Burn Care: Phases and First Aid

Burn Care Phases

• Burn care includes emergent/resuscitative, acute/intermediate, and rehabilitation phases
• Priorities exist for each phase
• Phases overlap; assessment and management of complications are not limited to specific phases

Emergent/Resuscitative Phase

• Time required to resolve immediate, life-threatening problems resulting from the burn injury
• Lasts up to 72 hours from the time the burn occurred
• Primary concerns involve hypovolemic shock and edema formation
• Ends when fluid mobilization and diuresis begin

First Aid for Minor Burns (First-Degree, Skin Intact)

• Run cool water over the burned area for five minutes
• In a cold environment, do not apply water; use a clean, cold, wet towel instead
• Reassure and keep the patient calm
• Cover the burn with a sterile non-adhesive bandage
• Protect the burn from friction and pressure

First Aid for Severe Burns (Second and Third-Degree)

• Do not remove burn clothing unless it comes off easily
• Ensure the patient is not in contact with burning materials
• Ensure the patient’s airway remains open
• Cover the burn with a cool, moist sterile bandage or clean cloth; a sheet is best for large burns
• Do not apply ointments or break blisters
• Separate burned fingers or toes with dry, sterile, non-adhesive dressings
• Elevate the burned area and protect it from pressure or friction
• Lay patients flat, elevate feet 12 inches to prevent shock, and cover the patient

What NOT to do in first aid for burns

• Do not place the patient in the shock position if a head, neck, back, or leg injury is suspected
• Do not apply ointment, butter, ice, medications, fluffy cotton dressing, adhesive bandages, cream, oil spray, or similar items
• Do not allow the burn to become contaminated
• Do not disturb blisters or dead skin
• Do not apply cold compresses or immerse a severe burn in cold water
• Do not place a pillow under the patient's head if there is an airway burn

Fluid and Electrolyte Changes in the Emergent/Resuscitative Phase

• Plasma accumulates into interstitial fluid, causing edema
• Generalized dehydration due to plasma leaks through damaged capillaries
• Reduced blood volume secondary to plasma loss, decreased blood pressure, and diminished cardiac output
• Decreased urinary output secondary to fluid loss and decreased renal blood flow
• Sodium and water retention are caused by increased adrenocortical activity
• Red blood cell hemolysis leads to hemoglobinuria and myonecrosis or myoglobinuria
• Massive cellular trauma releases K+ into extracellular fluid
• Large amounts of Na+ are lost in trapped edema fluid and shifts into cells as K+ is released
• Metabolic acidosis occurs as bicarbonate ions are lost along with sodium loss
• Hemoconcentration occurs as liquid blood components are lost into extravascular space

Nursing Management During the Emergent/Resuscitative Phase

• Administer 100% humidified oxygen
• Insert an endotracheal tube and initiates manual ventilation if severe respiratory distress or airway edema are present
• Assess the circulatory system quickly
• Apical pulse and blood pressure are frequently monitored
• Assess neurological status in patients with extensive burns
• Keep the patient nil per mouth (NPO)
• Encourage patients to cough to remove secretions
• Remove all things and jewelry
• Attend to the patient's family’s psychological needs, providing individualized psychosocial support
• Provide reassurance and support through explanations of procedures and adequate pain medication

Emergency Medical Management during the Emergent/Resuscitative Phase

• Provide suctioning and give bronchodilators as needed
• Perform endotracheal intubations when edema is present
• Remove chemicals from the eyes immediately, if present
• Assess for cervical spinal injuries or head injury if the patient was involved in electrical injury
• Obtain a history of preexisting disease, allergies, medications, and substance use
• Insert an IV catheter in a non-burned area
• Administer a large amount of IV fluids and monitors central venous pressure
• Insert a nasogastric tube connected to suction if nauseated
• Place an indwelling urinary catheter to accurately monitor urine output and renal function

Further Management During the Emergent Phase

• Obtain basic measurements (height, weight), arterial blood gases, hematocrit, electrolytes, urine analysis, and chest X-rays
• Provide tetanus prophylaxis
• Homodynamic instability results from loss of capillary integrity which causes fluid shift from intravascular to interstitial spaces plus decreased circulating blood
• Maintain normal blood pressure and urine output
• Achieve a systolic blood pressure exceeding 100 mm Hg
• Maintain a pulse rate less than 110/minute
• Achieve a urine output of 30 to 50 ml/hour

Fluid Replacement for Shock

• Fluid requirement for the first 24 hours is calculated by a physician based on the extent of the burn injury
• Some combination of fluid categories may be needed
• Types of fluids which may be required are colloids (whole blood, plasma and plasma expanders)
• Types of fluids which may be required are crystalloid or electrolyte solutions (physiologic sodium chloride or lactated ringer's solution)
• The Parkland (Baxter) formula is commonly used for fluid replacement
• A recommendation of 2 to 4 mL lactated Ringer's/kg/%TBSA burned for the first 24 hours

