Burns

(relates to Chapter 24, “Nursing Management: Burns,” in the textbook)

Burns

Occur when there is injury to the tissues of the body caused by heat, chemicals, electrical current, or radiation

Types of Burn Injury

Thermal Burns

Chemical Burns

Smoke Inhalation Injury

Electrical Burns

Cold Thermal Injury

Full-Thickness Thermal Burn

Partial-Thickness Burn to the Hand

Partial-Thickness Burns Due to Immersion in Hot Water

Types of Burn Injury

Thermal Burns

Caused by flame, flash, scald, or contact with hot objects

Most common type of burn

Types of Burn Injury
Chemical Burns

Result from tissue injury and destruction

from necrotizing substances

Most commonly caused by acids

Alkali burns cause protein hydrolysis and liquefaction

Types of Burn Injury
Chemical Burns

Respiratory and systemic problems

Eye injuries

Clothing containing the chemical should be removed

Tissue destruction may continue for up to 72 hours after a chemical injury

Types of Burn Injury
Smoke Inhalation Injuries

Result from inhalation of hot air or

noxious chemicals

Cause damage to respiratory tract

Important determinant of mortality

in fire victims

Types of Burn Injury
Smoke Inhalation Injuries

Three types:

• Carbon monoxide poisoning

• Inhalation injury above the

glottis

• Inhalation injury below the

glottis

Types of Burn Injury Smoke Inhalation Injuries

Carbon monoxide (CO) poisoning

• CO is produced by the incomplete

combustion of burning materials

• Inhaled CO displaces oxygen

Types of Burn Injury Smoke Inhalation Injuries

Carbon monoxide (CO) poisoning

• Hypoxia

• Carboxyhemoglobinemia

• Death

Types of Burn Injury Smoke Inhalation Injuries

Carbon monoxide (CO) poisoning

• Treat with 100% humidified oxygen

• CO poisoning may occur in the

absence of burn injury to the skin

• Skin color described as “cherry red”

in appearance

Types of Burn Injury Smoke Inhalation Injuries

Inhalation injury above the glottis

• Thermally produced

• Hot air, steam, or smoke

• Mechanical obstruction can occur

quickly

Types of Burn Injury Smoke Inhalation Injuries

Inhalation injury above the glottis

• Presence of facial burns

• Singed nasal hair

• Hoarseness, painful swallowing

• Darkened oral and nasal

membranes

Types of Burn Injury Smoke Inhalation Injuries

Inhalation injury below the glottis

• Injury is related to the length of

exposure to smoke or toxic fumes

• Pulmonary edema may not appear

until 12 to 24 hours after the burn

Types of Burn Injury
Electrical Burns

Result from coagulation necrosis caused

by intense heat generated from an

electrical current

May result from direct damage to nerves

and vessels causing tissue anoxia and

death

Electrical Burn- Hand

Electrical Burn- Back

Types of Burn Injury Electrical Burns

Severity of injury depends on the amount of voltage, tissue resistance, current pathways, surface area, and on the length of time of the flow

Types of Burn Injury Electrical Burns

Electrical sparks may ignite the patient’s

clothing, causing a combination of

thermal and electrical injury

Types of Burn Injury Cold Thermal Injury

Frostbite

Classification of Burn Injury

Severity of injury is determined by

- Depth of burn

- Extent of burn

- Location of burn

- Patient risk factors

Classification of Burn Injury
Burn Injury

- In the past, burns were defined by

degrees:

• First-degree, second-degree, and third-

degree burns

Cross Section of Skin

Classification of Burn Injury
Depth of Burn

- The ABA now advocates categorizing the

burn according to depth of skin

destruction:

• Partial-thickness burn

• Full-thickness burn

Classification of Burn Injury
Depth of Burn

- Superficial partial thickness

• Involves the epidermis

- Deep partial thickness

• Involves the dermis

- Full thickness

• Involves fat, muscle, bone

Classification of Burn Injury
Extent of Burn

- Two commonly used guides for

determining the total body surface area:

