pediatric burn case study for nursing students

Case Report: Burns

Mark J. Johnston, RN BSN Manager, Burn Program

Case: 15 Month old with a 19% TBSA burn

HPI: The patient is a 15 month old that sustained a 19%TBSA burn that was the result of hot water. The parents reported that the patient fell into a bathtub full of hot water at approximately 5am. The father awoke to him crying and pulled him out of the tub and ran cold water over the burn areas which were bilateral lower extremities and his lower torso and abdomen. The burns were initially described as not too bad so the father put him in bed and they fell back asleep. Later that morning they awoke and the patient had developed blisters so they presented to a local hospital. The regional Burn Center was consulted. The referring hospital described a ~30%TBSA burn. A left external jugular line was established and a foley catheter was placed. IVF were started at 75cc/hr in addition to a 250cc bolus.

Burn ICU: The patient arrived as a direct admit to the Burn Center. He had received 337.5cc of LR prior to arrival and had 75cc of urine output over 4 hours prior to the admission. 10 point ROS was negative, immunizations were up to date, he did not have any allergies and did not take any medications regularly. Vital signs were: BP 84/62, HR 159, RR 28, SpO2 99% and temp 36.2. His burns were dressed in silver sulfadiazine, he was given fentanyl and midazolam for his dressing and IV fluids continued at 75cc/hr. He was started on our Nurse Driven Resuscitation Protocol. A social work consult was ordered due to the nature of the injuries not being consistent with the mechanism of injury. The patient maintained an adequate amount of urine and so IV fluids were titrated downward and eventually discontinued. The patient was interactive and tolerating a regular pediatric diet. On post burn day (PBD) #1, the burns were dressed with a long term silver dressing. The patient spiked a temperature to 103.3. Child Protection and Law Enforcement were in contact with the patient�s mother as the father had been arrested for suspicion of causing the injuries to the patient.

On PBD#3 the patient had low urine output and PO intake was noted to be poor. A PIV was not able to be established after multiple attempts. Urine output became difficult to measure as it was frequently mixed with stool in the patient�s diaper. The patient was taken to the operating room so that an IJ line could be placed as well as a NJ enteral feeding tube and foley catheter. The patient was left intubated. Blood and urine cultures were sent. The patient was given albumin. He was noted to be hypothermic. ABG showed metabolic acidosis, he was tachycardic with an adequate blood pressure, WBC was 2.8 with zero neutrophils. Venous saturation was high as was his lactate. Due to the septic picture, the patient was started on antibiotics.

On PBD#4 the patient was hypotensive that intermittently improved with colloid infusion. He again developed a fever with marked metabolic acidosis. He developed ventilator dyssynchrony so he was pharmacologically paralyzed. He developed significant edema due to the necessary fluid resuscitation that was initially treated with furosemide. Blood and urine cultures were negative to date.

On PBD#5 the patient was started on a dexmedetomidine in hopes that the midazolam infusion could be discontinued. Due to ventilator dyssynchrony, elevated ventilator peak pressures, oliguria and a tense abdomen, he was taken to the operating room and underwent a decompressive laparotomy and placement of an abdominal wall silo. Postoperatively his diuretic dosing was increased and he was switched to a furosemide infusion and chlorothiazide due to poor urine output.

On PBD#6 the furosemide was switched to bumetanide. Fortunately, after the abdominal decompression, his renal function improved, urine output improved, and creatinine normalized. He remained on continuous dexmedetomidine, fentanyl, and midazolam infusions while intubated. He had good pain control and sedation.

Over the course of the subsequent days, the patient underwent three abdominal washouts and had the abdominal wound closed nine days after the laparotomy. He underwent tangential excision and cadaver grafting on PBD#14 and split thickness skin grafting on PBD#24. He was discharged on PBD#37.

Post Discharge: The patient was evaluated in the Burn Clinic 3 weeks after his discharge and he had 100% graft take and no other concerns. The patient was followed at regular intervals in the Burn Clinic and the patient had no other issues of concern.

Topic Review: Abdominal Compartment Syndrome in Pediatric Burn Resuscitation Burn patients receive a larger amount of fluids in the first 24 h than any other trauma patients because of the pathophysiological mechanisms occurring in the injury. Burn shock is a combination of hypovolemic shock and cell shock, characterized by specific microvascular and hemodynamic changes. In addition to the local lesion, the burn stimulates the release of inflammatory mediators that induce an intense systemic inflammatory response, producing an increase in vascular permeability in both the healthy and the affected tissue. The increased permeability provokes an outpouring of fluids from the intravascular space to the interstitial space, giving rise to edema, hypovolemia, and hemoconcentration. The amount of inhalation injury also has an effect on the clinical course, fluid requirements, and the patient's prognosis. The main objective of fluid administration in thermal trauma is to preserve and restore tissue perfusion and prevent ischemia, but resuscitation is complicated by the edema and transvascular displacement of fluids characteristic of this condition.1, 2, 3.

Since 1968, when Baxter and Shires developed the Parkland formula, there has been debate on the �perfect� burn resuscitation formula. The advances in hemodynamic monitoring, establishment of the 'goal-directed therapy' concept, and the development of new colloid and crystalloid solutions have put us closer to the �holy grail�. Severe burns have been shown to be a risk factor for developing intra-abdominal hypertension (IAH). Fluid resuscitation practices used in burn management further predispose patients to intra-abdominal hypertension. Many burn units still base their resuscitation practice on a formula created 40 years ago. In 1991, Dries and Waxman(4) had already suggested that resuscitation based only on the urinary output and vital signs might be suboptimal. Goal-directed fluid therapy has been an important concept in initial fluid resuscitation for major burns since this publication. Cardiac output has been considered one of the most important measures to guide volume therapy but few burn centers actually measure cardiac output during resuscitation. In recent years, several articles have reported on volume monitoring and replacement approach for goal-directed fluid resuscitation based on transpulmonary thermodilution (TTD) and arterial pressure wave analysis, which are less invasive .

• RE Barrow, MG Jeschke, DN Herndon Early fluid resuscitation improves outcomes in severely burned children Resuscitation, 45 (2000), pp. 91-96
• CP Artz, JA Moncrief The burn problem CP Artz, JA Moncrief (Eds.), The treatment of burns, W.B. Saunders, Philadelphia (1969), pp. 1-22
• JK Rose, DN Herndon Advances in the treatment of burn patients Burns, 23 (Suppl 1) (1997), pp. S19-S26
• DJ Dries, K Waxman Adequate resuscitation of burn patients may not be measured by urine output and vital signs Crit Care Med, 19 (1991), pp. 327-329

Burn Injury

Learn about the nursing care management of patients with burn injury in this nursing study guide .

Table of Contents

• What is Burn Injury? 

Classification

Pathophysiology, statistics and epidemiology, clinical manifestations, complications, assessment and diagnostic findings, medical management, nursing assessment, planning & goals, nursing priorities, nursing interventions, gerontologic considerations, discharge and home care guidelines, documentation guidelines, what is burn injury.

A nurse who cares for a patient with burn injury should be knowledgeable about the physiologic changes that occur after a burn, as well as astute assessment skills to detect subtle changes in the patient’s condition.

• Burn injury is the result of heat transfer from one site to another.
• Burns disrupt the skin, which leads to increased fluid loss ;  infection ; hypothermia ; scarring; compromised immunity; and changes in function, appearance, and body image .
• Young children and the elderly continue to have increased morbidity and mortality when compared to other age groups with similar injuries. Inhalation injuries in addition to cutaneous burns  worsen the prognosis.
• The severity of each burn is determined by multiple factors that when assessed help the burn team estimate the likelihood that a patient will survive and plan for the care for each patient.

Burns are classified according to the depth of tissue destruction as superficial partial-thickness injuries, deep partial-thickness injuries, or full-thickness injuries.

• Superficial partial-thickness . The epidermis is destroyed or injured and a portion of the dermis may be injured.
• Deep partial-thickness . A deep partial-thickness burn involves the destruction of the epidermis and upper layers of the dermis and injury to the deeper portions of the dermis.
• Full-thickness . A full-thickness burn involves total destruction of the epidermis and dermis and, in some cases, the destruction of the underlying tissue, muscle , and bone.

Tissue destruction results from coagulation, protein denaturation, or ionization of cellular components.

• Local response. Burns that do not exceed 20% of TBSA according to the Rule of Nines produces a local response.
• Systemic response. Burns that exceed 20% of TBSA according to the Rule of Nines produces a systemic response.
• The systemic response is caused by the release of cytokines and other mediators into the systemic circulation.
• The release of local mediators and changes in blood flow, tissue edema , and infection, can cause the progression of the burn injury .

A burn injury can affect people of all age groups, in all socioeconomic groups.

• An estimated 500, 000 people are treated for minor burn injury annually.
• The number of patients who are hospitalized every year with burn injuries is more than 40, 000, including 25, 000 people who require hospitalization in specialized burn centers across the country.
• The remaining 5, 000 hospitals see an average of three burns per year.
• Of those people admitted in burn centers, , 47% of their injuries occurred at home, 27% on the road, 8% are occupational, 5% are recreational, and the remaining 13% from other sources.
• 40% of these injuries are flame related, 30% scald injuries, 4% electrical, 3% chemical, and the remaining unspecified.
• Males have greater than twice the chance of burn injury than women.
• The most frequent age group for contact burns is between 20 to 40 years of age .
• The National Fire Protection Association reports 4, 000 fire and burn deaths each year.
• Of the 4,000, 3, 500 deaths occur from residential fires and the remaining 500 from other sources such as motor vehicle crashes, scalds, or electrical and chemical sources.
• The overall mortality rate, for all ages and for total body surface area burned is 4.9%.

The changes that occur in burns include the following:

• Hypovolemia . This is the immediate consequence of fluid loss and results in decreased perfusion and oxygen delivery.
• Decreased cardiac output . Cardiac output decreases before any significant change in blood volume is evident.
• Edema. Edema forms rapidly after burn injury.
• Decreased circulating blood volume. Circulating blood volume decreases dramatically during burn shock.
• Hyponatremia . Hyponatremia is common during the first week of the acute phase, as water shifts from the interstitial space to the vascular space.
• Hyperkalemia . Immediately after burn injury hyperkalemia results from massive cell destruction .
• Hypothermia. Loss of skin results in an inability to regulate body temperature.

To promote safety and avoid burns, the following must be done to prevent burns:

• Advise that matches and lighters be kept out of reach of children.
• Emphasize the importance of never leaving children unattended around fire or in bathroom/bathtub.
• Caution against smoking in bed , while using home oxygen, or against falling asleep while smoking.
• Caution against throwing flammable liquids onto an already burning fire.
• Caution against using flammable liquids to start fires.
• Recommend avoidance of overhead electrical wires and underground wires when working outside.
• Advise that hot irons and curling irons be kept out of reach of children.
• Caution against running an electrical cord under carpets or rugs.
• Advocate caution when cooking, being aware of loose clothing hanging over the stove top.
• Recommend having a working fire extinguisher in the home and knowing how to use it.

There are a lot of consequences involved in burn injuries that may progress without treatment.

• Ischemia. As edema increases, pressure on small blood vessels and nerves in the distal extremities causes an obstruction of blood flow.
• Tissue hypoxia. Tissue hypoxia is the result of carbon monoxide inhalation.
• Respiratory failure. Pulmonary complications are secondary to inhalational injuries.

