2. Prevention of Burns
• Fire extinguishers and smoke alarms
• Keep emergency phone numbers by phone
• Have family exit plans for fires
• Teach to “stop, drop, and roll”
• Store lighters and matches aware from children
and those unable to protect themselves
• Reduce water heater to < 120 degrees
3. Prevention of Burns
• Avoid sun exposure between 10am and
4pm, use sunblock, and protective clothing
• Avoid tanning beds
• Avoid smoking in bed and when drinking
ETOH or sedating medications
4. What is a burn?
• Injury to body tissue due to
– Heat
– Chemicals
– Electric current
– Radiation
• Effects of the injury are dependent upon
– Burning agent
– Duration of contact
– Type of tissue injured
6. Types of Burns
• Thermal (most common)
– Flame, flash, scald, or contact with hot objects
• Chemical
– Acids, alkalis, and organic compounds
– Damage to eyes as well as skin
• Cold Thermal (Frostbite)
7. Types of Burns
• Smoke and Inhalation Injury
– Carbon Monoxide Poisoning
• “cherry red” skin color and may not have other injuries
– Inhalation injury above the glottis (upper airway)
• Redness, blistering, and edema leading to obstructed airway
• Suspect if facial burns, singed nasal hair, painful swallow, and
burns around chest and neck
– Inhalation below the glottis (lower airway)
• Usually chemicals
• Signs of pulmonary edema and Acute Respiratory Distress
Syndrome (ARDSbut may not appear until 12-24 hours after
burn
8. Types of Burns
• Electrical
– If current passes through vital organs there are
more life-threatening results
– Determine contact points
– Risk of dysrhythmias for 24 hours, cardiac
arrest, severe metabolic acidosis, and
myoglobinuria which may lead to acute renal
failure
9. Treatment of Burns
• Related to the severity of the injury
– Depth of burn
– Extent of total body surface area (TBSA) burned
– Location of burn
– Patient risk factors
• Based on the severity – patients can either be
treated at any hospital or must be send to a
burn center (Table 25-3 p.475.)
10. Depth of Burn
• Partial-thickness
– First and second degree
– Epidermis and dermis
– Partial-thickness pink to cherry-red and are wet and
shiny with exudate; may have intact blisters and are
painful to touch and exposed air
11. Depth of Burn
• Full-thickness
– Third and fourth degree
– All skin layers
– Full-thickness appear dry and waxy white to
dark brown/black with minor sensation due to
nerves being destroyed
12. Extent of Burn
• TBSA measurement
• Rule of 9’s (Fig. 25-4 p. 476)
– Each side of leg = 9%
– Each side of arm = 4.5%
– Front or back torso = 18%
– Front or back head = 4.5%
– Genitalia = 1%
• Irregular burns
– Patient’s hand size is 1%
13. Location of Burn
• Face, neck, and cirumferential burns to
chest/back may cause respiratory distress due to
edema and obstruction – possible inhalation
injury also
• Hands, feet, joints, and eyes – problems
maintaining function during healing
– Circulatory compromise distal extremity;
compartment syndrome – assess Color, Motion, and
Sensation, pulse to extremities
• Ears and nose – high infection rate
14. Patient Risk Factors
• Older adults heal slower
• Poor prognosis if
cardiovascular, respiratory, or renal disease
due to demands burns have on the body
• Diabetes and PVD impaired healing
15. Pre-hospital Care
• Remove from source of burn
• Stop burning process
• <10% TBSA – cover with clean, cool, tap water
dampened towel
• >10% or electrical or inhalation
– A – patency and soot near nares/tongue, singed
hair, dark membranes
– B – check breathing
– C – check pulses and elevate burned limbs to level of
heart
16. Pre-hospital Care
• Do not cool large burns for more than 10
minutes or put ice on burns
– Leads to hypothermia
• Chemical burns
– Flush, flush, flush (20 min to 2 hours)
• Other injuries may take priority over burns
17. Emergent Phase
• Time required to resolve immediate, life-
threatening problems from burn injury (up
to 72 hours)
• Primary concerns
– Hypovolemic shock
– Edema formation
• Ends when diuresis begins
18. Hypovolemic Shock
• Massive fluid shift out of cells
– Second and third spacing
• May start within 20 minutes of burn injury
• ↓BP, ↑HR & RR
• ↑ H/H, K
• ↓ Na
20. Most Common Sign or Unconsciousness or
Altered Mental Status
• Hypoxia
• Head trauma, history of substance
abuse, sedation or pain medication
• Most patients are alert and are scared
