MEDICAL NUTRITION

THERAPY: BURN
PATIENTS
Amy Gabrielson
Objectives
Be able to classify different types of burns
and their severity.
Be able to understand how burns affect the
body.
Identify the medical treatments for burn
patients.
Identify the medical nutrition therapy for burn
patients and its importance to the patient.
Be able to understand the ethical issues that
accompany burn victims.
 Causes of Burns
Burns result from physical exposure to:
heat, chemicals, radiation or electricity
Injury affects the skin and in some cases
muscle and bone.
Severity of the burns is classified by how
deep the burn penetrates the body.

Nelms, Sucher, Long. (2007). Burns. Nutrition Therapy and

Pathophysiology. Belmont (CA): Thomson Higher Education.
 Burn
Exposure
Thermal Exposure- Direct contact with a
heat source
i.e. hot water, flames
Most common and commonly

occur in the home or workplace

Chemical Exposure
Coming into contact with chemicals that
cause a reaction on the body.

Nelms, Sucher, Long. (2007). Burns. Nutrition Therapy and Pathophysiology. Belmont (CA):
Thomson Higher Education.
 Burn exposure cont
Electrical Exposure
An electrical current moves through the
tissue
Severity correlates with voltage, location of
contact and amount of time exposed

Nelms, Sucher, Long. (2007). Burns. Nutrition Therapy and Pathophysiology. Belmont
(CA): Thomson Higher Education.
 Medical treatment is required for more
than1.1 million burn victims each year
with approximately 45,000
hospitalizations. 1
Mortality rate from burns has declined
significantly over the previous several
decades due to major advances in
medical care.2
1
National Institute of General Medical Sciences. Trauma, Shock, Burn and
Injury: Facts and Figures. Bethesda (MD): National Institute of General
Medical Sciences, National Institute of Health. Available from:
http://publications.nigms.nih.gov/factsheets/trauma_burn_facts.html
2
Nelms, Sucher, Long. (2007). Burns. Nutrition Therapy and Pathophysiology.
Belmont (CA): Thomson Higher Education.
 Burn Classifications
Superficial (First Degree)
Top layer of epidermis- sunburn
Partial Thickness (Second Degree)
Destruction of the epidermis and dermis
Full Thickness (Third & Fourth Degree)
Destroys all layers of skin and can involve
underlying muscle, organs and bones.

Morgan ED, Bledsoe SC, Barker J. (2000). Ambulatory management of burns. Am Fam
Phys. 62:2015-26
Nelms, Sucher, Long. (2007). Burns. Nutrition Therapy and Pathophysiology. Belmont (CA):
Thomson Higher Education.
Medline Plus (2009) www.nlm.nih.gov/.../ency/fullsize/1078.jpg
 Rule of 9s
Makes estimation of
body surface area
(BSA) affected by
burns.
Helps assess the
extent of the burn
and helps provide
basis for prescribing
fluid and medication.
Nelms, Sucher, Long. (2007). Burns. Nutrition Therapy and Pathophysiology. Belmont (CA): Thomson Higher
Education.

Monstrey, S, Hoeksema, H, Verbelen, J, Pirayesh, A, Blondeel, P. (2008). Assessment of burn depth and
wound healing potential. Burns. 34:761-769.
Assessment of Burn Depth
Burn depth needs to assessed to
determine treatment goals and actions.
Surgeons need to know burn depth to
assess potential for scarring.
Thermal imaging, Vital Dyes and Laser
Doppler imaging

Monstrey, S, Hoeksema, H, Verbelen, J, Pirayesh, A, Blondeel, P. (2008). Assessment of burn depth and
wound healing potential. Burns. 34:761-769.
Effects of Burn on the Body
Extensive inflammatory response
Rapid fluid shifts and accumulation.
Hypermetabolic state
Muscle protein catabolism
Decrease cardiac output because of increased
capillary permeability and vasodilation.
Heat loss
Increased blood glucose levels
Burn Shock

Potts, N.L., Mandleco, B.L. (2007). Pediatric Nursing: Second Edition. New York: Thomson Delmer Learning.
Goal of Medial Treatment
Prevent tissue necrosis
Maintain global tissue perfusion
Prevent infection
Reduce scarring
 Medical Treatment
Topical Agent- Prevents Infection
Silver Sulfadiazine cream, Silver Nitrate
Clean wound dressings
Some wounds require skin grafting
Requires multiple surgeries

