BURNS
o Description
- A nurse who cares for a patient with burn injury
should be knowledgeable about the physiologic
changes that occur after a burn, as well as astute
assessment skills to detect subtle changes in the
patient’s conditions
- Burn injury is the result of heat transfer from one
site to another.
- Burns disrupt the skin, which leads to increased
fluid 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.
- The severity of each burn is determined by multiple
factors that when assessed help the burn team
estimate the likelihood that a patient will survive
and plan for the care for each patient.
o Classification
- Superficial partial-thickness: The epidermis is
destroyed or injured and a portion of the dermis
may be injured.
- Deep partial thickness: A deep partial thickness
burn involves the destruction of the epidermis and
upper layers of the dermis and injury to the deeper
portions of the dermis.
- Full thickness: A full thickness burn involves total
destruction of the epidermis and dermis and, in
some cases, the destruction of the underlying
tissue, muscle, and bone.
o Pathophysiology
- Tissue destruction results from coagulation, protein
denaturation, or ionization of cellular components.
- Local response: Burns that do not exceed 20% of
TBSA according to the Rule of Nines produces a
local response
- Systemic response: Burns that exceeds 20% of TBSA
according to the Rule of Nines produces a systemic
response.
- The systemic response is caused by the release
of cytokines and other mediators into the systemic
circulation
- The release of local mediators and changes
in blood flow, tissue edema, and infection, can
cause progression of the burn injury
o Statistics and Epidemiology
- An estimated 500, 000 people are treated for minor
burn injury annually.
- The number of patients who are hospitalized every
year with burn injuries is more than 40, 000,
including 25, 000 people who require
hospitalization in specialized burn centers across
the country
- The remaining 5, 000 hospitals see an average of
three burns per year.
- Of those people admitted in burn centers, , 47% of
their injuries occurred at home, 27% on the road,
8% are occupational, 5% are recreational, and the
remaining 13% from other sources.
- 40% of these injuries are flame related, 30% scald
injuries, 4% electrical, 3% chemical, and the
remaining unspecified.
- Males have greater than twice the chance of burn
injury than women.
 - The most frequent age group for contact burns is
between 20 to 40 years of age.
- The National Fire Protection Association reports 4,
000 fire and burn deaths each year.
- Of the 4,000, 3, 500 deaths occur from residential
fires and the remaining 500 from other sources such
as motor vehicle crashes, scalds, or electrical and
chemical sources.
- The overall mortality rate, for all ages and for
total body surface area burned is 4.9%
o Clinical Manifestations
- Hypovolemia: This is the immediate consequence
of fluid loss and results in decreased perfusion and
oxygen delivery.
- Decreased cardiac output: Cardiac output
decreases before any significant change in blood
volume is evident.
- Edema: Edema forms rapidly after burn injury.
- Decreased circulating blood volume: Circulating
blood volume decreases dramatically during burn
shock.
- Hyponatremia: Hyponatremia is common during
the first week of the acute phase, as water shifts
from the interstitial space to the vascular space.
- Hyperkalemia: Immediately after burn injury
hyperkalemia results from massive cell destruction.
- Hypothermia: Loss of skin results in an inability to
regulate body temperature
o Prevention
- Advise that matches and lighters be kept out of
reach of children.
- Emphasize the importance of never leaving children
unattended around fire or in bathroom/bathtub.
- Caution against smoking in bed, while using home
oxygen, or against falling asleep while smoking.
- Caution against throwing flammable liquids onto an
already burning fire.
- Caution against using flammable liquids to start
fires.
- Recommend avoidance of overhead electrical
wires and underground wires when working
outside.
- Advise that hot irons and curling irons be kept out
of reach of children.
- Caution against running an electrical cord under
carpets or rugs
- Advocate caution when cooking, being aware of
loose clothing hanging over the stove top.
- Recommend having a working fire extinguisher in
the home and knowing how to use it.
o Complications
- Ischemia: As edema increases, pressure on small
blood vessels and nerves in the distal extremities
causes an obstruction of blood flow.
- Tissue hypoxia: Tissue hypoxia is the result of
carbon monoxide inhalation.
