Burn Injuries and Systemic Response (LPN)

• Burns are wounds resulting from energy transfer from a heat source, causing tissue damage through heat denaturation of cellular protein and interrupted blood supply.
• The extent of skin damage depends on the burning agent's temperature, the agent itself, exposure duration, tissue conductivity, and dermal structure thickness.
• Major burn injuries lead to functional skin alterations like loss of protection, temperature regulation issues, heightened infection risk, sensory changes, fluid loss, impaired skin regeneration, and excretory function impairment.
• A burn affecting over 45% of the body is considered a major burn injury.

Systemic Responses

• Burns impacting the skin's functional capacity affect almost all major body systems.

Fluid Balance

• Following a major burn, damaged cells release inflammatory mediators, leading to increased capillary permeability, plasma and protein leakage into tissues, blisters, edema, and intravascular volume loss.
• Water loss via evaporation from burned tissue can increase to 4 to 15 times the normal amount, while increased metabolism further contributes to water loss via the respiratory system.

Cardiac Function

• Cardiac output initially decreases after a major burn, further worsened by circulating plasma volume loss with severe hematologic and vascular changes.
• Increased capillary permeability causes plasma to shift into the interstitial space, leading to hypovolemia and potential hypovolemic shock within the first 48 hours post-burn if untreated.
• Loss of intravascular fluid results in a relative increase in hematocrit, and red blood cells are destroyed causing decreased platelet function which leads to thrombosis.

Loss of Thermoregulation

• The skin is the body's largest organ and first line of defense which assists with temperature regulation; major burn patients are at high risk for heat loss and hypothermia.
• Full-thickness burns destroy sweat glands, impairing thermoregulation.

Metabolic Changes

• Burn patients have very high metabolic demands, and hypermetabolism is aggravated by injuries, surgical interventions, and stress responses, leading to early and severe catabolism.
• Elevated catecholamine (epinephrine, norepinephrine) and glucagon levels, triggered by the stress response, can stimulate hyperglycemia.

Gastrointestinal Problems

• Major burns can cause gastric dilation, peptic ulcers, and paralytic ileus, often due to fluid shifts, dehydration, opioid analgesics, immobility, depressed gastric motility, and stress.

Renal Function

• Acute renal insufficiency can occur from hypovolemia and reduced cardiac output. Fluid loss and inadequate replacement decrease renal blood flow and glomerular filtration rate. Extensive burns cause muscle destruction, leading to myoglobin casts that block renal tubules and cause renal failure.

Pulmonary Effects

• Pulmonary effects are primarily related to smoke inhalation, but hyperventilation can occur in moderate to major burns proportional to the burn's severity. Increased oxygen consumption is associated with the hypermetabolic state, fear, anxiety, and pain.
• Administering massive volumes of IV fluids is common in severe burn patients, close hemodynamic monitoring is crucial to prevent fluid overload.

Immune Function

• Destroyed skin loses its first line of defense against infection. Major burns also depress immunoglobulin (Ig)A, IgG, and IgM.
• Vigilance in monitoring for infection in severely burned patients cannot be overstated as is presents a real and life-threatening risk.
• The principles of infection control (such as aseptic, sterile techniques, and universal/standard precautions) should be applied.

Evaluation of Burn Injuries

• Burn injury severity is assessed via the depth of tissue destruction, percentage of body surface area injured, burn cause, the patient's age, related injuries, medical history, and burn wound location.
• The Rule of Nines, a quick method for estimating burn size, divides the body into segments of 9% or multiples thereof, with the perineum counted as 1%. (This method is less accurate for children.)

Burn Depths

• Partial thickness (superficial): Bright red to pink, epidermis and papillae of dermis involved, blanches to touch, serum-filled blisters, glistening, moist, sensitive to air, temperature and touch, heals in 7-10 days.
• Partial thickness (deep): Second degree, epidermis, half to seven-eighths of dermis involved, blisters may be present, pink to light red to white, soft and pliable, blanching present, pressure may be painful because of exposed nerve endings, heals in 14–21 days; may need grafting to decrease scarring
• Full thickness: Third to fourth degree, involves epidermis, dermis, tissue, muscle and bone, snowy white, gray, or brown, texture is firm and leathery, inelastic, no pain because nerve endings are destroyed, grafting necessary to complete healing.

Burn Injuries

• Common causes include flames, contact, scalding, chemicals, electricity, and radiation.
• Older adults with thinner skin and comorbidities face increased risks, emphasizing prevention through measures targeting smoking and cooking habits.
• To prevent burns, keep hot water heater temperatures at safe bathing levels (120°F or just below the medium setting) and check water temperature before bathing or showering.

Inhalation Injury

• A major complication from flame burns that occurs in enclosed spaces.
• Incidence of infection increases with burn wound size, skin is critical defense against microorganisms.

Neurovascular Compromise

• Secondary to major burns from eschar formation, which increases pressure and decreases blood flow to distal areas.

