Burns and Patient Management

Burn wounds occur when there is

contact between tissue and an
energy source, such as heat,
chemicals, electrical current, or
radiation.

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The resulting effects of the
burn are influenced by the:

• intensity of the energy

• duration of exposure
• type of tissue injured

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 Burn Statistics
• At least 50% of all burn accidents can be
prevented
• children playing with fire account for more
than one-third of preschool deaths by fire
• In the US, approximately 2.4 million burn
injuries are reported each year.
• Burn injuries are second to motor vehicle
accidents as leading cause of accidental
death in the US
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What 2 types of clients account
for 2/3 of all burn fatalities?

• Older adults

• Children (especially preschool

aged children)

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 Where do most burns occur?
• Children, newborn to 4 y.o, from kitchen
and then the bathroom
• ages 5-74, most burn injuries occur
outdoors with next area-kitchen
• ages 75 and above, kitchen and then
outdoors

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Major cause of fires in the home
• Carelessness with cigarettes!!
• Hot water from water heaters set at high
levels above 140 degrees F (60 degrees C)
• cooking accidents
• space heaters
• combustibles - gasoline, lighter fluids, etc.
• chemicals

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 Types of Burn Injury
• Thermal burns-can be caused by flame, flash,
scald, or contact with hot objects
• Chemical burns-are the result of tissue injury
and destruction from necrotizing substances.
• Electrical burns-results from coagulation
necrosis that is caused by intense heat from an
electrical current
• Smoke & inhalation injury-inhaling hot air or
noxious chemicals
• Cold thermal injury-frostbite.
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 Referral Criteria
• 2nd or 3rd Degree Burns >10% BSA
• Burns to Face, Hands , Feet, Genitailia,
Perineum, or major Joints. ESPECIALY
CIRCUMFRENTIAL BURNS
• Electrical Burns
• Chemical Burns
• Inhalation Injury

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 Referral Criteria
• Burns with pre-existing PMHX that could
complicate recovery
• Concomitant trauma (If Major Trauma, The
Trauma Center , Not the Burn Center
should be the initial stabilizing unit)
• When in doubt , consult with a burn center

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 Thermal Burns
• most common type
• result from residential fires, automobile
accidents, playing with matches, improperly
stored gasoline, space heaters, electrical
malfunctions, or arson
• inhaling smoke, steam, dry heat (fire), wet
heat (steam), radiation, sun, etc...

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 Chemical Burn
2 types of chemical burns
• acids-can be neutralized
• alkaline- adheres to tissue, causing
protein hydrolyses and liquefaction
– examples: cleaning agents, drain cleaners, and
lyes, etc...

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Chemical Burn

• Different types of
burns

1 Outer skin layer

2 Middle skin layer
3 Deep skin layer
4 First degree burn
5 Second degree
burn
6 Third degree burn
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 Remember….
• With chemical burns, tissue destruction may
continue for up to 72 hours afterwards.
• It is important to remove the person from
the burning agent or vice versa.
• The latter is accomplished by lavaging the
affected area with copious amounts of
water.

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 Smoke and Inhalation Injury
• Can damage the tissues of the respiratory
tract

• Although damage to the respiratory mucosa

can occur, it seldom happens because the
vocal cords and glottis closes as a protective
mechanisms.

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3 types of smoke and inhalation
injuries
• 1. Carbon monoxide poisoning (CO
poisoning and asphyxiation count for
majority of deaths)

– Treatment- 100% humidified oxygen-draw

carboxyhemoglobin level- can occur without
any burn injury to the skin

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• 2. Inhalation injury above the glottis
(caused by inhaling hot air, steam, or
smoke.)
– Mechanical obstruction can occur quickly-True
ER! Watch for facial burns, signed nasal hair,
hoarseness, painful swallowing, and darkened
oral or nasal membranes

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• 3. Inhalation injury below glottis
– (above glottis-injury is thermally produced)
– below glottis-it is usually chemically produced.
– Amount of damage related to length of
exposure to smoke or toxic fumes
– Can appear 12-24 hours after burn

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 ELECTRICAL BURNS
• Injury from electrical
burns results from
coagulation necrosis
that is caused by
intense heat generated
from an electric
current.