- Respiratory failure: Pulmonary complications are
secondary to inhalational injuries
o Assessment and Diagnostic Findings
- Rule of Nines: A common method, the rule of nines
is a quick way to estimate the extent of burns in
adults through dividing the body into multiples of
nine and the sum total of these parts is equal to the
total body surface area injured.
- Lund and Browder Method: This method
recognizes the percentage of surface area of various
 anatomic parts, especially the head and the legs, as
it relates to the age of the patient.
- Palmer Method: The size of the patient’s palm, not
including the surface area of the digits, is
approximately 1% of the TBSA, and the patient’s
palm without the fingers is equivalent to 0.5% TBSA
and serves as a general measurement for all age
groups
o Medical Management
- Transport: The hospital and the physician are
alerted that the patient is en route so that life-
saving measures can be initiated immediately.
- Priorities: Initial priorities in the ED remain airway,
breathing, and circulation.
- Airway: 100% humidified oxygen is administered
and the patient is encouraged to cough so that
secretions can be removed by coughing.
- Chemical burns: All clothing and jewelry are
removed and chemical burns should be flushed.
- Intravenous access: A large bore (16 or 18 gauge) IV
catheter is inserted in the non-burned area.
- Gastrointestinal access: If the burn exceeds 20% to
25% TBSA, a nasogastric tube is inserted and
connected to low intermittent suction because
there are patients with large burns that
become nauseated.
- Clean beddings: Clean sheets are placed over and
under the patient to protect the burn wound from
contamination, maintain body temperature, and
reduce pain caused by air currents passing over
exposed nerve endings.
- Fluid replacement therapy: The total volume and
rate of IV fluid replacement is gauged by the
patient’s response and guided by the resuscitation
formula
o Nursing Assessment
- 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.
- 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.
- 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.
- Start cardiac monitoring if indicated. If patient has
history of cardiac or respiratory problems, electrical
injury.
- Check peripheral pulses on burned extremities
hourly; use Doppler as needed.
- Monitor fluid intake (IV fluids) and output (urinary
catheter) and measure hourly. Note amount
of urine obtained when catheter is inserted
(indicates preburn renal function and fluid status)
- Obtain history. Assess body temperature, body
weight, history of preburn weight, allergies, tetanus
immunization, past medical surgical problems,
current illnesses, and use of medications.
- Arrange for patients with facial burns to be assessed
for corneal injury.
- Continue to assess the extent of the burn; assess
depth of wound, and identify areas of full and
partial thickness injury.
 - Assess neurologic status: consciousness,
psychological status, pain and anxiety levels, and
behavior.
- Assess patient’s and family’s understanding of injury
and treatment. Assess patient’s support system and
coping skills.
1. Acute 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.
- Acute or intermediate phase begins 48 to 72 hours
after the burn injury.
- Focus on hemodynamic alterations, wound healing,
pain and psychosocial responses, and early
detection of complications.
- Measure vital signs frequently. Respiratory and
fluid status remains highest priority.
- Assess peripheral pulses frequently for first few
days after the burn for restricted blood flow.
- Closely observe hourly fluid intake and urinary
output, as well as blood pressure and cardiac
rhythm; changes should be reported to the burn
surgeon promptly.
- 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.
2. Rehabilitation Phase
- Rehabilitation should begin immediately after the
burn has occurred. Wound healing, psychosocial
support, and restoring maximum functional activity
remain priorities. Maintaining fluid and electrolyte
balance and improving nutrition status continue to
be important.
- Assess self concept, 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.
- 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.
- Document participation and self care abilities in
ambulation, eating, wound cleaning, and applying
pressure wraps.
- Maintain comprehensive and continuous
assessment for early detection of complications,
with specific assessments as needed for specific
treatments, such as postoperative assessment of
patient undergoing primary excision.
o Diagnosis
- Impaired gas exchange related to carbon monoxide
poisoning, smoke inhalation, and upper airway
obstruction.
- Ineffective airway clearance related to edema and
effects of smoke inhalation.
- Fluid volume deficit related to increased capillary
permeability and evaporative losses from burn
wound.
- Hypothermia related to loss of skin microcirculation
and open wounds.
