Burns

  1. Types
    1. Thermal: most common type; caused by flame, flash, scalding, and contact (hot metals, grease)
    2. Smoke inhalation: occurs when smoke (particular products of a fire, gases, and superheated air) causes respiratory tissue damage
    3. Chemical: caused by tissue contact, ingestion or inhalation of acids, alkalies, or vesicants
    4. Electrical: injury occurs from direct damage to nerves and vessels when an electric current passes through the body.
  2. Classification
    1. Partial thickness
      1. Superficial partial-thickness (first degree)
        1. depth: epidermis only
        2. causes: sunburn, splashes of hot liquid
        3. sensation: painful
        4. characteristics: erythema, blanching on pressure, no vesicles
      2. Deep partial thickness (second degree)
        1. depth: epidermis and dermis
        2. causes: flash, scalding, or flame burn
        3. sensation: very painful
        4. characteristics: fluid-filled vesicles; red, shiny, wet after vesicles rupture
    2. Full thickness (third and fourth degree)
      1. Depth: all skin layers and nerve endings; may involve muscles, tendons, and bones
      2. Causes: flame, chemicals, scalding, electric current
      3. Sensation: little or no pain
      4. Characteristics: wound is dry, white, leathery, or hard
  3. Medical management
    1. Supportive therapy: fluid management (IVs), catheterization
    2. Wound care: hydrotherapy, debridement (enzymatic or surgical)
    3. Drug therapy
      1. Topical antibiotics: mafenide (Sulfamylon), silver sulfadiazine (Silvadene), silver nitrate, povidone-iodine (Betadine) solution
      2. Systemic antibiotics: gentamicin
      3. Tetanus toxoid or hyperimmune human tetanus globulin (burn wound good medium for anaerobic growth)
      4. Analgesics
    4. Surgery: excision and grafting
  4. Assessment
    1. Extent of burn injury by rule of nines: head and neck (9%); each arm (9%), each leg (18%), trunk (36%), genitalia (1%) (See Figure 4.23)
    2. Lund and Browder method determines the extent of the burn injury by using client's age in proportion to relative body-part size.
    3. Severity of burn
      1. Major: partial thickness greater than 25%; full thickness greater than or equal to 10%
      2. Moderate: partial thickness 15%-25%, full thickness less than 10%
      3. Minor: partial thickness less than 15%; full thickness less than 2%
  5. Stages
    1. Emergent phase
      1. Remove person from source of burn.
        1. thermal: smother burn beginning with the head.
        2. smoke inhalation: ensure patent airway.
        3. chemical: remove clothing that contains chemical; lavage area with copious amounts of water.
        4. electrical: note victim position, identify entry/exit routes, maintain airway.
      2. Wrap in dry, clean sheet or blanket to prevent further contamination of wound and provide warmth.
      3. Assess how and when burn occurred.
      4. Provide IV route if possible.
      5. Transport immediately.
    2. Shock phase (first 24-48 hours)
      1. Plasma to interstitial fluid shift causing hypovolemia; fluid also moves to areas that normally have little or no fluid (third-spacing).
      2. Assessment findings
        1. dehydration, decreased blood pressure, elevated pulse, decreased urine output, thirst
        2. diagnostic tests: hyperkalemia, hyponatremia, elevated hct, metabolic acidosis
    3. Fluid remobilization or diuretic phase (2-5 days postburn)
      1. Interstitial fluid returns to the vascular compartment.
      2. Assessment findings
        1. elevated blood pressure, increased urine output
        2. diagnostic tests: hypokalemia, hyponatremia, metabolic acidosis
    4. Convalescent (Rehabilitation) phase
      1. Starts when diuresis is completed and wound healing and coverage begin.
      2. Assessment findings
        1. dry, waxy-white appearance of full thickness burn changing to dark brown; wet, shiny, and serous exudate in partial thickness
        2. diagnostic test: hyponatremia
  6. Nursing interventions
    1. Provide relief/control of pain.
      1. Administer morphine sulfate IV and monitor vital signs closely.
      2. Administer analgesics/narcotics 30 minutes before wound care.
      3. Position burned areas in proper alignment.
    2. Monitor alterations in fluid and electrolyte balance.
      1. Assess for fluid shifts and electrolyte alterations (see Table 4.5).
      2. Administer IV fluids as ordered (see Table 4.25)
      3. Monitor Foley catheter output hourly (30 ml/hour desired).
      4. Weigh daily.
      5. Monitor circulation status regularly.
      6. Administer/monitor crystalloids/colloids/H2O solutions.
    3. Promote maximal nutritional status.
      1. Monitor tube feedings/TPN if ordered.
      2. When oral intake permitted, provide high-calorie, high-protein, high-carbohydrate diet with vitamin and mineral supplements.
      3. Serve small portions.
      4. Schedule wound care and other treatments at least 1 hour before meals.
    4. Prevent wound infection.
      1. Place client in controlled sterile environment.
      2. Use hydrotherapy for no more than 30 minutes to prevent electrolyte loss.
      3. Observe wound for separation of eschar and cellulitis.
      4. Apply mafenide (Sulfamylon) as ordered.
        1. administer analgesics 30 minutes before application.
        2. monitor acid-base status and renal function studies.
        3. provide daily tubbing for removal of previously applied cream.
      5. Apply silver sulfadiazine (Silvadene) as ordered.
        1. administer analgesics 30 minutes before application.
        2. observe for and report hypersensitivity reactions (rash, itching, burning sensation in unburned areas).
        3. store drug away from heat.
      6. Apply silver nitrate as ordered.
        1. handle carefully; solution leaves a gray or black stain on skin, clothing, and utensils.
        2. administer analgesic before application.
        3. keep dressings wet with solution; dryness increases the concentration and causes precipitation of silver salts in the wound.
      7. Apply povidone-iodine (Betadine) solution as ordered.
        1. administer analgesics before application.
        2. assess for metabolic acidosis/renal function studies.
      8. Administer gentamicin as ordered: assess vestibular/auditory and renal functions at regular intervals.
    5. Prevent GI complications.
      1. Assess for signs and symptoms of paralytic ileus.
      2. Assist with insertion of NG tube to prevent/control Curling's/stress ulcer; monitor patency/drainage.
      3. Administer prophylactic antacids through NG tube and/or IV cimetidine (Tagamet) or ranitidine (Zantac) (to prevent gastric pH of less than 5).
      4. Monitor bowel sounds.
      5. Test stools for occult blood.
    6. Provide client teaching and discharge planning concerning
      1. Care of healed burn wound
        1. assess daily for changes.
        2. wash hands frequently during dressing change.
        3. wash area with prescribed solution or mild soap and rinse well with H2O; dry with clean towel.
        4. apply sterile dressing.
      2. Prevention of injury to burn wound
        1. avoid trauma to area.
        2. avoid use of fabric softeners or harsh detergents (might cause irritation).
        3. avoid constrictive clothing over burn wound.
      3. Adherence to prescribed diet
      4. Importance of reporting formation of blisters, opening of healed area, increased or foul-smelling drainage from wound, other signs of infection
      5. Methods of coping and resocialization


