BURNS

  • Traumatic injury to the skin or tissue due to thermal, cold, electrical, radiation, friction, or chemical exposure
  • Range from minor => life-threatening
  • Possibly permanently disfiguring and incapacitating
  • Depth of injury ranging from superficial to full thickness

Classification

  • 1st degree / Superfcial
  • 2nd Degree / Superficial/ Partial thickness
  • 2nd degree / Deep partial thickness
  • 3rd / 4th degree/ Full thickness burns

2nd degree/ Superficial

  • Injury extends from the epidermis into the *superficial layer of the dermis.
  • Thin-walled, fluid-filled blisters form.
  • Nerve endings are exposed to air when blisters break, causing pain.
  • Loss of the skin's barrier function occurs.

2nd degree Deep

  • Injury extends from the epidermis into the deep layers of the dermis.
  • Damage to hair follicles and glandular tissue occurs.
  • Thicker-walled blistery areas form that usually present as red or waxy white.
  • Nerve endings are exposed to air when blisters break, causing pain.
  • Skin loses its barrier function.
  • Grafting may be necessary.

1st degree/ Superficial:

  • local epidermal injury
  • non-life threatening

3rd & 4th degree/ Full thickness

  • Injury affects every body system and organ.
  • Injury extends into the subcutaneous tissue layer.
  • Muscle, bone, and interstitial tissues suffer damage (fourth-degree).
  • Interstitial fluids result in edema.
  • Immediate immunologic response occurs.
  • Wound sepsis may occur.
  • Injuries are painless because of extensive nerve damage.

Causes

  • Electrical: Contact with electrical source, faulty electrical wiring, or high-voltage power lines
  • Thermal: Contact with heat, steam, or flames
    Scald: Contact with hot water
  • Chemical: Contact, ingestion, inhalation, or injection of acids, alkali, or vesicants
  • Radiation: Exposure to sun, sun-lamps, or radiation therapy
  • Friction: Contact with rough surfaces, such as roadway, carpet, or gym floors
  • Cold exposure: Exposure to extreme cold (also known as frostbite)

Risk Factors

  • Dementia
  • Smoking
  • Poor socioeconomic status
  • Developmental disabilities (children)
  • Adults with chronic illness with poor mobility
  • Sun exposure /no sunscreen
  • Occupation w/ exposure to burn source: firefighters, cooks, electricians, chemical workers

Incidence

  • Burns affect 1.2 to 2 million people/ year in US.
  • Most =thermal (from heat).
  • Minor burns =most common type (young adults).
  • 69% occur @ home.

Complications

  • Anemia
  • Flexion contractures (affected area)
  • Scarring + disability (deformity /destruction of skin, nerves, vessels, and musculoskeletal tissue)
  • Gastroduodenal ulcer (increase gastric acid secretion from stress)
  • Hypovolemic shock
  • Malnutrition
  • Multiple organ dysfunction syndrome
  • Pneumonia
  • Acute respiratory distress syndrome
  • Respiratory collapse
  • Sepsis

Assessment

Hx

  • Cause of burn revealed (most commonly open flame or hot liquid)
  • Preexisting medical conditions
  • Estimated severity of the burn (according to the American Burn Association):
    • Minor
      • < 10% of total body surface area (TBSA) in adults
      • < 5% TBSA in adults over age 50
      • < 2% full-thickness burn
    • Moderate
      • 10% to 20% TBSA burn in adults
      • 5% to 10% TBSA in adults over age 50
      • 2% to 5% full-thickness burn
      • High-voltage injury
      • Suspected inhalation injury
      • Circumferential burn
      • Underlying medical problem, such as diabetes
    • Major

      • 20% TBSA burn in adults

      • 10% TBSA burn in adult over age 50

      • 5% full-thickness burn

      • High-voltage burn
      • Known inhalation injury
      • Any significant burn to the face, eyes, ears, genitalia, or joints
      • Significant associated injuries

Physical Findings

  • Depth / Size of burn
  • Estimated burn severity
  • Respiratory distress and cyanosis
  • Edema
  • Alterations in pulse rate, strength, and regularity
  • Stridor, wheezing, crackles, and rhonchi
  • Hoarseness
  • S3 or S4 heart sounds
  • Hypotension
  • Soot marks on face
  • Blisters or edema of oropharynx

