Learning Objective: Apply the nursing process, including reasoning skills and

knowledge of pathophysiology, to implement a client-centered plan of care for clients

experiencing burns.
Concepts: Treatment of Burns

Burns
• Occur when there is injury to tissues of body caused by heat, chemicals, electrical
current, or radiation
• Should be viewed as preventable
• A burn is an injury to the tissues of the body caused by heat, chemicals, electric
current, or radiation. The resulting effects are influenced by temperature of the
burning agent, duration of contact time, and type of tissue that is injured.
• An estimated 450,000 Americans seek medical care each year for burns.
• Approximately 40,000 people are hospitalized, one half of whom require care in
specialized burn centers.
• About 3,400 Americans die annually as a direct result of their burns.
• The highest fatality rates occur in children 4 years of age and younger and in
adults over 65.
• Although burn incidence has decreased over the past few years, burn injuries still
occur too frequently, and most should be viewed as preventable.
• The focus of burn prevention has shifted from blaming individuals and changing
individual behaviors to making legislative changes and collecting global burn data
to address the unique prevention needs of low- and middle-income countries.
• Coordinated national programs include child-resistant lighters, nonflammable
children’s clothing, tap water anti-scald devices, fire-safe cigarettes, stricter
building codes, hard-wired smoke detectors/alarms, and fire sprinklers.
• You can advocate for and teach about burn risk reduction strategies in the home
and at work.

Types of Burn Injury

• Thermal burns
• Chemical burns
• Smoke inhalation injury
• Electrical burns
• Cold thermal injury
Types of Burn Injury Thermal Burns
• Caused by flame, flash, scald, or contact with hot objects
• Scald injuries can occur in the bathroom or while cooking.
• Flash, flame, or contact burns can occur while cooking, smoking, burning leaves in
the backyard, or through misuse of gasoline or hot oil.
• Most common type of burn injury
• Severity of injury depends on
• Temperature of burning agent
• Duration of contact time
Types of Burn Injury Chemical Burns
• Result of contact with acids, alkalis, and organic compounds
• Alkali burns are hard to manage because they cause protein hydrolysis and
liquefaction
• Damage continues after alkali is neutralized
• In addition to tissue damage, eyes can be injured if they are splashed with a
chemical.
 • Acids can be found in many household cleaners and include hydrochloric, oxalic,
and hydrofluoric acid.
• Alkali burns can be more difficult to manage than acid burns because alkalis
adhere to tissue, causing protein hydrolysis and liquefaction. Alkalis are found in
cement, oven and drain cleaners, and heavy industrial cleansers.
• Organic compounds, including phenols and petroleum products (creosote and
gasoline), produce contact burns and systemic toxicity.
Types of Burn Injury Chemical Burns
• Results in injuries to
• Skin
• Eyes
• Respiratory system
• Liver and kidney
Types of Burn Injury Chemical Burns
• Chemical should be quickly removed from the skin
• Clothing containing chemical should be removed
• Tissue destruction may continue up to 72 hours after chemical injury
Types of Burn Injury Smoke Inhalation Injuries
• From inhalation of hot air or noxious chemicals
o Can cause damage to the tissues of the respiratory tract
• Cause damage to respiratory tract
o Redness and airway edema my result
• Major predictor of mortality in burn victims
o Rapid initial and ongoing assessment is critical
• Need to be treated quickly
o Assess for s/s of airway compromise and pulmonary edema that can develop
over the first 12-48 hours
Types of Burn Injury Smoke Inhalation Injuries
• Three types
• Metabolic asphyxiation
• The majority of deaths at a fire scene are the result of inhaling certain
smoke elements, primarily carbon monoxide (CO) or hydrogen cyanide
• Carbon monoxide (CO) poisoning
• Hypoxia and ultimately death when CO levels are 20% or greater
• Treat with 100% humidified oxygen
• CO poisoning may occur in absence of burn injury to skin
• CO is produced by incomplete combustion of burning materials
• Inhaled CO displaces oxygen
• Hypoxia
• Carboxyhemoglobinemia
• Death
• Upper airway injury
• Injury to mouth, oropharynx, and/or larynx
• Mucosal burns of the oropharynx and larynx are manifested by
redness, blistering, and edema (Table 24-3).
• Mechanical obstruction can occur quickly, presenting a true airway
emergency.
• Thermally produced
• Hot air, steam, or smoke
• Swelling may be massive and onset rapid
 • Eschar and edema may compromise breathing
• Swelling from scald burns can be lethal
• Reliable clues to this injury
• Presence of facial burns
• Singed nasal hair
• Hoarseness, painful swallowing
• Darkened oral and nasal membranes
• Carbonaceous sputum
• History of being burned in enclosed space
• Clothing burns around neck and chest

