REQUIRED READING:
Ignativicius, Workman, Mischler.  Medical-Surgical Nursing Across the Health Care Continuum.  3rd. ed.  Philadelphia:  W. B. Saunders. Chapter 71, pp. 1753-1785.
 
Whaley and Wong. Nursing Care of Infants and Children.
6th. ed. St. Louis: C.V. Mosby. Chapter 29, pp. 1336-1363.

The percentage of the body burned is determined by using a burn chart, such as the "rule of nines." This chart divides the body surface into areas, each of which represents 9 per cent or multiples of nine. The "rule of nines" is universally known and used for quick assessment of the total body surface area (TBSA).

In infants and small children, the surface area of the head and neck is greater and the lower extremity is smaller than the adult. Therefore, the Lund-Browder chart more accurately determines the extent of a burn. The figures from the chart are used in the calculation of replacement fluid requirements. See rule of nines chart in the text on page 1767.
 
 

The depth of the burn is classified as either superficial, partial-thickness, or full-thickness or fourth degree. In a superficial burn, the epidermal layer is damaged and hurt, and the wound is quite painful. The skin is characteristically red and dry. Redness generally subsides within 24 to 48 hours and scarring does not occur.

Deep partial thickness burns affect the dermal layer of the skin. The injured skin is red or mottled, possibly weepy with vesicles or blisters and considerable swelling. The time frame for re-epithelialization varies from 1 0 days to 4 weeks, depending on the severity. When healing is complete, the skin is usually somewhat discolored. If the burn is over ajointed area, a tightening and contracture may develop.

In a full thickness burn, the injury extends all the way through the subcutaneous tissue, sometimes to muscle and bone, and no regeneration can occur. The skin is leathery and charred. The surface is dry and edema is present. Burns of this depth must be autografted. Extensive third-degree burns are always considered critical.

Fourth degree burns injure and expose muscle, bone, and tendons, and may require amputation of extremities.

AGE

The age of the client is of great consequence, even when burns are small. In pediatric clients under age 2, the immunologic response to stress and trauma is not fully developed, and a burn injury can be overwhelming. In the elderly, these responses are diminished and the person's general health may be compromised by existing medical problems.
 

The part of the body burned is significant because burns of the hands, head, neck, chest, ears, face, perineum and feet require special attention. Prevention of contractures in these areas is crucial to good healing. Any time there is soot around the nose or mouth, burned nasal hairs, stridor, hoarseness, decreased breath sounds, upper airway damage should be suspected.
 
 

The client's history is extremely important and should include: previous disease or injury, burn injury history, medical history, previous treatment, preburn wt., current meds, and a physical assessment.

-In performing a physical assessment, do not forget to look for concurrent injuries. Burns may be associated with multiple trauma involving fractures, deep cuts, head injuries or electrical shock, resulting in respiratory or cardiac arrest.
 
 
 
 
 
 

The burn client's needs can be thought of as a process that consists of four phases of treatment, each with its own defined goals and outcomes. These phases are first aid or prehospital, acute, intermediate, and rehabilitation.

The first aid phase begins after the burn injury and ends with arrival at the medical facility. (See the following page for guidelines for pre-hospital care of burn victims).

The acute phase begins at arrival in the emergency department and continues for the next 48 to 72 hours. This is a critical phase of medical care. Nursing management should include the following:
 

1. MAINTENANCE OF AIRWAY PATENCY.

A. Assess the airway - This is of particular importance if the burn involved the face, head and neck, and if smoke inhalation occurred.

B. Auscultate the trachea, and monitor for adventitious breath sounds or decreased breath sounds.

C. If client is dyspneic or if there is carbon monoxide poisoning, a high liter flow of 8 to IO liters of oxygen is recommended.

D. If compromise is suspected, the victim may be intubated and ventilated.

Indications for intubation are airway obstruction and a PaO2 of less than 60 mm Hg.

The continuous monitoring by means of a pulse oximeter assists in assuring adequate oxygenation.

E. The client's level of consciousness should be carefully monitored. Burn victims are most often alert, oriented and cooperative even with extensive injuries. Deterioration of sensorium should be considered a serious symptom.
 
