Nursing Care of Clients with

Burn Injury
By: Loyda Amor N. Cajucom, MAN, RN
Burns (continued)

• Pathophysiology and etiology of burn

injury
– Tissue loss or damage
– Occurs between 40°C and 44°C and
above
– Local and systemic effects
– Zones of injury
• Coagulation
• Stasis
• Hyperemia
Burns (continued)
Factors Determining Burn Severity

• Extent
• Depth
• Age
• Medical History
• Body Part
• Complications
Burns (continued)

• Classification of burn injuries

–Size of injury
• Rule of nines
–Body divided into surface
areas of 9%
Burns (continued)
Burns (continued)

• Classification of burn injuries (continued)

– Size of injury
• Palmar surface
–Represents 1% of total body surface
area (TBSA)
• Lund and Browder method
–Most accurate and accepted method
–Surface measurements assigned to
each body part in terms of age of the
patient
Lund and Browder Method
Burns (continued)

– Depth of injury
• Superficial (first-degree burn)
• Partial-thickness (second-degree
burn)
–Superficial dermal
–Deep dermal
• Full-thickness (third-degree burn)
–Destruction down to and including
subcutaneous tissue
Superficial Partial-Thickness Burn
Deep Partial-Thickness Burn
Full-Thickness Burn
Deep Full-Thickness Burn
Classification of Burn by Depth
• Using the “rule of nines,” calculate the
percent of injury in an adult who was
injured as follows: the patient sustained
partial and full-thickness burns to one
half of his left arm, his entire left leg,
and his perineum.
a.28%
b.23.5%
c.45.5%
d.16%
• What is the likely depth of injury in a patient
with injuries described as moist, red, with
some blister formation, and very painful?
a.Superficial, first-degree burn
b.Partial-thickness, second-degree burn
c.Deep dermal partial-thickness, second-
degree burn
d.Full-thickness, third-degree burn
Burns (continued)

– Types of burn injuries

• Thermal: steam, scalds, contact
with heat, fire
• Electrical and lightning: low-voltage
(alternating current) or high-voltage
(alternating or direct)
• Chemical: acids and alkalis, tar,
and asphalt
• Radiation: exposure to industrial or
medical equipment
Burns (continued)

– Location of injury
• Burns on face, hands, feet,
genitalia, major joints, and
perineum are best treated at a burn
center
– Patient age and history
• Most at risk: younger than 2 years
and older than 60 years
• Assess for other injuries and
medical history
Classification of Burn by Severity
Burns

CLINICAL MANIFESTATIONS.
• Depending on the skin layers damage,
burn wounds are termed either partial
thickness burns or full-thickness burns.
Burn wounds are also classified as first,
second and third and fourth degree
burns.
Signs and Symptoms of Burns

A. Alteration in Fluid and

Electrolyte Balance
Signs and Symptoms of Burns

B. Alteration in Respiration
Signs and Symptoms of Burns

C. Alteration in Cardiac Function

Signs and Symptoms of Burns

D. Alteration in Comfort: Pain

Signs and Symptoms of Burns

E. Altered Level of Consciousness

• Which of the following causes can lead to excessive
burn edema and shock in the patient with injuries
totaling more than 50% total body surface area (TBSA)
burn?
a.The heat from the burn leads to immediate vascular wall
destruction and extravasation of intravascular fluid.
b.A positive interstitial hydrostatic pressure occurs in the
dermis leading to burn wound edema.
c.Plasma colloid osmotic pressure is decreased due to
protein leakage into the extravascular space.
d.Capillary permeability decreases in burned and
unburned tissue, leading to hypovolemia.
• A patient has full-thickness burns to his face, chest,
back, and bilateral upper arms. He was injured less than
24 hours ago. He sustained these injuries in a house fire
and is presumed to have inhaled smoke and sustained
an inhalation injury as well. He was nasally intubated in
the emergency department and placed on mechanical
ventilatory support. He is now showing signs of
increasing agitation and is demonstrating high peak
airway (ventilatory) pressures. What is the likely cause in
this change in his condition?
a.Uncontrolled pain
b.Hypovolemia
c.Hypoxemia and confusion
d.Decreased pulmonary compliance
Diagnostic Tests

• ABG
• Carboxyhemoglobin level
• Serial Chest X-ray
• Culture and Sensitivity
• Laryngoscopy and bronchoscopy
• PFT
• CBC and Serum Electrolyte Levels
• CK
• ECG
Burns (continued)

• Initial emergency burn management

– Goals
• Save life
• Minimize disability
• Prepare for definitive care
– First 24 to 36 hours most crucial
Burns (continued)