•Lower airway injury

• Injury to trachea, bronchioles, and alveoli
• Injury is related to length of exposure to smoke or toxic fumes
• Pulmonary edema may not appear until 12 to 48 hours after burn
• Manifests as acute respiratory distress syndrome (ARDS)
Types of Burn Injury - Electrical Burns
• Result from coagulation necrosis caused by intense heat generated from an
electric current
• May result from direct damage to nerves and vessels, causing tissue anoxia
and death
• Severity of injury depends on
• Amount of voltage
• Tissue resistance
• Current pathways
• Surface area
• Duration of flow
• Tissue densities offer various amounts of resistance to electric current.
• For example, fat and bone offer the most resistance, whereas nerves and
blood vessels offer the least resistance.
• Current that passes through vital organs will produce more life-threatening
sequelae than current that passes through other tissue
• Electrical sparks may ignite patient’s clothing, causing a combination of
thermal flash injury
• 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
• As with inhalation injury, a rapid assessment of the patient with electrical
injury must be performed. Transfer to a burn center is indicated.
• Determination of electric current contact points and history of the injury may
help reveal the probable path of the current and potential areas of injury.
• Contact with electric current can cause muscle contractions strong enough to
fracture the long bones and vertebrae. Another reason to suspect long bone
or spinal fractures is a fall resulting from the electrical injury. For this reason,
consider all patients with electrical burns at risk for a potential cervical spine
injury. Use cervical spine immobilization during transport and subsequent
diagnostic testing until injury is ruled out.
• Patients are at risk for dysrhythmias or cardiac arrest, severe metabolic
acidosis, and myoglobinuria
• Can lead to renal tubular necrosis (ATN)
 • The electric shock event can cause immediate heart standstill or
ventricular fibrillation. Delayed dysrhythmias or arrest can also occur
without warning during the first 24 hours after injury.
• Myoglobin and hemoglobin from damaged RBCs travel to kidneys
• Myoglobin from injured muscle tissue and hemoglobin from damaged
red blood cells (RBCs) are released into the circulation whenever
massive muscle and blood vessel damage occurs.
• Acute tubular necrosis (ATN)
• The released myoglobin pigments travel to the kidneys and can
block the renal tubules, which can result in acute tubular
necrosis (ATN) and eventual acute kidney injury
• Eventual acute kidney injury
Classification of Burn Injury
• Severity of injury is determined by
• Depth of burn
• Extent of burn in percent of TBSA
• Location of burn
• Patient risk factors
Cross Section of Skin
• The skin is divided into three layers: the epidermis, dermis, and subcutaneous
tissue. The epidermis, or nonvascular outer layer of the skin, is approximately as
thick as a sheet of paper. It comprises many layers of nonliving epithelial cells that
provide a protective barrier to the skin, hold in fluids and electrolytes, help to
regulate body temperature, and keep harmful agents in the external environment
from injuring or invading the body.
• The dermis, which lies below the epidermis, is approximately 30 to 45 times thicker
than the epidermis. The dermis contains connective tissues with blood vessels and
highly specialized structures consisting of hair follicles, nerve endings, sweat
glands, and sebaceous glands. Under the dermis lies the subcutaneous tissue,
which contains major vascular networks, fat, nerves, and lymphatics.
• The subcutaneous tissue acts as a heat insulator for underlying structures, which
include the muscles, tendons, bones, and internal organs.
Classification of Burn Injury - Depth of Burn
• Skin-reproducing (re-epithelializing) cells are located throughout the dermis and
along the shafts of the hair follicles and sebaceous glands.
• If significant damage to the dermis occurs (e.g., a full-thickness burn), remaining
skin cells are insufficient to regenerate new skin. A permanent, alternative source
of skin then needs to be found.
• Burns have been defined by degrees (first, second, third, and fourth)
• ABA advocates categorizing burn according to depth of skin destruction
• Partial-thickness burn
• Superficial partial-thickness burn
• Involves epidermis
• Deep partial-thickness burn
• Involves dermis

• Full-thickness burn
• Involves all skin elements, nerve endings, fat, muscle, bone
Classification of Burn Injury - Extent of Burn
• Two commonly used guides for determining the total body surface area
• Lund-Browder chart
 • Considered more accurate because the patient’s age, in proportion to
relative body-area size, is taken into account
• Rule of Nines
• Used for initial assessment
• Sage Burn Diagram (www.sagediagram.com)
• Rule of Nines Chart
• The extent of a burn is often revised after edema has subsided and a demarcation
of the zones of injury has occurred
Classification of Burn Injury - Location of Burn
• Severity of burn injury is determined by location of burn wound
• Face, neck, chest → respiratory obstruction
• may interfere with breathing because of mechanical obstruction
secondary to edema or leathery, devitalized burn tissue (eschar).
• These burns may also signal the possibility of smoke or inhalation
injury.
• Hands, feet, joints, eyes → self-care
• are of concern because they make self-care very difficult and may
jeopardize future function.
• Burns to the hands and feet are challenging to manage because of
superficial vascular and nerve supply systems that need to be
protected while the burn wounds are healing.
• Ears, nose, buttocks, perineum → infection
• the skin is very thin and the underlying skeleton is frequently exposed.
• Burns to the buttocks or perineum are at high risk for infection from
urine or feces contamination
• Circumferential burns of extremities can cause circulation problems distal to burn
• Patients may also develop compartment syndrome
• from direct heat damage to the muscles and subsequent edema and/or
preburn vascular problems.
Classification of Burn Injury - Patient Risk Factors
• Preexisting heart, lung, and kidney diseases contribute to poorer prognosis
• Because of the increased demands placed on the body by a burn injury
• Diabetes mellitus and peripheral vascular disease contribute to poor healing and
gangrene
• Especially with foot and leg burns
• Physical weakness renders patient less able to recover
• Alcoholism
• Drug abuse
• Malnutrition
• Concurrent fractures, head injuries, or other trauma leads to a more difficult time
recovering
Prehospital Care
• Remove person from source of burn and stop burning process
• Rescuer must be protected from becoming part of incident
• Electrical injuries
• Remove patient from contact with source
• Chemical injuries
• Brush solid particles off skin
• Use water lavage
• Chemical burns are best treated by quickly removing solid particles from the
skin.
 • Any clothing containing the chemical must also be removed as the burning
process continues while the chemical is in contact with the skin.
• The affected area should be flushed with copious amounts of water to
irrigate the skin anywhere from 20 minutes to 2 hours post exposure. Tap
water is acceptable for flushing eyes exposed to chemicals.
• Tissue destruction may continue for up to 72 hours after a chemical burn.
• Small thermal burns
• Cover with clean, cool, tap water—dampened towel
• Cooling of the injured area (if small) within 1-minute helps minimize the
depth of the injury
• Large thermal burns
• To prevent hypothermia, large burns should be cooled for no longer than 10
minutes.
• Circulation, airway, breathing
• Circulation: Check for presence of pulses and elevate the burned
limb(s) above the heart to decrease pain and swelling.
• Airway: Check for patency, soot around nares/on the tongue, singed
nasal hair, darkened oral or nasal membranes.
• Breathing: Check for adequacy of ventilation
• Do not immerse in cool water or pack with ice
• may cause extensive heat loss.
• Never cover a burn with ice, as this can cause hypothermia and
vasoconstriction of blood vessels, thus further reducing blood flow to
the injury.
• Remove burned clothing
• Wrap in clean, dry sheet or blanket
• to prevent further contamination of the wound and to provide warmth.
• Inhalation injury
• Watch for signs of respiratory distress
• Treat quickly and efficiently
• 100% humidified oxygen if CO poisoning is suspected
• Patients with both body burns and inhalation injury must be transferred to
the nearest burn center.
Emergent Phase
• The emergent phase ends when fluid mobilization and diuresis begin
• Emergent (resuscitative) phase is time required to resolve immediate problems
resulting from injury
• Up to 72 hours
• Primary concerns
• Hypovolemic shock
• Edema
• Emergent Phase Pathophysiology
• Fluid and electrolyte shifts
• Greatest threat is hypovolemic shock
• Caused by a massive shift of fluids out of blood vessels as a
result of increased capillary permeability
• Can begin as early as 20 minutes post burn
• Conditions Leading to Burn Shock
• At the time of major burn injury, capillary permeability is increased.
• All fluid components of the blood begin to leak into the interstitium,
causing edema and a decreased blood volume.
 •The red blood cells and white blood cells do not leak.
•Hematocrit increases, and the blood becomes more viscous.
•The combination of decreased blood volume and increased viscosity
produces increased peripheral resistance.
• Burn shock, a type of hypovolemic shock, rapidly ensues, and if it is
not corrected, death can result.
- Fluid and electrolyte shifts
• Colloidal osmotic pressure decreases
• As the capillary walls become more permeable, water, sodium, and
later plasma proteins (especially albumin) move into interstitial spaces
and other surrounding tissue. The colloidal osmotic pressure decreases
with progressive loss of protein from the vascular space. This results in
more fluid shifting out of the vascular space into the interstitial spaces.
• More fluid shifting out of vascular space into interstitial spaces
• Fluid also moves to areas that normally have minimal to no fluid, a
phenomenon termed third spacing. Examples of third spacing in burn injury
are exudate and blister formation, as well as edema in nonburned areas.

