Burn Chapter

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Gloria J. McNeal, BSN, MSN, CS,

Ph.D. (c): MEDICAL SURGICAL

NURSING:Critical Thinking in

Client Care, by Priscilla LeMoneand Karen Burke, @ 1996

Addison-Wesley Nursing.

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Nursing Care of Clients

with Burns

LEARNING OBJECTIVES

A fte r c omp le tin g th is c ha pte r, y ou wi/[ be able to

.• Describe the prevalence, incidence, and etiology of

burn injuries.

• Describe the pathophysiology of.maj or and minor burn

injuries,

• Estimate burn wound depth and extent.

• Classify types of bums and causative agents,

• Determine prehospital, intrahospital, and posthospital

intervention strategies,

• Identify laboratory and diagnostic tests used to monitor

bum therapies.

• Discuss the musing implications for burn wound man-

age.ment across all phases of care,

. • Provide client and family teaching specific to managing

burn injury d urin g a ll phases of care.

• Compare and contrast the advantages and disadvan-

tages of antimicrobial therapies used inburn care,

• Use the nursing process as a framework for developing

the standard of care for the burn-injured client.

Burns range in severity from a minor loss of small seg-

ments of the : outermost layer of the skin to a complex in-

jury involving all body systems. Treatments vary from

simple application of a topical antiseptic agent in an out-

patient clinic to an invasive, multisystem, interdisci-.

plinary health team approach in the aseptic environment

of a burn center. .

The Client with a Major Burn. . '" . .

A major burn typically involves serious injury to the un-

derlying layers of skin and covers a large body surface

area. The American Bum Association has classified burn

injuries into three categories-minor, moderate, major-

according to their severity (Table. 18-1). Major burns in-

volve injuries to the head, hands, feet, perineum, and

626

joints; al l inhalation injuries; electrical injuries; extensive

bum injuries involving large body surface areas; and in-

juries to high-risk clients.'

Overview

A bum is an alteration in skin integrity resulting in tissue

loss or damage. A transfer of energy from a source of heat

to the human body mitiates a sequence of physiologic

events that in the most severe: cases leads to irreversible

tissue destruction.

Etiology

There are [our types of burn injury: thermal, chemical]

electrical, and radiation. Although all four types can lead

to generalized tissue damage and multisystem involve-

ment, the causative agents and priodty treatment mea-

sures are unique to each (Table 18-2),



Chapter 18 Nursing Care of Clients with Burns

Minor Burn Injury

;, ': tabit:i8j~·.·;] Am e ric an B urri Association Classification o f Bu rn Injury, ; :~ . ; - -. = . ' , .:

627

Moderate Burn Injury Major Burn Injury

Excludes electrical inju ry, mhalation

injury, complicated injuries (such asmultiple trauma)' and all clients who are

considered to be at high risk (such as

older adults and those with chronic

illnesses)

Second-degree burns of less than 15%

of the total body surface area in adults

Third-degree burns of less than 2% of

the total body surface area not involving

special care areas (eyes, ears, face, hands,

f e e t, p e ri ne um)

Excludes electrical injury, inhalation in-

jury, complicated injuries (such as mul-

tiple trauma). and all clients who are

considered to be at high risk (such as

older adults an d those with chronic ill-mosses)

Second-degree bums of 15% to 25% of

the total body surface area in adults

,

Third-degree burns of le ss th an 10% of

the total body surface area not involving

special care areas (eyes, ears, face,

hands, feet, perineum)

Includes all burns of the hands; face,

eyes, ears, feet, and perineum; all elec-

trical injuries, inhalat ion injuries, mult i-

ple trauma injuries, and all'clients who

are considered to be at high risk

Second-degree burns of greater than

25% of t he t ot al b od y surface area inadults

All third-degree bums of 10% or

greater of the total body surface area

Nore. Burn injuries described in this table (except minor burns) should be treated in n specialized burn center. These cri teria have been escabl lshed by the

American Burn Association.

Thermal Burns Thermal bums result from ' exposure

to dry heal (flames) or m oist h e at (ste am a nd h o t l iq uid s) .

T he y are the most common burn injuries and occur pre-

dominantly in children and older adults, Direct exposure

to the source of heat causes cellular destruction that can

result in charring of vascular, b ony, m uscle , and ne rvous

tissue.

Chemical Burns Chemical bums are caused by direct

skin contact with ei ther acidic or basic agents. More than

25,000 products found in the home or workplace can

cause chemical bums, The chemical destroys tissue pro-tein, leading to necrosis. Acids cause coagulation necro-

sis, wher eas bases cause l tqu if ica ti on necrosis. The injury

progresses as long as the agent is in direct contact with

body surfaces (A ch aue r, 1 98 7; B osw ick, 1987; Klein &:

O'Malley, 1987), '

Chemical a ge nts a re fu rth e r c la ssifie d according to th e

manner by which they structurally alter proteins, Oxidiz-

ing agents, such as household bleach, alter protein con-

figuration through the c hem ic al p ro ce ss of reduction.

Corrosives, such as lye , cause e xte nsive protein denatura-

ti011.Protoplasmic poisons, such as organic compounds,

form salts with prote.ins, inhibiting calcium and other

ions needed for cell viability: The severity of the chemical

burn is related to the type of agent, the concentration of

th e agent, the mechanism o f action, the: duration of con-

tact, and the amount of body surface area exposed

(Achauer , 1987; Boswick, 1987; Klein &O'Malley; 1987).

See the box on page 628 for a list of household cleaning

agen ts that may cause burns.

Electrical Burns The severity of electrical bums de e

pends on the type and duration of current, and amount of

voltage. It is particularly difficult to assess the extent of

th e electrical bum injury, because the destructive

precesses initiated by the electrical insult persist for

weeks beyond th e time of th e incident. E le c tr ic it y f ol lows

the path of least resistance, which in the human body

Lends to lie along muscles, bone, blood vessels, and

nerves. Necrosis of the tissue results from impaired blood

flow, secondary to blood coagulation at the site of the

electrical injury. More than 90% of electrical burn

wounds that develop gangrene result in amputation

(Achauer, 1987; Boswick, 1987; Jepsen, 1992; Martyn,

1990).

Alternating current, as is found inconventional house-

holds, produces repeated electrical surges that lead to

tetanic muscl e cont rac ti on s . Such susta ine d m uscle . con-

tractions inhibit respiratory efforts for the duration of

contact and result in respiratory arrest. Direct current, as

in injury from a ligh tning bolt , e xpose s th e body to ve ry

high voltage for an instantaneous period of time. High

v olt ag e in ju ry usual ly r e su lt s in entry and e xit wounds,

The flash-over effect, a phenomenon unique to lightning

injury, actually saves the client from death. It is seen in

those instances in which the curre.nt travels along the out-

side of Ithe clients body to the ground, thereby sparing theinternal organs from harm (Achauer, 1987; Boswick,

1987; Jepsen, 1992; Martyn , 1990).

Radiation Burns Radiation burns are usually associ-

ated with sunburn or radiation treatment fo r cancer.

Th e se kinds of bums tend to be s up e rf ic ia l, in vo lv in g

only the outermost layers of the epidermis. All functions

of the skin remain intact. Symptoms are limited to mild

systemic reactions: headache, chills, l oc al d is com fo rt ,



628 Unit + Responses toAltered Skin Integrity

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Types, Causative Agents, and Priority

Treatment Measures [or Bums

Causative Agent Priority Treatment·

Thermal Open flame

Steam

Hot liquids (water,. grease, tar, metal)

Adds

Strong alkalis

Chemical

Electrical Direct current

Alternating

current

Lightning

Radiation Solar (ultraviolet)

X-raysRadioactive agents

Extinguish flame.

Flush with cool water.

Consult fire department.

Neutralize or dilute

chemical.

Remove clothing.

Consult Poison Control

Center.

Disconnect source of

current.

Initiate CPR if necessary.

Move to area of safety.

Consult electrical experts.

Shield the skin

appropriately.Limit time of Exposure.

Move the client away from

[he radiation source.

Consult a radiatton expert.

nausea, and vomiting. More extensive exposure to radia-

tion or radioactive. substances, as in nuclear power acci-

dents, leads to the same degree of tissue damage and mul-

tisystem involvement associated with other types o f burns

(Bomberger &: Dannenfelser, 1984; Dressler, Hozid, &

Nathan, 1988}

Epidemiology

An estimated 2 million Americans suffer burn injuries

each year, 70,000 to 108,000 of whom require hospital-

ization. Annually, 12,000 die as a result of burn wound

complications. Sixty-eight percent of burns occur in the

home, 24% in the workplace. Home bum injuries occur

most frequently in the kitchen and bathroom (Achauer,

1987).

Risk Factors

There are two groups who face a high risk for burns and

to whom preventive strategies must be targeted: children

and seniors. Young children may suffer burns as a result

of child abuse, accidental scalding, or playing with

matches. Older adults are known to be burn prone and

make up 15% of all burn. admissions (Staley &Richard,

1993). Sensory awareness can diminish as a result of ag-

ing (Richard &Staley, 1994), andmany older adults may

experience burns from heating pads, stoves, or showering

inexcessively hot water. Smoldng while intoxicated has

been associated with fires started in bed linen and uphol-

stered furniture.

Household Cleaning Agents That May

Cause Burns

• I III

• Drain cleaners

• Lye• Industrial-strength

ammonia

• Household

ammonia

• Oven cleaners

• Toilet bowl cleaners• Dishwasher

detergents

• Bleach

Educational programs to alert the public to the need

for greater caution to prevent burns in these two age

groups can help decrease the incidence of bum injury.

Prevention

Although treatments have improved Significantly over the

last several decades, there is no cure for burns. Prevention

remains the primary goal (DiMola, 1993} With the pub-

lies increasing attention to health promotion and disease

prevention, the nursing profession currently is well posi-

tioned to collaborate with other disciplines to develop

initiatives to reduce the number of burn injuries. Fat ex-

ample, as client advocates, nurses can alert political lead-

ers to the need to pass legislation aimed at reducing the

incidence of bums. Appropriate legislative themes might

center around safety in the workplace (e.g., requirements

for smoke alarms/sprinkler systems), on the highways

(e.g., regulations regarding the transportation of flamma-

ble liquids), and in the horne (e.g., requirements for

safety devices for water heaters and wood-burning Slaves,

and for self-extinguishing cigarettes) (Boswick, 1987;

Hammond, 1993; Rutan, Desai, & Herndon, 1993). As

educators, nurses can develop teaching plans for families

and communities to heighten awareness of the problem.

As researchers, nurses can investigate conditions leading

to burn injury and suggest methods to reduce its preva-

lence. Working together with health care policy makers

and community leaders, nurses can join the effort to

lower the numbers of burn cases treated annually.

Pathophysiology

The pathophysiologic changes specific to major burn. in-

juries involve all body systems. Extensive loss of skin, the

body's protective barrier, can result in massive infection,

fluid and electrolyte imbalances, and hypothermia. Often

the person inhales the products of combustion; exposure

to the heat source in this manner compromises respira-

tory [unction. Cardiac dysrhythmias and circulatory fail-

ure are common manifestations of serious burn injuries.



Third spacing Hypoxia t T-cell Skin lo ss Hyperacidity tGFR t C a ta bo lism

I I I I I I It BP t Respiration t B-cel l Senso ry lo ss Ileus t Creatinine tAnabolism

I I I I I . I . It Pulse Rhonch i tWBCs ~Temp Melena t BUN Weigh110ss

I I I I I It RBCs . t Ci li a ry movemen t t Proteins Hematemesis tspeCil iC Acidosis

I I I Igravity It Ca rd ia c o u tp u t A i rway obstruction Phagocy tosis tAbdomina l I Hyperg Iy cemia

Igirth t Ur ic ac id

t Tissue per fus ion IMyoglobinuria

Figure18-1 E ffe cts o f a s ev er~ b urn o n m ajo r b od y s ys te ms a nd m eta bo lis m.

A profound catabolic state dramatically increases caloric

expenditure and nutritional deficiencies, An alteration in

gastrointestinal motility predisposes the client to develop-

ing paralytic ileus, and hyperacidity leads to the forma-

tion of gastric and. duodenal ulcerations. Dehydration

slows glomerular filtration rates and renal clearance of

toxic wastes and may lead to acute tubular necrosis and

renal failure.

Systemic Responses

Amajor burn can disrupt the physiologic processes of the

cardiovascular, immune, integumentary, respiratory, gas-

trointestinal, and urinary systems. Moreover, overall body

metabolism may be profoundly altered. Svsterruc re-

sponses to burns are shown in Figure 18-1 and ate dis-

cussed in the following sections,

Cardiovascular System Although the pathophysio-

logic mechanisms of postbum vascular changes and fluid

volume shifts are not clearly understood, three processes

occur early in the postburn phase: 0) an increase in mi-

crovascular permeability at the burn wound site; (2) a

generalized impairment of cel l wall function, resulting in

intracellular edema; and (3) an increase in osmotic pres-

sure of the burned tissue, leading to extensive fluid accu-mulation (Martyn, 1990). Within minutes of the burn in-

jury, a massive amount of fluid shifts from the

intracellular and intravascular compartments into the in-

terstitium, thereby creating a slate of hemodynamic insta-

bility, called burn shock. This shifting is the direct result

of a 1055 of cell wall integrity at the site of injury and in the

capillary bed. Fluid leaks from the capillaries into inter-

stitial compartments located at the burn wound site and

throughout the body, resulting in a decrease in fluid vol-

Chapter 18 Nursing Care of Clients with Burns 629

ume within the intravascular space. Plasma proteins and

sodium escape into the interstitium, enhancing edema

formation. Blood pressure falls as cardiac output dimin-

ishes. Vasoconstriction results as the vascular system at-

tempts to compensate for fluid loss. Abnormal platelet ag-

gregation and white blood cell (WEC) accumulation

result in ischemia in the deeper tissue below the bum,

leading to eventual thrombosis. Red blood cells (RBCs)

and WBCs remain in the circulation, producing an eleva-

tion in erythrocyte and leukocyte counts secondary to

hemoconcentration (Achauer, 1987; Boswick, 1987;

Burgess, 1991; Richard &: Staley, 1994)_

The leakage of fluid into the interstitium compromises

the lymphatic system, resulting in intravascular hypo-

volemia and edema at the bum wound site. Edematous

body surfaces impair peripheral circulation and result in

necrosis of the underlying tissue. During bum shock,

potassium ions leave the intracellular compartment, pre-

disposing the client to developing cardiac dysrhythmias

The· process of burn shock continues until capillary in-

tegrity is restored, usually within 24 hours of the injury

(Achauer , 1987; Boswick, 1987; Burgess, 1991; Richard

& I: Staley, 1994).

Bum shock reverses when fluid is reabsorbed from theinterstitium into the intravascular compartment. The

blood pressure rises as cardiac output increases, and uri-

nary output improves. Diuresis continues from several

days to 2 weeks postburn, DUling this phase, the extra

cardiac workload may predispose the elderly client, or the

client with cardiovascular disease, to fluid volume over-

load (Achauer, 1987). Fluid restriction, diuretic therapy,

and close monitoring of hemodynamic function ar e

needed to support circulatory function (Martyn, ]990)



630 Unit 4 Responses toAltered Skin Integrity

~ ~ ; ~ : ~ : - . ~ _c :" ~'~. '~. '_~ ': :>, ' : ' : ' :_;>':~~~{

fJ 'aJ.j I¢18.:.,3'.:i,'

Manifestations of Carbon

Monoxide Poisoning. , , ' . . - ' ~ " ' :, < . '. ~ ~ ' ;'. . . : ~ .- . ~ . ~ . ~ . ~:. ~~ .~\ :.1 ~ .. :: ," -

Level of

Carbon Monoxide Manifesta tions

10% to 20% Headache, dizziness, nausea, abdomi-

nal pain

Headache, nausea, drowsiness, dizzi-

ness, i rr it ab il ity ; confus ion , stupor,hypotension, bfadycardis., skin color

r anging [ rom pale to dark le d

Convulsion, coma, hypotension,

tachycardia

Death

21% to 40%

41% to 60 %

>60%

Fluid replacement and maintenance are the major

goals of treatment during the early phases of the burn in-

jury Even after capillary integrity is restored, fluid lossescontinue until closure of the burn wound is effected. The

client is placed on a fluid maintenance plan over the du-

ration of the acute 'phase (Achauer, 1987; Boswick, 1987;

Burgess, 1991; Richard &: Staley, 1994),

Immune System The function of the immune system

is to protect the human .body from invasion by foreign

microorganisms. The capillary leak that occurs in the

early stages of the bum injury continues throughout the

burn shock phase and impairs the active components of

both the cell-mediated and humoral immune systems

(Achauer, 1987; Boswick, 1987; Robins, 1989; Tribett,

1989).The humoral immune system relies on B cells to pro-

duce antibodies or immunoglobulins (see Chapter S) In

the bum client, the serum levels of all immunoglobulins'

are significantly diminished. Serum protein levels remain

persistently low throughout the clinical course until

wound closure is effected. A marked decrease in I-cell

counts results in a reduction of cytotoxic activity and sup-

pression of the cell-mediated immune system (Achauer,

1987; Boswick, 19B7; Robins, 1989; Tribett, 1989).

