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Causes and symptoms
Thermal burn treatment
|Classification Of Burns|
|The burned area is painful. The outer skin is
reddened. Slight swelling is present.
|The burned area is painful. The underskin is affected.
Blisters may form. The area may have a wet, shiny
appearance because of exposed tissue.
|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.
Chemical burn treatment
Electrical burn treatment
burnsThe 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.
|Mean LOS:||5.3 days|
|Description:||MEDICAL: Extensive Burns or Full Thickness Burns With MV 96+ Hours Without Skin Graft|
|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.
|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.|
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.
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.
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.
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).
|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|
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.
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.
|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
DiagnosisIneffective airway clearance related to airway edema
OutcomesRespiratory status: Gas exchange; Respiratory status: Ventilation; Symptom control behavior; Treatment behavior: Illness or injury; Comfort level
InterventionsAirway management; Anxiety reduction; Oxygen therapy; Airway suctioning; Airway insertion and stabilization; Cough enhancement; Mechanical ventilation; Positioning; Respiratory monitoring
Planning and implementation
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.
|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
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.
- 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")
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?
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?