- Pain related to tissue and nerve injury
 - Anxiety related to fear and the emotional impact of
burn injury
o Planning & Goals
- Maintenance of adequate tissue oxygenation.
- Maintenance of patent airway and adequate airway
clearance.
- Restoration of optimal fluid and electrolyte balance
and perfusion of vital organs.
- Maintenance of adequate body temperature.
- Control of pain.
- Minimization of patient’s and family’s anxiety
o Nursing Priorities
- Maintain patent airway/respiratory function.
- Restore hemodynamic stability/circulating volume.
- Alleviate pain.
- Prevent complications.
- Provide emotional support for patient/significant
other (SO).
- Provide information about condition, prognosis, and
treatment
o Nursing Interventions
1. Promoting Gas Exchange and Airway Clearance
- Provide humidified oxygen, and monitor arterial
blood gases (ABGs), pulse oximetry, and
carboxyhemoglobin levels.
- Assess breath sounds and respiratory rate, rhythm,
depth, and symmetry; monitor for hypoxia.
- 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.
- Report labored respirations, decreased depth of
respirations, or signs of hypoxia to physician
immediately; prepare to assist with intubation and
escharotomies.
- Monitor mechanically ventilated patient closely.
- Institute aggressive pulmonary care measures:
turning, coughing, deep breathing, periodic
forceful inspiration using spirometry, and tracheal
suctioning.
- Maintain proper positioning to promote removal of
secretions and patent airway and to promote
optimal chest expansion; use artificial airway as
needed.
2. Restoring fluid and Electrolyte Balance
- Monitor vital signs and urinary output (hourly),
central venous pressure (CVP), pulmonary artery
pressure, and cardiac output.
- Note and report signs of hypovolemia or fluid
overload.
- Maintain IV lines and regular fluids at appropriate
rates, as prescribed. Document intake, output, and
daily weight.
- Elevate the head of bed and burned extremities.
- Monitor serum electrolyte levels (eg, sodium,
potassium, calcium, phosphorus, bicarbonate);
recognize developing electrolyte imbalances.
- Notify physician immediately of decreased urine
output; blood pressure; central venous, pulmonary
artery, or pulmonary artery wedge pressures; or
increased pulse rate.
3. Maintaining Normal Body Temperature
- Provide warm environment: use heat shield, space
blanket, heat lights, or blankets
- Assess core body temperature frequently.
- Work quickly when wounds must be exposed to
minimize heat loss from the wound.
4. Minimizing Pain and Anxiety
- Use a pain scale to assess pain level (ie, 1 to 10);
differentiate between restlessness due to pain and
restlessness due to hypoxia.
- Administer IV opioid analgesics as prescribed, and
assess response to medication; observe for
respiratory depression in patient who is not
mechanically ventilated.
- Provide emotional support, reassurance, and simple
explanations about procedures.
- 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.
- Provide pain relief, and give antianxiety medications
if patient remains highly anxious and agitated after
psychological interventions.
5. Monitoring and Managing Potential Complications
- 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
- Respiratory status immediately to physician; and
assist as needed with intubation or escharotomy.
- 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 fluid resuscitation
as ordered in response to physical findings;
continue monitoring fluid status.
- 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 fluids as
prescribed.
- 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.
- Paralytic ileus: Maintain nasogastric tube on low
intermittent suction until bowel sounds resume;
auscultate abdomen regularly for distention and
bowel sounds.
- Curling’s ulcer: Assess gastric aspirate for blood and
pH; assess stools for occult blood; administer
antacids and histamine blockers
(eg, ranitidine [Zantac]) as prescribed
6. Restoring Normal fluid Balance
- Monitor IV and oral fluid intake; use IV infusion
pumps.
- Measure intake and output and daily weight
- Report changes (e.g., blood pressure, pulse rate) to
physician.
7. Preventing Infection
- Provide a clean and safe environment; protect
patient from sources of cross contamination (e.g.,
visitors, other patients, staff, equipment).
- Closely scrutinize wound to detect early signs of
infection.
8. Monitor culture results and white blood cell counts
 - Practice clean technique for wound care procedures
and aseptic technique for any invasive procedures.
