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.
• Thermal burns: most common, occurs when source is direct to skin ( flames, hot h2o,
fire works)
• Elderly have less pain receptors and are therefore more prone to burn injuries, pts w/ DM
also prone to burns because of diabetic neuropathy.
• Ingestion of chemicals: do not make victim vomit!! Call posien control
• Eye contact w/ chemicals: flush!!
• Flushing chemical wounds works best if done 20min-2 hrs after burn. Flush fot 15-20
min. remove clothing and jewlrey exposed to chemical
• Alkali burns: cause protein hydrolysis and liquification. Alkali found in ovens, fertilizers
and drain cleaners.
• Chemical burns continue bruning for 72 hoours after chemical is removed

• Smoke and inhalation injuries result from inhalation of hot air or noxious chemicals.

• Injury above glottis: cause inhalation of hot air, steam or smoke. s/s= singed nasal hair,
dysphagia, dark oral mucous membranes , hx of being burned in an enclosed space. Can
cause mechanical obstruction

• Injury below the glottis: cause usually chemically induced. Pulmonary edema may not
appear until 12 -24 hrs after burn. s/s : constant coughing, wheezing ( indicates there is
still an airway) dyspnea,

• Electrical burn injurys. All pts with electrical injuries considered risk for cervical spine
injury. Burns cause tetnay and victim cannot let go of item. 1st turn off power source!!!
Do not touch pt until source is off!!! Electricity follows path way of least resistance. Fat
and bone highest resistance. Nerves / blood vessel have less resistance. Severity is
difficult to determine. Most damage is below skin. Can cause bone fx!! If current passes
through heart will see ekg changes! If passes through head, may see neuro changes check
pulses distal to burns. Complications: Metabolic acidosis, cardiac arrest,
myoglobinemia ARF due to blockage of kidney vessels. Delayed dysrythmias can
occur up to 24 hrs after burn. Monitor ABG’s quickly, NaHCO3 to alkalize urine. Keep
urine at 75-100 ml/hr!!

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

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

Key Points 25-2

• Burn prevention programs focus on child-resistant lighters; nonflammable children’s

clothing; stricter building codes; smoke detectors/alarms; and fire sprinklers.

• Nurses need to advocate for scald- and fire risk–reduction 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.

• Superficial partial thickness burns: ex: sun burn. Involves only epidermis. s/s:
blanching on pressure

• Deep partial thickness burns: involves epidermis and dermis. Most pain* because nerve
endings found here. s/s: blisters*( red, shiny, and wet appearance), pain*,

• Full thickness burns: involves fat, muscle, bone, dermis, epidermis. Pain may or may
not be felt because nerves are destroyed. s/s : dry, waxy white appearance, coagulation
necrosis. surgical interventions necessary

• Second- and third-degree burn extent can be determined using total body surface area
based on two guides: Lund-Browder chart ( used in hospital. Takes into consideration
bsa. More detailed. Tells how much fuilds to give) and Rule of Nines ( NINES: used for
immediate assessment in field) . Burn extent is often revised after edema subsides and
demarcation of injury zones occurs.

• Location of burns:

• 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, genitalia, nose, ear burns are susceptible to infection due to low blood supply .
Circumferential burns to extremities can cause circulatory compromise distal to the burn
(check 5 P’S pulse, pallor, parastesia . can cause compartment syndrome.)

• Burn management is organized chronologically into three phases: emergent

(resuscitative), acute (wound healing), and rehabilitation (restorative). Overlaps in care
exist from one phase to another.

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

Key Points 25-3

• Skin reproducing cells are found in dermis. If damaged pt needs graft!

PRE HOSPITAL PHASE

• Remove person from source of burn.
• For major burns, raise extremity above level of heart to decrease swelling
• Ø immurse area in water! Can lead to heat loss
• Ø cover with ice: may cause frost bite
• Remove clothing. If clothing is stuck to skin, do not remove
• Wrap wound in dry clean cloth to prevent further contamination

EMERGENT PHASE
• Period of time required to resolve immediate, life-threatening problems. Phase may last
from time of burn to 3 or more days, can continue 24 to 48 hours. Usually lasts 12 hrs

• 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.

• Cells become permeable, H20 and NA move to interstitial spaces, ↑ in blood viscocity
(Hct↑ due to hemoconcentration from fluid loss) watch for thrombosis. Can begin in as
early as 20 min. s/s: edema, ↓bp, ↑pulse, ↑k, adynamic ilius caused from shock, shivering
from heat loss, altered LOC usually due to hypoxia

• Complications:
• Cardiovascular system: dysrhythmias and hypovolemic shock. Escharotomy: scaple
incision to eachar, is done to restore circulation to compromised extremities reduced
chances of compartment syndrome
o
o Respiratory system: vulnerable to upper airway injury causing edema formation
and obstruction of airway, and inhalation injury. Asses for crackles! Normal CXR
initially. Changes will appear 24-48 hours post burn. ABG’s normal initially.

o Renal system: if patient is hypovolemic, kidney blood flow may decrease, causing
renal ischemia. If it continues, acute renal failure may develop. With full-
thickness and electrical burns, myoglobin and hemoglobin are released into the
bloodstream and occlude the renal tubules can lead to acute tubular necrosis

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

Key Points 25-4

• 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.