The compromise in the humoral and cell-mediated im-

mune systems constitutes a state of acquired immunode-

Iiciency which places the burn client at risk for infection.

The period of vulnerability is transient and may last from1 to 4 weeks following the onset of the burn injury Dur-

. ing this time frame, opportunistic infections can develop

an d produce death despite aggressive antimicrobial ther-

apy (Achauer, 1987; Boswick, 1987; Robins, 1989: Iri-

bett, 1989).

'Integumentary System The integumentary system

functions as a thermoregulator, a synthesizer of vitamin

D, an excretory organ, a sensory organ, as well as a bar-

tier against infection. The burn injury impairs the nor- .

mal physiologic functions of the skin (Achauer, 1987;

Bos-wick, 1987; Burgess, 1991; Richard &: Staley, 1994).

Heat transfer to skin is a complex: phenomenon. Dur-

ing burning, the temperature of the skin rises in an in-

verse relation to the distance from the heat source. A ther-

mal gradient hottest at the skin surface is established at

the onset of the bum injury. I f the microcirculation of.the

skin remains intact during burning, it cools and protectsthe deeper portions of the skin and cools the outer surface

once the heat source is removed. With extensive burn in-

jmy, the integrity 0 f the microcirculation is lost, and the

burning process continues even after the heat source is re-

moved (Boswick, 1987).

The overall thickness of the dermis and epidermis

varies considerably from one area of the body to another,

Similiar temperatures produce different depths of injury

to different body parts. For example, in the adult, skin

covering the medial aspe ct of th e forearm is thinner and

more easily damaged than the skin covering the back of

the same person, Skin dissipates heat maximally in areas

of greatest vascularization. When heat absorption exceedsth e rate of dissipation, cellular temperatures rise, and skin

tissue is destroyed (BOSWick, 1987; Richard & Staley,

1994), .

Respiratory System Inhalation injury is a frequent

and oftenlethal complication of burns. The injury may

range from mild respiratory inflammation to massive pul-

monary failure. Exposure to asphyxiants, smoke, and

heat initiates the pathophysiologic processes associated

with inhalation injury (Achauer , 1987; Boswick, 1987;

Cioffi &: Rue, 1991; Martyn, 1990; Richard & Staley,

1994).

Carbon monoxide, a common asphyxiant, is a color-

less, tasteless, odorless gas that displaces oxygen to bind

with hemoglobin, forming carboxyhemoglobin, The re-

sulting decrease in arterial oxyhemoglobin produces tis-

sue hypoxia. Carbon monoxide impairs both oxygen de-

livery and cellular oxygen use (Achauer, 1987; Boswick,

1987; Cioffi &Rue, 1991; Martyn, 1990; Richard &Sta-

ley, 1994). The clinical manifestations of carbon monox-

ide poisoning range from mild visual impairment to coma

and death (Table 18-3).

Smoke poisoning results when toxic gases and particu-

late matter, the products of incomplete combustion, de-

posit directly onto the pulmonary mucosa. The composi-

tion of the products of combustion depends 011 the

combustible material, the rate at which the temperature

increases, and the amount of ambient oxygen present. Ir-

ritant gases and particulate matter have a direct cytotoxic

effect. The degree of injury is determined by their solubil-

ity in water, duration of exposure, and the size of the par-

ticulate or aerosol droplet (Cioffi & ' Rue, 1991).

Inflammation occurs at localized sites within the air-

way and is manifested as hyperemia. As a result, cells are

destroyed and the bronchial cilia are rendered inactive.



Because the mucociliary transport mechanism no longer

functions, the client may develop bronchial congestion

and infection.

Interstitial pulmonary edema develops secondary to

extravasation of fluid from the pulmonary vasculature

into the interstitial compartment of the lung tissue. Sur-

factant is inactivated, and atelectasis and alveolar collapse

may result. Sloughing 01 the damaged and dead lung tis-sue occasionally produces debris that may lead to com-

plete airway obstruction (Cioffi &- Rue , 1991).

Edema damage s th e uppe r and lower airways. Expo-

sure t o compounds with a high water solubility causes

upper airway damage. Lowerairway damage is caused by

compounds with a lower water solubility and the ability

L a pe ne trate m ore distal areas (Achauer, 1987; Boswick,

1987; Cioffi.aRue, 1991; Richard &Staley, 1994).

Upper airway thermal injury results from the inhala-

tion of heated air. Physical findings include the presence

o f soot, charring, edema, blisters, and ulcerations along

the mucosallining of the oropharynx 'and larynx. The re-

sulting edema in the airway peaks within the first 24 to 48hours of injury (Achauer, 1987; Boswick, 1987; Cioffi & :Rue, 1991~Richard &Staley, 1994),

Lower airway thermal. injury is a rare occurrence. Be-

cause the lower airway is protected by laryngeal reflexes,

thermal injury below the vocal cords is seldom seen.

However, when it does occur, it is typically associated

with the inhalation of steam or explosive gases or the as-

piration of h ot liquld s. The xenon pe rfusi on -ven ti la t ion

lung scan and flexible bronchoscopy are used to confirm

lower airway injury. Both are employed as early diagnos-

tic procedures (Achauer, 1987; Boswick, 1987; Cioffi &:

Rue, 1991; Richard &: Staley, 1994). '

Gastrointestinal System Curling's ulcer is an acute

ulceration of the stomach or duodenum that forms fol-

lowing the bum injury Abdominal pain, acidic gastric pH

levels, hernatemesis, and melanotic stool may indicate the

presence of gastric ulcer formation (Achauer, 1987;

Boswick, 1987; Richard &. Staley, 1994).

A decrease in or absence of bowel sounds is a manifes-

tation of paralytic ileus (adynamic bowel) secondary to

bum trauma, Th e resulting ce ssanon of intestinal motilityleads to gastric distention, nausea, vomiting, and herna-

temesis (Achauer, 1987; Boswick, 1987; Richard & 7 Staley,

1994; Swearingen, Sommers, &:Miller, 1988).

Urinary System During the early stages of the burn

injury, m a s s i v e fluid losses O C G . u r . These losses, if

unchecked, lead to dehydration, hemoconcentration, and

oliguria. Dark brown concentrated urine may indicate

myoglobinuria. Acute tubular necrosis and renal failure

may deve lop if fluids are ' not ade quate ly replaced

(Achauer, 1987; Boswick, 1987; Burgess, 1991; Richard

& Staley, 1994).

Metabolism Two distinct phases characterize. the

bodys metabolic response to the burn injury. Lasting over

Chapter 18 Nursing Care of Clients with Bums 631

the first 3 days of the injury is the ebb pha se , which is

manifested by decreased oxygen consumption, fluid im-

balance, shock, and inadequate circulating volume. These

. responses protect the body from the initial impact of the

injury (Boswick, 1987; Martyn, 1990; Richard &: Staley,

1994).

A second phase, the flow p ha se , occurs when adequate

burn resuscitation has been accomplished. This phase ischaracterized by increases in cellular activity and protein

catabolism, Lipolysis, arid gluconeogenesis. The basal

metabolic rate (BMR) significantly increases, reaching

twice the normal rate. Body weight and heat drop dra-

matically. Total e n e rgy e xpe ndit ur e may exceed 100% of

normal BMR. Hypermetabolism persists until after

wound closure has been accomplished and may reappear

i f comp lica tio ns o cc ur (B osw ic k, 1987; Martyn, 1990).

Stages of Burn Injury

Th e clinical course of treatment for th e burn client is di-vided into three stages: the emergent/resuscitative stage,

the acute stage, and the rehabilitative stage (Burgess,

1991). Although these stages ar e useful predictors of the

clinical needs of the burn client, it is important to recog-

nize that the process o f b urn injury is d yn am ic and that in

many cases, the clinical stage may not be dearly delin-

eated. Assessment and management of the burn-injured

client are ongoing processes that are determined by the

clinical picture and last throughout the course of treat-

ment. Figure 18-2 shows the bum clients progression

through th e health care system during each clinical stage

of burn care . During each stage, different groups of

nur se s , p h y si ci an s, and allied health care specialists col-

laborate to manage the clients recovery.

Emergent/Resuscitative Stage The emergent/resusci-

tative stage lasts approximately 48 to T2 hours, from the

onset of injury through su ccessful fluid resuscitation

(Burgess, 1991). During this stage, health care workers

estimate the extent of burn injury, institute initial first-aid

measures, and implement fluid resuscitation therapies.

The client is assessed for shock and evidence of respira-

tory distress. I f indicated, intravenous lines are inserted,

and the client may be prophylactically intubated. During

this stage, health care workers determine whether the

client is to be transported to a bum center for the com-

plex intervention strategies of the professional, interdisci-plinary burn team.

Acute Stage The acute stage begins with diuresis and

ends with closure of the bum wound (Burgess, 1991).

During this stage, wound care management, nutritional

therapies, and measures to control infectious processes

are initialed. Hydrotherapy and excision and grafting of

fun-thickness wounds are performed as soon as possible

after injury Enteral and parenteral nutritional interven-

tions are started early in the treatment plan to address.




Acute stage I

...~~dical:.·

. . . : su rg ica l

unit.

H e E i l t t i · · · : :

· c a r eteam

~ ..

~

• Fluid

managemen t

• Ven t il a ti on

• Su rg e ri es

• Hy d ro t he rap y

• I \ Jut ri t i on• Physical therapy

• W ound care

• Medicatio ns

• P sy cho sb c la l

support

• T he rma l

• Chem ica l·• Radiation

• E le c tr ic a l

• F lu id

r e su scl ta f o n

• Ven t il a to r y

managemen t

• E l im i na te

burn source

··Support vital

functions

• T r an spo r t

• Nu tr it io n

• W ound care

• P hy sic altherapy

• Med ica ti on

• Psychosocial

support

Pre-hospital care Intra-hospital care

Figure 1B -2 T he clie nt's p ro gre ss io n thro ug h th e h ea lth ca re s ys te m du rin g th e e me rg en t,

a cu te , a nd rehabilitative stages o f burn injury.

caloric needs resulting from extensive energy expendi-

ture. Measures to combat i.nfection are implemented dur-

ing this stage, including the administration of topical and

systemic antimicrobial agents. Pain management consti-

tutes a significant segment of the nursing care planthroughout the clinical course of the burn-injured. client.

The administration of narcotic pharmaceutical agents

must precede all invasive procedures to maximize client

comfort and to reduce the anxieties associated with

wound debridement and intensive physical therapy.

Rehabilitative Stage The rehabilitative stage begins

with wound closure and ends when the clie:nt returns to

-the highest level of health restoration (Burgess, 1991).

During this stage, the primary focus is the biopsychoso-

cial adjustment of the client, specifically the prevention of

conrractures and scars and the clients successful resump-

tion of work, family. and social roles through physical, vo-

cational, occupational, and psychosocial rehabilitation.

The client is taught to perform range-of-motion (ROM)

exercises to enhance mobility and to support injured

joints.

Prehospital Care

Treatment at the scene of the injury includes measures to

Limit the severity of the burn and support vital functions.

Soc)al ~E ! rv , ice

• A DL s

• v ooanona ltraining

• P sy cho soc ia l

support

• Phys ica l lhe rapy

• Communityresources

• Follow-up

Post-hospital care

Emergency Measures to Limit Burn Severity

Before attempting to remove the client from the source of

burn injury, rescuers must ensure their own safety. De-

pending on the. causative agent, rescuers may need to

consult with experts to determine the best way to elimi-nate the source of the injury Once the safety of the res-

cuers has been established, all prehospital interventions

are aimed at eliminating the heat source, stabiliZing [he

client's condition, identifying the type of bum, preventing

beat loss, reducing wound contamination, and preparing

for emergency transport (Achauer, 1987; Boswick, 19B7;

Burgess, 1991; Dressler e .l al., 1988; Martyn, 1990). Re-

stricrive jewelry and clothing is removed at the scene to

prevent circumferential constriction of the torso ~nd ex-

tremities.

Thermal Burns I f the thermal injury has been caused

by dry heat, smother inflamed clothing or lavage with wa-

ter. Assist the client to initiate a "SLOp, drop, and roll" ma-

neuver to extinguish the flame. and limit the extent of

burn (Achauer, 1987). Once the flame has been extin-

guished, cover the body to prevent hypothermia. If the

thermal injury has been caused by moist heat, lavage the

area with cool water.

Chemical Burns For chemical burns, immediately re-

move the clothing, and use a hose or shower to lavage the



involved area thoroughly. Unusual chemicals may require

consultation with the poison control center for instruc-

tions regarding appropriate treatment (Klein &O'Malley;

1987).

Electrical Burns Electrical injuries pose serious poten- '

tial harm to both rescuer and client. Ensure that the

source of electrical current has been di.sconnected, ormove the client to safety using nonconductive devices

that can serve as rods to push the client away from the en-

ergy source. Monitor the client for cardiopulmonary ar-,

rest. If the client is unresponsive, assess for the presence

of cardiac and respiratory Eubction. If indicated, begin

cardiopulmonary resuscitation (CPR). A spinal cord in-

jury may be present secondary to the forceful contraction

of the muscles of the neck and back during exposure to

the current. I f possible.place the client in a cervical collar

and transport the client on a spinal board (Achauer, 1987;

Jepsen, 1992; Martyn, 1990).

Radiation Burns Radiation injuries are usually minor

and involve only the epiderrnal Iayer of skin. Treatment

focuses on helping normal body mechanisms promote

wound healing. For severe radiation burns, such as those.

that result from industrial radiation accidents, trained

personnel may need to re nde r th e area s af e fo r entry prior

to rescue. AILinterventions are aimed at shielding, estab-

lishing distance, and limiting the time of exposure to the

radioactive source (Bomberger & Dannenfelser, 1984).

Emergency Measures to Support Vital Function

Th e initial assessment of the client's respiratory and h e -

modynamic status begins with an evaluation of the clients

airway breathing, and circulation (the ABCs of care). Pre-

hospital care personnel determine the adequacy of venti-

lation and circulation and institute the following mea-

sures as necessary.

Cardiopulmonary Resuscitation If the client has no

pulse and is not breathing, begin CPR Establish an air-

way; and start mouth-to-mouth breathing and chest com-

pressions. Continue CPR until, spontaneous cardiopul-

monary function returns or until the emergency

management team takes aver. .

When the. emergency team arrives, begin oxygen ther-

apy. Use high-flow oxygen for a11suspected cases of in-

halation injury. Observe for the cessation of respiration in

the client with a history of chronic obstructive pulmonarydisease (COPD), and reduce oxygen flow accordingly If

the client is unconscious and carbon monoxide poisoning

is suspected, administer 100% oxygen until blood gas

measurements are obtained (Boswick, 1987). Agitation,

anxiety, and combative behavior may indicate hypoxia;

Do not include sedation in the initial treatment.

When available, connect the client to a cardiac moni-

tor and observe for dysrhythrnias. Watch for the develop-

ment of premature ventricular contractions (pves), runs

, .Chapter 18 Nursing Care of Clients with Butns 633

of ventricular tachycardia, and ventricular standstill. Treat

according to protocol.

