Burns

Burns

 

Definition

Burns are injuries to tissues caused by heat, friction, electricity, radiation, or chemicals.

Description

Burns are characterized by degree, based on the severity of the tissue damage. A first-degree burn causes redness and swelling in the outermost layers of skin (epidermis). A second-degree burn involves redness, swelling and blistering, and the damage may extend beneath the epidermis to deeper layers of skin (dermis). A third-degree burn, also called a full-thickness burn, destroys the entire depth of skin, causing significant scarring. Damage also may extend to the underlying fat, muscle, or bone.

The severity of the burn is also judged by the amount of body surface area (BSA) involved. Health care workers use the "rule of nines" to determine the percentage of BSA affected in patients more than 9 years old: each arm with its hand is 9% of BSA; each leg with its foot is 18%; the front of the torso is 18%; the back of the torso, including the buttocks, is 18%; the head and neck are 9%; and the genital area (perineum) is 1%. This rule cannot be applied to a young child's body proportions, so BSA is estimated using the palm of the patient's hand as a measure of 1% area.

The severity of the burn will determine not only the type of treatment, but also where the burn patient should receive treatment. Minor burns may be treated at home or in a doctor's office. These are defined as first- or second-degree burns covering less than 15% of an adult's body or less than 10% of a child's body, or a third-degree burn on less than 2% BSA. Moderate burns should be treated at a hospital. These are defined as first- or second-degree burns covering 15%-25% of an adult's body or 10%-20% of a child's body, or a third-degree burn on 2%-10% BSA. Critical, or major, burns are the most serious and should be treated in a specialized burn unit of a hospital. These are defined as first- or second-degree burns covering more than 25% of an adult's body or more than 20% of a child's body, or a third-degree burn on more than 10% BSA. In addition, burns involving the hands, feet, face, eyes, ears, or genitals are considered critical. Other factors influence the level of treatment needed, including associated injuries such as bone fractures and smoke inhalation, presence of a chronic disease, or a history of being abused. Also, children and the elderly are more vulnerable to complications from burn injuries and require more intensive care.

Causes and symptoms

Burns may be caused by even a brief encounter with heat greater than 120°F (49°C). The source of this heat may be the sun (causing a sunburn), hot liquids, steam, fire, electricity, friction (causing rug burns and rope burns), and chemicals (causing a caustic burn upon contact).

Signs of a burn are localized redness, swelling, and pain. A severe burn will also blister. The skin may also peel, appear white or charred, and feel numb. A burn may trigger a headache and fever. Extensive burns may induce shock, the symptoms of which are faintness, weakness, rapid pulse and breathing, pale and clammy skin, and bluish lips and fingernails.

Diagnosis

A physician will diagnose a burn based upon visual examination, and will also ask the patient or family members questions to determine the best treatment. He or she may also check for smoke inhalation, carbon monoxide poisoning, cyanide poisoning, other event-related trauma, or, if suspected, further evidence of child abuse.

Treatment

Burn treatment consists of relieving pain, preventing infection, and maintaining body fluids, electrolytes, and calorie intake while the body heals. Treatment of chemical or electrical burns is slightly different from the treatment of thermal burns but the objectives are the same.

Thermal burn treatment

The first act of thermal burn treatment is to stop the burning process. This may be accomplished by letting cool water run over the burned area or by soaking it in cool (not cold) water. Ice should never be applied to the burn. Cool (not cold) wet compresses may provide some pain relief when applied to small areas of first- and second-degree burns. Butter, shortening, or similar salve should never be applied to the burn since it prevents heat from escaping and drives the burning process deeper into the skin.

If the burn is minor, it may be cleaned gently with soap and water. Blisters should not be broken. If the skin of the burned area is unbroken and it is not likely to be further irritated by pressure or friction, the burn

There are three classifications of burns: first-degree, second-degree, and third-degree burns.

(Illustration by Electronic Illustrators Group.)

should be left exposed to the air to promote healing. If the skin is broken or apt to be disturbed, the burned area should be coated lightly with an antibacterial ointment and covered with a sterile bandage. Aspirin, acetaminophen (Tylenol), or ibuprofen (Advil) may be taken to ease pain and relieve inflammation. A doctor should be consulted if these signs of infection appear: increased warmth, redness, pain, or swelling; pus or similar drainage from the wound; swollen lymph nodes; or red streaks spreading away from the burn.

