Burns - Comprehensive Notes

Objectives

  • At the end of this presentation the student of NUR 3202 will be able to:
    • Identify the signs and symptoms of Burns
    • Describe the pathophysiological changes that occur following a Burn injury
    • Explain the diagnostic studies used in Burn assessment
    • Outline the nursing interventions when caring for a Burn patient
    • Identify complications of burn injury
    • Discuss the medical and surgical management used when managing burn patients
    • Briefly discuss a detailed overview of Burns
    • Differentiate between the types and degrees of Burns
    • Identify and define Burns and Related Terminologies
    • Identify the common causes of Burns

Definitions

  • A burn is an injury to the skin or deeper tissues caused by contact with heat, chemicals, electricity, or radiation.
    • Burns range in severity and are classified into degrees based on depth and extent of tissue damage.
  • Contractures: Scar tissue that shrinks and tightens, which can restrict movement of joints.
  • Hypovolemia: A state in which the blood plasma volume is reduced, leading to a decreased overall circulating blood volume.
  • Edema: The abnormal accumulation of fluid in the body's tissues, which results in swelling.
  • Hyponatremia: A condition characterized by an abnormally low concentration of sodium in the blood.

Overview of Burns

  • A burn is defined as an injury to the skin, or deeper tissues, resulting from exposure to sources such as intense heat, chemicals, electricity, or radiation.
    • A burn is an injury to some or all of the skin’s layers, which includes the epidermis, dermis, and subcutaneous tissue.
  • Burns are categorized into degrees based on severity.
    • A first-degree burn is one where only the superficial layer of the skin is damaged, causing redness along with pain and discomfort.
    • More serious burns go deeper into the skin while its functionalities, often termed as ‘more serious burns,’ leading to the need for greater treatment.
  • Undermining the skin’s vital functions of protection, sensation, and regulation, initiates a complex healing process which requires extensive medical treatment.

Types of Burns

  • Thermal Burns
  • Chemical Burns
  • Mechanical Burns
  • Electrical Burns
  • Radiation Burns
  • Cold Burns

Thermal Burns

  • A thermal burn is a burn to the skin that is caused by an external heat source.
    • Dry thermal: involves flames, very hot objects.
    • Wet thermal: steams and hot liquids.
  • Symptoms:
    • Swelling
    • Blisters
    • Pain
    • Skin that's white or charred or red

Chemical Burns

  • Chemical burns are not usually thermic, but are caused by tissue reaction to noxious substances, the amount of tissue damage will depend on the chemical and exposure time.
  • Symptoms:
    • Pain
    • Redness
    • Swelling
    • Discoloration of the skin
    • Scabs or blisters
    • Dry and cracked skin

Mechanical Burns

  • Mechanical burns are caused when a person’s skin gets scraped off after coming in contact with hard objects such as the floor or road.
  • Symptoms:
    • The area appears red
    • Swelling
    • Itchy skin

Electrical Burns

  • Electrical burns occur when an electric current passes through the body, converting electrical energy into heat and causing tissue damage.
    • Electrical burns may have a point of entry and a point of exit.
  • Symptoms:
    • Tingling sensation
    • Weakness
    • Headaches
    • Lightheadedness
    • Seizures
    • Irregular heart rhythm
    • Confusion

Radiation Burns

  • Radiation burns happen when someone is exposed to the sun’s UV rays for a long period or due to other radiation sources.
    • It can also occur due to radiation therapy that cancer patients go through.
  • Symptoms:
    • Blisters
    • Itchy skin
    • Skin that is dry and peels
    • Open sores
    • Swelling

Cold Burns

  • Cold burns occur when a person is exposed to ice for prolonged periods.
    • The water in their cells slowly begins to freeze, followed by constriction of the blood vessels, which can also result in blood clots.
  • Symptoms:
    • Blister
    • Tingling
    • Pain
    • The affected area turning dark, grey, or red

Classification of Burn Depth

  • Tissue Layers:
    • Epidermis
    • Dermis
    • Subcutaneous tissue
    • Muscle
  • Depth of Burn:
    • Superficial
    • Partial thickness
    • Deep partial thickness
    • Full thickness

First-Degree Burns (Superficial Burns):

  • Description: These burns involve only the epidermis, the outermost layer of the skin.
  • Presentation: The affected area appears red and painful, similar to a mild sunburn, but without blistering.
  • Healing: Typically, first-degree burns heal on their own within 7–10 days, usually without scarring.
  • Example: Mild sunburn is a common example of a first-degree burn.