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 Electrical Burns
• Can cause tissue anoxia and death
• The severity depends on amount of voltage,
tissue resistance, current pathways, and
surface area in contact with the current and
length of time the current flow was
sustained.

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 Electrical injury can cause:
• Fractures of long bones and vertebra
• Cardiac arrest or arrhythmias--can be delayed
24-48 hours after injury
• Severe metabolic acidosis--can develop in
minutes
• Myoglobinuria--acute renal tubular necrosis-
myoglobin released from muscle tissue
whenever massive muscle damage occurs--
goes to kidneys--and can mechanically block
the renal tubules due to the large size!
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 Electrical injury can cause:
• Fractures of long bones and vertebra
• Cardiac arrest or arrhythmias--can be delayed
24-48 hours after injury
• Severe metabolic acidosis--can develop in
minutes
• Myoglobinuria--acute renal tubular necrosis-
myoglobin released from muscle tissue
whenever massive muscle damage occurs--
goes to kidneys--and can mechanically block
the renal tubules due to the large size!
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 Electrical injury can cause:
• Fractures of long bones and vertebra
• Cardiac arrest or arrhythmias--can be delayed
24-48 hours after injury
• Severe metabolic acidosis--can develop in
minutes
• Myoglobinuria--acute renal tubular necrosis-
myoglobin released from muscle tissue
whenever massive muscle damage occurs--
goes to kidneys--and can mechanically block
the renal tubules due to the large size!
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Treatment of electrical burns…
• Fluids--Ringers lactate or other fluids-
flushes out kidneys--you want 75-100 cc/hr
until urine sample clear
• an osmotic diuretic (Mannitol) may be
given to maintain urine output

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Cold Thermal Injury (Frostbite)
• Can be localized such as frostbite
• systemic (hypothermia)

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 Classification of Burn Injury
• Treatment of burns is directly related to the
severity of injury!
• Severity is determined by:
– depth of burn
– external of burn calculated in percent of total
body surface (TBSA)
– location of burn
– patient risk factors
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26
 DEPTH OF BURNS
• Burn injury involves the destruction of the
integumentary system.
• What is the function of the
integumentary system?
– Protective
– holds in fluids and electrolyes
– regulates heat
– keeps harmful agents from injuring or invading
the body
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 Burns are defined by...
• Were defined by degrees in the past! First,
second, and third degree
• 2 common guidelines now used are the:
– Lund-Browder Chart
– Rule of Nines

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 Rule of Nines
• In the adult, most areas of
the body can be divided
roughly into portions of
9%, or multiples of 9. This
division, called the rule of
nines, is useful in
estimating the percentage
of body surface damage an
individual has sustained in
burn.
• In small children,
relatively more area is
taken up by the head
and less by the lower
extremities.
Accordingly, the rule
of nines is modified.
In each case, the rule
gives a useful
approximation of
body surface.
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Rules of Nines

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 Location of Burns
• Has a direct relationship to the severity of
the burn.
• Face, neck & chest burns may inhibit
respiratory illness RT mechanical
obstruction secondary to edema or eschar
formation

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 Complicating or Co-Morbid
Factors
• Associated Trauma
• Inhalation Injuries
• Circumferential Burns
• Electricity
• Age (Young or Old)
• Pre-Existing Disease
• Abuse
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3 Phases of Burn Management

–emergent (resuscitative)
–acute
–rehabilitative

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 Pre-hospital Care
• Remove from area! Stop the burn!
• If thermal burn is large--FOCUS on the
ABC’s
– A=airway-check for patency, soot around
nares, or signed nasal hair
– B=breathing- check for adequacy of
ventilation
– C=circulation-check for presence and
regularity of pulses