Various methods are used to determine the TBSA affected by burns.

• Rule of Nines. A common method, the rule of nines is a quick way to estimate the extent of burns in adults through dividing the body into multiples of nine and the sum total of these parts is equal to the total body surface area injured.
• Lund and Browder Method. This method recognizes the percentage of surface area of various anatomic parts, especially the head and the legs, as it relates to the age of the patient.
• Palmer Method. The size of the patient’s palm , not including the surface area of the digits, is approximately 1% of the TBSA, and the patient’s palm without the fingers is equivalent to 0.5% TBSA and serves as a general measurement for all age groups.

Burn care is a delicate task any nurse can have and being knowledgeable in the proper sequencing of the interventions is very essential.

• Transport. The hospital and the physician are alerted that the patient is en route so that life-saving measures can be initiated immediately.
• Priorities. Initial priorities in the ED remain airway, breathing, and circulation.
• Airway. 100% humidified oxygen is administered and the patient is encouraged to cough so that secretions can be removed by coughing .
• Chemical burns. All clothing and jewelry are removed and chemical burns should be flushed.
• Intravenous access . A large bore (16 or 18 gauge) IV catheter is inserted in the non-burned area.
• Gastrointestinal access. If the burn exceeds 20% to 25% TBSA, a nasogastric tube is inserted and connected to low intermittent suction because there are patients with large burns that become nausea ted.
• Clean beddings. Clean sheets are placed over and under the patient to protect the burn wound from contamination, maintain body temperature, and reduce pain caused by air currents passing over exposed nerve endings.
• Fluid replacement therapy. The total volume and rate of IV fluid replacement is gauged by the patient’s response and guided by the resuscitation formula.

Nursing Management

Nursing management in burn care requires specific knowledge on burns so that there could be a provision of appropriate and effective interventions.

The nursing assessment focuses on the major priorities for any trauma patient; the burn wound is a secondary consideration.

• Focus on the major priorities of any trauma patient. the burn wound is a secondary consideration, although aseptic management of the burn wounds and invasive lines continues.
• Assess circumstances surrounding the injury.  Time of injury, mechanism of burn, whether the burn occurred in a closed space, the possibility of inhalation of noxious chemicals, and any related trauma .
• Monitor vital signs frequently.  Monitor respiratory status closely; and evaluate apical, carotid, and femoral pulses particularly in areas of circumferential burn injury to an extremity.
• Start cardiac monitoring if indicated.  If patient has history of cardiac or respiratory problems, electrical injury.
• Check peripheral pulses on burned extremities hourly; use Doppler as needed.
• Monitor fluid intake ( IV fluids ) and output (urinary catheter) and measure hourly. Note amount of urine obtained when catheter is inserted (indicates preburn renal function and fluid status).
• Obtain history. Assess body temperature, body weight, history of preburn weight, allergies, tetanus immunization , past medical surgical problems, current illnesses, and use of medications.
• Arrange for patients with facial burns to be assessed for corneal injury.
• Continue to assess the extent of the burn; assess depth of wound, and identify areas of full and partial thickness injury.
• Assess neurologic status: consciousness, psychological status,  pain and anxiety levels, and behavior.
• Assess patient’s and family’s understanding of injury and treatment. Assess patient’s support system and coping skills.

Acute Phase

The acute or intermediate phase begins 48 to 72 hours after the burn injury. Burn wound care and pain control are priorities at this stage.

Acute or intermediate phase begins 48 to 72 hours after the burn injury.

• Focus on hemodynamic alterations, wound healing , pain and psychosocial responses, and early detection of complications.
• Measure vital signs frequently.  Respiratory and fluid status remains highest priority.
• Assess peripheral pulses frequently for first few days after the burn for restricted blood flow.
• Closely observe hourly fluid intake and urinary output, as well as blood pressure and cardiac rhythm ; changes should be reported to the burn surgeon promptly.
• For patient with inhalation injury, regularly monitor level of consciousness, pulmonary function, and ability to ventilate; if patient is intubated and placed on a ventilator , frequent suctioning and assessment of the airway are priorities.

Rehabilitation Phase

Rehabilitation should begin immediately after the burn has occurred . Wound healing, psychosocial support, and restoring maximum functional activity remain priorities. Maintaining fluid and electrolyte balance and improving  nutrition status continue to be important.

• In early assessment, obtain information about patient’s educational level, occupation, leisure activities, cultural background, religion, and family interactions.
• Assess self concept, mental status, emotional response to the injury and hospitalization, level of intellectual functioning, previous hospitalizations, response to pain and pain relief measures, and sleep pattern.
• Perform ongoing assessments relative to rehabilitation goals, including range of motion of affected joints, functional abilities in ADLs, early signs of skin breakdown from splints or positioning devices, evidence of neuropathies (neurologic damage), activity tolerance , and quality or condition of healing skin.
• Document participation and self care abilities in ambulation , eating, wound cleaning , and applying pressure wraps.
• Maintain comprehensive and continuous assessment for early detection of complications, with specific assessments as needed for specific treatments, such as postoperative  assessment of patient undergoing primary excision.

Nursing diagnoses for burn injuries include:

• Impaired gas exchange related to carbon monoxide poisoning, smoke inhalation, and upper airway obstruction.
• Ineffective airway clearance related to edema and effects of smoke inhalation.
• Fluid volume deficit related to increased capillary permeability and evaporative losses from burn wound.
• Hypothermia related to loss of skin microcirculation and open wounds.
• Pain related to tissue and nerve injury.
• Anxiety related to fear and the emotional impact of burn injury.

Main Article : 11 Burn Injury Nursing Care Plans

To implement the plan of care for a burn injury patient effectively, there should be goals that should be set:

• Maintenance of adequate tissue oxygenation .
• Maintenance of patent airway and adequate airway clearance.
• Restoration of optimal fluid and electrolyte balance and perfusion of vital organs.
• Maintenance of adequate body temperature.
• Control of pain.
• Minimization of patient’s and family’s anxiety .
• Maintain patent airway/respiratory function.
• Restore hemodynamic stability/circulating volume.
• Alleviate pain.
• Prevent complications.
• Provide emotional support for patient/ significant other (SO).
• Provide information about condition, prognosis, and treatment.

Nursing care of a patient with burn injury needs to be precise and effective.

Promoting Gas Exchange and Airway Clearance

• Provide humidified oxygen, and monitor arterial blood gases ( ABGs ), pulse oximetry , and carboxyhemoglobin levels.
• Assess breath sounds and respiratory rate, rhythm, depth, and symmetry; monitor for hypoxia.
• Observe for signs of inhalation injury: blistering of lips or buccal mucosa; singed nostrils ; burns of face, neck, or chest; increasing hoarseness ; or soot in sputum or respiratory secretions.
• Report labored respirations, decreased depth of respirations, or signs of hypoxia to physician immediately; prepare to assist with intubation and escharotomies.
• Monitor mechanically ventilated patient closely.
• Institute aggressive pulmonary care measures: turning, coughing, deep breathing , periodic forceful inspiration using spirometry, and tracheal suctioning.
• Maintain proper positioning to promote removal of secretions and patent airway and to promote optimal chest expansion; use artificial airway as needed.

Restoring fluid and Electrolyte Balance

• Monitor vital signs and urinary output (hourly), central venous pressure (CVP), pulmonary artery pressure, and cardiac output.
• Note and report signs of hypovolemia or fluid overload .
• Maintain IV lines and regular fluids at appropriate rates, as prescribed. Document intake, output, and daily weight.
• Elevate the head of bed and burned extremities.
• Monitor serum electrolyte levels (eg, sodium , potassium , calcium , phosphorus, bicarbonate); recognize developing electrolyte imbalances.
• Notify physician immediately of decreased urine output;  blood pressure ; central venous, pulmonary artery, or pulmonary artery wedge pressures; or increased pulse rate .

Maintaining Normal Body Temperature

• Provide warm environment: use heat shield, space blanket, heat lights, or blankets.
• Assess core body temperature frequently.
• Work quickly when wounds must be exposed to minimize heat loss from the wound.

Minimizing Pain and Anxiety

• Use a pain scale to assess pain level (ie, 1 to 10); differentiate between restlessness due to pain and restlessness due to hypoxia.
• Administer IV opioid analgesics as prescribed, and assess response to medication ; observe for respiratory depression in patient who is not mechanically ventilated.
• Provide emotional support, reassurance, and simple explanations about procedures.
• Assess patient and family understanding of burn injury, coping strategies, family dynamics, and anxiety levels. Provide individualized responses to support patient and family coping; explain all procedures in clear, simple terms.
• Provide pain relief , and give antianxiety medications if patient remains highly anxious and agitated after psychological interventions.

Monitoring and Managing Potential Complications

• Acute respiratory failure: Assess for increasing dyspnea , stridor, changes in respiratory patterns; monitor pulse oximetry and ABG values to detect problematic oxygen saturation  and increasing CO2; monitor chest xray s; assess for cerebral hypoxia (eg, restlessness, confusion ); report deteriorating
• respiratory status immediately to physician; and assist as needed with intubation or escharotomy.
• Distributive shock : Monitor for early signs of shock (decreased urine output, cardiac output, pulmonary artery pressure, pulmonary capillary wedge pressure, blood pressure , or increasing pulse) or progressive edema. Administer fluid resuscitation as ordered in response to physical findings; continue monitoring fluid status.
• Acute renal failure : Monitor and report abnormal urine output and quality, blood urea nitrogen (BUN) and creatinine  levels; assess for urine hemoglobin or myoglobin; administer increased fluids as prescribed.
• Compartment syndrome: Assess peripheral pulses hourly with Doppler; assess neurovascular status of extremities hourly (warmth, capillary refill, sensation, and movement); remove blood pressure cuff after each reading; elevate burned extremities; report any extremity pain, loss of peripheral pulses or sensation; prepare to assist with escharotomies.
• Paralytic ileus: Maintain nasogastric tube on low intermittent suction until bowel sounds resume; auscultate abdomen regularly for distention and bowel sounds.
• Curling’s ulcer : Assess gastric aspirate for blood and pH; assess stools for occult blood; administer antacids and histamine blockers (eg, ranitidine [Zantac]) as prescribed.

Restoring Normal fluid Balance

• Monitor IV and oral fluid intake; use IV infusion pumps.
• Measure intake and output and daily weight.
• Report changes (e.g., blood pressure , pulse rate) to physician.

Preventing Infection

• Provide a clean and safe environment; protect patient from sources of cross contamination (e.g., visitors, other patients, staff, equipment).
• Closely scrutinize wound to detect early signs of infection.

Monitor culture results and white blood cell counts.

• Practice clean technique for wound care procedures and aseptic technique for any invasive procedures. Use meticulous hand hygiene before and after contact with patient.
• Caution patient to avoid touching wounds or dressings; wash unburned areas and change linens regularly.

Maintaining Adequate Nutrition

• Initiate oral fluids slowly when bowel sounds resume; record tolerance—if vomiting and distention do not occur, fluids
• may be increased gradually and the patient may be advanced to a normal diet or to tube feedings.
• Collaborate with dietitian to plan a protein and calorie-rich diet acceptable to patient. Encourage family to bring nutritious and patient’s favorite foods. Provide nutritional and vitamin and mineral supplements if prescribed.
• Document caloric intake. Insert feeding tube if caloric goals cannot be met by oral feeding (for continuous or bolus feedings); note residual volumes.
• Weigh patient daily and graph weights.