Use meticulous hand hygiene before and after
contact with patient.
- Caution patient to avoid touching wounds or
dressings; wash unburned areas and change linens
regularly.
9. Maintaining Adequate Nutrition
- Initiate oral fluids slowly when bowel sounds
resume; record tolerance—if vomiting and
distention do not occur, fluids
- May be increased gradually and the patient may be
advanced to a normal diet or to tube feedings.
- Collaborate with dietitian to plan a protein and
calorie-rich diet acceptable to patient. Encourage
family to bring nutritious and patient’s favorite
foods. Provide nutritional and vitamin and mineral
supplements if prescribed.
- Document caloric intake. Insert feeding tube if
caloric goals cannot be met by oral feeding (for
continuous or bolus feedings); note residual
volumes.
- Weigh patient daily and graph weights.
10. Promoting Skin Integrity
- Assess wound status.
- Support patient during distressing and painful
wound care.
- Coordinate complex aspects of wound care and
dressing changes.
- Assess burn for size, color, odor, eschar, exudate,
epithelial buds (small pearl-like 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 significant changes to the physician.
- Inform all members of the health care team of
latest wound care procedures in use for the patient.
- Assist, instruct, support, and encourage patient and
family to take part in dressing changes and wound
care.
- Early on, assess strengths of patient and family in
preparing for discharge and home care.
11. Relieving Pain and Discomfort
- Frequently assess pain and discomfort; administer
analgesic agents and anxiolytic medications, as
prescribed, before the pain becomes severe. Assess
and document the patient’s response to medication
and any other interventions.
- Teach patient relaxation techniques. Give some
control over wound care and analgesia. Provide
frequent reassurance.
- Use guided imagery and distraction to alter
patient’s perceptions and responses to pain;
hypnosis, music therapy, and virtual reality are also
useful.
- Assess the patient’s sleep patterns daily; administer
sedatives, if prescribed.
- Work quickly to complete treatments and dressing
changes.
12. Encourage patient to use analgesic medications
before painful procedures.
- Promote comfort during healing phase with the
following:
- Oral antipruritic agents, a cool environment,
frequent lubrication of the skin with water or a
silica-based lotion, exercise and splinting to prevent
skin contracture, and diversional activities.
13. Promoting Physical Mobility
- Prevent complications of immobility
(atelectasis, pneumonia, edema, pressure ulcers,
and contractures) by deep breathing, turning, and
proper repositioning.
- Modify interventions to meet patient’s needs.
Encourage early sitting and ambulation. When legs
are involved, apply elastic pressure bandages before
assisting patient to upright position.
- Make aggressive efforts to prevent contractures
and hypertrophic scarring of the wound area after
wound closure for a year or more.
- Initiate passive and active range-of-motion
exercises from admission until after grafting, within
prescribed limitations.
- Apply splints or functional devices to extremities for
contracture control; monitor for signs of vascular
insufficiency, nerve compression, and skin
breakdown.
14. Strengthening Coping Strategies
- Assist patient to develop effective coping strategies:
Set specific expectations for behavior, promote
truthful communication to build trust, help patient
practice coping strategies, and give positive
reinforcement when appropriate.
- Demonstrate acceptance of patient. Enlist a non
involved person for patient to vent feelings without
fear of retaliation.
- Include patient in decisions regarding care.
Encourage patient to assert individuality and
preferences. Set realistic expectations for self care.
15. Supporting Patient and Family Processes
- Support and address the verbal and nonverbal
concerns of the patient and family.
- Instruct family in ways to support patient.
- Make psychological or social work referrals as
needed.
- Provide information about burn care and expected
course of treatment.
- Initiate patient and family education during burn
management. Assess and consider preferred
learning styles; assess ability to grasp and cope with
the information; determine barriers to learning
when planning and executing teaching.
- Remain sensitive to the possibility of changing
family dynamics.
16. Monitoring and Managing Potential Complications
- Heart failure: Assess for fluid overload, decreased
cardiac output, oliguria, jugular vein distention,
edema, or onset of S3 or S4 heart sounds.