Maintaining Ventilation All burn injuries involving

the face, neck, or anterior chest require prophylactic intu-

bation. Tracheal intubation is required when edema ob-

structs the airway. Pulmonary edema, a se.quela of inhala-

tion injury, requires mechanical ventilatory managementwith large tidal volume, positive end expiratory pressure

(PEEP), and oxygen concentrations that maintain oxygen

saturation Levelsabove 90% .

All bum-injured clients must be frequently assessed

for respiratory distress. Signs and symptoms include

hoarseness, dyspnea, tachypnea, stridor, cyanosis, wheez-

ing, crackles, poor chest excursion, progressive changes

on chest X-ray film, and deteriorating ABGs.

Nursing measures for on-scene airway management

include interventions to promote alveolar oxygen e 1 1 -

change. Position t he . client with the head elevated at

greater than 30 degrees, and administer oxygen. Employ

frequent nasotracheal suctioning to maintain a patent air-way. Auscultate the lungs often on site to.monitor respira-

tory status. Continuous pulse oximetry is used [Dr ongo-

ing assessment of the clients oxygen Saturation levels

(Achauer, 1987; Gof11 et al. 1991; Martyn, 1'990; Rue &'

Cioffi, 1991).

Maintaining Circulation At the scene of the injury,

insert large-bore intravenous lines to begin fluid manage-

ment. Fluid replacement therapy is necessary in a n burnwounds that involve more than 20 % of the total body sur-

face area. Many formulae are, available to calculate the

fluid requirements of the severely burn-injured client.

The most commonly used is the Parkland/Baxter formula.

Several types of fluids are used to restore fluid volume:

colloids, crystalloids, blood, and blood products. See the

section on fluid resuscitation on page 637 for a more ex-

tensive discussion.

Continuously assess the clients hemodynamic status at

the scene by auscultating heart and lung sounds and by

observing level of consciousness, cardiac rate and rhy-

thm, blood pressure, and urine output (Achauer, 1987;

Boswick, 1987; Burgess, 1991; Martyn, 1987).

Maintaining Body Temperature The client loses heat

through open burn-injured areas via evaporation and ra-

diation. At the scene of the injury, use blankets and heavy

clothing Lo maintain body core temperatures at 99.6 tolOl F (37.5 to 38.3 C).

Emergency Department Care

On arriving at the hospital, the client is taken to the

emergency department. Prehospital personnel report to

the emergency department staff all findings and medical

interventions that occurred at the scene of the injury. The

nurse obtains a history of the injury; estimates the depth



634 Unit 4 Responses to Altered Skin Integrity

i ;T~bleLM! Characteristics of Burns, by Depth; . . . . . . . . . ' · " 1

First- Degree Third-Degreeharacteristic Second-Degree

S kin layers lost Epidermis

Skin appearance over burn Red to gray; may have: local

edema

Skin funcuon

Pain sensation

Manifestations at the'

burn site

Present

Present

Moderate pain; local edema

Regular cleaning

Topical agent of choice

Scarring

Time Lo heal

None

3 to 5 days

Epidermis and de.rmis

Fluid-li11ed blisters; may ap-

pear waxy white with deeppartial-thickness burns

Absent

Present

Severe pain; edema; weeping

of fluid

Regular cleaning

Topical ag en t o f choice

May require s ki n g ra ft in g

o[ten extensive

1 to several months

Epidermis, dermis, and un-

derlying tissues

Waxy white; dry, leathery;

charred

Absent

Absent

Little pain; edema

Regular cleaning

Topical agent of choice

Skin substitutes

Excision of eschar

skin grafting

Of grafted area

Requires skin grafting to heal

and extent of the burn, begins fluid resuscitation, and

maintains ventilation according to protocol.

History of the Burn Injury

Once the client. arrives at the emergency department

(ED), the staff must act quickly to obtain the history of

the burn injury, including the time of the injury, the

causative agents, the early treatment, the medical history;

and the clients age and body weight. In most cases; the

client is awake and oriented and able to rela te the .infor-mation during [he emergent phase of care. Because

changes in sensorium w in become evident within the first

few hours following a major bum injury, the nurse ob-

tains as much information gs is possible immediately on

tile client's arrival.

Time of Injury In many cases, the client is admitted to

the ED an hour Dr more after the injury occurred. The

time of the burn injury must be documented as precisely

as possible at the scene, because all fluid resuscitation cal-

culations are based on the time of the burn injury, not on

th e time of the clients arrival at the ED.

Identification of the Cause Because the type of burn

injury determines which nursing measures take priority,

the nurse must identify the specific causative agent to es-

tablish the appropriate plan of care,

First-Aid Treatment Prior to the arrival of medical

personnel, the client or family may have applied home

remedies to treat the bum wound. It is important [or the

nurse to ascertain and document the nature of all home

treatment interventions, including the application of neu-

tralizmg agents, liquids, and immobilizing devices used

to splint associated injuries. Tetanus toxoid is adminis-

tered early in the treatment plan, often in the field.

Past Medical History Clients with histories of respira-

tory, cardiac, renal, metabolic, neurologic, gastrointesti-

nal, or skin diseases; alcohol abuse; or altered immune

states require more intense observation.

Age Older adults tend to require more supportive care.

Medications Drugs, either prescribed or recreational,

taken by the client prior to the burn injury may further

complicate the treatment regimen. Drugs that affect any

of the major body systems or cause mood alterations will

need to be factored into the treatment plan. As part of the

early assessment, the nurse obtains and documents blood

levels of therapeutic pharmaceutical agents and mood-

altering substances.

Body Weight During the acute and rehabilitative

phases of the burn injury, the client will lose as much as

20% of preburn weight. This fact will have Significant im -

plications for all clients, especially for those who were un-

derweight or cachectic at the time of the injury

Classification of Burn Depth

Tissue damage following a burn is determined primarily

by two factors: the extent of the burn (the percentage of

body surface area involved) and the depth of the burn

(the layers of underlying tissue affected), The recognized

system for describing a bum injury, developed by the

American Burn Association, uses both the extent and

depth of burn to classify bums as minor, moderate, or



1-

Full thickness


Partial thickness

Normal tissue

Finit·degree burn:

epidermis is destroyed

Second·degre9c burn:

burn extends into dermis

Third-degree burn:

burn destroys all of dermis and

may reach SUbcutaneous tissue

Fourth-degree bum:

burn extends into musde a'nd bone

major (see Table 18-1). Formulas for estimating the ex-

tent of a burn are discussed on page 636 (Achauer, 1987;

Boswick, 1987; Burgess, 1991; Martyn, 1987; Richard &:

S tal ey, 1994) .

The depth of a bum may be classified in one of [ourcategories: first-degree, se.cond-degree, third-degree, or

fourth-degree. Characteristics ofbums within each classi-

fication are summarized in Table 18-4 and illustrated in

Figure 18-3.

First-Degree Burn A first-degree burn involves only

, rhe epidermal layer of the skin. Because the skin remains

intact, first-degree bums are usually not calculated into

estimates of the extent of burn injury. Local pain and ery-

thema are present at the site of the bum,and blisters may

form within the first 24 hours. First-degree bums involv-

ing large body surface a re as m ay cause chills, headache,

pain at the site, nausea, and vomiting, The injury usually

heals in 3 1O 5 days without scar formation. These kinds

of burns are treated with mild analgesics and the applica-

tion of water-soluble lotions. Causative agents include ul-

traviolet solar radiation (sunburn) and mild radiation

bums associated with cancer treatment.

In o ld e .r clients, extensive first-degree burns m ay le ad

to systemic dehydration secondary to fluid losses into

blistered areas and profound nausea and vomiting, Treat-

ment focuses on rehydrating the client with intravenous

fluids.

Second-Degree Burn Second-degree burn injuries are

subclassified into superficial and deep partial-thickness

wounds (Figure 18-4). Superficial injuries involve the

epidermal and dermal Layers of the skin and are red to

pale iVOlY in color. Pluid-fiiled blisters form immediately,and the client experiences pain at the site. Healing occurs

in 21 to 28 days and, depending on the clients genetic

heritage, mayor may not be associated with extensive

scarring. Generally, darker-pigmented races (people of

A sia n a nd A fric an descent) are m ore susce ptib le to hyper-

trophic scarring (Richard &:Staley, 1994).

Deep partial-thickness burns involve the destruction

of the entire dermal layer. A flat dry blister forms at the

site, and pain is either absent or greatly diminished. The

surrounding tissue of lesser depth may, however, have in-

tact pain SEnsors and be sensitive to touch. Healing oc~

CUTS in 30 days. Because t h e s e :wounds are associated with

extensive scarring, contemporary therapeutic: mterven-tions include excision of the wound and skin grafting to

effect early wound closure.

Third-Degree Burn Third-degree lull-thickness burns

invo lye all layers of the skin and subcutaneous tissues.

These burns are white, cherry red, or black (Figure

18-5). Skin loses its elasticity, resulting in a leathery ap-

pearance, with progressive restriction of circumferential

wounds involving the extremities or torso. Visibly throm-

bosed superficial blood vessels are evident. Deep blisters

Figure 18-3 Burn-injury

classification according to the

d ep th o f t he b urn .



636 Unit 4 Responses toAltered Skin Integrity

Figure 18-4 Partial-thickness burn injury,

may form under dry dehydrated skin. Because all pain

sensors have been destroyed, third-degree bums are char-

acteristically painless. Injuries larger than 2 inches in di-

ameter will not heal and will require skin grafting.

Fourth-Degree Burn Fourth-degree burns involve all

layers of underlying tissue: bone, muscle , blood vessels,

and nerves. These injuries tend to be extensive and to re-

quire grafting. Bone tissue that is left exposed invariably

dies, leading to a nonhealing wound with potential for i n -fection. One method of treating exposed bone involves

drilling holes into the marrow cavity to permit the out-

growth of granulation tissue, which eventually covers th e

bone. The use of pedlcles or flaps to cover exposed bone

is a ls o an effective method of treatment. I f th e joint is ex-

posed, the involved extremity in many cases must be am-putated. If exposed joints can be kept moist and fre e of

infection, however, they can sometimes obtain coverage

from granulation tissue. Immobilizing the joint with pins

or splints may also help promote return of granulation tis-

sue (Richard &: S ta le y , 1994 ).

Burn Zones Burns have a characteristic skin surface

appearance that resembles a b ulls-e ye , w ith the most se-

vere burn located centrally and the lesser burns located

along the peripheral wound edges. Depending on the in-

te nsity of burning, burns consist of one, two, or three

concentric three-dimensional zones closely correspond-

ing on the skin surface to areas of first-, second-, or third-

degree burns, respectively:

• The outer z on e o j e ly th em a blanches on pressure and

heals in 2 to 7 days postburn.

• The medial z on e o f s ta sis is initially moist, red, and blis-

tered and blanches on pressure. It becomes pale and

necrotic on days 3 to 7 postburn.

• The inner zone oj coagu1 atiofl immediately appears

leathery and coagulated. It merges with the necrotic

zone of stasis in3 to 7 days postburn (BOSWick, 1987).

Figure 18-5 Full-thickness burn injury.

Estimation of Burn Extent

Although many burn injuries are treated in local tertiary

care facilities, the American Burn Association has devel-

oped guidelines for determining whether the client

should be transported to a burn center for interdisciplin-

ary approaches to treatment and rehabilitation. Clients

who should be treated at bum centers include: those with

• A burn covering 10% or more oIbody surface and who

ar e less than 10 or greater than 50 years of age.

• Aburn covering 20% or more of body surface and who

are between the ages of 10 and 50,

• A burn involving the hands, feet, face, eyes, ears, or

perineum.

• An inhalation injury.

• An electrical injury.

• Any burn associated with extenuating problems, pre-

existing illness, fractures, or other trauma (Burgess,

1991).

There are several methods used for determining the

extent of injury The "rule. of nines" is a rapid method of

estimation used during the prehospital and emergency

care phases (Figure 18-6). In this method, the body is di-

vided into five surface areas: head, trunk, arms, legs, and

perineum, and percentages are assigned to each body

area. For example, a client with burns of the face, anterior

right ann, and anterior trunk has burn injury involving

27% of the total body surface area (TBSA) (Achauer,

1987; Martyn, 1990; Richard &: Staley; 1994; Rue &

Cioffi, 1991).

On th e clients admission to the hospital, critical care

area, or burn center, more accurate methods for estimat-

ing the extent of injury are employed. The Lund and

Browder method (Figure 18-7) determines surface area

measurements for each body part according t o the age ofthe client (Rue &: Cioffi, 1991). .



Anterior

An te r io r h ead

an d neck,41 /2%

Totals

Anterior and posterior

he ad and ne ck, 9%

1An te r io r u ppe rl imbs, 9%

An te r io r a nd po s te ri orupper limbs, 18%

1

1Per ineum 1%

1An te r io r l owe r

limbs,1B%

An te r io r a nd po st e ri or

lower l imbs, 36%

100%


Posterior

Posterior head

and neck,4'/2%

Posterior upperlimbs, 9%

Posterior lower

l imbs, 18%

Figure 18-6 T he "ru le o f n ine s" is a m eth od o f q uick ly e stim ating th e p erce nta ge o f T BS A

·affected by a burn injury. A l th o ugh usef ul in emergency care situations, th e ru le o f n in es is no t

a cc ura te fo r e stim a tin g T B SA fo r a du lts w ho a re s ho rt. o be se , o r v ery th in .

Fluid Resuscitation

To counteract the eEfe~ts of bum shock, fluid resuscita-

tion guide.lines are used to replace the extensive fluid and

electrolyte; losses associated with major bum injuries,

Fluid replacement is necessary in all bum wounds that

involve more than 20% of the TBSA. Colloids, crystal-

loids, blood, and blood products are used for fluid resus-

citation and maintenance.

There are several formulas (such 3S th e Brooke army

formula, Evans formula, and hypertonic saline solution)

that may be used to replace fluid loss. Th e Pa rk la nd /B ax-

ter formula, however, is the most commonly used (see the

box on page 639), Fluids are administered through large-

bore centrallines at rates sufficient to maintain urine o u t -put at 30 to 50 ml./h. Lactated Ringers solution is the in-

travenous . fluid of choice because it most closely

approximates the bodys extracellular fluid composition.

To calculate the fluid resuscitation rate using the Park-

land/Baxter formula, the nurse determines the total

amount of intravenous solution to infuse over the first 24

hours postburn, The rate is based on 4 mUkg per percent

.of nlSA burned: 50% of the total amount is administered

over the first 8 hours postburn, 25% over the second 8

hours postburn, and 25% over the third 8 hours post-

burn, Over the second 24 hours postbum, the lactated

Ringers solution is discontinued and a colloid (e.g., albu-

min, plasmanate, or dextran) is infused at a rate of 0.3 to

0.5 mUkg per percent of TBSA burned, along with dex-

trose in water titrated to maintain urine output.

FLuid resuscitation rates are adjusted periodically

throughout the emergent stage of care. The nurse should

be particularly aware of several situations that may war-

rant the administration of fluids at rates inexcess of the

calculations needed to maintain adequate urine output:

initial underestimation of the burn size, sequestration of

fluid into the lung tissue in inhalation injury, electrical in-

jury (which tends to cause more extensive damage than is

immediately visible), fourth-degree burns, and inordi-

nately delayed starts of fluid resuscitation.

During the fluid resuscitation stage, the client may re-

quire invasive hemodynamic monitoring (see Chapter

28). A pulmonary artery catheter monitors cardiac out-

put, cardiac index, and pulmonary artery wedge pres-

sures. All measurements must be maintained within nor-

mal Iimns to effect adequate fluid resuscitation (Boswick,

1987; Burgess, 1991;Martyn, 1990; Rue cSrCioffi, 1991).




Figure 18-7 The Lund and

Browder burn assessment chart.

This method of est imat ing TBSA

affected by a b urn in ju ry is m ore

accurate than the "rule of nines"

because it accounts f or c ha na e s

in b od y surface area across the

life span,

AreaAge (y e ar s)

% % % %

0-1 1-4 5-9 10-15 Adult 1G 2 D 3G Total

Head 19 17 i3 10 7

Neck 2 2 2 2 2

Ant. trunk 13 13 13 13 13

Post trunk 13 13 13 13 13

R. buttock 2~ 2~ 21.. 21..

2+2 2 2L but tock 21 21- 21 21 2 . 1 .

