Chapter 26: Burns: Assessment & Management

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Welcome to the Deep Dive.

We're here to take vital insights from core texts and, well, get them straight to you.

Today, we're tackling a really big one, nursing care for patients with

We're distilling Lewis's Medical Surgical Nursing, the 12th edition, into a discussion that's

hopefully super useful for you, our future nursing colleagues.

We'll cover everything from fairly minor burns right up to those catastrophic injuries and really look at how burns affect, well, pretty much every system in the body.

It's definitely an essential topic.

I mean, the numbers are pretty staggering.

You've got nearly half a million people in the U .S.

seeking burn care each year, 40 ,000 hospitalizations, and globally, it's even bigger.

11 million seeking care, about 180 ,000 deaths annually.

It just highlights how crucial nurses are.

You're really at the center of that whole multidisciplinary team, doctors, OTs, PTs, dietitians, social workers, helping patients and families through something incredibly tough.

That really sets the scene.

Okay, so let's build that foundation.

What actually causes burns and how do we start categorizing them?

It's kind of shocking how many burns are actually preventable.

This isn't just about treatment.

It's a public health thing where nurses can really step up.

Simple things like child -resistant lighters, anti -spell devices and showers, and education -safe cooking, checking water heater temps, avoiding bad wiring.

As future nurses, you have this role in prevention too, not just reacting after the fact.

That's exactly right.

When prevention fails, knowing the type of burn is the first step in figuring out the right response.

Thermal burns, they're the most common thing, hot liquids, steam, flames, touching hot metal.

The key thing for you to remember here isn't just the temperature but how long the contact lasted.

A quick touch versus prolonged exposure.

Very different outcomes.

Then you have chemical burns,

acids, alkalis, organic compounds.

Now what's really important is that alkalis things like lye, even in wet cement, cause something called liquefaction necrosis.

It sounds nasty and it is.

It lets the chemical penetrate deeper, often causing more damage than acids.

Okay, so identifying that chemical quickly is key.

And electrical burns.

These are notoriously deceptive, what you see on the outside.

It might not tell the whole story at all.

The current generates intense heat inside the body.

The damage follows the path the electricity took.

Severity depends on voltage, tissue resistance, where the current traveled, did it cross the heart,

the brain, and how long the contact was.

Oh, and it can cause these really strong muscle contractions too.

Strong enough to cause fractures.

So always think about potential cervical spine injury with electrical burns.

And a major complication, myoglobinuria.

Muscle breaks down, releases myoglobin, which can clog up to kidneys and lead to acute kidney injury, or AKI.

Really serious stuff.

Okay, so different types, very different mechanisms and risks.

Got it.

Understanding the type is step one.

But then we need to know how bad it is, right?

Which brings us to classifying the severity.

The American Burn Association, the ABA, gives us guidance here.

Yes, there are five main things we look at to gauge severity.

One, the depth of the burn.

Two,

the extent how much of the body surface area is involved, the TBSA.

Three, the location.

Four, any pre -existing health problems the patient has.

And five, any other injuries that happen at the same time.

Right.

Let's talk depth first.

We used to say first, second, third degree, but the ADA terms are more descriptive.

Partial thickness and full thickness.

So partial thickness means epidermis, maybe part of the dermis.

Nerve endings might still be intact, so these can be really painful.

You've got superficial partial thickness, looks like a bad sunburn, basically.

Red, maybe some mild swelling.

Then deep partial thickness.

These look worse.

Think fluid -filled blisters, shiny, wet -looking skin, very red, and usually, yeah, severely painful.

And then full thickness burns.

These are a whole different level.

Here, the entire epidermis and dermis are destroyed.

The injury might go even deeper.

Muscle, fat, even bone.

And what's often surprising, these burns are usually painless.

Why?

Because the nerve endings themselves are destroyed.

They often look dry, maybe waxy white or brown, or even charred and black, leathery, hard.

That takeaway.

These burns always need surgery, like skin grafting, to heal.

Okay, and estimating the extent.

The TBSA, that's a core nursing skill.

For adults, in an emergency, we often use the rule of nines.

It's a quick way to estimate, like, an arm is roughly 9%, the whole back is 18%.

But for kids, the Lund -Brauder chart is better because, you know, kids' body proportions are different and change as they grow.

Getting that TBSA right is crucial for planning fluid resuscitation.

Absolutely.

And location matters hugely.

Burns on the face, neck, or all the way around the chest.

Big red flags for airway problems, swelling, or that tight escher can cut off breathing fast.

Burns on hands, feet, over joints.

Think about function.

Long -term mobility can be severely impacted.

