Chapter 62

Management of Patients With

Burn Injury
Burn Injuries

 Approximately 486,000 people require medical

attention of burns every year
 Most burns occur in the home
 Young children and the older adults are at high risk for
burn injuries
 Nurses must play an active role in the prevention of
burn injuries by education regarding prevention
concepts and promoting safety legislation

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Goals Related to Burns

 Prevention
 Institution of lifesaving measures for the severely
burned person
 Prevention of disability and disfigurement through early
specialized and individualized care
 Rehabilitation through reconstructive surgery and
rehabilitation programs

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Classification of Burns #1

 First-degree burns
o Superficial injuries that involve outermost layer of
skin; sunburn
 Second-degree burns
o Involve entire epidermis and varying portions of the
dermis; painful with blisters
 Third-degree burns (Full thickness)
o Total destruction of the epidermis, dermis, and
underlying tissue, lack of sensation

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Classification of Burns #2

 Fourth-degree burns:
o Deep burn necrosis
o Extends into deep tissue, muscle, or bone
o Figure 62-2

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Factors to Consider in Determining Burn
Depth

 How the injury occurred

 Causative agent (flame or scalding liquid)
 Temperature of agent
 Duration of contact with the agent
 Thickness of the skin at the injury
o Thin skin is easier to damage

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Methods to Estimate Total Body Surface
Area (TBSA) Burned

 Rule of nines
o Most common
o Based on anatomic regions
 Lund and Browder method
o Recognizes % of TBSA of various anatomic parts
 Palmer method
o Used to estimate extent of scattered burns
o Size of patient’s hand, including fingers is 1% TBSA

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Rule of Nines

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Pathophysiology of Burns

 Burns are caused by:

o Chemical injury
o Heat transfer from one site to another
 Thermal (includes electrical)
o Skin and mucosa of upper airway most common
site
 Radiation

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Physiologic Changes

 Burns more than 30% may produce a local and

systemic response and are considered major burns
 Systemic response includes release of cytokines and
other mediators into systemic circulation
 Fluid shifts and shock result in tissue hypoperfusion and
organ hypofunction
o All goes to the burn to try to repair it.

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Effects of Major Burn Injury

 Fluid and electrolyte shifts

 Cardiovascular effects
 Pulmonary injury
o Upper airway
o Lower airway
o Carbon monoxide poisoning
o Restrictive defects
 Renal and GI alterations
 Immunologic alterations
o HCT goes through the roof
 Effect on thermoregulation
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Phases of Burn Injury

 Refer to Table 62-3

 Emergent or resuscitative phase
o Onset of injury to completion of fluid resuscitation
 Acute or intermediate phase
o From beginning of diuresis to wound closure
 Rehabilitation phase
o From wound closure to return to optimal physical
and psychosocial adjustment

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Emergent or Resuscitative Phase—
On-the-Scene Care

 Prevent injury to rescuer

 Stop injury: extinguish flames, cool the burn, irrigate
chemical burns
 ABCs: Establish airway, breathing, and circulation
 Start oxygen and large-bore IVs
 Remove restrictive objects and cover the wound
 Do assessment surveying all body systems and obtain a
history of the incident and pertinent patient history
 Note: Treat patient with falls and electrical injuries as
for potential cervical spine injury

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Emergent or Resuscitative Phase
 Patient is transported to emergency department
 Fluid resuscitation is begun
 Foley catheter is inserted
 Patient with burns exceeding 20% to 25% should have
an NG tube inserted and placed to suction
 Patient is stabilized and condition is continually
monitored
 Patients with electrical burns should have ECG
 Address pain; only IV medication should be
administered, NPO
 Psychosocial consideration and emotional support
should be given to patient and family
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Nursing Management in the Care of the
Patient in the Emergent Phase of Burn Care

 ABC
 Vital signs and hemodynamic status
 Monitor for fluid volume deficit
 Assess extent of the burn
 Refer to Chart 62-6

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Use of the Nursing Process in the Care of the Patient in
the Emergent Phase of Burn Care—Potential
Complications and Collaborative Problems

 Acute respiratory failure

 Distributive shock
 Acute kidney injury
 Compartment syndrome- when fluids shift to one area
causing so much pressure-emergent, can be internal
bleeding, STAT issue. Pt must be assessed ASAP
 Paralytic ileus
 Curling ulcer

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Acute or Intermediate Phase

 48 to 72 hours after injury

 Continue assessment and maintain respiratory and
circulatory support, fluid and electrolyte balance, GI and
renal function
 Prevention of infection, burn wound care, pain
management, modulation of the hypermetabolic
response, and early positioning/mobility