• Escharotomy: scaple incision to eachar, is done to restore circulation to compromised

extremities

• Early and aggressive nutritional support decreases mortality and complications, optimizes
healing of burn, and minimizes negative effects of hypermetabolism and catabolism.

• Maintain airway by possibly intubation. Extubation is not done unitl edema subsides.
Swallow eval must be done by speech therapist before extubated patient begins feeding..
Tch pt to cough and deep breath Q hr and reposition Q1-2 hrs, suction prn. Place pt in
Semi- Folowers to increase lung expansion. If cervical injury, place pt in translenburg
position. Humidified 100% 02 . pts with major injuries to face and neck must be
intubated w/in 1-2 hrs of injury. Fiboroptic bronchoscopy: washes out lungs, can be used
as early dx tool for suspected inhalation injury w/in 6-12 hrs after injury

• Insert urinary cath! Maintain urine out put 75-100ml/hr

• Baxter fluid replacement guidelines: 2 large bore needles (18 guage). 4ml LR (X)
%TBSA (X) kg of pt. ½ of total to be givin 1st 8 hrs. ¼ of total givin 2nd 8 hrs. ¼ of total
givin at 3rd 8 hrs. crystalloid formulas ( lacated ringers) given initially. Colloid solutions (
albumin) given after cap permeability is back to normal

• Give tetnas shot if pt hasn’t hade one in past 10 yrs.

• Immersion in water more then 20-30 min can cause electrolyte loss

• Open method of wound care: abx topical cream ( silvadine) applied to wound site. No
dressings are applied. Tx type usually for facial burns

• Multiple dressing changes for wound care tx: new dressings must be sterile. Dressings
saturated in petroleum jelly to prevent adherence of dressing to burn.

• Eye exams done for all pts with facial burns.

• Ø pillows!!! Keep perineum clean and dry. Hands and arms should be extended and
elevated above heart. Ears should be free of pressure. Early ROM to prevent contractures.
For neck burns. Place pillows behind shoulders to hyperextend neck

• Morphine drug of choice for pain control IVP only!! ØIM or sub Q can cause tissue
sloughing. Have pt involved in their own pain control for better pain management.
Prevent procedural pain and break through pain by continuous pain medication. Esp
before procedures

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

Key Points 25-5

• Nutritional therapy: 5000 kcal/day recommended, ↑proteins , Ø tpn!! Ng only. Nutrition

is needed in gut not circulation wait until bowel sounds are present before initiating
feeding. Øh20

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..

• Bowel sounds usually return

• Manifestations include eschar from partial-thickness wounds. Once removed, re-

epithelialization 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.

• Always a risk for rejection of graft even if graft is pts own

• Because the body is trying to reestablish fluid and electrolyte homeostasis, it is important
for the nurse to follow the patient’s serum electrolyte levels closely (hypo- or
hypernatremia, hypo- or hyperkalemia).

• ↓NA (<135) s/s: weakness, dizziness, muscle cramps, fatigue, ha, ↑ hr, confusion. Tx::
have pt drink concentrated beverages ex, soda, juice. Due to hydro therapy longer then
20-30 min

• ↑NA (> 145) s/s: thirst, dried furry tongue, lethargy, confusion, seizures. Due to large
amounts of hypertonic fluid replacement

• ↑k (>5.5) s/s: ekg changes, muscle weakness , diary causes:: RF , adrenal insuffiency
( addisons disease)

• ↓ k ( <3.5) s/s:: loss of deep tendon reflexes, muscle cramps, constipation. Due to iv
therapy with no k supplements, prolonged suctioning, hydrotherapy longer then 20-30
min

• s/s of sepsis: ↑↓ temp, ↑hr/ rr, ↓bp/ urine output, confusion, loss of appetite, chills wbc
( 10-20 X 10 ^9)

• monitor for high blood sugar. Normal. Insulin IV = Tx

• ulcers: crulings ulcer from stress. Due to ↑hcl production after burns. Tx: proton pump
inhibitors, histamine blockers,

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

Key Points 25-6

• 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.

• CEA: cultured epithleal graft, harvesting pts own skin from unburned sites. Keratinocytes
are biopsied and grown in medium containing growth factor. Takes 18-25 days to grow.

• 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.

• Pain management usually involve morphine + anti anxiety med ( versed)

• 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. Encourage families to
bring pts favorite foods to aid pt in increasing appetite

• ↑ protein and carb foods.

• Weight loss should not be more then 10 % of pts pre burn weight

• New skin is fragile and must be protected from direct sun for 6 -9 months

• Exercise and ROM should be done after hydro therapy, pressure garmanet can prevent
hypertrophic skin scars. Must be worn for 24 hrs for 12-18 months tch pt itching will
occur in areas that are healing.

• Weigh pts every day to evaluate fulid status

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.

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

Key Points 25-7

• 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.

• It takes longer for darker skin to return to normal or near normal color because
melenocytes where dystroyed by burn injury.

• Skin contractures caused by scar shortening most common complication of rehabilitation

phase

• 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.

• 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.

• Pt may cope using regression. May be healthy for py. Usually only last short time.

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