Promoting Skin Integrity

• Assess wound status.
• Support patient during distressing and painful wound care.
• Coordinate complex aspects of wound care and dressing  changes.
• Assess burn for size, color, odor, eschar, exudate, epithelial buds (small pearl-like clusters of cells on the wound surface),  bleeding , granulation tissue, the status of graft take, healing of the donor site, and the condition of the surrounding skin; report any significant changes to the physician.
• Inform all members of the health care team of latest wound care procedures in use for the patient.
• Assist, instruct, support, and encourage patient and family to take part in dressing changes and wound care.
• Early on, assess strengths of patient and family in preparing for discharge and home care.

Relieving Pain and Discomfort

• Frequently assess pain and discomfort; administer analgesic agents and anxiolytic medications, as prescribed, before the pain becomes severe. Assess and document the patient’s response to medication and any other interventions.
• Teach patient relaxation techniques. Give some control over wound care and analgesia. Provide frequent reassurance.
• Use guided imagery and distraction to alter patient’s perceptions and responses to pain; hypnosis, music therapy, and virtual reality are also useful.
• Assess the patient’s sleep patterns daily; administer sedatives, if prescribed.
• Work quickly to complete treatments and dressing changes.

Encourage the patient to use analgesic medications before painful procedures.

• Promote comfort during healing phase with the following:
• oral antipruritic agents, a cool environment, frequent lubrication of the skin with water or a silica-based lotion, exercise and splinting to prevent skin contracture, and diversional activities.

Promoting Physical Mobility

• Prevent complications of immobility (atelectasis, pneumonia , edema, pressure ulcers , and contractures) by deep breathing, turning, and proper repositioning.
• Modify interventions to meet patient’s needs. Encourage early sitting and ambulation . When legs are involved, apply elastic pressure bandages before assisting patient to upright position.
• Make aggressive efforts to prevent contractures and hypertrophic scarring of the wound area after wound closure for a year or more.
• Initiate passive and active range-of-motion exercises from admission until after grafting, within prescribed limitations.
• Apply splints or functional devices to extremities for contracture control; monitor for signs of vascular insufficiency, nerve compression, and skin breakdown.

Strengthening Coping Strategies

• Assist patient to develop effective coping strategies: Set specific expectations for behavior, promote truthful communication to build trust, help patient practice coping strategies, and give positive reinforcement when appropriate.
• Demonstrate acceptance of patient. Enlist a non involved person for patient to vent feelings without fear of retaliation.
• Include patient in decisions regarding care. Encourage patient to assert individuality and preferences. Set realistic expectations for self care.

Supporting Patient and Family Processes

• Support and address the verbal and nonverbal concerns of the patient and family.
• Instruct family in ways to support patient.
• Make psychological or social work referrals as needed.
• Provide information about burn care and expected course of treatment.
• Initiate patient and family education during burn management. Assess and consider preferred learning styles; assess ability to grasp and cope with the information; determine barriers to learning when planning and executing teaching.
• Remain sensitive to the possibility of changing family dynamics.
• Heart failure : Assess for fluid overload , decreased cardiac output, oliguria, jugular vein distention, edema, or onset of S3 or S4 heart sounds.
• Pulmonary edema: Assess for increasing CVP, pulmonary artery and wedge pressures, and crackles; report promptly. Position comfortably with head elevated unless contraindicated. Administer medications and oxygen as prescribed and assess response.
• Sepsis : Assess for increased temperature, increased pulse, widened pulse pressure, and flushed, dry skin in unburned areas (early signs), and note trends in the data. Perform wound and blood cultures as prescribed. Give scheduled  antibiotics on time.
• Acute respiratory failure and acute respiratory distress syndrome (ARDS): Monitor respiratory status for dyspnea , change in respiratory pattern, and onset of adventitious sounds. Assess for decrease in tidal volume and lung compliance in patients on mechanical ventilation . The hallmark of onset of ARDS is hypoxemia on 100% oxygen, decreased lung compliance , and significant shunting; notify physician of deteriorating respiratory status.
• Visceral damage (from electrical burns): Monitor electrocardiogram ( ECG ) and report dysrhythmias; pay attention to pain related to deep muscle ischemia and report. Early detection may minimize severity of this complication. Fasciotomies may be necessary to relieve swelling and ischemia  in the muscles and fascia; monitor patient for excessive  blood loss and hypovolemia after fasciotomy .
• Contractures: Provide early and aggressive physical and occupational therapy; support patient if surgery is needed to achieve full range of motion.
• Impaired psychological adaptation to the burn injury:
• Obtain psychological or psychiatric referral as soon as evidence of major coping problems appears.

Promoting Activity Tolerance

• Schedule care to allow periods of uninterrupted sleep . Administer hypnotic agents, as prescribed, to promote  sleep .
• Communicate plan of care to family and other caregivers .
• Reduce metabolic stress by relieving pain, preventing chilling or fever , and promoting integrity of all body systems to help conserve energy. Monitor fatigue , pain, and fever to determine amount of activity to be encouraged daily.
• Incorporate physical therapy exercises to prevent muscular atrophy and maintain mobility required for daily activities.
• Support positive outlook, and increase tolerance for activity by scheduling diversion activities in periods of increasing duration.

Improving Body Image and Self-Concept

• Take time to listen to patient’s concerns and provide realistic support; refer patient to a support group to develop coping strategies to deal with losses.
• Assess patient’s psychosocial reactions; provide support and develop a plan to help the patient handle feelings.
• Promote a healthy body image and selfconcept by helping patient practice responses to people who stare or ask about the injury.
• Support patient through small gestures such as providing a birthday cake, combing patient’s hair before visitors, and sharing information on cosmetic resources to enhance appearance.
• Teach patient ways to direct attention away from a disfigured body to the self within.
• Coordinate communications of consultants, such as psychologists, social workers, vocational counselors, and teachers, during rehabilitation.

Teaching Self-care

• Throughout the phases of burn care, make efforts to prepare patient and family for the care they will perform at home. Instruct them about measures and procedures.
• Provide verbal and written instructions about wound care, prevention of complications, pain management , and nutrition.
• Inform and review with patient specific exercises and use of elastic pressure garments and splints; provide written instructions.
• Teach patient and family to recognize abnormal signs and report them to the physician.
• Assist the patient and family in planning for the patient’s continued care by identifying and acquiring supplies and equipment that are needed at home.
• Encourage and support followup wound care.
• Refer patient with inadequate support system to home care resources for assistance with wound care and exercises.
• Evaluate patient status periodically for modification of home care instructions and/or planning for reconstructive  surgery .

In a patient with burn injury, the expected outcomes are:

• Absence of dyspnea .
• Respiratory rate between 12 and 20 breaths/min.
• Lungs clear on auscultation ,
• Arterial oxygen saturation greater than 96% by pulse oximetry.
• ABG levels within normal limits.
• Patent airway
• Respiratory secretions are minimal, colorless, and thin.
• Urine output between 0.5 and 1.0 mL/kg/h.
• Blood pressure higher than 90/60 mmHg.
• Heart rate less than 120 bpm.
• Body temperature remains between 36.1ºC and 38.3ºC

The following are interventions you must consider when caring elderly people with burn injury.

• Elderly people are at higher risk for burn injury because of reduced coordination , strength, and sensation and changes in  vision .
• Predisposing factors and the health history in the older adult influence the complexity of care for the patient.
• Pulmonary function is limited in the older adult and therefore airway exchange, lung elasticity, and ventilation can be affected.
• This can be further affected by a history of smoking.
• Decreased cardiac function and coronary artery disease  increase the risk of complications in elderly patients with burn injuries. Malnutrition and presence of diabetes mellitus or other endocrine disorders present nutritional challenges and require close monitoring.
• Varying degrees of orientation may present themselves on admission or through the course of care making assessment of pain and anxiety a challenge for the burn team.
• The skin of the elderly is thinner and less elastic, which affects the depth of injury and its ability to heal.

The focus of rehabilitative interventions is directed towards outpatient care, home care, or care in a rehabilitation center.

• Wound care . The patient and the family are instructed to wash small clean, open wounds daily with mild soap and water and to apply the prescribed topical agent or dressing.
• Education. The patient and the family require careful written and verbal instructions about pain management , nutrition, prevention of complications, specific exercises, and the use of pressure garments and splints.
• Follow up care. Patients who receive care in a burn center usually return to the burn clinic periodically for evaluation , modification of burn care instructions, and planning for reconstructive surgery .
• Referral. Patients who return home after a severe burn injury, those who cannot manage their own burn care, and those with inadequate support systems need referral for home care.

The nurse should document the following data to ensure that each care documented is a care that is done.

• Breath sounds and character of secretions.
• Respiratory rate, pulse oximetry/O2 saturation, vital signs.
• Plan of care and those involved in the planning.
• Teaching plan.
• Client’s response to interventions, teachings, and actions performed.
• Use of respiratory devices or adjuncts.
• Conditions that may interfere with oxygen supply.
• I&O, fluid balance , changes in weight, urine specific gravity.
• Attainment or progress toward desired outcomes .
• Modifications to the plan of care.

Posts related to Burn Injury:

• 11 Burn Injury Nursing Care Plans
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• Burn Injury Nursing Management NCLEX Practice Quiz 2 (20 Items)
• Impaired Tissue Integrity

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• v.115(5); Sep-Oct 2018

Evaluation and Management of the Burn Patient: A Case Study and Review

Advances in the management of burn patients have contributed to significant improvements in morbidity and mortality over the last century. The physiologic insult from this injury pattern, however, still requires extensive surgical intervention, resuscitation and multidisciplinary care. This paper will review the standard of care of these patients in the context of a recent case study from our institution.

Introduction

In spite of a decreasing frequency of burn-related injuries in the 21 st century due to improved manufacturing production of commercial goods, thermal injury in the United States is still a major injury pattern. Over 200,000 patients in the United States alone were burned between 2005 and 2016, resulting in over 6000 deaths. 1 Mankind has been dealing with thermal injuries for thousands of years, yet “modern” burn care has evolved exponentially over the last 50–60 years. Advances in resuscitation, operative care and grafting techniques, infection prevention and treatment, and mitigation of hypermetabolism have all improved survival and recovery. In spite of these advances, however, questions and controversies regarding best practices are still prevalent, and numerous burn centers and laboratories across the United States continue to research various aspects of burn care, from the resuscitative phase to the reconstructive and recovery phase.

These advances in burn care have improved burn survival from a near 100% mortality seen with a burn size of 30% in the early 1900s, 2 to survival estimates over 50% in young, healthy patients with burn sizes up to 95%. 3 Nonetheless, the acute phase of resuscitation still generates significant controversy and is not a standardized process. One can query the resuscitation protocols of various burn units throughout the country and find many variations, from the usage of crystalloid-only formulae to adding colloid at various time points in the acute period, to the usage of “rescue therapies” and what they constitute and when to use them. While this review will not go into great detail of the variations, we will describe our initial burn evaluation, subsequent resuscitation, and overall management plan in caring for a seriously thermally-injured patient.