2 2 '"2 2 2

Genitalia 1 1 1 1 1

R,U, arm 4 4 4 4 4

L,U. arm 4 4 4 4 4

R.L, arm 3 3 3 3 3

L,L, arm 3 3 3 3 3

R, hand 2 . 1 . 2 . 1 . 21 21. 21..2 2 2 2 2

L, hand 2.1. 2 . 1 . 21 . 2 . 1 . 212 2 2 2 2

R, thigh 51 . 6.1. 8 . 1 . 81. 912 2 2 2 2

L. thigh 51. 6.1. 81- 81- 9j_2 2 2 2 2

R , le g 5 5 51. 6 72

L, leg 5 5 51 . 6 72

R , foot 31- 3 1 3+ 31- 3+2

L, toot 31 31. 31. 3j_ 3 . 1 .2 2 2 2 2

Total

. . . . . . . _ _ _. ... - . . . . ~

Ventilatory Management

Upon the client's admission to the ED, several baseline as-

sessments of respiratory status must be obtained: chest x -ray study,ABGs, vital signs] and carboxyhemoglobin lev-

Burn Evaluation

--~ Seve r it y o f b u rn

- - /1° ~

I

~2°I

I"

II3"

els. Intubation is indicated for all clients with burns of the

chest, face, or neck. Th e primary treatment plan is ori-

ented toward preventing atelectasis and maintaining alve-

olar oxygen exchange. Airway management is a funda-




Fluid Replacement Guidelines for the First 24 Hours Post Burn

Parkland/Baxter Formula

1. Formula: 4 mL X kg body weight X % TBSA

burned

2. Fluids: Lactated Ringer's

3. Administration: Give half in the first 8 hours and

half over the next 16 hou rs

Brooke Army Formula

1. Formula: 2 mL X kg body weight X % of total

body surface area (TBSA) bumed + 2.000 mL per

24 hours for maintenance fluid

2. Fluids:

a. Colloids: 0. 5 mL X kg body weight X % TBSA

burned (see Chapter 5)

b. Lactated Ringer's: 1.5 mL X kg body weight X% TBSA burned

c. 5% dextrose in water [or maintenance

3. Administration: Give half in the first Shams an d

half over the next 16 hours

Evans Formula

1. Formula: 2 mL X kg body weight X % TBSA

burned

2. Fluids:

a. Colloids: 1 ml, X kg body weight X % TBSA

burned (see Chapter 5)

mental nursing measure in the control of ventilation and'

includes positioning. respiratory toileting, oxygenation,

drug administration, and continuous assessment.

Positioning Maintain the head of the bed at 30 degrees

or greater to maximize the clients ventilatory efforts. Tum

the client side to side every 2 hours to prevent hypostatic

pneumonia.

Respit:atory Tofleting To keep airway passages clear,suction the client frequently; encourage the client to use

incentive spirometry hourly, and help the client perform

coughing and deep-breathing exercises every 2 hours.

Intubation In the face o f impending airway obstruc-

lion, the client will require intubation. Nasotracheal tube

placement is the preferred route because it seems La be

better tolerated and can be more: effectively secured. If the

client has suffered nasolabial burns, however, the orotra-

.II III II

b. Normal saline: 1 mg X kg body weight X %

TBSA burned

c. 5% dextrose in. water (or insensible water loss

3: Administration: Give half in the Iirst 8 hours and


Consensus Formula

L Formula: 2 to 4 mL X kg body weight X % TBSA

burned

2. Fluids: Lactated Ringers

3. Administration: Give half in. the first 8 hours and


Winski Formula

1. Formula: 2 mL X kg body weight X % TBSAburned

2. Fluids: lactated Ringers and maintenance fluicls

J. Administration: Give half in the first 8 hours and


Hypertonic Saline Solution

1. Formula: Solution containing 25D mEq of sodium

per liter of solution

2, Fluids; Hypertonic saline withadded sodiumL

3. Administration: Give at a rate to maintain an

hourly urinary output of 30 mL (in adults)

cheal route is preferred. Nasotracheal and oro tracheal in-

tubation is reserved for short-term. ventilatory manage-

ment. For long- term ven tilatory management (i.e., greater

than 3 weds), a tracheostomy is performed.

Oxygenation Humidification of either mom air or oxy-

ge n helps prevent the drying of tracheal secretions. Ambi-

ent air or oxygen flow is based on ABG results. The client

may be placed on a face mask, steam collar, Tpiece, me-

chanical ventilation with PEEp, pressure support ventila-tion, or high-frequency jet ventilation. The goal of all

therapies is to maintain adequate tissue oxygenation with

the least amount of inspired oxygen flow necessary.

Drug Admiuistration Medications used to dilate con-

stricted bronchial passages are administered intra-

venously and as inhalants to control bronchospasms and

wheezing. Mucolytic agents are employed to liquefy tena-

cious sputum and aid in expectoration.




Continuous Assessment An arterial line is placed in

the client with major burn injury for continuous assess-

ment of ABGs. Pulmonary artery pressure catheters also

are inserted to measure pulmonary vascular resistance

( PVR ) , pulmonary artery pressure (PAP) , pulmonary cap-'

illary wedge pressure (PCWP), and mixed venous oxygen

sa tu rat io n (S V 0 2). The PV R and PA P rise in the presence

of hypoxia. The SV02 is the average percentage ofhemo-

globin bound with oxygen in the venous blood and re-

flects overall tissue utilization of oxygen. Pu1se oximetry,

a noninvasive assessment, is used to monitor arterial oxy-

gen saturation levels, especially during routine nursing

procedures. Frequent auscultation of lung sounds, docu-

mentation of sputum production, observation of signs of

respiratory distress, and monitoring of hemodynamic pa-

rameters are al l priority nursing responsibilities (Cioffi. et

al., 1991; Eisenberg, 1991; Rue &Cioffi, 199~).

Inpatient Collaborative Care

After stabilization in the emergency department, theclient is transferred to the critical care unit or a special-

ized burn center, where continuous monitoring of labora-

t ory t es ts , administration of pharmaceutical agents, pain

control, wound management, and nutrition support ther-

apies constitute the initial plan o f care.

The Burn Team

The bum team (see figure 18-2) is composed of an in-

terdisciplinary group of health care professionals, who to-

gether plan the care and treatment of the bum-injured'

client during the acute and rehabilitative phases. The

burn team co nsist s o f the nurse, physician, physical t he r -

apist, nutritionist, social worker, and burn technician.Th e team members meet regularly to discuss client

progress and to determine collaboratively the most effec-

tive regimen of care (Achauer, 1987: Boswick, 1987).

Nurse Burn nursing is a subspecialty of critical care

nursing practice. In addition to the routine procedures

per formed by the critical care nurse, the bum nurse car-

ries out hydrotherapy, applies skin grafts according to

protocol, maintains laminar flow environments, assesses

the extent and depth of the bum injury; and calculates

fluid replacement. Burn nurses continue their education

on an ongoing basis by attending in-service programs and

national conferences.

Physician The bum physician is a specially trained

medical practitioner who usually serves as the director of

the bum unit or center and establishes a n treatment pro-

tocol. Research-based strategies guide all practice and

procedure, and are developed and implemented under

the direct supervision of the burn physician.

Physical Therapist The physical therapist works to-

gether with the nurse in the burn unit at the bedside. The

therapist determines the exercise regimen, which is im-

plernented early in the treatment plan. Splinting, progres~

sive ambulation, active and passive ROM exercises, and

the application of pressure support garments are collabo-

ratively Included in the: plan of care under the guidance

and direction of the therapist.

Nutritionist The nutritionist works closely with the

nurse and physician to calculate the client's daily caloricneeds. The nutritionist collaboratively determines the

composition of feeding formulas, taking into considera-

tion all laboratory findings, anthropometric measure-

ments, parenteral therapies, and the changing clinical pic-

ture.

Social Worker The social worker meets with the fam-

ily unit early in the admission process to begin to plan for

the rehabilitative phase of care. The social worker assesses

the home and social environment and makes referrals to

appropriate community resources.

Burn Technician The burn technician is a supportive

member of the team who has been specially trained to im-plement advanced procedures under the: direct supervi-

sion of the' burn nurse. The complex nursing care O f the

burn-injured client often necessitates 2:1, or higher,

nurse-client ratios. The nurse-bum technician dyad is a

cost-effective approach to delivering the kind of highly

technical, labor-intensive care needed in the burn unit.

The burn technician helps maintain the level of care re-

quired.

Laboratory and Diagnostic Tests

The following laboratory tests and procedures are ordered

early in the treatment phase to evaluate the clients

progress and to modify intervention strategies (Cioffi &Rue, 1991; Swearingen etal., 1988):

• Culture and sensiLivity reports indicate the presence of

infection in sputum, blood, urine, and wound tissue.

• U rinalY5i5 indicates the adequacy of renal perfusion

and the client's nutritional status. In catabolic states,

nitrogen is excreted in large amounts into the urine.

Nitrogen loss is measured through 24-hour mine col-

lections for total nitrogen, urea nitrogen, and amino

acid nitrogen. Myoglobinuria, which manifests as a

dark brown, wine-colored urine, signals the develop-

ment of acute tubular necrosis. Loss of plasma protein

and dehydration lead to proteinuria and elevated urinespecific gravity. Glycosuria is a transient development

following major burn injury that indicates a need to

adjust the nutritional program.

• H em atocrit is elevated secondary to hernoconcentra-

tion and fluid shifts from the intravascular compart-

ment.

• H em og[obin is decreased secondary to hemolysis.

iI' Sodium l~ve1sare decreased secondary to massive fluid

shifts into the interstitium. .



1 - - - - - - -;

• B lood urea nitrogen. (B UN ) is elevated secondary to de~

hydration,

• Potassium levels initially are elevated during burn

shock, as a result of cell lysis and fluid shifts into the

extracellular space, Potassium levels decrease after

burn shock resolves, as fluid shifts back to intracellular

.and intravascular compartments,• T otal protein, album in, transfe.rrin, prealbum in, retinol

b in din g p ro tein , a lp ha l- acid glyc op ro tein , a nd C "l'ea ctiv e

protein are indicators of protein synthesis and nutri-

tional status, Because of the fluid shifts that occur dur-

ing the early stages of the burn injury, they are more

useful markers during th e rehabilitative phase of care,

• C reatine phosphohina se ( CP K ) is elevated following an

electrical burn, secondary to extensive muscle damage,

• B lood type and crossmatch are performed on the clients

arrival to the unit in case transfusions are required,

• WBCs are elevated in the presence of infection and de-

pleted in immunodeficient states,

• C re attil1 ne is elevated in the presence of renal insuffi-

ciency.

• B lood glucose is transiently elevated after major burn in-

jury Hyperglycemia is treated by adjusting the nutri-

tional program or administering exogenous insulin,

The following diagnostic tests may be ordered:

• 5er ialABGs indicate the presence of hypoxia and acid-

base disturbances and indicate client responses to

changes ill oxygen therapies. The burn-injured client

may demonstrate elevated or lowered pH, decreasedPeo2, decreased P02, and low-normal bicarbonate

levels.• Pulse oximetry allows continuous assessment of oxygen

saturation levels. The burn-injured client may have

saturation levels below 95%,

• Serioi chest X-ray studies document changes within the

first 24 to 48 hours that may reflect the presence of

atelectasis, pulmonary edema, or acute respiratory dis-

ease CARD),

• V entilation" perju sL on scan is performed following the in-

travenous injection of isotope xenon 133, Serial scin-

tiphotograms are taken to determine pulmonary clear-

ance of the isotope, A complete washout of the isotope

occurs in 90 seconds, Delayed pulmonary clearance,

(i.e. greater than 90 seconds) indicates lower airway

injury.

Ii Flexible bronchoscopy permits direct visualization of the

upper airways, The procedure can be performed at the

bedside with appropriate administration of conscious

sedation. The bronchoscope is inserted into the tra-

chea via the the nose or mouth and advanced to the

bronchi. The bronchial passages are observed for evi-

dence of burn injury and presence of mechanical ob~

struction.

-----_.-_._


• P ulmonary function tests include forced vital capacity

(FVC) , forced expiratory volume in 1 second (FEVl),

and forced mid-expiratory flow {FEF). All values are

decreased in the presence of airway obstruction, The

nurse an d respiratory therapist assess vital capacity,

tidal volume, and minute ventilation frequently at the

beds ide , to monitor for the development of respiratory

distress or failure.

• Se liar e le ct roca rd i og rams (ECGs ) are necessary to rnoni-

tor th e development of dysrhythmias, especially those

associated with hypokalemiC and hyperkalemic states,

• In dire ct ca lor im etlY is used to track the clients basal

metabolic rate. The basal metabolic rate (BMR) , a

function of the bodys energy expenditure, depends on

th e extent of the burn injury Total energy expenditure

(TEE) in th e bum-injured client may be elevated to

15% to 100% more than basal metabolic needs.

Pharmacology

Pain Control Second- and some third-degree burns

cause excruciating pain. In the early stages of care, intra"

venously administered narcotics are the best means of

managing pain. Once the client has been stabilized, it is

appropriate to administer narcotic agents prior to initiat-

ing hydrotherapy or intensive exercising routines. The in-

tramuscular route of administration should be avoided

until hemodynamic stability and unimpaired tissue perfu-

sion returns.

As the client enters the rehabilitative stage of care, al-

ternative therapies for pain control may be added to the

plan of care. Distraction, self-hypnosis, guided imagery,

and relaxation techniques are helpful adjuncts in manag-ing pain. The nurse can help the client engage in t hese

therapies, Allowing the client some control in the treat-

ment process is another important nursing intervention in

the effective management of pain . Pa t ien t -cont rol led anal- .

gesia (PCA) has been demonstrated to enhance the clients

ability to cope with pain. AlLowing the client to participate

in planning treatment and scheduled procedures gives the

client more control over his or her environment and fos-

ters the development of coping strategies (Achauer, 1987;

Martyn, 1990; Richard & " Staley, 1994), See Chapter 4 for

a discussion of strategies for managing pain,

Antimicrobial Agents Most invasive wound infections

are caused by the following organisms: Pseudomonas

aerug inosa, En te robact er c loacae , K l eb si el la , S taphylococcus

aureus, enterococci, an d Candida. To eliminate infection

on the surface of the bum wound, topical antimicrobial

t he rapy is used. There are many antimicrobial agents

available. The three most Widely used are 0,5% silver ni-

trate, 1% silver sulfadiazine, and 10% mafenide acetate.

The latter two agents are broad-spectrum antibiotics that

are supplied in a cream form. Using aseptic technique,

the nurse applies th e cream directly to the wound or to a



642 Unit 4 Responses toAltered Sldn Integrity

TOPICAL ANTIMICROBIAL AGENTS

Mafenide acetate (Sulfamylon)

Silver nitta te

Silver sulfadiazine (Silvadene) ..

The use of tcptcal antimicrobial therapy was first in-

vestigated more than 60 years ago. Researchers found

that the most effect ive topical agents are those that (1)

act against the major pathogens responsible fo r caus-

ing bum wound infection, (2) achieve levels of con-

centration sufficient to decrease microbial coloniza-

tion, (3) are rapidly excreted or metabolized, (4) ar e

nontoxic, and (5) are easy to use and inexpensive

(Martyn, 1990).

Mafenide Acetate

Mafenide is a synthetic antibiotic closely related chern-

ically but not pharmacologically to the sulfonamides,

Although the mechanism of action is unclear, the drug

appears to interfere with the metabolism of bacterial

cells. Mafenide is a bacteriostatic agent effect ive against

many gram-positive and gram-negative organisms

(Martyn, 1990).

For topical administration, mafenide is used in an

8.5% cream in a water-miscible base. Following appli-

cation, the drug is rapidly diffused through the bum

e sch ar an d absorbed systemically.

In the general circulation, mafenide metabolizes to a

weak carbonic anhydrase inhibitor known as p-car-

boxybenzenesulfonamide, a substance: that impairs the

renal mechanisms involved in the buffering of blood.

