Burn Injury

Chapter 28
CARE OF PATIENTS WITH

BURNS
Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Burns
Occur when there is injury to tissues of the body caused by heat, chemicals,
electrical current, or radiation
Should be viewed as preventable
Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Burns
Epidermis (outer layer of the skin)
0.15 mm thick but thinner in older adults
layer can grow back after a burn injury
no blood vessels nutrients are diffused from the dermis
Dermis
Thicker than epidermis
contains blood vessels, sensory nerves, hair follicles,
lymph vessels, sebaceous glands and sweat glands
skin cannot restore itself

Types of Burn Injury

Dry heat
Moist heat
Contact
Chemical
Electrical burns: entry and exit site

Electrical Burns
Severity of injury depends on
Amount of voltage
Tissue resistance
Current pathways
Surface area
Duration of the flow


Electrical Burns
Current that passes through vital organs will produce more life-threatening
sequelae than current that passes through other tissue
Electrical sparks may ignite patients clothing, causing a combination of
thermal flash injury


Electrical Burns
Severity of injury can be difficult to assess, as most damage occurs beneath skin
Iceberg effect
Electrical current may cause muscle spasms strong enough to fracture bones

Classification of Burn Injury

Severity of injury is determined by
Depth of burn: how deep into the skin the burn goes
Superficial: Epidermis
Extent of burn in percent of TBSA( total body surface area)
Location of burn
Patient risk factors

Identify the Burn Depth

Superficial/Partial Burns
Superficial/Partial
involves the epidermis, blistering, healing
is rapid
3-6 days for this injury to heal
No scar formation
Table 28-1

Deep Partial Burn
Deep Partial Burn

Deep Partial: Involves the epidermis and dermis,
redness or white to skin, moderate edema
Takes 3-6 weeks to heal
Scar formation does occur
A few healthy cells remain

Full Thickness
Full Thickness Burns

Full Thickness: Involves the epidermis, dermis, and fat
Fatty tissue and blackened skin (eschar?) can be seen
May see muscle or bone involved
The deeper it is, the less pain is felt: the nerve endings are
destroyed
Will not heal on its own, skin and blood vessels are
destroyed
Patient will require a skin graft

Extent of Burn - determined by TBSA
Why is it important to know?
Determines the amount of fluids and calories the patient
will need

Extent of Burn
Two commonly used guides for determining the total body surface area
Lund-Browder chart
Considered more accurate: takes age into consideration
Rule of Nines
Used for initial assessment
More general, quicker

Rule of Nines Chart

Know how to determine
percentage of burns


Smoke Inhalation Injuries
From inhalation of hot air or noxious chemicals
Cause damage to respiratory tract
Major predictor of mortality in burn victims
Need to be treated quickly


Location of Burn
Severity of burn injury is determined by location of burn wound
Face, neck, chest respiratory obstruction
from inhalation of chemicals or indirect heat to the area - causes inflammation
which can lead to obstructions
Hands, feet, joints, eyes self-care deficit
Ears, nose, buttocks, perineum infection
There can be contamination from urine and feces: buttocks and perineum
Ear and nose have a poor blood supply


Location of Burn
Eschar formation can cut off blood supply and interfere with
healing
Circumferential burn to the chest area: interfere with
breathing, constrict the chest wall to move
make sure the pt is breathing and doesnt develop
Patients may also develop compartment syndrome


Patient Risk Factors
Pre-existing cardiovascular, respiratory, and renal diseases contribute to poorer
prognosis
Diabetes mellitus and peripheral vascular disease contribute to poor healing
and gangrene
will be more difficult to recover


Patient Risk Factors
Physical debilitation renders patient less able to recover
Alcoholism
Drug abuse
Malnutrition
Concurrent fractures, head injuries, or other trauma leads to a more difficult
time recovering
Difficult time to recover