Classification Of Burns
First-Degree (Minor)	The burned area is painful. The outer skin is reddened. Slight swelling is present.
Second-Degree (Moderate)	The burned area is painful. The underskin is affected. Blisters may form. The area may have a wet, shiny appearance because of exposed tissue.
Third-Degree (Critical)	The burned area is insensitive due to the destruction of nerve endings. Skin is destroyed. Muscle tissues and bone underneath may be damaged. The area may be charred, white, or grayish in color.

In situations where a person has received moderate or critical burns, lifesaving measures take precedence over burn treatment and emergency medical assistance must be called. A person with serious burns may stop breathing, and artificial respiration (also called mouth-to-mouth resuscitation or rescue breathing) should be administered immediately. Also, a person with burns covering more than 12% BSA is likely to go into shock; this condition may be prevented by laying the person flat and elevating the feet about 12 in (30 cm). Burned arms and hands should also be raised higher than the person's heart.

In rescues, a blanket may be used to smother any flames as the person is removed from danger. The person whose clothing is on fire should "stop, drop, and roll" or be assisted in lying flat on the ground and rolling to put out the fire. Afterwards, only burnt clothing that comes off easily should be removed; any clothing embedded in the burn should not be disturbed. Removing any smoldering apparel and covering the person with a light, cool, wet cloth, such as a sheet but not a blanket or towel, will stop the burning process.

At the hospital, the staff will provide further medical treatment. A tube to aid breathing may be inserted if the patient's airways or lungs have been damaged, as can happen during an explosion or a fire in a enclosed space. Also, because burns dramatically deplete the body of fluids, replacement fluids are administered intravenously. The patient is also given antibiotics intravenously to prevent infection, and he or she may also receive a tetanus shot, depending on his or her immunization history. Once the burned area is cleaned and treated with antibiotic cream or ointment, it is covered in sterile bandages, which are changed two to three times a day. Surgical removal of dead tissue (debridement) also takes place. As the burns heal, thick, taut scabs (eschar) form, which the doctor may have to cut to improve blood flow to the more elastic healthy tissue beneath. The patient will also undergo physical and occupational therapy to keep the burned areas from becoming inflexible and to minimize scarring.

In cases where the skin has been so damaged that it cannot properly heal, a skin graft is usually performed. A skin graft involves taking a piece of skin from an unburned portion of the patient's body (autograft) and transplanting it to the burned area. When doctors cannot immediately use the patient's own skin, a temporary graft is performed using the skin of a human donor (allograft), either alive or dead, or the skin of an animal (xenograft), usually that of a pig.

The burn victim also may be placed in a hyperbaric chamber, if one is available. In a hyperbaric chamber (which can be a specialized room or enclosed space), the patient is exposed to pure oxygen under high pressure, which can aid in healing. However, for this therapy to be effective, the patient must be placed in a chamber within 24 hours of being burned.

Chemical burn treatment

Burns from liquid chemicals must be rinsed with cool water for at least 15 minutes to stop the burning process. Any burn to the eye must be similarly flushed with water. In cases of burns from dry chemicals such as lime, the powder should be completely brushed away before the area is washed. Any clothing which may have absorbed the chemical should be removed. The burn should then be loosely covered with a sterile gauze pad and the person taken to the hospital for further treatment. A physician may be able to neutralize the offending chemical with another before treating the burn like a thermal burn of similar severity.

Electrical burn treatment

Before electrical burns are treated at the site of the accident, the power source must be disconnected if possible and the victim moved away from it to keep the person giving aid from being electrocuted. Lifesaving measures again take priority over burn treatment, so breathing must be checked and assisted if necessary. Electrical burns should be loosely covered with sterile gauze pads and the person taken to the hospital for further treatment.

Alternative treatment

In addition to the excellent treatment of burns provided by traditional medicine, some alternative approaches may be helpful as well. (Major burns should always be treated by a medical practitioner.) The homeopathic remedies Cantharis and Causticum can assist in burn healing. A number of botanical remedies, applied topically, can also help burns heal. These include aloe (Aloe barbadensis), oil of St.-John's-wort (Hypericum perforatum), calendula (Calendula officinalis), comfrey (Symphytum officinale), and tea tree oil (Melaleuca spp.). Supplementing the diet with vitamin C, vitamin E, and zinc also is beneficial for wound healing.