Second-Degree Burns (Partial-Thickness Burns):

  • Description: These burns extend beyond the epidermis into part of the dermis (the middle layer of the skin).
  • Presentation: They are characterized by redness, swelling, blistering, and increased pain due to nerve involvement in the dermis.
  • Healing: Healing may take several weeks and can result in scarring; deeper (or full- thickness) partial burns may require medical treatment such as dressings or grafting.

Third-Degree Burns (Full-Thickness Burns):

  • Description: In third-degree burns, the injury involves the entire thickness of the skin—both the epidermis and the full dermis.
  • Presentation: The skin may appear white, charred, or leathery. Because nerve endings are destroyed, these burns might be less painful initially, although adjacent areas can be very painful.
  • Healing: These burns typically require surgical intervention (like skin grafting) as the skin cannot regenerate on its own.

Fourth Degree Burns

  • Description: fourth-degree burns extend even deeper, involving underlying structures such as muscles, tendons, nerves, and sometimes even bone. This full-thickness, multiplanar tissue destruction sets these injuries apart, making them particularly life-threatening.
  • Presentation: The skin may appear charred or black, white waxy appearance, exposed structures, lack of pain.
  • Healing: Healing from fourth-degree burns is a complex and prolonged process due to the extensive tissue damage involved. Unlike less severe burns, fourth-degree burns often require surgical interventions such as debridement, skin grafting, or even amputations to manage the injury and promote recovery. May take months to years.

Phases of Burn Injury

Emergent (resuscitative) phase

  • Time Frame: Begins at the moment of injury and typically lasts up to 48–72 hours.
  • Primary Concern: The immediate aim is to stabilize the patient and mitigate life- threatening complications. Key actions include maintaining the airway, supporting breathing and circulation, and initiating fluid resuscitation.

Acute (Inflammatory) Phase

  • Time Frame: Follows the stabilization period and may last several days to weeks, depending on the severity and extent of the burn.
  • Primary Concern: This phase is focused on wound care, infection prevention, and controlling the systemic inflammatory response.

Rehabilitation (Reconstructive) Phase

  • Time Frame: Begins after the wounds have closed or been surgically managed and can last for months to years.
  • Primary Concern: Long-term recovery, function, and quality of life. This phase focuses on the restoration of function, prevention of contractures, psychosocial support, and, if necessary, reconstructive surgery to improve both function and appearance.

Etiology

  • Burns are injuries to the skin or deeper tissues caused by external sources such as heat, chemicals, electricity, radiation, or friction. The main causes include:
    • Thermal burns: From direct contact with flames, hot objects, steam, or scalding liquids.
    • Chemical burns: From exposure to strong acids, alkalis, or other corrosive substances.
    • Electrical burns: From electrical currents passing through the body, causing deep tissue damage.
    • Radiation burns: From exposure to ultraviolet rays (e.g., sunburn) or radiation therapy.
    • Mechanical/Friction burns: From abrasion against rough surfaces, often combined with heat.
    • Extreme cold

Risk Factors

  • Socioeconomic factors
  • Age (children and older adults)
  • Gender (female)
  • Occupations that increase exposure to fire
  • Underlying medical condition, including epilepsy, peripheral neuropathy, and physical and cognitive disabilities
  • Poverty, overcrowding, and lack of proper safety measures
  • Placement of young girls in household roles such as cooking and care of small children
  • Alcohol abuse and smoking
  • Easy access to chemicals used for assault (such as in acid violence attacks)
  • Use of kerosene (paraffin) as a fuel source for non-electric domestic appliances
  • Inadequate safety measures for liquefied petroleum gas and electricity.

Signs and Symptoms

  • The signs and symptoms depend on the severity and depth of the burn:
    • First Degree Burns
      • Redness
      • Pain
      • Dry skin
      • Peeling skin
    • Second Degree Burns
      • Blisters
      • Deep redness
      • Swelling
      • White or discolored patches
    • Third Degree Burns
      • Charred or leathery skin
      • White or waxy appearance
      • Pain
      • Swelling
    • Other symptoms may include:
      • Hypovolemic Shock
      • Dehydration
      • Infection
      • Airway burns

Pathophysiology

  • Superficial: Epidermis
  • Partial-thickness: Dermis
  • Full-thickness: Subcutaneous tissue

Complications of Burns

  • Exposure to Injurious Substance (flames, heat, cold, chemicals, radiation)