Resuscitation/Early Phase of Burn Injury

Continues for about 24 to 48 hours
The resuscitation phase is the first phase of a burn injury. It begins at the onset
of injury and continues for about 24 to 48 hours. During this phase, the injury is
evaluated and the immediate problems of fluid loss, edema, and reduced blood
flow are assessed. The priorities for management during this period are to (1)
secure the airway, (2) support circulation by fluid replacement, (3) keep the
patient comfortable with analgesics, (4) prevent infection through careful
wound care, (5) maintain body temperature, and (6) provide emotional support.
Vascular changes that occur:

Fluid shifts from vascular to interstitial space
capillary leak syndrome
concerned with the systemic effects of the burn: ABCs are priority
Goals of management?
General Management for All Types of Burns

Assess for airway patency.
Administer oxygen as needed.
Cover the patient with a blanket.
Keep the patient on NPO status.
Elevate the extremities if no fractures are obvious.
Obtain vital signs.
Initiate an IV line, and begin fluid replacement.
Administer tetanus toxoid for prophylaxis.
Perform a head-to-toe assessment.
Specific Management
Flame Burns
Smother the flames.
Remove smoldering clothing and all metal objects.
Chemical Burns
If dry chemicals are present on skin or clothing, DO NOT WET THEM.
Brush off any dry chemicals present on the skin or clothing.
Remove the patient's clothing.
Ascertain the type of chemical causing the burn.
Do not attempt to neutralize the chemical unless it has been positively identified
and the appropriate neutralizing agent is available.
Electrical Burns
At the scene, separate the patient from the electrical current.
Smother any flames that are present.
Initiate cardiopulmonary resuscitation.
Obtain an electrocardiogram (ECG).
Radiation Burns
Remove the patient from the radiation source.
If the patient has been exposed to radiation from an unsealed source, remove his
or her clothing (using tongs or lead protective gloves).
If the patient has radioactive particles on the skin, send him or her to the nearest
designated radiation decontamination center.
Help the patient bathe or shower.
Concerned with the systemic effects of the burn

ABC is a priority
Airway/respiratory first
Assess for signs of inhalation injuries: facial involvement,
singed hair on face, mouth is black
Breathing
Key signs that your patient is deteriorating for inhalation injury
Hoarseness, brassy cough, difficulty swallowing, drooling, stridor wheezing

Look at respiratory effort (use of accessory muscle)
If patient shows signs of inhalation injury, what will you as the nurse do?
Interventions
Give oxygen
Call Rapid Response! prepare for intubation
Make sure there is intubation equipment at the bedside
Once they are showing signs of inhalation injury, there are at risk for
respiratory arrest/failure, the airways getting more narrow
Suction
HOB elevated: Sit patient up, turning pt frequently
Encourage patient to use incentive spirometer
Monitor ABGs labs
Factors Determining Airway Obstruction or Inhalation Injury
Patients who were injured in a closed space
Patients with extensive burns or with burns of the face
Intra-oral charcoal, especially on teeth and gums
Patients who were unconscious at the time of injury
Patients with singed scalp hair, nasal hairs, eyelids, or eyelashes
Patients who are coughing up carbonaceous sputum
Changes in voice such as hoarseness or brassy cough
Use of accessory muscles or stridor
Poor oxygenation or ventilation
Edema, erythema, and ulceration of airway mucosa
Wheezing, bronchospasm
Factors Determining Airway Obstruction or Inhalation Injury
A change in respiratory pattern may indicate a pulmonary injury. The patient may:
Become progressively hoarse
Develop a brassy cough
Drool or have difficulty swallowing
Produce sounds on exhalation that include audible wheezes, crowing, and stridor
Any of these changes may mean the patient is about to lose his or her airway.
Immediately apply oxygen and call Dr
Circulation
C - Patient is at risk for hypovolemic shock: big cause of death in this phase
Fluid resuscitation must be started immediately!
Monitor edema, urine output, vital signs (BP, pulse)
To determine how much fluid infusion the pt needs we use Parkland formula
Fluid Resuscitation of the Burn Patient
Initiate and maintain at least one large-bore IV in an area of intact skin (if
possible).
Coordinate with physicians to determine the appropriate fluid type and total
volume to be infused during the first 24 hours postburn.
Administer one half of the total 24-hour prescribed volume within the first 8
hours postburn and the remaining volume over the next 16 hours.
Assess IV access site, infusion rate, and infused volume at least hourly.

