26
Burns
Cecilia Bidigare
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Coping Nutrition
Fluids and Electrolytes Pain
Gas Exchange Perfusion
Infection Tissue Integrity
LEARNING OUTCOMES
1. Relate the causes of burns to prevention strategies for burn 6. Outline the nutrition needs of the burn patient.
injuries. 7. Compare burn wound care techniques and surgical
2. Distinguish between partial-thickness and full-thickness options for partial-thickness and full-thickness burn
burns. wounds.
3. Apply tools used to determine the severity of burns. 8. Prioritize nursing interventions in the management of the
4. Compare the pathophysiology, clinical manifestations, burn patient’s physiologic and psychosocial needs.
complications, and interprofessional care throughout the 3 9. Examine the physiologic and psychosocial aspects of burn
burn phases. rehabilitation.
5. Compare the fluid and electrolyte shifts during the 10. Develop a plan of care to prepare the burn patient and
emergent and acute burn phases. caregiver for discharge.
KEY TERMS
chemical burns excision
debridement full-thickness burns
electrical burns inhalation injuries
eschar partial-thickness burns
escharotomy thermal burns
The focus of this chapter is the nursing care of patients with often have anxiety when anticipating painful dressing changes.
burn injuries. Heat, chemicals, electric current, or radiation Coping with pain daily can affect the patient physically and
can cause significant burns. Injury severity ranges from mild to mentally. Others fear possible permanent lifestyle changes and
life-threatening. Patients with less serious burns are managed in disfigurement.
outpatient clinics. Those with major burn injuries will require The needs of patients with major burns are extensive. They
prolonged hospitalization in a specialty burn center. require the expertise of many health care team members. These
A burn injury affects many body systems. A patient exposed include nurses, health care providers (HCP), occupational (OT)
to smoke may have problems with gas exchange. Expect to see and physical (PT) therapists, dietitians, social workers, psychol-
fluid and electrolyte imbalances. Full-thickness burns can alter ogists, and clergy. Nurses caring for burn patients usually have
perfusion to limbs. Patients with burns are at risk for malnu- extensive specialized training. Providing care to burn patients
trition and immobility. Infection is a constant threat. The most can be emotionally and physically challenging. However, it is
common cause of death after a major burn injury is multiple very rewarding to work as a burn team member and contribute
organ dysfunction syndrome as a response to sepsis. to the recovery of patients with devastating injuries.
Patients and caregivers often experience overwhelming An estimated 486,000 Americans seek medical care each
emotions, including fear, anger, guilt, or depression. Patients year for burns.1 Around 40,000 people are hospitalized, with
494
, CHAPTER 26 Burns 495
TABLE 26.1 Common Sources of Burn TABLE 26.2 PROMOTING POPULATION
Injury HEALTH
Home Hazards Strategies to Reduce Burn Injury in Homes
Bathroom and Kitchen
• Water heaters set at 120°F (60°C) or higher • Install and maintain smoke alarms in your home—on every floor and near
• Microwaved food all rooms family members sleep in. Test your smoke alarms once a month to
• Steam, hot grease, or liquids from cooking make sure they are working properly. Use long-life batteries when possible.
• Create and practice a family fire escape plan. Involve kids in the planning.
General Household Make sure everyone knows at least 2 ways out of every room. Identify a
• Carelessness with cigarettes, matches, candles central meeting place outside.
• Heat lamps • Use safe cooking practices, such as never leaving food unattended on the
• Fireplaces (e.g., gas, wood) stove. Supervise or restrict children’s use of stoves, ovens, and especially
• Flammables (e.g., starter fluid, gasoline, kerosene) microwaves.
• Frayed or defective wiring • Set your water heater’s thermostat to 120°F or lower.
• Multiple extension cords per outlet • Store chemicals in approved, labeled containers
• Open space heaters • Replace or repair frayed wiring.
• Outdoor grills (e.g., propane, charcoal) • Avoid outdoor activities during electrical (e.g., lightning) storms.
• Ensure the electrical power source is off before beginning repairs.
Occupational Hazards • Never use gasoline or other flammable liquids to start a fire.
• Cement • Never leave candles unattended or near open windows or curtains.
• Chemicals • Consider a flame-retardant smoking apron for older or “at-risk” people.
• Combustible fuels • Before placing a child in the bath or getting in the bath yourself, test the
• Electricity from power lines water.
• Fertilizers, pesticides • Have a “kid-free zone” of at least 3 feet around the stove and areas where
• Hot metals hot food or drink is prepared or carried.