Burns - Diagnostic Tests

• Diagnosed through physical assessment and diagnostic tests (CBC, BUN, serum glucose/electrolytes, serum protein/albumin, urinalysis), if inhalation injury is suspected: ABGs, bronchoscopy, carboxyhemoglobin levels and wound cultures
• Stages of burn care include the Emergent (injury onset to fluid resuscitation completion), Acute (diuresis start to wound closure), and Rehabilitation (wound closure to optimal functional return) phases.

Emergent Stage

• Stop the burning process immediately by removing clothes, cooling the wound with tepid water and covering the patient with clean sheets to prevent shivering and contamination. Address ABCs (airway, breathing, circulation) first. Stabilize the patient by establishing an airway, ensuring oxygenation, inserting an IV line, and stabilizing fractures/hemorrhage. Inhalation injury is suspected during enclosed space fires exposure. Humidified oxygen is administered and IV fluids for hypovolemic shock. Pain is treated with IV opioid analgesics.

Acute Stage

• Multidisciplinary burn team care includes wound closure without infection, minimal scarring, maximized function, adequate comfort, nutritional and fluid/electrolyte support, and PCA.
• Nasogastric enteral feeding within 4-6 hours reduces mortality and infectious morbidity with calorie needs reevaluated weekly using indirect calorimetry (or individualized per patient if unavailable).
• Supplemental enteral (oral intake is possible only) or parenteral (used only when enteral feeding is not feasible) feeding is preferred,
• The wound is cleansed and debrided daily to promote healing, prevent infection, and provide a clean bed for grafting. Wound cleansing is achieved by showering or bedside care.

Eschar

• Debridement can be performed mechanically, surgically, chemically or through a combination of methods and can be accomplished with scissors and forceps, or wet-to-moist, or wet-to-dry dressings. Chemical debridement involves proteolytic enzymatic agents while surgical requires full thickness excision of burn and skin graft.
• Release circumferential burn pressure from edema (acts like a tourniquet, impeding arterial and venous flow, impairing distal pulses and restricts chest expansion) with an escharotomy (linear excision through the eschar to the superficial fat).
• Provide adequate padding before escharotomy.

Burn Dressing and Topical Treatment

• Chosen depending on the area, extent and depth of injury, health-care provider preference, and can be open or closed. Limit bulk to facilitate ROM. Never wrap skin-to-skin surfaces. Base dressings on wound size, absorption, protection, and debridement type; wrap extremities distal to proximal, without wrapping dressings too tightly and elevate affected extremities.

Antibiotic Agents

• Silver sulfadiazine 1% cream (Silvadene): Intermediate penetration of eschar; butter on in thick layer and cover with light dressings once or twice a day.
• Mafenide acetate (Sulfamylon): Premedicate for pain, butter on, open exposure method, apply three to four times daily, keeps eschar soft for easier debridement.
• Silver nitrate solution 0.5%: Poor penetration of eschar, ineffective on established wound infections; apply with wet dressings and change twice daily and soak every 2 hours.
• Bacitracin (Baciguent): Poor penetration of eschar; butter on and reapply every 4 to 6 hours.
• Gentamicin (Garamycin): Painful on application; apply gently three to four times daily.
• Mupirocin (Bactroban): May cause burning, itching, and pain on application; apply three times daily.
• Neomycin/bacitracin/polymyxin (Neosporin): Apply one to three times daily.
• Biological dressings use tissue from living/deceased humans/animals to aid healing and stimulate epithelialization for burn/donor sites and clean, excised wounds before grafting, and cellular dressings use varied layers for matrix creation.

Synthetic Dressings

• Manage partial-thickness burns/donor sites; are more readily available, less costly, and easier to store than biological dressings, but contain no antimicrobial agents.
• Synthetic and biological dressings provide temporary wound coverage for full/partial-thickness injuries to maintain the wound surface, ready either until a donor site is available, or until the wound is ready for autografting.

Skin Grafts

• Autograft: a skin graft from the patient's unburned skin placed on the clean, excised burn.
  • Split-thickness skin graft (STSG): Includes the epidermis and part of the dermis, and may be applied as a sheet graft or a meshed graft.
    • A sheet graft is used for cosmetic effect on the face, neck, upper chest, breast, or hand, and it is placed on the area as a full sheet
      • A meshed graft is especially useful when a patient's burns are extensive, resulting in few available donor sites. Graft “take,” or vascularization, is complete in about 3 to 5 days. - Full-thickness skin grafts (FTSG): Includes the epidermis and entire dermal layer. It can be a sheet graft or pedicle flap and is used over areas of muscle loss, soft tissue loss, hands, feet, and eyelids, donor sites usually require STSG for closure.
    • A pedicle graft or flap is a skin flap which is attached to an adjacent area in need of grafting.