Monitor these vital signs at least hourly:
Blood pressure
Pulse rate
Respiratory rate
Breath sounds
Voice quality (if not intubated)
Oxygen saturation
End-tidal carbon dioxide levels

Assess urine output at least hourly:
Volume
Specific gravity
Color
Character
Presence of protein
Assess for fluid overload:
Formation of dependent edema
Engorged neck veins
Rapid, thready pulse
Presence of lung crackles or wheezes on auscultation
Measure additional body fluid output hourly

Application of Parkland Formula

A Patient weighing 154 lbs has a burn with a TBSA of 50%. The patient was
found at home at 8am and arrived to the hospital at 10am.
How much fluid should be administer in the first 8 hours? Calculate the
rate.
4 x patient weight in kg x TBSA : this will give you the total volume of fluid
First 8 hours administer half of the total volume
Must infuse within the first 8 hours: time starts from when the burn injury
occurred, not the time they arrived at the hospital.
Rate divided by 6 instead of 8
EX. A Patient weighing 154 lbs has a burn with a TBSA of 50%. The patient
was found at home at 8am and arrived to the hospital at 10am.
Application of Parkland Formula

How much fluid should be administer in the first 8
hours? Calculate the rate.
154 lbs= 70kg
4ml x 70kg x 50% = 14,000
14,000 : 2 = 7,000 ml
7,000ml : 6h = 1,167 ml/h
Evaluation after Giving Fluids
Monitor their response: Urine output is a key indicator, Vital

signs (BP, HR)
Patient will have a foley catheter to measure UOP accurately
Facial Edema Before and After Fluid Resuscitation
Treat pain: Morphine, Dilaudid
Monitor closely
PCA pump
P - Pain
Strong pain meds: if pt will have a respiratory depression he
has to be intubated
Facial Edema Before and After Fluid Resuscitation

Surgical Management of Burns

Escharotomy
Fasciotomy

Escharotomy
Incision made through tight eschar to

relieve pressure and allow normal
blood flow and breathing.
Fasciotomy
A surgical procedure in which an incision

is made through the skin and
subcutaneous tissues into the fascia of the
affected compartment to relieve the
pressure in and restore circulation to the
affected area in the patient with acute
compartment syndrome.
Escharotomy - eschar can cut off blood supply and interfere with healing, can be
done at the bedside
Fasciotomy - under anesthesia
**Although a patient may come in with a horrific burn injury, were more worried about
systemic effects that are acutally more detrimental
Acute Phase of Burn Injury

Begins about 36 to 48 hr after injury; lasts until wound
closure is completed
Fluid starts to shift back from interstitial into the
vascular space
Urine output will increase even more
Concern about infection
Wound care
Nutrition
Mobility

Infection prevention
Sterile technique
No flowers in the room
At risk for pseudomonas
Minimize visitors: children and those with illness should not be allowed
Immunization: Depends on pt immunization status, tetanus ( burn wound
is breeding ground for the organism)
Only give systemic antibiotics and only if patient is showing signs of
infections
Signs of infection: look at the wound, temperature
Hyperinflammatory response: high temperature - give nsaids, tylenol,

Wound care:
Debriding: remove dead tissue, ensure viable tissue to
promote healing
Risk for hypothermia - because skin is removed
Premedicate with pain medication before wound care
Once debrided, a topical ointment is applied Silvedine

Nutrition
Requires a lot of calories hypermetabolic state
burns more calories
Can exceed 5,000 calories/day
High protein, high protein supplements
Can request food at any time, consider the patients
preferences
Promotes healing

