Erbil Polytechnik University

Koya Technical Institue _ Nursing Department

Prepared By : Shaima Luqman Ahmed

Stage : Second _ Group : D

Subject : Adult Nursing

Supervisor : Rebwar M. Mohamed

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A burn is a type of injury to skin, or other tissues, caused by heat, cold, electricity,
chemicals, friction, or radiation (like sunburn). Most burns are due to heat from hot
liquids (called scalding), solids, or fire. While rates are similar for males and females
the underlying causes often differ. Among women in some areas, risk is related to
use of open cooking fires or unsafe cook stoves. Among men, risk is related to the
work environments.Alcoholism and smoking are other risk factors.Burns can also
occur as a result of self-harm or violence between people

Second-degree burn of the hand

.A moderate sunburn sustained over the course of four hours spent in the sun

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Scalding caused by a radiator explosion. Picture of my hand two days after the
.explosion, taken by me

)Major 2nd-degree burn (boiling water

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fourth degree burns to the fingers and 2nd degree burns to the palmer surface of
the hand

Burns that affect only the superficial skin layers are known as superficial or first-
degree burns.They appear red without blisters and pain typically lasts around three
days. When the injury extends into some of the underlying skin layer, it is a partial-
thickness or second-degree burn. Blisters are frequently present and they are often
very painful. Healing can require up to eight weeks and scarring may occur.In a full-
thickness or third-degree burn, the injury extends to all layers of the skin.Often there
is no pain and the burnt area is stiff. Healing typically does not occur on its own. A
fourth-degree burn additionally involves injury to deeper tissues, such as muscle,
tendons, or bone.The burn is often black and frequently leads to loss of the burned
.part

Burns are generally preventable.Treatment depends on the severity of the

burn.Superficial burns may be managed with little more than simple pain
medication, while major burns may require prolonged treatment in specialized burn
centers.Cooling with tap water may help pain and decrease damage; however,
prolonged cooling may result in low body temperature.Partial-thickness burns may
require cleaning with soap and water, followed by dressings.It is not clear how to
manage blisters, but it is probably reasonable to leave them intact if small and drain
them if large.Full-thickness burns usually require surgical treatments, such as skin
grafting. Extensive burns often require large amounts of intravenous fluid, due to
capillary fluid leakage and tissue swelling.The most common complications of burns
.involve infection.Tetanus toxoid should be given if not up to date

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In 2015, fire and heat resulted in 67 million injuries.This resulted in about 2.9 million
hospitalizations and 176,000 deaths.Most deaths due to burns occur in the
developing world, particularly in Southeast Asia. While large burns can be fatal,
treatments developed since 1960 have improved outcomes, especially in children
and young adults. In the United States, approximately 96% of those admitted to a
burn center survive their injuries. The long-term outcome is related to the size of
burn and the age of the person affected

Signs and symptoms

The characteristics of a burn depend upon its depth. Superficial burns cause pain
lasting two or three days, followed by peeling of the skin over the next few
days.Individuals suffering from more severe burns may indicate discomfort or
complain of feeling pressure rather than pain. Full-thickness burns may be entirely
insensitive to light touch or puncture.While superficial burns are typically red in
color, severe burns may be pink, white or black.Burns around the mouth or singed
hair inside the nose may indicate that burns to the airways have occurred, but these
findings are not definitive.More worrisome signs include: shortness of breath,
hoarseness, and stridor or wheezing.Itchiness is common during the healing process,
occurring in up to 90% of adults and nearly all children.Numbness or tingling may
persist for a prolonged period of time after an electrical injury.Burns may also
produce emotional and psychological distress

Cause
Burns are caused by a variety of external sources classified as thermal (heat-related),
chemical, electrical, and radiation. In the United States, the most common causes of
burns are: fire or flame (44%), scalds (33%), hot objects (9%), electricity (4%), and
chemicals (3%). Most (69%) burn injuries occur at home or at work (9%),and most
are accidental, with 2% due to assault by another, and 1–2% resulting from a suicide
attempt. These sources can cause inhalation injury to the airway and/or lungs,
.occurring in about 6%

Burn injuries occur more commonly among the poor.Smoking and alcoholism are
other risk factors. Fire-related burns are generally more common in colder climates.
Specific risk factors in the developing world include cooking with open fires or on the
floor as well as developmental disabilities in children and chronic diseases in adults

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Pathophysiology
Three degrees of burns