Key terms

Debridement — The surgical removal of dead tissue.

Dermis — The basal layer of skin; it contains blood and lymphatic vessels, nerves, glands, and hair follicles.

Epidermis — The outer portion of skin, made up of four or five superficial layers.

Shock — An abnormal condition resulting from low blood volume due to hemorrhage or dehydration. Signs of shock include rapid pulse and breathing, and cool, moist, pale skin.

Prognosis

The prognosis is dependent upon the degree of the burn, the amount of body surface covered, whether critical body parts were affected, any additional injuries or complications like infection, and the promptness of medical treatment. Minor burns may heal in five to 10 days with no scarring. Moderate burns may heal in 10-14 days and may leave scarring. Critical or major burns take more than 14 days to heal and will leave significant scarring. Scar tissue may limit mobility and functionality, but physical therapy may overcome these limitations. In some cases, additional surgery may be advisable to remove scar tissue and restore appearance.

Prevention

Burns are commonly received in residential fires. Properly placed and working smoke detectors in combination with rapid evacuation plans will minimize a person's exposure to smoke and flames in the event of a fire. Children must be taught never to play with matches, lighters, fireworks, gasoline, and cleaning fluids.

Burns by scalding with hot water or other liquids may be prevented by setting the water heater thermostat no higher than 120°F (49°C), checking the temperature of bath water before getting into the tub, and turning pot handles on the stove out of the reach of children. Care should be used when removing covers from pans of steaming foods and when uncovering or opening foods heated in a microwave oven.

Thermal burns are often received from electrical appliances. Care should be exercised around stoves, space heaters, irons, and curling irons.

Sunburns may be avoided by the liberal use of a sunscreen containing either an opaque active ingredient such as zinc oxide or titanium dioxide or a nonopaque active ingredient such as PABA (para-aminobenzoic acid) or benzophenone. Hats, loose clothing, and umbrellas also provide protection, especially between 10 A.M. and 3 P.M. when the most damaging ultraviolet rays are present in direct sunlight.

Electrical burns may be prevented by covering unused electrical outlets with safety plugs and keeping electrical cords away from infants and toddlers who might chew on them. Persons should also seek shelter indoors during a thunderstorm to avoid being struck by lightning.

Chemical burns may be prevented by wearing protective clothing, including gloves and eyeshields. Chemical agents should always be used according to the manufacturer's instructions and properly stored when not in use.

Resources

Organizations

Shriners Hospitals for Children. 2900 Rocky Point Drive, Tampa, FL 33607-1435. (813) 281-0300. http://www.shrinershq.org.

Other

HealthAnswers.com. http://www.healthanswers.com.

Burns

(bernz),

Allan, Scottish anatomist, 1781-1813. See: Burns ligament, Burns falciform process, Burns space.

burns

The damage response of the skin and underlying tissues to high temperature from any source. Burns may be partial or full thickness, the latter requiring grafting.

Burns

DRG Category:	933
Mean LOS:	5.3 days
Description:	MEDICAL: Extensive Burns or Full Thickness Burns With MV 96+ Hours Without Skin Graft
DRG Category:	935
Mean LOS:	5 days
Description:	MEDICAL: Non-Extensive Burns

Burns have a catastrophic effect on people in terms of human life, suffering, disability, and financial loss. Burns are the third leading cause of accidental death in the United States; approximately 4,000 people die each year from burns. Each year, an estimated 500,000 Americans experience burns severe enough to seek medical care. Most burn care is delivered in the emergency department, although 40,000 people require hospitalization each year in the United States. The physiological responses to moderate and major burns are outlined in Table 1.

