Burns 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.

How to calculate the Total Burn Surface Area (TBSA)

One of the most commonly used methods in assessing the extent of burns is the Rule of Nines. This method divides the patient’s body using an imaginary border to segment areas. Below is a table presenting the scoring of both adults and a child.

Burns Rule of Nine

How to replace loss fluid

The most widely used formula to replace the loss fluid from burns is the Parkland formula. This is the delivery of fluid replacements via Intravenous infusion. The formula is summarized as 4ml of Ringer’s Lactate per kilograms (body weight) per % of TSBA.

    • Half of the computed amount to be delivered must be infused within the first 8 hours after the injury.
    • The remaining fluid will be delivered in the next 16 hours.

Nursing Assessment

  • Causative agent (boiling water, flame, chemical, etc.)
  • Age
  • Duration of exposure
  • Home treatment has done
  • Height and weight
  • Allergies (food and drug)
  • Extent and depth of burns
  • Respiratory status
  • Presence of infection

Nursing Interventions

1. Ensure good oxygenation and ventilation

  • Assess for the presence of hypoxemia and administer appropriate amount of oxygen if necessary.
  • Assess for signs of respiratory involvement like burned nose and mouth, blistering of buccal mucosa, singed nasal hairs, and increasing hoarseness of voice.
  • Monitor the quality and quantity of respiration.
  • Monitor ABG abnormalities.

2. Ensure efficient cardiac output

  • Monitor vital signs.
  • Monitor sensorium

3. Promote peripheral circulation

  • Remove jewelry and other accessories.
  • Elevate extremities if not contraindicated.
  • Monitor peripheral pulses every hour.

4. Maintain fluid balance

  • Monitor intake and output (I & O)

5. Avoiding infection

  • Sterile wound cleansing and apply prescribed topical ointments.
  • Pack wounds with a sterile dressing or specially designed burn pads.
  • Monitor body temperature every 2 hours for the first 24 hours.
  • Offer radiant warmer if the patient is having hypothermia.
  • Administer prescribed medications (antipyretics and antibiotics).
  • Monitor wound regularly.

6. Prevent UTI

  • Monitor urine output including color, amount, and frequency (if the patient is not in IFC).
  • Catheter care for patients with IFC.

7. Promote ROM and ADLs
8. Offer foods high in protein, vitamin C, and high caloric.
9. Control pain

  • Monitor pain regularly.
  • Administer prescribed analgesics and do diversional activities like offering newspapers and magazines (if available).
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