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 Other precautions...
• Burn too large--don’t immerse in water due
to extensive heat loss
• Never pack in ice
• Pt. should be wrapped in dry clean material
to decrease contamination of wound and
increase warmth

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 Emergent Phase
(Resuscitative Phase)
• Lasts from onset to 5 or more days but
usually lasts 24-48 hours
• begins with fluid loss and edema formation
and continues until fluid motorization and
diuresis begins
• Greatest initial threat is hypovolemic
shock to a major burn patient!

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Complications during emergent
phase of burn injury are 3
major organ systems...
–Cardiovascular
–Respiratory
–Renal systems

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 Cardiovascular Systems
• Arrhythmias, hypovolemic shock which may lead to
irreversible shock
• circulation to limbs can be impaired by
circumferential burns and then the edema formation
• Causes: occluded blood supply thus causing
ischemia, necrosis, and eventually gangrene.
• Escharotomies (incisions through eschar) done to
restore circulation to compromised extremities.

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 Respiratory System
• Vulnerable to 2 types of injury
– 1. Upper airway burns that cause edema formation &
obstruction of the airway
– 2. Inhalation injury can show up 24 hrs later-watch
for resp. distress such as increased agitation or change
in rate or character of resp.
– preexisting problem (ex. COPD) more prone to get
resp. infection
• Pneumonia is common complication of major burns
• Is possible to overload with fluids--leading to pulmonary
edema
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 Renal System
• Most common renal complication of burns
in the emergent phase is ATN. Because of
hypovolemic state, blood flow decreases,
causing renal ischemia. If it continues, acute
renal failure may develop.

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 Nursing management in the
emergent phase is...
• Airway management-early nasotracheal or
endotracheal intubation before airway is actually
compromised (usually 1-2 hours after burn)
• ventilator? ABGs? Escharotomies?
• 6-12 hours later-Bronchoscopy to assess lower resp.
tact
• high fowler’s position-cough & deep breathe every
hour, turn q 1-2 hrs, chest physiotherapy, suction
prn
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 Fluid Shifts
• Massive fluid shifts out of blood vessels as
a result of increased capillary permeability.
When capillary walls become more
permeable, water, sodium, and later plasma
protein (esp. albumin) moves into
interstitial spaces & other tissues. The
colloidal osmotic pressure decreases with
loss of protein from the vascular space. This
called second spacing.

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 Third Spacing
• Fluids goes into areas with no fluids and
this is called third spacing. Examples of
third spacing are exudate and blister
formation.

• Net result is decreased volume, depletion

due to fluid shifts = edema, decreased blood
pressure, and increased pulse
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 Hypovolemic Shock
• Occurs when there is a loss of intravascular
fluid volume. The volume is inadequate to
fill vascular space and is unavailable for
circulation.
• Also, burns have a direct loss of fluid due to
evaporation.

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 Inflammation & Healing
• Burn injuries casue coagulation necrosis
whereby tissues and vessels are damaged or
destroyed
• Wound repair begins within the first 6-12
hours after injury.

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 Immunologic Changes
• Are caused by burns.
• Skin barrier destroyed and all changes make
the burn patient more susceptible to
infection
• Pt may be in shock from pain and
hypovolemia.

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 Other factors to consider...
• Full-thickness burns and deep partial
thickness burns are initially anesthetic
because nerve endings are destroyed.
• Superficial to moderate partial thickness
burns are very painful. Why?