Mobility:
Prevent contractures: ROM to the affected extremity
Scar formation can limit the range of motion ability
Out of bed as soon as possible
Rehabilitative Phase of
Burn Injury
Begins with wound closure, ends when patient returns
to highest possible level of functioning
Emphasis on psychosocial adjustment, prevention of
scars and contractures, resumption of preburn activity
Social work, referrals
Rehabilitative Phase of Burn Injury (contd)

This phase may last years or even a lifetime if patient needs to adjust to
permanent limitations
A patient arrives to the ED with superficial facial burns from an explosion

in his apartment building. He has productive carbonaceous sputum with
labored respirations and singed hair.
Based on these findings what is the highest priority of care for this patient?
Airway!
Patient is showing signs of inhalation injury: carbonaceous sputum,
singed hair, labored respirations
(contd)
Which symptoms may indicate a pulmonary injury from the inhalation?
(Select all that apply.)
A.
B.
C.
D.
E.
Development of a brassy cough

Drooling
Clear speech
Audible wheeze
Clear breath sounds
(contd)
Twenty minutes later, assessment of the patient reveals loud wheezing on
exhalation. What is the nurses best action at this time?
A.
B.
C.
D.
Check the patients SaO2 with pulse oximetry.

Apply oxygen and call the Rapid Response Team.
Call a CODE and bring the crash cart to the room.
Call respiratory therapy for a treatment with a bronchodilator.
Chapter 28
AUDIENCE RESPONSE SYSTEM

QUESTIONS
Question 1
A patient is admitted to the ED with burns to his lower legs and hands after
a gas can exploded. What is the initial nursing priority on admission?
A.
B.
C.
D.
Assess and treat his pain. step 4

Use the rule of nines to estimate his percent of body surface area
burned. step 2
Evaluate his airway and circulation. step 1
Place two IV catheters and initiate fluid resuscitation. step 3
Question 2
It has been 12 hours since a patient has been admitted for burns to his face
and neck and for inhalation injuries. He had been wheezing audibly, but at
this time the nurse notes that his wheezing has stopped. What should the
nurse do?
Document this improvement in the patients condition.
Re-assess his breathing in an hour.
Check the patients SPO2 level.
Notify the physician immediately.
Question 3
A patient has been receiving dressing changes with silver sulfadiazine
(Silvadene) for burn injuries over both lower arms. The nurse notices that
the patients white blood cell count has dropped significantly over the past
4 days. What may this change indicate?
A.
B.
C.
D.
The patients infection is improving.

The patient is having an allergic reaction to the silver sulfadiazine.
The patient has kidney disease.
The patient has an electrolyte imbalance.

Burn Injury

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Chapter 28

CARE OF PATIENTS WITH

Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Types of Burn Injury

Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Types of Burn Injury

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Types of Burn Injury

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Types of Burn Injury

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Classification of Burn Injury

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Identify the Burn Depth

Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Identify the Burn Depth

Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Deep Partial Burn

Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Identify the Burn Depth

Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Full Thickness Burns

Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Classification of Burn Injury

Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Classification of Burn Injury

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Rule of Nines Chart

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Types of Burn Injury

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Classification of Burn Injury

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Classification of Burn Injury

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Classification of Burn Injury

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Classification of Burn Injury

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Resuscitation/Early Phase of Burn Injury

Vascular changes that occur:

Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

General Management for All Types of Burns

Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Concerned with the systemic effects of the burn

Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Hoarseness, brassy cough, difficulty swallowing, drooling, stridor wheezing

Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Factors Determining Airway Obstruction or Inhalation Injury

Patients who were injured in a closed space

Patients with extensive burns or with burns of the face

Intra-oral charcoal, especially on teeth and gums

Patients who were unconscious at the time of injury

Patients with singed scalp hair, nasal hairs, eyelids, or eyelashes

Patients who are coughing up carbonaceous sputum

Changes in voice such as hoarseness or brassy cough

Use of accessory muscles or stridor

Poor oxygenation or ventilation

Edema, erythema, and ulceration of airway mucosa