Parkland Formula Application

• Administer ½ of total fluid in first 8 hours
• Administer ¼ of total fluid in second 8 hours
• Administer ¼ of total fluid in third 8 hours
• For example: for a 70kg patient with 50% BSA burned use the consensus formula: 2 to 4 ml/kg %BSA Use 4 ml × 70 kg × 50 TBSA burned = 14,000 ml/24 hours to plan administration:

Fluid Administration Plan

• Administer ½ of total in first 8 hr = 7000 mL (875 mL/hr)
• Administer ¼ of total in second 8 hr = 3500 mL (437 mL/hr)
• Administer ¼ of total in third 8 hr = 3500 mL (437 mL/hr)

Fluid Replacement Notes

• All formulas are estimates; fluids must be titrated based on the patient’s response
• Monitor hourly urine output and vital signs
• Patients with an electrical injury have greater fluid requirements
• Mannitol [Osmitrol] is required to increase urine output and overcome high levels of hemoglobin and myoglobin
• Overestimation of TBSA contributes to "fluid creep”
• Colloidal solutions (e.g., 5% albumin) may be given after 12 to 24 hours postburn
• The replacement volume is calculated based on the patient’s body weight and TBSA burned
• Hourly assessments should be made using clinical parameters; use urine output parameter
• Urine output should be 0.5 to 1 mL/kg/hr, or 75 to 100 mL/hr for electrical burns
• Assess cardiac parameters by ensuring MAP is greater than 65 mm Hg, systolic BP is greater than 90 mm Hg, and heart rate is less than 120 beats/minute

Emergent Phase Nursing Process: Assessment

• Check vital signs frequently and monitor respiratory status
• Evaluate apical, carotid, and femoral pulses to detect heart disease
• If all extremities are burned, apply a sterile dressing under the blood pressure cuff to protect from contamination
• Assess the IV site if an arterial catheter is used
• Insert an indwelling urinary catheter and monitor fluid intake and output
• Assess urine for myoglobin resulting from muscle damage
• Measure body temperature and body weight
• Assess the burn wound extent, level of consciousness, psychological status, pain, and anxiety

Impaired Gas Exchange R/T Carbon Monoxide Poisoning Interventions

• Provide humidified oxygen to provide moisture to injured tissues
• Supplemental oxygenation increases alveolar oxygenation
• Assess and monitor breath sounds, respiratory rate, rhythm, depth, symmetry, monitor
• Look for erythema or blistering of lips, buccal mucosa, singed nostrils, burns of face, neck, or chest, or increased hoarseness
• Monitor arterial blood gas values, pulse oximetry readings, and carboxyhemoglobin levels
• Report labored respirations, decreased depth of respirations, or signs of hypoxia to physician
• Prepare for intubation and escharotomies
• Monitor mechanically ventilated patient

Ineffective Airway Clearance R/T Edema Intervention

• Maintain patent airway through positioning, secretion removal, and artificial support if required
• Provide humidified oxygen
• Use turning, coughing, and deep breathing exercises
• Encourage incentive spirometry; perform suction if needed

Nursing Interventions for Deficient Fluid Volume

• Observe vital signs frequently - central venous or pulmonary artery pressure and urine output.
• Monitor urine output at least hourly and weigh pt daily
• Maintain and regulate IV fluids, as prescribed

Nursing Interventions for Hypothermia:

• Provide warm environment use heat shield, space blanket, heat lights or regular blankets
• Work quickly when wounds are exposed
• Assess/monitor core body temperature, consistently

Nursing Interventions for Potential Pain

• Assessment of patient pain, using the pain scale, to manage effectively
• Promote relaxation
• Provide analgesics, as prescribed
• Evaluation/reevaluation of current pain status

Nursing Interventions for Anxiety

• Provide successful support to the patient
• Open communication regarding burn injuries
• Coping strategies
• Reassurance
• Medicate, if necessary

Potential collaborative problems

• Acute respiratory failure
• Distributive shock
• Acute renal failure
• Compartment syndrome
• Paralytic ileus
• Curling's Ulcer

Acute Phase of Burn Care

• Begins with the start of diuresis, near wound closure, about 48-72 hours post-burn
• Focus on respiratory and circulatory state
• Fluid and electrolyte balance
• Promote gastrointestinal function
• Provide wound care
• Provide pain management
• Help prevent complication
• Provide nutritional Support

Acute Phase: Fluid and Electrolyte Changes

• Hemodilution occurs as fluid enters the intravascular compartment, with a loss of destroyed red blood cells
• Increased urinary output with intravascular fluid shift
• Sodium deficit occurs with the use of diuretics
• Potassium deficit
• Metabolic acidosis occurs as a result of sodium depletion