• Sparks from live electric sources • Never hold a child while you are cooking, drinking a hot liquid, or carrying
• Steam pipes hot foods or liquids.
• Tar
For example, severe injury can occur with exposure to lye
60% receiving care in specialized burn centers. About 3275 and sulfuric acid, common chemicals used to unclog sinks
Americans die each year from their injuries. Worldwide, over 11 in homes. Exposure to wet cement, oven cleaners, and heavy
million people seek medical attention annually for burn injuries, industrial cleaners can cause chemical burns. Chemicals such
and about 180,000 die.2 Although burn injuries in the United as phenols (chemical disinfectants) and petroleum products
States have decreased over the past 20 years, injuries still occur, (creosote and gasoline) cause not only external burns but
often to those living in low- and middle-income counties.3 also systemic toxicity. Acid chemicals cause tissue necrosis.
Most burn accidents are preventable when safety policies are Alkaline chemicals cause liquefaction necrosis, which can be
in place. Coordinated national burn prevention programs in more damaging. Some chemicals will have heat-producing
higher-income countries have focused on child-resistant light- reactions once exposed to the skin, causing superficial blisters
ers, tap water anti-scald devices, stricter building codes, hav- or even deep burns.
ing smoke detectors, and burn safety education curriculums in
schools.4 As a nurse, you can advocate for and teach about burn Electrical Burns
prevention strategies (Tables 26.1 and 26.2). Electrical burns result from the intense heat generated from an
electric current. Direct damage to nerves and vessels can cause
TYPES OF BURN INJURY tissue anoxia and cell death. The severity of an electrical injury
depends on the voltage, tissue resistance, current pathways, sur-
Thermal Burns face area in contact with the current, and length of time that
Thermal burns are due to exposure to external heat sources the current flow was sustained (Fig. 26.1). Current that passes
such as hot metals, scalding liquids, steam, or flames. The sever- through vital organs (e.g., brain, heart, kidneys) causes more
ity of the injury depends on the temperature of the burning life-threatening sequela when compared to a current passing
agent and duration of skin contact. This is the most common through other tissues. The severity of an electrical injury can be
type of burn injury. Causes of thermal injury include grease fires hard to determine initially since most of the damage is below
when cooking, house fires, smoking, and the use of gasoline for the skin.
cleaning or incineration. Contact with an electric current can cause muscle contrac-
tions strong enough to fracture the long bones and vertebrae.
Chemical Burns Forceful propulsion of the body from an electrical source can
Contact with acids, alkalines, or organic compounds can cause cause injuries such as spinal and limb fractures. For this rea-
chemical burns through absorption, inhalation, or ingestion. son, consider cervical spine injury for all patients with electrical
Dangerous chemicals are in homes, businesses, and industries. burns.
, 496 SECTION 5 Problems Related to Altered Sensory Input
TABLE 26.3 Burn Center Referral Criteria
Burn injuries that should be referred to a burn center include the following:
• Partial-thickness burns greater than 10% total body surface area (TBSA)
• Burns that involve the face, hands, feet, genitalia, perineum, or major
joints
• Third-degree burns in any age-group
• Electrical burns, including lightning injury
• Chemical burns
• Inhalation injury
• Injury in patients with preexisting medical disorders that could complicate
management, prolong recovery, or affect mortality
• Any patient with burns and concomitant trauma (e.g., fractures) in which
the burn injury poses the greatest risk for morbidity or mortality. In such
cases, if the trauma poses a greater immediate risk, the patient may be
stabilized in a trauma center before being transferred to a burn unit. HCP
A B judgment is necessary in such situations and would be in concert with the
regional medical control plan and triage protocols.
• Burned children in hospitals without qualified personnel or equipment for
the care of children
• Burn injury in patients who will need special social, emotional, or rehabili-
tative intervention
Source: American Burn Association: Guidelines for the operation
of burn centers. Retrieved from http://ameriburn.org/wp-content/
uploads/2017/05/burncenterreferralcriteria.pdf.
and dermis, and (4) blood supply to the area. Burn injury
is determined according to the extent of injury through the
epidermis, dermis, and underlying structures. One method
describes an injury as first, second, third, or fourth degree.
