• Burns destroy the structural integrity of the skin, disrupting its normal functions of regulating temperature, maintaining fluid status, protecting against infection, covering nerve endings, and establishing identity.² The skin is composed of two layers, the epidermis and the dermis, and is supported by a subcutaneous layer that is rich in blood vessels (Fig. 120-1).

• The depth of burns has historically been classified as first-degree (into epidermis), second-degree (into dermis), or third-degree (through skin into subcutaneous tissue; Table 120-1).^1,2

• The depth of a burn wound is directly related to the temperature intensity and the duration of contact with the burning agent. The burning agent can be thermal (i.e., flame, contact, or scald), chemical, or electrical. An inhalation injury should always be suspected if the patient was in an enclosed space with a fire; mortality rate is significantly increased when burns are compounded by smoke inhalation.⁴

• The burn injury produces three zones of injury: the zone of coagulation (cellular death), zone of stasis (vascular impairment, potentially reversible tissue injury), and zone of hyperemia (increased blood flow and inflammatory response). Decreased perfusion of the burn wound can cause the zone of stasis to deteriorate, deepening the initial wound. This progressive destruction can be minimized by providing adequate oxygenation and fluid resuscitation, alleviating pressure on the injured tissue, maintaining local and systemic warmth, and decreasing edema by elevating the burned area.¹

• Assess for areas where full-thickness eschar is circumferential. Because of the inelastic nature of eschar, it may act like a tourniquet as edema develops, requiring surgical release (escharotomy) to prevent circulatory or respiratory compromise (Fig. 120-4).

• Monitor pulses, capillary refill, and sensation distal to circumferential eschar. Signs and symptoms that indicate a need for escharotomy include cyanosis of distal unburned skin, unrelenting deep tissue pain, progressive paresthesias, and progressive decrease or absence of pulse.¹

• Adequacy of respiratory excursion must be assessed because circumferential eschar of the trunk can lead to decreased tidal volume and agitation (Fig. 120-5).¹

• Escharotomy is performed at the bedside by a physician, with a scalpel or electrocautery used to cut the eschar longitudinally. Bleeding should be minimal because only dead tissue is cut; any bleeding can be controlled with sutures, silver nitrate sticks, collagen packing, or electrocautery. Pain is usually managed with small intravenous doses of opiates and benzodiazepines.

• Burn size may be determined with several methods.²⁰

• The inflammatory response causes a massive fluid shift to the interstitial space during the first 24 hours, with mobilization of fluid starting after 72 hours. Fluid resuscitation with a balanced salt solution is based on the patient’s weight and burn size (partial-thickness and full-thickness wounds).¹⁷ Large wounds are prone to huge evaporative water losses that require close monitoring of volume status.

• Effective resuscitation results in adequate urinary output (30 to 50 mL/hr or 0.5 to 1.0 mL/kg/hr) and mean arterial blood pressure of at least 60 mm Hg as surrogate markers of end-organ perfusion and hemodynamic stability.¹⁷

• Burns of specific anatomic areas need special consideration. Assess eyes for injury and treat chemical exposure with copious normal saline solution irrigation; treat burned ears with a topical antimicrobial cream and protect from pressure by eliminating use of pillows or dressings about the head; elevate burned extremities; consider the need for an indwelling urinary catheter in the patient with perineal burns; and shave hair growing through the burn wounds. Two burned surfaces that contact each other need dressings between them to prevent fusing as they heal (e.g., between toes, skin folds).

• Emergency treatment of thermal injuries includes initially cooling the burned skin with tepid water (never with ice) while recognizing the importance of preventing hypothermia.¹ In preparation for transfer, the airway should be assessed and 100% oxygen administered; large-bore intravenous (IV) access should be established and fluid resuscitation started; patients should be on nothing by mouth (NPO) status; wounds should be wrapped with a clean, dry sheet and possibly blanket; pain medication should be given in small IV doses, with recognition that coexisting injuries or medical conditions exacerbate the effects of opiates; tetanus prophylaxis should be administered; and all initial treatment should be documented.¹

• Initial treatment of chemical burns includes removing saturated clothing, brushing off any powdered chemical, and continuously irrigating involved skin with copious amounts of water for 20 to 30 minutes. Neutralizing chemical burns with another chemical is contraindicated because the procedure generates heat. Burned eyes must be irrigated with large volumes of normal saline solution followed by an eye examination.¹ Some chemicals are absorbed systemically through burn wounds; contact the local poison control center to determine whether further treatment is indicated.² Ensure all providers wear appropriate personal protective equipment to prevent unintentional chemical exposure.