    • Destruction of tissue (skin, connective tissue, bone)
    • Local Inflammation in response to burn damage
    • ↓ mechanical barrier against infection
      • Local Infection
      • Systemic spread of infection
      • Sepsis (systemic spread of inflammatory factors)
    • Loss of fluid (evaporation, bleeding, edema)
      • ↑ blood vessel permeability
      • Leakage of fluids from blood/intravascular space into interstitium and third space (peritoneum, lungs, etc)
      • Reduced total blood volume
      • Hypovolemic Shock
      • ↓perfusion of body tissue with 02/nutrients and CO2/waste removal from tissues
      • End organ damage (brain, kidneys, liver, gut)
    • Loss of heat through damaged skin
      • Hypothermia
    • If burn is large, systemic release of inflammatory factors
      • Massive pulmonary edema clogs up alveoli
      • Acute Respiratory Distress Syndrome (ARDS)
    • Improper activation of clotting factors
      • Disseminated Intravascular Coagulation (DIC)
    • Damage to nerves
      • Complete destruction
        • Permanent loss of nerve
      • Neuropathic Pain
    • Disfigurement

  • Major complications include:

    • Loss of Function
    • Permanent loss of nerve
    • Neuropathic pain
    • Disseminated Intravascular Coagulation (DIC)
    • Local Infection
    • Sepsis
    • Hypothermia
    • Disfigurement (Contractures)
    • Loss of Function
    • Acute Respiratory Distress Syndrome (ARDS)
    • End Organ Damage (Brain, kidneys, Liver, Gut)
    • Pulmonary Injury
    • Curling's ulcer

Diagnostic Studies

  • While the diagnosis of a burn is mainly clinical (based on physical examination), certain diagnostic studies help assess the extent of injury, detect complications, and guide treatment:
    • Blood Tests
      • CBC
      • BUN and Creatinine
      • Lactate levels
      • Carboxyhemoglobin Levels
    • Urinalysis
    • CT Scans
    • X-rays
    • Assessment of Depth and extent
    • Inhalation Injury Assessment
    • Pain and swelling Assessment
    • Infection Check

Rule of Nines

  • The rule of nine is a quick assessment used to estimate how much percentage of the body was burnt in adults.
    • The body is broken down into sections with each section being approximately 9%, adding up to 9% or multiples of 9%.
    • It is done to help determine how much fluids is needed for resuscitation and also to assess the severity of the burnt body surface area.
    • Adult:
      • Head - 9%
      • Each arm - 9% (front 4.5% & Back 4.5%)
      • Each leg - 18% (front 9% & Back 9%)
      • Front of torso - 18%
      • Back of torso - 18%
      • Genital area - 1%
    • Child:
      • Head and neck - 9%
      • Each arm - 9% (Front 4.5% & Back 4.5%)
      • Each leg - 14% (Front 7% & Back 7%)
      • Front of torso - 18%
      • Back of torso - 18%
      • Genital area - 1%
    • As children grow the head percentage decreases and the leg percentage increases gradually towards adult percentages.

Medical Management

  1. Establishment of airway and administration of oxygen; mechanical ventilation as needed
  2. IV fluid replacement in the first 24 hours (e.g., electrolyte solutions and colloids such as blood and plasma) to maintain circulation
    • Volume of fluid replacement is based on the percentage of body surface area involved and client’s weight (e.g., Parkland/Baxter, Brooke Army Hospital, or Evans formulas)
    • Half of fluid is administered in the first 8 hours; the second half is administered over the next 16 hours
  3. IV fluid replacement in subsequent hours depends on urinary output, blood tests, and hemodynamic pressures
  4. Insertion of a urinary retention catheter; hourly urinary output to monitor kidney function and influence fluid replacement
  5. Insertion of a central line to monitor hemodynamic pressures (e.g., central venous pressure [CVP], pulmonary capillary wedge pressure [PCWP])
  6. Vital signs monitored every 15 minutes
  7. Serum electrolytes and blood gases to monitor levels and assist in deciding replacement therapy
  8. Tetanus toxoid booster administration; tetanus human immune globulin for passive immunity if not previously immunized
  9. Clear liquids followed by a high-protein, high-carbohydrate, high-fat, high-vitamin diet as tolerated. Caloric needs may be as high as 5000 calories daily; high calorie enteral feedings may be necessary (research demonstrates that early nutritional support within several hours of injury can decrease mortality and complications)
  10. Maintenance of surgical asepsis
  11. Daily hydrotherapy; water temperature should be tepid (98° to 100° F)
  12. Skin grafting to close wounds, limit fluid loss, promote healing, and limit contractures
    • Heterograft (xenograft): skin from animals, usually pigs (porcine xenograft); temporary covering
    • Homograft (allograft): skin from another person or cadaver; temporary covering
    • Autograft: skin from another part of client’s body
      • Mesh graft: machine used to mesh skin obtained from donor site so it can be stretched to cover larger area of burn
      • Postage stamp graft: earlier method of accomplishing the same goal as the mesh graft; a small amount of skin is used to cover a larger area; donor skin is cut into small pieces and applied to burn
      • Sheet grafting: large strips of skin placed over burn as close together as possible
      • Cultured epithelial auto grafting is used for massive burn treatment
    • Synthetic coverings
  13. Surgical, mechanical, or enzymatic debridement to promote healing and decrease infection
  14. IV antibiotics based on wound culture and sensitivity [C&S]; topical antibiotics (e.g., mafenide ointment, silver nitrate solution, silver sulfADIAZINE, neomycin, bacitracin, polymyxin B); used to limit infection
  15. Opioids to reduce pain and sedatives to decrease anxiety; given IV or orally because of decreased muscle absorption

