Burn Injuries

In this lesson we’re going to talk about burn injuries. Now this is one of my favorite things to talk about, because I was blessed to have the opportunity to work in the burn ICU at Parkland Hospital in Dallas, which is where a huge amount of burn treatment research has been done over the years. If you don’t work at a burn unit you may not see as much of this, but I want to give you the most important things that you need to know to be successful in nursing school, on the NCLEX, and when you start working as a nurse.

I’m sure you’re all generally familiar with what a burn is, it is damaged to the skin due to some source of heat or chemical activity. There’s actually four types of burns, one is a thermal burn which is the most common. This is caused by fire or by touching something hot. The second type is a radiation burn, obviously caused by radiation. A sunburn is a good example of this. You could also get a chemical burn from caustic chemicals. Anything that is too acidic or to alkaline can cause serious chemical burns. And you could also get an electrical burn from an electrical shock. The biggest problem with any kind of burn, is that we’re losing the benefits of the skin in that area. The skin is our number one protector against infection, and our number one regulator of temperature. So these patients are at high risk for infection, as well as severe hypothermia. The other problem we see in Burns is that the inflammatory process can cause what’s known as a capillary leak. This literally means the capillaries are leaking fluid. This fluid could leak out into third spaces like the extremities or the abdomen, or out of the wound itself. So patients are at risk for hypovolemia as well.

You are probably relatively familiar with the degrees of burns, but let’s review them really quickly. A first degree burn is red and painful skin that is typically intact. This could be from a sunburn, or something I’ve experienced a few times when I touch my curling iron to my neck or splash boiling water on my hand. A second degree burn is a partial thickness burn, meaning it goes through the epidermis down to the dermis, it can involve broken skin or blisters and it’s typically pink or red and painful. Third degree burns are full thickness Burns which means the burn extends through the dermis. Because the nerve endings are in the dermis, and have now been burned and damaged, 3rd degree burns are often painless for patients. What we will see is essentially dead tissue, and it presents as either white or black eschar which has a thick leathery appearance. So you can see the white in the middle of this burn – that is a third degree burn. My husband actually sustained a third degree burn once when he was grilling outside. He literally came inside and warned me that he had dropped a coal out of the grill and to be careful. Then he proceeded to walk back outside barefoot and step on it. As soon as he cleaned off the charcoal I could tell it was a third degree burn because it was a white circle on the bottom of his foot. Now 4th degree burns are Burns that have destroyed the skin all together and have exposed muscle and or bone. This is very common in electrical burns like you see here.

So let’s say you’re working in the ER and patient comes in with a burn injury, what do we need to do? well the first thing is to make sure the burning has stopped. If it’s a chemical burn we need to remove their clothes and we need to irrigate the wound to remove the chemicals. then we’re going to assess the patient to determine the severity of the situation. The first thing that we need to know is how much of their body has been burned. to do this with adults we use something called the rule of nines. in Pediatrics will use a Lund Browder chart, but it works similarly in that each part of the body is assigned a value. in adults the head and neck are 9% total. each arm is 9% total. Each leg is 9% front and 9% back, so 18% each. The front of the chest and abdomen is 18% and the back is 18%, so the trunk as a whole is 36%. And then the genitalia is assigned 1%. So let’s say a patient comes in with the full right arm front and back and the entire front of their trunk burned. That would be 9% for the arm and 18% for the front of the trunk, so 27% total. This gives us our Total Body Surface Area or TBSA. We want to find out the patient’s weight in kilograms – preferable to weigh them, but an estimated weight will suffice. We also want to decide the degree of burns and whether there are any other injuries. Many times other injuries get overlooked because of severe burns. Once we have all of this information, we can decide whether or not the patient needs to be transferred to a specialty Burn Unit. I’ve included some of those criteria in the outline. Then we’re going to use this information to help guide our treatment.

Like I said before these patients are at high risk for hypovolemia because of the loss of fluids, so fluid resuscitation becomes one of our top priorities. we actually use what’s known as the Parkland burn formula as a guideline to initiate fluid resuscitation. This is 4 times TBSA times weight in kg. So using the example I already gave, let’s say the patient was 100kg. 4 times 27% times 100 = 10,800 mL. So that’s how much fluid we can estimate that he needs in the first 24 hours after the burn, and we usually give at least half of that in the first 8 hours. However, this is just a guideline to get started – what we really want is to just make sure the kidneys are being perfused – so we titrate to urine output. As long as the urine output is normal, we are happy. And, of course we want to assess for edema because could be third-spacing that fluid.

Our second major priority is to prevent infection. not only do they have large open wounds, but they have lost their skin as a barrier from infection in the environment. so we’re going to do very meticulous dressing changes and wound care and most burn units maintain reverse isolation or sterile environments. this means everyone who enters the room wears a cap a gown and a mask to protect the patient from infection. We also know that these patients are going to have a ton of pain and they’re going to go through multiple surgeries and dressing changes 2 to 3 times a day which can be extremely painful. If the patient is able to use a PCA button we will use PCA pain control, otherwise we will just administer meds frequently, usually opioid analgesics. and finally we want to make sure we’re optimizing nutrition because that is going to promote wound healing. They have to get enough protein. If we need to we will put in an NG tube for feeds or possibly even place a PICC line for TPN if necessary.

Now a lot of patients with severe burns will require skin grafting to cover their wounds. most of the time this is what’s known as an autologous skin graft, which means that they get it from healthy tissue on the same patient. A lot of times they’ll go to the patient’s upper thigh or chest or abdomen, they will slice off the top layer of skin, then they mesh that piece of skin and stretch it over the burn wound. As the wound heals it will heal over that graft and the skin will begin to heal and scar. our biggest concern here is going to be preventing infection and monitoring for rejection of this graft. We want to see that the wound is granulating through it and that it is sticking well to the wound bed. And keep in mind that they now have two wounds because of the donor site. Personally, I think this is one of the coolest medical Marvels out there. In the outline will find a link to a video that shows how a thin piece of skin can be meshed and stretched to a larger area, it’s really so cool.

So as we’ve already talked about, our top priority nursing concepts for a patient with a burn injury are going to be fluid and electrolytes, infection control, and comfort. The care plan attached to this lesson will help you out with more detailed nursing interventions and rationales.

So let’s recap quickly. There are four General types of burns, thermal, radiation, chemical, and electrical. And 4 degrees of burns depending on the thickness of tissue involved. We use the rule of nines to determine the total body surface area burned, or the Lund Browder chart if it’s a pediatric patient. We use that percentage and the patient’s wait to determine how much fluid they’re going to need in their first 24 hours. Our priorities are fluid resuscitation and titrating that to normal urine output. We also want to focus on infection prevention with meticulous dressing changes, antibiotics and antibiotic ointments, and monitoring graft and donor sites. And we want to make sure the patient’s pain is controlled really well, especially medicating them before and during dressing changes.

Okay guys, those are the most important things to know for burns. Check out all the resources attached to this lesson to learn more, and let us know if you have any questions. Now, go out and be your best self today. And, as always, happy nursing!