• Tar can be removed with mineral oil, a petrolatum-based ointment, or solvent.¹⁶

• Electrical injuries (Fig. 120-7) result when the body becomes part of the pathway for the electrical current. Deep burns may occur from tissue resistance where the patient contacted the electrical source and where the patient was grounded. Initially of greater concern than the burns is the high incidence of cardiac dysrhythmias, myoglobinuria resulting in acute tubular necrosis, and neurologic sequelae. Monitoring electrocardiographic (ECG) results, increasing urine output to 100 mL/hr in the presence of dark port-colored urine, assessing for associated trauma, and establishing baseline neurologic status are vital in the treatment of the electrical injury patient.^1,20

• Criteria for transferring patients to a specialized burn care facility have been adopted by the American Burn Association and the American College of Surgeons. These criteria are listed in Table 120-2.

• Care of the burn wound and associated healing are determined by the extent and depth of the injury and the overall condition of the patient.

• Most burn centers use clean technique for dressing removal and wound cleansing, with sterile technique for sterile dressing application only.²

• Wound care should be done in a warm area. Many burn units have replaced traditional hydrotherapy tanks with shower tables for large wound care procedures to allow water run-off, thus decreasing leaching of electrolytes and minimizing wound exposure to perineal-contaminated water. Emergency equipment must always be immediately available during hydrotherapy procedures. As wounds decrease in size and patients approach discharge, bathtubs and showers offer reasonable options for wound cleansing.

• Initial wound cleansing requires thorough débridement of all devitalized tissue. Blisters are generally unroofed.¹⁸ Use of dry gauze is effective to gently remove burned tissue, with use of a slow and deliberate wiping motion. Wash the wounds with gentle pH neutral liquid soap solution or wound cleanser and pat dry with clean towels.

• Topical antimicrobial agents limit bacterial proliferation and fungal colonization in burn wounds. The three most commonly used agents are 1% silver sulfadiazine (Silvadene, Monarch Pharmaceuticals, Inc., Bristol, TN), 10% mafenide acetate (Sulfamylon, UDL Laboratories, Inc., Rockford, IL), and 0.5% silver nitrate solution (Table 120-3).⁷ Systemic antibiotics are not routinely administered to burn patients because of the high risk for development of antibiotic resistance.¹⁵

• Eschar is a leathery layer of devitalized tissue that covers full-thickness burns. Bacterial action causes eschar to separate from the wound bed. However, the use of topical antimicrobial agents and early excision has minimized the nurse’s involvement in eschar removal.

• Survival rates for burn patients are markedly improved with early excision and grafting.⁶ The most important predictors of mortality are the patient age and the extent of the burn, with the presence of inhalation injury and comorbidity crucial factors. Although the burn wound has the most obvious potential for infection, the lower respiratory tract is the most common site of infection and carries the highest incidence of sepsis and death.⁴

• An autograft (skin graft taken from the patient) is the only treatment that can heal a full-thickness burn wound.¹¹ Wounds with higher than 105 organisms per gram of tissue impede graft adherence, so expedient grafting is desirable.¹⁵

• Burn wound management accomplishes three primary goals: protect the wound, reduce metabolic demand, and provide comfort.

