
with increased not found signs of fluid gravity and color of
capillary volume deficiency or urine.
permeability and dehydration with KH: b. Weigh the weight every
loss through a. Moist mucous day
evaporation of burns membranes c. Measure the
b. Good skin circumference of the
integrity burned extremities on a
c. Electrolyte values daily basis as indicated
within normal d. Perform collaboration
limits. programs include: Install
d. The intake and / maintain urine catheter.
output of the e. Give IV calculated fluid
patient's body fluid replacement,
is balanced electrolytes, plasma,
e. CVP monitoring, albumin.
capillaries and f. Monitoring of laboratory
peripheral pulse examination results (Hb,
 strength. electrolytes, sodium).
g. Give medication as
indicated (diuretic)
h. Monitoring vital signs
every hour during the
emergency period, every
2 hours during the acute
period, and every 4
hours during the
rehabilitation period. -
Urine color. - Input and
output per hour during
the emergency period,
every 4 hours during the
acute period, every 8
hours During the
rehabilitation period.
General status every 8
hours.

4. Ineffective tissue After a nursing action, it is a. Measure TD on

perfusion disorders expected that the patient's burned extremities
associated with blood flow to the b. Encourage active
decreased or peripheral tissue is motion exercises
interrupted arterial / adequate c. Collaborate in
venous blood flow Results Criteria: maintaining fluid
a. The peripheral replacement
pulse is palpable d. Collaboration in
with the same overseeing
quality and electrolytes especially
strength sodium, potassium,
b. Capillary filling is and calcium
good e. Collaborate to avoid
c. Normal skin color IM or SC injection
on the injured area
d. Assess color,
sensation,
movement, and
peripheral pulse.
e. Elevate the ailing
limb.

5. Damage to skin Objectives: After the a. Elevate the graft area

integrity b / d nursing action, the patient when possible /
damage to is expected to show tissue appropriate. Maintain
secondary skin regeneration Criteria desired position and
 surface destruction results: b. immobilization area
of skin layer. a. Achieve timely when indicated.
healing in burns c. Maintain a bandage
areas. over the new graft
b. Assess / measure area and / or donor
size, color, depth side as indicated.
of wound, note d. Wash the side with
necrotic tissue and mild soap, wash, and
conditions around minyaki with cream,
the wound. some time of the day,
c. Perform after the dressing is
appropriate burn removed and the
care and infection healing is complete.
control measures. e. Perform collaborative
d. Keep the wound programs, prepare /
closure as aids surgical
indicated. procedure

6. Pain associated with After being given nursing Pain management:

skin / tissue damage care for 3x24 Hour client
comfort level increases,
controlled pain dg KH:
Clients report pain relief
with pain scales 2-3
a. Facial expression
calm
b. Clients can rest
and sleep
a. Assess the pain
comprehensively
(location,
characteristics,
duration, frequency,
quality and
precipitation factor).
b. Observe nonverbal
reactions from
discomfort.
c. Use therapeutic
communication
techniques to know the
previous client's pain
experience.
d. Control of
environmental factors
that affect pain such as
room temperature,
lighting, noise.
e. Reduce the pain
precipitation factor.
f. Choose and do pain
management
(pharmacological / non
pharmacological).
g. Teach non-
 pharmacological
techniques (relaxation,
distraction etc.) to
overcome pain.
h. Collaboration for
analgesic
administration
i. Evaluate pain relief /
pain control measures.

H. Evaluation
1. Expected Patient Outcomes
a. Demonstrates activity tolerance required for desired daily activities
b. Adapts to altered body image
c. Demonstrates knowledge of required selfcare and followup care
d. Exhibits no complications
 CHAPTER IV
COVER

A. Conclution
Burns are a fairly common injury often faced by doctors and nurses.
Heavy types exhibit relatively high morbidity and degree of defect compared
with other causes of injury. Costs needed in handling high. Causes of burns
other than direct or indirect fire burning, as well as exposure to high
temperatures from sun, electricity, and chemicals.
Preschool children account for over two-thirds of all burn fatalities.
Clinicians use a special chart (Lund-Browder Chart) for children that provides
a picture and a graph to account for the difference in body surface area by age.
Serious burn injuries occur most commonly in males, and in particular, young
adult males ages 20 to 29 years of age, followed by children under 9 years of
age. Individuals older than 50 years sustain the fewest number of serious burn
injuries.The younger child is the most common victim of burns that have been
caused by liquids. Preschoolers, school-aged children, and teenagers are more
frequently the victims of flame burns.
B. Suggestion
Rehabilitation should begin immediately after the burn has occurred. Wound
healing, psychosocial support, and restoring maximum functional activity
remain priorities. Maintaining uid and electrolyte balance and
improving nutrition status continue to be important.
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