TABLE 4.25 Guidelines and Formulas for Fluid Replacement for Burns

Consensus Formula

Evans Formula

Brooke Army Formula

Parkland/Baxter Formula

Lactated Ringer's: 2-4 ml x wt. in kg x % body surface area (BSA) burned. Half to be given in first 8 hrs after burn; remaining fluid to be given over next 16 hrs.

1. Colloids: 1 ml x wt. kg x % BSA burned
2. Electrolytes (saline): 1 ml x wt. kg x % BSA burned
3. Glucose (5% in water): 2000 ml for insensible loss
Day 1: Half to be given in first 8 hrs; remaining half over next 16 hrs.
Day 2: Half of previous day's colloids and electrolytes; all of insensible fluid replacement
Maximum of 10,000 ml over 24 hours.
Second and third degree burns exceeding 50% BSA calculated on basis of 50% BSA

1. Colloids: 0.5 ml x wt, kg x % BSA burned
2. Electrolytes (lactated Ringer's): 1.5 ml x wt, kg x % BSA burned
3. Glucose (5% in water): 2000 ml for insensible loss
Day 1: Half to be given in first 8 hrs; remaining half over next 16 hrs.
Day 2: Half of colloids, half of electrolytes, all of insensible fluid replacement
Second and third degree burns exceeding 50% BSA calculated on basis of 50% BSA.

Lactated Ringer's: 4 ml x wt, kg x % BSA burned.
Day 1: Half to be given in first 8 hours; half to be given over next 16 hours
Day 2: Varies; colloid is added.



  1. For children, the rule of nines is modified; the head of a small child is 18%-19%, the trunk 32%, each leg 15%, each arm 9 1/2%.
  2. Burns in infants and toddlers are frequently due to spills (pulling hot fluids on them or falling into hot baths); for older children, flame burns are more frequent.

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