C The ABA recommends using the terms partial-thickness burns
Fig. 26.1 Types of burn injury. (A) Superficial, partial-thickness scald and full-thickness burns to classify burns (Figs. 26.2 and 26.3).
burn to the thigh. (B) Deep, partial-thickness flame burn to the hand. Partial-thickness burns involve the epidermis and sometimes
(C) Full-thickness flame burn to posterior chest and arm. (Courtesy Judy part of the dermis. A full-thickness injury occurs if the epi-
Knighton, Toronto, Canada.) dermis and dermis are destroyed. Eschar is another name for
full-thickness nonviable burn tissue. Burns can extend beyond
Electrical injury puts the patient at risk for respiratory arrest, the skin and involve tendons, ligaments, muscle, and adipose.
severe metabolic acidosis, and myoglobinuria. An electric shock Table 26.4 compares the various burn classifications according
can cause immediate cardiac standstill or ventricular fibrillation. to the depth of injury
Massive muscle and blood vessel damage can release myoglobin
from injured muscle and hemoglobin from damaged red blood Extent of Burn
cells (RBCs). Myoglobin can block the renal tubules resulting in Nurses are responsible for estimating the extent of burn injury.
acute kidney injury (AKI; see Chapter 51). The Lund-Browder chart (Fig. 26.4A) and the Rule of Nines (Fig.
26.4B) are common methods used to determine burn TBSA. We
Cold Thermal Injury often use the Rule of 9’s for initial adult triage. Use the Lund-
Cold thermal injury, or frostbite, is discussed in Chapter 21. Browder formula for children because it considers the patient’s
age in proportion to relative body-area size. Electronic tools
(e.g., the Sage Burn Diagram at www.sagediagram.com) and
CLASSIFICATION OF BURN INJURY mobile applications (e.g., BurnMed, Mersey Burns) are available
Severity is determined by (1) depth of burn, (2) extent of burn for estimating TBSA.
calculated in percent of total body surface area (TBSA), (3) loca-
tion of the burn, (4) preexisting health issues, and (5) associated Location of Burn
injuries. The American Burn Association (ABA) provides refer- The location of the burn injury influences the severity. Face,
ral criteria based on injury severity to determine which patients neck, and circumferential torso burns may interfere with gas
need specialized treatment in a burn center (Table 26.3).5 exchange. Circumferential leathery eschar can restrict chest
movement. Edema from inflammation and fluid resuscitation
Burn Depth Classification can narrow the airway.
Four factors influence burn depth: (1) temperature of the Hand, foot, and joint burns can limit mobility and func-
agent, (2) duration of contact, (3) thickness of the epidermis tion. Full-thickness circumferential extremity burns can impair
Burns
Cecilia Bidigare
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Coping Nutrition
Fluids and Electrolytes Pain
Gas Exchange Perfusion
Infection Tissue Integrity
LEARNING OUTCOMES
1. Relate the causes of burns to prevention strategies for burn 6. Outline the nutrition needs of the burn patient.
injuries. 7. Compare burn wound care techniques and surgical
2. Distinguish between partial-thickness and full-thickness options for partial-thickness and full-thickness burn
burns. wounds.
3. Apply tools used to determine the severity of burns. 8. Prioritize nursing interventions in the management of the
4. Compare the pathophysiology, clinical manifestations, burn patient’s physiologic and psychosocial needs.
complications, and interprofessional care throughout the 3 9. Examine the physiologic and psychosocial aspects of burn
burn phases. rehabilitation.
5. Compare the fluid and electrolyte shifts during the 10. Develop a plan of care to prepare the burn patient and
emergent and acute burn phases. caregiver for discharge.
KEY TERMS
chemical burns excision
debridement full-thickness burns
electrical burns inhalation injuries
eschar partial-thickness burns
escharotomy thermal burns
The focus of this chapter is the nursing care of patients with often have anxiety when anticipating painful dressing changes.
burn injuries. Heat, chemicals, electric current, or radiation Coping with pain daily can affect the patient physically and
can cause significant burns. Injury severity ranges from mild to mentally. Others fear possible permanent lifestyle changes and
life-threatening. Patients with less serious burns are managed in disfigurement.
outpatient clinics. Those with major burn injuries will require The needs of patients with major burns are extensive. They
prolonged hospitalization in a specialty burn center. require the expertise of many health care team members. These
A burn injury affects many body systems. A patient exposed include nurses, health care providers (HCP), occupational (OT)
to smoke may have problems with gas exchange. Expect to see and physical (PT) therapists, dietitians, social workers, psychol-
fluid and electrolyte imbalances. Full-thickness burns can alter ogists, and clergy. Nurses caring for burn patients usually have
perfusion to limbs. Patients with burns are at risk for malnu- extensive specialized training. Providing care to burn patients
trition and immobility. Infection is a constant threat. The most can be emotionally and physically challenging. However, it is
common cause of death after a major burn injury is multiple very rewarding to work as a burn team member and contribute
organ dysfunction syndrome as a response to sepsis. to the recovery of patients with devastating injuries.