Case Presentation

A 58-year-old female patient was activated as a Level 1 trauma alert after being involved in a house explosion with resultant fire. She was awake and alert with no loss of consciousness at the scene but sustained significant thermal injuries per EMS report. She was intubated pre-hospital for “airway protection” out of concern for inhalation injury with facial burns. Initial evaluation revealed an older woman, orally intubated with bilateral breath sounds, mildly tachycardic in the 100s, moderately hypertensive in the 160s/90s, with readily apparent full-thickness burns to the face, neck, anterior torso, bilateral arms, and bilateral legs ( Photos 1 and 2 ). Secondary survey and imaging revealed no further injuries. At this juncture, it’s important to remember and remind the non-burn or trauma center practitioner that a thermally-injured patient is still a “trauma” patient. While a large, third degree burn certainly elicits a significant morbid response in many observers, spending significant time managing the burn wounds while neglecting potential internal hemorrhage will invariably lead to a delay in treatment and worse outcomes.

Patient Initial Burns

The patient was immediately taken to our specialized Burn Operating Room once other injuries were ruled out and both non- and -excisional debridement of her burn wounds occurred, with resultant wound dressing application. Her upper body burns were debrided and dressed with antimicrobial dressings. She then resuscitated for the next 48 hours, ultimately receiving approximately 3.3 mL/kg/%TBSA in the first 24 hours post-injury based on a TBSA of 63%, primarily full-thickness (third degree). Resuscitation continued over the first 48 hours, and the patient underwent serial excisional debridement and wound preparation procedures over the next few weeks. Given the size of her burns, we opted to utilize cultured epidermal autografts for assistance with skin/wound coverage. It is important to note that during the entirety of our patient’s two-month hospitalization she received attentive multidisciplinary care including efforts from nutrition services, therapy services, social work, as well as the nursing and physician teams. After continued local wound and graft care the patient was discharged on HD61 to a rehabilitation facility, where she stayed for approximately three weeks until discharge home, where she now lives independently and is continuing to improve.

Evaluating overall burn size can, likewise, be difficult to the untrained. While we expect that many in the medical field have heard of “the rule of 9s”, establishing the rule in practice is trickier. Many studies have evaluated overall accuracy of pre-burn center size estimates from both EMS and referring hospitals, many of which are incorrect. What is perhaps more troubling is that the inaccuracies run in both direction, i.e. overestimating burn size is as frequent as underestimating. The American Burn Association (ABA) has a list of Burn Center Referral Criteria as well as a helpful guide to the “Rule of 9s for public usage on their main website, reprinted in this summary ( Figure 1 ).

ABA Burn Referral Criteria

Historically, “burn surgery” consisted of reconstruction and scar release if the patient survived. Lieutenant Colonel C.P. Artz, in 1955, discussed “exposing” the burn wounds to air until eschar forms, “[i]n full-thickness burns there is dehydration of the pearly white or charred dead skin, and it is converted into a protective eschar....This eschar serves as a temporary physiological cover until liquefaction occurs beneath it in 14 to 21 days.” 4 It wasn’t until the 1970s that a Yugoslavian surgeon, Zora Janzekovic, described her experience tangentially excising deep partial- and full-thickness burn wounds in over 1,600 patients that “burn surgery” truly developed into a surgical subspecialty. 5 Most modern burn units excise deep-partial and full-thickness burn wounds “early,” typically 24–72 hours post-injury. In our experience, “early” means at or near admission, as burned tissue is a nidus of the inflammatory cascade that potentially leads to the “burn shock” phenomenon. 6

Fluid resuscitation of the thermally injured patient is, in many ways, the most important early aspect of burn care, and likely contributes most to overall improvement in burn survival. The need for fluid resuscitation was first recognized in modern times in the 1920s. A physiologist at Yale Hospital, Dr. Frank Underhill, while caring for 20 burn-injured patients, discovered upon evaluation of burn-blister fluid a composition quite similar to plasma. He correctly theorized that “burn shock,” or the hemodynamic instability that occurs after a major burn injury, was a hypovolemic state and that an intravascular volume-based treatment was necessary. 7 In 1942 the “Cocoanut Grove” nightclub, a popular, Pacific-Island themed club in Boston, Ma., caught fire. Drs. O. Cope and F. D. Moore cared for a majority of the patients between Boston City and Massachusetts General Hospitals, and in so doing helped codify the relationship between patient size and overall burn size as they related to fluid resuscitation. This resuscitation work was further advanced by C. Baxter and T. Shires at Parkland Hospital in Dallas, Texas, in the 1960s and 70s, ultimately leading to the Parkland™ formula, or 4mL/kg/%TBSA of Lactated Ringers solution, which is the most common burn resuscitation formula used in the United States. 8

Large body-surface area burns are typically very difficult to close in an expedited manner, primarily due to lack of donor site autograft to use. To combat this issue numerous tissue substitutes have been developed over the last several decades. C. P. Artz, described earlier, relates using “postmortem homografts,” “removed from the body of a deceased person under aseptic conditions soon after death…”. 4 In modern times, “postmortem homografts” are now standardly called allografts and are typically utilized in a cryopreserved rather than fresh fashion. These are nearly always temporary dressings meant for wound coverage and desiccation prevention. Concerns of disease transmission, skin supply, and expense make the use of allografts somewhat problematic. Bioengineered “skin substitutes” have been utilized in large body surface area burns for decades. The first, and perhaps most widely used is a bilaminar product called Integra.™ Developed in the 1980s, it combines bovine collagen and shark cartilage-derived chondroitin-6-sulfate, and allows for vascularization and formation of a neodermis when placed on full-thickness burns. The outer layer is a Silastic silicone-based material that acts like an epidermis and allows for protection of the fragile underlying collagenous material. Once the collagen is engrafted in a few weeks, it allows for placement of an ultra-thin split-thickness skin graft. Similar materials have been developed for use in burn care, including another bovine collagen product called Primatrix™ as well as a Hyaluronic acid derivative called Hyalomatrix.™ In very large burns with extremely limited donor sites, cultured “skin” has been utilized with great success at wound closure. Called Epicel,™ confluent sheets are grown into epidermis within two to three weeks from a sample of patients’ full-thickness skin sample by a company in Cambridge, Massachusetts. These sheets can then be implanted on a prepared wound and are FDA-approved for compassionate use in large burns. The end-result is a closed but imperfect wound as the thin epidermal layer offers little resistance to blistering or shearing. The expense associated with its usage is also considerable. An offshoot of “cultured” skin is a product commonly called “spray-on skin” in social media and by the public. ReCell™ is a real-time non-cultured skin graft alternative that is presently being evaluated by the FDA. By obtaining a small full-thickness skin sample, a clinician prepares a suspension containing basal keratinocytes using a proprietary kit in real-time that may be “sprayed” on an excised and prepared wound bed in an approximate 80:1 expansion, which is truly donor-site sparing. 9 Thus, on HD2 a 6 × 2 cm full-thickness skin sample from our patient was sent for growth of epidermal sheets which were implanted without complication approximately one month after injury.

Burn care is a true “team effort,” and, in fact, was likely the first “team-centered” surgical subspecialty developed after more than 500 people were killed and 3,000 injured in the “Texas City Disaster” in 1947, still considered to be America’s “worst industrial accident.” 10 The injured were cared for by Dr. T. Blocker and the University of Texas Hospital in Galveston, and during their convalescence were cared for by a team comprising nurses, physicians, therapists, nutritionists, and social workers to maximize outcomes. The team recognized the need for early nutrition, early mobilization, and aggressive wound care. These concepts are still followed today.

Care of the patient with a large body-surface area burn is complex, lengthy, and fraught with potential complications. These complications can be anticipated and minimized in burn centers accustomed to the complexities of major burn care; ultimately yielding improved survival and functional outcomes. The patient in this article, in spite of an anticipated initial mortality approaching 70% on admission, survived to discharge with only a few treatable complications, and is currently home, driving, and otherwise living independently. Her burn scars are being managed with outpatient scar exercises such as moisturization, massage, and compression. This positive outcome is the norm in burn centers, and an excellent example of why patients with major burn injuries should be cared for in these specialized centers. Any patient with a significant burn, even if not delineated on the ABA referral list, warrants discussion with a burn-trained surgical team.

Jeffrey S. Litt, DO, FACS, is Assistant Professor of Surgery, Burn Director, Division of Acute Care Surgery, Department of Surgery, University of Missouri School of Medicine, Columbia, Missouri.

Contact: ude.iruossim.htlaeh@sjttil

J. Litt received Acelity/KCI Speaker Honoraria.

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In this section

Nursing management of burn injuries

Introduction

Definition of Terms

Assessment  - ABCD

Management  - Fluids and Burn Dressings

Companion Documents

Evidence Table

Children are vulnerable to sustaining a burn injury due to their physiological, psychological, and developmental differences.     Burn injuries have a significant impact on paediatric patients and may affect a range of body systems. The impact of these injuries on children and families is often long lasting. As the injury itself and required treatment often causes distress, pain and anxiety, appropriate management by nurses is essential in providing family centered care.     Ongoing care requirements are based on the size, depth, anatomical site and mechanism of injury.  

The aim of this clinical guideline is to assist and support nursing staff at The Royal Children’s Hospital to plan and deliver care to children with burn injuries, across all departments including: Emergency, Paediatric Intensive Care Unit, Inpatient Units, Theatres and Outpatients.  

Definition of terms 

• Burns Multidisciplinary Team – consists of Burns Consultant/Fellow, Burns Clinical Nurse Consultant, Burns registrar/resident, Nurse Coordinator, Occupational Therapist, Physiotherapist, Dietitian, Social Work, Mental Health, Child Life Therapy (CLT), Specialist Clinics Team.
• % TBSA – percentage of total body surface area burnt (not including erythema or superficial burns) calculated using the Lund Browder chart .
• Minor Burn – In paediatric burns a minor burn is considered to be less than 10% TBSA.
• Major Burn – In paediatric burns a major burn is considered to be more than 10% TBSA.

Burn injuries cause a significant insult on the body and a thorough ABCD assessment, followed by a full head to toe and focused assessment are vital to ensure clinical issues/deterioration are identified early and appropriate management initiated. See Burns- Acute management CPG for further details of burn injury assessment.  Assessment of the pediatric patient with a burn injury should occur on admission and regularly throughout care.  Detailed information regarding completion and documentation of ABCD, head to toe and focused assessments can be located on the Nursing Assessment Clinical Guideline .  Burns specific information is outlined below.

Airway and Breathing 

Assessment and monitoring of airway patency and breathing should be carefully observed as patients at risk of inhalation burns can deteriorate up to 72 hours post burn injury, particularly if they have:

• Sustained burns in an enclosed space (at risk due to smoke inhalation)
• Have facial burns
• Singed nasal hairs
• Facial swelling
• Blackened sputum
• Stridor or hoarseness of voice 
• Respiratory distress/increased work of breathing

If inhalation burns are suspected high flow oxygen therapy via a Hudson mask should be administered to the patient and changes/abnormal findings reported to the treating team immediately for further assessment and management. 

Circulation

Children who sustain burns injuries are at increased risk of circulatory compromise due to significant fluid loss and fluid shifts, these patients must be closely monitored for:

• Signs and symptoms of hypovolemia.
• Signs and symptoms of hypothermia.

Other circulatory concerns include:

• Circumferential burns should be identified, monitored for circulatory compromise ( neurovascular observations nursing guideline ) and the affected area elevated where ever possible.
• Consider the need for an ECG and continuous cardiac monitoring if the burn is of electrical origin.

