Nursing Care of the Burned Client

Joyce M. Black, PhD, RN

A “minor” burn happens to someone else.

Anonymous burn victim.

How serious is the burn problem? 1.4 million people seek care for

burn injuries yearly 54,000 hospitalizations 5,000 deaths annually

How do burn injuries occur? Thermal Burns

flames, hot liquids, semi-liquids (steam), semi-solids (tar) or hot objects

the most common etiology

How do burn injuries occur? Chemical Burns

strong acids, alkali, or organic compounds

depth of injury determined by: - concentration - volume - duration of contact - type of chemical

How do burn injuries occur? Electrical Burns

• lightning• faulty or exposed wiring

- electrical wiring - high-voltage power lines

How do burn injuries occur? Radiation Burns

least common form of burns exposure to radioactive source

- nuclear radiation accidents

- ionizing radiation exposure - prolonged exposure to ultraviolet

light ( sunburn)

Who is at risk of burn injury? 75% due to action of the victim Contact with scalding liquids

elderly with mental and /or physical limitations

reduce temperatures on water heaters clothing ignition during meal prep

no flammability standards yet cigarette-related mattress fires playing with matches need for operable smoke detectors

What are the responses to burn injury? If the burn is greater than 25%

BSA: Systemic and proportional response

If burn is less than 25% BSA:• Localized to injured area

Response characterized by early system hypofunction followed by hyperfunction

Nervous System Response Neurological problems uncommon

unless injury was associated with: A fall An explosion Impaired brain perfusion Closed-space fire Inhalation injury Ingested drugs

Usually awake and alert on admission

Fluid and Electrolyte Response Vasoactive substances released from

injured tissues increases capillary permeability

Direct heat injury to vessels further increases permeability

Fluids are shifted throughout entire body, not just in burned area

Leads to hypovolemic shock Low B/P, high Hct,

Cardiovascular Response Catecholamine release and

hypovolemia increases HR and peripheral vascular resistance (PVR)

Initial decrease in cardiac output ? Myocardial depressant factor May explain unresponsiveness to

fluids in extensive burn injuries

Pulmonary Response Without inhalation injury,

pulmonary response is minimal Rise in minute rate and tidal volume Slight increase in pulmonary

resistance and a decrease in lung compliance

Renal System Response Blood shunted from kidneys:

If fluids not replaced, prerenal renal failure can develop

Hemoglobin and myoglobin can become trapped in nephron Can lead to renal failure Presents as

hemoglobinuria/myoglobinuria RX= fluids, tubular diuretics

Gastrointestinal (GI) Response Decreased blood flow initially:

Ileus Risks of bleeding - Erosions lead to - Ulcerations (called Curlings ulcers

in burn victims)

Immune Response Depressed immune function:

Decreased lymphocyte activity Decreased immunoglobulin production Suppression of complement Altered neutrophil and phagocyte

function Increases risk of sepsis and

infections

Psychological Response Influenced by:

Age Personality Cultural and ethnic background Extent and location of injury Impact on body image Cause of injury (self-inflicted vs.

victim of others)

Four Stages of Psychosocial Response Impact Stage

Shock, disbelief, feelings of being overwhelmed

Family and client need assurance, proximity to the client, information

Retreat Stage repression, withdrawal, denial,

suppression Family needs to know that these

responses are normal and self-protective

Psychological Response Continued… Acknowledgment Stage

Begins when client accepts the injury Mourns actual or perceived losses Family and client may benefit from meeting

other burned clients Reconstructive Phase

Accepts limitations imposed by injury Begins to plan realistically for the future May benefit from job retraining

Pain Response Burns hurt!!! Background pain

Pain while at rest or with nonprocedural activities

Continuous and low intensity Procedural pain

Related to therapeutic modalities Debridement especially painful Acute and high intensity

Can the respiratory tract be burned? Direct heat injury is uncommon Respiratory tract is very efficient at

cooling inspired air Air entering pharynx at 518 degrees is

cooled to 122 degrees by the time it reaches the trachea

Reflex closure of glottis Only live steam can burn

It has 6,000 times the heat carrying capacity

What substances burn the respiratory tract? By products of combustion

Wood, cotton, paper Acetaldehyde, formaldehyde

Petroleum• Acrolein (tear gas)

Wool, silk• Ammonia, hydrogen cyanide, hydrogen sulfide

Polymer of plastic• Hydrochloric acid, hydrogen cyanide, ammonia

How does inhalation injury occur? Asphyxiants (most common) From carbon monoxide (CO) produced

when organic material is burned CO poisoning manifestations

5-10% = impaired visual acuity 11-20% = flushing, headache 21-30% = nausea, impaired dexterity 31-40% = vomiting, dizziness, syncope 41-50% = tachypnea, tachycardia > 50% = coma, death