• Lund-Browder chart

• Rule of nines

Lund-Browder Chart

Rule of Nines Chart

Classification of Burn Injury
Location of Burn

Location of the burn is related to the

severity of the injury:

Face, neck, chest ( respiratory

obstruction

Hands, feet, joints, and eyes ( self-care

Ears, nose ( infection

Classification of Burn Injury
Location of Burn

- Circumferential burns of the extremities

can cause circulatory compromise

- Patients may also develop compartment

syndrome

Classification of Burn Injury Patient Risk Factors

- Older adults heal more slowly than young

adults

- Preexisting cardiovascular, respiratory,

renal disease

- Diabetes mellitus

Classification of Burn Injury Patient Risk Factors

- Alcoholism

- Drug abuse

- Malnutrition

- Concurrent fractures, head injuries, or

other trauma

Phases of Burn Management

Prehospital Care

Emergent (Resuscitative)

Acute

Rehabilitative

Prehospital Care

• Remove the person from the source of the burn and stop the burning process

• The caregiver must be protected from becoming part of the incident

Prehospital Care

Electrical Injuries

- Remove patient from contact of source

Chemical Injuries

- Brush solid particles off the skin

- Water lavage

Prehospital Care

• Small Thermal Burns

- Cover with clean, cool, tap water-

dampened towel

• Large Thermal Burns

- Airway, breathing, and circulation

Prehospital Care

• Large Thermal Burns

- Do not immerse in cool water or pack

with ice

- Wrap in clean, dry sheet or blanket

- Remove burned clothing

Emergent Phase

• Emergent phase is the period of time

required to resolve the immediate problems

resulting from burn injury

Emergent Phase

• From burn onset to 5 or more days

• Usually lasts 24 to 48 hours

• The phase begins with fluid loss and edema

formation and continues until fluid mobilization and diuresis begin

Emergent Phase
Pathophysiology

• Fluid and Electrolyte Shifts

- Greatest threat is hypovolemic shock,

caused by a massive shift of fluids out of

blood vessels as a result of increased

capillary permeability

Conditions Leading to Burn Shock

Emergent Phase
Pathophysiology

• Fluid and Electrolyte Shifts

- Colloidal osmotic pressure decreases,

resulting in more fluid shifting out of the

vascular space into the interstitial spaces

Emergent Phase
Pathophysiology

• Fluid and Electrolyte Shifts

- The net result of the fluid shift is

intravascular volume depletion

• Edema

• ( Blood pressure

• ( Pulse

Emergent Phase
Pathophysiology

• Fluid and Electrolyte Shifts

- Normal insensible loss: 30 to 50 ml per

hour

- Severely burned patient: 200 to 400 ml per

hour

Emergent Phase
Pathophysiology

• Fluid and Electrolyte Shifts

- RBCs are hemolyzed by a circulating

factor released at the time of the burn

- Thrombosis

- Elevated hematocrit

Emergent Phase
Pathophysiology

• Fluid and Electrolyte Shifts

- Na+ shifts to the interstitial spaces and

remains until edema formation ceases

- K+ shift develops because injured cells

and hemolyzed RBCs release K+ into

extracellular spaces

Effects of Burn Shock

Emergent Phase
Pathophysiology

• Inflammation and Healing

- Neutrophils and monocytes accumulate at

the site of injury

- Fibroblasts and collagen fibrils begin

wound repair within the first 6 to 12

hours after injury

Emergent Phase
Pathophysiology

• Immunologic Changes

- Burn injury causes widespread

impairment of the immune system

- The skin barrier is destroyed

- ( Circulating levels of immunoglobulins

- WBC changes

Emergent Phase
Pathophysiology

• Immunologic Changes

- Depression of neutrophil chemotactic, phagocytic, and bactericidal activity

- ( T helper cells

- ( T suppressor cells

- ( Interleukin-1 and interleukin-2

Emergent Phase
Clinical Manifestations

• Shock from pain and hypovolemia

• Blisters

• Adynamic ileus

• Shivering

• Altered mental status

Emergent Phase