 
 
 

2. FLUID RESUSCITATION

Fluid resuscitation is needed in major burn care. The body responds to a severe burn with increased capillary permeability; diffusion of the intravascular fluid into the extravascular tissue, imbalance of electrolytes, and diminished blood volume.

The white cells, red cells, and platelets remain in the blood vessels, whereas the fluid portion of the blood escapes through the vessel walls. When, because of the capillaries dilate, they become porous; fluid leaks into the surrounding which act like sponges, and edema forms.

The normal cutaneous insensible loss ranges between 700 mL and 1000 mL per day with severe burns.

Fluid resuscitation is aimed at correcting these homeostatic imbalances by replacing calculated amounts of fluid in the circulating volume. The maximum loss of fluid occurs within 12 to 18 hours after the burn. The total quantity of fluid required to correct this volume deficit is replaced in the first 24 hours following the burn injury.
 

Fluid resuscitation formulas should serve as "guides." The actual rate of infusion, volume, or content of fluids used must be determined by the client's response.

Two major considerations in fluid resuscitation are: Fluid resuscitation must begin promptly and the fluid must be given in adequate quantity to maintain perfusion of vital organs.

The Parkland (Baxter) and modified Brooke formulas are the most widely used resuscitation formulas. The content of the fluid include in the initial 24-hour resuscitation period include crystalloids and colloids.
 
 

The amount of fluid required to correct the deficit is calculated to be 2 to 4 mL per cent burn per kilogram of body weight. Administration of the fluids takes place over a 24-hour period with half the amount given in the first 8 hours and the remainder over the next 16 hours.
 

3.OBTAIN LAB DATA

If smoke inhalation is suspected, arterial blood gases and carboxyhemoglobin levels should be obtained along with other baseline laboratory data, including complete blood count (CBC) electrolytes, SMA, bleeding times, and urinalysis.
 

4. MONITOR URINARY OUTPUT.

Monitoring of urinary output is paramount. Insertion of a foley catheter will allow measurement of UOP. Measurement of the hourly output is the simplest and most accurate means of determining the success of fluid resuscitation. If fluid resus is sufficient, UOP will be in the range of 0.5 mL per KG of body weight per hour, with an average of 30 to 50 mL per hour in the adult. In children, UOP should be at least I mL per KG per hour.
 

Because very little fluid leaves the body, the weight gain may be as much as 20 to 30 pounds.
 

Obtaining a baseline weight and weighing the client daily will provide an accurate record in determining fluid balance.
 

Usually within 24 to 48 hours, the capillaries regain their integrity and a "fluid shift occurs; the edema fluid in the interstitial space is pulled back into the intravascular

spaces. The result is massive diuresis. The client increases urine output as much as threefold.
 

Because large amounts of potassium may be excreted during the increased urine output, potassium supplements should be given.
 

5. ASSESS NUTRITIONAL STATUS.
 

When GI function returns after approximately I to 3 days, an oral diet may be initiated, progressing from liquids to solids. Burn injuries produce a hypermetabolic state in the client at a rate that is proportional to the size of the burn injury. Hypermetabolism is proportional to the percent of burn injury up to 50% Past 50% there is no further increase in requirements. If nutritional needs cannot be met through oral feedings, then enteral feedings, peripheral fat emulsions, or total parenteral nutrition may be necessary to support the immune function and survival of the client.

Several major complications may involve the GI tract, resulting from burn shock. During the burn shock phase, blood volume is decreased; therefore, blood flow is shunted away from the GI tract. In burns involving over 20 per cent TBSA, the GI functions are diminished or may stop entirely, causing an ileus. A client who has severe burns may require insertion of a nasogastric tube to relieve gastric distention.
 
 
 
 

Curling's ulcer, a state in which the mucosal lining of the GI tract ulcerates and bleeding can occur. The bleeding may be gross and microscopic. This is believed to occur secondary to the stress that a burned client endures.

This ulcer may have a quick onset, or may have a more insidious onset. If an ulcer occurs, the client is rendered NPO until peristalsis is noted. This is followed by a regimen of antacids or milk per NG tube to alter the acidity of the gastric PH. The administration of Tagamet by IV infusion is also used.
 