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 Still more factors to consider...
• Severe dehydration is possible even though the
patient maybe edematous--Why?
• May have an dynamic ileus RT body’s response to
massive trauma and potassium shifts--Why?
• Shivering due to chilling caused by heat loss,
anxiety, and pain
• unable to recall events RT hypoxia associated with
smoke inhalation, or head trauma or overdose of
sedatives or pain meds
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 Fluid Therapy
• 1 or 2 large bore IV replacement lines (may need
jugular or subclavian)
• Cutdown rare RT increased risk of infection &
sepsis
• Fluid replacement based on: size/depth of burn, age
of pt., & individualized considerations--ex.
Dehydration in preburn state, chronic illness
• options- RL, D5NS, dextam, albumin, etc.
• there are formula’s for replacement: Parkland
formula and Brooke formula
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 Assessment of adequacy of
fluid replacement
• Urinary output is most commonly used parameter
• urine OP-30-50 cc/hr in an adult
• cardiopulmonary factors- BP (systolic 90-100
mmHg, pulse less than 100, resp 16-20 breaths per
min. (BP more accurate with arterial line)
• sensoruim-alert, oriented to time, place, & person

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 Wound Care for Burns
• Can wait until patent airway, adequate
circulation, fluid replacement is in place!

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 Full-thickness burns are

• Will be dry and waxy white to dark brown

• will have little to no sensation because
nerve endings have been destroyed

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 Partial thickness burns
• Are pink to cherry red, wet, shiny with
serous exudate
• May or may not have intact blisters and are
very painful when touched or exposed to air

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 Cleansing and Debridement
• Can be done in tank, shower, or bed
• Debridement may be done in surgery.
(Loose necrotic skin is removed)
• bath given with with surgical detergent,
disinfectant, or cleansing agent to reduce
pathogenic organisms

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 Infection is the most serious
threat to further tissue injury
and possible sepsis.
• SURVIVAL is related to prevention of wound
contamination.
– Source of infection is pt’s own flora,
predominantly from the skin, resp. tract, and GI
tract.
– Prevention of cross contamination from other
patients is the priority for nurses!
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 2 methods used to control
infections in burn wounds...
• Open method- pt’s burn is covered wit ha
topical antibiotic and has no dressing
• Closed method-uses sterile gauze
impregnated with or laid over a topical
antibiotic. Dressings changed 2-3 times q
24 hrs.

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 Wound Care continued...
• Staff should wear disposable hats, gowns, gloves,
masks when wounds are exposed
• appropriate use of sterile vs. nonsterile
techniques
• keep room warm
• careful handwashing
• any bathing areas disinfected before and after
bathing
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• Coverage is the primary goal for burn
wounds. Since usually not enough unburned
skin for immediate skin grafting, other
temporary wound closure methods are used
– Allograph or homograft (same species which is
usually from cadavers) is used for wound
closure-- temporary--3 days to 2 wks
– Porcine skin-heterograft or xenograft (different
species)--temporary--3 days to 2 wks
– autograft or cultured epithelial autograft- (pt’s
own skin and cell culture)- permanent

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Surgeons use a dermatome (left) to remove
donor skin and a mesher (right) to put
holes in it.

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• Surgeons agree that no single product or
technique is right for every burn situation. And so
far, there's no true replacement for healthy, intact
skin, which is the body's largest organ, and one of
the most complex. It's the first line of defense
against infection and dehydration, but it's
more than just a physical barrier. Skin also
helps control temperature, through
adjustments of blood flow and evaporation of
sweat. It's an important sensory organ, too.

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 Other care measures include
• Face is vascular and subject to increased
edema- use open method if possible to
decrease confusion and disorientation
• eye care-use saline rinses, artificial tears
• hands &arms-extended and elevated on
pillows or in slings to minimize edema, may
need splints to keep them in functional
positions
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• Ears- keep free of pressure. Ear burns-no
pillows! Neck burns should not use pillows
in order to decrease wound contraction.
• Perineum-must be kept clean & dry.
Indwelling foley will help in this & also to
provide hourly outputs.
• Lab tests prn to monitor electrolyte
imbalance and ABGs
• Physical therapy stared immediately