At temperatures greater than 44 °C (111 °F), proteins begin losing their three-
dimensional shape and start breaking down.This results in cell and tissue damage.
Many of the direct health effects of a burn are secondary to disruption in the normal
functioning of the skin. They include disruption of the skin's sensation, ability to
prevent water loss through evaporation, and ability to control body
temperature.Disruption of cell membranes causes cells to lose potassium to the
.spaces outside the cell and to take up water and sodium

In large burns (over 30% of the total body surface area), there is a significant
inflammatory response. This results in increased leakage of fluid from the capillaries,
and subsequent tissue edema. This causes overall blood volume loss, with the
remaining blood suffering significant plasma loss, making the blood more
concentrated.Poor blood flow to organs such as the kidneys and gastrointestinal
.tract may result in kidney failure and stomach ulcers

Increased levels of catecholamines and cortisol can cause a hypermetabolic state

that can last for years.This is associated with increased cardiac output, metabolism, a
fast heart rate, and poor immune function

Diagnosis
Burns can be classified by depth, mechanism of injury, extent, and associated
injuries. The most commonly used classification is based on the depth of injury. The
depth of a burn is usually determined via examination, although a biopsy may also
be used. It may be difficult to accurately determine the depth of a burn on a single
examination and repeated examinations over a few days may be necessary.In those
who have a headache or are dizzy and have a fire-related burn, carbon monoxide
.poisoning should be considered.Cyanide poisoning should also be considered

Burn severity is determined through, among other things, the size of the skin
affected. The image shows the makeup of different body parts, to help assess burn
.size

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Size
Burn severity is determined through, among other things, the size of the skin
affected. The image shows the makeup of different body parts, to help assess burn
.size

The size of a burn is measured as a percentage of total body surface area (TBSA)
affected by partial thickness or full thickness burns.First-degree burns that are only
red in color and are not blistering are not included in this estimation. Most burns
.(70%) involve less than 10% of the TBSA

There are a number of methods to determine the TBSA, including the Wallace rule of
nines, Lund and Browder chart, and estimations based on a person's palm size.The
rule of nines is easy to remember but only accurate in people over 16 years of
age.More accurate estimates can be made using Lund and Browder charts, which
take into account the different proportions of body parts in adults and children.The
size of a person's handprint (including the palm and fingers) is approximately 1% of
their TBSA

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To determine the need for referral to a specialized burn unit, the American Burn
Association devised a classification system. Under this system, burns can be
classified as major, moderate and minor. This is assessed based on a number of
factors, including total body surface area affected, the involvement of specific
anatomical zones, the age of the person, and associated injuries. Minor burns can
typically be managed at home, moderate burns are often managed in hospital, and
.major burns are managed by a burn center

Prevention
Historically, about half of all burns were deemed preventable. Burn prevention
programs have significantly decreased rates of serious burns. Preventive measures
include: limiting hot water temperatures, smoke alarms, sprinkler systems, proper
construction of buildings, and fire-resistant clothing.Experts recommend setting
water heaters below 48.8 °C (119.8 °F).Other measures to prevent scalds include
using a thermometer to measure bath water temperatures, and splash guards on
stoves. While the effect of the regulation of fireworks is unclear, there is tentative
evidence of benefit with recommendations including the limitation of the sale of
.fireworks to children

Management
Resuscitation begins with the assessment and stabilization of the person's airway,
breathing and circulation.If inhalation injury is suspected, early intubation may be
required.This is followed by care of the burn wound itself. People with extensive
burns may be wrapped in clean sheets until they arrive at a hospital. As burn wounds
are prone to infection, a tetanus booster shot should be given if an individual has not
been immunized within the last five years.In the United States, 95% of burns that
present to the emergency department are treated and discharged; 5% require
hospital admission.With major burns, early feeding is important.Protein intake
should also be increased, and trace elements and vitamins are often required.
.Hyperbaric oxygenation may be useful in addition to traditional treatments

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Intravenous fluids
In those with poor tissue perfusion, boluses of isotonic crystalloid solution should be
given.In children with more than 10–20% TBSA burns, and adults with more than
15% TBSA burns, formal fluid resuscitation and monitoring should follow. This should
be begun pre-hospital if possible in those with burns greater than 25% TBSA.The
Parkland formula can help determine the volume of intravenous fluids required over
the first 24 hours. The formula is based on the affected individual's TBSA and weight.
Half of the fluid is administered over the first 8 hours, and the remainder over the
following 16 hours. The time is calculated from when the burn occurred, and not
from the time that fluid resuscitation began. Children require additional
maintenance fluid that includes glucose. Additionally, those with inhalation injuries
require more fluid.While inadequate fluid resuscitation may cause problems, over-
resuscitation can also be detrimental. The formulas are only a guide, with infusions
ideally tailored to a urinary output of >30 mL/h in adults or >1mL/kg in children and
.mean arterial pressure greater than 60 mmHg

While lactated Ringer's solution is often used, there is no evidence that it is superior
to normal saline.Crystalloid fluids appear just as good as colloid fluids, and as colloids
are more expensive they are not recommended.Blood transfusions are rarely
required. They are typically only recommended when the hemoglobin level falls
below 60-80 g/L (6-8 g/dL) due to the associated risk of complications. Intravenous
catheters may be placed through burned skin if needed or intraosseous infusions
.may be used

Wound care
Early cooling (within 30 minutes of the burn) reduces burn depth and pain, but care
must be taken as over-cooling can result in hypothermia. It should be performed
with cool water 10–25 °C (50.0–77.0 °F) and not ice water as the latter can cause
further injury. Chemical burns may require extensive irrigation. Cleaning with soap
and water, removal of dead tissue, and application of dressings are important
aspects of wound care. If intact blisters are present, it is not clear what should be
done with them. Some tentative evidence supports leaving them intact. Second-
.degree burns should be re-evaluated after two days

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In the management of first and second-degree burns, little quality evidence exists to
determine which dressing type to use.It is reasonable to manage first-degree burns
without dressings.While topical antibiotics are often recommended, there is little
evidence to support their use. Silver sulfadiazine (a type of antibiotic) is not
recommended as it potentially prolongs healing time.There is insufficient evidence
to support the use of dressings containing silver or negative-pressure wound
therapy. Silver sulfadiazine does not appear to differ from silver containing foam
.dressings with respect to healing

Medications
Burns can be very painful and a number of different options may be used for pain
management. These include simple analgesics (such as ibuprofen and
acetaminophen) and opioids such as morphine. Benzodiazepines may be used in
addition to analgesics to help with anxiety. During the healing process,
antihistamines, massage, or transcutaneous nerve stimulation may be used to aid
with itching. Antihistamines, however, are only effective for this purpose in 20% of
people.There is tentative evidence supporting the use of gabapentin and its use may
be reasonable in those who do not improve with antihistamines. Intravenous
.lidocaine requires more study before it can be recommended for pain

Intravenous antibiotics are recommended before surgery for those with extensive
burns (>60% TBSA). As of 2008, guidelines do not recommend their general use due
to concerns regarding antibiotic resistance and the increased risk of fungal
infections. Tentative evidence, however, shows that they may improve survival rates
in those with large and severe burns. Erythropoietin has not been found effective to
prevent or treat anemia in burn cases.In burns caused by hydrofluoric acid, calcium
gluconate is a specific antidote and may be used intravenously and/or topically.
Recombinant human growth hormone (rhGH) in those with burns that involve more
than 40% of their body appears to speed healing without affecting the risk of
.death.The use of steroids is of unclear evidence

Surgery
Wounds requiring surgical closure with skin grafts or flaps (typically anything more
than a small full thickness burn) should be dealt with as early as
possible.Circumferential burns of the limbs or chest may need urgent surgical release
of the skin, known as an escharotomy.This is done to treat or prevent problems with
distal circulation, or ventilation. It is uncertain if it is useful for neck or digit
.burns.Fasciotomies may be required for electrical burns

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Skin grafts can involve temporary skin substitute, derived from animal (human donor
or pig) skin or synthesized. They are used to cover the wound as a dressing,
preventing infection and fluid loss, but will eventually need to be removed.
Alternatively, human skin can be treated to be left on permanently without
.rejection

There is no evidence that the use of copper sulphate to visualise phosphorus

particles for removal can help with wound healing due to phosphorus burns.
.Meanwhile, absorption of copper sulphate into the blood circulation can be harmful

Alternative medicine
Honey has been used since ancient times to aid wound healing and may be beneficial
in first- and second-degree burns. There is moderate evidence that honey helps heal
partial thickness burns. The evidence for aloe vera is of poor quality. While it might
be beneficial in reducing pain,and a review from 2007 found tentative evidence of
improved healing times, a subsequent review from 2012 did not find improved
healing over silver sulfadiazine. There were only three randomized controlled trials
.for the use of plants for burns, two for aloe vera and one for oatmeal