 

6. MONITOR VITAL SIGNS.
 

Vital signs should be measured at least every hour, and IV titration done hourly. The PH, color, and amount of urine should be noted. A cardiac monitor should be used, especially during fluid resuscitation. Monitoring the body temperature is also important. The temperature can fluctuate as a result of exposure to the environment. Hypothermia or hyperthennia may indicate sepsis.
 

7. ADMINISTER TETANUS TOXOID, if applicable.
 
 
 

The intermediate phase follows the acute phase and continues until wound healing is complete. Extensive wound care with debridement and skin grafting may be needed during this phase to achieve burn wound closure.
 

The major goal of burn wound care is to close the wound as soon as possible. A most important objective is to prevent infection through meticulous cleansing and wound debridement. Other goals are to foster the development of granulation tissue, to promote re-epithelialization and to prepare the wound for grafting. Additionally, the reduction of scarring and contractures is a priority. Finally, the provision of client comfort with appropriate use of analgesia, or anesthesia is essential throughout the recovery period.
 

Wounds are usually cleansed at least daily, using a variety of methods. Sterile water can be used with a mild antibacterial cleansing agent and a topical agent applied after cleansing. When the eschar begins to separate from the viable tissue in approximately 1 0 days, more frequent cleansing and debridement is warranted. The wound itself and surrounding skin should be inspected for signs of local infection. Intact blisters may be left intact if they do not appear contaminated and do not compromise joint function.

If burn wounds are deep or large, and regeneration is not possible, a skin transplant or graft of the client's own skin is required. Priority areas of skin grafting include the face, the hands, the feet, and other areas with joints. Focusing care on these areas will promote earlier functional ability and will reduce contracture development. When burns are extremely extensive, the chest and abdomen may be grafted first to reduce the wound burn surface area prior to functional and cosmetic considerations.
 

Grafts may be permanent or temporary and are of different thicknesses; full-thickness or split thickness. These terms denote the depth of the dermis that is used. Grafts "take" or become a permanent part of the wound surface in three stages, which usually is complete in about 7 to IO days.
 

Debridement has two major purposes: removal of tissue contaminated by foreign bodies and bacteria, thereby protecting clients from invasive infection, and removal of burn eschar. It can be accomplished through mechanical, surgical, or enzymatic means.
 

Mechanical debridement involves the use of scissors and forceps in an attempt to encourage eschar separation and removal. This may be performed by experienced nurses and physical therapists. Mechanical debridement is usually done in conjunction with daily dressing changes and wound cleansing procedures. Mechanical debridement is also achieved through the use of coarse mesh dressings, which are applied "wet to dry."
 

Surgical debridement employs the use of either primary excision of the full thickness of the skin or excision of thin layers of the dermis down to freely bleeding viable tissue. This type of debridement is becoming increasingly common, because it contributes to decreased complications from invasive burn wound sepsis and a shorter time period from injury to wound closure and hospital discharge.
 

Enzymatic debriding agents reduce the need for surgical debridement. However, they are not antibacterial and must be used in conjunction with a topical antibacterial agent. The wound cannot be immediately grafted after enzymatic debridement because the wound bed may not be suitable to accept a skin graft.

Periods of required immobilization after grafting, pain that limits a patient's independent exercise, and a lengthy period of hospitalization produce muscle atrophy and decreased range of motion, strength, endurance, and coordination.

Wound contracture further inhibits mobility when burns are over joints. Nurses should work with physical and occupational therapists to plan a program of positioning, splinting, and exercise that counteracts the flexor forces that pull patients into contracted positions. However, caution should be used in exercising joints with deep burns and tendon injuries.
 
 
 
 
 
 

concerned with survival alone; this phase overlaps the intermediate phase. During the rehabilitative phase, preparations are begun to assist the client to return to as normal an existence as is possible.

COMPLETE THE FOLLOWING BURNS SCENARIO:

P.C. is a 65 year old widow, who is admitted to the emergency room after being burned in a house fire. She had attempted to start a wood fire in her fireplace, which ignited her clothing. There are four types of burn injury. all four types can lead to tissue damage and multi system involvement. The causative agents and priority treatments are specific to each. What type of burn injury did P.C. have? Compare and contrast the effects of each type of burn.
 