Bicarbonate excretion in the urine increases, and am-

monia and chloride excretion decreases. ·T o maintain

normal acid-base balance, the pulmonary system ef-

fects a compensatory hyperventi latory state. If the

compensatory hyperventilation is insufficient, the

client develops metabolic acidosis.

Nursing Responsibilities

I Use mafenide with caution in clients with renal or

pulmonary disease.

mesh gauze pad that is then applied to the wound and

changed twice daily Silver nitrate is applied as a wet

dressing, which is changed twice daily and soaked every

2 hours. With each dressing change, the nurse carefully

assesses the wound for evidence of healing or signs of in-

fection. The nurse tracks all culture and sensitivity re.-

ports, which serve as the basis for the selection of the an-

• Approximately 3% t o S O l o o'r ~lients develop '8 . h y -persensitivity t o m afe nid e, resulting in a macu-

lopapular rash on th e unburned areas. Assess the

client for the following; ...

Pruritus

Facial edema

Swelling

. .U r fli :a i" ia '. '· ;: ' '

Blisters

Eosinophilia

I f hypersensitivity reactions occur, discontinue the

drug and administer antihistamines.

• Monitor the client for superinfection within the

burn eschar, in the subeschar tissue, or in viable tis-

sue adjacent to the wound ..

Client' and ·Family T e a c h i n i r ? ' : " · : " ·

• Expect pain or a bumingsensarion following d.rug

application. Take appropriate measures to control

pain before applying the drug.

I Apply the drug to clean, debrided. burn wounds

once or twice. daily. Continue applications until

healing is apparent (Martyn, 1990).

• If any signs of allergy develop, discontinue the drug

and notify the physician ..

I Report any sudden and prolonged increases in res-

piratory rate.

Silver Nitrate

Silver nitrate. is a bacteriostatic agent that 'inhibits a

wide variety of gram-positive and gram-negative or-

ganisms. Its antimicrobial effect is due. to the actions of

silver ions, which markedly alter the microbial cell.

wall and membrane. Additionally, the drug denatures

bacterial protein, thereby inactivating and precipitat-

ing the microbes (Martyn, 1990).


• Silver nitrate is used as a 0.5% solution in distilled

water. Apply the solution to bulky gauze dressings

every 2 hours, and provide complete dressing

changes twice daily.

timicrobial agent. The choice of topical antibiotic is based

on the extent of the bum wound, the presence of identi-

f ied bac te r ia l organisms, and client response.

Prophylactic administration of systemic antimicrobial

agents is not recommended. Because the avascular bum-

injured tissue cannot maintain therapeutic blood levels of

antimicrobial agents, it is difficult to control the: growth of, .




• Silver nitrate ha s limiteripeni=tratirig ability and is

ineffective if used more th an 72 hours follow in g aburn injury: ,

• At the local tissue level, silver nitrate immediately

interacts with chloride ions toform a b lack silve r

chloride precipitate t ha t discolors both the bum

wound and th e adjacent t issues. The discoloration

significantly hampers visual inspection of thewound, '

• High concentrations of the drug result in cellular

toxicity of surrounding healthy tissue,

• Because large amounts ofwater are systemically ab- ,

sorbed from the dressing site, th e client may

dem onstrate a hypotonic s ta te . Hyponat rem i a an d

hypochloremic alkalosis are common manifesta-

'tions in burn-injured clients treated with silver ni-trate (Martyn, 1990).

.' __ .,

Client and Family Teaching,

• W atch for and report any signs and symptoms of

hypotonicity: swell ing, weight gain, difficulty in

breathing.

,Ii T his d ru g c a U s e : S - f l . b hck"di~ cb lcjratib h on all skin

surfaces and dressings withwhic~ it, comes into

contact,

• Becaus~dlscolotationcan c6riceal eWdence of infec-

t ion, watch for systemic manifestations of infection:

fever,malaise, rapid pulse rate, listlessness,

• Saturate the wound dressings every 2. hou 1'5 with a

0.5% aqueous solution of the drug. Change the

dressings completely twice daily

Silver ·SuIfadiazhlti:"<,;i:' "

Silver sul[adia2iile:;'~ sulfoharhide,· iS tl1eiiiost com-

monly used topical agent. Th e drug acts on the cell

membrane and cell wall of susceptible bacteria and

, binds to cellular DNA.The drug is b ac te ric id al an d ef -

fective against a wide variety ofgram-negative and

gram-positive organism s,' ,',: , ', ' : '.: • ' ' ~ ' : • _ _ r , _ _ : :~ ~,_ - •

: " ' , . . ' ~ .; ~ ~_ : " . ' _ ' ~ - - ~ - : < .~ -~>",. ' ~ · ~ ~ . _ , : , . ~ 5 ~ > · ~ . ·

bacteria at t h e s it e . Further, the indiscriminate use ofsystemic

agents contributes to the development of resistantstrains,

Systemic antimicrobial therapy is, however, indicated

in the immediate preoperative and postoperative period

associated with excision and autogmfting. Postopera-

tively, the therapy is discontinued as soon as the clients

hemodynamic status returns to normal, usually within

... '~


II' Many clients develop a marked leukopenia in re-sponse to this dmg, which tends to improve spon-

taneously over th e course of therapy This finding

does not contraindicate use of the. drug (Boswick,

1987).

• Hypersensitivity to silver sulfadiazine has been re-

ported in a small numbe r of cases. I f the clie nt de -

v elo ps h yp erse nsit iv it y, a dm in iste r antihistamine,

an d change th e topical agent.

• If sulfa crystals form in the urine, keep the client

well hydrated (Boswick, 1987). ",

• Treatment with this drug can cause systemic uptake

of p ro py le ne g ly co l, which results in an elevated

serum osmolality an d high urine specific gravity in

the client who is not dehydrated. These findingstend to create confusion during the fluid resuscita-

tive stage of care. Whenever the' serum osmolality

an d urine specific gravity fail LO correlate with a

clinical picture that reflects fluid volume overload

(elevated CVP/PCWp , rhonchi/wheezing, edema),

suspect systemic propylene glycol uptake (BOSwick ,

1987)., 1 .: , __ . / ~ -. :.

Client and Family Teaching

• Apply the drug t o c le an : de bride d w oun ds once or

twice . daily, completely covering th e b urn wound at

al l times (Martyn, 1990),• Continue applying the drug until healing is appar-

ent (Martyn, 1990).

• If any sig ns o f allergy develop, discontinue th e drug

and notify the physician.

• Watch fo r evidence of concentrated urine, and no-

tify the physician.

• I f not contraindicated, drink la rg e amoun ts of fluids

to prevent sulfa crystals from forming in the urine. '

the first 24 hours. In the Long-term treatment of identif ied

infectious processes, drug administration is l imited to the

least amount of time required to eradicate the infection

(Boswick, 1987; Duncan &Driscoll, 1991; Martyn, 1990;

Walter, 1993; Weber &: Tompkins, 1993). See the accom-

panying box for a discussion of the nursing implications

for topical antlmicrobial t he rapy for the burn client.




Calculating Total Energy Expenditure

from Metabolic Cart Measurements:.~.:. ..: .. .:":;.;.-

TEE = REE X activity factor X injury factor

REE = Resting energy expenditure (reading from metabolic

cart)

TEE = Total energy expenditure

Ac tiv [t y F a ct or s

1.2 = bedridden patient

1.3 = ambulatory patient

I nj ur y Fa .c to rs

1.2 = surgery1.35 = trauma

1.6 "" sepsis

2.1 =burns

Tetanus Prophylaxis If th e client's immunization sta-

tus is in doubt, tetanus toxoid is administered intramus-

cularly early in the acute phase of care to prevent Clostrid-

ium te ta ni infection (Boswick, 1987).Prevention of Gastric Hyperacidity To prevent Curl-

ings ulcer, an e rosion of the gastric and duodenal linings

associated with burn injury, hyperacidity must be con-

trolled. A nasogastric tube is placed during the emergent

phase of care, and gastric aspirant is obtained hourly The

gastric pH should be assessed and maintained at levels

above 5. To control gastric acid secretion during the acute

phase of care, histamine H2 blockers (e.g., cimetidine and

ranitidme) can be administered intravenously, either in-

termittently or as continuous infusi.ons. As soon as bowel

sounds become audible, the client isp laced on an antacid

regimen (Driscoll et al. 1993; Hansbrough &. Hans-

brough, 1993; Martyn, 1990).

Nutritional Support

A total assessment of the nutritional needs of the bum-

injured client is crucial in planning nutritional support

therapies to decrease catabolic states. The nurse and nu-

tritionist collaborate to develop the clients dietary plan,

carefully evaluating the clients energy needs prior to im-

plementing the selected nutritional therapy

Energy expenditure depends on the extent of catabo-

lism and the client's physical activity, size, age, and sex.

An anthropometric assessment includes measurement of

height, weight, and triceps skinfold thickness. Both the

nurse and nutritionist perform anthropometric assess-

ments on an ongoing basis to monitor kcal expenditure.

These assessments' are not always reliable indicators,

however; for example, the administration of large

amounts of intravenous fluids, the application of bulky

immobilizing devices, and the amputation of extremities

can account for changes inweight. Additionally, upper

arm anthropometry, which indicates fat stores and muscle

mass, may be difficult to perform if the burn injury in-

.valves the upper extremities.

Recently the metabolic cart has been demonstrated to

be a more accurate indicator of energy needs. The cart,

which can be taken to the bedside, functions on the prin-

ciple of indirect calorimetry, which refers to the calcula-

tion of TEE by measuring respiratory gas exchange. Indi-

rect calorimetry. is based on the theory that oxygen

consumption and carbon dioxide production profile in-

tracellular metabolism. The cart generates estimates o f theresting energy expenditure CREE) and the respiratory

quotient (RQ), a measurement that represents the ratio of

carbon dioxide production (Ve02) to oxygen consump-

tion 0102) (Table 18-5). Indirect calorimetry should be

performed at regular intervals and the client's dietary reg-

imen adjusted accordingly (Swearingen et al., 1988).

Enteral. Feeding Traditional dietary management

based on oral intake seldom meets the kcal requirements

necessary to reverse negative nitrogen balance and begin

the reparative process. Enteral feedings are therefore in-

stituted within 24 to 48 hours of the burn injury to offset

hypermetabolism, improve nitrogen balance, and de-crease length of hospital stay. A nascintestinal feeding

tube is placed under fluoroscopy, with the tip extending

past the pylorus to prevent reflux and aspiration.

To maintain proper tube placement, the nurse moni-

tors and documents the position of the tube. Tube place-

ment is determined by pH-paper or pl-l-meter measure-

ments. (See the accompanying research box.) Because

nasointestinal feeding tubes have very small diameters,

they rend to dislodge during vigorous coughing or vomit-

ing episodes. Additionally, such tubes are also prone to

clogging and must be frequently flushed to maintain pa-

tency, especially after the administration of medications.

The nurse auscultates bowel sounds and measures ab-

dominal girth frequently to monitor feeding tolerance.

Gastric secretions may accumulate above the level of

the pylorus despite appropriate nasointestinal tube place-

ment. It may be necessary to connect the nasogastric tube

to low-intermittent suction to maintain gastric decom-

pression. If aspiration is suspected, th e nurse suspends all

feedings until tube placement is verified. .

A feeding pump can control the continuous infusion of

tube feedings. Initial feedings are calculated at one-half

the kcal need and advanced at the Tate of 10 mLlh until

the recommended daily kcal intake is reached. The nurse

evaluates the clients tolerance of the feedings and reports

any evidence of vomiting, diarrhea, or constipation. The

nutritionist can modify the feeding formula to reduce

these complications. As the client becomes able to toler-

ate oral feedings, the tube feeding is slowly titrated off

(Carlson &'Jordon, 1991).

Parenteral Nutrition Although enteral feeding is the

preferred nutritional therapy, it is contraindicated in

Curling's ulcer, bowel obstruction, feeding intolerance,

pancreatitis, or septic ileus. 'When the. enteral rome can-



Chapter 18 Nursing Care of Clients with BUrns 645

Applying Research to Nursing Practice: Feeding Tube Placement

The nurse is responsible for ensuring that all enteral

tubes are <correctly positioned, Inaccurate tube place-

ment may lead to pulmonary complications, such as

pneumonitis, pleuritis, empyema, sepsis, and aspira-tion. Small-bore enteral tubes tend to be the most dif-

ficult to insert and can be easily displaced during

retching, vomiting, violent coughing, O r tracheal sue-

noning, Standard nursing protocol requires that the

nurse verify tube placement on initial insertion, prior

to all bolus feedings, and once per shift during contin-

uous feedings .

• < In one study, researchers investigated the use of pH

meters in differentlating gastric, intestinal, and inad-

vertent respiratory placement of feeding tubes

(M eth eny, R ee d, Wiersema, McSweeney, Wehrle, &:

dark, 1993), The study sample consisted of 405 aspi-

rates [rom small-bore nasogastric tubes and 389 aspi-rates [rom nasointestmal tubes, The samples were ob-

tained from 605 subjects ranging from age 18 to 94,

Although over half of the sample population received

gastric acid inhibitors, all clients receiving antacids ei-

ther orally or by tube within 4 hours of testing were

excluded from the study to prevent interference with

the measurement of pH values, Aspirates were ob-

tained within 5 minutes of abdominal radiographic

imaging, which was used to verify tube placement.

Ga~tric contents were aspirated 1 hour after feedings

or medication administration, and the feeding tube

was flushed with 20 mL of air to clear all substances

prior to each aspiration, Because Inany of the subjects

were confused and frequently removed their own

tubes, were transferred to other facilities, or could not

be studied [or all phases of the investigation, pH-meter

readings of the gastric contents, not the clients them-

selves, were the focus of analysis,

.Implications for Nursing

In the severely burn-injured client, continuous enteral

feedings arc instituted early in the treatment phase to

offset hypermetabolism, The continual assessment offeeding tube placement is a priority nursing interven-

tion, The study indicated that whereas pH measure-

ment cannot confirm the initial placement of enteral

tubes, pl-I-metered testing can be an appropriate

means to detect manual manipulation or tube migra-

tion, Although this study reported only those findings

associated with pH-meter measurements! it did point

out the differences noted between pfI-meter readings

and pli-paper readings. The researchers found that

pll-meter readings tended to be 0.5 unit higher than

pH-paper readings, a finding especially evident in

clients receiving acid inhibitors, Moreover, pri-paper

readings are based on the use of color charts; differ-ences in the ways people interpret the readings can

also affect [be accuracy of these measurements.

Critical Thinking in Client Care

1. This study included clients at both ends of the age

spectrum, How might differences in gastric motil-

ity and gastric acid productivity in the younger

versus aged client affect the study'S results?

2, How might subjective assessments based on pH-

paper measurement differ from objective assess-

ments obtained with pH-meter measurement?

3, Why do pH measurements correlate well with ra-diographic findings of tube placements?

4, Deve lop a plan to teach nurses to perform pH-

paper and pft-meter gastric measurements using

radiographic findings to corroborate tube place-

merit.

not be used, a central venous catheter is inserted via the

subclavian or jugular vein for the administration of total

parenteral nutrition (TPN} Prior to initiating TPN, the

nurse must verify central line placement on chest X-ray

film, All risks associated with central lines require astutenursing observation and continuous assessment for

catheter contamination, pneumothorax, air embolism,

and venous thrombosis,

Cleaning the Wound

&oon as the clients condition stabilizes, the nurse pre-

pares the client for hydrotherapy. Depending on the

medical protocol, the client may be submersed into a

Hubbard tank, hosed over a spray table, showered, or

given a bed bath (Figure 18-8). The nurse applies a mild

cleaning solution, such a s chlorhexidine gluconate (Hibi-

dens), to the wound site and gently washes the burned

area. Because this is a very painful procedure, the client.

will need appropriate medication, To maintain body tem-perature, the nurse warms the client using heat shields

and warm bathwater, Hydrotherapy remains part of the

daily cleaning routine until wound closure is accom-

plished, See the box on page 646 for the nursing implica-

tions for hydrotherapy

Debriding the Wound

Burned tissue releases chemical mediators that stimulate

phagocytosis in an attempt to digest debris that is !e[t by



646 Unit 4 Responses toAltered Skin lntegrity

~.. '_ oli. 'D .....