• The Parkland Formula

• Adults
• 4mL TBSA (%) x body weight (kg) = fluid resuscitation for 24
hours
• 50% given in the first 8 hours
• 50% given in the last 16 hours

• End point
• urine 0.5-1.0 ml/kg/hour
Children
• 4mL/ kg for first 10 kg of bodyweight plus
• 2mL.kg for second 10 kg of body weight plus
• 1mL/kg for >20 kg body weight
• End point
• urine 1.0-1.5 ml/kg/hour
• Rule of Nines Children
 Fluid and electrolyte shifts
• Normal insensible loss: 30 to 50 mL/hr
• Severely burned patient: 200 to 400 mL/hr
 Fluid and electrolyte shifts
• Net result of fluid shift is intravascular volume depletion
• Edema
• ↓ Blood pressure
• ↑ Pulse
 Fluid and electrolyte shifts
• RBCs are hemolyzed by a circulating factor released at time of burn
• Thrombosis
• Elevated hematocrit
• The circulatory system is also affected by hemolysis of RBCs from
circulating factors (e.g., oxygen free radicals) released at the time of the
burn, as well as by the direct insult of the burn injury.
• Thrombosis in the capillaries of burned tissue causes an additional loss of
circulating RBCs.
 • An elevated hematocrit is commonly caused by hemoconcentration due to
fluid loss. After fluid balance is restored, the hematocrit levels to drop.
 Fluid and electrolyte shifts
• K+ shift develops first because injured cells and hemolyzed RBCs release
K+ into extracellular spaces
• Na+ rapidly moves to interstitial spaces and remains until edema
formation ends
• Toward the end of the emergent phase, capillary membrane permeability
is restored if fluid replacement is adequate.
• Fluid loss and edema formation end.
• Interstitial fluid gradually returns to the vascular space.
• Diuresis occurs, and the urine has a low specific gravity.
Phases of Burn Management
 Emergent (resuscitative)
 An overlap in care exists from one phase to another. For example, although the
emergent phase is seen as beginning in the emergency department, care often
begins in the prehospital phase, depending on the skill level of paramedics at the
scene.
 Acute (wound healing)
 Wound care is the primary focus of the acute phase, but it also takes place in both
the emergent and rehabilitative phases.
 Rehabilitative (restorative)
 Planning for rehabilitation begins on the day of the burn injury or admission to the
burn center.
 Formal rehabilitation begins as soon as functional assessments can be performed.
Emergent Phase
• Inflammation and healing
• Neutrophils and monocytes accumulate at site of injury
• Fibroblasts and collagen fibrils begin wound repair within first 6 to 12 hours
after injury
• Immunologic changes
• Immune system is challenged when burn injury occurs
• Skin barrier is destroyed
• Bone marrow is depressed
• Circulating levels of immune globulins are decreased
• WBCs develop defects
• Emergent Phase - Clinical Manifestations
• Shock from hypovolemia
• Frequently, areas of full-thickness and deep partial-thickness burns are at
first painless because the nerve endings are destroyed.
• Superficial to moderate partial-thickness burns are very painful.
• Blisters
• Filled with fluid and protein are common in partial-thickness burns
• Paralytic ileus
• Shivering
• result of chilling that is caused by heat loss, anxiety, or pain.
• Altered mental status
• usually results from hypoxia associated with smoke inhalation.
• Other possibilities include head trauma, history of substance abuse, or
excessive amounts of sedation or pain medication.
• Emergent Phase - Complications
 • Cardiovascular system
• Dysrhythmias and hypovolemic shock
• Impaired circulation to extremities
• Tissue ischemia
• Paresthesias
• Necrosis
• Escharotomies of Chest and Arm
• An escharotomy (a scalpel or electrocautery incision through the full-
thickness eschar) is frequently done after transfer to a burn center to
restore circulation to compromised extremities.
• Impaired microcirculation and ↑ viscosity → sludging
• Initially, blood viscosity is increased because of the fluid loss that
occurs in the emergent period. Microcirculation is impaired by damage
to skin structures that contain small capillary systems. These two
events result in a phenomenon termed sludging. Sludging is corrected
by adequate fluid replacement.