Patients and caregivers often experience overwhelming An estimated 486,000 Americans seek medical care each
emotions, including fear, anger, guilt, or depression. Patients year for burns.1 Around 40,000 people are hospitalized, with
494
, CHAPTER 26 Burns 495
TABLE 26.1 Common Sources of Burn TABLE 26.2 PROMOTING POPULATION
Injury HEALTH
Home Hazards Strategies to Reduce Burn Injury in Homes
Bathroom and Kitchen
• Water heaters set at 120°F (60°C) or higher • Install and maintain smoke alarms in your home—on every floor and near
• Microwaved food all rooms family members sleep in. Test your smoke alarms once a month to
• Steam, hot grease, or liquids from cooking make sure they are working properly. Use long-life batteries when possible.
• Create and practice a family fire escape plan. Involve kids in the planning.
General Household Make sure everyone knows at least 2 ways out of every room. Identify a
• Carelessness with cigarettes, matches, candles central meeting place outside.
• Heat lamps • Use safe cooking practices, such as never leaving food unattended on the
• Fireplaces (e.g., gas, wood) stove. Supervise or restrict children’s use of stoves, ovens, and especially
• Flammables (e.g., starter fluid, gasoline, kerosene) microwaves.
• Frayed or defective wiring • Set your water heater’s thermostat to 120°F or lower.
• Multiple extension cords per outlet • Store chemicals in approved, labeled containers
• Open space heaters • Replace or repair frayed wiring.
• Outdoor grills (e.g., propane, charcoal) • Avoid outdoor activities during electrical (e.g., lightning) storms.
• Ensure the electrical power source is off before beginning repairs.
Occupational Hazards • Never use gasoline or other flammable liquids to start a fire.
• Cement • Never leave candles unattended or near open windows or curtains.
• Chemicals • Consider a flame-retardant smoking apron for older or “at-risk” people.
• Combustible fuels • Before placing a child in the bath or getting in the bath yourself, test the
• Electricity from power lines water.
• Fertilizers, pesticides • Have a “kid-free zone” of at least 3 feet around the stove and areas where
• Hot metals hot food or drink is prepared or carried.
• Sparks from live electric sources • Never hold a child while you are cooking, drinking a hot liquid, or carrying
• Steam pipes hot foods or liquids.
• Tar
For example, severe injury can occur with exposure to lye
60% receiving care in specialized burn centers. About 3275 and sulfuric acid, common chemicals used to unclog sinks
Americans die each year from their injuries. Worldwide, over 11 in homes. Exposure to wet cement, oven cleaners, and heavy
million people seek medical attention annually for burn injuries, industrial cleaners can cause chemical burns. Chemicals such
and about 180,000 die.2 Although burn injuries in the United as phenols (chemical disinfectants) and petroleum products
States have decreased over the past 20 years, injuries still occur, (creosote and gasoline) cause not only external burns but
often to those living in low- and middle-income counties.3 also systemic toxicity. Acid chemicals cause tissue necrosis.
Most burn accidents are preventable when safety policies are Alkaline chemicals cause liquefaction necrosis, which can be
in place. Coordinated national burn prevention programs in more damaging. Some chemicals will have heat-producing
higher-income countries have focused on child-resistant light- reactions once exposed to the skin, causing superficial blisters
ers, tap water anti-scald devices, stricter building codes, hav- or even deep burns.
ing smoke detectors, and burn safety education curriculums in
schools.4 As a nurse, you can advocate for and teach about burn Electrical Burns
prevention strategies (Tables 26.1 and 26.2). Electrical burns result from the intense heat generated from an
electric current. Direct damage to nerves and vessels can cause
TYPES OF BURN INJURY tissue anoxia and cell death. The severity of an electrical injury
depends on the voltage, tissue resistance, current pathways, sur-
Thermal Burns face area in contact with the current, and length of time that
Thermal burns are due to exposure to external heat sources the current flow was sustained (Fig. 26.1). Current that passes
such as hot metals, scalding liquids, steam, or flames. The sever- through vital organs (e.g., brain, heart, kidneys) causes more
ity of the injury depends on the temperature of the burning life-threatening sequela when compared to a current passing
agent and duration of skin contact. This is the most common through other tissues. The severity of an electrical injury can be
type of burn injury. Causes of thermal injury include grease fires hard to determine initially since most of the damage is below
when cooking, house fires, smoking, and the use of gasoline for the skin.
cleaning or incineration. Contact with an electric current can cause muscle contrac-
tions strong enough to fracture the long bones and vertebrae.
