Burns

Created by Nicole Shafar RN,

BSN

Objectives
Safe and Effective are Environment
Apply principles of asepsis to protect
burn patients and open wounds.
Manage the patients environment to
prevent infection from auto
contamination and cross contamination
in patients with burn injuries.

Objectives Continued
Health Promotion and Maintenance
Teach everyone fire prevention
strategies
Instruct everyone on the correct use of
placement of smoke detectors and
carbon monoxide detectors.

Objectives Continued
Psychosocial Integrity
Support the patient and family in coping with
permanent changes in appearance and
function
Encourage the burn patient with wound and
scars to participate in burn care.
Assess the patients and familys use of
coping strategies related to burn injury,
treatment, possible changes and outcomes.
Allow patients who have lost family members,
homes or jobs time to grieve for their losses.

Objectives Continued
Psychosocial Integrity
Identify burn patients at risk for inhalation
injury.
Compare the manifestations of superficial,
partial-thickness, and full-thickness burn
injuries.
Explain the expected manifestations of neural
and hormonal compensation during the
resuscitation/emergent phase of burn injury.
Prioritize nursing care for the patient during the
resuscitation/emergent phase of burn injury.

Objectives Continued
Use laboratory data and clinical
manifestations to determine the
effectiveness of fluid resuscitation/emergent
phase of burn injury.
Prioritize nursing care for the patient during
the acute phase of burn injury.
Coordinate with the nutritionist to meet the
nutritional needs for the patient during the
acute phase of the burn injury.
Evaluate the patients wound healing during
the acute phase of the burn injury.

Objectives Continued
Compare pain management for patients in
the resuscitation/emergent and acute
phases of burn injury.
Describe the characteristics of infected burn
wounds.
Use appropriate positioning and range-ofmotion interventions for prevention of
mobility problems in the patient with burns
Coordinate nursing care for the patient
during the rehabilitation phase of burn
injury.

Classifications
Superficial Partial Thickness
Deep Partial Thickness
Full Thickness

Visualizing Burn Depth

Superficial Partial Thickness

Of all burn types; this type has the
least damage because the epidermis is
the only part of the skin that is injured.
Symptoms: redness with mild edema,
pain and increased sensitivity to heat.
Blisters. Desquamation (peeling of dead
skin) occurs for 2 to 3 days after the burn.
The area heals rapidly in 3-5days without
a scar or other complication.

Deep Partial Thickness

Wounds extend deeper into the skin dermis,
and fewer healthy cells remain. In these
patients, blisters usually do not form
because the dead tissue layer is so thick and
sticks to the underlying dermis that it does
not readily lift off the surface. Heals in 36wks, but scar formation results.
Symptoms: the wound surface is red and dry
with white areas in deeper parts. It may blanch
slowly or not at all, edema is moderate and pain
is less than superficial burns.

Full Thickness
Wounds occur with destruction of the
entire epidermis and dermis, leaving no
true skin to heal on its own. Will require
grafting. Take weeks to months to heal.
Symptoms: has a hard, dry leathery
eschar that forms from coagulated
particles of destroyed dermis. Eschar must
slough off or be removed before healing
can occur.

Deep Full Thickness Burn

Extend beyond the skin into
underlying fascia and tissues. These
injuries damage muscle, bone,
tendons and leave them exposed.
Symptoms: the wound is blackened and
depressed, and sensation is completely
absent. These wounds need excision and
grafting. Amputation may be needed
when an extremity is involved.

Changes From Burn Injury

Changes include:
Cardiac
Pulmonary
GI (Curlings ulcer)
Metabolic
Immunologic

Vascular Changes Resulting

From Burn Injury
Fluid shiftthird spacing or capillary leak
syndrome, usually occurs in the first 12 hr
and can continue 24 to 36 hr
Profound imbalance of fluid, electrolyte,
and acid-base, hyperkalemia and
hyponatremia levels, and
hemoconcentration
Fluid remobilization after 24 hr, diuretic
stage begins 48 to 72 hr after injury,
hyponatremia and hypokalemia

Cardiac Changes
Heart rate increases
Cardiac output decreases

Pulmonary Changes

Respiratory failure
Inhalation injury
Sloughing
Pulmonary insufficiency and infection

Gastrointestinal Changes

Decreased blood flow

Mucosa is impaired
Peristalsis is affected
Curlings ulcer

Metabolic Changes
Increases metabolism
Caloric needs double or triple
depending on the extend of injury.
Increased core body temperature

Immunologic Changes
Protective barrier destroyed
Inflammatory response activated
Suppressed immune function

Compensatory Responses to
Burn Injury
Inflammatory compensation can
trigger healing.
Sympathetic nervous system
compensation occurs when any
physical or psychological stressors
are present.

Etiology of a burn Injury

Dry heat
Moist heat
Contact burns
Chemical injury
Electrical injury
Radiation injury

Resuscitation/Emergent
Phase
Is the first phase of a burn injury. The
primary goals for this period are to:
secure the airway
support circulation by fluid replacement
keep the patient comfortable with analgesics
prevent infection through careful wound care
maintain body temperature
provide emotional support

Respiratory Manifestations

Direct airway injury

Carbon monoxide poisoning
Thermal injury
Smoke poisoning
Pulmonary fluid overload
External factors

Cardiovascular Assessment
Hypovolemic shock is a common
cause of death in the emergent
phase in patients with serious
injuries.
Monitor vital signs.
Monitor cardiac status, especially in
cases of electrical burn injuries.

Renal/Urinary Assessment
Changes are related to cellular debris
and decreased renal blood flow.
Myoglobin is released from damaged
muscle and circulates to the kidney.
Assess renal function, blood urea
nitrogen, serum creatinine, and
serum sodium levels.
Examine urine for color, odor, and
presence of particles or foam.

Skin Assessment
Determine size and depth of injury.
Determine percentage of total body
surface area affected.
Use "rule of nines," using multiples of
9% of total body surface area.

Rule of Nines

Nonsurgical Management
IV fluids
Monitoring patient response to fluid
therapy
Drug therapy

Surgical Management
Escharotomy
Fasciotomy

Acute Phase of Burn Injury

Begins about 36 to 48 hr after injury and lasts until
wound closure is completed
Care directed toward continued assessment and
maintenance of the cardiovascular and respiratory
systems, as well as toward GI and nutritional status,
burn wound care, pain control, and psychosocial
interventions Begins about 36 to 48 hr after injury and
lasts until wound closure is completed
Care directed toward continued assessment and
maintenance of the cardiovascular and respiratory
systems, as well as toward GI and nutritional status,
burn wound care, pain control, and psychosocial
interventions

Assessment
Assessments include those of:
Cardiopulmonary
Neuroendocrine
Immune
Musculoskeletal

Nonsurgical Management
Mechanical dbridement:
Hydrotherapy

Enzymatic dbridement:
Autolysis
Collagenase

Positioning to Prevent
Contractures

See Chart page 544

Head
Neck
Hip

Dressing the Burn Wound

Standard wound dressings
Biologic dressings:
Homografthuman skin
Heterograftskin from other species
Amniotic membrane
Cultured skin
Artificial skin

Biosynthetic dressings
Synthetic dressings

Surgical Management
Surgical excision
Wound covering:
Skin graft

Nonsurgical Management
Drug therapy
Isolation therapy
Environmental management

Rehabilitative Phase
Rehabilitation begins with wound closure
and ends when the patient returns to the
highest possible level of functioning.
Emphasis during this phase is on
psychosocial adjustment, prevention of
scars and contractures, and resumption
of preburn activity.
This phase may last years or even a
lifetime if patient needs to adjust to
permanent limitations.