In-Depth Notes on Burns in Medical-Surgical Nursing for the Exam

Burns: Epidemiology

• Statistics (2017): In the United States, there were approximately 1,319,500 fires reported, leading to 3,400 civilian deaths. Additionally, about 14,670 civilian injuries occurred due to these fires. The majority of burn injuries occur in residential settings, often as a result of common household activities such as cooking, heating, and electrical mishaps.

• Etiology: Major causes of burn injury can be categorized as follows:

  • 43% Fire/Flame: This includes burns from open flames, such as house fires and explosions, which can lead to severe injuries and fatalities.

  • 34% Scald: Caused by hot liquids or steam, this type of burn is commonly seen in children and the elderly, who are at higher risk of accidental scalds from hot beverages or bath water.

  • 9% Contact: These burns occur from direct contact with hot surfaces or objects, such as stoves or curling irons, often resulting in more superficial pain and injury.

  • 4% Electrical: Electrical burns can have severe consequences as they may not only damage the skin but also affect internal organs; injuries often vary dramatically depending on the voltage and current.

  • 3% Chemical: Chemical burns are caused by corrosive substances and can lead to serious injuries that require specialized medical treatment depending on the chemical involved.

  • 7% Other: This encompasses all other types of burn injuries, such as those from radiation, flash burns, and unusual or rare cause scenarios.

Pathophysiology of Burns

• Burns classification:

  • Thermal Burns: Result from flash, scald, or contact with hot objects; these can be caused by house fires, cooking accidents, or other environmental factors. Severity is influenced by the temperature of the heat source and the duration of contact. Immediate first aid can be crucial for thermal burns to minimize damage.

  • Electrical Burns: These are particularly insidious as the extent of injury is often not visible on the skin. Electrical burns can disrupt normal heart rhythms and cause deep tissue damage, necessitating prompt medical intervention.

  • Chemical Burns: Classified into three types—acids, alkalis, and organic compounds. Each type has different treatment protocols due to their unique properties and effects on tissue.

  • Radiation Burns: Often resulting from prolonged exposure to radiation, such as sunburn or exposure in a medical setting, severity primarily depends on the type, dose, and duration of exposure.

Burn Depth Classifications

1. Superficial Burns: Affects only the epidermis, characterized by mild erythema and superficial pain. These burns typically heal in 24-72 hours without scarring, example being sunburn where damaged skin may peel.

2. Superficial Partial-Thickness Burns: Involves the epidermis and superficial dermis, causing significant pain, swelling, and redness. These burns generally heal in 1-2 weeks with minimal scarring, often treated conservatively.

3. Deep Partial-Thickness Burns: Extends deeper into the dermal layers and may result in a waxy appearance with decreased blood flow. Healing can take several weeks, and there may be a need for skin grafting if the damage is extensive.

4. Full Thickness Burns: Complete destruction of the epidermis and dermis, extending into subcutaneous tissue. These burns are insensate due to nerve damage and are characterized by a dry, leathery texture and eschar. Immediate medical attention is required, and skin grafting is often necessary for healing.

Assessment of Burn Severity

• % Total Body Surface Area (TBSA): Key to evaluating burn severity includes:

  • Rule of Palm: The patient's palm, including fingers, is considered approximately 1% of TBSA, useful for quick assessments.

  • Rule of Nines: Common in emergency settings, this method divides the body into sections that represent 9% or multiples of 9% of TBSA.

  • Modifications for children are important due to their different body proportions. Children have larger heads relative to their body size.

  • Lund and Browder Classification: This more advanced method is considered the most accurate in determining TBSA by incorporating the patient’s age into calculations.

• Zones of Burn Injury: Understanding the zones can aid in optimizing treatment:

  • Zone of Coagulation: Where the most severe damage occurs; cellular necrosis is present due to direct heat exposure.

  • Zone of Stasis: Surrounds the coagulation zone, where blood flow is impaired but can potentially be salvaged with immediate treatment.

  • Zone of Hyperemia: Characterized by increased blood flow to aid recovery, with potential for complete healing if adequately managed.

Systemic Effects of Major Burn Injuries

• Respiratory: Increased risk of mortality from inhalation injuries, with a high incidence of pneumonia and pulmonary complications noted in severely burned patients. Assessment for airway burns is crucial.

• Cardiovascular: Burn injuries frequently result in combined distributive shock due to vasodilation and hypovolemic shock caused by fluid losses, requiring careful fluid resuscitation strategies.

• Fluid & Electrolytes: The risk of imbalances, notably hyperkalemia and hypokalemia, often complicates the burn injury as fluid shifts occur.

• Renal: Acute tubular necrosis risk from myoglobin and hemolysis leading to potential renal failure; monitoring kidney function is critical post-burn.

• Gastrointestinal: May experience decreased nutrient absorption and complications like abdominal compartment syndrome due to massive fluid resuscitation.

• Metabolic: Patients enter a hypermetabolic state with energy expenditure often doubling or tripling, lasting for 1-3 years, necessitating aggressive nutritional support.

• Immunological: The risk of infections is significantly elevated leading to systemic inflammatory response syndrome (SIRS); infection control measures are paramount in management.

Management of Burn Injuries

• Emergent Phase: Immediate approaches focus on airway maintenance, fluid resuscitation based on TBSA burned, and pain management strategies.

• Intermediate Phase: Goals during this phase emphasize wound healing, intensive infection prevention, and meeting nutritional needs via enteral or parenteral support.

• Rehabilitative Phase: Long-term goals include pain management strategies, optimizing physical rehabilitation to restore function, and psychological support to address emotional difficulties arising from trauma.

Nursing Management

• Assessment: Continuous evaluation of life-threatening injuries, ensuring respiratory functions are stable, and monitoring fluid volume status.

• Nursing Diagnoses: Commonly include anxiety related to the traumatic event, risk for infection due to open wounds, and impaired gas exchange especially if inhalation injuries are present.

• Interventions: Regular assessments for pain levels, addressing nutritional requirements, and meticulous wound care to promote healing and avoid complications.

• Evaluating Outcomes: Important outcomes to track include adequate pain control, nutritional adequacy, and successful wound healing without infection during recovery.