Evelin Malinti, MSN

4/1/2011 1
The skin has an important role to play in the
fluid and temperature regulation of the
body. If enough skin area is injured, the
ability to maintain that control can be lost.
The skin also acts as a protective barrier
against the bacteria and viruses that inhabit
the world outside the body.
There are three
layers:
1. Epidermis, the
outer layer of the
skin.

2. Dermis, made up
of collagen and
elastic fibers and
where nerves,
blood vessels,
sweat glands, and
hair follicles reside.

3. Hypodermis
or subcutaneous
tissue, where
larger blood
vessels and nerves
are located. This is
the layer of tissue
that is most
important in
temperature
regulation.
 Burns are a result of transfer energy from a heat
source to the body
 Human skin can tolerate temperatures up to 42-
440 C (107-1110 F) but above these, the higher
the temperature the more severe the tissue
destruction
 Below 450 C (1130 F), resulting changes are
reversible but >450 C, protein damage exceeds
the capacity of the cell to repair

4
• Influenced by:
• Age
• Burn depth
• Extent of Body surface area
injured
• Presence of inhalation injury
• Other injury and the location
• Past medical history
  Thermal
 Chemical
 Inhalation
 Electrical
 Radiation

4/1/2011 6
Scald Burns Flame Burns
 Radiation (Flash) Burns

Chemical (Acid) Burns

 Severe swelling
peaks 24-72 hrs after
Electrical Burns
Exit Wounds

Electrical burns mummified

1st 2 fingers later removed

Electrical Burns
Entrance Wounds

Entrance wound of electrical

burns from an overheated tool
• First-degree Burns (mild): epidermis
 Pain, erythema & slight swelling, no blisters
 Tissue damage usually minimal, no scarring
 Pain resolves in 48-72 hours

• Superficial Second-degree Burns:

entire epidermis & variable dermis
 Vesicles and blisters characteristic
 Extremely painful due to exposed nerve
endings
 Heal in 7-14 days if without infection

• Midlevel to Deep Second-degree Burns:

 Few dermal appendages left
 There are some fluid & metabolic effects

• Full-thickness or Third-Degree: entire

epidermis and dermis, no residual epidermis
 Painless, extensive fluid & metabolic deficits
 Heal only by wound contraction, if small, or if
big, by skin grafting or coverage by a skin flap
 2nd degree Burn 1 day