Formula to calculate ideal amount of fluid required to rehydrate & prevent further damage to burn patient

  • TOTAL CRYSTALLOID FLUID in FIRST 24HRS = 4mL \times % TBSA \times BODY WEIGHT kg

Nursing Management

  1. Apply cool, moist dressing at the site of injury; neutralize burn if caused by chemical (e.g., acid, base); flush with water and apply the opposite chemical in a weak form as ordered
  2. Monitor vital signs, CVP or PCWP, and intake and output (I&O) (hourly urine output) as ordered; notify healthcare provider if output decreases below 30 mL/hr or increases above 50 mL/hr
  3. Observe for clinical findings of metabolic acidosis and electrolyte imbalances, particularly of calcium, potassium, and sodium and metabolic acidosis
  4. Administer fluid and electrolytes as ordered
  5. Monitor respiratory function (e.g., characteristics of respirations, breath sounds, arterial blood gases, pulse oximetry)
  6. Administer oxygen as ordered
  7. Elevate the head of bed
  8. Encourage coughing, deep breathing, and use of incentive spirometer
  9. Prevent infection
    • Monitor for clinical findings of infection (e.g., increasing temperature and white blood cell (WBC) count, odor); promptly culture exudate if infection is suspected
    • Follow principles of protective precautions (e.g., gown, gloves, mask, hair covering) during contact because of client’s compromised ability to resist infection
    • Administer tetanus toxoid as prescribed
    • Administer IV and topical antibiotics as prescribed
    • Use sterile technique for wound care
  10. Apply pressure dressings as ordered to reduce contractures and scarring
  11. Support joints and extremities in functional alignment and perform range-of-motion (ROM) exercises; use beds or mattresses designed to avoid pressure
  12. Provide care related to skin graft
    • Keep donor sites dry (which are covered with a nonadherent dressing and wrapped in absorbent gauze); remove just absorbent gauze as non-adherent dressing will separate as healing occurs
    • Monitor grafts, which generally are covered with light pressure dressing for approximately 3 days; after graft has “taken,” roll cotton-tipped applicators gently over graft to remove underlying exudate; exudate allowed to remain can promote infection and prevent graft from adhering; instruct to restrict mobility of affected part
    • Monitor for clinical findings of infection (e.g., foul-smelling drainage, temperature elevation); promptly culture exudate if infection is suspected
    • Instruct to avoid exposure of graft and donor sites to the sun
  13. Provide physical and emotional support while turning
  14. Keep room temperature warm and humidity high
  15. Prevent gastrointestinal (GI) erosion
  16. Observe for clinical findings of stress ulcer
  17. Give prescribed drugs to decrease or neutralize hydrochloric acid
  18. Provide small, frequent feedings; diet high in protein, carbohydrates, vitamins, and minerals; moderate in fat; adequate calories for protein sparing
  19. Administer medication for pain as prescribed and particularly before dressing change
  20. Provide emotional support
    • Expect client to express negative feelings; accept negative feelings
    • Explain need for staff wearing gowns and masks
    • Assist to cope with change in body image
    • Give realistic reassurance; convey a positive attitude
    • Encourage participation in self-care
    • Refer client and family to support groups and rehabilitative services

Brain Teaser

  • Part 1
    • A 25-year-old male patient who weighs 79 kg has sustained burns to the back of the right arm, posterior trunk, front of the left leg, and their anterior head and neck.
    • Using the Rule of Nines, calculate the total body surface area percentage that is burned.
      • Back of right arm- 4.5
      • Posterior trunk- 18
      • Front of left leg- 9
      • Anterior head & neck -4.5
    • Answer: 36%
  • Part 2
    • Use the Parkland formula to calculate the total amount of Lactated Ringer's solution that will be given over the next 24 hours.
    • Answer: 11,376 mL