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Nursing Management of the Patient in
the Acute/Intermediate Phase #1

 Restoring fluid balance

 Preventing infection
 Modulating hypermetabolism
 Promoting skin integrity
 Relieving pain and discomfort
 Promoting mobility
 Strengthening coping strategies

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Nursing Management of the Patient in
the Acute/Intermediate Phase #2

 Strengthening coping strategies

 Supporting patient and family processes
 Monitoring and managing complications

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Use of the Nursing Process in the Care of the
Patient in the Acute Burn Care—Collaborative
Problems and Potential Complications

 Heart failure and pulmonary edema

 Sepsis
 Acute respiratory failure
 Visceral damage (electrical burns)

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Rehabilitation Phase

 Rehabilitation is begun as early as possible in the

emergent phase and extends for a long period after the
injury
 Focus is on wound healing, psychosocial support, self-
image, lifestyle, and restoring maximal functional
abilities so that the patient can have the best quality
life, both personally and socially
 The patient may need reconstructive surgery to
improve function and appearance
 Vocational counseling and support groups may assist
the patient

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Question #1

Is the following statement true or false?

Breathing must be assessed and patent airway

established immediately during the initial minutes of
emergency burn care

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Answer to Question #1

True

Breathing must be assessed and patent airway

established immediately during the initial minutes of
emergency burn care

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Management of Shock—Fluid
Resuscitation

 Maintain blood pressure of greater than 100 mm Hg

systolic and urine output of 30 to 50 mL/hr; maintain
serum sodium at near-normal levels
 Consensus formula
 Evans formula
 Brooke Army formula
 Parkland Baxter formula
 Hypertonic saline formula
 Note: Adjust formulas to reflect initiation of fluids at the
time of injury

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Fluid and Electrotype Shifts—Emergent
Phase

 Generalized dehydration
 Reduced blood volume and hemoconcentration
 Decreased urine output
 Trauma causes release of potassium into extracellular
fluid: hyperkalemia
 Sodium traps in edema fluid and shifts into cells as
potassium is released: hyponatremia
 Metabolic acidosis

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Fluid and Electrolyte Shifts—Acute Phase

 Fluid reenters the vascular space from the interstitial

space
 Hemodilution
 Increased urinary output
 Sodium is lost with diuresis and due to dilution as fluid
enters vascular space: hyponatremia
 Potassium shifts from extracellular fluid into cells:
potential hypokalemia
 Metabolic acidosis

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Question #2

Formulas are only a guide for burn care fluid

resuscitation. How often must the patient’ s response to
fluid therapy (heart rate, blood pressure, and urine
output) be evaluated?
A. Every hour
B. Every 2 hours
C. Every 3 hours
D. Every 4 hours

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Answer to Question #2

A. Every hour

The patient’s response to fluid therapy (heart rate, blood

pressure, and urine output) should be evaluated at least
hourly

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Burn Wound Care

 Wound cleaning
o Hydrotherapy
 Use of topical agents: refer to Table 62-4

 Wound debridement
o Natural debridement
o Mechanical debridement
o Surgical debridement
 Wound dressing, dressing changes, and skin grafting

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Pain Management #1

 Burn pain has been described as one of the most severe

forms of acute pain
 Pain accompanies care and treatments such as wound
cleaning and dressing changes
 Types of burn pain
o Background or resting
o Procedural
o Breakthrough

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Pain Management #2

 Analgesics
o IV use during emergent and acute phases
o Morphine
o Fentanyl
o Other
 Role of anxiety in pain
 Effect of sleep derivation on pain
 Nonpharmacologic measures

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Nutritional Support

 Burn injuries produce profound metabolic abnormalities,

and patient with burns have great nutritional needs
related to stress response, hypermetabolism, and
requirement for wound healing
 Goal of nutritional support is to promote a state of
nitrogen balance and match nutrient utilization
 Nutritional support is based on patient preburn status
and % of TBSA burned
 Enteral route is preferred. Jejunal feedings are
frequently used to maintain nutritional status with a
lower risk of aspiration in a patient with poor appetite,
weakness, or other problems

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Home Care Instruction

 Mental health
 Skin and wound care
 Exercise and activity
 Nutrition
 Pain management
 Thermoregulation and clothing
 Sexual issues

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Other Major Care Issues

 Pulmonary care
 Psychological support of patient and family
 Patient and family education
 Restoration of function

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