22. Complications
• Respiratory distress
– Upper airway – obstruction and asphyxia due to
swelling
– Lower airway – oxygenation issues (ABGs)
• Renal
– Acute renal failure due to hypovolemia
– Myoglobin and hemoglobin breakdown and get
stuck in the kidney tubules
23. Nursing Care During Emergent Phase
• Airway Management
– 100% humidified O2 (also treatment for CO poisoning)
– High fowler’s position; reposition every 1-2 hours
– Cough & Deep Breathe every hour
– Early intubation (prevents tracheostomy)
– Ventilatory support (ABG monitoring)
– Bronchoscopy after smoke inhalation
– Bronchodilators
24. Nursing Care During Emergent Phase
• Fluid Therapy
– 2 large bore IVs if >15% TBSA
– Central line if necessary
– LR (initially) or Albumin (after first 12-24hrs)
– Parkland Formula (Table 25-12 p. 483) for
amount to replace – may tweak per patient
– Adequacy of fluid resuscitation best determined
by Urine Output
• MAP >65, BP>90, HR<120
25. Nursing Care During Emergent Phase
• Wound Care
– Cleansing and gentle debridement in shower
(<104 degrees) or at bedside every morning and
dressing change in patient’s room in evening is
common routine
– Extensive debridement occurs in the OR
– Provide emotional support
– New antimicrobial dressings can be left on 3-14
days which decreases dressing changes
26. Nursing Care During Emergent Phase
• Wound Care
– Infection from patient’s own flora is possible
• Be very cognizant about standard precautions
– Open method
• Covered with antimicrobial but no dressing
– Closed method (multiple dressing change)
• Sterile gauze dressings with/over antimicrobial
• Changed every 12-24 hours
• Most choose this concept of moist wound healing
27. Nursing Care During Emergent Phase
• Wound Care
– Use appropriate Personal Protective Equipment
– May be non-sterile when removing old and washing
the wound
– Sterile gloves to apply ointments and dressings
– Keep room warm about 85 degrees
– Good hand washing
– May use cadaver skin or biosynthetic options to cover
burns until skin grafting can occur
– Early ROM occurs with dressing changes
28. Nursing Care During Emergent Phase
• Pain management
– IV route initially
• Switch to PO for longer pain control once GI tract able to
digest
– Sedatives/hypnotics and antidepressants can help with
anxiety, insomnia, and/or depression
– Individualized to the patient
• Tetanus immunization to all
• Topical antimicrobials only unless septic
• Prevent DVTs so Lovenox or low-dose Heparin
29. Nursing Care During Emergent Phase
• Nutrition therapy
– Once fluid replacement done
– Early and aggressive nutrition support within
several hours of the burn can optimize healing
– <20% TBSA can usually eat enough
– Intubated or large burns need enteral feedings
• Watch for paralytic ileus
• Start 20-40 ml/hr and up to goal within 24-48hrs
30. Acute Phase
• Movement of extracellular fluid and diuresis and
ends with burn completely covered by skin graft or
when healed (weeks to months)
• ↓ H/H & K, ↑Na
• Additional psychological support during this time
• Partial thickness eschar separates and underneath is
pink scar tissue – full-thickness takes longer
• Monitor Sodium and Potassium abnormalities
during diuresis (look at signs/symptoms for both)
31. Acute Phase
• Monitor for infection
• Neurologic changes such as confusion or delirium
• Musculoskeletal system
– Scar tissue makes movement harder
• GI system
– Ileus, diarrhea from feedings, constipation from pain
meds, Curling’s ulcer (h-2 antagonists & PPIs)
• Endocrine
– Increased blood sugar due to stress
32. Rehabilitation Phase
• Starts once healed to ability to resume a level of
self-care activity (2 weeks to 7/8 months)
• Assist patient in normal functioning
• Rehabilitate from functional and cosmetic
reconstructive surgery
• Contractures
– Shortening of scar tissue near joints
– Less pain when joint flexed which is cause
33. Older Patients and Burns
• More complications
– DM, HF, and COPD
• Pneumonia more frequent
• Longer healing times
• Surgery less tolerated
• Delirium and weaning from ventilator
challenging
34. Emotional Needs
• Regression
– Revert to behavior that has helped in previous stressful
situations
• New fears develop as become independent
• Open and frequent communication helps
• Fear, anxiety, guilt, and depression
• PTSD
• Help them seek appropriate help
• Support groups