Pain assessment

Detailed information regarding paediatric pain assessment can be located on the Pain Assessment Nursing Clinical Guideline . Information regarding procedural pain management can be located on the Procedural Pain Management Clinical Guideline .   

Wound assessment

Assessment of the burn injury should occur on the initial presentation to the Royal Children’s Hospital as well as prior to completing wound care throughout the inpatient stay and outpatient visits. Burn injuries can take up to 10 days to truly present the depth and extent of injury so reassessment is vital. As burn injuries heal accurate wound assessment will ensure wound management is altered as needed to ensure appropriate wound care continues to be delivered to the patient.  Wound assessment of a burn injury includes (available on Electronic medical Records):

• Assessment of Total Body Surface Area (TBSA) burnt, utilising the Lund Browder chart. Areas of erythema and superficial burns are not included in calculations of TBSA.
• Assessment of depth of burn injury. 
• Assessment of wound healing.

Accurate documentation of wound assessment should be recorded. Further information regarding wound assessment in a burn injury can be located on the Burns Clinical Practice Guideline   as well as the Burns Unit: Clinical Information .  Further information regarding wound assessment and healing can be located on the Wound Care Clinical nursing guideline .

A thorough patient history should be collected on admission to hospital.    Specific information regarding the burn injury must be obtained from the patient, family and first responders as this will inform ongoing treatment. History taking should include:  

• Time of injury
• Mechanism of injury: How the burn occurred/type of burn, including length of exposure and estimated temperatures of heat source.
• Was first aid completed? If so, what type and for how long?
• Tetanus status of the patient (if not up to date consider immunisation, see Immunisation of inpatients Clinical Guideline .)

In addition to this information a detailed patient and family history should also be obtained. Further information regarding this can be located on the Nursing Assessment Nursing Clinical Guideline .  Non accidental injuries must be considered when the history does not match with the injury or inconsistencies with the history/story occur. Refer to medical staff & social work. Victorian Forensic Paediatric Medical Service (VPFMS) can also be notified. For further information regarding non accidental injuries refer to the Child Abuse Clinical Guideline .

Social history

Burn injuries are traumatic and life altering events which can significantly impact the patient and their family. Early support from social work, contact with CLT and chaplains should be offered to the child, siblings and family. It may also be appropriate to consider referrals to mental health/psychology.   

Management 

Completion of first aid for a child who has sustained a burn injury is an important initial aspect of care as it assists with pain relief as well as minimising the progression of tissue damage. First aid is effective for up to three hours post time of injury. If appropriate first aid was not initiated and it is still within the 3 hour time frame post burn injury, first aid should be completed as outlined below, prior to any wound care: 

• The area of tissue damage should be cooled with cool running water for 20 minutes. 
• Ensure the unburnt areas of the patient are covered and warm to prevent hypothermia.

Further information regarding burn injury first aid including burns to the eye area and chemical burns can be found on the Burns Clinical Practice Guideline . 

For initial fluid management see Burns Acute Management CPG  

Burn injuries greater than 10% TBSA and including the dermis result in circulatory compromise secondary to fluid loss via damaged tissue, widespread vasodilation as well as increase capillary permeability and fluid shifts (third spacing). This can result in hypovolemia leading to burns shock. Therefore it is vital that adequate fluid is administered to the patient in combination with ongoing circulatory and fluid balance assessment.     

• A Strict Fluid Balance must be maintained at all times, including all intake (both intravenous and oral) and strict measurement of all output (weigh nappies, weigh pans/bottle, measure IDC)  
• Fluid resuscitation is required in patients who have >10-15% TBSA.   
• Patients receiving fluid resuscitation may need two large bore Intravenous cannulas inserted  
• Fluid resuscitation is calculated utilising the modified parkland formula. For further information regarding this please see the Burns Acute management CPG .  
• An IDC is essential for patients receiving fluid resuscitation to allow close monitoring of fluid status and adjustment of IVT as necessary.   
• Expected urine output is 1ml/kg/hr unless otherwise stated by the medical team.  
• U&E’s should be monitored 8 hourly while patient is receiving fluid resuscitation.   
• Fluid resuscitation rates will need to be adjusted to accommodate the patients urine output.   

Burn pain can be extremely intense and distressing for paediatric patients and can also be challenging to manage due to the individual experience and its unique characteristics.  Initial and ongoing pain management is vital to ensure patient comfort, maximise healing and minimise risk of mental trauma/post-traumatic stress.   

• Initial pain relief should be administered immediately following an accurate pain assessment, further information regarding initial pain management can be located on the Burns Clinical Practice Guideline .  
• Pre-emptive analgesia may be necessary prior to re-positioning, physiotherapy and follow up outpatient appointments.
• Reassessment and evaluation of pain management is vital, referral to Children’s Pain Management Service may be necessary.  

Burn pain experienced by patients is likely to increase during procedures such as dressing changes. Management of pain during burn dressing changes is discussed in detail below ( preparing for a dressing change ).  

Preparation for Burns Dressing

Preparation of patient and family.

Burn dressing changes can produce feelings of anxiety and distress in both patients and their families. It is very important that both patients and families are physically and emotionally prepared and well informed regarding the procedure and the pain management options.    

• Families/primary care givers should be given a thorough explanation of the procedure, where appropriate pictures could be used to visualise the procedure along with orientation to the treatment room/bathroom to be used.  
• Referral to CLT prior to the procedure may assist in explaining and preparing the patient for the dressing change.   CLT are also able to empower the child to identify distraction techniques, as well as provide support and distraction throughout the procedure.  
• Where possible and appropriate children should be given the opportunity to choose whether they want to participate in wound care for example assisting to remove dressings.  

For further information, staff and families can access reducing children’s discomfort during tests and procedures kids health info factsheet .  Assessment 

 Assessment

Children who are planned to undergo a burns dressing change should have an ABCD assessment completed along with pain assessment prior to the dressing change commencing.   The child will require continuous ABCD monitoring and pain assessment throughout the procedure to ensure that analgesics provide are adequate and effective. 

Pre Medication/ Pain Relief

Burns dressing changes can be painful and distressing for children.   Nursing staff should assess the child’s pain prior to the procedure commencing and pre-emptive analgesia should be administered. Staff should re-evaluate the effectiveness prior to the procedure commencing and throughout the procedure.   Choice of analgesia is an individual process and staff should take into account the % TBSA, depth, amount of debridement required as well as the pain tolerance, distress and past experience of the child. Review of analgesia/sedation requirements for previous dressing changes is essential.   The Children’s Pain Management Service (CPMS) may also be utilised to assist in planning procedural pain relief for burns dressing changes .    Options may include:   

• Simple analgesia such as Paracetamol and NSAIDs  
• Oral Analgesia such as Opioids (Oxycodone), Tramadol, Ketamine and Oral Sedatives such as Benzodiazepines e.g. Diazepam, Midazolam  
• Intravenous Sedation/Analgesics including infusions, PCA or intermittent bolus (Morphine/Fentanyl/Ketamine)  
• Nitrous Oxide (refer to the procedural sedation ward and ambulatory care p rocedure)  
• Intranasal medications such as Intranasal Fentanyl  
• Anaesthetics may be involved to provide sedation (Ketamine/Propofol) and continuous monitoring of the patient. 

A combination of the above options may be ordered and utilised to provide pain relief. Further information regarding this can be located on the Procedural Sedation – ward and ambulatory care procedure or through consultation with CPMS or comfort kids.   

Pain Assessment should occur continuously throughout the procedure by observing the behaviour and comfort level of the child as well as using an appropriate pain assessment scale.   If analgesia and sedative agents prescribed are not providing effective pain management/sedation then the procedure should be paused until appropriate analgesia/sedation is available and pain is manageable. Escalation to the children’s pain management service or Burns resident can occur at any stage throughout the procedure.    As the patient’s burn injury heals, analgesia and sedative agents utilised throughout the procedure should start to be slowly weaned with the support of CPMS, medical teams and senior nursing staff.   All sedative agents should be administered in line with the Sedation and Procedural Sedation Ward and Ambulatory Areas procedure .  

Staffing Requirements

To complete a burns dressing change in a safe and time efficient manner which minimises patient and family distress, staffing requirements must be considered.   

• Simple analgesia: 1-2 nursing staff of which 1 is experienced in burns dressing changes.  
• Oral sedation agents: 2-3 nursing staff of which 1 monitors the patient, 1 is experienced in burns dressing and 1 staff member assists.  
• Nitrous Oxide: 2-4 nursing staff of which 1 is accredited in nitrous oxide administration, 1 is experienced in burns dressing and 1-2 staff members assists  
• IV agents: An Anaesthetist and Anaesthetic technician are required; 2-3 nursing staff of which 1 is experienced in burns dressing and 1-2 nursing staff members to assist  

All roles must be designated prior to commencement of dressing change and the patient should remain in line of sight to staff at all times. For further information refer to the Sedation and Procedural Sedation Guideline Ward and Ambulatory Care Areas procedure .   Burn injuries which have a large TBSA percentage and patients with reduced mobility may require increased staff numbers to assist in dressing changes. For further information refer to the High Dependency and Special Nursing Care nursing guideline .  

Preparation of environment and equipment

• For children who have larger %TBSA burn injuries (>10%) consider using a treatment area where heaters can be utilised to minimise the risk of hypothermia. These heaters should be turned on prior to the dressing change commencing. (i.e. Platypus Burns Bathroom, Theatre)  
• Adequate preparation of the environment should be completed prior to the child being taken into the treatment room/bathroom.   
• Physiotherapy/Occupational therapy – to review patient mobility and splinting requirements.  
• Medical team – to review burn injury and wound healing.  
• Clinical photography  

Staff Roles

Prior to the procedure a team leader should be allocated. Other team member’s roles/responsibilities ie. Dressings nurse, sedationist, observations nurse, hygiene nurses should also be communicated.    An ISBAR handover should also occur; identifying patient name, age, weight, allergies, procedure, any pre procedure medication and staff roles.    

Burns dressing

Staff should adhere to the aseptic technique procedure for all aspects of wound care outlined below. 

Removal of previous dressing

Removal of the previous dressing should not damage the healing burn wound and should be as atraumatic as possible. The use of an adhesive remover, normal saline or water will assist with gentle removal of previous dressings.  

Wound Management

Clean the wound using a soft wipe with water, normal saline, pH neutral soap or cetrimide (please note cetrimide is not to be used on face or scalp). Enough pressure should be applied to debride the damaged skin and remove exudate, loose skin and slough.   Consider the need for a wound swab and complete if necessary.    Debridement of any blisters present allows for wound bed assessment and appropriate dressing application.     The wound and surrounding skin should be dry before application of the dressing.  

Personal Hygiene

Ensure the patient’s personal hygiene is thoroughly attended to if the burns dressing change is occurring in the bath or shower. If the patient is not having a bath use a sponge to clean non dressed areas. 

Application of Burns Dressing 

• A thorough wound assessment should occur with every dressing change and will determine the appropriate dressing required (see wound assessment above).  
• Dressings should cover all area where tissue damage has occurred but avoid unburnt skin as maceration may occur.  
• A crepe bandage/tubifast/tubigrip assists with securing dressings as well as absorbing some excess fluid. They also add pressure to support with scar management.  
• Oedema is common in the initial days post burn, therefore tight circumferential bandages should not be applied. Elevation of the limb in the immediate days post injury will limit swelling.  
• Dermal burns produce a large amount of exudate in the initial few days and changing of the outer bandage or tubifast may need to occur. Where possible retaping/securement of the dressing should occur unless a dressing change is scheduled.  