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 Drug Therapy
• Analgesics and Sedatives
• given for pt comfort
• IV pain meds initialy due to:
– GI function is slowed or impaired because of
shock or paralytic ileus
– IM injections will not be absorbed well

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 Drug Therapy
• Tetanus immunization- given routinely to
all burn patients because of the likelihood
of anaerobic burn-wound contamination
• Antimicrobial agents-usually topical due to
little or no blood supply to the burn eschar
so little delivery of the antibiotic to wound
• Drug of choice is: Silver sulfadiazine

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 Nutritional Therapy
• Fluid replacement takes priority over
nutritional needs in the initial emergent
phase. Why?
• NG tube is inserted and connected to low
intermittent suction for decompression.
When bowel sounds return (48-72 hrs) after
injury, start with clear liquids and progress
up to a diet high in proteins and calories

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• Burn patients need more calories & failure to
provide will lead to delayed wound healing
and malnutrition.
• Give calorie containing liquids instead of
water due to need for calories and potential
for water intoxication
• Enteral feedings into the duodenum
(recommended) can: reduce n&v, more
continuous feedings, and increase wd healing!

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 Acute Phase
• Begins with mobilization of extracellular
fluid and subsequent diuresis.
• Is concluded when the burned area is
completely covered or when wounds are
healed. May take weeks or months.
• Pt is no longer grossly edematous due to
fluid mobilization, full & partial thickness
burns more evident, bowel sounds return, pt
more aware of pain and condition.

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• Healing begins when WBCs have
surrounded the burn and phagocytosis
begins, necrotic tissue begins to slough,
fibroblasts lay down matrices of collagen
precursors to form granulation tissue.
• Partial-thickness burns (if kept free from
infections) will heal from edges and from
below. (10-14 days)
• Full-thickness burns must be covered by
skin grafts.

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 Laboratory Values
• Sodium- Hyponatremia can occur due to: silver
nitrate topical oints as a result of sodium loss
through eshcar, hydrotherapy, excessive GI
drainage, diarrhea, excessive water intake
– S/S of hyponatremia: weakness, dizziness, muscle
cramps, fatigue, HA, tachycardia, & confusion
• Hypernatremia can occur: too much hypertonic
fluids, improper tube feedings, inappropriate fluid
administration
– S/S of hypernatremia: thirst; dried furry tongue;
lethargy; confusion; and possible seizures
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• Potassium- hyperkalemia is note if pt is in renal
failure, adrenocortical insufficiency, or massive
deep muscle injury with lg. amts. of potassium
released from damaged cells. Cardiac
arrhythmias and ventricular failure can occur if
K+ level greater >7mEq/L. muscle weakness &
EKG changes are noted.
– Hypokalemia is noted with silver nitrate therapy
and long hydrotherapy. Other causes: vomiting,
diarrhea, prolonged GI suction, prolonged IV
therapy without K+ supplementation. Constant K+
losses occur through the burn wound.
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 Complications of Acute Phase
• Infection- due to destruction of body’s 1st line of
defense. Partial thickness wds can convert to full-
thickness wds with infection present. Pt may get
sepsis from wound infections. Signs of sepsis are:
high temp., increased pulse & resp., decreased BP,
and decreased urinary output, mild confusion,
chills, malaise, and loss of appetite. WBC bet.
10,000 and 20,000. Infections usually gram neg.
bacteria (pseudomonas, proteus)
• Obtain cultures from all possible sources: IV,
foley, wound, oropharynx, and sputum
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• Cardiovascular- same as in emergent phase
• Neurologic-possible from electrical injuries
• Musculoskeletal-has the most potential for
complications during acute phase due to healing
and scar formation making skin less supple and
pliant. ROM limited, contractures can occur
• Gastrointestinal-adynamic ileus results from
sepsis, diarrhea or constipation (RT narcotics &
decreased mobility), gastric ulcers RT stress,
occult blood in stools possible
• Endocrine-stress DM might occur-assess
glucose prn 72
Nursing management-acute phase
• Predominant therapeutic interventions are:
– fluid replacement, physical therapy, wd care, early
excision and grafting, and pain management
• Fluid replacement continues from emergent
phase to acute phases--given for: fluid losses,
administer medications, & for transfusions.
• Physical therapy- to maintain optimal joint
function
• Pain management- most critical functions as a
nurse.
• Nutritional therapy-provide adequate proteins
& calories 73
• Wound Care- the goals are cleanse and debride
the area of necrotic tissue &debris, minimize
further damage to viable skin, promote patient
comfort, & reepithelialization or success with
skin grafting.
• Care for donor site and other grafts necessary
• Excision and grafting-eschar removed to
subcutaneous tissue or fascia, graft applied to
tissue
– Cultured epithelial autograft (CEA)uses patient’s
own cells to grow skin-permanent
– artificial skin is the latest trend. Examples: Alloderm,
Life-Skin, etc. 74
 Rehabilitation Phase
• Defined as beginning when the patient’s burn
wound is covered with skin or healed and patient
is capable of assuming some self-care activity.
• Can occur as early as 2 weeks to as long as 2-3
months after the burn injury
• Goals for this time is to assist patient in resuming
functional role in society & accomplish
functional and cosmetic reconstruction.