And places like ears and the nose, thin tissue, cartilage, not great blood supply, they get infected easily.

Buttocks, perineum too.

High infection risks from contamination.

You have to consider where the burn is.

It's really clear how these factors all interplay.

And the ABA has specific referral criteria for when a patient needs to go to a specialized burn center.

Things like partial thickness burns covering more than 10 % TBSA, any full thickness burn.

Burns on those critical areas, face, hands, feet, perineum, major joints.

Also electrical, chemical, or inhalation injuries.

Patients with underlying health issues like diabetes.

Or if there's other trauma involved.

That table in the textbook, table 26 .3, definitely one for you to know, inside out.

All right, with that groundwork laid, let's walk through the phases of burn management.

It really is a journey.

Three main phases.

Emergent or resuscitative, acute or wound healing, and rehabilitative or restorative.

Starting with the emergent phase.

This is all about immediate life -saving care, usually the first 72 hours.

It actually starts before they even get to the hospital.

Scene safety first, obviously.

Stop the burning, get the clothes off, flush chemicals.

Cool the burn briefly, but then cover them with a dry, clean sheet while dry to prevent hypothermia.

They lose heat incredibly fast.

And a huge nursing point here.

Don't get tunnel vision on the burn.

Are there other major injuries?

Head trauma, internal bleeding, prioritize.

And the pathophysiology driving everything in this phase is burn shock.

It's a nasty mix of distributive and hypovolemic shock.

What's happening is the capillaries become incredibly leaky.

Just massive permeability increase.

So fluid, sodium, vital proteins, they all pour out of the blood vessels into the surrounding tissues.

We call that third spacing.

This leads to huge edema, the blood volume plummets, blood pressure drops, heart rate skyrockets.

Without rapid fluid resuscitation, you get organ damage, especially acute kidney injury, and potentially death.

You also get major electrolyte shifts.

Potassium rushes out of the damaged cells into the bloodstream so you might see hyperkalemia right at the start.

Meanwhile, sodium gets pulled into those swollen tissues along with the fluid.

This whole chaotic phase starts to resolve when the capillaries regain their integrity and that fluid starts shifting back where it belongs.

And don't forget the immune system.

It takes a massive hit immediately.

The skin barrier is gone.

Immune cells don't work properly.

Huge risk for infection right from the get -go.

Clinically, what will you see?

Well, patients are usually alert.

Unless they have an inhalation injury or other trauma, maybe substance use involved, they'll likely be very frightened, anxious.

Shivering is common, partly heat loss, partly anxiety, partly pain.

And pain, it's variable.

Remember those deep partial thickness burns?

Scrutiating.

But full thickness, often painless because the nerves are gone.

That's a key assessment finding.

Okay.

So the complications in this emergent phase sound intense.

Respiratory, cardiovascular, renal.

What's the absolute top priority you're watching for?

For me, always respiratory, particularly inhalation injury.

Could be from breathing in toxic fumes like carbon monoxide.

Could be heat damage above the vocal cords causing rapid swelling or injury below the glottis leading to inflammation, edema, and eventually pneumonia.

And here's a critical point for you.

Pneumonia, often a later complication, is frequently the actual cause of death in burn patients.

So early detection of respiratory issues is paramount.

But for clues,

hoarseness, black flecks in the sputum, carbonaceous sputum, maybe that cheery red skin from CO poisoning, increasing agitation or anxiety.

Beyond the lungs, cardiovascular problems are huge, mainly from that burn shock.

And if you have a deep burn that goes all the way around a limb or the chest, a circumferential burn,

the swelling underneath that tight leathery escher can cut off blood flow.

That might require an esgrotomy basically, cutting through the escher to relieve pressure and restore circulation or allow a chest to expand.

And renal complications, AKI from low blood volume or from that myoglobin area we mentioned earlier, clogging the kidney, two goals.

Wow.

Okay.

This really underscores the urgency of nursing and interprofessional management in the emergent phase.

Your quick quick quick quick quick.

Airway management has to be number one.

Get them sitting up high foulers, slap on a percent oxygen, maybe aerosolized meds, encourage deep breathing and coughing.

And be ready for intubation, especially with blimps to the face or neck, or signs of distress.

Getting that tube in early is way better than struggling during a crash intubation later.

Fluid therapy is the other absolute cornerstone.

Burns over 20 % TBSA.

You need two large bore IVs.

Minimum.

We use formulas like the ABA or Parkland, maybe two to four millimiles of lactated ringers per kilo per percent TBSA.

Half of that total volume goes in during the first eight hours from the time of injury.

But, and this is key, it's just a guide.

You must titrate those fluids based on how the patient responds.