Additional products may be utilised on burns wounds at the discretion of medical and nursing staff.

For further information regarding the above and additional products please refer to the wound care guideline . 

Specific body areas  

Facial burn’s care.

Facial burns may require regular wound care including cleansing followed by application of paraffin cream. Parents should be encouraged to be involved in providing this care.  

If dressings are utilised on the face balaclavas can be made from large tubifast and used to secure dressing products.  

Additional information can be located on the Burns Medical Treatment .  

Hand Burn’s Care  

Any dressing applied to fingers, should ensure fingers are taped individually. Padding must be applied to web spaces to prevent further friction/pressure area injury. Initially fingers which have circumferential burns should be dressed with the finger tips exposed to monitor neurovascular status. Once oedema has decreased the finger tips can be enclosed in the dressing.  

Referral to hand therapy is vital.  

Documentation  

A summary post dressing change should be documented including: pain relief/ sedation and effect, non-pharmacological techniques and effect, parental involvement, wound assessment, dressing product utilised, staff present (including allied health, interpreter etc.) and plan of ongoing care. See Nursing Documentation Clinical Guideline for further information.  

Nutrition  

Nutrition plays a vital role in burn healing, minimising complications of care and meeting the increased metabolic demands associated with paediatric patients with burns. A diet high in protein, calcium, energy and micronutrients (in particular Zinc and Vitamin C) has been shown to be most beneficial for wound healing. Children should be encouraged to eat and drink foods high in these nutrients and nutritional supplements such as Sustagen™ may also be required.  

Insertion of a nasogastric tube and commencement of enteral feeds should be considered for children who sustain significant burn injuries and/or facial burns and are unable to tolerate adequate oral intake. Where possible feeds should commence within 6 - 8 hours of the burn injury.   

Referral to the Burns Team Dietician is recommended for all patients with significant burn injuries, facial burns, infants as well as patients who are not tolerating adequate oral intake.  

Management of Itch

Itching is a common and debilitating issue in the healing phase of a burn injury.

The following may assist in reducing itch:

-       Advise child and parent to avoid scratching - short finger nails will assist in this.

-       Consider use of antihistamines i.e. Periactin or Certizdine 

-       Avoid overheating the child

-       Fragrance free moisturiser (Sorbolene™) may assist.

-       Distraction will play a big role in patient comfort

Scar management:

Strategies to reduce scar development post burn injury include:

• Regular bathing and showering 
• Massage with fragrance free moisturiser (Sorbolene™) should be massaged into the healed skin at least twice daily to daily.
• Pressure therapy in the form of tubifast/tubigrip, tapes, pressure garments and silicone may be prescribed by Physiotherapy (PT) or Occupational therapy (OT). It is often recommended that garments are worn continuously except during personal hygiene.

Physiotherapy / occupational therapy – splinting & positioning:

Physiotherapy (PT) and Occupational therapy (OT) may be necessary throughout both inpatient stay and outpatient management for patients who have sustained a burn injury.  Significant burn wounds and those over joints are at high risk of contracture development. This can have an impact on both growth and mobility. Prevention of contractures needs to occur early and to assist in this PT and OT will prescribe patients with a splinting and positioning regime. To aid PT/OT in assessing the patient’s burn injury and range of movement it is often beneficial for them to attend changes of dressings. It is vital that these regimes are adhered to by nursing staff. Paediatric patients may find the splints and positioning regimes uncomfortable and distressing.  It is important to educate both patient and family on the importance of splints and the positioning regimes.  Strategies to support splinting and positioning regimes include:

• Regular and pre-emptive analgesia 
• CLT, distraction and rewards (i.e. sticker charts)    

Concerns regarding splinting and positioning regimes should be documented and reported back to PT/OT so as appropriate alterations to regimes can be initiated. 

Discharge planning

The decision for a patient to be discharged should have involvement from the burns multidisciplinary team and family meetings may be beneficial for planning purposes. Early discussion regarding discharge may facilitate a smoother transition home for the family.  

Children may be ready for discharge when: 

• Pain is able to be appropriately managed at home 
• An appropriate plan for wound care and follow up has been made
• Nutritional requirements are being met
• Mobility, positioning and splinting are able to be managed at home 

The following should be discussed with the family and child prior to discharge

• Pain management and itch plan, including plan for procedures (outpatients dressing changes) 
• Home care of burn wound 
• Nutritional requirements 
• PT/OT recommendations 
• Medical review
• When to return to hospital – ED/Specialist Clinics 

Companion documents

• Nursing competency workbook – burns dressing, assessment, and fluid management of burns.
• Lund Browder chart
• Nursing Assessment
• Neurovascular Observations
• Extravasation guideline
• Pain Assessment and Measurement
• Procedure Management
• Nursing Documentation
• High Dependency and Special Nursing Care
• Immunisation of inpatients
• Child Abuse
• Aseptic technique
• Procedural sedation - ward and ambulatory areas 
• Clinical Information
• Burns on the face
• Burns clinic at RCH

Evidence table

The evidence table for this nursing guideline can be found here .

Please remember to read the  disclaimer .

The development of this nursing guideline was coordinated by Kate Glassford, Nurse Coordinator & Clinical Nurse Specialist Platypus Ward, and approved by the Nursing Clinical Effectiveness Committee. Updated July 2022.  

Pediatric Interactive Clinical Cases

• A 2-Year-Old With Intracranial Hemorrhage This 2-year-old black male, with a past medical history significant for sickle cell anemia and hemophilia B, presented with altered mental status. Clinical Case, August 07, 2006
• Six-Week-Old Female With Bulging Anterior Fontanel The week prior to admission, the infant had fever up to 101º F and had 3 episodes of non-bloody, non-bilious emesis and mild diarrhea. Clinical Case, April 04, 2006
• A 10-Year-Old With Electrical Burn What other effects might this patient experience? Clinical Case, February 13, 2006
• A 3-Year-Old With Bullous Lesions This toddler presented with a progressively worsening rash. Clinical Case, October 24, 2005
• A 6-Year-Old Girl With Fever and Abdominal Pain A 6-year-old girl presented to the emergency room with a 3-hour history of left side abdominal pain and fever. Clinical Case, September 20, 2005
• Respiratory Failure in a 22-Month-Old Boy The child was noted to be cyanotic while in the waiting room of a dentist's office and required intubation during transport. Clinical Case, May 05, 2005
• A 14-Year-Old Boy With Hepatic Failure A 14-year-old previously healthy white boy transferred to our institution for treatment of hepatic failure and hypotension. Clinical Case, February 28, 2005
• 10-Year-Old With History of a Fall Since her bike handle hit her abdomen, the patient has experienced 4-5 episodes of nonbilious, nonbloody vomiting. Clinical Case, December 30, 2004
• Unusual Physical Finding in 2 Vietnamese Girls Healthcare providers must understand the rationale for traditional treatments practiced by ethnic groups so that resultant physical findings can can be more easily distinguished from abuse. Clinical Case, August 17, 2004
• Case #10 - Respiratory Failure in a 7-Month-Old Black Female Read about this 7-month-old girl with a history of failure to thrive who presented with acute respiratory failure, and test your diagnostic acumen. Clinical Case, June 24, 2004
• Infant With Intestines Outside of Abdominal Wall This infant was found to have multiple loops of intestine outside the abdominal wall. Read the details and test your diagnostic acumen. Clinical Case, April 05, 2004
• A 13-Year-Old With Facial Rash, Fever, and Recurrent Infections A 13-year-old black girl presented with a 1-year history of hyperpyigmented discoloration of the skin under her eyes and a 5-day history of subjective fever. Read on and make your diagnosis. Clinical Case, January 22, 2004
• Case #7 A 13-year-old white male with a long history of recurrent otitis media presented with a 1-week history of increasing earache and mucopurulent discharge. Clinical Case, August 29, 2003
• A 7-Year-Old Girl With Fever, Vomiting, and Abdominal Pain A 7-year-old girl presented with an 11-day history of fever, cough, abdominal pain, and vomiting. Clinical Case, July 16, 2003
• Case #5 -- A 4-Year-Old Boy With an Abdominal Mass Test your diagnostic skills with our series of Pediatric Interactive Cases. Clinical Case, May 12, 2003
• Interactive Case #4 - A Child With Painless Wounds This 8-year-old presented with a finger injury; she also had a history of an unhealed wound on her great toe for 1 year. What is your diagnosis? Clinical Case, March 18, 2003
• Case #3 - Acute Respiratory Distress in a 3-Year-Old at Daycare A 3-year-old white male developed stridor and respiratory distress while eating lunch at his daycare facility. Clinical Case, February 11, 2003
• Pediatric Interactive Clinical Cases Review the physical exam findings, lab results, and ECG in this interactive case of a 13-year-old girl who presented with a 10-day history of subjective fever and pain in multiple joints. Clinical Case, January 09, 2003
• Acute Illness in a Patient With a Chronic Cough Since Birth An 11-month-old black girl presented with a history of fever and cough for 3 days. Clinical Case, December 09, 2002

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Pediatric Burn Care: Unique Considerations in Management

Affiliations.

• 1 Division of Plastic and Reconstructive Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Division of Plastic and Reconstructive Surgery, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA. Electronic address: [email protected].
• 2 Division of Trauma and Emergency Medicine, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA.
• PMID: 28576249
• DOI: 10.1016/j.cps.2017.02.017

Severe pediatric burns require a multidisciplinary team approach at a specialized pediatric burn center. Special attention must be paid to estimations of total body surface area, fluid resuscitation and metabolic demands, and adequate analgesia and sedation. Long-term effects involve scar management and psychosocial support to the child and their family. Compassionate comprehensive burn care is accomplished by a multidisciplinary team offering healing in the acute setting and preparing the child and family for long-term treatment and care.

Keywords: Pediatric burn; Pediatric burn management; Pediatric burn nutrition; Pediatric burn resuscitation; Pediatric burn wound care.

Copyright © 2017 Elsevier Inc. All rights reserved.

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Burn injuries in the ICU

A case scenario approach.

Simko, Lynn Coletta PhD, RN, CCRN; Culleiton, Alicia L. DNP, RN, CNE

Lynn Coletta Simko is a clinical associate professor at the Duquesne University School of Nursing, Pittsburgh, Pa.

Alicia L. Culleiton is an RN at MedExpress, Pittsburgh, Pa.

The authors have disclosed that they have no financial relationships related to this article.

Severe burn injuries offer many unique challenges for critical care nurses. This article uses a case scenario to review various types of burn injuries, burn pathophysiology, and what nurses need to know to provide comprehensive assessment and resuscitative care to patients with this type of injury.

This article uses a case scenario to review various types of burn injuries, burn pathophysiology, and what nurses need to know to provide comprehensive assessment and resuscitative care to patients with this type of injury.

Caring for a patient with severe burn injuries offers many unique challenges for critical care nurses. The following case study, about a young male patient named Abe, illustrates a common situation. This article reviews various types of burn injuries and what you need to know to provide initial resuscitative care for patients with severe burn injuries. A future article will be based on Abe's unfolding case scenario and will describe various treatment modalities necessary to manage the extended care of patients with burn injuries in the ICU, including what nurses need to know about skin grafting and in-hospital rehabilitation.