. ~ "

Nursing Implications for Hydrotherapy:

Tubbing

The purpose of hydrotherapy is to provide an oppor-

tunity for an initial assessment of the wound following

a thorough cleansing. Hydrotherapy is 'also employeddaily to remove topical agents and debride the wound.

Depending on medical protocol, the client may be sub-

mersed in a Hubbard lank (tubbing), hosed over a

spray table, showered, or given a bed bath.


• Prepare lhe client for the tubbing procedure as soon

as possible after admission to the bum unit. Prior t otransporting the client to the tub room, ensure that

the client is hemodynamically stable.

• Follow strict isolation procedure. Thoroughly disin-

fect the tub before and after bathing the client.

• Maintain a warm environment.

• Explain the entire tubbing process to the client, in-

cluding the. pain that he or she can expect and how

it will be managed.

• Pain management is a primary concern. Prophylac-

tically, administer narcotic analgesia, and make

every effort to promote relaxation and comfort.

• Allow the client to participate in the planning of this

daily routine. to lower anxiety

• Gently lower the client into the rub, completelysubmersing the burn wound.

decaying necrotic tissue. Necrotic tissue that remains de-

spite phagocytic action retards healing and prolongs in-

flammation. Debridement is the process of removing

dead tissue from the wound. Three methods of debride-

ment are employed: mechanical, enzymatic, and surgical.

Mechan ic al d e br id emen t is performed during hydro-

therapy by the nurse or therapist. In this procedure, loose

.necrotic tissue iswashed with a washcloth or gauze pad to

remove dead skin and separate eschar. Blistered skin is

grasped with a dry gauze and gently removed. The edges

of blisters or eschar are trimmed with blunt scissors.Wounds should be rubbed sufficiently hard to remove de-

bris ye t not cause bleeding. Following debridement, th e

nurse shaves hair from the bum site. Hair tends to trap

debris, foster bacterial growth, and cause: pain during de-

bridement procedure.

Enzymat ic debridement involves the use 'of a topical

agent to dissolve and remove necrotic tissue. Following

hydrotherapy; the nurse applies an enzyme of choke in a

thin layer directly to the wound and covers It with one

• Wash the bum wound with a mild disinfectant so-

lution, and allow it to soak to soften the eschar.

• DUling hydrotherapy, remove eschar with sterile

scissors and forceps.

• Shave thehair on and around the burn wound.

• Have the client perform ROM exercises during hy-

drotherapy

• To minimize heat 10s5, pain sensations, and elec-

trolyte depletion, limit the entire procedure to 30

minutes.

Client and Famity Teaching

• Instruct in the importance of performing active

ROM exercises during the tubbing procedure.• Explain all rationale supporting the implementation

o f this very uncomfortable procedure.

• Assure the client that the procedure will be discon-

tinued as soon as the wound shows evidence of

healing.

• Teach the client how to prevent contractures, em-

phasizing the need for aggressive exercise therapy

early in the rehabilitative phase. Help the client un-

derstand how hydrotherapy facilitates the exercise

routine.

layer o f fine mesh gauze. The nurse tl~en applies a topical

antimicrobial agent, covers the wound with a bulky wet

dressing, and immobilizes the wound with expandable

mesh gauze. .

Surgi ca l debri demen t is discussed under the section on

surgical managemenc of the burn wound.

Dressing the Wound

Once the wound has been cleaned and debrided, itmay

be dressed using one of two methods. In the open

method, the bum wound remains open to ail', coveredonly by a t opica l antimicrobial agent . This method allows

the wound to be easily assessed; however, it can be used

only where strict isolation precautions are followed. Top-

ical agents must be frequently reapplied because they

tend to rub off onto the bedding.

In the closedmethod, a topical antimicrobial agent is

applied to the wound site, which is covered with gauze or

a nonadherent dressing and then gently wrapped with a

gauze roll bandage (Figure 18-9). With the closed



r:'igure18-9 Closed method of dressing a burn.

method, burn wounds are usually dressed twice daily and

as needed. Dressings are applied circumferentially in adistal-to- proximal manner. All fingers and toes are

wrapped separately. For wet-to-dry dressings, a thick

gauze. is applied to maintain moisture. and is soaked every

2 hours with the ordered solution.

Surgical Management of the Burn Wound

Three surgical interventions are commonly employed to

manage the burn wound: surgical debridement, escha-

rotomy, and autografting.

Surgical Debridement Surgical debridement refers to

the process of excising the wound to the level of fascia

(fascial excision) or sequentially removing thin slices of

the burn wound to the level of viable tissue (sequential

excision). Because fascial excision, Or fasciectomy, sacri-

fices potentially viable fat and lymphatic tissue, its use is

reserved for clients with extensive or fourth-degree

burns. The most common technique is electrocautery

with cutting and coagulating current capabilities. Sequen-

tial excision is performed with the use of a dermatome.

Shallow bums and some of moderate depth bleed briskly

after one slice. I f bleeding does not occur, the procedure

is repeated until a viable bed of dermis or subcutaneous

fat is reached. Following surgical debridement, the client

is returned to the bum unit (Boswick, 1987; Richard &:

Staley, 1994)

Escharotomy The burn injury results in the formation

of necrotic skin and subcutaneous tissue. During the

acute stage of the injury, a hard crust (eschar) [arms,

which covers the wound and harbors necrotic tissue. The

. eschar is characteristically leathery and rigid, When the

bum eschar forms circumferentially around the torso or

extremities, i t acts as a tourniquet, impairing circulation.

Left unchecked, the affected body part becomes gan-

grenous.

Chap ter 18 Nursing Ca reoo f Clients with BClrTIS 6

Figure 18-10 Escharotomy. The surgical procedure consists

of rernovlnq the eschar formed on [he skin and underlying tissue

fo llowing severe burns. The procedure is particularfy helpful in

restoring ci rculation to the extremities of clients when scar tissue

forms a light, constrictive band around the circumference of a

limb.

To prevent circumferential constriction of the torso

extremity, an escharotomy is performed by the physicianwith a scalpel or by electrocautery (Figure 18-10). A ste

ile surgical incision is made longitudinally along the e

tremity or the trunk to release taut skin and allow for e

pansion caused by edema fannation (Achauer, 198

Richard &: Staley; 1994). In the first 24 hours following

the procedure, the incision should be gently packed wit

fine mesh gauze. After 24 hours, the site may be treated

with a direct application of silver sulfadiazine. See the bo

on page 648 for the nursing implications for the clien

undergoing escharotorny

Autografting Autografting, a procedure performed i

the surgical suite. is used to effect permanent skin coverage. Skin L S removed from healthy tissue (donor site) o

the burn-injured client and applied to the bum wound

(Figures 18-11 and 18-12). Aft e r the autograft is applied,

the grafted area is immobilized. The site is assessed dail

for evidence of adherence. The client resumes ROM exer

cises 5 days postgmft. As the wound heals, the client may

complain of itching, which can be treated with the appli-

c at io n o f m ild lotions.

The nurse assesses the donor site postoperatively fo

healing and the absence of infection and applies a dress-

ing such as Op-Site directly to the donorsite. Op-Site is

biosynthetic transparent dressing that permits frequent

direct observation of the wound throughout the healingprocess. At any sign of infection, the nurse removes syn

thetic dressings and applies antimicrobial agents.

Cultured epithe lia! autograft ing is a new technique in

which skin cells are removed from unburned sites on the

clients body and are then minced and placed in a culture

medium for growth. Over a 5- to 7 -day period, the cells

expand 50 to 70 times the size of the initial biopsies. The

cells are again 'separated out and placed in a new culture

medium for continued growth. With this technique,



6+8 Unit 4 - Responses to Altered Skin lntegnty

c. Observe for evidence of cyanosis, tachypnea,

anxiety, or restlessness.

• For circumferential burn wounds of the neck, assess

for evidence of respiratory distress. Prepare theclient [or prophylactic intubation.

• Monitor fo r excessive blood loss, and transfuse the'

client if indicated.

• Dress the open wound (escharotomy) with topical

antimicrobial agents as ordered.

Nursing Implications for Circumferential Wound Management: Escharotomy

• I!l II

When a burn wound totally encircles an extremity, the

torso, or the neck, the client is at risk fo r impaired lis-

sue perfusion of the involved area. To prevent arterial

occlusion. a circumferential burn wound may need tobe excised. An escharotomy is a lengthwise incision

made by the physician along the circumferential burn

wound to release tension and permit unobstructed ar-

terial blood flow. The nurse continuously assesses the

involved area and notifies the physician of the need to

perform this emergent procedure, which is done at the

bedside. Because only the dead burn wound tissue is

excised, the client experiences very lit tle pain.

.Nursing Responsibilities

• For circumferential bum wounds of the extremity,

assess the extremity for absence of blood flow:

a. Using a Doppler ultrasound stethoscope, check

hourly for the presence of a pulse.

b. Assess the extremity hourly for warmth, color,

sensation, and capillary refill.

c. Observe for evidence of numbness or tingling.

• For circumferential bum wounds of the torso, as-

sess for evidence of respiratory distress:

a. Obtain ABGs as needed.

b. Auscultate lung sounds hourly.

enough skin can be grown aver a period of 3 to 4 weeksto. cover an entire human body. The cells are prepared in

sheets and attached to petroleum jelly gauze backing,

which is applied to the bum wound site. The procedure is

conducted in the aseptic environment of the operating

room. After 7 to 10 days, the petroleum jelly gauze back-

ing is removed and non adherent dressings applied to pre-

vent mechanical trauma to the cells.

Burn Wound Closure: Biologicand Biosynthetic

Dressings

The terms biologic dressing and biosynthetic dressing

refer to any temporary material that rapidly adheres to the

wound bed, promotes healing, and/or prepares the burn

wound for permanent autograft coverage. Ideally, these

kinds of dressings should be easy to apply and remove,

inexpensive, nonantigenic, elastic, able to reduce pain,

able to serve as a bacterial barrier, and able to enhance the

natural healing process. The dressings are applied to the

burn wound as soon as possible. Covering the wound

eliminates the 105s of water through evaporation, reduces

infection, and promotes wound healing. Biologic and

Client Teaclling

• Teach the client the importance of reporting any ev-idence of impaired circulation: numbness, tingling,

blue color to the extremity, absence of sensation.

• Assure the diem that the procedure will not be

painful and will provide immediate relief.

• Teach the client the importance of protecting the

open wound (escharotomy) from infection.

• Explain the rationale supporting prophylactic intu-

bation for burn wounds involving the head and

neck.

• Provide assurance that a n blood loss will be re-

placed and that bleeding at the site will be con-

trolled.

biosynthetic dressings that are currently in use includehomograft (allograft), heterograft (xenograft), amnionic

membranes, and synthetic materials.

Homograft, or allograft, is human skin that has been

harvested from cadavers. It is stored in skin banks located

throughout th e nation. Th e development of methods to

achieve prolonged storage of frozen, viable skin has in-'

creased the use of this dressing; however, its short supply

and expense still pose problems. It is manufactured as

strips that are cut to the pattern of the burn and applied

using sterile technique. Under normal circumstances, a

homograft is rejected within 14 to 21 days following ap-

plication.

Heterograft, or xenograft, is skin obtained .from an

animal, usually the pig. The use of this grafting material

was first reported in 1880. Although fresh porcine het-

erograft is available to some centers, frozen heterograft is

much more commonly used. Once applied, heterograft

appears to undergo early softening and lysis from enzy-

matic action from the wound. As a result, frequent

changes of the heterograft dressing are necessary. Because

of the high infection rates associated with this dressing,



Figure 18-11 Skingrafting procedure.

silver-nitrate-treated porcine heterograft has been devel-

oped to retard microbial growth. The nurse assesses the

wound at each dressing change, cleaning and trimming

the heterograft umil the wound heals, Heterograft is sup-

plied in meshed and unmeshed rolls and sheets of various

sizes.

Amnioni c membrane s have been used as biologic dress-

ings since 1912. They are readily available and inexpen-

sive. Because they tend to disintegrate within 48 hours af-

ter application, frequent dressing changes ar e necessary.Amnionic membranes are less effective than homograft

and heterograft dressings in reducing evaporative loss.

The multiple problems associated with the use of bio-

logic dressings have driven the.development of synthetic

matelials. O ne such m ate rial is B iob ran e, a composite ma-

terial consisting of nylon mesh bonded to silicone that

has proved successful in the temporary coverage of sec-

ond- and third-degree burns. Whereas Biobrane adheres

well to moderately clean wounds, it cannot adhere to or

lower bacterial C01..1nts in grossly contaminated wounds .

Biobrane dressing is supplied in various sizes, cut to fi t

the wound site, and secured with tape or steri-strips. It

spontaneously separates from the wound when the un-

derlying tissue heals. Hydrocolloid dressings are another

type of biosynrheuc material, They are occlusive wafers

composed of gumlike materials that provide a water-resis-

tant outer layer for coverage of the donor site. They pro-t ec t healing tissue from excessive drying, liquefy necrotic

tissue, and absorb wound drainage (Boswick, 1987:

Fowler; Cuzzell, & Papen, 1991).

Preventing Scars, Keloids, and Contractures

In normal healing following a minor bum injury, the

newly formed skin closely resembles its neighboring tis-

sue, The epidermis does not thicken or heighten as a scar.

However, when a burn injury extends into [he dermal

.Chapter 18 NursingCare of Clients with Burns 649

I=' igure 18-12 Skin graft for burn injury (autograft) .

layer of skin, the skin is repaired through scar formation.

Two types of excessive scar may develop, A hypertrophic

scar is an overgrowth of dermal tissue that remains within

th e boundaries of the wound. A keloid is a scar t ha t

extends beyond th e boundaries of th e original wound,

During the healing process, the burn scar shrinks and

becomes fixe d and inelastic, resulting in contracture of

the wound. A contracture is a permanent shortening of

connective tiSSUE, Once a contracture forms, the tissue re-

sists being stretched, and 'its inelasticity limits body

movement. Positioning, splinting, exercise] and constant

pressure application help prevent contractures from

fanning (Richard &; S t al e y, 1 994 ).

Positioning During the course o f therapy, the clientmust be maintained in positions that prevent contractures

from forming, Because flexion is the natural resting posi-

tion of joints and extremities, early physical therapy in-

cludes maintaining antideformity positions (Table 18-8).

Splinting Splints are used to immobilize body parts

and prevent contractures of the joints. They are applied

and removed according to schedules established by the

physical therapist.

Exercise Early in the acute phase of care, [he client's

physical therapist prescribes active and passive ROM ex-

ercises, which are performed during hydrotherapy and

every Z hours at the bedside. Earlyambulation is also partof the plan of care once the clients condition becomes

stable,

Support Garments Applying uniform pressure can

prevent or reduce hypertrophic scarring. Tubular support

bandages are applied 5 to 7 days postgraft to maintain a

tension ranging from 10 to 20 mm Hg to control scarring.

The client wears custom-made elastic pressure garments

for 6 months to a year postgraft (Figure. 18-13),




:..Table'iS -v-6 " · : <'" . ', : .-' , :"'

Positioning the Client with Burns

Area Burned Position

To achieve hypel'extellSion, place a rolled Lowel or small soft pillow under t11Eneck or shoulder.

To achieve extension, us e no pillow.

To achieve ab,h~ctiol1 and external rotation of the anterior shoulder. abduct the arm 90 degrees from the

side of the trunk, To achieve flexion and interior 1 ' 0 1 ( [ £ 1 0 1 1 of the posterior shoulder, position the an n slightlybehind the midline of the body. . .

To achieve extension ~lllclsu!Jil1atioll, maintain the j oint ill extended position, palm upward.

To achieve extf11siort, use a splint to maintain 30 "to 4S degrees of extension.

To achieve fleXion and exzension, use splints.

To maintain slight abductiol1, place a pillow between the legs; use a trochanter roll to prevent external rota-

tion.

To achieve extmsion, position th e client in the supine position with the knees extended and in the supine

position with the feet hanging over the. lower end of the mattress; knee splints may also be used; while the

client sits in a chair, legs should be elevated and extended.