Nelms, Sucher, Long. (2007). Burns. Nutrition Therapy and Pathophysiology. Belmont (CA): Thomson Higher Education.
Nutrition Therapy Goals
Promote wound healing
Maintain lean body mass
Restore fluid levels
Fluid Therapy
Need for fluid resuscitation to maintain global
tissue perfusion.
Parkland Formula is used to calculate the
amount of fluid to use to resuscitate the patient
based on burn percentage.
4mL/kg/% burn in the first 24 hrs, half of which
is given in the first 8 hours
Be careful not to over resuscitate in fear or burn
edema.
Vitamin C and Vasopressin help reduce fluid
requirements
Tricklebank, S. (2009). Modern trends in fluid therapy for burns. Burns. 35: 757-767.
Hypermetabolism
Catecholamines, cortisol, and other
glucocorticoids are increased in burn victims
due to the stress state of the body causing a
hypermetobolic response.
Epinephrine and norepinephrine increase 10-
fold in people with burns greater that 30-40%.
Hypermetabolic state lasts 9-12 months after
a burn.

Chan, M.M., Chan, G.M. (2009). Nutrition therapy for burns in children and adults. Nutrition.
25:261-269.
Glucose Metabolism
Accelerated gluconeogenesis, glucose
oxidation and plasma clearance of glucose
Blood glucose levels increase due to
insulin resistance and breakdown of
glycogen stores
Glucagon excretion by the liver increases
initially after the burn and slows down as
wound heals
Chan, M.M., Chan, G.M. (2009). Nutrition therapy for burns in children and adults. Nutrition.
25:261-269.
Chang D. Michael, Peck Yih. (1999). Nutrition Support for Burn Injuries. J Nutr Biochem. 10:380-396.
Potts, N.L., Mandleco, B.L. (2007). Pediatric Nursing: Second Edition. New York: Thomson Delmer
Learning.
.
Muscle Protein Catabolism
Protein catabolism increases in burn
patients leading to protein losses of 260
mg protein/kg/hr.

Chang D. Michael, Peck Yih. (1999). Nutrition Support for Burn Injuries. J Nutr Biochem. 10:380-396.
Nutrition Therapy
Always prefer oral intake if possible
Preserves GI function
Food has therapeutic qualities that tube
feedings do not
If a patient cannot consume 80% of
estimated caloric or protein needs,
enteral feeding is needed
TPN may be contraindicative because of
infection but should be used if necessary

Chang D. Michael, Peck Yih. (1999). Nutrition Support for Burn Injuries. J Nutr Biochem. 10:380-396.
 Table 1: Nutrition Support for Burn
Injuries
Stressors Stress Burn factor Stres Table 1 Use of the
Factor s modified Harris-
s Facto
rs
Benedict equations
Activity factor to estimate
20% TBSA 1.2
Confined to 1.2 resting energy
2025% TBSA 1.6
bed expenditure
Out of bed 1.3 Men:
2530%TBSA 1.7
BEE=(66.47+13.75W
Injury factor +5.0H-
3035% TBSA 1.8
Minor 1.2 6.76A)x(Activity
operation
3540% TBSA 1.9 Factor)x(Injury and/or
Skeletal 1.3 Burn Factor)
trauma Women:
40% TBSA 2.0
Major 1.4 BEE=(655.1+19.56W
surgery
+1.85H-
Sepsis 1.6 4.68A)x(Activity
Chang D. Michael, Peck Yih. (1999). Nutrition Support Factor)
for Burn Injuries. J Nutr Biochem. 10:380-396. x(Injury and/or Burn
Factor)
 Protein Requirements
Amino acids are important for collagen synthesis
for wound healing
Maintaining visceral protein is important for organ
function especially for immune systems
Maintaining intercostal muscles and the
diaphragm is imperative for respiratory efficiency
1.4-2.2 g/kg protein requirement for burns
Urinary nitrogen losses increase with severity of
the burn injury
Trauma patient may lose 20-25 g of lean body
nitrogen daily
Chang D. Michael, Peck Yih. (1999). Nutrition Support for Burn Injuries. J Nutr Biochem. 10:380-396.
Protein Requirement cont
Protein requirement estimate:
Combine 24-hour urinary nitrogen loss, 2 to 4 g of
nitrogen for fecal loss and 4 to 5 g/d for
anabolism.
Convert each gram of nitrogen to 6.25 g of
protein.
Patients are likely to miss feedings if in
surgery frequently so should be given high
protein formulas between surgeries
Be aware of uremia- increase free water
Generally 20-25% of calories from protein
Chang D. Michael, Peck Yih. (1999). Nutrition Support for Burn Injuries. J Nutr Biochem. 10:380-396.
Lipid requirements
Lipid stores are critical for long-term fuel after
major thermal burns
Fat oxidation is higher in hypermetabolic patients
than in normal patients
Fat consumption should not exceed 30% of the
diet to avoid diarrhea
Beneficial because
Fat is a more concentrated form of energy

