the management of a patient burned by flames, hot liquids, explosives, chemicals, or electric current. Partial-thickness burns may be first degree, involving only the epidermis, or second degree, involving the epidermis and dermis, whereas full-thickness or third-degree burns involve all skin layers. Second-degree burns covering more than 30% of the body and third-degree burns on the face and extremities, or more than 10% of the body surface, are critical. In the first 48 hours of a severe burn, vascular fluid, sodium chloride, and protein rapidly pass into the affected area, causing local edema, blister formation, hypovolemia, hypoproteinemia, hyponatremia, hyperkalemia, hypotension, and oliguria. The initial hypovolemic stage is followed by a shift of fluid in the opposite direction, resulting in diuresis, increased blood volume, and decreased serum electrolyte level. Potential complications in serious burns include circulatory collapse, renal damage, gastric atony, paralytic ileus, infections, septic shock, pneumonia, and stress ulcer (Curling's ulcer), characterized by hematemesis and peritonitis.
method The extent of the burn; its cause; its time of occurrence; and the patient's age, weight, allergies, and any preexisting illness are recorded. If respiratory distress is present, endotracheal intubation or tracheostomy may be performed. Specimens are obtained for urinalysis; blood type; blood urea nitrogen level; hematocrit; prothrombin time; electrolyte levels; blood gases; and cultures of nasal, throat, wound, and stool organisms. Parenteral fluids and electrolytes, antibiotics, tetanus prophylaxis, and pain medication are administered as ordered; large doses of analgesics and sedatives are avoided when possible to prevent depression of respiration and masking of symptoms. An indwelling urinary catheter is inserted, and a nasogastric tube and catheter for monitoring central venous pressure may be indicated. Local treatment of the burn may use the closed method or the more frequently used open method, in which the injured area is cleaned and exposed to air and the patient is kept warm by a blanket or linen over a bed cradle or by a heater or lamp. In the closed method, a germicidal or bacteriostatic cream, ointment, or solution is applied to the burn, and the wound is covered with a dressing. A porcine heterograft may be used to cover the wound temporarily. This technique prevents fluid loss and reduces the risk of infection, but the graft dries in 1 or 2 days and may pull and cause pain. Newly developed artificial skin holds great promise for treating severe burns. During the acute stage of a burn, the patient's blood pressure, pulse, respiration, and cerebrovascular pressure are checked every 30 to 60 minutes, and the rectal temperature every 2 to 4 hours. Oral hygiene and assistance in turning, coughing, and deep breathing are provided every 2 hours, and the patient's sensorium is evaluated hourly. If oral fluids are ordered, juices and carbonated drinks are offered, but plain water and ice chips are avoided. Fluid intake and output are measured hourly; if a child excretes less than 1 mL/kg of urine or an adult less than 0.5 mL/kg, a diuretic or an increase in IV infusion of fluid may be necessary. Blood transfusions, steroid therapy, and antipyretics may be ordered; aspirin is contraindicated. Excessive chilling and exposure to upper respiratory and wound infections are carefully prevented. Burned extremities are elevated, and contractures are prevented by using firm supports to keep affected areas properly aligned. The patient is weighed daily at the same time on the same scale, and, after the initial acute period, an adequate intake of a high-calorie, high-protein diet is encouraged. To stimulate appetite, the patient is offered frequent small meals of preferred foods and beverages that are high in potassium. Vitamins may be required. Tranquilizers may be given before wound care, but narcotics for pain usually are not needed after the acute phase. The patient is encouraged to stand for a few minutes every hour or every second hour and is generally able to walk in 7 to 10 days, but convalescence may be prolonged. Burn patients often are frightened, withdrawn, and disoriented initially, but after a few days they may become angry, depressed, or rebellious and need emotional support to help them cooperate with their treatment and rehabilitation. Extensive plastic surgery and repeated skin grafts may be required to restore function and the physical appearance of burn patients.
interventions The burn patient requires intensive, prolonged care to prevent complications and disfiguring contractures. The nurse administers parenteral fluids and medication, implements wound care, closely monitors the patient's condition, limits physical discomfort, provides emotional support and diversion, and encourages the family to visit regularly and become involved in the patient's care.
outcome criteria The outcome for the severely burned patient depends greatly on the detailed, near-constant care required during the acute phase of treatment. Scarring may cause residual dysfunction and discouragement. Encouragement to participate fully in physical therapy and to continue treatments may be helpful. Although protection from infection is essential, the nurse does not isolate the patient unless necessary.