To achieve a l1wtral position, usea padded footboard and ankle splints to avoid inversion and everston,

Head and neck

Shan lder/axtlla

Elbow

Wrist

Fingers

Legs

Knee

Ankle

Figure18-13 Pressure garment worn to prevent hypertrophfc

scarring following a burn in jury,

Nursing Care

The goals of the nursing plan of care [or the burn-injured

client are to

• Maintain Iluid balance.

• Control infection.

II Enhance mobility

.. Reduce pain.

.. Preserve coping mechanisms.

.. Improve gas exchange.

• Reestablish skin integrtty

.. Promote tissue perfusion.

.. Restore adequate nutrition.

.. Educate the client and family unit in the rehabilitative

process.

Table 16-7 lists ove-rall nursing interventions CO T theemergent, acute, and rehabilitative stages of burn injuly

Because the rehabilitative stage is long term, sometimes

lOISLing for years, the client and family unit may experi-

ence extensive psychologic reactions ranging from denial

to extreme depression.

Impaired Skin Integrity

The burn injury signi!l..canLlyimpairs skin integrity The

severity of wounds varies according to the depth of the

burn. General treatment measures are designed to restore

normal skin [unction as quickly as possible. Nursing care

focuses on assessing and cleaning the wound and control-

ling infection.

Nursing interventions with rationales follow:

11 Estimate the extent and depth of the bum wound. Th e

sev erity of the bum injury is the basis J or d .eterm in ing

wh.ich t y p e oj d re ss ing i s appropriate.

• Obtain relevant history. A n prehosp1taI therapies must be

reported t o h e l l' p ri or lt iz e n ur si ng mea Stltes s pec ific to ca re

o j th e shin.



Chapter 18 Nursing Care of Clients with Bums 651

Stage of Burn Injury End Point

: table IS ' " ' - 7 0 1 Nursing Interventions in Various Stages of Burn Injury.~ - , '-. ' ..- ".',,;

Onset Nursing Interventtons

EmergenliResuscitative Oceu rrenee 0 f

bum injury

Suc ce s sf ul f lu id

resuscitation

Acute Wound closureiuresis

Remove client from heat source .

I ni ti at e f ir st a id .

Assess extent of bum injury.

P re v e nt h y p ot h e rm ia .

Assess for shock.

Determine need for intubation.

De te rm in e n ee d fo r intravenous t herapy .Follow protocol for fluid resuscitation.

Obtain history

Transport to tertiary care facility.

Begin hydro therapy .

D e te rm ine n ee d [or excision ofbum wound.

Control spread of infection.

Institute w ound care .

Start nutrition support.

Graft burn wound.

Initiate physical therapy.Manage pain.

Preven t scar formation.

Continue p h y si ca l t h e ra py .

Address psychosocial, cultural, and spiritual needs.

Consider occupational therapy.

Consider vocational training.

Assess home maintenance management.

Rehabilitative Wound closure Return to highest le ve l of

heal th restoration

• A ssess fo r th e p re se nc e of pa in . Th e presence or absence:

of pain at the bum wound site is a critical fin ding tha t ind i-

cates d epth oj the injwy.

• Initiate hydrotherapy- In the hemod ynamicaUy stable

c lie n t, h yd r ot he rapy is institLlted e arly to b eg in w ou nd de -

brid em ent and allow assessm ent of w ound appearanCf .

• A pply topical antimicrobial agents. ContrOlling ilyectio1t

is a priolity of care.

• D ress th e burn wound using the open or closed

method as ordered. M aintaining asepsis controls the

sprmd of irifection.

• Apply a biologic or biosynthetic dressing as ordered.Ear ly coverage of the burn wound r ee st ab li sh es t he s hi n' s

p rD t ecL ive ba rr ie r.

• Provide special skin care to sensitive body areas.

a. Clean burns involving the eyes with normal saline

or sterile water. If contracture of the eyelid devel-

ops, apply drops or ointment to the eye to prevent

corneal abrasion.

b . G ently wipe burns of the lips with saline-soaked

p ad s. A pp ly an antibiotic ointment as ordered. Assess

the mouth frequently> and perform mouth care rou-

tinely If an oral endotracheal tube is in place, repo-

sition it often to prevent pressure sore formation.

b. Gently debride bums of the nose, and apply

mafenide acetate cream. Position nasogastric and

nasotracheal tubes to prevent excessive pressure.c. Apply mafenide acetate cream t o burns of the ear.

Gently debride and thoroughly clean the waund

with a w ate r spray. D o not cover e ars w it h dressings.

Do not use pillows; to reduce pressure to the area,

use a foam doughnut instead. .

d. Clean burns of th e perineum during hydrotherapy.

Assess the area for evidence of infection, and rinse

thoroughly after toileting.

c. K eep exposed bone 01' te ndon in a moist environ-

menl until grafting occurs. Soak wet-to-wet dress-

ings frequently and reapply every 4 hours,

• The eyes, 1 1 1 o u t h , nose, e n r s , perinel-pn, an d e xp osed d eep ert is su es r eq ui re more inLensive t reatmen t therap ie s.

Fluid Volume Deficit .

In the early stages of the burn injury, m anaging th e clients

fluid balance and maintaining hemodynamic stability

take p rio rit y Ma ss iv e fluid losses occur immediately fol-

lowing the injury and continue throughout the first 2 LO 5

days. During this period, nursing care focuse s on re stor-

ing fluid losses and continuously assessing hemodynamic

parameters .





• A sse ss vital signs fre que ntly V ita l sig ns ra pid ly d eter u»

rnre when f lu id res tl Sc it at ion is inadequate.

• Follow prescribed formulas for intravenous fluid re - .suscitation. Therapy Jo r hurt ! shock is : aimed at Stlpportilig

th e clie nt th ro ug h th e pufod o f hypovo lem ic ins tab il it y.• Monitor intake and output hourly Report urine out-

puts of less than 50 mUh. Intake and output measure-

m en ts in dic ate th e a de qu ac y o jflu id n :: sL ls cita L io l1 .

• W e igh the client daily. Body weigh t is u sed . to calculate

fluid requirements.

• Monitor hemodynamic status, including CVP and

PCWP Inadequate fluid resuscitation is m anifested by a

drop in th e c en tra l v en ou s p re ssu re and p ulm oltm y c ap il-

l ar y w edge p re ss ur e.

• Test al l stools and emesis for the presence of b lood. O c-

c ult b lo od in eme sis o r s to ol in d ic ate s in te rn al b le ed in g.

• Maintain a heated environrnent. Hypothermia leads to

shivering Cindfurther loss oj body flU id th ro ug h increased

energy e xp enqit ur e and catabo li sm .

• Monitor the client for fluid volume overload. Older

clients an.d th os e w ith ~ lI 1d er 1y in g cardiac d ise ase m ay

demonstrate s ym ptoms o f co ng estiv e hear t f ai lu re dwin,g

the f lu id resusci tat ion stage.

I

•Risk for Infect jon

From the onset of the burn injury, loss of the body's nat-

ural barrier to the externalenvironment predisposes the

client to developing infection. Nursing measures focus on

controlling infectious processes. The nurse obtains dailylaboratory tests, maintains nutritional therapies, and ap-

plies antimicrobial agents to monitor and prevent the

sp read of infection, a maj or complication of the bum in-

jury


II; Monitor and record body temperature every 2 . hours.

Elevated body t emperah{re i11d i ca te s the presence oj irifec.

lion.

• Obtain daily WEC counts. L eu lw cyte co un ts a re illclic a~

tors oj immune s ys tem junc tio n.

• Determine tetanus immunization status. B urn c lie nts

are a t ri.sh fo r a na ero bic in fe ctio n ca used b y Clostridiumtetani.

• Maintain h igh ke al intake. N~LtJition.al support provides

the nutrients need ed for maintaining the body's defense

mechanisms.

• Maintain an aseptic environment. Strict i so la ti on t ech-

niq ue d eters the d ev elo pm ent o j no socom ial injection.

• Culture all wounds and body secretions as ordered.

Cu ltu re and s en sit iv it y r e p o r i s id en tify the presence o f in -

fe ctio us m ic ro be s a nd in dica te a pp ro prla te a ntim ic ro bia l

therapies.

• Observe the client for signs of infection. Continuou

assessment enables the nurse to ev aluate interv entio

strategies.

Impaired Physical Mobility

As the burn wound heals and new skin tissue forms,

involved area tends to shrink. Contractures form atsite and Significantly limit mobility, especially when

joint is involved. Physical therapy therefore plays an i

portant role, beginning in the early stages of treatmen

The nurse institutes ambulation and planned exerci

regimens as soon as the clients condition stabilizes.


III Perform active or passive ROM exercises to all join

every 2 hOUTS. as ordered. Ambulate when stable. Re

u la r ex erc is e p re ve nts fu rth er lo ss o f m otio n, r esto re s m ov

m en t, a nd im pro ve s fu nc tio na l s ta tu s.

• Apply splints as ordered. Maintain antideformity pos

tions, and reposition the client hourly S plin tin g a nd ps it ioning retard th e jormation of contractures.

• Maintain l imbs infunctional alignment. This preserve

joint mobility. .

• A nticipate the need fo r analgesia. Administering ana

gesics promotes tlte tuents corrrjort during vigorous exerci

ing sessions.

Altered Nutrition: Less Than Body Requirements

The burn injury initiates a complex series of events th

have a profound effect on the bodys use of nutrients an

expenditure- of energy Daily kcal requirements are dete

mined by the nutritionist, and as soon as possible, entera

feedings are initiated.. Duodenal tubes are placed to e

hance intestinal absorption and retard gastric reflux. Pa

enteral nutrition is reserved for those instances in whic

enteral feedings are contraindicated. Nursing measures

focus on assessing feeding tolerance and use of nutrients,

preventing gastric ulcer formation, and maintaining ade

quate bowel evacuation,


• Maintain nasogastric/nasointestinal tube placement.

Correct tube placement ensures a pp ro pria te a bs orp tio n

l1utl ieltts and prevents aspiration

• M a in ta in e nt era l/ pa re nte ra l nutritional support as o

dered. Observe and report any evidence of feeding in

tolerance: diarrhea, vomiting, excessive gastric res

idue, abdominal distention, absent bowel sounds, an

constipation. The l1utl'itionist, in collaboration Wit)l th

physician, selects an d ind iv id ualizes the feed ing jonn uIa

a ccord in g to th e clients d aily en erg y ex pend iture req uire

m en ts a nd fe ed in g to le ra nc e. F a ilu re to m ain ta in rates o

infusion predisposes the c li en t to continued c ata bo lism a n

negative nitrogen b a l a n . c e .

~ Weigh the client daily. Anti Ir opometl1 c meaSL ir emen ts in

d ic ate th e ad eq uacy o f nutr it io na l Sltpport therapies.



• Obtain daily laboratory values for protein, iron, CBC,

glucose, and albumin. De cre ase d s erum vclues indicate

ilwdequate nutrit ional intal~e.

• Administer antacids and histamine H2 b lo ck e rs . Ma in -

tain gastric pH above 5< Lowering gasbic aci d it y r et ar d s

the d ev elopm ent of ukers.

Pain

With, extensive first-degree and all second-degree burns,

[he client experiences excruciating pain. Early in the

treatment phase , once the client's hemodynamic status

becomes stable, narcotic analgesics are administered to

minimize discomfort; in addition, these medications are

administered prophylactically before the client undergoes

any painful procedure. For more persistent or continuous

pain, PCA may be appropriate. As the client progresses to

the rehabilitative stage, nonnarcotic analgesia and relax-

ation techniques are prescribed. Nursing measures focus

on implementing both pharmaceutical and psychosocial

pain-control strategies.


• Assess the client's level of pain. Fain tolerance is the du-

ration and intensity of pain that the client is able to endure.

Pa in tolerance di f fers j rom one client to the nex t and may'

vary in th e same clie nt in d iffer en t situ a. tio ns .

• Anticipate the need for prophylactic analgesia. Deter-

mine whether PCA is appropriate. The inability to man-

age pain re suus in fee lin gs o f d es pair a nd fru str atio n.

_ Administer narcotic analgesics as ordered. Nurs es ' f ea r

o f p re cip it ati ng a dd ic lio n o ft en malus them reluctant to a d-

m inister na.rcotics. D uring the acute stage ofbLlll1

injLlJy,Itow ev el; inv asiv e proced ures and exposed nwrosEI1S01j

nerve e nd in gs d ic ta te the n eed J ul' 11a1'cotic pharmaceutical

agents.

• Explain to the client al l procedures and expected levels

of discomfort. Clients. who are p repa re d f or p a i n f U l proce-

dures C l n d k n o w befo t" ehan d th e a ct ua l s e l 1 5 a t i o n s they w mfeel e xpe ri ence l es s stress.

• Explore other methods of nonnarcotic pain control.

The use of noninvasive pain-relie] measures ( e. g. , r ela x-

at/ on, m .assage, d istraction) can enhance the therapcut ic

e ff ec ts o f pain- re li ef medicat ions .

• Allow the client to verbalize the pain experience. Each

individual e xp erie nce s a nd ex pre sse s p ain il l his or her ow n

manner, us ing va rio tl s soc iocultura l adaptat ion techniques.

Powerlessness

Usually, the client with a major bum injury endures a

lengthy hospital stay Involving many treatments and care

protocols that are beyond his or her control. During the

early stages, furthermore, much of the care regimen in-

volves excruciating pain. Further still, the foreign envi-

ronment of the burn unit makes it difficult for the client

to relate to the immediate surroundings. For example, the


need to control infection in the burn unit requires hospi-

tal personnel and family members to don sterile clothing

prior to coming to the clients bedside. Family members

and nursing personnel appear radically different when

they are masked and gowned, and their odd appearance

can add to the bum-injured clients sense of alienation.

Decr e as ing t h e clients feelings of powerlessness during

the emergent and acute stages of burn care often poses a

challenge La the nurse. Balancing care protocol with the

clients need for control is difficult, but the nurse can best

accomplish this objective by maintaining an objective ap-

proach and by implementing established psychosocial

nursing interventions.


• Allow the client as much control over the surround-

ings and daily routine as possible. For example, allow

the client to choose times of dressing changes. Power-

lessness d eriv es from the be1ief that one is unable to inj1 u-

ence the outcom e oj a situation.• Keep needed items within reach, such as call bell, uri-

rial, water pitcher, and tissues. Th is rein forces the clients

feelings oj control.

• A llow the client to express feelings. The nurse can hd p

the client cope by therapeuticaU y listening, by d isplaying a

caring presence, by c la rl f. yi ng mis conc ep ti on s, a nd by pro-

Viding posi tive jeedbach.

• Set short-term, realistic goals. For example, set a goal

for the client to ambulate from bedside to chair twice

daily. Small incn:mCll ta l g a i l 1 S are easier to achiev e and aL -

low Jorfrequel1t posi ti ve rein forcement .

• Help the client access supportive mechanisms, such asspiritual/cultural healing, support group consultation,

and psychologic intervention. T hese resources can en-

able O w client to d iscover new life meanings and to cope

1 1 1 0 1 ' e e f f e c t i v e l y

Other Nursing Diagnoses

Other nursing diagnoses that may be appropriate for the

burn-injured client follow:

• Inej) 'ectiv e B reathing P attern related to respiratory dis-

tress

• Altered Tissue Peljusion related to circumferential burn

wound of the extremities/torso

• R i~·h for Impaired H ome M aintenance Mo.l1agentent re-

lated to unavailable support system

• R ish [o: Ineffectiv e lildividual Coping related to change in

body image

If An.:'dety related to lack of knowledge

. . A nl ic ip atO lY GJieving related to developing awareness

ofloss

• S ensory/ Perceptual A lterations related to sensory over-

lo ad /d ep riv at io n, s le e p p at te rn disturbance



~5+ Unit 4 Responses to Altered Skin Integrity


Client and family teaching is an important component of

all phases of burn care. As treatment progresses, the nurse

encourages family members to assume more responsibil-

it y in providing care. From admission to discharge, the

nurse teaches the client and family to assess aLLfindings,

implement therapies, and evaluate progress.

Rehabilitation Care

Early in Lhe plan of care, explain to the client and family

the long-term goals of rehabilitation care: to prevent soft

tissue deformity, protect skin grafts, maintain physiologic

function, manage scars, and return the client to his or her

optimal level of independence. The teaching plan focuses

on helping the client and family prevent dehydration, in-

fection, and pain; maintain adequate nutrition and skin

integrity; and restore mobility and psychosocial well-

being.

