Lewis et al: Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 7th edition Key Points Chapter 25:

Nursing Management: Burns

Burns are body tissue injuries due to heat, cold, chemicals, electrical current, or radiation. Smoke and inhalation injuries result from inhalation of hot air or noxious chemicals.

The resulting effect of burns is influenced by the temperature of the burning agent, the duration of contact time, and the tissue type injured.

Burn prevention programs focus on child-resistant lighters; nonflammable childrens clothing; stricter building codes; smoke detectors/alarms; and fire sprinklers. Nurses need to advocate for scald- and fire riskreduction strategies in the home. Occupational health nurses need to educate workers to reduce scald, chemical, electrical, and thermal injuries in the work setting. Burn treatment is related to injury severity determined by depth. The extent is calculated by the percent of the total body surface area (TBSA), location, and patient risk factors. Burns are defined by degrees: first degree (same as sunburn), second degree, and third degree. A more precise definition of second- and third-degree burns includes the depth of skin destruction: partial-thickness and full-thickness. Second- and third-degree burn extent can be determined using total body surface area based on two guides: Lund-Browder chart and Rule of Nines. Burn extent is often revised after edema subsides and demarcation of injury zones occurs. Face, neck, and circumferential burns to the chest/back area may inhibit respiratory function with mechanical obstruction secondary to edema or leathery, devitalized tissue (eschar) formation. These injuries may cause inhalation injury and respiratory mucosal damage. Hands, feet, and eye burns may make self-care difficult and jeopardize future function. Buttocks or genitalia burns are susceptible to infection. Circumferential burns to extremities can cause circulatory compromise distal to the burn. Burn management is organized chronologically into three phases: emergent (resuscitative), acute (wound healing), and rehabilitation (restorative). Overlaps in care

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Key Points exist from one phase to another.

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EMERGENT PHASE Period of time required to resolve immediate, life-threatening problems. Phase may last from time of burn to 3 or more days, but it usually lasts 24 to 48 hours.

A primary concern is the onset of hypovolemic shock and edema formation. Toward the end of the phase, if fluid replacement is adequate, the capillary membrane permeability is restored. Fluid loss and edema formation cease. The interstitial fluid gradually returns to the vascular space. Diuresis occurs with low urine specific gravities. Manifestations include shock from the pain and hypovolemia. Areas of full-thickness and deep partial-thickness burns are initially anesthetic because the nerve endings are destroyed. Superficial to moderate partial-thickness burns are painful. Shivering occurs as a result of chilling, and most patients are alert. Unconsciousness or altered mental status is usually a result of hypoxia associated with smoke inhalation, head trauma, or excessive sedation or pain medication. Complications: o Cardiovascular system: dysrhythmias and hypovolemic shock o Respiratory system: vulnerable to upper airway injury causing edema formation and obstruction of airway, and inhalation injury o Renal system: if patient is hypovolemic, kidney blood flow may decrease, causing renal ischemia. If it continues, acute renal failure may develop. With fullthickness and electrical burns, myoglobin and hemoglobin are released into the bloodstream and occlude the renal tubules. Management includes a rapid and thorough assessment and intervention of airway management, fluid therapy, and wound care. Analgesics are ordered to promote patient comfort. Early in the postburn period, IV pain medications are given. Early and aggressive nutritional support decreases mortality and complications, optimizes healing of burn, and minimizes negative effects of hypermetabolism and catabolism.

ACUTE PHASE Begins with the mobilization of extracellular fluid and subsequent diuresis. Phase concludes when burned area is completely covered by skin grafts or when wounds are healed. This may take weeks or many months.

Manifestations include eschar from partial-thickness wounds. Once removed, reepithelialization appears as red or pink scar tissue. Margins of full-thickness eschar take longer to separate. As a result, they require surgical debridement and skin grafting for healing.

Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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Because the body is trying to reestablish fluid and electrolyte homeostasis, it is important for the nurse to follow the patients serum electrolyte levels closely (hypo- or hypernatremia, hypo- or hyperkalemia). Complications include wound infection progressing to transient bacteremia as result of manipulation (e.g., after hydrotherapy and debridement). Same cardiovascular and respiratory system complications as in emergent phase may continue. Patient can become extremely disoriented, withdraw, or be combative. This is a transient state, lasting from a day to several weeks. Range of motion may be limited and contractures can occur. Paralytic ileus results from sepsis. Diarrhea and constipation may also occur. Management involves wound care with daily observation, assessment, cleansing, debridement, and dressing reapplication. Individualized and consistent pain assessment and care are essential. Note two kinds of pain: continuous, background pain existing throughout day and night, and treatment pain associated with dressing changes, ambulation, and rehabilitation activities. First line of treatment is pharmacologic. Then use nonpharmacologic strategies, such as relaxation tapes, visualization, hypnosis, guided imagery, and biofeedback. Rigorous physical therapy throughout recovery is imperative to maintain joint function. Nutritional therapy provides adequate calories and protein to promote healing.

REHABILITATION PHASE Begins when wounds have healed and patient is able to resume self-care activity. Phase occurs as early as 2 weeks or as long as 7 to 8 months after the burn.

Goals are to assist the patient in resuming a functional role in society and accomplish functional and cosmetic reconstructive surgery. Manifestations include new skin appearing flat and pink, then raised and hyperemic; itching occurs with healing. Complications are skin and joint contractures and hypertrophic scarring. Management includes positioning, splinting, and exercise to minimize contracture. Burned legs may be wrapped with elastic (e.g., tensor/Ace) bandages to assist the circulation to the leg graft and donor sites. Patient education and hands-on instruction need to be provided in dressing changes and wound care. Continuous exercise and physical/occupational therapy cannot be overemphasized. Encouragement and reassurance are necessary for patient morale, attaining independence, and returning to preburn activities.

Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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For patient with emotional needs, it is important that the nurse have understanding of circumstances of burn, family relationships, and prior coping experiences with stressful situations. Patient may experience fear, anxiety, anger, guilt, and depression.

Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc.