BURNS: THERMAL/CHEMICAL/ELECTRICAL (ACUTE AND CONVALESCENT PHASES)
Each year, more than 2 million burn injuries occur in the United States; approximately 100,000 people require hospital care. Thermal burns, which are the most common type, occur because of fires, motor vehicle crashes, home fires, hot liquid spills, electrical malfunctions, and war. Survival rates have risen because of newer treatments and skin barrier development; however, moderate and severe burns account for many dollars spent on physical and psychological rehabilitation.
Thermal burns: Injuring agent can be flame, hot liquid, or contact with hot object. Flame burns are associated with smoke/inhalation injury.
Chemical burns: Occur from type/content of injuring agent, as well as concentration and temperature of agent.
Electrical burns: Occur from type/voltage of current that generates heat in proportion to resistance offered and travels the pathway of least resistance (i.e., nerves offer the least resistance and bones the greatest resistance). Underlying injury is more severe than visible injury.
Superficial partial-thickness (first-degree) burns: Involve only the epidermis. Wounds appear bright pink to red with minimal edema and no blisters. The skin is often warm/dry.
Moderate partial-thickness (second-degree) burns: Involve the epidermis and dermis. Wounds appear red to pink with moderate edema and moist, weeping blisters.
Deep partial-thickness (second-degree) burns: Involve the deep dermis. Wounds appear pink to pale ivory with moderate edema and blisters. These wounds are dryer than moderate partial-thickness burns.
Full-thickness (third-degree) burns: Involve all layers of skin, subcutaneous fat, and may involve the muscle, nerves, and blood supply. Wound appearance varies from white to cherry red to brown or black, with blistering uncommon. These wounds have a dry, leathery texture.
Full-thickness (fourth-degree) burns: Involve all skin layers plus muscle, organ tissue, and bone. Charring occurs.
CARE SETTING
The following adult patients are admitted for acute care and during the rehabilitation phase may be cared for in a subacute or rehabilitation unit: those with partial-thickness burns more than 15% total body surface area (TBSA) or whose age is considered high risk (older than 65 years of age); full-thickness burns more than 2% of TBSA; burns of face, both hands, perineum, or both feet; or inhalation and all electrical burns.
RELATED CONCERNS
Disaster considerations
Fluid and electrolyte imbalances
Metabolic acidosis (primary base bicarbonate deficiency)
Psychosocial aspects of care
Respiratory acidosis (primary carbonic acid excess)
Sepsis/septicemia
Surgical intervention
Total nutritional support: parenteral/enteral feeding
Upper gastrointestinal/esophageal bleeding
Patient Assessment Database
Data depend on type, severity, and body surface area involved.
ACTIVITY/REST
May exhibit:
Decreased strength, endurance
Limited range of motion (ROM) of involved areas
Impaired muscle mass, altered tone
CIRCULATION
May exhibit
Hypotension (shock)
(with burn injury Peripheral pulses diminished distal to extremity injury; generalized peripheral
involving more vasoconstriction with loss of pulses, mottling of skin, and coolness (electrical shock) than 20% TBSA): Tachycardia (shock/anxiety/pain)
Dysrhythmias (electrical shock)
Tissue edema formation (all burns)
EGO INTEGRITY
May report:
Feeling scared, self-conscious, conspicuous, angry, embarrassed, different
Concerns about family, job, finances, disfigurement
May exhibit:
Anxiety, crying, dependency, denial, withdrawal, hostility, aggressive behavior
ELIMINATION
May exhibit:
Urinary output decreased/absent during emergent phase; color may be pink (hemochromogens from damaged red blood cells [RBCs]) or reddish black if myoglobin present, indicating deep-muscle damage
Diuresis (after capillary leak sealed and fluids mobilized back into circulation)
Bowel sounds decreased/absent, especially in cutaneous burns of more than 20%, because stress reduces gastric motility/peristalsis
FOOD/FLUID
May exhibit:
Generalized tissue edema (swelling is rapid and may be extreme in early hours after injury)
Anorexia, nausea/vomiting
NEUROSENSORY
May report:
Mixed areas of numbness, tingling, burning pain
Changes in vision, decreased visual acuity (electrical shock)
May exhibit:
Changes in orientation, affect, behavior
Decreased deep tendon reflexes (DTRs), reflexes and sensation in injured extremities
Seizure activity (electrical shock)
Corneal lacerations, retinal damage (electrical shock)
Rupture of tympanic membrane (electrical shock)
Paralysis (electrical injury to nerve pathways)
PAIN/DISCOMFORT
May report:
Pain varies, e.g., first-degree burns are extremely sensitive to touch, pressure, air movement, and temperature changes; second-degree moderate-thickness burns are very painful, whereas pain response in second-degree deep-thickness burns depends on intactness of nerve endings; third-degree burns are painless
RESPIRATION
May report:
Confinement in a closed space, prolonged exposure (possibility of inhalation injury)
May exhibit:
Hoarseness, wheezy cough, carbonaceous particles on face/in sputum, drooling/inability to swallow oral secretions, and cyanosis (indicative of inhalation injury)
Thoracic excursion may be limited in presence of circumferential chest burns
Upper airway stridor/wheezes (obstruction due to laryngospasm, laryngeal edema)
Breath sounds: Crackles (pulmonary edema), stridor (laryngeal edema), profuse airway secretions/ wheezing (rhonchi)
SAFETY
May exhibit:
Skin:
General: Exact depth of tissue destruction may not be evident for 3–5 days because of the process of microvascular thrombosis in some wounds; unburned skin areas may be cool/clammy, pale, with slow capillary refill in the presence of decreasedcardiac output as a result of fluid loss/ shock state
Flame injury: There may be areas of mixed depth of injury because of varied intensity of heat produced by burning clothing; singed nasal hairs; dry, red mucosa of nose and mouth; blisters on posterior pharynx, circumoral and/or circumnasal edema
Chemical injury: Wound appearance varies according to causative agent; skin may be yellowish brown with soft leather-like texture; blisters, ulcers, necrosis, or thick eschar. (Injuries are generally deeper than they appear cutaneously, and tissue destruction can continue for up to 72 hr after injury.)
Electrical injury: The external cutaneous injury is usually much less than the underlying necrosis; appearance of wounds varies and may include entry/exit (explosive) wounds of current, arc burns from current moving in close proximity to body, and thermal burns due to ignition of clothing
Other: Presence of fractures/dislocations (concurrent falls, motor vehicle accident; tetanic muscle contractions due to electrical shock)
TEACHING/LEARNING
Discharge plan considerations:
DRG projected mean length of inpatient stay: dependent on burn percentage and specific surgical procedure(s) required
May require assistance with treatments, wound care/supplies, self-care activities, homemaker/maintenance tasks, transportation, finances, vocational counseling
Changes in physical layout of home or living facility other than home during prolonged rehabilitation
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Complete blood count (CBC): Initial increased hematocrit (Hct) suggests hemoconcentration due to fluid shift/loss. Later decreased Hct and RBCs may occur because of heat damage to vascular endothelium. Leukocytosis (decreased white blood cells [WBCs]) can occur because of loss of cells at wound site and inflammatory response to injury.
Arterial blood gases (ABGs): Baseline especially important with suspicion of inhalation injury. Reduced Pao2/increased Paco2 may be seen with carbon monoxide retention. Acidosis may occur because of reduced renal function and loss of compensatory respiratory mechanisms.
Carboxyhemoglobin (COHb): Elevation of more than 15% indicates carbon monoxide poisoning/inhalation injury.
Serum electrolytes: Potassium level may be initially elevated because of injured tissues/RBC destruction and decreased renal function; hypokalemia can occur when diuresis starts; magnesium level may be decreased. Sodium level may initially be decreased with body water losses; hypernatremia can occur later as renal conservation occurs.
Alkaline phosphatase: Elevated because of interstitial fluid shifts/impairment of sodium pump.
Serum glucose: Elevation reflects stress response.
Serum albumin: Albumin/globulin ratio may be reversed as a result of loss of protein in edema fluid.
Blood urea nitrogen (BUN)/creatinine (Cr): Elevation reflects decreased renal perfusion/function; however, Cr level can elevate because of tissue injury.
Urine: Presence of albumin, hemoglobin (Hb), and myoglobin indicates deep-tissue damage and protein loss (especially seen with serious electrical burns). Reddish-black color of urine is due to presence of myoglobin.
Random urine sodium: More than 20 mEq/L indicates excessive fluid resuscitation; less than 10 mEq/L suggests inadequate fluid resuscitation.
Wound cultures: May be obtained for baseline data and repeated periodically.
Chest x-ray: May appear normal in early postburn period even with inhalation injury; however, a true inhalation injury presents as infiltrates, often progressing to whiteout on x-ray (adult respiratory distress syndrome [ARDS]).
Fiberoptic bronchoscopy: Useful in diagnosing extent of inhalation injury; findings can include edema, hemorrhage, and/or ulceration of upper respiratory tract.
Flow volume loop: Provides noninvasive assessment of effects/extent of inhalation injury.
Lung scan: May be done to determine extent of inhalation injury.
Electrocardiogram (ECG): Signs of myocardial ischemia/dysrhythmias may occur with electrical burns.
Photographs of burns: Provide documentation of burn-wound and comparative baseline to evaluate healing.
NURSING PRIORITIES
1. Maintain patent airway/respiratory function.
2. Restore hemodynamic stability/circulating volume.
3. Alleviate pain.
4. Prevent complications.
5. Provide emotional support for patient/significant other (SO).
6. Provide information about condition, prognosis, and treatment.
DISCHARGE GOALS
1. Homeostasis achieved.
2. Pain controlled/reduced.
3. Complications prevented/minimized.
4. Dealing with current situation realistically.
5. Condition/prognosis and therapeutic regimen understood.
6. Plan in place to meet needs after discharge.
Each year, more than 2 million burn injuries occur in the United States; approximately 100,000 people require hospital care. Thermal burns, which are the most common type, occur because of fires, motor vehicle crashes, home fires, hot liquid spills, electrical malfunctions, and war. Survival rates have risen because of newer treatments and skin barrier development; however, moderate and severe burns account for many dollars spent on physical and psychological rehabilitation.
Thermal burns: Injuring agent can be flame, hot liquid, or contact with hot object. Flame burns are associated with smoke/inhalation injury.
Chemical burns: Occur from type/content of injuring agent, as well as concentration and temperature of agent.
Electrical burns: Occur from type/voltage of current that generates heat in proportion to resistance offered and travels the pathway of least resistance (i.e., nerves offer the least resistance and bones the greatest resistance). Underlying injury is more severe than visible injury.
Superficial partial-thickness (first-degree) burns: Involve only the epidermis. Wounds appear bright pink to red with minimal edema and no blisters. The skin is often warm/dry.
Moderate partial-thickness (second-degree) burns: Involve the epidermis and dermis. Wounds appear red to pink with moderate edema and moist, weeping blisters.
Deep partial-thickness (second-degree) burns: Involve the deep dermis. Wounds appear pink to pale ivory with moderate edema and blisters. These wounds are dryer than moderate partial-thickness burns.
Full-thickness (third-degree) burns: Involve all layers of skin, subcutaneous fat, and may involve the muscle, nerves, and blood supply. Wound appearance varies from white to cherry red to brown or black, with blistering uncommon. These wounds have a dry, leathery texture.
Full-thickness (fourth-degree) burns: Involve all skin layers plus muscle, organ tissue, and bone. Charring occurs.
CARE SETTING
The following adult patients are admitted for acute care and during the rehabilitation phase may be cared for in a subacute or rehabilitation unit: those with partial-thickness burns more than 15% total body surface area (TBSA) or whose age is considered high risk (older than 65 years of age); full-thickness burns more than 2% of TBSA; burns of face, both hands, perineum, or both feet; or inhalation and all electrical burns.
RELATED CONCERNS
Disaster considerations
Fluid and electrolyte imbalances
Metabolic acidosis (primary base bicarbonate deficiency)
Psychosocial aspects of care
Respiratory acidosis (primary carbonic acid excess)
Sepsis/septicemia
Surgical intervention
Total nutritional support: parenteral/enteral feeding
Upper gastrointestinal/esophageal bleeding
Patient Assessment Database
Data depend on type, severity, and body surface area involved.
ACTIVITY/REST
May exhibit:
Decreased strength, endurance
Limited range of motion (ROM) of involved areas
Impaired muscle mass, altered tone
CIRCULATION
May exhibit
Hypotension (shock)
(with burn injury Peripheral pulses diminished distal to extremity injury; generalized peripheral
involving more vasoconstriction with loss of pulses, mottling of skin, and coolness (electrical shock) than 20% TBSA): Tachycardia (shock/anxiety/pain)
Dysrhythmias (electrical shock)
Tissue edema formation (all burns)
EGO INTEGRITY
May report:
Feeling scared, self-conscious, conspicuous, angry, embarrassed, different
Concerns about family, job, finances, disfigurement
May exhibit:
Anxiety, crying, dependency, denial, withdrawal, hostility, aggressive behavior
ELIMINATION
May exhibit:
Urinary output decreased/absent during emergent phase; color may be pink (hemochromogens from damaged red blood cells [RBCs]) or reddish black if myoglobin present, indicating deep-muscle damage
Diuresis (after capillary leak sealed and fluids mobilized back into circulation)
Bowel sounds decreased/absent, especially in cutaneous burns of more than 20%, because stress reduces gastric motility/peristalsis
FOOD/FLUID
May exhibit:
Generalized tissue edema (swelling is rapid and may be extreme in early hours after injury)
Anorexia, nausea/vomiting
NEUROSENSORY
May report:
Mixed areas of numbness, tingling, burning pain
Changes in vision, decreased visual acuity (electrical shock)
May exhibit:
Changes in orientation, affect, behavior
Decreased deep tendon reflexes (DTRs), reflexes and sensation in injured extremities
Seizure activity (electrical shock)
Corneal lacerations, retinal damage (electrical shock)
Rupture of tympanic membrane (electrical shock)
Paralysis (electrical injury to nerve pathways)
PAIN/DISCOMFORT
May report:
Pain varies, e.g., first-degree burns are extremely sensitive to touch, pressure, air movement, and temperature changes; second-degree moderate-thickness burns are very painful, whereas pain response in second-degree deep-thickness burns depends on intactness of nerve endings; third-degree burns are painless
RESPIRATION
May report:
Confinement in a closed space, prolonged exposure (possibility of inhalation injury)
May exhibit:
Hoarseness, wheezy cough, carbonaceous particles on face/in sputum, drooling/inability to swallow oral secretions, and cyanosis (indicative of inhalation injury)
Thoracic excursion may be limited in presence of circumferential chest burns
Upper airway stridor/wheezes (obstruction due to laryngospasm, laryngeal edema)
Breath sounds: Crackles (pulmonary edema), stridor (laryngeal edema), profuse airway secretions/ wheezing (rhonchi)
SAFETY
May exhibit:
Skin:
General: Exact depth of tissue destruction may not be evident for 3–5 days because of the process of microvascular thrombosis in some wounds; unburned skin areas may be cool/clammy, pale, with slow capillary refill in the presence of decreasedcardiac output as a result of fluid loss/ shock state
Flame injury: There may be areas of mixed depth of injury because of varied intensity of heat produced by burning clothing; singed nasal hairs; dry, red mucosa of nose and mouth; blisters on posterior pharynx, circumoral and/or circumnasal edema
Chemical injury: Wound appearance varies according to causative agent; skin may be yellowish brown with soft leather-like texture; blisters, ulcers, necrosis, or thick eschar. (Injuries are generally deeper than they appear cutaneously, and tissue destruction can continue for up to 72 hr after injury.)