– Airway management
• First priority: protect airway
• Cervical precautions if spinal injury suspected
• Facial burns: suspect inhalation injury
• Enclosed space: suspect carbon monoxide
poisoning
• Administer 100% oxygen
• Observe continuously
• May need to be intubated
Burns (continued)

–Respiratory management
• Circumferential full-
thickness burns to chest
wall
• Escharotomies
Burns (continued)

– Circulatory management
• Parkland formula
– First 8 hours after injury, give half of calculated
amount of fluid
– 25% is given in the second 8 hours
– 25% in the third 8 hours
• Lactated Ringer’s solution of choice
• Intravenous access
• Monitor urine output, heart rate, blood
pressure, and level of consciousness
• Keep on cardiac monitor
Calculations for Fluid Resuscitation
Burns (continued)

– Pathophysiology of burn shock

• Burn injuries greater than 35%
TBSA
• Hypovolemic shock and burn
edema
• Systemic mediators
• Depressed cardiac contractility
– Early fluid resuscitation is essential
Burns (continued)

–Kidney management
• Foley catheter with hourly
output for burns > 15% to 20%
BSA
• Adequate UOP for adults = 0.5
to 1 mL/kg per hour
• Adequate UOP for children = 1
mL/kg per hour
Burns (continued)

–Gastrointestinal management
• More than 20% TBSA:
prone to gastric dilation and
paralytic ileus
• Gastrointestinal activity
resumes in 24 to 48 hours
• Prone to Curling stress
ulcers
Burns (continued)

– Pain management
• Burns are very painful
• Give intravenous opiates -
morphine sulfate and fentanyl
• Administer benzodiazepines for
anxiolysis
• Do not give intramuscular or
subcutaneous pain medications
because absorption is
unpredictable
Burns (continued)

–Extremity pulse assessment

• Edema formation may cause
neurovascular compromise
• Doppler flow probe best way to
check arterial pulses
• Escharotomy may be indicated
for circumferential burns of the
extremities
Burns (continued)

–Wound care
• Cover with clean, dry dressings
or sheets
• Keep patient warm
• Tetanus prophylaxis for burns
greater than 10% TBSA
–Burn center referral
 American Burn Assoc
says send these to a burn center

• Partial thickness burns >10% BSA

• Burns involving the face, hands, feet, genitalia,
perineum, or major joints
• full thickness/3 degree burn
• Electrical, Chemical, and Inhalation burns

• In combat, all but the most superficial

burn should be evacuated
 Burn care products

• < 20% TBSA 2nd degree – Silvadene (SVC)

Cream BID
• Any > 20% TBSA-SVC and Sulfamylon (SMC) alt
BID
• 3rd degree burn – SVC and SMC alt BID
• *SMC only to the ears * Bacitracin Opth to
face
Care of small burns

What can YOU do?

 Care of small burns
• Clean entire limb with
soap and water (also under nails).
• Apply antibiotic cream
(no PO or IV antibiotic).
• Dress limb in position of function, and
elevate it.
• No hurry to remove blisters unless infection occurs.
• Give pain meds as needed (PO, IM, or IV)
• Rinse daily in clean water; in shower is very practical.
• Gently wipe off with clean gauze.
 Blisters

• In the pre-hospital setting, there is no hurry

to remove blisters.
• Leaving the blister intact initially is less
painful and requires fewer dressing
changes.
• The blister will either break on its own,
or the fluid will be resorbed.
Blisters break on their own
Upper arm burn day 1 day 2

Burn “looks worse” the next day because of

blisters breaking and oozing
Upper arm burn

121

• Blisters show probable partial thickness burn.

• Area without blister might be deeper partial
thickness.
Debride blister using simple instruments
Medic debriding blister
After debridement
 Before and after debridement

• Removing the blister leaves a weeping, very tender

wound, that requires much care.
Silver sulfadiazene
Arm burn 4 days
Arm burn 7 days – note the exudate
Foot burn
debridement

Before debriding
and applying
cream,
clean entire foot
(including
toes and nails).
 Silver- impregnated dressings
(Silverlon)

• Apply wet silver dressing

directly on the burn.
• Creams or dressings
under the silver dressing
impede the antimicrobial action.
• Keep it moist!
• Remove it, rinse it out, replace it on the burn.
Steps in using silver-impregnated
dressings

• Clean the burn and surrounding area.

• Soak silver-impregnated dressing and gauze in
STERILE WATER or BOTTLED DRINKING
WATER
• Apply silver-impregnated dressing
(over-lapping edges are best).
• Wrap with the moist gauze.
• Secure with mesh, gauze, or tape.
• Keep it moist with WATER, every 12h or so More
frequent in hot arid environments
 pics
Soak silver dressings and gauze
in WATER (not saline).