Complications

• Cardiovascular System

- Arrhythmias and hypovolemic shock

- Edema

- Ischemia

- Necrosis

Emergent Phase
Complications

• Cardiovascular System

- Gangrene

- Impaired microcirculation and increased

viscosity ( sludging

Emergent Phase
Complications

• Respiratory System

- Upper respiratory tract injury

• Mechanical airway obstruction and

asphyxia

Emergent Phase
Complications

• Respiratory System

- Inhalation injury

• Direct insult at the alveolar level

• Interstitial edema

• Patient may not exhibit signs during

first 24 hours

Emergent Phase
Complications

• Respiratory System

- Pneumonia

- Pulmonary edema

• Urinary System

- Acute tubular necrosis (ATN)

Emergent Phase
Nursing and Collaborative Management

• Airway Management

- Early nasotracheal or endotracheal

intubation

- Escharotomies of the chest wall

- Fiberoptic bronchoscopy

- Humidified air and 100% oxygen

Emergent Phase
Nursing and Collaborative Management

• Fluid Therapy

- Two large-bore IV lines

- A cutdown is a final measure

- Parkland (Baxter) formula for fluid

replacement

- Colloidal solutions

Emergent Phase
Nursing and Collaborative Management

• Wound Care

- Should be delayed until a patent airway,

adequate circulation, and adequate fluid

replacement have been established

Emergent Phase
Nursing and Collaborative Management

• Wound Care

- Cleansing

• Can be done in a hydrotherapy tub, cart

shower, shower, or bed

- Debridement

• May need to be done in the OR

• Loose necrotic skin is removed

Debriding Full-Thickness Burn

Emergent Phase
Nursing and Collaborative Management

• Wound Care

- Immersion in a tank

• Longer than 20 to 30 minutes can cause

electrolyte loss from open burned areas

• Can lead to chilling and cross-

contamination of wounds

Emergent Phase
Nursing and Collaborative Management

• Wound Care

- Shower

• Tap water not exceeding 104° is

acceptable

• Surgical detergent, disinfectant, or

cleaning agent may be used

• The patient may be bathed two times

daily

Emergent Phase
Nursing and Collaborative Management

• Wound Care

- Infection is the most serious threat to

further tissue injury

• Source of infection is the patient’s own

flora

Emergent Phase
Nursing and Collaborative Management

• Wound Care

- Open method

• Burn is covered with a topical antibiotic

with no dressing over the wound

Emergent Phase
Nursing and Collaborative Management

• Wound Care

- Multiple dressing changes

• Sterile gauze dressings are laid over a

topical antibiotic

• The dressings may be changed from

2 to 3 times every 24 hours, to once

every 3 days

Emergent Phase
Nursing and Collaborative Management

• Wound Care

- Allograft or homograft skin

• Commonly used

• Rejection eventually occurs

Emergent Phase
Nursing and Collaborative Management

• Other Care Measures

- Facial care

• Performed by the open method

- Eye care for corneal burns

• Done with slightly warmed physiologic

saline rinses as often as every hour

Emergent Phase
Nursing and Collaborative Management

• Other Care Measures

- Hands and arms should be extended and

elevated on pillows or slings

- Ears should be kept free of pressure

• No use of pillows

Emergent Phase
Nursing and Collaborative Management

• Other Care Measures

- Head can be elevated using a donut roll

- Perineum must be kept as clean and dry

as possible

- Routine lab tests

- Early ROM exercises

Emergent Phase
Nursing and Collaborative Management

• Drug Therapy

- Analgesics and sedatives

• morphine

• meperidine (Demerol)

• haloperidol (Haldol)

• lorazepam (Ativan)

• midazolam (Versed)

Emergent Phase
Nursing and Collaborative Management

• Drug Therapy

- Tetanus immunization

• Given routinely to all burn patients

Emergent Phase
Nursing and Collaborative Management

• Drug Therapy

- Antimicrobial agents

• Topical agents

- silver sulfadiazine (Silvadene)