Electrical injury: The external cutaneous injury is usually much less than the underlying necrosis; appearance of wounds varies and may include entry/exit (explosive) wounds of current, arc burns from current moving in close proximity to body, and thermal burns due to ignition of clothing
Other: Presence of fractures/dislocations (concurrent falls, motor vehicle accident; tetanic muscle contractions due to electrical shock)
TEACHING/LEARNING
Discharge plan considerations:
DRG projected mean length of inpatient stay: dependent on burn percentage and specific surgical procedure(s) required
May require assistance with treatments, wound care/supplies, self-care activities, homemaker/maintenance tasks, transportation, finances, vocational counseling
Changes in physical layout of home or living facility other than home during prolonged rehabilitation
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Complete blood count (CBC): Initial increased hematocrit (Hct) suggests hemoconcentration due to fluid shift/loss. Later decreased Hct and RBCs may occur because of heat damage to vascular endothelium. Leukocytosis (decreased white blood cells [WBCs]) can occur because of loss of cells at wound site and inflammatory response to injury.
Arterial blood gases (ABGs): Baseline especially important with suspicion of inhalation injury. Reduced Pao2/increased Paco2 may be seen with carbon monoxide retention. Acidosis may occur because of reduced renal function and loss of compensatory respiratory mechanisms.
Carboxyhemoglobin (COHb): Elevation of more than 15% indicates carbon monoxide poisoning/inhalation injury.
Serum electrolytes: Potassium level may be initially elevated because of injured tissues/RBC destruction and decreased renal function; hypokalemia can occur when diuresis starts; magnesium level may be decreased. Sodium level may initially be decreased with body water losses; hypernatremia can occur later as renal conservation occurs.
Alkaline phosphatase: Elevated because of interstitial fluid shifts/impairment of sodium pump.
Serum glucose: Elevation reflects stress response.
Serum albumin: Albumin/globulin ratio may be reversed as a result of loss of protein in edema fluid.
Blood urea nitrogen (BUN)/creatinine (Cr): Elevation reflects decreased renal perfusion/function; however, Cr level can elevate because of tissue injury.
Urine: Presence of albumin, hemoglobin (Hb), and myoglobin indicates deep-tissue damage and protein loss (especially seen with serious electrical burns). Reddish-black color of urine is due to presence of myoglobin.
Random urine sodium: More than 20 mEq/L indicates excessive fluid resuscitation; less than 10 mEq/L suggests inadequate fluid resuscitation.
Wound cultures: May be obtained for baseline data and repeated periodically.
Chest x-ray: May appear normal in early postburn period even with inhalation injury; however, a true inhalation injury presents as infiltrates, often progressing to whiteout on x-ray (adult respiratory distress syndrome [ARDS]).
Fiberoptic bronchoscopy: Useful in diagnosing extent of inhalation injury; findings can include edema, hemorrhage, and/or ulceration of upper respiratory tract.
Flow volume loop: Provides noninvasive assessment of effects/extent of inhalation injury.
Lung scan: May be done to determine extent of inhalation injury.
Electrocardiogram (ECG): Signs of myocardial ischemia/dysrhythmias may occur with electrical burns.
Photographs of burns: Provide documentation of burn-wound and comparative baseline to evaluate healing.
NURSING PRIORITIES
1. Maintain patent airway/respiratory function.
2. Restore hemodynamic stability/circulating volume.
3. Alleviate pain.
4. Prevent complications.
5. Provide emotional support for patient/significant other (SO).
6. Provide information about condition, prognosis, and treatment.
DISCHARGE GOALS
1. Homeostasis achieved.
2. Pain controlled/reduced.
3. Complications prevented/minimized.
4. Dealing with current situation realistically.
5. Condition/prognosis and therapeutic regimen understood.
6. Plan in place to meet needs after discharge.
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