Abe's story

The helicopter transport system notified their local Burn ICU (BICU) at 2400 that they were flying to a site in central Pennsylvania, and would be arriving within the hour. The transport was for a 14-year-old Amish boy who had stoked the fire in a wood-burning stove and an explosion occurred. As a result, the patient, Abe, had sustained an 82% total body surface area (TBSA) thermal burn (calculated using the Lund-Browder chart). Abe had sustained bilateral full-thickness circumferential burns to his legs and feet, arms and hands, genitalia, and deep partial-thickness burns to his head, neck, and anterior trunk. Abe's mother flew with him from his home to the hospital and remained in the BICU during his initial care.

Before Abe's arrival to the BICU, the flight nurse and flight team stabilized Abe by initiating cervical spine precautions, endotracheally intubating him, and providing sedation/analgesia with I.V. propofol and morphine via two large-bore peripheral venous catheters. In anticipation of Abe's arrival, the nursing staff readied the trauma room. They prepared for an arterial line placement, primed tubing for fluid replacement with lactated Ringer (LR) solution, obtained a pediatric-size urinary catheter and tetanus vaccine, readied a ketamine drip, and notified their respiratory therapy department that they would need a mechanical ventilator.

Upon initial assessment, Abe's right and left pedal pulses were not palpable, but were audible with a hand-held Doppler device. Radial pulses were 1 + /0-3 + bilaterally. A right brachial arterial line and a right interior jugular central venous catheter were inserted and Abe's team began burn wound care. On reassessment, the nursing staff noted that both his pedal and radial pulses were absent bilaterally. Considering these findings, emergent bilateral upper and lower extremity escharotomies were performed. At this point of care, Abe's clinical status was critical, but stable.

As the nursing staff provided care for Abe, they became aware that there were many cultural, societal, and religious issues that would need to be considered in Abe's multidisciplinary plan of care. For example, following Abe's arrival, his father called the BICU and requested to speak to Abe's mother. Neither parent had a mobile telephone, and their house did not have a landline, so her husband was calling from a nearby hardware store. The nursing team called on their facility's social worker to determine appropriate ways to keep the patient's family updated, and also in an effort to anticipate any further needs the parents might have.

Although burn incidence has decreased slightly over the years, burn injuries still occur frequently, with an estimated 3,275 fire and burn deaths occurring in the United States each year (this figure includes deaths from smoke inhalation and poisoning). 1 In addition, about 40,000 patients who sustain burn injuries require medical treatment or hospitalization yearly. According to the American Burn Association (ABA), 43% of burn-related hospital admissions are due to fire or flame injury, 34% are due to scald injury, 9% are due to contact burn injuries, 4% are due to electrical burns, 3% are due to chemical burns, and 7% are due to miscellaneous causes. 1

According to the National Burn Repository, pediatric burn injuries typically occur between ages 1 and 15 years and comprise 30% of all burns. 2 Abe, for example, falls into this category. The majority of adult burn injuries occur between ages 20 and 59, accounting for 54% of burns, and are most likely to affect patients between ages 20 and 30. 2

Burn injuries are some of the most expensive catastrophic injuries to treat. For instance, when treating a burn injury of greater than 10% TBSA, total hospital charges for surviving patients average $257,582 and $340,474 for nonsurvivors. 2

Defining burn injuries

Burn injuries involve the partial or complete destruction of the integumentary system: the skin. The skin is divided into three layers: the epidermis, dermis, and subcutaneous tissue (see Three-dimensional view of the skin ). The skin is one of the largest organs in the body and has many functions, including protection against injury and infection, thermoregulation, regulation of fluid losses, vitamin D synthesis, and sensory contact with the environment. When the skin is damaged or destroyed by a burn, it can lead to local and systemic disturbances such as compromised immunity, hypothermia, increased fluid losses, infection, and changes in appearance, function, and body image. 3

Burn injuries are described by the causative agent, depth, and severity.

Types of burns

A burn injury is described by its cause: thermal, chemical, electrical, radiation, inhalation, or cold exposure (frostbite). Children most often suffer from scalds, whereas adults often suffer from flame burns. 4,5

• Thermal burns result from contact with hot substances that cause cell injury by coagulation, including flames, hot solid objects, hot liquids, and steam. 5 The time the skin is in contact with hot substances and the thickness of the patient's skin determine the depth of the wound. Oil-based liquids such as cooking oil and grease have higher boiling points and cause deeper burns than scalds with water or other liquids. 3 Burns from hot solid objects such as metal (a curling iron), heated glass, plastic, or stone are all considered thermal burns; this includes Abe's burn from the explosion of the wood-burning stove heating his family's home.
• Chemical burns destroy tissue and continue to do damage for up to 72 hours unless neutralized. Further, systemic absorption of some chemicals can be life-threatening. 5 Causes of chemical burns are strong acids, alkali agents, and organic compounds. 6 Acids are commonly found in household cleaners such as rust removers, acidification for home swimming pools, and bathroom cleaners. These cause protein coagulation, which results in less extensive injuries. Alkali agents such as wet cement, oven cleaners, and fertilizers cause deeper burns due to liquefaction necrosis, which lets the chemical penetrate deeper into tissues. 6 Organic compounds that cause chemical burns include gasoline and chemical disinfectants, which can cause severe coagulation necrosis and produce a layer of thick, nonviable tissue called eschar, which is normally present in full-thickness burns. 6
• Electrical burns are classified as low voltage (under 1,000 volts) or high voltage (1,000 volts or higher). 6 Electrical injuries can cause death from ventricular fibrillation or paralysis of the respiratory muscles; dysrhythmias can occur with low voltage, but are more commonly seen in high-voltage injuries. The extent of damage from an electrical burn may initially appear minor and the patient may only have small entry and exit wounds. Extensive damage can appear within several days to weeks—a phenomenon known as the iceberg effect—because the skin surface shows little injury and hides massive injury beneath. 6 Instead of conducting the electricity, bones, muscle, tendons, and fat respond to electrical injury by producing heat. Most injuries occur to muscles surrounding the long bones. 6 The magnitude of the electrical damage depends on the duration and strength of the current flow as well as the pathway of the current and the resistance to the current flow through the tissue. 5
• Radiation burns result from exposure to sunlight, tanning booths, X-rays, or nuclear emissions or explosions. Ionizing radiation can produce tissue damage and be directly associated with cancer by striking a vital molecule such as DNA. 3,5 Sunburn is usually a superficial burn, but radiation can also cause full-thickness burns.
• Inhalation burns can occur concurrently with thermal or chemical burns. If the patient has thermal burns, the signs and symptoms of inhalation burns include facial burns, hoarseness, soot in the nose or mouth, carbon in the sputum, lip edema, and singed eyebrows, eyelashes, and/or nasal hair. 6 Hot smoke usually burns the pharynx and steam can also burn the smaller airways below the glottis. Many toxic chemicals produced in fires injure the smaller airways with chemical burns. 5 Manufacturing of illegal methamphetamine can cause thermal and chemical burns and associated inhalation burns. 6 Regardless of the cause of the inhalation injury, the patient needs immediate respiratory interventions such as endotracheal intubation and mechanical ventilation, and measurement of carboxyhemoglobin (COHgb) cyanide and lactic acid levels. 6
• Frostbite (cold exposure) is temporary or permanent tissue damage resulting from exposure to very cold temperatures. Any area left uncovered in very cold temperatures can become frostbitten, but the most commonly affected areas are the fingers, toes, chin, earlobes, cheeks, and nose. 7 Blood flow to the skin's outer layer is reduced and the skin tissue freezes and begins to die. Without treatment, frostbite can progress to necrosis, gangrene, hypothermia, and cardiac arrest. Because frostbite causes damage to the skin, some patients are treated in the BICU as burn patients, although initial treatment for frostbite is different than that for burns. Salvage of digits increases with rapid rewarming, early surgical consultation, and possible administration of fibrinolytics. 7

In the past, burn injuries were classified as first-, second-, third-, and occasionally fourth-degree burns. In recent years, the ABA has recommended a more precise definition of burns, categorizing them according to depth of tissue injury: 8

• epidermal or superficial burns (first-degree)
• partial-thickness burns, when the epithelium is burnt but the dermis is spared (second-degree; these may also be classified as superficial or deep partial thickness)
• full-thickness burns, when the full thickness of the skin including superficial and deep dermis is destroyed (third-degree)
• deep full thickness, or exposure of fascia, muscles, and/or bone (fourth-degree).

See Classification of burns by depth of injury for more information.

Size matters

Burn size is expressed as a percentage of TBSA. For example, a partial-thickness burn of more than 10% TBSA is serious and needs referral to a burn center (although there are many reasons why a patient with a burn injury might require referral; see Should the patient go to a burn center? ). 9

Initially, assessing the extent of a burn injury is necessary to guide therapy. Nurses can estimate the TBSA burned on an adult using the rule of nines. 6 The rule is based on dividing the adult body into anatomical regions by factors of nine. The rule of nines varies between infants and adults because infants' heads are proportionally larger compared with adults (see Rule of nines: Estimating burn size in adults ). Although the rule of nines provides a rapid method for calculating the size of the injury, it can overestimate the TBSA burned, so nurses must follow their facility's protocol for estimating the extent of a burn injury. 6

Other common methods for measuring burn size include the Lund-Browder chart and the Palm Method. 6 The Lund-Browder chart is highly recommended because it corrects for the large head-to-body ratio of infants and children; once Abe arrived to the BICU, this method was used to estimate the extent of his burn injuries.

The Palm Method is used for small scattered burns such as grease and scald burns. The patient's palm, including the fingers, equals 1% TBSA in children and adults. 6 Often, the Palm Method will be completed first as a quick assessment until the Lund-Browder chart can be completed.

Location matters

The location of a burn injury can predispose a patient to both early and late complications. 10 Based on this knowledge, Abe's nurses were vigilant for complications as outlined in this section.

Circumferential burns of the extremities (see Ring of fire ) can lead to vascular compromise resulting in compartment syndrome, and circumferential burns to the thorax can impair chest wall expansion, causing respiratory distress or failure. Burns of the chest, head, and neck are also associated with pulmonary complications. Facial burns are associated with corneal abrasions, burns of the ears with auricular chondritis, and burns of the perineal area are prone to autocontamination by urine and feces. 10

Lastly, burns over the joints immediately affect the patient's range of motion, which may be exacerbated later by hypertrophic scarring (see Troublesome scars ). Intensive therapy to prevent permanent disability is crucial. 3

Pathophysiology

Understanding the pathophysiology of a burn injury is vital for effective management and optimal patient outcomes. Different causes lead to different burn injury patterns, which require specific interventions.