On admission to ER, you note second and third degree burns to her face and neck, anterior and posterior thorax and the right arm and axilla. Estimate the percentage of body burned, according to the "rule of nines."
 

P.C. is wheezing and dyspneic on admission and you note sooty sputum and singed nasal hairs. Because of the burns to the face and chest, what is the greatest danger for P.C. at this point? What medical and nursing actions will probably be taken to prevent the complication?
 

Because fluid resuscitation is needed in major burn care, aggressive IV therapy is initiated in the ER. Several formulas are used in determining adequate fluid replacement. What is the purpose of using a fluid resuscitation formula for the initial management of burns?
 

In reviewing her history, how many factors are present that decrease the prognosis for her recovery?
 

Identify which body organs are especially sensitive to inadequate tissue perfusion and whose parameters of function are monitored closely after a burn injury.
 

P.C. is admitted to intensive care. Her urinary output for the past hour was 15 mL. Should she be given more fluids or a diuretic?
 

Laboratory studies are done every 2-4 hours. The lab sends up P.C.'s values: Hgb
 

15.5/100mL,Hct=52%, Serum K+=4.Meq/L, Serum Glucose = 134/100mL. What actions do you take? Give rationales for your answers.
 

P.C. has orders for Meperidine 10mg IM Now & 4 hrs and Morphine 2 mg IV push now and Q 2 hours PRN for pain management. Which medication should you give and why?
 
 

It has now been 24 hours since P.C.'s burns occurred. You note that on the previous shift, bowel sounds were hypoactive and abdominal girth we 54 cm. She reports mild abdominal pain and bowel sounds are now absent and abdominal firth is now 55cm.

After notification of physician, what actions do you anticipate and Why?
 

A burned client is at risk for Curling's ulcer development. Define and describe how this type of ulcer is treated.
 

After four days, P.C. is scheduled to begin hydrotherapy. The first session is scheduled in 45 minutes. She has an order for Demerol IV and Oxycodone HCL P.O. Q 4-6 hours. It has been 4 hours since she received the last medication. Which drug do you choose to give and why?
 

P.C. has not been eating much of the food on her trays. Yesterday's caloric intake was 850 calories. Her admission weight was 124#; while her current weight is 114. She is 5'5 inches tall. Using the formula to estimate energy requirements, what is her estimated caloric need since she has been burned? In additional to not eating, what are some other possible causes of her weight loss?
 

Since P. C. has sustained burns to the right arm, she is experiencing Altered peripheral tissue perfusion R/T constriction secondary to circumferential burns. The physician will perform an escharotomy on the arm this morning. Identify the topics you will include in your preprocedure teaching for her. CHECK ALL THAT APPLY.
 

_____a. She will be given medication that will put her to sleep during the procedure.
 

_____b. A lengthwise incision will be made through eschar to relieve

pressure that is slowing circulation to the hands.
 

_____c. She will experience very little pain during the procedure

because the eschar contains no nerve endings.
 

_____d. There will be very little bleeding during or after the

procedure.
 
 

The highest priority nursing interventions for P.C. after the escharotomy include:
 

Circle the correct choice.
 

a. assessment of radial pulses as well as color, movement, and sensation of the hands and fingers.
 

b. assessment for fever, purulent drainage from the incision sites, and swelling with red streaks on the hands or fingers.
 

c. elevation of both arms and application of local pressure to control postprocedure bleeding.
 

d. assessment of the client's vital signs, measures to prevent aspiration, and promotion of safe recovery from the anesthetic.
 
 

One of the potential risks to burns to the axilla is contracture. What nursing interventions are used to reduce this risk?
 

P.C. is ready for skin grafting. She undergoes debridement and split-thickness and full-thickness and full thickness skin grafting.  The donor sites are on the thigh.  What assessments should you make of the donor sites and what is the appropriate nursing care?
 
 

Her surgeon plans to send her home with an antiscar support garment.  Explain the purpose of this garment.
 

Develop discharge teaching plans for P.C. on graft and donor site care, nutritional needs, activities to prevent contractures, and care of the antiscar support garment.