• Venous thromboembolism (VTE)

• Burn patients are at an increased risk for venous thromboembolism
(VTE) if one or more of the following conditions are present: advanced
age, morbid obesity, extensive or lower-extremity burns, concomitant
lower-extremity trauma, and prolonged immobility. VTE prophylaxis
with anticoagulant drugs should be started, unless contraindicated.

• Respiratory system
• Upper airway distress may occur with or without smoke inhalation, and
airway injury at either level may occur in the absence of burn injury to the
skin.
• The patient may need a fiberoptic bronchoscopy and carboxyhemoglobin
blood levels to confirm a suspected inhalation injury.
• Look in the prehospital and ED notes to see if the patient was exposed to
smoke or fumes.
• Examine any sputum that the patient may produce for any carbon.
• Watch for signs of impending respiratory distress, such as increased
agitation, anxiety, restlessness, or a change in the rate or character of the
patient’s breathing as symptoms may not be present immediately.
• The patient with preexisting respiratory problems is more likely to develop a
respiratory infection.
• Upper airway burns
• Edema formation
• Mechanical airway obstruction and asphyxia
• Lower airway injury
• Pneumonia
• Common complication of major burns and the leading cause of
death in patients with an inhalation injury
• Pulmonary edema
• Urinary system
• ↓ Blood flow to kidneys causes renal ischemia
• Acute tubular necrosis (ATN)
• Adequate fluid replacement can counteract obstruction of the tubules.
Emergent Phase - Nursing/Interprofessional Management
• Airway management
• Depending on the acuity of the patient, the duration of time spent in each
phase varies greatly, and conditions improve and worsen unpredictably on
an almost daily basis. Care changes accordingly. Although physiotherapy and
occupational therapy are a focus of the acute and rehabilitative phases,
proper positioning and splinting begin at the time of admission.
• Early endotracheal intubation
• Early intubation removes the need for emergency tracheostomy after
respiratory problems have become apparent. In general, the patient
with major injuries involving burns to the face and neck requires
intubation within 1 to 2 hours after burn injury.
• After intubation, the patient is placed on ventilatory support, and the
delivered oxygen concentration is based on ABG values. Extubation
may be indicated when the edema resolves, usually 3 to 6 days after
burn injury, unless severe inhalation injury exists.
• Escharotomies of the chest wall
• to relieve respiratory distress secondary to circumferential, full-
thickness burns of the neck and chest.
• Fiberoptic bronchoscopy
• Within 6 to 12 hours after injury in which smoke inhalation is
suspected, a fiberoptic bronchoscopy should be performed to assess
the lower airway.
• Humidified air and 100% oxygen
• When intubation is not done, treatment of inhalation injury includes
administration of 100% humidified O2 as needed.
• Place the patient in a high Fowler’s position, unless contraindicated
(e.g., spinal injury), and encourage coughing and deep breathing every
hour.
• Reposition the patient every 1 to 2 hours, and provide chest
physiotherapy and suctioning as ordered.

• Fluid therapy
• Establishing IV access is critical for fluid resuscitation and drug
administration.
• Two large-bore IV lines for >15% TBSA to handle large volumes of fluid
• For burns >30% TBSA, a central line for fluid and drug administration
and blood sampling should be considered. An arterial line also should
be considered if frequent ABGs or invasive BP monitoring is needed.
• Type of fluid replacement based on size/depth of burn, age, and individual
considerations
• Fluid replacement is achieved with crystalloid solutions (usually
lactated Ringer's), colloids (albumin), or a combination of the two. IV
saline is usually started during the prehospital phase.
• Colloidal solutions (e.g., albumin) may be given. However,
administration is recommended after the first 12 to 24 hours post burn,
when capillary permeability returns to normal or near normal. After this
time, the plasma remains in the vascular space and expands the
circulating volume. The replacement volume is calculated based on the
patient’s body weight and TBSA burned.
• Parkland (Baxter) formula for fluid replacement
• most common formula used, followed by the modified Brooke formula.
 • It is important to remember that all formulas are estimates and must
be titrated based on the patient’s physiologic response.
• For example, patients with an electrical injury may have greater than
normal fluid requirements.
• Assessment of the adequacy of fluid resuscitation is best made using
clinical parameters. Urine output is the most commonly used
parameter.
• Wound care
• Should be delayed until a patent airway, adequate circulation, and adequate
fluid replacement have been achieved
• Partial-thickness wounds are pink to cherry red and wet and shiny with
serous exudate. These wounds may or may not have intact blisters and are
very painful when touched.
• Full-thickness wounds have no blisters and will have only minor, localized
sensation because nerve endings have been destroyed.
• Cleansing
• Can be done on a shower cart, in a shower, or on a bed
• Debridement
• May need to be done in the OR
• Loose necrotic skin is removed
• Patients find the first wound care to be both physically and mentally
demanding. Provide emotional support to build trust.