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 Clinical Manifestations
• Burn wd either heals by primary intention
or by grafting.
• Scars may form & contractures.
• Mature healing is reached in 6 months to 2
years
• Avoid direct sunlight for 1 year on burn
• new skin sensitive to trauma

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 Complications
• Most common complications of burn injury
are skin and joint contractures and
hypertrophic scarring
• Because of pain, pts will assume flexed
position. It predisposes wds to contracture
formation
• Use of physical therapy, pressure garments,
splints, etc. are used
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 Nursing management during
rehabilitation phase
• Must be directed to returning patient to
society, address emotional concerns,
spiritual and cultural needs, self-esteem,
teaching of wound care management,
nutrition, role of exercises and physical
therapy explained. A common emotional
response seen is regression.

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Special needs of the nursing staff
• The staff of burn units are prone to higher
rates of burn-out. The care of a burn patient
is a long journey that the patient, nurse, and
significant others must travel. The road to
recovery is full of potential threats to the
patient. Support services are necessary for
the medical team of any long-term burn
patients.
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 Care of BURNS
B - breathing
body image
U - urine output
R - rule of nines
resuscitation of fluid
N - nutrition
S - shock
silvadene
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B- Breathing- keep airway open.
Facial burns, singed nasal hair,
hoarseness, sooty sputum, bloody
sputum and labored respiration
indicate TROUBLE!
TROUBLE
Body Image- assist Bernie in
coping by encouraging
expression of thoughts and
feelings.
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U- URINE OUTPUT- in an adult,
urine output should be 30-70 cc
per hour, in the child 20-50 cc per
hour, and in the infant, 10-20 cc
per hour. Watch the K+ to keep it
between 3.5-5.0 mEq/L. Keep the
CVP around 12 cm water
pressure!

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R- RESUSCITATION OF FLUID- Salt &
electrolyte solutions are essential over the
1st 24 hours. Maintain B/P at 90-100
systolic. ½ of the fluid for the first 24 hrs
should be administered over the first 8 hour
period, then the remainder is administered
over the next 16 hours. First 24 hour
calculation starts at the time of injury.
RULE OF NINE’S- used for adults to
determine burn surface area!

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N-NUTRITION- protein &
calories are components of the
diet! Supplemental gastric tube
feedings or hyperalimentation
may be used in pts with large
burned areas. Daily weights will
assist in evaluating the nutritional
needs!

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S-SHOCK- Watch the B/P, CVP, and
renal function.
Silvadene-for infection.

REMEMBER THESE PEOPLE ARE

AFRAID AND NEED
SUPPORT!!!!!

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