Inhalation injuries cont… Smoke Poisoning

Inhalation of combustion by-products Noxious chemicals and particulates

Produces edema, epithelial sloughing and ARDS

Inhalation Injuries Leading cause of death in burn

victims Most inhalation injury victims never

reach the hospital Seen in 30% of victims of residential

fires High risk clients:

Trapped in enclosed, smoke filled spaces

How can I recognize inhalation injury? Look for:

Facial burns, singed nasal hairs Erythema or edema of oropharnyx or

nasophanyx Stridor, wheezing, dyspnea Hoarse voice or change in voice carbonaceous sputum, cough

Examine by brochoscopy or xenon-133 lung scan

Management of Inhalation Injuries Frequent ABG’s Continuous oximetry Monitor for respiratory alkalosis,

hypoxia, hypercapnia Monitor carboxyhemoglobin Hyperbaric oxygen therapy (HBO) Mechanical Ventilation with PEEP?

How do I determine burn severity? Burn depth Burn size Burn location Age General health Mechanism of burn injury

Determining burn depth Superficial partial thickness (aka

first degree) Mild to severe erythema Skin blanches with pressure Painful Pain eased by cooling Desquamation in 3-7 days Heals on its own

Determining burn depth Partial thickness burn (aka second degree)

Large, thick blisters (wet or shiny if blisters open)

Yellow, red, white eschar Mottled red base Edematous Painful Sensitive to cold air Heals in 14-28 days Healing rate varies with depth and infection

Determine burn depth Full thickness injury (aka third degree)

Surface is dry and black, brown, red, white Edematous May have exposed sub-q tissue, muscle or

bone Little pain Desquamates in 2-3 weeks Cannot heal on its own unless very small Subject to hypertrophic scar and contractures

Determine burn size Size of burn (excluding first degree

areas) Percent body surface areas (BSA) Most accurate after debridement Rule of nines

Quick assessment Body parts are nines or multiples of nines

Lund and Browder charts Age-specific More accurate after exposure

Determine burn location Burns of the head, chest, neck have

pulmonary complications Burns of the eyes have corneal abrasions Burns of the ears subject to tissue loss burns of the hands subject to contracture

and may lead to permanent disability Circumferential burns prone to vascular

compromise

Determine age and general health Mortality higher for children > 4

yrs and elderly over 65 General health Systemic diseases

Cardiac disease 3.5-4 times mortality rate

Alcoholism 3 times mortality rate

Determine mechanism of injury Chemical burns

Systemic toxicity from absorption Organ failure

Esp hydrocarbons from petroleum products

Determine mechanisms of injury Electrical burn

Injuries always worse than they first seem

AC more dangerous than DC Heat is generated as electricity travels

through the body Myoglobin release leads to ARF Fractures Cataracts

ABA Severity Classification for Burns Minor Burns

< 15% BSA in adults < 10% BSA in children < 10% BSA in adults > 40 years No functional or cosmetic impairment

or disability

ABA Severity Classification for Burns Moderate Burns

15-25% BSA in adults 10-20% BSA in children < 10 yrs 10-20% BSA in adults > 40 < 10% BSA full thickness burn of the

face, eyes, ears, hands, feet, or perineum

Phases of Burn Treatment Emergent Period – from the time of

injury until fluid resuscitation is completed

Acute Period – from time of fluid resuscitation until ungrafted BSA < 20%

Rehabilitation Period – from the time of ungrafted BSA < 20% until total rehabilitation

Management of Minor Burns History of injury, past medical history,

allergies, usual medications Wound Care – cleansing, debridement,

dressing Twice daily with mild antimicrobial ointment

Oral analgesia Tetanus immunization Teach about ROM, elevation

ABA Severity Classification for Burns Severe Burns

25% BSA in adults 20% BSA in children < 10 yrs Burns of face, eyes, ears, hands, feet,

or perineum High-voltage electrical injury All burns with concomitant inhalation

injury or major trauma

Burn Care Phases Emergent Phase

From time of injury until capillary integrity restored and diuresis begins

Goals are prevention of hypovolemic shock and preservation of vital organ function

Prehospital Burn Care Stop the Burning Process!