• Shower
• Once-daily shower
• Dressing change in morning and evening
• Infection is most serious threat to further tissue injury
• Source of infection is patient’s own flora
• mostly from the skin and respiratory and gastrointestinal (GI)
tracts.
• Preventing cross-contamination is a priority
• Open method
• Burn is covered with topical antibiotic with no dressing over wound
• Usually limited to the care of facial burns
• Multiple dressing changes or closed method
• Sterile gauze dressings are laid over topical antibiotic
• Dressings may be changed from every 12 to 24 hours to once every 14
days
• Application of Silver Sulfadiazine to Moistened Gauze
• When open burns wounds are exposed, staff should wear
• Disposable hats
• Masks
• Gowns
• Gloves
• Autograft
• Patient’s own skin
• Allograft or homograft skin
• Usually from cadavers
• Typically used with newer biosynthetic options
• Other care measures
• Facial care
 • Performed by open method
• The face is highly vascular and is subject to a great amount of edema.
• often is covered with ointments and gauze but is not wrapped, to limit
pressure on delicate facial structures
• Eye care for corneal burns
• Antibiotic ointment is used
• Periorbital edema may frighten patient
• Always check that the patient’s eyelashes are not turned inward
toward the eyeball. You must provide assurance that the swelling
is not permanent.
• An ophthalmology examination should occur soon after admission for
all patients with facial burns.
• Ears should be kept free of pressure
• because of their poor vascularization and tendency to become infected
• No use of pillows
• pressure on the cartilage may cause chondritis, and the ear may
stick to the pillowcase, causing pain and bleeding.
• Hands and arms should be extended and elevated on pillows or foam wedges
• Hands and arms should be extended and elevated on pillows to
minimize edema. Splints may need to be applied to burned hands and
feet to keep them in positions of function.
• Perineum must be kept as clean and dry as possible
• Indwelling catheter
• Perineal care
• Regular, once- to twice-daily perineal and catheter care in the presence
or absence of a perineal burn wound is essential
• Assess the need for an indwelling urinary catheter on a daily basis and
remove when no longer needed to limit the risk of a urinary tract
infection.
• Routine laboratory tests
• to monitor fluid and electrolyte balance.
• ABGs are drawn to assess adequacy of ventilation and oxygenation in
patients with suspected or confirmed inhalation or electrical injury
• Early ROM exercises
• Physical therapy is begun immediately, sometimes during
showering/dressing changes and before new dressings are applied.
• Movement aids the shift of the leaked fluid back into the vascular bed.
• Active and passive exercise of body parts also maintains function,
prevents skin and joint contractures, and reassures the patient that
movement is still possible
• Drug therapy
• Analgesics and sedatives
• Morphine
• Hydromorphone (Dilaudid)
• Haloperidol (Haldol)
• Lorazepam (Ativan)
• Midazolam
• Early in the postburn period, IV pain medications should be given because
• Onset of action is fastest with this route.
• GI function is slowed or impaired as the result of shock or paralytic
ileus.
 • Intramuscular (IM) injections will not be absorbed well in burned or
edematous areas, causing pooling of medications in the tissues. When
fluid mobilization starts, the patient could be inadvertently overdosed
from the interstitial accumulation of previous IM drugs.
• Evaluate the pain management plan often, since the patient's needs may
change and tolerance to drugs may develop over time. Remember that the
patient's pain level may not directly correlate with the extent and depth of
burn. Analgesic needs can vary from one patient to another, so consider a
multimodal approach to pain control.
• Sedative/hypnotics and antidepressant agents can also be given with
analgesics to control the anxiety, insomnia, and/or depression that patients
may experience.