Other Physical Findings

  • Respiratory distress and cyanosis
  • Edema
  • Alterations in pulse rate, strength, and regularity
  • Stridor, wheezing, crackles, and rhonchi
  • Hoarseness
  • S3 or S4 heart sounds
  • Hypotension
  • Soot marks on face
  • Blisters or edema of oropharynx
  • Depth and size of burn

Full-thickness (third-degree)

  • Waxy white, leathery, or charred skin that does not blanch and is nonpliable to palpation
  • Destruction of all layers of skin and subcutaneous layers, resulting in an avascular burn w/o tenderness
  • increased risk of infection and sepsis

Superficial (first-degree)

  • erythema of tissue
  • skin blanching with pressure
  • possible tenderness (resembles sunburn)

Partial-thickness:

Superficial partial-thickness

  • red, blistered, highly tender skin
  • blanching with pressure
  • no scarring
  • Deep partial-thickness
  • Possibly red or waxy white (mottled appearance from patchy, cheesy white to red)
  • No blanching with pressure
  • significantly delayed or absent capillary refill time
  • impaired sensation
  • painful to pressure
  • blistering

Monitoring

  • Vital signs
  • Pain level + effectiveness of interventions
  • Respiratory status
  • Cardiac status
  • Burn areas, including evidence of healing
  • S&S of infection + shock
  • I&O
  • Daily weight
  • Fluid balance
  • Nutritional status
  • emotional status /coping mechanisms

Patient Teaching

Diagnostics
Laboratory

  • Arterial blood gases:
    • levels may show evidence of smoke inhalation, decreased alveolar function, and hypoxia.
      *CBC
    • may show decreased Hemoglobin / hematocrit from blood loss
  • CMP: Complete metabolic Panel
    • fluid losses and shifts=> abnormal electrolyte levels.
  • BUN
    • fluid losses => increase
  • UA:
    • myoglobinuria +hemoglobinuria.
  • Carboxyhemoglobin:
    • inhalation burns /exposure to enclosed fires =>level increases

Procedures

  • Electrocardiography
    • myocardial ischemia/ injury / arrhythmias ( especially in electrical burns or carbon monoxide poisoning)
  • Fiber-optic bronchoscopy
    • shows airway edema from inhalation burns /steam injuries.

Fluid Replacement post burn injury
To replace fluid in an adult with a burn, use the Parkland formula:

  • 4 mL × patient's weight (kg) × % TBSA burn (lactated Ringer solution)
  • Give one-half of volume in the first 8 hours, and then infuse the remainder over 16 hours.

Medications

  • Tetanus toxoid booster
  • Analgesics,
    • I.V. morphine sulfate
    • methadone hydrochloride (Dolophine) severe pain
    • codeine phosphate-acetaminophen (Tylenol w/ Codeine)
    • oxycodone hydrochloride-acetaminophen (Percocet)
    • hydrocodone bitartrate-acetaminophen (Norco) moderate pain
  • Mannitol (Osmitrol) (oliguria in electrical burns)
  • Silver sulfadiazine (topically)
    🚫 Avoid applying silver sulfadiazine to the face (prevent permanent facial discoloration)
  • bacitracin ointment (superficial partial-thickness burns)
  • Mafenide (severe infected burns + no response 2 silver sulfadiazine)
  • Histamine-2 blockers (stress ulcer prophylaxis for severe burns)
    • cimetidine (Tagamet)
    • ranitidine (Zantac)
    • famotidine (Pepcid)
  • Insulin therapy (glycemic control for severe burns)
  • Oxygen therapy

General Treatment

  • Eliminate burn source; cessation of the burning process
  • Decontaminate chemical burns
  • Remove constrictive clothing / jewelry
  • Assess + Secure Airway, breathing, and circulation
  • Intubate for inhalation injury
  • Administer Oxygen /maintain SpO2 94%–98%
  • ECG monitoring x 1st 24 h
  • Prevent hypoxia
  • I.V. fluids through large-bore line: urine output
    • 0.5 to 1 mL/kg/hour
    • electrical injuries /rhabdomyolysis / myoglobulinuria present= urine output at 1 to 2 mL/kg/hour
  • Urine Output qh =Foley Cath
  • NG tube for decompression + aspiration prevention
  • Wound care
  • Physical / Occupational therapy
  • VTE prophylaxis if hospitalized
  • Prepare patient 4 transport to burn center, if appropriate

Diet
*NPO until burn severity established => high-protein, high-calorie BS return