Mild Burn

2nd degree Burn 2 days

2nd degree Burn 1 hr

 Rule of Nines
 Rule of Palms
 Lund & Browders chart
  Head & Neck =
9%
 Each upper
extremity
(Arms) = 9%
 Each lower
extremity
(Legs) = 18%
 Anterior trunk=
18%
 Posterior trunk
= 18%
 Genitalia
(perineum) =
4/1/2011
1% 13
• Metode
Lund dan
Browder
–
menentu
kan luas
luka
bakar
berdasar
kan usia
pasien.
 Infant Rule of Nines
 Mild: 10% (for quick assessment
of total body surface
 Moderate: area affected by burns)
10-30% Anatomic Surface
 Severe: > 30% structure area
Head 18%
• Hospitalization Anterior Torso 18%
for > 10% of Posterior Torso 18%
body surface Each Leg 14%
area Each Arm 9%
Perineum 1%
 Burn Shock
 Pulmonary complications due to
inhalation injury
 Acute Renal Failure
 Infections and Sepsis
 Curling’s ulcer in large burns over
30% usually after 9th day
 Extensive and disabling scarring
 Psychological trauma
 Cancer called Marjolin’s ulcer, may
take 21 years to develop
• Injured tissue  Increased permeability of entire
vascular tree  loss of water, electrolytes and
proteins from the vascular compartment  severe
hemoconcentration
• Protein leakage  resultant hypoproteinemia,
increased osmotic pressure in the interstitial
space
• Decreased cell membrane potential cause inward
shift of Na+ and H2O  cellular swelling
• In the injured skin, effect maximal 30 min after
the burn but capillary integrity not restored until
8-12 hours after, usually resolved by 3-5 days
• In non-injured tissues, only mild and transient
leaks even for burns >40% BSA
 Cardiac output decreases due to:
1) Decreased preload induced by fluid shifts
2) Increased systemic vascular resistance caused
by both hypovolemia and systemic
catecholamine release
3) A myocardial depressant factor has been
described that impairs cardiac function
 Cardiac output normal within 12-18 hours, with
successful resuscitation
 After 24 hours, it may increase up to 2 ½
times the normal and remain elevated until
several months after the burn is closed
 The red-cell mass decreases due to direct losses
 Immediate, 1-2 hours after, and delayed, 2-7
days postburn, hemolysis occurs due to damaged
cells and increased fragility
 Anemia within 4-7 days is common and expected,
typically, will persist until wound healing occur;
depressed erythropoietin levels documented
 Early mild thrombocytopenia (sequestration)
followed by thrombocytosis (2-4x normal) and
elevated fibrinogen, factor V and factor VIII levels
commonly by end of the 1st week
 A “normal” platelet or fibrinogen level may be an
early sign of disseminated intravascular
coagulation
 Persistent thrombocytopenia is associated with
poor prognosis -- suspect sepsis
 Severe catabolism with breakdown of muscle
protein for gluconeogenesis as acute response
 Prostaglandins and cytokines implicated in
increased core temperature of 1-20 C and in
initiating acceleration of nitrogen catabolism
 Plasma levels of catecholamines, glucagon and
cortisol all increase, maximal in patients with 50-
60% TBSAB, while insulin and thyroid hormone
levels decrease
 Hypermetabolic response may approach 200% of
BMR remaining elevated for months after burn
closed
 Early enteral feeding associated with lessening of
the hypermetabolic response
 Renal blood flow and GFR decrease soon after
due to hypovolemia, decreased cardiac
output, and elevated systemic vascular 
oliguria and antidiuresis develops during 1st
12-24 hours
 Followed by a usually modest diuresis as the
capillary leaks seal, plasma volume
normalizes, and cardiac output increases after
successful resuscitation and coinciding with
onset of the postburn hypermetabolic state,
and hyperdynamic circulation
 Mechanical barrier to infection is impaired because
of skin destruction
 Immunoglobulin levels decreased as part of
general leak and leukocyte chemotaxis,
phagocytosis, and cytotoxic activity impaired
 The reticuloendothelial system's depressed
bacterial clearance is due to decreases in opsonic
function
 These changes, together with a non-perfused,
bacterially-colonized eschar overlying a wound full
of proteinaceous fluid, put the patient in a
significant risk for infection
  Inflamamtion 2-4 days
 Proliferation 4-21 days
 Remodelling 21 days – 1 year

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1. Extinguish flames by rolling in the ground, cover
child with blanket, coat or carpet
2. After determining airway is patent, remove
smoldering clothes and constricting accessories
during edema phase in the 1st 24-72 hours after
3. Brush off remaining chemical if powdered or solid
then wash or irrigate abundantly with water
4. Cover burn wounds with clean, dry sheet and
apply cold (not iced) wet compresses to small
injuries; significant burns (>15-20% BSA)
decreases body temperature which
contraindicates use of cold compress dressings
5. If burn caused by hot tar, mineral oil to remove it
For 1st and 2nd degree burns less than 10%
BSA
 Blisters should be left intact and
dressed with silver sulfadiazine cream
 Dressings should be changed daily
washing with lukewarm water to remove
any cream left
 Fluid infusion must be started
immediately
 NGT insertion to prevent gastric
dilatation, vomiting and aspiration
 Urinary catheter to measure urine output
 Weight important and has to be taken
daily
 Local treatment delayed till respiratory
distress and shock controlled
 Hematocrit and bacterial cultures
necessary
 Parkland formula Oral supplementation may
start 48 hr after as homogenized milk or soy-
based products given by bolus or constant
infusion via NGT
 Albumin 5% may be used to maintain serum
albumin levels at 2 g/dl
 Packed RBC recommended if hematocrit falls
below 24% (Hgb <8 g/dl)
 Sodium supplementation may be needed if
burns greater than 20% BSA
Resusitasi cairan:
• Cristalloid fluid – RL yang hangat selama
24 jam pertama.
• Parkland Baxter formula: 4 ml x kgbb x %
tbsa
• RL 4ml X Kg body weight X TBSA%
burned
• ½ that total amt. given 1st 8 hours
• ¼ that total amt. given each next 8
hours
• 24 berikutnya diganti dengan D5%.
  Hitung jumlah cairan pengganti
yang diberikan pada klient
dengan 30% TBSA burned
dengan berat badan 60kg?
1st 8 hours= _____or ____cc/hr
2nd 8 hours= _____or ____cc/hr
3rd 8 hours= _____or ____cc/hr