System Impact of Moderate or Major Burns

Table 1. System Impact of Moderate or Major Burns

SYSTEM	PHYSIOLOGICAL CHANGES
Cardiovascular	Fluid shifts from the vascular to the interstitial space occur because of increased permeability related to the inflammatory response. Hypovolemic shock may result or it may be overcorrected by overzealous fluid replacement, which can lead to hypervolemia. Hypertension occurs in about one-third of all children with burns, possibly caused by stress.
Pulmonary	Pulmonary edema brought about by primary cellular damage or circumferential chest burns limiting chest excursion can occur. Byproducts of combustion may lead to carbon monoxide poisoning. Inhalation of noxious gases may cause primary pulmonary damage or airway edema and upper airway obstructions.
Genitourinary	Potential for renal shutdown brought about by hypovolemia or acute renal failure exists. Massive diuresis from fluid returning to the vascular space marks the end of the emergent phase. Patients may develop hemomyoglobinuria because of massive full-thickness burns or electric injury. These injuries cause the release of muscle protein (myoglobin) and hemoglobin, which can clog the renal tubules and cause acute renal failure.
Gastrointestinal	Paralytic ileus can result from hypovolemia and last 2 or 3 days. Children are particularly susceptible to Curling’s ulcer, a stress ulcer, because of the overwhelming systemic injury.
Musculoskeletal	Potential exists for the development of compartment syndrome because of edema. Escharatomy (cutting of a thick burn) may be needed to improve circulation. Scarring and contractures are a potential problem if prevention is not started on admission.
Neurological	Personality changes are common throughout recovery because of stress, electrolyte disturbance, hypoxemia, or medications. Children are particularly at risk for postburn seizures during the acute phase.

Causes

Most burns result from preventable accidents. There are six classifications of burn wounds based on injury mechanism: scalds (by liquids, grease, or steam), contact burns, fire (flash or flame), chemical, electrical, and radiation. Thermal burns (scalds, contact, fire), which are the most common type, occur because of fires from motor vehicle crashes, accidents in residences, and arson or electrical malfunctions. Children may be burned when they play with matches or firecrackers or because of a kitchen accident. Chemical burns occur as a result of contact with, ingestion of, or inhalation of acids, alkalis, or vesicants (blistering gases). The percentage of burns actually caused by abuse is fairly small, but they are some of the most difficult to manage. Neglect or inadequate supervision of children is fairly common. Effective prevention and educational efforts such as smoke detectors, flame-retardant clothing, child-resistant cigarette lighters, and the Stop Drop and Roll program have decreased the number and severity of injuries.

Genetic considerations

There are no genetic considerations with burn injuries.

Gender, ethnic/racial, and life span considerations

Preschool children account for over two-thirds of all burn fatalities. Clinicians use a special chart for children (Lund-Browder Chart) that provides a picture and a graph to account for the difference in body surface area by age. Serious burn injuries occur most commonly in males, and, in particular, young adult males ages 20 to 29, followed by children under age 9. Individuals older than 50 sustain the fewest number of serious burn injuries.

The younger child is the most common victim of burns that have been caused by liquids. Preschoolers, school-aged children, and teenagers are more frequently the victims of flame burns. Young children playing with lighters or matches are at risk, as are teenagers because of carelessness or risk-taking behaviors around fires. Toddlers incur electrical burns from biting electrical cords or putting objects in outlets. Most adults are victims of house fires or work-related accidents that involve chemicals or electricity. The elderly are also prone to scald injuries because their skin tends to be extremely thin and sensitive to heat.

Because of the severe impact of this injury, the very young and the very old are less able to respond to therapy and have a higher incidence of mortality. In addition, when a child experiences a burn, multiple surgeries are required to release contractures that occur as normal growth pulls at the scar tissue of their healed burns. Adolescents are particularly prone to psychological difficulties because of sensitivity regarding body image issues. While no gender considerations are known to exist, Native American and African American children are more than two and three times more likely than white children to die in a fire.

Global health considerations

In 2011, the World Fire Statistics Centre released fire-related death data by country (from lowest to highest number of deaths per 100,000 persons) from 2006 to 2008. The countries with the lowest incidences include Singapore (0.11) and Switzerland (0.30). Those with the highest include Hungary (1.81) and Finland (2.08). Research in Ireland and Greece suggests that the incidence of burns increases during holidays that feature the use of celebratory fireworks. Lowest cost as adjusted direct losses occurred in Singapore and Slovenia, and highest costs occurred in France and Norway.

Assessment

History

Obtain a complete description of the burn injury, including the time, the situation, the burning agent, and the actions of witnesses. The time of injury is extremely important because any delay in treatment may result in a minor or moderate burn becoming a major injury. Elicit specific information about the location of the accident because closed-space injuries are related to smoke inhalation. If abuse is suspected, obtain a more in-depth history from a variety of people who are involved with the child. The injury may be suspect if there is a delay in seeking healthcare, if there are burns that are not consistent with the story, or if there are bruises at different stages of healing. Note whether the description of the injury changes or differs among family or household members.