Dehydration

Teach the client and family unit how to assess for evi·

de nee of fluid volume deficit. Explain the rationale 51.1p·

porting all fluid therapies and emphasize the need to re·

port immediately all signs and symptoms of fluid

imbalance: We igh t 1 0s 5, oliguria, dry mucous membranes.

Infection

Teach the client and family the rationale. supporting asep·

sis. Instruct them to protect the client from exposure to

people with colds or infections and to follow aseptic tech-

nique meticulously when caring for the wound. Ensure

that the client and family are able to recognize all signsand symptoms of infection: fever, poor wound healing

purulent drainage, malaise.

Mobility

Consultation with physical therapy begins early in the

treatment plan and continues throughout the long-term

rehabilitative process. Explain to the client and family the

need [or progressive physical activity and help them es-

t'ablish realistic goals. Explain the rationale supporting

the use of splints, pressure support garments, and other

assistive devices, and demonstrate how to apply them.

Ensure that the client and family understand the impor-

tance of reporting any evidence of lack of progress.

Nutrition

Identify and answer all questions related to the clients

nutritional therapies. Consult with a nutritionist early in

the treatment plan and throughout rehabilitation to help

the client and family maintain adequate daily keal intake.

Instruct them to report immediately any evidence of mal-

nutrition, such as food intolerance, weight 1055, or

cachexia.

Pain

Encourage the client and family to express concerns re

lated to pain management, Explain the causes of pain and

discomfort and the rationale supporting the use of anal

gesia. Teach the client and family alternative pain-control

therapies, such as guided imagery, relaxation techniques,

and diversiorial activities. Instruct them to report evidence of inadequate pain control: facial grimacing, ver-

balization of pain, guarding,

Skin Cue

lnstruct the client and family in the care of the graft and

donor sites. Provide the rationale supporting the use of a n

pressure support gannents, emphasizing the need to re-

port any evidence of inadequate wound healing: altered

skin integrity. drainage, swelling, redness.

Psychosocial Adaptation

Encourage. the client and family to express their [ears and

concerns, and provide referrals to appropriate commu-nity resources. The circumstances surrounding the burn

injury are often emotionally charged and challenge the

nurse to consider all psychosocial implications. Power-

lessness, anger, gUilt, anxiety, and feelings of loss are com-

mon reactions to burn injury and may be related to inef-

fective coping mechanisms. The goal of psychosocial

nursing care is to promote functional adaptation and to

facilitate psychologic adjustment. The burn injury can

precipitate dramatic changes in the clients self-concept,

role function, value system, and interpersonal relation-

ships. Direct the client and family to occupational ther-

apy, social service, clergy, and/or psychiatric services as

approprtate.Three basic stages of burn recovery have been consis-

tently identified: early, intermediate, and long-term. The

duration of each stage varies from client to clie nt and de -pends on the clients preburn psychologic state, the extent

of th e injury, and the treatment environment.

In the early stage of recoYeJY, the client undergoes in-

tensive critical care. Direct psychologic intervention is

generally inappropriate during this stage: rather, inter-

ventions are directed toward mainLaining the client's fam-

ily support system and helping family members work

through their grief and maintain a sense of calm and

hope. The presence of the family alleviates the clients

anxiety and agitation and helps the client cope with the

sensory overload of the burn unit.

The inLeI1nit te l1 t s tage oj r e C O V E r y is characterized by the

clients return to a state of physical stability. The client is

moved out of the critical care environment, and the pro-

cedures associated with wound care become matters of

routine. The most common psychologic problems experi-

enced by the bum-injured client during this stage include

depression and post-traumatic stress disorder (PTSD).

Depression tends to occur in clients whose hospital stays



, -

exceed 1 month. Brief psychologic counseling is helpful

during this stage and may include treatment with antide-

pressants, especially when the episodes are severe or as-

sociated with suicidal ideation. PTSD is characterized by

repeated intrusive memories of the burn injury, which ag-

itate the. client and cause the client to avoid situations that

provoke these memories. PTSD is brief an d self-limiting,seldom occurring beyond hospital discharge. Less severe

psychologic difficulties, such as nightmares, a nx ie t y, a nd

regression, may occur but usually subside spontaneously.

Behavioral difficulties, such as hostility, noncompliance,and acting out, may also occur. The family call employ

behavior modification, limit setting, and the help of sup-

port groups to minimize these behaviors.

The long-term stage of recovery begins when the client

leaves the hospital and returns to the community setting.

The first year following discharge is usually the most dif-

ficult and is characterized by problems associated with

vocational and emotional adjustment Clients frequently

experience depression and anxiety, which typically de-crease in intensity after the first year. Problems with self-

esteem and diminished quality of life, however, may re-

quire more long-term' psychologic adjustment. Family

support is extremely important during this stage. Com-

munity support resources can also help the cli.ent adjust .

successfully. Ongoing psyc;hologic counseling may be

necessary for clients with histories of ineffective and dys-

functional coping skills (Richard &. Staley; 1994).

-.' '. . :Applymg. dle NUrsing P roH :ss : ... :: : .: .::~ ':.' • - . _ •• ' - ,L t :' . . " ( .o ~ r , ' r, : :

Case Study of a Client with Major Burn:

Craig Howard

Craig Howard, a 39-year-old truck driver, is admitted to

the hospital following an accident in which the cab of his

truck caught on fire. He was freed from the truck by a

passing motorist, who stayed with him until the rescue

team arrived and transported him to a local ED. Mr.

Howard's wife, Mary, an d twin daughters, Jessica and

J an e, a ge 10, have been notified.

Assessment

On his admission to the ED, Mr. Howard is diagnosed

with second- and third-degree bums of the anterior chest,

arms, and hands. A quick assessment based on the rule of

nines estimates the extent of his burn injury at 36% of

TBSA His vital signs are as follows: T, 96.2 F (35.6 C );

P , 140; R, 40; BP,98/60. In the J:ield, the paramedics had

inserted a large-bore central line into Mr. Howard's light

subclavian vein and stalled the rapid infusion of lactated

Ringers solution. Mr. Howard is receiving 40% humidi-

fied oxygen via face mask. InitialABGs are as follows: pH,

7.49; Po2 , 60 mm Hg; Peo2 ' 32 mm I-Ig; bicarbonate,


22 mEq/L Lung sounds indicate inspiratory and expira-

tory wheezing. and 8 persistent cough reveals sooty spu-

tum production. A F ole y catheter is inserted and initially

drains a moderate amount of dark, concentrated urine. A

nasogastric tube is connected to low-intermittent suction.

Mr. Howard is alert and oriented. and complains of severe:

pain associated with the bum injuries. The burn unit isnotified, and Mr. Howard is prepared for transfer.

Diagnosis

On Mr. Howards arrival to the burn unit, Ana Salazar,

RN, assesses Mr. Howard and makes the following priori-

tized nursing diagnoses:

• R ish J O T ln effe cliv e A in va y C le ara nc e related to increas-

ing lung congestion secondary to smoke Inhalation

• F luid Volume De f ic it related to abnormal fluid loss sec-

ondary to burn injury

• R isl, for Altered T issue P erjusion related to peripheral

constriction secondary to circumferential bumwounds of the arms

Expected Outcomes

The expected outcomes established in Ms. Salazars plan

of care specify that during the emergent phase of care, Mr.

How ard w ill

• Demonstrate a patent airway, as evidenced by clear

breath sounds; absence of cyanosis; and vital signs,

chest X-ray findings, and ABGs within normal limits.

• Demonstrate adequate fluid volume and electrolyte

balance, as evidenced by urine output, vital signs.

mental status, and laboratory finclings within normal

limits.

• Demonstrate adequate tissue perfusion, as evidenced

by palpable pulses, warm extremities, normal capillary

refill, and absence of paresthesia.

Planning and Implementation

Ms. Salazar plans and implements the following interven-

tions for Mr. Howard eluring the emergent phase of care:

• Prepare ML Howard [or prophylactic nasotracheal in-

tubation to maintain airway patency

.. Initiate fluid resuscitation therapy USing the Park-

land/Baxter formula to calculate intravenous fluid rate

for the first 24 hours postburn ..

• Assist the physician to perform escharotomies of both

upper extremities.

Evaluation

Tile nurse anesthetist has inserted a nasotracheal tube

and connected Mr. Howard to a T-piece delivering 40%

oxygen, Vigorous respiratory toileting has significantly

improved his ABGs. Bronchodilators have been paren-

terally administered and mucolytic agents added to his



656 Unit 4 Responses toA ltered Skin Integrity

respiratory treatments. His tracheal secretions have begun

to show evidence of clearing,

Hourly urine outputs indicate adequate fluid resuscita-

tion. Urine output has been maintained at 50 mUh, and

color and concentration have improved. CVP readings

have been maintained at 6 em H20, and blood pressure

has increased to 100/64. The pulse rate has decreased to100.

To improve tissue perfusion of both arms, the physi-

cian has performed bilateral escharotomies and Ms.

Salazar has dressed the wounds using sterile procedure.

The extremities have demonstrated improved circulation.

Crttical Thinking in the Nursing Process

1. Explain the rationale for the immediate insertion of a

Foley catheter and nasogastric tube.

2. An escharotomy was performed on both arms, W hywas this procedure necess~ry in Mr. Howards case?

3. What is the rationale supporting the intravenous ad-ministration of narcotics to control Mr. Howard's

pain?

4. Explain the purpose of instituting hydrotherapy early

in Mr. Howards treatment plan.

S. Explain the sequence of events that led to a fluid and.

electrolyte shift during the first 24 to 48 hours after

Mr. Howard sustained his injury:

6. One week following Mr. Howard's accident, fluid and

electrolyte balance we re r es to re d . and infection W<lS

controlled. Nevertheless, his condition remained se-

rious. Over the next several months, the treatment

plan was aimed at the prevention or early detection ofother complications. Identify three of these potential

burn complications, and discuss preventive strate-

gies.

The Client with a Minor

Burn Wound'. . . , "

A minor bum injury is usually created in an outpatient fa-

cility: The goal of therapy is to promote wound healing,

eliminate discomfort, maintain mobility, and prevent in-

fection.

Pathophysiology

. Minor burn injuries consist of first-degree burns that are

no t extensive, superficial second-degree burns that in-

volve less than 15% of USA, and third-degree bUQ1S that

involve less than 2% of TBSA, excluding the special care

areas (eyes, ears, face, hands, feet, perineum, and joints).

Minor burn injuries are not associated with immunosup-

pression, hypermetabolism, or increased susceptibility to

infection.

Sunburn

Sunburns result from exposure to ultraviolet light. Such

injuries, which tend to be first-degree, are more com-

monly seen in clients with Lighter skin. Proper use of sun-screen and limiting sun exposure. to the less hazardous

hours of the day (before 10 a.m, and after 3 p.m.) can

prevent sunburn, Because the skin remains intact, the

symptoms in most cases are mild and are limited to pain,

nausea, vomiting. skin redness, chills, and headache.

Treatment is performed on an outpatient basis and gener-

ally consists of applying mild lotions, increasing liquid in-

take, administering mild analgesics, and maintaining

warmth , Older adults ar e monitored for e vide nce of e x-tensive dehydration.

Scald Burn

Minor scald burns result from exposure tomoist heat andinvolve first-degree and superficial second-degree burns

of less than 15% of TBSA . The goals of therapy are to pre-

vent wound contamination and to promote healing. The

nurse teaches the client to apply antibiotic solutions and

light dressings and to maintain adequate nutritional in-

take. Mild analgesics may be ordered to help the client

cany our activities of daily living. Tetanus toxoid is ad-

ministeredas appropriate,

Collaborative Care

At the scene of the injury, small burns may be rinsed with

tepid water to reduce pain. Ice packs should be avoided.

In th e field, the wound should be covered with a clean

cloth until appropriate treatment becomes available.

Outpatient treatment follows the same general guide-

lines as thosefor major burn injuries. TI1e history and

physical examination include the following:

• ~sessment of the extent and depth of the bum injury

• Identification of the cause

• Time of the incident

• Previous medical history

• Age of the client

• Body weight

• Medications

'"' First-aid treatment

In the outpatient facility, the wound may be washed

with mild soap and water. Tar and asphalt can be re-

moved with mineral oil, petroleum ointments, or Medisol

(a citrus and petroleum distillate with hydrocarbon struc-

ture). As with major burns, the tetanus toxoid booster is

recommended for all clients whose immunization histo-

ries are in doubt. Potent topical chemotherapeutic agents,



such as maEenide acetate, silver sulfadiazine, or povidone-

iodine, should not be applied to a minor bum wound. Al-

t h o ug h con tr ov e rs y regarding th e care of blisters remains,

blisters may be managed in one of three ways: left intact,

e vacuate d, or debrided. Follow-up care [o r the minor

. burn injury includes twice daily wound cleansing with

application of bland ointment, ROM exercises to affectedjoints, and weekly clinic appointments until the wound

heals comple te ly (Boswick, 1987; Marlyn, 1990).

Nursing Care

Although the nurse seldom treats the minor burn in the

acute care environment, the burn treatment methods

used in the outpatient setting follow the same standard

approaches to C~\1"e. General nursing measures include

taking the history, estimating the extent and depth of the

injury, cleaning the wound, applying topical agents,

dressing th e wound, controlling pain, and establishing

.follow-up care.

History Taking

In gathering client information, the nurse must be alert

for an y evidence of underlying disease th at may compli-

c at e th e h e alin g process. Histories of chronic illness-sub-

stance abuse, or inadequate family support systems may

make outpatient treatment inadvisable. The nurse obtains

the diems immunization history and administers tetanus

toxoid as indicated.

Estimate of Extent/Depth of Wound

In most cases, the rule of nines is an adequate means of

determining the extent of the injury Only first-degree and

superficial second-degree bums are treated in the outpa-tient setting. More extensive injuries require hospiraliza-

tion.

WOUIuLCleaning .

The nurse cleans the wound according to protocol, which

usually consists of washing the area gently with a mild

soap and water and patting it dr y using sterile technique.

The nurse assesses the wound for evidence of infection.

Topical Agents

O nly ve ry mild ointments are used to cover the wound

and prevent infection. The use of potent topical antimi-

crobial agents is not recommended.

Wound Dressing

The nurse uses either the open or closed method to dress

the wound according to protocol. The nurse explains the

dressing technique and teaches the client to follow the

prescribed regimen.

Pain Control

The client is encouraged to us e mild analgesics during the

initial phases of care. As healing progresses, pharmaceuti-

cal agents are discontinued, and alternative pain manage-

C h ap te r 1 8 Nursing Care o fC l ie n ts w it h Burn s 657

ment therapies (relaxation, distraction, guided imagery)

are employed.

Follow-Up

Depending on the severity of th e wound, the client re-

turns [or follow-up care within the next 24 hours and

weekly thereafter until the wound has healed completely.


In the outpatient setting, the client and family manage the

minor burn wound throughout the rehabilitative process.

The client returns to the c lini c o r docto rs office regularly

until the wound has healed completely. In developing

and Implementing the teaching plan, the nurse supports

client and family participation in care.

The nurse teaches the client and family

• To identify and report signs and symptoms of impaired

wound healing:

a. Change in healthy appearance of the-wound (al-tered skin integrity, swelling, blister formation, ery-

t h ema)

b. Signs of infection (fever, purulent drainage, foul

odo~ .

c. Ill-fitting pressure garment (discomfort, numbness,

tingling)

.. The importance of adequate nutritional intake:

a. Mow to identify a change in food tolerance (mani-

festecl by diarrhea, weight toss, muscle atrophy)

b. How to prepare nutritionally balanced meals

c. How to maintain adequate fluid intake

II Wound care:

a. Daily cleaning with mild soap and water

b. Use of sterile technique to change dressings

c.. Correct application of ordered topical agents

• Active ROM exercises:

fl.. Exercise of limbs and joints daily as ordered

b. Gradual increase in endurance

• Pain management:

a. Use of mild analgesics as ordered

b. Implementation of alternative pain management

therapies

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Burn Chapter