5/3/2018 31
 Three syndromes:
1. Early CO poisoning, airway obstruction &
pulmonary edema major concerns
2. ARDS usually at 24-48 hrs or much later
3. Pneumonia and pulmonary emboli as late
complications (days to weeks)
 Assessment:
1. Observation (swelling or carbonaceous material
in nasal passages
2. Laboratory determination of
carboxyhemoglobin and ABGs
 Treatment:
1. Maintain patient airway by early ET intubation,
adequate ventilation and oxygenation
2. Aggressive pulmonary toilet and chest
physiotherapy
 Tetanus prophylaxis: 250-500 IU or 3000 units
equine ATS ANST IM; Toxoid
 Antibiotic of choice is one that will include
Pseudomonas in its spectrum; most frequent
pathogens in burns are Staphylococcus aureus,
Pseudomonas aeruginosa and the Klebsiella-
Enterobacter species
 Topical therapy:
 0.5% Silver nitrate dressing
 Mafenide acetate or Sulfacetamide acetate
cream
 Silver sulfadiazine cream
 Povidone-iodine ointment
 Gentamicin cream or ointment
 Important to provide adequate
analgesia, anxiolytics and
psychological support to:
a) Reduce early metabolic stress
b) Decrease potential for posttraumatic
stress syndrome
c) Allow future stabilization and
rehabilitation
 Family support patient through
grieving process and help accept
long-term changes in appearance
Enteral nutrition support with a high–protein, high–carbohydrate
diet is recommended, and timing may be critical.
Feedings started within ~ 4 to 36 hours following injury appear to
have advantages over delayed (> 48 hours) feedings.

Enteral support can reduce the burn–related increase in secretion of

catabolic hormones and help maintain gut mucosal integrity.
The duodenal route is better tolerated than gastric feeding, due to an
18% failure rate in the latter from regurgitation.

Total parenteral nutrition (TPN) is not recommended, due to its

ineffectiveness in preventing the catabolic response to burns.TPN also
impairs immunity and liver function and increases mortality, when
compared with enteral nutrition.
ENERGY AND
MACRONUTRIENT SUPPORT
Significant weight loss is preventable with nutritional support.
Recommended daily energy intake is as follows:
for adults,
25 calories per kilogram plus 40 calories per each percent
of burn area
for children,
1,800 calories plus 2,200 calories per m2 of burn area.

Individualized nutrition assessment is recommended for patients

with burns on >20% of TBSA
•High–carbohydrate, low–fat diets for burn patients result in less
proteolysis and more improvement in lean body mass, compared
with high–fat diets,and may reduce infectious morbidity and
shorten hospitalization time, when compared with a high–fat
regimen.

•However, the benefit of a high–carbohydrate formula must be

balanced against the risk for hyperglycemia, which can negatively
influence the outcome of critically ill patients. Nearly all burn
patients experience insulin resistance as part of their
hypermetabolic response and will need to be placed on an insulin
drip to maintain tight control of their blood glucose level.

•Protein and fluid needs must also be considered carefully. Protein

oxidation rates are 50% higher in burn patients, and protein needs
are ~1.5 to 2.0 grams/kg. Water loss can be as much as 4
liters/m2/day, and a range of 30 to 50 ml/hour is given depending
on urine output
 Memerulan waktu yang lama dan menjadi
tantangan bagi perawat.
 Psychological support.
 Wound healing: keloid, skar 
penggunakan kompresi pada luka, injeksi
kortikosteroid, scar massage.
 ROM –bertahap, libatkan keluarga,
perhatikan kenyamanan klien.
  Impaired skin integrity
 Risk for infection
 Imbalanced nutrition
 Impaired physical mobility
 Disturbed body image

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