• Tetanus immunization
• Given routinely to all burn patients
• because of the likelihood of anaerobic burn wound contamination.
• If patient has not received an active immunization within 10 years
before the burn injury, tetanus immune globulin should be considered.
• Antimicrobial agents
• Topical agents
• Some topical burn agents penetrate the eschar and inhibit
bacterial invasion of the wound.
• Silver sulfadiazine
• Silver-impregnated dressings (Acticoat Flex, Silverlon, AQUACEL
Ag Burn) can be left in place anywhere from 3 to 14 days and are
used in many burn centers. Silver sulfadiazine (Silvadene,
Flamazine) and mafenide acetate (Sulfamylon) creams are also
used
• Mafenide acetate
• Systemic agents are not usually used in controlling burn flora
• because little or no blood supply to the burn eschar is available,
and consequently, delivery of the antibiotic to the wound is
limited.
• increases the chance of development of multiresistant
organisms.
• Initiated when diagnosis of invasive burn wound sepsis is made
• Sepsis remains a leading cause of death in the patient with major
burns, which may lead to multiple organ dysfunction syndrome.
Systemic antibiotic therapy is started when the diagnosis of
sepsis is made, or when some other source of infection (e.g.,
pneumonia) is identified.
• VTE prophylaxis
• Low-molecular-weight heparin or low-dose unfractionated heparin is
started
• Those with high bleeding risk, VTE prophylaxis with sequential
compression devices, or compression stockings recommended
• Nutritional therapy
• Fluid replacement takes priority over nutritional needs
• Early and aggressive nutritional support within hours of burn injury
• Decreases complications and mortality
• Optimizes burn wound healing
 • Minimizes negative effects
• Hypermetabolic state
• Resting metabolic expenditure may be increased by 50% to 100%
above normal
• Core temperature is elevated
• Caloric needs are about 5000 kcal/day
• Early, continuous enteral feeding promotes optimal conditions for
wound healing
• Supplemental vitamins and iron may be given
• Failure to supply adequate calories and protein leads to malnutrition
and delayed healing.
• Calorie-containing nutritional supplements and milkshakes are often
given because of the great need for calories.
• Protein powder can also be added to food and liquids.
• Supplemental vitamins may be given as early as the emergent phase,
with iron supplements often started in the acute phase.
Acute Phase
• This may take weeks or months
• Begins with mobilization of extracellular fluid and subsequent diuresis
• Concludes when
• Partial thickness wounds are healed and/or
• Full thickness burns are covered by skin grafts
• Acute Phase - Pathophysiology
• Diuresis from fluid mobilization occurs, and patient is less edematous
• Bowel sounds return
• Healing begins as WBCs surround burn wound and phagocytosis occurs
• The depth of the burn wounds may be more apparent as they “declare”
themselves as partial- or full-thickness.
• The patient may now become aware of the enormity of the situation and will
benefit from emotional support and information.
• Necrotic tissue begins to slough
• Granulation tissue forms
• Partial-thickness burn wounds heal from edges and from dermal bed
• Full-thickness burns must have eschar removed and skin grafts applied
• Acute Phase - Clinical Manifestations
• Partial-thickness wounds form eschar
• Once eschar is removed, reepithelialization begins
• Epithelial buds from the dermal bed eventually close in the
wound, which then heals spontaneously without surgical
intervention, usually within 10 to 21 days.
• Full-thickness wounds require debridement
• Margins of full-thickness eschar take longer to separate. As a
result, full-thickness wounds require surgical debridement and
skin grafting for healing.
• Acute Phase - Laboratory Values
• Sodium
• Hyponatremia can develop from
• Excessive GI suction
• Diarrhea
• Manifestations of hyponatremia include weakness, dizziness,
muscle cramps, fatigue, headache, tachycardia, and confusion.
 • Water intoxication
• dilutional hyponatremia called water intoxication, from excess
water intake
• To avoid this condition, offer the patient fluids other than water,
such as juice, soft drinks, or nutritional supplements to drink.
• Hypernatremia may develop following
• Successful fluid replacement
• Improper tube feedings
• Inappropriate fluid administration
• Manifestations of hypernatremia include thirst; dried, furry
tongue; lethargy; confusion; and possibly seizures.
• Restrict sodium in IVs, oral feedings
• Potassium
• Hyperkalemia may occur if patient has
• Renal failure
• Adrenocortical insufficiency
• Massive deep muscle injury
• Large amounts of potassium is released from damaged cells
• Hyperkalemia can cause
• Heart dysrhythmias and ventricular failure
• Muscle weakness
• ECG changes
• Hypokalemia occurs with
• Vomiting, diarrhea
• Prolonged GI suction
• Lengthy IV therapy without potassium
• Signs and symptoms of hypokalemia include fatigue, muscle weakness,
leg cramps, heart dysrhythmias, paresthesias, and decreased reflexes
Acute Phase - Complications
• Infection
• A burn injury destroys the body’s first line of defense, the skin.
• The burn wound is now colonized with the person’s own organisms.
• If the levels of bacteria between the eschar and viable wound bed rise to
greater than 105/g of tissue, the patient has a burn wound infection.
• Wound infections may be treated with systemic antibiotics based on wound
culture results.
• Localized inflammation, induration, and suppuration
• Partial-thickness burns can change to full-thickness wounds in the presence
of infection
• Watch for signs and symptoms
• Hypothermia or hyperthermia
• Increased heart and respiratory rate
• Decreased BP
• Decreased urine output
• Acute Phase
Complications
• Cardiovascular and respiratory systems
• Same complications can be present in emergent phase and may continue
into acute phase
• In addition, new problems might arise, requiring timely intervention
• Neurologic system
 • Probable causes of neurologic complications include electrolyte imbalance,
stress, cerebral edema, sepsis, sleep disturbances, and the use of analgesics
and antianxiety drugs.
• No physical symptoms unless severe hypoxia from respiratory injuries or
complications from electrical injuries occur
• Disorientation
• Combative
• Hallucinations
• Delirium
• more acute at night and occurs more often in the older patient.
• Transient state
• This is a transient state, lasting from a day or two to several weeks, but
complications and sequelae can last for years and be quite serious.
• Variety of causes have been considered
• Musculoskeletal system
• The musculoskeletal system is particularly prone to complications during the
acute phase and the involvement of the physical and occupational therapist
is vitally important.
• Decreased ROM
• As the burns begin to heal and scar tissue forms, the skin is less supple
and pliant, ROM may be limited, and contractures can occur.
• Contractures
• Because of pain, the patient will prefer to assume a flexed position for
comfort. Have the patient to stretch and move the burned body parts as
much as possible. Splinting can be beneficial to prevent/reduce contracture
formation.
• Gastrointestinal system
• Paralytic ileus
• Can be caused by sepsis
• Diarrhea
• From the use of enteral feedings or ABX
• Constipation
• From side effects of opioids, decreased mobility and low fiber diet
• Curling’s ulcer
• type of gastroduodenal ulcer characterized by diffuse superficial
lesions (including mucosal erosion). It is caused by a generalized stress
response due to decreased blood flow to the GI tract
• Aim to prevent Curling’s ulcer by feeding the patient as soon as
possible after the burn injury. Antacids, H2-histamine blockers (e.g.,
ranitidine [Zantac]), and proton pump inhibitors (e.g., esomeprazole
[Nexium]) are used prophylactically to neutralize stomach acids and
inhibit histamine and the stimulation of hydrochloric acid (HCl acid)
secretion

• Endocrine system
• ↑ Blood glucose levels
• Watch for temporary increases in blood sugar due to stress hormones
like cortisol and catecholamines.
• These hormones trigger the body to release stored glycogen and
produce more glucose
• ↑ Insulin production
 • Hyperglycemia
• Although insulin production increases, its effectiveness may decrease,
causing higher blood sugar levels
• Hyperglycemia may also be caused by the increased caloric intake
necessary to meet some patients’ metabolic requirements.
• When this occurs, treat with IV or subcutaneous insulin, not decreased
feeding.
• Check blood glucose levels frequently, and give insulin as ordered.
Point-of-care glucose tests can be used, but serum tests are more
accurate.
• As the patient’s metabolic demands are met and less stress is placed
on the entire system, this stress-induced condition is reversed.