  • Increased hydration w/high-calorie/protein drinks
    *no free water
    *Enteral feedings if unable to take food orally
  • TPN if unable to take food by mouth
  • Control of Blood Glucose levels (hypermetabolic stress response / receiving TPN)

Activity

  • Limitations based on extent + location of burn and treatment
  • PT

Surgery

  • Debridement
  • Fasciotomy / escharotomy
  • Skin grafting

Nursing Interventions

  • Imediate, aggressive burn treatment.
  • Strict sterile technique.
  • Remove pt's clothing; cover all burned areas with dry sheets.
  • Remove constrictive items, (rings/ watches) to prevent tourniquet effect.
  • Administer 100% O2 for all major burns; maintain saturation between 94%-98%; anticipate need for endotracheal intubation + mechanical ventilation.
  • Perform appropriate wound care
    • Whirlpool hydrotherapy
    • daily or twice-daily wound cleaning w/ dressing changes.
  • Administer fluid replacement therapy as ordered
  • Insert Foley catheter (evaluate hourly urine output)
  • Give analgesics as ordered.
    • if administering morphine I.V. give small freq doses+ be alert for respiratory depression
  • Ensure patent I.V. access.
  • Pre-medicate pt w/ analgesics before:
    • dressing changes
    • wound care
    • hydrotherapy
  • In pt w/electrical burns +evidence of myoglobulinuria increase fluids to decrease risk of kidney failure.
  • mannitol (Osmitrol-alkalization agent) if fluid boluses don't increase urine output / decrease urinary pigmentation
    Institute continuous cardiac monitoring for the 1st 24 h post electrical burn.
  • Auscultate heart /lung sounds for changes.
  • Institute hemodynamic monitoring as appropriate.
  • Daily patient weight.
  • Reposition pt min q two hours,
  • Assess skin integrity + perform skin care.
  • Provide NG tube feedings if ordered + indicated, or
  • TPN if the patient is expected to be on NPO status for > 5 days.
  • Provide a high-calorie/ high-protein diet once bowel function returns.
  • Administer histamine-2 blockers (ulcer prophylaxis)
  • Obtain specimens for laboratory testing, including CBC, BUN / creatinine + ABG's.
  • Prepare the patient +family for possible surgery (escharotomy or skin grafting)
  • Apply antiembolism stockings /sequential compression stockings (prevent VTE)
  • Encourage verbalization +provide support.
  • Allow the patient & family to verbalize fears /concerns
  • Provide honest explanations /answers
  • Assist with positive coping strategies

General

  • injury, diagnostic testing, + treatment, including the use of analgesics for pain relief
    appropriate wound-care methods, including dressing changes, topical applications, and types of dressings
  • pain-relief measures, including the use of analgesics
  • prescribed medications, including drugs, dosages, schedule of administration, rationale for use, and possible adverse reactions
  • appropriate nutritional plan, including ways to increase calories and protein in the diet
  • signs and symptoms of infection
  • signs and symptoms of complications
  • infection-control measures
  • activity and exercise program as indicated
  • care of the donor and skin graft sites if appropriate
  • burn-prevention measures, if indicated
  • long-term nature of the care required if surgery or skin grafting is indicated.

Discharge Planning

  • coordinate discharge planning efforts w/ care team including bedside nurse, social worker, care manager, psychiatrist, burn specialist, physical therapist, and surgeon.
  • Determine the appropriate post-hospital setting to be discharged to.
  • Assess pt /family understanding of the diagnosis, treatment, prognosis, follow-up, +warning signs for which to seek medical attention.
  • Assess the pt's cognitive status.
  • Assess the pt's level of independence prior to admission + how the p's current illness will impact his independence.
  • Identify the pt's formal /informal supports.
  • Identify the pt's and family's goals, preferences, comprehension, and concerns about discharge.
  • Confirm arrangements for transportation to initial follow-ups.
  • Assess/confirm the pt's + family's understanding of prescribed medication, including dosage, administration, expected results, duration, and possible adverse effects.
  • Assess/confirm the patient's ability to obtain medications+ identify the party responsible for obtaining medications.
  • Ensure that the patient +caregivers have been given medical contact information.
  • Provide contact information for local support groups/ services.
  • Document the discharge planning evaluation in the patient's clinical record, including who was present/involved in discharge planning and teaching.
  • Document the pt's understanding of the teaching provided and if follow-up teaching is needed.