There is little evidence that vitamin E helps with keloids or scarring.Butter is not
recommended. In low income countries, burns are treated up to one-third of the
time with traditional medicine, which may include applications of eggs, mud, leaves
or cow dung. Surgical management is limited in some cases due to insufficient
financial resources and availability.There are a number of other methods that may
be used in addition to medications to reduce procedural pain and anxiety including:
virtual reality therapy, hypnosis, and behavioral approaches such as distraction
.techniques

Patient support
Burn victims require support and care – both physiological and psychological.
Respiratory failure, sepsis, and multi-organ system failure are common in
hospitalized burn victims. To prevent hypothermia and maintain normal body
temperature, burn victims with over 20% of burn injuries should be kept in an
]environment with temperature at or above 30 degree Celsius.[better source needed

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Metabolism in burn victims proceeds at a higher than normal speed due to whole
body process and rapid fatty acid substrate cycles, which can be countered with an
adequate supply of energy, nutrients, and antioxidants. Enteral feeding a day after
resuscitation is required to reduce risk of infection, recovery time, non-infectious
complications, hospital stay, long-term damage, and mortality. Controlling blood
.glucose levels can have an impact on liver function and survival

Risk of thromboembolism is high and acute respiratory distress syndrome (ARDS)

that do not resolve with maximal ventilator use is also a common complication. Scars
are long-term after effects of a burn injury. Psychological support is required to cope
with the aftermath of a fire accident, while to prevent scars and long term damage
to the skin and other body structures consulting with burn specialists, preventing
infections, consuming nutritious foods, early and aggressive rehabilitation, and using
.compressive clothing’s are recommended

Complications
A number of complications may occur, with infections being the most common.In
order of frequency, potential complications include: pneumonia, cellulitis, urinary
tract infections and respiratory failure.Risk factors for infection include: burns of
more than 30% TBSA, full-thickness burns, extremes of age (young or old), or burns
involving the legs or perineum.Pneumonia occurs particularly commonly in those
.with inhalation injuries

Anemia secondary to full thickness burns of greater than 10% TBSA is common.
Electrical burns may lead to compartment syndrome or rhabdomyolysis due to
muscle breakdown.Blood clotting in the veins of the legs is estimated to occur in 6 to
25% of people. The hypermetabolic state that may persist for years after a major
burn can result in a decrease in bone density and a loss of muscle mass.Keloids may
form subsequent to a burn, particularly in those who are young and dark skinned.
Following a burn, children may have significant psychological trauma and experience
post-traumatic stress disorder. Scarring may also result in a disturbance in body
image. In the developing world, significant burns may result in social isolation,
.extreme poverty and child abandonment

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References
Burns - British Association of Plastic Reconstructive and Aesthetic Surgeons". " ^
..BAPRAS

a b c d e f g h i j k l m n o Herndon D, ed. (2012). "Chapter 3: Epidemiological, ^

Demographic, and Outcome Characteristics of Burn Injury". Total burn care (4th ed.).
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a b c d e f g h i Herndon D, ed. (2012). "Chapter 4: Prevention of Burn Injuries". ^

.Total burn care (4th ed.). Edinburgh: Saunders. p. 46. ISBN 978-1-4377-2786-9

a b c d e f g h "Burns". World Health Organization. September 2016. Archived from ^

.the original on 21 July 2017. Retrieved 1 August 2017

a b "Burns Fact sheet N°365". WHO. April 2014. Archived from the originalon 10 ^
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a b c d e f g h i j k l m n o p q Granger J (January 2009). "An Evidence-Based ^

Approach to Pediatric Burns". Pediatric Emergency Medicine Practice. 6 (1). Archived
.from the original on 17 October 2013

Ferri, Fred F. (2012). Ferri's netter patient advisor (2nd ed.). Philadelphia, PA: ^
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.2016

a b c Haagsma JA, Graetz N, Bolliger I, Naghavi M, Higashi H, Mullany EC, et al. ^

(February 2016). "The global burden of injury: incidence, mortality, disability-
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a b c d e f g h i Herndon D, ed. (2012). "Chapter 1: A Brief History of Acute Burn ^

Care Management". Total burn care(4th ed.). Edinburgh: Saunders. p. 1. ISBN 978-1-
.4377-2786-9

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