Physical examination

The most common symptoms are thermal injury to the skin and signs of smoke inhalation (carbonaceous sputum, singed facial or nasal hairs, facial burns, oropharyngeal edema, vocal changes). Although the wounds of a serious burn injury may be dramatic, a basic assessment of airway, breathing, and circulation (ABCs) takes first priority. Once the ABCs are stabilized, perform a complete examination of the burn wound to determine the severity of injury. The American Burn Association (ABA) establishes the severity of injury by calculating the total body surface area (TBSA) of partial- and full-thickness injury along with the age of the patient and other special factors (Table 2).

Characteristics of Burns

Table 2. Characteristics of Burns

SUPERFICIAL EPIDERMAL (1ST DEGREE)	SUPERFICIAL AND DEEP PARTIAL THICKNESS (2ND DEGREE)	FULL THICKNESS (3RD AND 4TH DEGREE)
Erythema, blanching on pressure, mild to moderate pain, no blister (typical of sunburn). Only structure involved is the epidermis	Superficial: Papillary dermis is affected with blisters, redness, and severe pain because of exposed nerve endings Deep: Reticular dermis affected with blisters, pale white or yellow color, absent pain sensation	3rd degree: All levels of the dermis along with subcutaneous fat. Blisters may be absent with leathery, wrinkled skin without capillary refill. Thrombosed blood vessels are visible, insensitive to pain because of nerve destruction 4th degree: Involvement of all levels of dermis as well as fascia, muscle, and bone

The “rule of nines” is a practical technique used to estimate the extent of TBSA involved in a burn. The technique divides the major anatomic areas of the body into percentages: In adults, 9% of the TBSA is the head and neck, 9% is each upper extremity, 18% is each anterior and posterior portion of the trunk, 18% is each lower extremity, and 1% is the perineum and genitalia. Clinicians use the patient’s palm area to represent approximately 1% of TBSA. Serial assessments of wound healing determine the patient’s response to treatment. Ongoing monitoring throughout the acute and rehabilitative phases is essential for the burn patient. Fluid balance, daily weights, vital signs, and intake and output monitoring are essential to ensure that the patient is responding appropriately to treatment.

Psychosocial

Even small burns temporarily change the appearance of the skin. Major burns will have a permanent effect on the family unit. A complete assessment of the family’s psychological health before the injury is essential. Expect pre-existing issues to magnify during this crisis, and identify previous ways of coping in order to facilitate dealing with the crisis. Guilt, blame, anxiety, fear, and depression are commonly experienced emotions.

Diagnostic highlights

Test	Normal Result	Abnormality With Condition	Explanation
Fiberoptic bronchoscopy	Normal larynx, trachea, and bronchi	Thermal injury and edema to oropharynx and glottis	Used to investigate suspected smoke inhalation and damage from noxious gases
Carboxyhemoglobin levels	8%–10% in smokers; < 8% in nonsmokers	> 10% indicates potential inhalation injury; > 30% is associated with mental status changes; > 60% is lethal	Carbon monoxide binds to hemoglobin with an affinity 240 times greater than that of oxygen

Other Tests: Because burns are the result of trauma, there are no tests needed to make the diagnosis. Some of the more common tests to monitor the patient’s response to injury and treatment are complete blood count, arterial blood gases, serum electrolytes, blood and wound cultures and sensitivities, chest x-rays, urinalysis, and nutritional profiles.

Primary nursing diagnosis

Diagnosis

Ineffective airway clearance related to airway edema

Outcomes

Respiratory status: Gas exchange; Respiratory status: Ventilation; Symptom control behavior; Treatment behavior: Illness or injury; Comfort level

Interventions

Airway management; Anxiety reduction; Oxygen therapy; Airway suctioning; Airway insertion and stabilization; Cough enhancement; Mechanical ventilation; Positioning; Respiratory monitoring

Planning and implementation

Collaborative

minor burn care.

Minor burn wounds are cared for by using the principles of comfort, cleanliness, and infection control. A gentle cleansing of the wound with soap and water two or three times a day, followed with a topical agent such as silver sulfadiazine or mafenide, prevents infection. Minor burns should heal in 7 to 10 days; however, if they take longer than 14 days, excision of the wound and a small graft may be needed. Oral analgesics may be prescribed to manage discomfort, and all burn patients need to receive tetanus toxoid to prevent infection.

major burn care.

