Burn Injury Severity and Nursing Care

Learning Objectives

• Learners will be able to identify the incidence and factors affecting burn injury severity in the US.
• Learners will be able to describe the local and systemic effects of major burn injuries.
• Learners will use the nursing process to provide care for burn patients during emergent/resuscitative, acute/intermediate, and rehabilitative phases.
• Learners will compare priorities of care, including fluid replacement, wound management, and other concerns.

Introduction

• All adults experience burn injury at some point.
• Burn injuries are painful, costly, disfiguring, and require extensive rehabilitation.
• Large burns have high morbidity and mortality.
• Burn injuries can affect people of all ages and socioeconomic backgrounds.
• Burn patients have longer hospital stays.
• Men experience burn injuries more than women.
• Overall mortality from burns is 2.9%.

Incidence

• Flame burns contribute to 41% of burn cases.
• Scald burns make up 35% of burn cases.
• Direct contact accounts for 10%.
• Electrical burns account for 3%.
• Chemical burns account for 3%.
• Inhalation burns account for 3%.
• Other causes account for 5%.

Gerontologic Considerations

• Mortality from burns is higher in older adults.
• Older adult skin is thinner and less elastic, impacting injury depth and healing.
• Older burn patients have a higher risk of complications including pneumonia, respiratory failure, septicemia, cellulitis, wound infections, kidney injury, arrhythmias, and other hospital-acquired infections.

Prevention

• Most burn injuries are preventable.

Outlook for Survival and Recovery

• Age, depth, extent of body burned, inhalation injury presence, other injuries, and comorbid conditions influence burn injury severity.
• Young children and older adults have higher morbidity and mortality rates when compared to other age ranges.
• Burn depth is determined by the degree of tissue destruction.

Characteristics of Burns According to Depth

• First-degree (superficial): Includes sunburn, characterized by redness, blanching with pressure, minimal edema. Healing is complete in a few days.
• Second-degree (partial thickness): Includes scalds and flash flame. Characterized by blisters, mottled red base, and edema. Healing takes 2-3 weeks. Scarring and discoloration are possible.
• Third-degree (full thickness): Characterized by dryness, pale white or charred appearance. Shows coagulated vessels. Requires grafting to heal.
• Fourth-degree (full thickness deep tissue): Involves fat, fascia, muscle, or bone. Requires grafting and amputations, if possible, are likely. Healing is more challenging and is not easily achievable without further intervention.

Outlook for Survival and Recovery (continued)

• Extent of body surface area injured is measured using methods like the Rule of Nines, Lund and Browder method, and the Palmer method.

Pathophysiology

• Burn injury results from chemical or heat transfer causing tissue damage.
• The depth of the injury depends on burn agent temperature and contact time.
• The zones of burn injury include coagulation, stasis, and hyperemia.
• Burns exceeding one-third TBSA result in major injuries accompanied by local and systemic inflammatory responses.
• Initial systemic events after major burn injuries include hemodynamic instability caused by capillary leakage and fluid shifts.
• This can progress into hypovolemic shock.

Pathophysiologic Changes with Severe Burns (Table 57-2)

• Cardiovascular alterations: Cardiac depression, edema, hypovolemia.
• Pulmonary alterations: Vasoconstriction, edema.
• Gastrointestinal alterations: Impaired motility, absorption, vasoconstriction, and mucosal barrier function loss.
• Kidney alterations: Vasoconstriction, altered thermoregulation, and increased metabolic demand.
• Immunologic alterations: Increased susceptibility to infection.
• Thermoregulatory alterations: Hypothermia common in early phase.
• Gastrointestinal alterations: Often include paralytic ileus (absence of intestinal peristalsis), Curling's ulcer, and bacterial translocation.

Pathophysiology (continued)

• Cardiovascular alterations: initial decrease in cardiac output, compensation via vasoconstriction and increased heart rate, hypovolemia due to loss of plasma volume.
• Fluid and electrolyte alterations: Edema formation, often within 4 hours of superficial burns, with deeper burns having up to 18 hours. Edema can necessitate escharotomy and/or fasciotomy; reabsorption occurs approximately 4 days post-burn.
• Pulmonary alterations: Inhalation of smoke or other thermal agents can lead to injury. Signs and symptoms: Singed nasal hair as indicator, hoarseness, stridor, dyspnea, and others.
• Kidney alterations: Muscle damage, particularly by electrical burns, can release myoglobin, which may cause acute tubular necrosis and kidney failure if kidneys can't process and eliminate.
• Immunological alterations: increased risk of sepsis.
• Thermoregulatory alterations: Hypothermia.

Management of Burn Injury–On the Scene

• Remove patient from source of injury.
• Stop burning process, protecting rescuer.
• Establish airway, deliver 100% oxygen.
• Insert IV catheter.
• Cover wound with clean, dry gauze.
• Administer ABCDE (airway, breathing, circulation, disability, and exposure) care.

Management of Burn Injury–Medical

• Transport patient to nearest ER.
• Prioritize airway, breathing, and circulation.
• Administer fluid resuscitation for burns exceeding 20% TBSA using lactated Ringer's solution (RL) calculated based on body surface area burned.
• Obtain peripheral IV access.
• Consider escharotomies or fasciotomies as needed.

Nursing Management (Emergent/Resuscitative Phase)

• Establish airway, breathing, circulation, and maintain adequate ventilation.
• Manage fluid and electrolyte imbalances.
• Monitor and maintain body temperature.
• Monitor for and prevent infection.
• Assess, monitor, and support the patient's emotional, psychological, psychological, and spiritual wellbeing.
• Provide adequate pain relief and manage discomfort.
• Prevent complications as identified.

Nursing Management (Acute/Intermediate Phase)

• Prevention of infection.
• Wound cleaning, wound dressings, and wound debridement.
• Remove devitalized tissue and any contamination from damaged tissue to facilitate wound healing.
• Wound grafting as needed.
• Manage pain, including use of pain scales, medications, and other interventions as required.

Nursing Management (Rehabilitative Phase)

• Activity intolerance management in relation to pain.
• Disturbed body image.
• Impaired mobility, due to contractures or hypertrophic scarring.
• Lack of knowledge regarding post-discharge home care and recovery needs.

Monitoring and Managing Potential Complications

• Acute respiratory failure.
• Acute respiratory distress syndrome.
• Heart failure.
• Pulmonary edema.
• Sepsis.
• Delirium

Rehabilitation Phase

• Rehabilitation starts promptly after burns.
• It's a multidisciplinary process focused on physical and psychosocial recovery to return patient to highest possible functional level.
• Rehabilitation phase complications include neuropathic pain, nerve entrapment, wound breakdown, hypertrophic scarring, contractures and impaired joint mobility.