Donor Sites

• They are considered partial-thickness wounds that heal in 10-14 days. Treatment is provided with semiocclusive dressings (OpSite, Biobrane, Tegaderm) to promote moisture for reduced infection risk and appropriate pain management.

Immobilizing the skin graft

• Dressings may be bulky to assist in immobilization and should not be disturbed with circulation checks and elevation to maintain circulation.

Rehabilitation

• Therapy started during the acute phase continues towards physical and psychosocial function which can take months to years. Correct positioning is critical, as is to avoid contractures, therefore specific exercise programs are implemented.
• Itching may be intense as the burn heals, so it is important to control itching as scratching can impair healing and increase infection.
• Treatment for postburn itching can include pharmacological interventions (antihistamines, gabapentin, and topical anesthetics) and nonpharmacological approaches (pressure, colloidal oatmeal baths, moisturizers, and massage therapy) and can disrupt role function general health and ability to cope. Psychological support from support groups, counselors, and psychiatrists is important.
• Major burn is painful and frightening for the patient and the family, therefore general information to collect includes extent, depth, agent, duration of contact, severity and location of pain, associated injuries, immediate first aid treatment, and psychological information, including other people injured, additional losses (e.g., home, pets), whether the patient was at fault, and how this injury affects the patient's role function.

Inhalation Injury/Electrical Injury/Chemical Burns

• Suspect in fire in enclosed space.
• With electrical ask about voltage, duration of contact, host susceptibility (wet or dry skin), entry and exit sites, and associated falls.
• With chemical determine the type of agent and duration of exposure.

General Nrsg Care Guidelines

• Use caution with heating pads, water temperature, and electrical equipment as burns during hospitalization are considered preventable Never Events.
• For chemical burns, initiate immediate copious tepid water lavage for 20 minutes along with simultaneous removal of contaminated clothing. Do not neutralize chemical because this takes too much time and resulting reaction may generate heat and cause further skin injury.
• If heat is felt on wound, cool with tepid tap water or sterile water, while keeping patient from chilling as depth of injury increases with length of exposure to the burning agent.
• Remove clothing and jewelry.
• Do not apply ice.
• Cover patient with clean sheet or blanket.
• Ensure burn wound is clean and free of wound debris.

Other Nursing DX

• Priority nursing diagnoses include Impaired Gas Exchange related to upper airway edema, carbon monoxide (CO) poisoning, and edema of alveolar capillary membranes, as evidenced by abnormal arterial blood gases (ABGs) and elevated CO level. Expected Outcomes: The patient's gas exchange will be improved as evidenced by patent airway, CO level less than 10%, clear lung sounds, partial pressure of oxygen (PaO2) 80 to 100 mm Hg, partial pressure of carbon dioxide (PaCO2) 35 to 45 mm Hg, oxygen saturation (SpO2) 95%, responsiveness, and awareness. Regular monitoring detects changes in pulmonary function for planning care.
• Impaired Skin Integrity related to thermal injury as evidenced by presence of burn lesions. Expected Outcomes: The patient's skin integrity will be improved as evidenced by the stopping of burning process and healing of burned areas with no infection present.
• Acute Pain related to burns or graft donor sites.

Deficient fluid volume

• Nursing Diagnosis: Deficient Fluid Volume related to evaporative losses from wound, capillary leak, and decreased fluid intake as evidenced by urine output less than 30 to 50 mL per hour, hypotension, tachycardia, and weight loss
• Expected Outcomes: The (adult) patient will maintain adequate circulating volume as evidenced by urine output of 30 to 50 mL/hr, blood pressure within normal limits, heart rate between 60 and 100 beats per minute, and stabilized body weight.
• Record intake and output (I&O) hourly during emergent/acute stages.
• Examine for signs and symptoms of hypovolemia (e.g., hypotension, tachycardia, tachypnea, extreme thirst, restlessness, disorientation).
• Monitor electrolytes and complete blood count (CBC) and report abnormal results to HCP.
• Fluid replacement begins immediately to prevent hypovolemia and administer or monitor IV fluids as ordered via large-bore IV catheter.

Physical mobility and peripheral perfusion

• Nursing Diagnosis: Impaired Physical Mobility related to burn healing, pain, and contractures, so perform active and passive range of motion exercises on affected areas to prevent contractures and hypertrophic scarring.
• Nursing Diagnosis: Ineffective Peripheral Tissue Perfusion related to circumferential burns, blood loss, and decreased cardiac output as evidenced by weak pulses so monitor pulses, capillary refill, sensation, color, swelling, and movement
• In the above scenario, use Doppler ultrasound as needed to detect weak pulses. Monitor for numbness, tingling, and increased pain in burned extremity, as well as elevate burned extremity above level of the heart, and report changes in data findings promptly.

Burn Care - Risk of infection

• Use sterile technique. Immunoglobulins are depressed at time of severe burn injury so vaccines may be depressed.
• Continually monitor for and report signs and symptoms of sepsis.
• Administer systemic antibiotics and topical agents as prescribed.