Wound Dressings

• Cleaning of affected area, then applying topical agent/covering with a few dressing layers
• Wound dressings for infection prevention
• Purpose of wound dressing includes; protective barrier, immobilized, depride to wound from dead tissues and promote physical comfort

Dressing Methods

• Include exposure, occlusive or hydrotherapy
• Exposure: Affected air exposed to air, w/o dressing
• Precautions can vary based on microorganisms
• Occlusive: Application of thin gauze directly to antimicrobial layer of topical ointment
• Hydrotherapy: Immersing the patient, tub, and shower (w/ or w/o direct water to wounds)

Wound Dressing Changes

• Unit care, treatment, or hydrotherapy to provide dressing changes
• PPE gear recommended - mask , gown/plastic apron, gloves, hair cover
• Debriding of wounds, cleansing to remove dead tissue from sight and skin
• Inspection during procedure is recommended - eschar, drainage, epithelization and color
• Transferral back to patient bed after changing wound dressing

Hydrotherapy

• Facilitate washing, cleansing and debridement of burned regions, typically, showering or bathing.
• Advantages include eschar and medications being simple to remove, exercises (ROM) and comprehensive wound inspections
• Disadvantages include increases in anxiety, sodium and heat loss. Ventilator /IV care may be problematic

Wound Debridement

• The removal of any outside material located around safe tissue,
• Protect from bacteria with debridement and promote skin healing
• Forms include mechanical or natural. Surgical can as well too

Wound Healing Disorders

• Keloids and scarring. The failure to heal wound, may derive from infections or insufficient albumin levels

Burned Patient: Infection Control

• Monitor the early symptoms of infection/sepsis,
• Reduce reservoir to reduce microorganisms - by decreasing patient visitors or plants at facility
• With burn injuries, it is important to clean using aseptic/antimicrobial techniques and observe universal precautions
• Infection control is the main goal

Burn patients also need nutritional support

• Nutrition consist mainly of assessment, planning, and monitoring of components
• Nutrition is important during the acute phase
• Nutritional support is useful (enteral tube feeding/ oral diets) or even diet modifications. Calories and protein should be optimized

Indication for Parenteral Nutrition

• Inadequate nutrition for clinical reasons, prolonged exposure of wounds and malnutrition is an indicator
• Body measurements, caloric count and plasma proteins should be monitored consistently

Skin Graft

• Surgical methods utilized to cover destroyed surfaces - the transplanting of skin
• Helps with ulceration from skin, or burns.
• Autograft, Allograft, Xenograft are types.
• Donor location cleaned from bacteria or dead tissue, prior to grafting

Skin Grafting:

• Graft is secured w surrounding tissue
• 48 hours needed, to make sure the new adherence
• The healing time may be couple weeks and donor site, may form scars

Skin Graft May Be Rejected Due To:

• Movement
• Bleeding
• Infection
• Poor nutrition

Patient Care Post Grafting

• Occlusion and the patient's body positioning matter for mobilization
• Assessment of edema, infection is prioritized

Pain Management and Nursing Process for Acute Phase

• Initial steps focus on assessment from the nurse, as relates to all complications. Hand, eye and sensory skills may be applied
• Fluid excess as regards capillary integrity
• Reduced vascularity of vessels and excessive bleeding require monitoring

Intervention and Diagnosis Phase

• Vital and output needs to be evaluated with diuretics/ pumps
• Also, to assess is weight, fluid status
• Wound inspection is most important

Nursing diagnosis

• It focuses on the risk of infection with lack of skin barrier/decrease in immune activity. Reduce flower usage since it promotes bacteria

Reduced/Inadequate Nutrition

• Impaired skin, also open wounds are important. Promoting nutrition and cleanliness is prioritized.

Related Nerves/Pain

• Focus on imagery distraction and relaxation techniques and pain management. Reduction of pain is the top goal

Collaborative Problems

• There are several includes respiratory failure, sepsis/edemas and damage to body

Rehabilitation phase

• Initiating wound care and self-managing
• Prioritizing psychological and physical functional roles
• Emphasize rehab and avoid late complications
• Promoting range of motion, and preventing skin breakdown

Rehab Phase Goals:

• Edema decreased, ROM is prioritized
• Body healing and function come together for independent living
• Therapist assistance may be needed

Phases of Physiological Recovery of Burn Injury:

• Psychological phases are essential at this time
• Critical Phase: - pain, medication confusion
• Acute: phase depression and acknowledging issues
• Final stage- family/emotional health is critical

Further Rehab Elements:

• Promote relationships and quality of life overall
• Help with challenges to family needs, as well

Rehab Phase Complications

• Heterotopic ossification: can be improved with motion exercises
• Partial thickness is addressed thru keeping pliable skin
• Contractures: are decreased with body alignment/exercises.

Potential Issues During Rehab Phase Cont:

• If there is a wound- clean it/maintain and elevate adequate nutrition
• Pain/ complex regional pain
• Burn/ scar joints - are all symptoms