• A débrided full-thickness wound may be protected from infection and drying through the use of biologic dressings when donor sites are not available for autografting. Allograft, or homograft, refers to the use of “nonself” human skin grafts; such a graft becomes vascularized by the patient and risks rejection if it stays in place too long. Xenograft, or heterograft, is nonhuman skin obtained from commercial pigskin (porcine) processing companies; it forms a collagen bond with the wound and protects it for a period of time until donor sites are available for autografting. Porcine xenograft may be placed over clean partial-thickness wounds to protect the wound while it heals beneath the xenograft.¹¹

• Integra (Integra Lifesciences Corporation, Plainsboro, NJ) is an acellular matrix composite graft that may be placed on débrided full-thickness burns. Capillaries and collagen grow into this matrix in about 3 weeks, forming a neodermis, which is then grafted with the patient’s own epidermal cells. The matrix is slowly biodegradable and cannot be detected with wound biopsy after complete healing.¹¹ This allows for improved wound coverage and use of thinner donor sites but requires two surgeries. Thinner autografts allow more rapid healing of donor sites and produce less hypertrophic donor site scarring.

• Biosynthetic dressings such as Biobrane (UDL Laboratories, Inc., Rockford, IL) have been used to cover clean partial-thickness wounds to facilitate healing.^11,22 Biobrane is a two-layer, semisynthetic dressing composed of knitted-elastic nylon fabric that is mechanically bonded to a thin, Silastic, semipermeable membrane and coated with collagen polypeptides.²² As the wound heals beneath, the dressing can be peeled away.²²

• Topical antimicrobial agents are used to reduce wound colonization. Commonly used creams include silver sulfadiazine (Silvadene) and 10% mafenide acetate (Sulfamylon), antibacterial ointments such as bacitracin, and liquid soaks such as mafenide acetate 5% solution and 0.5% silver nitrate.⁷ Creams and ointments are applied every 12 hours or as needed to cover the wound. Dry protective dressings prevent premature removal of the topical. Damp gauze dressings saturated with antimicrobial solution are changed every 24 hours, but dressings require moistening (“wet-down”) every 4 to 6 hours to ensure activity of agent.

• Negative-pressure wound therapy may be used to maintain fresh graft placement, improve wound bed vascularization, and reduce microbial activity.²⁰

• The burn patient’s condition is hypermetabolic until burn wounds are closed and healing is complete. Increased caloric and protein requirements for wound healing are usually met through nasogastric or nasojejunal tube feeding to maintain mucosal integrity in large burns. Zinc and vitamin C have also been shown to be important in wound healing. Current research is evaluating the role of arginine and fish oil in decreasing infections,¹³ glutamine’s role in maintaining mucosal integrity and reducing infection,¹³ and insulin’s ability to preserve muscle mass.²¹ Additional treatments include use of β-blockade⁹ to reduce metabolic demand and oxandrolone¹⁰ to increase anabolism.

• Burn patients should be encouraged to consume a high-protein diet. Supplementation with high-calorie nutritional drinks facilitates meeting energy needs. Large quantities of free water should be discouraged because risk for hyponatremia is high after a large burn.

• During wound care because heat lost through the wound, along with shivering, increases the metabolic rate.

• An individualized plan for pain control should be in place for both background pain (pain that is continuously present), breakthrough pain (associated with activity of daily living), and procedural pain (intermittent pain related to procedures).^5,14 Unrelieved pain can lead to stress-related immunosuppression, an increased potential for infection, delayed wound healing, and depression. Subcutaneous and intramuscular injections should be avoided because absorption is poor and unreliable as a result of edema. Intravenous administration of medication is preferred in critically ill patients; oral medication is preferred in noncritical patients with a functioning gastrointestinal system.^5,14 As the wound heals, the patient has more discomfort from itchiness and less discomfort from pain.¹⁴ A moisturizing lotion prevents drying and reduces pruritus. Nonpharmacologic techniques can be learned to assist with the management of pain and itch.^3,5,14

• Burn wounds contract during the healing phase. Self-care and range-of-motion exercises are encouraged. Stretching exercises and proper positioning are vital to prevent contractures and loss of function.⁸ Static splinting is sometimes added to maintain sustained stretch.⁸ Hypertrophic scar formation is countered through the use of topical silicone gel sheeting and pressure garments worn 24 hours a day until the scars mature and soften (6 to 18 months).¹⁹ Keloids, if they form, may require surgery, steroid injections, and pressure treatment.¹⁹

• Grafts and donor sites on the lower extremities require support during healing when the patient is out of bed. Application of elastic bandages to extremities may prevent pooling of venous blood, permanent discoloration, or skin breakdown.