Apply the
silver dressing.

Wrap with moist gauze.

Secure with mesh, gauze, or tape.
 First few days
• Moisten dressing with WATER every 12h or so.
• Remove outer gauze and silver dressing every
day.
– Inspect the burn.
– Rinse exudate off burn.
• Rinse exudate off silver dressing with WATER.
• Return same silver dressing to the burn.
• Apply new outer gauze moistened with WATER.
 pics
Moisten with WATER
q12h or so.

Moisten well
to remove it each day.
Rinse it out, and put it
back on the burn.
After several days

• Replace silver dressing

– every 2 - 5 days
– depending on amount of exudate, cellular
debris
• First wet the silver dressing before removing it.
• Don’t pull on it if it’s stuck – moisten it more.
• Apply new moist silver dressing and gauze.
 Hands and feet

This is rather deep and

might require grafting.
But initial management
is basic.

Dressings should not impede circulation.

Leave tips of fingers exposed.
Keep limb elevated.
Hands and feet

• Allow use of the hands in dressings by day.

• Splint in functional position by night.
• Keep elevated to reduce swelling.
Hands and feet
• Fingers might develop
contractures if active
measures are not taken to
prevent them.
 Genitalia

• Shower daily, rinse off old cream, apply new cream.

• Insert Foley catheter if unable to urinate due to swelling.
Escharotomy - indications

• Circulation to distal limb is in danger due to swelling.

– Progressive loss of sensation / motion in hand / foot.
– Progressive loss of pulses in the distal extremity by
palpation or doppler.
• In circumferential chest burn, patient might not be able
to expand his chest enough to ventilate,
and might need escharotomy of the skin of the chest.
Escharotomy - complications
COMPLICATIONS
• Bleeding: might require ligation of superficial veins
• Injury to other structures: arteries, nerves, tendons
NOT every circumferential burn requires escharotomy.
• In fact, most DO NOT need escharotomy.
• Repeatedly assess neuro-vascular status of the limb.
• Those that lose circulation and sensation need
escharotomy.
 Escharotomy

• Eschar = burned skin

• Escharotomy = cut burned skin to
relieve underlying pressure
• Similar to bivalving a tight cast.
• Cut along inside and outside of limb
from good skin to good skin
• Knife can be used, or cautery.
• Use local or no anesthesia.
(Full-thickness burn should have no
sensation, but underlying tissues
do!)
• Using the Parkland formula for fluid
resuscitation and your knowledge of injury
calculations using the “rule of nines,” calculate
the estimated fluid requirements during the first
8 hours for a 75-kg patient with the following
injuries: full-thickness burns to the anterior
chest, perineum, and entire right leg.
a.2775 mL
b.5550 mL
c.8325 mL
d.11,100 mL
Special Management
Considerations
• Inhalation injury (leading cause of fire-
related death)
– Carbon monoxide (CO) poisoning
• Normal HbCO is less than 2%
• 40% to 60% = unresponsive
• 15% to 40% = varying levels of
central nervous system dysfunction
• Clinical signs and symptoms
related to central nervous system
and heart
Special Management Considerations
(continued)

• Inhalation injury
–Upper airway injury
• Heat may cause upper
airway obstruction
• Intubation may be
necessary
–Lower airway injury
 Special Management Considerations
(continued)

• Nonthermal burns
– Chemical
• pH of product
• Initially, flush with large amounts of
water
• Treatment
– Electrical
• Internal damage not always
apparent
• Rhabdomyolysis
• Cardiac dysrhythmias
Burns: Nursing Management
• Resuscitation phase
– Oxygenation alterations
• Nursing actions
–Assess breath sounds
–Administer oxygen
–Monitor HbCO levels
–Elevate head of bed
–Assess and assist with pulmonary
secretion removal
–Suction as needed
–Observe for airway obstruction and
respiratory compromise
–Prepare for intubation
Burns: Nursing Management (continued)

• Resuscitation phase (continued)

– Impaired gas exchange
• CO poisoning
• Chemical pneumonitis
• Acute respiratory distress syndrome
– Ineffective airway clearance
• Laryngeal swelling and upper airway
obstruction
• Laryngospasm
– Ineffective breathing pattern
• Circumferential full-thickness burns to chest
Burns: Nursing Management (continued)

• Resuscitation phase (continued)