- Pulmonary edema: Assess for increasing CVP,
pulmonary artery and wedge pressures, and
crackles; report promptly. Position comfortably with
head elevated unless contraindicated. Administer
medications and oxygen as prescribed and assess
response.
- Sepsis: Assess for increased temperature, increased
pulse, widened pulse pressure, and flushed, dry skin
in unburned areas (early signs), and note trends in
the data. Perform wound and blood cultures as
prescribed. Give scheduled antibiotics on time.
- Acute respiratory failure and acute respiratory
distress syndrome (ARDS):Monitor respiratory
status for dyspnea, change in respiratory pattern,
and onset of adventitious sounds. Assess for
decrease in tidal volume and lung compliance in
patients on mechanical ventilation. The hallmark of
onset of ARDS is hypoxemia on 100% oxygen,
 decreased lung compliance, and significant
shunting; notify physician of deteriorating
respiratory status.
- Visceral damage (from electrical burns): Monitor
electrocardiogram (ECG) and report dysrhythmias;
pay attention to pain related to deep muscle
ischemia and report. Early detection may minimize
severity of this complication. Fasciotomies may be
necessary to relieve swelling and ischemia in the
muscles and fascia; monitor patient for
excessive blood loss and hypovolemia after
fasciotomy.
- Contractures: Provide early and aggressive physical
and occupational therapy; support patient
if surgery is needed to achieve full range of motion.
- Impaired psychological adaptation to the burn
injury:
- Obtain psychological or psychiatric referral as soon
as evidence of major coping problems appears.
17. Promoting Activity Tolerance
- Schedule care to allow periods of uninterrupted
sleep. Administer hypnotic agents, as prescribed, to
promote sleep.
- Communicate plan of care to family and other
caregivers.
- Reduce metabolic stress by relieving pain,
preventing chilling or fever, and promoting integrity
of all body systems to help conserve energy.
Monitor fatigue, pain, and fever to determine
amount of activity to be encouraged daily.
- Incorporate physical therapy exercises to prevent
muscular atrophy and maintain mobility required
for daily activities.
- Support positive outlook, and increase tolerance for
activity by scheduling diversion activities in periods
of increasing duration.
18. Improving Body Image and Self-Concept
- Take time to listen to patient’s concerns and
provide realistic support; refer patient to a support
group to develop coping strategies to deal with
losses.
- Assess patient’s psychosocial reactions; provide
support and develop a plan to help the patient
handle feelings.
- Promote a healthy body image and self-concept by
helping patient practice responses to people who
stare or ask about the injury.
- Support patient through small gestures such as
providing a birthday cake, combing patient’s hair
before visitors, and sharing information on cosmetic
resources to enhance appearance.
- Teach patient ways to direct attention away from a
disfigured body to the self within.
- Coordinate communications of consultants, such
as psychologists, social workers, vocational
counselors, and teachers, during rehabilitation.
19. Teaching Self-care
- Throughout the phases of burn care, make efforts
to prepare patient and family for the care they will
perform at home. Instruct them about measures
and procedures.
- Provide verbal and written instructions about
wound care, prevention of complications, pain
management, and nutrition.
- Inform and review with patient specific exercises
and use of elastic pressure garments and splints;
provide written instructions.
 - Teach patient and family to recognize abnormal
signs and report them to the physician.
- Assist the patient and family in planning for the
patient’s continued care by identifying and
acquiring supplies and equipment that are needed
at home.
- Encourage and support follow-up wound care.
- Refer patient with inadequate support system to
home care resources for assistance with wound
care and exercises.
- Evaluate patient status periodically for modification
of home care instructions and/or planning for
reconstructive surgery.
o Evaluation
- Absence of dyspnea.
- Respiratory rate between 12 and 20 breaths/min.
- Lungs clear on auscultation,
- Arterial oxygen saturation greater than 96% by
pulse oximetry.
- ABG levels within normal limits.
- Patent airway
- Respiratory secretions are minimal, colorless, and
thin.
- Urine output between 0.5 and 1.0 mL/kg/h.
- Blood pressure higher than 90/60 mmHg.
- Heart rate less than 120 bpm.
- Body temperature remains between 36.1ºC and
38.3ºC