• The burn wound should not be exposed to the sun for a year because new scars sunburn easily.

• Patients should be instructed to select clothing that blocks sun and to use sunscreen on exposed grafts, generally for life.

• Personal protective equipment as needed (e.g., gown, mask, goggles)

• Nonsterile gloves

• Sterile gloves

• Warm water

• Mild pH-neutral liquid soap, as ordered

• Normal saline (NS) solution

• Washcloths

• Towels

• Scissors and forceps (clean and sterile)

• Topical agents, as ordered

• Tongue depressors

• Sterile dressings as needed (e.g. gauze, Exu-dry [Smith & Nephew, St. Petersburgh, FL])

• Rolled dressing, gentle tape, or netting to secure dressings

• Pillows to elevate extremities

• Pain and sedation medication (as prescribed)

• Provide detailed wound care instructions in writing or on videotape or DVD. Demonstrate wound care, and have patient and family return the demonstration before the planned discharge. Continue to involve patient and family in wound care for the remainder of the admission, and encourage them to ask questions. Provide positive feedback. Arrange for home care or clinic visits to follow up on wound care. Rationale: Education validates patient and family understanding and ability to perform wound care and allows time for them to develop a level of comfort. The opportunity to reinforce important points is provided.

• Explore resources the patient will have for wound care at home (e.g., availability of running water, tub versus shower). Rationale: This measure ensures that the patient is knowledgeable about care based on what adjustments need to be made at home.

• Simplify wound care and assess the family’s ability to provide care at home. Rationale: Continued care of the wound may be necessary after discharge.

• Teach patient and family about signs and symptoms of infection and the importance of reporting these in a timely manner. Rationale: The patient and family can recognize problems early so that appropriate measures can be instituted by the healthcare provider.

• Teach patient and family about pain control; assess the patient’s personal acceptable level of pain. Rationale: Education and assessment decrease concerns about pain, facilitate individualized pain relief plan, and foster cooperation with care.

• Teach patient and family about pain management, including types of medications prescribed, timing of medications in relation to wound care, and nonpharmacologic pain strategies.⁵ Rationale: Comfort at home is supported.

• Provide instruction to the patient and family about the normal changes seen in the wound, including epithelial islands, healing margins, dryness on epithelialization, epidermal fragility on shearing, hypervascularization of the healed wound, and venous congestion in the dependent wound. Rationale: Anxiety about appearance is reduced.

• Teach patient and family about care of healed burns, including medications to reduce itching,^3,14 use of nonperfumed moisturizers, protection from shear, and protection from sun exposure for a minimum of a year. Rationale: Education reduces complications and promotes patient satisfaction.

• Explain the rationale to the patient and family about the wearing and care of pressure garments. Rationale: Pressure garments need to fit properly to reduce scar formation, and they can be difficult to apply.¹⁹

• Discuss the importance of mobility and proper positioning (e.g., splinting) on function. Self-care (activities of daily living) and range-of-motion exercises should be encouraged during the healing phase. Rationale: Contractures associated with healing skin, improper positioning, and immobility are prevented.

• Identify caloric needs for healing and suggest appropriate nutritional supplements. Rationale: Metabolic needs are increased for months after discharge, and a balanced diet facilitates gain of muscle mass versus adipose tissue.

• Inform patient and family that nightmares, alterations in body image, and psychologic disturbances are experienced by many burned patients.²⁰ Provide resources, including someone to follow up with, if desired. Rationale: Information increases awareness of these problems and reassures patient and family that these experiences, although unpleasant, are not abnormal.

• Provide patient and family with follow-up appointments and someone to call with any problems. Rationale: Necessary information for further care and follow-up is provided.

Patient Assessment

Patient Preparation

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