Extinguish burning clothes Remove saturated clothing

(chemicals/scalds) Cool the tar burn Copiously irrigate the chemical burn Do not attempt to neutralize Brush dry chemicals off, do not activate with

water Shut off power or remove source of

electricity using a dry, nonconductive object

Prehospital Burn Care Assess the ABCs

Establish airway Ensure adequate breathing (100% oxygen

via non rebreather mask for suspected inhalation injury

Assess circulation Assess for associated trauma Conserve body heat Start a large bore IV in unburned skin Transport

Initial Care of the Burn Victim Reevaluate ABCs and associated trauma

100% oxygen or HBO when high COHb levels Obtain IV Access

Large bore IV in unburned skin, proximal to burn or central access

Estimate BSA size of burn Begin fluid resuscitation

Goal is to provide adequate circulating volume without fluid overload

Principles of Fluid Resuscitation Purpose is to prevent hypovolemic shock

while capillaries are highly permeable Time zero is the time of injury, not the time

fluid resuscitation began Fluid formulas are only guidelines Fluids titrated to maintain urine output Colloids and dextrose given after 24 hours

to prevent increased edema and diuresis

Fluid Resuscitation Guidelines-Brooke First 24 hours

LR 1.5 ml/kg/%burn Colloid 0.5mg/kg/%burn

Second 24 hours LR 1/2 to ¾ of first 24 hr volume Colloid ½ to ¾ first 24 hr volume

Fluid ResuscitationGuidelines-Evans Evans formula

First 24 hours NS 1ml/kg/% burn Colloids 1ml/kg/% burn Dextrose in water 2000ml

Second 24 hours ½ volume of NS, ½ volume of colloid,

2000 ml Dextrose

Fluid ResuscitationGuidelines-Parkland First 24 hours

LR 4ml/kg/% burn No colloids or dextrose

Second 24 hours Colloid 0.3 – 0.5 ml/kg/ % burn Titrate Dextrose solution to maintain

urine output

How much fluid does this burn victim need? Using Parkland formula calculate

fluid needs for 70 kg man with 50% BSA burn

Initial Care of the Burn Victim Insert NG tube Baseline Vital Signs Assess Urine Output

Indwelling catheter Assess for

hemoglobinuria/myoglobinuria Can lead to renal failure (ATN) Increase fluids to maintain 75-100ml output

if present

Initial Care of Burn Victim Baseline Lab studies

Glucose, BUN, Creatinine, Electrolytes, Hematocrit, ABGs and COHb

Pain assessment and Management IV morphine No oral meds or injections (no

digestion or absorption) Tetanus Immunization

Initial Care of Burn Victim Date Collection

Time of injury Loss of consciousness Burned in enclosed space Associated trauma History of past medical problems

Initial Care of Burn Victim Date Collection, cont

If chemical burn Specific chemical Concentration Duration of exposure Use of irrigation

If electrical burn Source, voltage Type of current

Initial Wound Care Irrigate contaminants from wound Debride broken blisters Leave intact blisters alone Cover with antimicrobial and dressings

Open method for face, neck, perineum Closed method for remainder of body

Wrap distal to proximal Elevate extremities Monitor pulses and respirations

Principles of a Releasing Escharotomy

1. Relieve Respiratory Distress

2. Prevent Circulatory Occlusion

Periods of Burn Treatment Emergent Period – from the time of

injury until fluid resuscitation is complete

Acute Period – from fluid resuscitation until ungrafted BSA less than 20%

Rehabilitation Period – from less than 20%BSA ungrafted until total rehabilitation

The Acute Phase of Burn Management Acute phase from fluid resuscitation to

wound closure Care focuses on:

Infection control Wound care nutritional support Pain management Psychosocial support Physical therapy Control of scarring

Why is a burn wound so likely to become infected? Optimal conditions for bacterial

growth Warm environment Dark environment Moisture Food present in eschar and body fluids pH is alkaline Anaerobic/aerobic environment

How can the risk of infection be reduced? Use antimicrobials Support immune functions Provide adequate nutrition Eliminate reservoirs of infection Reduce risk of contamination

Infection control Prevent transmission of micro

organisms Common sources are oropharnyx, fecal

flora, unburned skin, cross contamination

Vigilant monitoring for infection, sepsis Use of additional isolation techniques Use of aseptic technique Use of antimicrobials

Wound Infection – Septicemia

Wound Care Debridement

Hydrotherapy Mechanical debridement

Dressings Scissors, forceps

Wound Care –Debridement Enzymatic Debridement

Proteolytic and fibrinolytic topical enzymes to eschar

Digest necrotic tissues Require a moist environment Usually confined to small area and qd Pain and bleeding can result Do not use on wounds adjacent to major

body cavities, or with exposed nerves or tendons

Wound Debridement –Surgical Excision of devitalized tissues

Tangential excision Very thin layers of eschar removed until

viable tissue reached Facilitates healing and grafting

Fascial excision For deep burn wounds

Assess for bleeding and manage pain

Topical Antimicrobials Ideal agent would:

Promote eschar separation Not destroy granulation or epithelial tissue Be broad spectrum Stay on the wound for 24 hours Produce no pain during application Have limited allergies Be of reasonable cost Have no serious side effects

What are my choices for topical antimicrobials? Silver sulfadiazine

Broad spectrum, including yeast and fungi Apply bid, apply to dressing first Separates when stored at warm temps Does not produce pain upon application Transient leukopenia is a SE Costs about $12.00 per 50 gm jar The most common agent used

What are my choices for topical antimicrobials? Mafenide acetate (Sulfamylon)

Broad spectrum, little fungal activity Is applied twice daily in thin layers on

dressings Can inhibit carbonic anhydrase leading

to metabolic acidosis Produces pain and burning on

application Use with caution in clients with renal

failure

What are my choices for topical antimcirobials? Silver nitrate solution

Broad spectrum, including Candida Penetrates eschar poorly Stains everything black-brown Needs multiple layers of dressings Dressings need to be remoistened

every 2 hrs SEs include: decreased Na, Cl, K, Ca

What are the advantages of biologic dressings? Decrease evaporative water loss Decrease protein loss Decrease bacterial proliferation Decrease pain Maintain body temperature Protect granulation tissue Protect exposed vessels, tendons,

nerves

What temporary wound covers can be used? Temporary Wound Covers

Rejection slow due to natural immune suppression after burn injury

Decrease fluid loss, pain, and risk of infection

Improve survival Options

Amnionic membrane Dressing changed every 2 days

What temporary wound covers can be used? Allograft (cadaveric)

Harvested within 24 hrs of death Used to debride exudative wounds Used to cover and protect wounds

ready for grafting Used to cover and protect meshed

autografts

What temporary wound covers can be used? Xenograft (heterograft)

Harvested after slaughter, then preserved for storage

Used to promote healing of clean, superficial burns

Changed every 2-5 days

How is the burn wound permanently covered? Autograft ( Split-thickness skin

graft/STSG) Surgical removal of client’s own

unburned or healed burned skin Only permanent means to heal wound Are not “rejected” but can fail to take

or become infected Sheet grafts or meshed grafts Can be harvested for application later

What does the graft site need? Immobilization Elevation Assessment of fluids beneath graft

that prevent adherence to wound bed Blood, fluid

Assessment of infection

What care does the donor site need? Realize that donor sites increase

the size of the wound May increase caloric needs, fluid

needs Donor site is covered to facilitate

healing Moist dressings preferred

Usually heals in 10-14 days

What nutritional needs do burn clients have? Basal metabolic rate increased by

40-100% Metabolic rates slow as wound closes Aggressive nutritional support

needed Common formula is:

(25 kcal x Kg) + 40 kcal x % burn) How many calories does a 70 Kg man

with a 50% burn wound need to eat?

How can nutritional needs be supported? Monitor weights, labs Six feedings a day Supplements within foods Tube feedings hs Hyperalimentation

For prolonged ileus Sepsis reported

Difficult to get clients to eat, then difficult to get them to stop eating

How can pain be managed? Influenced by many factors: depth of

burn, extent stage of healing Also influenced by psychological factors:

anxiety, fear, past experiences with pain, separation from home/family, personality

Medications include: narcotics, nitrous oxide, NSAIDS (ulcerative)

Nonpharmcologic interventions: hypnosis, guided imagery, art and play, relaxation, biofeedback and music

Periods of Burn Treatment Emergent Period – from the time of

injury until fluid resuscitation is complete

Acute Period – from fluid resuscitation until ungrafted BSA less than 20%

Rehabilitation Period – from less than 20%BSA ungrafted until total rehabilitation

The Rehabilitation Phase Begins as wounds are being closed and

ends when client reaches full potential Focuses on:

Wound healing, scar revision at 1 year Preventing or minimizing deformities Increasing strength and function Providing emotional support and community

reintegration Providing education

How can functional outcome be maximized? Splinting

Static and dynamic splints To prevent contractures

Positioning Elevation NOT the position of maximum comfort

Exercise (AROM/PROM)

How can functional outcome be maximized? Control of scarring

Keloids vs hypertrophic scars Need for continuous pressure

Elastic wraps early Pressure garments later

Worn 23 hrs a day for 18-24 months

Scar revision after a year

Burn Prevention Educate the public

Smoke detectors Fire escape plans Safety in the home

Influence Legislation Flame retardant clothing

Promote Industrial Fire Safety

Never forget, there is a person in every

burned body.