For patients with a major injury, effective treatment is provided by a multidisciplinary team with special training in burn care. In addition to the physician and nurse, the team includes specialists in physical and occupational therapy, respiratory therapy, social work, nutrition, psychology, and child life for children. The course of recovery is divided into four phases: emergent-resuscitative, acute-wound coverage, convalescent-rehabilitative, and reorganization-reintegration.

The emergent-resuscitative phase lasts from 48 to 72 hours after injury or until diuresis takes place. If the patient cannot be transported immediately to a hospital, remove charred clothing and immerse the burn wound in cold (not ice) water for 30 minutes. Note that cooling has no therapeutic value if delayed more than 30 minutes after injury. The cold temperature is thought to be related to reduced lactate production, reduced acidosis, and reduced histamine and other mediator release. In addition to ABCs management, the patient receives fluid resuscitation, maintenance of electrolytes, aggressive pain management, and early nutrition. Wounds are cleansed with chlorhexidine gluconate, and care consists of silver sulfadiazine or mafenide and surgical management as needed. To prevent infection, continued care includes further débridement by washing the surface of the wounds with mild soap or aseptic solutions. Then the physician débrides devitalized tissue, and often the wound is covered with antibacterial agents such as silver sulfadiazine and occlusive cotton gauze. The nutritional needs of the patient are extensive and complex. Initially metabolic rate is low because of decreased cardiac output, but a severe burn can double the metabolic rate and cause the release of large amounts of amino acids from the muscles. Nutritional assessment and support occurs within the first 24 hours after the burn, and feedings are initiated enterally by feeding tube if possible. A nutritional consult is needed to determine exact caloric and nutrient needs.

The acute-wound coverage phase, which varies depending on the extent of injury, lasts until the wounds have been covered through either the normal healing process or grafting. The risk for infection is high during this phase; the physician follows wound and blood cultures and prescribes antibiotics as needed. Wound management includes excision of devitalized tissue, surgical grafting of donor skin, or placement of synthetic membranes. Inpatient rehabilitation takes place during the convalescent-rehabilitative phase. Although principles of rehabilitation are included in the plan of care from the day of admission, during this time, home exercises and wound care are taught. In addition, pressure appliances to reduce scarring, or braces to prevent contractures, are fitted. The reorganization phase is the long period of time that it may take after the injury for physical and emotional healing to take place.

Pharmacologic highlights

Medication or Drug Class	Dosage	Description	Rationale
Topical antimicrobial agents	Silver sulfadiazine	Cream that lowers bacterial counts, minimizes water evaporation, and decreases heat loss	Antimicrobial agent that is not irritating and has the fewest adverse effects
	Mafenide acetate	Bacterial coverage for gram-negative and anaerobic coverage; deep eschar penetration	Painful but readily absorbed and can lead to metabolic acidosis

Other Drugs: Tetanus prophylaxis, analgesia to manage the severe pain that accompanies thermal injury, other topical applications such as polymyxin B or Acticoat (dressings that release silver ions), H2 blockers

Independent

The nursing care of the patient with a burn is complex and collaborative, with overlapping interventions among the nurse, the physician, and a variety of therapists. However, independent nursing interventions are also an important focus for the nurse. The highest priority for the burn patient is to maintain the ABCs. The airway can be maintained in some patients by an oral or nasal airway or by the jaw lift-chin thrust maneuver. Patency of the airway is maintained by endotracheal suctioning, the frequency of which is dictated by the character and amount of secretions. If the patient is apneic, maintain breathing with a manual resuscitator bag before intubation and mechanical ventilation.

If the patient is bleeding from burn sites, apply pressure until the bleeding can be controlled surgically. Remove all constricting clothing and jewelry to allow for adequate circulation to the extremities. Implement fluid resuscitation protocols as appropriate to support the patient’s circulation. If any clothing is still smoldering and adhering to the patient, soak the area with normal saline solution and remove the material. Wound care includes collaborative management and other strategies. Cover wounds with clean, dry, sterile sheets. Do not cover large burn wounds with saline-soaked dressings, which lower the patient’s temperature. If the patient has ineffective thermoregulation, use warming or cooling blankets as needed and control the room temperature to support the patient’s optimum temperature. If the patient is hypothermic, limit traffic into the room to decrease drafts and keep the patient covered with sterile sheets. Help the patient manage pain and distress by providing careful explanations and teaching distraction and relaxation techniques.