Chemical Burns Forceful propulsion of the body from an electrical source can
Contact with acids, alkalines, or organic compounds can cause cause injuries such as spinal and limb fractures. For this rea-
chemical burns through absorption, inhalation, or ingestion. son, consider cervical spine injury for all patients with electrical
Dangerous chemicals are in homes, businesses, and industries. burns.
, 496 SECTION 5 Problems Related to Altered Sensory Input
TABLE 26.3 Burn Center Referral Criteria
Burn injuries that should be referred to a burn center include the following:
• Partial-thickness burns greater than 10% total body surface area (TBSA)
• Burns that involve the face, hands, feet, genitalia, perineum, or major
joints
• Third-degree burns in any age-group
• Electrical burns, including lightning injury
• Chemical burns
• Inhalation injury
• Injury in patients with preexisting medical disorders that could complicate
management, prolong recovery, or affect mortality
• Any patient with burns and concomitant trauma (e.g., fractures) in which
the burn injury poses the greatest risk for morbidity or mortality. In such
cases, if the trauma poses a greater immediate risk, the patient may be
stabilized in a trauma center before being transferred to a burn unit. HCP
A B judgment is necessary in such situations and would be in concert with the
regional medical control plan and triage protocols.
• Burned children in hospitals without qualified personnel or equipment for
the care of children
• Burn injury in patients who will need special social, emotional, or rehabili-
tative intervention
Source: American Burn Association: Guidelines for the operation
of burn centers. Retrieved from http://ameriburn.org/wp-content/
uploads/2017/05/burncenterreferralcriteria.pdf.
and dermis, and (4) blood supply to the area. Burn injury
is determined according to the extent of injury through the
epidermis, dermis, and underlying structures. One method
describes an injury as first, second, third, or fourth degree.
C The ABA recommends using the terms partial-thickness burns
Fig. 26.1 Types of burn injury. (A) Superficial, partial-thickness scald and full-thickness burns to classify burns (Figs. 26.2 and 26.3).
burn to the thigh. (B) Deep, partial-thickness flame burn to the hand. Partial-thickness burns involve the epidermis and sometimes
(C) Full-thickness flame burn to posterior chest and arm. (Courtesy Judy part of the dermis. A full-thickness injury occurs if the epi-
Knighton, Toronto, Canada.) dermis and dermis are destroyed. Eschar is another name for
full-thickness nonviable burn tissue. Burns can extend beyond
Electrical injury puts the patient at risk for respiratory arrest, the skin and involve tendons, ligaments, muscle, and adipose.
severe metabolic acidosis, and myoglobinuria. An electric shock Table 26.4 compares the various burn classifications according
can cause immediate cardiac standstill or ventricular fibrillation. to the depth of injury
Massive muscle and blood vessel damage can release myoglobin
from injured muscle and hemoglobin from damaged red blood Extent of Burn
cells (RBCs). Myoglobin can block the renal tubules resulting in Nurses are responsible for estimating the extent of burn injury.
acute kidney injury (AKI; see Chapter 51). The Lund-Browder chart (Fig. 26.4A) and the Rule of Nines (Fig.
26.4B) are common methods used to determine burn TBSA. We
Cold Thermal Injury often use the Rule of 9’s for initial adult triage. Use the Lund-
Cold thermal injury, or frostbite, is discussed in Chapter 21. Browder formula for children because it considers the patient’s
age in proportion to relative body-area size. Electronic tools
(e.g., the Sage Burn Diagram at www.sagediagram.com) and
CLASSIFICATION OF BURN INJURY mobile applications (e.g., BurnMed, Mersey Burns) are available
Severity is determined by (1) depth of burn, (2) extent of burn for estimating TBSA.
calculated in percent of total body surface area (TBSA), (3) loca-
tion of the burn, (4) preexisting health issues, and (5) associated Location of Burn
injuries. The American Burn Association (ABA) provides refer- The location of the burn injury influences the severity. Face,
ral criteria based on injury severity to determine which patients neck, and circumferential torso burns may interfere with gas
need specialized treatment in a burn center (Table 26.3).5 exchange. Circumferential leathery eschar can restrict chest
movement. Edema from inflammation and fluid resuscitation
Burn Depth Classification can narrow the airway.
Four factors influence burn depth: (1) temperature of the Hand, foot, and joint burns can limit mobility and func-
agent, (2) duration of contact, (3) thickness of the epidermis tion. Full-thickness circumferential extremity burns can impair