You're watching urine output closely aiming for 0 .5 to one milliliter KGHER in adults, watching heart rate, blood pressure, oh and electrical burns.

They often need even more out that myoglobin.

And wound care starts right away in the ED.

Gentle cleansing, maybe some initial debridement.

Keep the room warm, like 85 degrees Fahrenheit, to fight off shivering and conserve energy.

Use personal protective equipment, obviously.

Topical antimicrobials are common.

Silver, so betazine is a classic, but always ask out silver allergies first.

Specific areas need special care.

Faces usually get ointment, maybe loose gauze, but never wrapped tightly.

Eyes need checking, maybe artificial tears.

Hands and arms.

Elevate them to reduce swelling.

PT gets involved early with splints and range of motion to keep things functional.

For drug therapy, pain control is huge.

5e opioids are standard morphine, hydromorphone, fentanyl.

Often needs sedatives too, like lorazepam or midazolam.

It's really a multimodal approach.

And remember that pain paradox.

Sometimes the worst looking burns aren't the most painful.

Oh, and tetanus shot, always.

Burn wounds are prime territory for Clostridium tetani.

Finally, nutrition.

Burn patients go into this hypermetabolic state, burning calories like crazy, breaking down muscle.

Early nutrition support within hours if possible, often via a feeding tube.

Entral nutrition is absolutely critical.

It helps reduce complications, supports healing.

High protein, high carbs are the focus.

The dietitian is your best friend here.

That's a lot to manage in those first few days.

Okay, so the patient stabilized somewhat.

Fluid shifts are resolving.

Now we move into the acute phase.

This is all about wound healing.

But this raises an important question.

What new hurdles pop up now?

This phase can drag on for weeks, even months.

Yeah, in the acute phase, things might seem calmer on the surface.

Vital stabilizing, maybe.

But underneath, the body's working incredibly hard.

White blood cells are cleaning up the wound.

Necrotic tissue starts slipping off.

Healing begins from the edges of partial thickness wounds.

But patients often report more pain now.

Think about it.

Daily dressing changes, scrubbing, physical therapy, stretching tight tissue.

Plus, they can develop opioid tolerance.

And this is typically when major surgical debridement and skin grafting happen.

Fluid and electrolytes are still a balancing act.

You might see hyponatremia, low sodium, maybe from GI losses, or if they drink too much plain water.

That can cause confusion, even seizures.

Or hyperkalemia, hypotassium, especially with big muscle injuries or kidney problems.

That's dangerous for the heart.

So yeah, still watching those labs like a hawk.

And the number one danger in this phase has got to be infection, right?

Absolutely.

That primary defense, the skin, is gone.

The immune system is still suppressed.

Wounds inevitably get colonized by bacteria.

You're watching for local signs, redness, spreading, pus, maybe a change in wound appearance.

But crucially, also systemic signs.

Fever, chills, confusion, drop in blood pressure.

That signals sepsis, a major killer in burn patients.

Vigilance is key.

And while other tissues can linger, musculoskeletal complications really come to the forefront now.

Contractors.

As that scar tissue matures, it shrinks, it tightens, pulling joints into bent positions.

This is why PT and OT are so relentless, positioning, splinting, constant range of motion exercises.

It's a battle to maintain function.

We also worry about curling ulcers, stress ulcers in the stomach or duodenum from all the physiological stress.

Early feeding helps prevent them, along with meds like H2 blockers or PPIs.

So the focus of nursing and interprofessional management shifts here.

It's about preventing infection, getting those wounds closed, managing pain during intense therapy and keeping the patient moving.

Wound care is ongoing assessment, cleansing, debridement.

Sometimes enzymatic debriding agents are used.

More specialized dressings, maybe silver impregnated ones.

Again, check those allergies.

And excision and grafting become central.

Excision is the surgery to remove the dead escher down to healthy tissue, then grafting.

The gold standard is an autograft using the patient's own healthy skin, often taken from the thigh or abdomen.

It can be meshed to cover a larger area.

For huge burns where donor sites are limited,

sometimes cultured epidermal autografts, CEA, are an option.

Skin cells are grown in a lab from a biopsy, takes weeks though.

Caring for both the graft site, making sure it takes and the donor site helping it heal quickly with minimal pain are major nursing responsibilities.

Pain management here is complex.

You've got that constant background ache plus sharp, intense pain during procedures.

It really demands that multimodal approach.

Maybe long acting opioids plus short acting ones for breakthrough pain.

Maybe a PCA pump, definitely anxiolytics.

And non -drug methods.

Relaxation, guided imagery, music, they can really help.