Depending on the type and extent of injury, dressing changes are generally performed daily; twice-a-day dressing changes may be indicated for infected wounds or those with large amounts of drainage. While dressing protocols vary, one method is to cleanse the wound with sponges saturated with a wound cleanser such as poloxamer 188 to remove the topical antibiotics. Then cover the wound with antibiotic cream. As the wounds heal, use strategies such as tubbing, débridement, and dressing changes to limit infection, promote wound healing, and limit physical impairment. If impaired physical mobility is a risk, place the patient in antideformity positions at all times. Implement active and passive range of motion as needed. Get the patient out of bed on a regular basis to limit physical debilitation and decrease the risk of infection. Implement strategies to limit stress and anxiety.

Evidence-Based Practice and Health Policy

Parry, I., Walker, K., Niszczak, J., Palmieri, T., & Greenhalgh, D. (2010). Methods and tools used for the measurement of burn scare contracture. Journal of Burn and Care Research, 31(6), 888–903.

• Contractures are a significant complication of burns and can result in major functional deficits. Objective and consistent measurement of contractures is necessary to determine their responsiveness to treatments.
• A survey questionnaire completed by 121 burn therapists revealed that the most prevalent methods of measuring contractures include goniometry, visual estimation, using a tape measure, and photography.
• However, among these therapists, 12% reported they do not measure extremity contractures, 19% do not measure neck contractures, 36% do not measure facial contractures, and 56% do not measure trunk contractures.
• Reasons given for not measuring contractures included lack of time, measurement tools that were not sensitive enough, and that the measurements do not influence the treatment.

Documentation guidelines

Emergent-resuscitative Phase
• Flow sheet record of the critical physiological aspects of this time period; depending on the patient’s condition, documentation times may be established for 15-minute intervals or less for vital signs and fluid balance
• Flow sheet record or information related to the condition of the wound, wound care, and psychosocial issues

Acute-wound Coverage Phase
• The condition of the wound, healing progress, graft condition, signs of infection, scar formation, and antideformity positioning are important documentation parameters
• Psychosocial issues and the family’s involvement in care are also important information

Rehabilitative Phase
• Status of healing and the appearance of scars, as well as the patient’s functional abilities
• Ability of the patient and family to perform the complex care required during the months to come

Discharge and home healthcare guidelines

Patient teaching is individualized, but for most patients, it includes information about each of the following:

wound management.

This includes infection control, basic cleanliness, and wound management.

scar management.

Functional abilities, including using pressure garments, exercises, and activities of daily living, must be assessed and taught.

nutrition.

Nutritional guidelines are provided that maintain continued healing and respond to the metabolic demands that frequently last for some time after initial injury.

follow-up.

If respiratory involvement exists, include specific teaching related to the amount of damage and ongoing therapy. Teach various techniques for dealing with the reaction of society, classmates, or those in the workplace. Explain where and how to obtain resources (financial and emotional) for assisting the family and patient during the recovery process.

Patient discussion about Burns

Q. How do you define burns? I know there are first, second and third degree burns, but I'm not sure what that means. And how do you calculate the percentage of your body burned? ("he has 18% second degree burn")

A. First, second, or third degree describes the depth of injury. First-degree burns are the most shallow (superficial). They affect only the top layer of skin (epidermis). Second-degree burns extend into the middle layer of skin (dermis). Third-degree burns involve all three layers of skin (epidermis, dermis, and fat layer).
Doctors determine the severity of the burn by estimating the percentage of the body surface that has been burned. Special charts are used to show what percentage of the body surface various body parts comprise. For example, in an adult, the arm constitutes about 9% of the body.

Q. How to treat minor burns? I got burned the other day while cooking. How do I treat minor burns in the best way?

A. Here is a video with instructions on how to treat first degree burns:
http://www.5min.com/Video/How-to-Treat-Minor-Burns-21796008

Q. How to prevent burns from babies? I have a 4 month old baby and when I gave him a bath last night, he turned red because of the hot water. After the bath the color faded but now I am worried, can this burn him?

A. yes,you need to make sure the water isnt to hot,it only needs to be luke warm,a babies skin is very senitive while they are young,i know i have 3 kids,although my little girl isnt real senitive to hot things.