Vegetable oils contain essential fatty acids and

fat soluble vitamins

Help with infection

Chang D. Michael, Peck Yih. (1999). Nutrition Support for Burn Injuries. J Nutr Biochem. 10:380-396.
Lipid Study
A randomized study of 43 adolescent and
adult burned patients were administered a
low-fat diet (15% total calories from fat)
Administered enterally of parenterally
Less pneumonia, improved respiratory
function, faster nutritional status and shorter
length of care was found in comparison to a
high fat diet of 35% of calories from fat
Recommended 12-15% of calories to be
lipids
Chan, M.M., Chan, G.M. (2009). Nutrition therapy for burns in children and adults. Nutrition.
25:261-269.
Garrel D.R, Razi M, Lariviere F, Jobin N, Naman N, Emptoz-Bonneton A, et al. (1995) Improved clinical
status and length of care with low-fat nutrition support in burn patients. JPEN 19:482-91
Carbohydrate Requirements
Carbohydrate metabolism is significantly affected
in burn patients
Gluconeogenesis from Alanine and other AAs
are elevated
Carbohydrates are good sources for protein
sparing especially for nitrogen retention
High carbohydrates can contribute to
hyperglycemia in which case a diet can be
altered to increase fat in the diet
Recommended 60% of the calories from CHO, not
surpassing 400g/d or1600 kcal/d
Chan, M.M., Chan, G.M. (2009). Nutrition therapy for burns in children and adults. Nutrition.
25:261-269.
Chang D. Michael, Peck Yih. (1999). Nutrition Support for Burn Injuries. J Nutr Biochem. 10:380-396.
Assessing Nutritional Status
Pre-Albumin and Albumin for protein
status
Pre-Albumin 15 mg show malnutrition
<10mg/dl- Deficient
Albumin <3.0mg/dl- Deficient
Weight loss of 5% in 30
days=Malnutrition

Chan, M.M., Chan, G.M. (2009). Nutrition therapy for burns in children and adults. Nutrition.
25:261-269.
 Vitamin C
Needed for edema prevention
Involved in collagen synthesis for wound
healing
Aid in immune functioning

Chan, M.M., Chan, G.M. (2009). Nutrition therapy for burns in children and adults. Nutrition.
25:261-269.
 Vitamin A
Needed for immune function
Epithelialization
5000 IU of Vitamin A per 1000 cal of
enteral feeding is recommended

Chan, M.M., Chan, G.M. (2009). Nutrition therapy for burns in children and adults. Nutrition.
25:261-269.
 Vitamin D and Calcium
Burns cause an impairment in the
metabolism of Vitamin D
Burn patients are more susceptible to
fractures so calcium and vitamin D should
be administered
Calcium- 1000 mg daily
Vitamin D- 200-400 IU daily
Maintain serum 25-hydroxy vitamin D level of
30-60 ng/Ml

Chan, M.M., Chan, G.M. (2009). Nutrition therapy for burns in children and adults.
Nutrition.
 Zinc and Copper
Zinc and copper deficiencies have been
seen in burn patients most likely from
tissue breakdown and urinary excretion.
Supplementation is recommended for
patients

Chan, M.M., Chan, G.M. (2009). Nutrition therapy for burns in children and adults.
Nutrition.
Ethical Issues
The quality of care and the recovery of
burn patients depend on the amount of
effort the healthcare providers put into
the patient.
Quality of life
Summary
Burns result from thermal, chemical and
electrical sources
Burns are classified as Superficial, Partial
thickness and Full-thickness
Rule of 9s for BSA %
Burns cause a inflammatory, stress response
affecting many bodily systems
Protein is essential for wound healing
Vitamins and Minerals supplements are
neccesary
Questions?
Thank you