Pre -medicating before painful things like dressing changes or therapy is absolutely essential so the patient can tolerate it.

And PT and OT are just constant.

Active range of motion, passive range of motion.

Often done during dressing changes when pain meds are peaking.

Custom splints are made to hold joints in functional positions, preventing those contractures.

But you have to check the skin under the splints regularly too.

Nutrition remains critical.

The body still needs massive amounts of calories and protein to rebuild tissue.

Dietitians fine -tune the plan, maybe adding antioxidant supplements.

The goal is usually to prevent losing more than 10 % of their pre -burn weight.

Calorie counts, weekly weights you're tracking it all.

Okay, so we've navigated the crisis, managed the acute healing.

Now, looking towards the future, the rehabilitation phase, or restorative phase, this is about getting back to life.

It starts when most wounds are closed and the patient can start doing more for themselves.

Can take weeks, months, even longer.

Yeah, this phase is all about dealing with the aftermath.

Healing continues, but it results in scarring.

New skin forms, but it's different.

It might be flat and pink initially, but often becomes raised, red, maybe itchy, that's hypertrophic scarring.

The key intervention here is pressure garments.

Patients wear these tight -fitting garments sometimes for 23 hours a day for a year or even longer to help flatten those scars.

Itching puritus is a huge complaint.

Moisturizers and histamines, sometimes meds like gabapentin can help, and that new skin.

It's fragile, easily injured,

also less sensitive to temperature and touch sometimes.

Sun protection is vital months of avoiding direct sun, then diligent sunscreen use.

The biggest long -term physical challenge remains skin and joint contractures.

Areas like the neck, armpits, elbows, fingers, knees, they're high risk.

It reinforces why that earlier PTOT was so critical and needs to continue.

So nursing and interprofessional management in rehab shifts again.

Now it's about discharge planning, long -term adaptation.

This means intensive patient and caregiver education.

How to do wound care at home, manage scars, use moisturizers, protect from sun.

They need to know when to call the burn team signs of infection worsening pain and understand that follow -up including potential reconstructive surgeries down the line is crucial.

Exactly.

And we continue ongoing assessment and support.

Still managing pain, ensuring adequate nutrition, reinforcing those exercises.

We also have to consider gerontologic factors.

Older adults often have deeper burns because their skin is thinner.

Healing takes longer.

They have more complications due to other health issues.

Rehab is often slower and returning to fully independent living can be a real challenge.

And we absolutely cannot forget the emotional and psychological impact.

This is huge for both patients and their families.

What do you think often gets missed here by newer nurses?

Probably the depth and breadth of the emotional toll.

It's not just sadness.

It's fear, anger, guilt, depression, profound anxiety about their appearance, about relationships, about their future.

Body image issues are almost universal.

Self -esteem takes a massive hit.

So as nurses, our role is to create a safe space for them to talk about these fears, to listen without judgment, to connect them with resources of peer support like the Phoenix Society is incredibly powerful.

And don't forget the caregivers.

They're exhausted, scared, feeling helpless too.

They need support just as much.

We also need to address cultural need, spiritual needs, even sexuality, providing guidance on how intimacy might change.

And mental health support is key.

Many occasions develop PTSD or other issues.

Early psych intervention makes a difference.

The goal isn't just survival.

It's helping them find meaning and growth after the trauma.

And lastly, a word about the nurses themselves.

Burn care is tough.

It's physically demanding, emotionally draining.

Seeing these injuries, dealing with odors, managing intense pain, it takes a toll.

It is so important for burn nurses to practice self -care,

to lean on colleagues, to use resources like employee assistance programs.

Burnout is real.

You have to look after yourself to provide good care.

That's a really vital point.

It's incredibly challenging work, but also, as you said, so rewarding.

Nurses in burn care make an unbelievable difference.

So wrapping this up, what does it all mean for you, our future nurse listeners?

We've walked through those three key phases.

Emergent, acute,

rehabilitative.

Remember the priorities.

Emergent is all about ABCs, airway, breathing, circulation, fluids.

Acute is about fighting infection, closing wounds, managing pain through intense therapy.

Rehabilitative focuses on maximizing function and supporting that long, often difficult psychosocial recovery.

And in every single phase, your assessment skills, your interventions, your teaching, and your compassion are absolutely central.

Yeah.

And if you connect this to the bigger picture,

seeing a burn patient through their journey, it's really witnessing incredible resilience.

It's a privilege, honestly, to be part of that.

And it's a powerful reminder that nursing isn't just about fixing the physical damage.

True recovery involves supporting the person, body, mind, spirit as they navigate immense changes and rebuild their lives.

It really shows the profound impact of truly comprehensive nursing care.