Acute Phase - Nursing/Interprofessional Management

• Predominant therapeutic interventions in acute phase
• Wound care
• Excision and grafting
• Pain management
• Physical and occupational therapy
• Nutritional therapy
• Wound care
• Daily observation
• Assessment
• Cleansing
• Debridement
• Dressing reapplication
• Enzymatic debridement
• Agents made of natural ingredients (collagen)
• Speeds up removal of dead tissue from healthy wound bed
• Cleanse with soap and water or normal saline-moistened gauze
• To gently remove old antimicrobial agent and any loose necrotic tissue,
tissues, scabs, or dried blood
• Cover with antimicrobial creams (silver sulfadiazine, silver-impregnated
dressings)
• When the partial-thickness burn wounds have been fully debrided, a
protective, coarse or fine-meshed, grease-based (paraffin or petroleum)
gauze dressing is applied to protect the re-epithelializing keratinocytes as
they resurface and close the open wound bed.
• Appropriate coverage of graft
• Gauze next to graft followed by middle and outer dressings
• followed by saline-moistened middle dressing, and dry gauze
outer dressing.
• Unmeshed sheet grafts used for facial grafts
• Grafts are left open
• Complication of leaving graft open: Blebs
• Blebs prevent the graft from permanently attaching to the
wound bed.
• The evacuation of blebs is best performed by aspiration
with a tuberculin syringe and only by those trained in this
specialized skill.
• Excision and grafting
 • Management of full-thickness burn wounds involves early removal (surgical
excision) of the necrotic tissue followed by application of split-thickness
autograft skin.
• Many patients, especially those with major burns, are taken to the OR for
wound excision on day 1 or 2 (emergent phase). The wounds are covered
with a biological dressing or allograft for temporary coverage until
permanent grafting can occur.
• Eschar (devitalized tissue) is removed down to subcutaneous tissue or fascia
• Surgical excision can result in massive blood loss.
• Topical application of epinephrine or thrombin, application of extremity
tourniquets, and application of a new fibrin sealant (Artiss) all work to
decrease surgical blood loss
• Graft is placed on clean, viable tissue
• Wound is covered with autograft
• Donor skin is taken with a dermatome
• Choice of dressings varies
• Grafts are attached with
• Fibrin sealant
• Sutures or staples
• Negative pressure wound therapy (wound vac)
• With early excision, function is restored, scar tissue minimized
• Frequent observation for bleeding and circulation problems and appropriate
nursing interventions can help identify and manage complications that would
interfere with graft survival. Facial, neck, and hand burns require skilled
nursing care to identify and manage clots quickly for the best functional and
esthetic outcomes.
• Donor Site Being Harvested
• Donor skin is taken from the patient for grafting by means of a dermatome,
which removes a thin (14/1000 to 16/1000 inch) split-thickness layer of skin
from an unburned site.
• The donor skin can be meshed (usually ratio of 1.5:1) to allow for greater
wound coverage, or it may be applied as an unmeshed sheet for a better
cosmetic result when grafting the face, neck, and hands. The donor site now
becomes a new open wound.
• Covering Donor Site With Hydrophilic Foam Dressing
• The goals of donor site care are to promote rapid, moist wound healing,
decrease pain at the site, and prevent infection.
• Choices of dressings vary among burn centers and include transparent
dressings (e.g., Opsite), xenograft, silver sulfadiazine, silver-impregnated
dressings, calcium alginate, and hydrophilic foam dressings.
• Nursing care of the donor site is specific to the dressing selected. Several of
the newer dressing materials offer decreased healing time, which allows
earlier reharvesting of skin at the same site.
• The average healing time for a donor site is 10 to 14 days.

• Cultured epithelial autographs (CEAs)

 method of getting permanent skin from a person with limited available
skin for harvesting
• Grown from biopsies obtained from the patient’s own skin
• Used in patients with a large body surface burn area or those with
limited skin for harvesting
 • CEA grafts generally form a seamless, smooth replacement skin tissue.
• Problems related to CEA include a poor graft take due to thin epidermal
skin graft loss during healing, infection, and contracture development
• Artificial skin
• Life-threatening full-thickness or deep partial-thickness wounds where
conventional autograft is not available or advisable
• Consists of both dermal and epidermal elements
• The Integra artificial skin dermal regeneration template is an example
of a skin replacement system. It needs to be applied within a few days
postburn for greatest success.
• Integra artificial skin has a bilayer membrane composed of acellular
dermis and silicone. The wound is excised, the bilayer membrane is
placed dermal layer down, and the wound is wrapped with dressings in
the OR.
• The dermal layer functions as a biodegradable template that
induces organized regeneration of new dermis by the body.
• The silicone layer remains intact for 3 weeks as the dermal layer
degrades and epidermal autografts become available.
• The silicone is removed during a second surgical procedure and
replaced by the patient's own epidermal autografts.
• Another dermal replacement is AlloDerm, a cryopreserved allogenic
dermis. Human allograft dermis, harvested from cadavers, is
decellularized to make it immunogenic and then freeze-dried.
• Pain management
• Patients experience two kinds of pain
• Continuous background pain
• IV infusion of an opioid provides steady, therapeutic level of the
drug
• Or slow-release, twice-a-day oral opioid
• Around the clock oral analgesics can also be used
• Treatment-induced pain
• Analgesic and an
• Breakthrough doses of analgesia need to be available, regardless of the
regimen selected. Anxiolytics, which can enhance analgesics, are also
indicated and include lorazepam (Ativan) or midazolam (Versed).
• For treatment-induced pain, premedicate with an analgesic and possibly an
anxiolytic via the IV or oral route.
• For patients with an IV, a short-acting analgesic, such as fentanyl
(Sublimaze) is often used
• Nonpharmacologic strategies
• Relaxation breathing
• Visualization, guided imagery
• Hypnosis
• Biofeedback
• Music therapy
• Physical and occupational therapy
• Good time for exercise is during or after wound cleaning when the skin is
softer and bulky dressing are removed
• Passive and active ROM
• Splints should be custom-fitted
 • Ensure that the patient with neck burns continues to sleep without pillows or
with the head hanging slightly over the top of the mattress to encourage
hyperextension.
• Nutritional therapy
• Meeting daily caloric requirements is crucial
• Caloric needs should be calculated by dietitian
• High-protein, high-carbohydrate foods
• The patient may benefit from an antioxidant protocol, which includes
selenium, acetylcysteine, ascorbic acid, vitamin E, zinc, and a multivitamin.
• Monitor laboratory values (e.g., albumin, prealbumin, total protein,
transferrin)
• Ideally, weight loss should not be more than 10% of preburn weigh
• Weigh your patient weekly to evaluate progress
Rehabilitation Phase
• The rehabilitation phase begins when
• Wounds have healed
• Patient is engaging in some level of self-care
• This can occur as early as 2 weeks or as long as 7 to 8 months after a major
burn injury.
• Goals for the patient now are to:
• work toward resuming a functional role in society
• rehabilitate from any functional and cosmetic postburn reconstructive
surgery that might be necessary.