–Fluid resuscitation
• Deficient fluid volume
–Burn shock
–Potassium
–Sodium
Burns: Nursing Management (continued)
• Resuscitation phase (continued)
– Risk for infection
• Burn wound is most common source
of infection
• Daily wound inspection
• Antibiotics based on positive culture
results
• Good handwashing technique
• Gowns, gloves, and masks worn
• Infection precautions must be adhered
to by everyone, including family
Burns: Nursing Management (continued)
• Resuscitation phase (continued)
– Tissue perfusion
• Ineffective renal tissue perfusion
– Myoglobinuria, hemoglobinuria,
hypoperfusion, and hypovolemia
• Ineffective cerebral tissue perfusion
– Associated head injury, hypovolemia,
hypoxemia, CO poisoning, and electrolyte
imbalances
• Ineffective peripheral tissue perfusion
– Third spacing
– Circumferential burns
• Ineffective gastrointestinal tissue perfusion
– Paralytic ileus and Curling ulcer
Burns: Nursing Management (continued)

• Resuscitation phase (continued)

–Tissue perfusion
• Invasive monitoring
–Central venous pressure,
arterial catheter, pulmonary
artery catheter
• Hypothermia
• Laboratory assessment
Burns: Nursing Management (continued)

• Acute care phase

–Inflammatory phase
• Immediately after injury
–Proliferative phase
• 4 to 20 days after injury
–Maturation phase
• 20 days after injury
Burns: Nursing Management (continued)

• Impaired tissue integrity

– Healing of burn wound
• Prompt application of topical
antimicrobial
• Multiple contaminants
– Wound cleansing
• Daily cleaning and inspection
• Manage pain and control
hypothermia
Burns: Nursing Management (continued)

–Wound care
• Maintain moist wound
environment to prevent wound
infection
• Different methods
–Open
–Semiopen
–Closed
Burns: Nursing Management (continued)

– Topical antibiotic therapy

– Wound debridement
• Mechanical
• Enzymatic
• Surgical
Burns: Nursing Management (continued)

• Burn wound closure

– Skin substitutes
• Temporary
– Polyurethane film
– Biosynthetic dressing
– Hydrocolloid dressings
Burns: Nursing Management (continued)
Burns: Nursing Management (continued)

• Definitive burn wound closure

– Autograft (self)
– Biosynthetic skin substitutes
• Homograft (allograft): cadaver
• Heterograft (xenograft): pigskin
– Synthetic skin
• Integra
– Long-term postgraft wound care
Burns: Nursing Management (continued)
Burns: Nursing Management (continued)

• Acute pain
– Individualized and subjective
– Guideline-based approach
– Different types of pain
• Background
• Breakthrough
• Procedural
Burns: Nursing Management (continued)

– Partial-thickness burns have a great deal of

pain
– Experience pain daily
– Mostly managed with pharmacotherapy
Burns: Nursing Management (continued)

• Imbalanced nutrition: less than body

requirements
– Basal metabolic rate is 40% to 100% more
than the normal rate
– Goal is to provide adequate calories to
prevent starvation and enhance wound
healing
– Enteral and oral routes preferred
Burns: Nursing Management (continued)

• Rehabilitation phase
– Impaired physical mobility
• Contractures
– Outpatient burn care
• The weight of your burn patient is
estimated at 85 kg. TBSA burn is
estimated at 25% deep partial-
thickness to areas of the chest, back,
and left arm and 20% full-thickness to
the right arm, right upper leg, and areas
on the face. What is your initial plan for
fluid replacement?
a.5950 mL of LR for the first 8 hours, 5950
mL of LR over the next 16 hours
b.2868 mL of normal saline (NS) for the first
8 hours, 5737 mL of hypertonic NS over
the next 16 hours
c.11900 mL of dextran evenly divided over
the first 24 hours
d.11,475 mL of LR evenly divided over the
first 24 hours
References:
• Critical Care Nursing by Urden, 6th Edition
• Medical-Surgical Nursing by Ignatavicius, 6th Edition
• Manual of Critical Care Nursing by Baird, Keen and
Swearingen, 5th Edition, 2005
• Advanced Burn Life Support Course,
American Burn Association, 1994
• Textbook of Military Medicine, Part I, Vol 5, Conventional
Warfare, OTSG, 1991
• Textbook of Surgery, Sabiston, editor
W. B. Saunders, 1986
• http://www.ebmedicine.net/topics.php?paction=showTopicSeg&
topic_id=111&seg_id=2138
• http://reference.medscape.com/features/slideshow/thermal-
burns
• http://www.vicburns.org.au/management-of-a-patient-with-a-
minor-burn-injury/wound-management/dressings/early-
managment-of-small-burn-injuries.html