- bacitracin

• Systemic agents not usually used

Emergent Phase
Nursing and Collaborative Management

• Nutritional Therapy

- Fluid replacement takes priority over

nutritional needs

- When bowel sounds return at 48 to 72

hours, oral intake can be initiated beginning

with clear liquids

Emergent Phase
Nursing and Collaborative Management

• Nutritional Therapy

- Hypermetabolic state

• Resting metabolic expenditure may be

increased by 50% to 100% above normal

• Core temperature is elevated

• Caloric needs are about 5000 kcal/day

Emergent Phase
Nursing and Collaborative Management

• Nutritional Therapy

- Hypermetabolic state

• Early, continuous enteral feeding

promotes optimal conditions for wound

healing

• Supplemental vitamins and iron may be

given

Acute Phase

• The acute phase begins with the mobilization

of extracellular fluid and subsequent diuresis

• The acute phase is concluded when the burned

area is completely covered by skin grafts or

when the wounds are healed

Surgeon Harvesting Skin

Donor Site After Harvesting

Healed Donor Sites

Healed Split-Thickness Skin Graft

Application of Cultured Epithelial Autograft

Healed Cultured Epithelial Autograft

Acute Phase
Pathophysiology

• Diuresis from fluid mobilization occurs, and

the patient is no longer grossly edematous

• Bowel sounds return

• Healing begins when WBCs have surrounded

the burn wound and phagocytosis occurs

Acute Phase
Pathophysiology

• Necrotic tissue begins to slough

• Formation of granulation tissue

• A partial-thickness burn wound will heal from

the edges

• Full-thickness burns must be covered by skin grafts

Acute Phase
Clinical Manifestations

• Partial-thickness wounds form eschar

• Once eschar is removed, epithelialization begins

- Expected to occur in 10 to 14 days

• Full-thickness wounds require debridement

Escharotomy of the Lower Extremity

Acute Phase
Laboratory Values

• Sodium

- Hyponatremia can occur if hydrotherapy is

longer than 20 to 30 minutes or from

excessive GI drainage

- Water intoxication

Acute Phase
Laboratory Values

• Sodium

- Hypernatremia

• May develop following successful fluid

replacement

• Improper tube feedings

Acute Phase
Laboratory Values

• Potassium

- Hyperkalemia noted if patient has

• Renal failure

• Adrenocortical insufficiency

• Massive deep muscle injury

Acute Phase
Laboratory Values

• Potassium

- Hyperkalemia can cause

• Cardiac arrhythmias and ventricular

failure

• Muscle weakness

• ECG changes

Acute Phase
Laboratory Values

• Potassium

- Hypokalemia can be caused by

• Lengthy hydrotherapy

• Vomiting, diarrhea

• Prolonged GI suction and IV therapy

without supplementation

Acute Phase
Complications

• Infection

- Localized inflammation, induration, and

suppuration

- Partial-thickness burns can become full-

thickness wounds in the presence of

infection

Acute Phase
Complications

• Infection

- Wound infection may progress to transient

bacteremia

- Patient may develop sepsis

Acute Phase
Complications

• Cardiovascular and Respiratory Systems

- Same complications can be present in

the emergent phase and may continue into

the acute phase

Acute Phase
Complications

• Neurologic System

- Usually no problems unless severe hypoxia

occurs

- Disorientation

- Combative

Acute Phase
Complications

• Neurologic System

- Hallucinations

- Delirium

- ICU psychosis syndrome

- Use of analgesics and antianxiety drugs

Acute Phase
Complications

• Musculoskeletal System

- Decreased ROM

- Contractures

• Gastrointestinal System

- Adynamic ileus

- Curling’s ulcer

Contracture of the Axilla

Acute Phase
Complications

• Endocrine System

- ( Blood glucose levels

- ( Insulin production

- Hyperglycemia

Acute Phase
Nursing and Collaborative Management

• Wound Care

- Daily observation

- Assessment

- Cleansing

- Debridement

Acute Phase
Nursing and Collaborative Management

• Wound Care

- Appropriate coverage of the graft:

• Fine-mesh gauze next to the graft

followed by middle and outer dressings

• Sheet skin grafts must be kept free of

blebs

Acute Phase
Nursing and Collaborative Management

• Excision and Grafting

- Eschar is removed down to the

subcutaneous tissue or fascia

- Cultured Epithelial Autographs (CEA)

• CEA is grown from biopsies obtained

from the patient’s own skin

Acute Phase
Nursing and Collaborative Management

• Excision and Grafting

- Artificial Skin

• Life-threatening full-thickness or deep

partial-thickness wounds where

conventional autograft is not available or

advisable

Acute Phase
Nursing and Collaborative Management

• Pain Management

- Opioid every 1 to 3 hours for pain

- Several drugs in combination

• Morphine with haloperidol

Acute Phase
Nursing and Collaborative Management

• Pain Management

- Nonpharmacologic strategies

• Relaxation tapes

• Visualization, guided imagery

• Biofeedback

• Meditation

Acute Phase
Nursing and Collaborative Management

• Physical and Occupational Therapy

- Exercise during and after hydrotherapy

- Passive and active ROM

- Splints should be custom-fitted

Acute Phase
Nursing and Collaborative Management

• Nutritional Therapy

- Calculation of caloric needs by dietitian

- High-protein, high-carb foods

- Diet supplements

- Patients should be weighed on a regular

basis

Acute Phase
Nursing and Collaborative Management

• Psychosocial Care

- Social worker

- Nursing staff

- Pastoral care

Rehabilitation Phase

• The rehabilitation phase is defined as

beginning when the patient’s burn wounds are

covered with skin or healed and the patient is

able to resume a level of self-care activity

Rehabilitation Phase
Pathophysiologic Changes and
Clinical Manifestations

• The burn wound heals either by primary

intention or by grafting

• Layers of epithelialization begin

rebuilding the tissue structure

• Collagen fibers add strength to

weakened areas

Rehabilitation Phase
Pathophysiologic Changes and
Clinical Manifestations

• In approximately 4 to 6 weeks the area becomes raised and hyperemic

• Mature healing is reached in 6 months to 2 years

• Skin never completely regains its original color

Rehabilitation Phase
Pathophysiologic Changes and
Clinical Manifestations

• Discoloration of scar fades with time

• Pressure can help keep scar flat

• Newly healed areas can be hypersensitive or

hyposensitive to cold, heat, and touch

• Healed areas must be protected from direct

sunlight for 1 year

Rehabilitation Phase
Complications

• Skin and joint contractures

- Most common complications during rehab

phase

• Hypertrophic scarring

Rehabilitation Phase
Nursing and Collaborative Management

• Both patient and family actively learn how to

care for healing wounds

• An emollient water-based cream should be used

• Cosmetic surgery is often needed following major burns

Rehabilitation Phase
Nursing and Collaborative Management

• Role of exercise cannot be overemphasized

• Constant encouragement and reassurance

• Address spiritual and cultural needs

• Maintain a high-calorie, high-protein diet

• Occupational therapy

Gerontologic Considerations

• Normal aging puts the patient at risk for injury

because:

- Unsteady gait

- Failing eyesight

- Diminished hearing

- Preexisting medical conditions

- Wounds take longer to heal

Emotional Needs of the
Patient and Family

• Family members need to understand the

importance of reestablishing the patient’s

independence

• Encourage the family to participate as team members during hospitalization

Emotional Needs of the
Patient and Family

• Early psychiatric intervention

• Assess psychoemotional cues

• A common emotional response is regression

• Issue of sexuality must be met with honesty

• Family and patient support groups

Special Needs of the Nursing Staff

• The nurse cares for patients who, at times, may be unpleasant, hostile, apprehensive, and

frustrated

• Nurses new to burn nursing often find it

difficult to cope