• Rehabilitation Phase - Pathophysiologic Changes

• Burn wound heals either by spontaneous reepithelialization or by skin
grafting
• Layers of keratinocytes begin to rebuild the tissue structure
• Collagen fibers add strength to weakened areas
• The new skin appears flat and pink
• In approximately 4 to 6 weeks, area becomes raised and hyperemic
• Mature healing is reached about 12 months
• when suppleness has returned, and the pink or red color has faded to a
slightly lighter hue than the surrounding unburned tissue. It takes
longer for more heavily pigmented skin to regain its dark color because
many of the melanocytes have been destroyed.
• Skin never completely regains its original color
• Discoloration of scar fades with time
• Scar contour elevates and enlarges
• Newly healed areas can be hypersensitive or hyposensitive to cold, heat, and
touch
• Rehabilitation Phase - Complications
• Skin and joint contractures
• Most common complications during rehab phase.
• Positioning, splinting, and exercise should be used to minimize contracture.
• Areas that are most susceptible to skin and joint contractures include the
anterior and lateral neck areas, axillae, antecubital fossae, fingers, groin
areas, popliteal fossae, knees, and ankles.
• Some areas encompass major joints. Not only does the skin over these areas
develop contractures, but also underlying tissues, such as the ligaments and
tendons, have a tendency to shorten during the healing process.
 • Encourage proper positioning, splinting, and exercise to minimize this
complication. These procedures should be continued until the skin matures.
• Therapy is aimed at the extension of body parts because the flexors are
stronger than the extensors.
• Burned legs may first be wrapped with elastic (e.g., tensor/Ace) bandages to
assist with circulation to leg graft and donor sites before ambulation.
• Burned arms can be wrapped with a layer of tubular elastic gauze (e.g.,
Tubigrip). This interim pressure prevents blister formation, promotes venous
return, and decreases pain and itchiness.
• Once the skin is completely healed and less fragile, custom-fitted pressure
garments replace the elastic bandages and tubular gauze.
• Rehabilitation Phase - Nursing/Interprofessional Management
• Encourage both patient and caregiver to participate in care
• Skills for dressing changes
• Wound care
• Before discharge, have the patient or caregiver return demonstrate
(show-back) the proper dressing change.
• In addition, make sure the patient or caregiver knows when to contact
the burn team (e.g., signs of infection, increased pain) and the need to
keep outpatient visits to ensure good wound healing.
• Use water-based creams (Vaseline Intensive Rescue, Sween, Complex 15)
• Oral antihistamines are used at bedtime if itching persists.
• Reconstructive surgery is frequently required after a major burns
• The role of exercise cannot be overemphasized
• Constant encouragement and reassurance
• Constant encouragement and reassurance are necessary to maintain a
patient’s morale, particularly once the patient realizes that recovery can be
slow.
• Rehabilitation may need to be a primary focus for at least the next 6 to 12
months.
• essential patient be encouraged to discuss their fears regarding loss of their
life as they once knew it, loss of function, temporary/permanent deformity
and disfigurement, return to work and home life, and financial burdens
resulting from a long and costly hospitalization and rehabilitation.
• Care should also be taken to address individual spiritual and cultural needs,
as both these facets of a patient’s life play a role in recovery.
• Pastoral care and cultural groups may be helpful resources to the patient,
caregiver, and health care team.
• Patients can be assisted toward a realistic and positive appraisal of their
particular situation, emphasizing what they can do instead of what they
cannot do.
• In a society that values physical beauty, alterations in body image can result
in psychologic distress.
• Encouraging appropriate independence, an eventual return to preburn
activities, and interactions with other burn survivors will involve the patient
in familiar activities that may bring comfort and help to restore self-esteem.
• Counseling, which may have started in the acute phase of care, can be
offered after discharge.
• Patients appreciate reassurance that their feelings during this period of
adjustment are normal, and that their frustration is to be expected as they
attempt to resume a normal lifestyle.
Gerontologic Considerations
• Normal aging puts the patient at risk for injury because of the possibility of
• Unsteady gait
• Limited eyesight
• Diminished hearing
• The fact that wounds take longer to heal
Emotional Needs of the Patient and Caregivers
• Many emotional and psychologic needs
• Assess circumstances of burn injury
• Burn survivors often experience anxiety, guilt, and depression
• New fears arise during recovery
• “Can I really do this?” “Am I a desirable person?” “How can I go outside
looking like this?” These challenges confront patients throughout their
recovery and perhaps for years to come.
• Self-esteem may be adversely affected
• Address spiritual and cultural needs
• Issue of sexuality must be met with honesty
• Family and patient support groups
Special Needs of Nursing Staff
• You may find it difficult to cope with burn injuries
• Know you provide care that makes a critical difference
• Practice good self-care