The body's compensatory mechanisms start with the inflammatory response, which is initiated by cellular injury. The most important activator of the inflammatory response is the mast cell, which releases biochemical mediators, such as histamine and chemotactic factors, and synthesizes other mediators, such as leukotrienes and prostaglandins. 11 Histamine, the major vasoactive amine released by the mast cells, causes increased capillary permeability and exudation resulting in edema, decreased intravascular volume, hypotension, tachycardia, oliguria, tachypnea, and shock. 11 The sympathetic nervous system (SNS) is stimulated and the fight-or-flight response is activated. This causes gastrointestinal hypomotility (ileus), thirst, adrenal stimulation (causing increased catecholamine release, increased metabolic rate, and increased aldosterone secretion), hepatic stimulation (causing release of glycogen stores), increased blood glucose levels, and vasoconstriction. 11

Systems breakdown

Burns negatively affect every system in the patient's body. Respiratory system effects include direct airway injury, inhalation injury, carbon monoxide poisoning, smoke inhalation (damage to epithelial cells in the lower respiratory tract secondary to inhaling oxides, the products of combustion), pulmonary edema, alveolar damage, and decreased oxygen diffusion. 3

Cardiovascular system effects include fluid volume deficit, decreased mean arterial pressure, decreased cardiac output, hypovolemic shock (secondary to extensive fluid shifts), and decreased myocardial contractility (impaired cardiac function improves 24 to 30 hours postinjury). 6 For example, in Abe's situation, although he had received several liters of LR during helicopter transport, on presentation he demonstrated a fluid volume deficit and was experiencing episodes of hypotension. Further, electrical burns can cause myocardial infarction, ECG changes, ventricular fibrillation, and cardiac arrest. 6

Renal system effects are indirect. Decreased cardiac output leads to decreased renal perfusion and oliguria that can culminate in acute kidney injury (AKI). In addition, after a burn injury, damaged red blood cells release hemoglobin and potassium, and skeletal muscle cells release myoglobin. Both hemoglobin and myoglobin are filtered by the glomerulus and degraded, releasing heme pigment. Heme pigment, especially in the setting of fluid volume deficit, can cause AKI. 12 Marked release of hemoglobin or myoglobin usually causes red or brown urine, otherwise known as myoglobinuria. Abe's nurses saw some of these effects when they initially inserted an indwelling urinary catheter, because he only produced 30 cc of dark brown urine.

Gastrointestinal system effects include ileus secondary to SNS activation. 3,6 Abe presented with no audible bowel sounds and was diagnosed with an ileus. Other effects include Curling ulcer (stress ulcer). Curling ulcer formation is triggered by the stress response and the histamine released in the inflammatory response. Intra-abdominal hypertension and abdominal compartment syndrome can be caused by circumferential eschar formation and the inflammatory response, which will damage the gut, kidneys, and liver. 3,6

Neuroendocrine system effects include an increased metabolic rate to compensate for the initial low core body temperature because of loss of skin. The increased metabolic demand increases caloric needs and leads to a negative nitrogen balance and catabolism that slows tissue building and healing. 6 Increased cortisol levels can cause insulin resistance and hyperglycemia. 11

Musculoskeletal system effects include contractures and complications secondary to immobility and the healing process.

Immune system effects include immunosuppression secondary to the immediate, prolonged, and severe immunologic and inflammatory responses to a major burn injury. 11

Assessment and initial management

The emergency management of a patient with a burn injury begins with the initial assessment and treatment of life-threatening injuries. For Abe, many, if not all, of the following assessments and treatment modalities were initially completed by the flight team. However, it does not matter whether a burn patient's initial acute care starts in an ED or a specialized BICU; it is the nursing and medical staff's responsibility to ensure the following have been completed.

Stabilize the patient's cervical spine if this has not already been done. The true mechanism of injury may not be clear (for example, as with Abe, the patient may have been both burned and propelled in an explosion).

Follow the specific aspects of the primary survey during initial evaluation of every patient with a burn injury: 13,14

• Airway . The airway is the primary concern, especially if a patient has an inhalation injury. Assess for stridor (an ominous sign that suggests the patient's upper airway is at least 85% narrowed), increased work of breathing, facial burns, soot in the nares or mouth, singed facial hair or nasal hair, edema of the lips and oral cavity, coughing, hoarseness, inability to tolerate secretions, and circumferential neck burns. 13,15
• Ventilation . Determine adequacy of ventilation by assessing the patient's respiratory rate, depth, and work of breathing, auscultating bilateral breath sounds, and observing for dyspnea. Obtain an SpO 2 (remembering that it may be inaccurate in the presence of carbon monoxide), and a co-oximetry reading (which can detect COHgb) if indicated and available. Rapid identification of circumferential burns of the trunk and neck are key, as a bedside escharotomy may be warranted. 15
• Cardiovascular status . Every patient with a major burn should be placed on a cardiac monitor, with continuous pulse oximetry and vital sign evaluation at frequent intervals. Assess for the presence of peripheral pulses and grade their amplitude; evaluate capillary refill time, skin color, and temperature (in both burned and unburned skin), and observe for obvious arterial bleeding. Fluid management based on the patient's age, weight, burn severity, associated injuries, and comorbidities should be initiated once the extent of the burn injury is established. 16

During this stage of the primary assessment, remember that a complete cardiovascular assessment includes evaluation of perfusion to all extremities (noting any circumferentially burned extremities). Vascular compromise must be addressed immediately and ideally prior to loss of distal pulses (which is a late clinical finding).

If decreased or absent peripheral pulses are noted, an escharotomy is indicated. 16 Abe presented with unpalpable pedal pulses, which were audible with a Doppler; on further assessment, both his pedal pulses and radial pulses were absent. Bilateral upper and lower escharotomies needed to be performed to ensure that his extremities were adequately perfused.

• Disability, deficit, and deformity . Use the Alert, Verbal, Pain stimuli, Unresponsive Scale (AVPU; see A look at the AVPU scale ) to quickly determine the patient's level of consciousness and carefully evaluate for any abnormalities. In addition, in the stable environment of an acute care setting, obtain a Glasgow Coma Scale (GCS) score, assessing best eye, verbal, and motor responses to establish baseline mental status. 15 Assess for associated injuries, substance abuse, hypoxemia, decreased cerebral perfusion related to hypovolemia, and brain injury resulting from head trauma.
• Exposure/environmental control . Gently remove the patient's nonadherent clothing and jewelry to prevent continued tissue damage. If the patient's face is burned, remove glasses or contact lenses. Cover the patient with a clean blanket and ensure a warmed environment to prevent further contamination of the burn wounds and to provide warmth. 15

As you complete the primary survey, obtain vital signs and establish I.V. access (this may include the initiation of two large-bore peripheral venous catheters if the patient has burns over 15% or more of TBSA and/or central venous catheter placement). Elevate burned extremities above heart level to decrease edema. Administer I.V. analgesia as prescribed and assess its effectiveness often, using a valid and reliable pain intensity rating scale. 15

After the initial focused assessment is completed and the patient is stabilized, obtain a history of events while performing a comprehensive physical assessment (secondary survey). The main priorities are to determine the potential for an inhalation injury, presence of concomitant injuries or trauma, and any preexisting comorbidities that may influence the physical assessment findings or patient outcomes.

A simple way to initially accomplish this is to use the SAMPLE mnemonic: S igns and symptoms, A llergies, current M edications (including illegal substances or alcohol), P ertinent/ P ast history, L ast oral intake, and E vents leading up to the injury. 17 This can only be accomplished if the patient is alert. If the patient is unable to answer these questions, question family members or witnesses to the burn injury. 17 In Abe's case, he was not alert or speaking because he had been endotracheally intubated and sedated. The only source of information and patient history was his mother.

Determine the extent and depth of the burn, and ask the following questions: 18

• What is the patient's chief complaint (for example, dyspnea or pain)?
• Did the burn occur in an enclosed space?
• Were explosives or chemicals involved?
• What was the source of the burning agent (for example, electrical, hot liquids, flame)?
• What is the status of the patient's tetanus immunization?

At the completion of the secondary survey, the following should be determined: indicated imaging studies, lab analysis, and adjunctive measures not limited to indwelling urinary catheters and nasogastric tube placement.

About fluid resuscitation

Fluid resuscitation efforts should begin as soon as possible for patients with burns of 15% of TBSA or more; otherwise, the patient may experience hypovolemic shock. 6 Nurses should insert an indwelling urinary catheter to assist in monitoring fluid balance.

Several fluid resuscitation formulas are available, and a formula usually is prescribed by the burn trauma surgeon. All formulas are based on the TBSA burned, the patient's weight in kilograms (kg), and the patient's age. Half of the fluid volume is administered in the first 8 hours postburn, and the remainder is given over the next 16 hours. The ABA recommends titrating the fluids to maintain a urine output of 0.5 to 1.0 mL/kg/hour in adults and 1 to 1.5 mL/kg/hour in children weighing less than 30 kg. 6

Using the Parkland formula, which was created to help calculate fluid replacements for burn patients, and Abe's weight of 36 kg, the following equation was used to determine his fluid resuscitation requirements over 24 hours: %TBSA × weight in kg × 4, or 82% × 36 kg × 4 mL = 11,808 mL in 24 hours, half of that in the first 8 hours (5,904 mL), or 738 mL/hour. 6

In the case of a patient who has sustained a high-voltage electrical burn, the target range for urine output is 75 to 100 mL/hour in adults and 1 mL/kg/hour in children until their urine becomes clear to prevent renal tubular obstruction from heme pigment. Avoid administering diuretics, which may aggravate dehydration. 6 The patient's mental status, vital signs, hourly urine output, and urine specific gravity are valuable indicators of the patient's response to fluid resuscitation.

Because of the massive volumes of I.V. fluids administered to patients with burn injuries (rates of 1,000 mL/hour are common), diligently assess the patient's hemodynamic status to avoid inducing fluid overload. Complications of “fluid creep,” or excess fluid resuscitation, include abdominal compartment syndrome, peripheral compartment syndrome, and acute respiratory distress syndrome. 19,20

Fluid resuscitation after the first 24 hours is accomplished by using isotonic crystalloids as well as colloids. Dextrose solutions and electrolyte replacement (especially potassium replacement) is initiated. LR solution is isotonic and does not increase intravascular oncotic pressure. Because of increased capillary permeability in patients with burns, only 25% of the LR solution infused in the initial fluid resuscitation will actually stay in the intravascular space. This is one reason for the large fluid volumes needed in fluid replacement. 6

Once the increased capillary permeability has decreased (8 to 12 hours after the burn injury), colloids such as albumin may be given to help restore intravascular volume. Colloids increase the oncotic pressure in the vascular space, pulling interstitial fluid into the intravascular space. This helps decrease the edema associated with burn injuries. Newer guidelines suggest administering colloids earlier than in the past. 20 Albumin and/or fresh frozen plasma is sometimes recommended earlier in the fluid resuscitation period, and may decrease the large volumes of crystalloids that are needed, thus decreasing fluid creep. 19,20

Interventions

For all burn patients, it is imperative that you continually monitor vital signs, level of consciousness, respiratory status, and cardiac rate and rhythm. Continue to identify and treat other associated injuries (such as head injury, pneumothorax, or fractures). Remember specific interventions for common types of burns:

• Thermal . Assess the patient for inhalation injuries. For adults with burns of more than 15% TBSA, begin fluid replacement as prescribed and insert an indwelling urinary catheter. 21 Knowing that Abe would require very aggressive fluid resuscitation, a pediatric indwelling urinary catheter was inserted upon admission to the BICU.
• Chemical . Assess the patient's ABCs before starting decontamination procedures. Endotracheal intubation and mechanical ventilation may be needed for patients with significant inhalation injuries or circumferential full-thickness burns to the neck or chest. Remove dry chemicals from the patient's skin (utilize protective garments when indicated), then use saline or tap water to flush chemicals from the burn (for 30 minutes, or up to 2 hours). Contact the poison control center for more information on handling chemicals, and protect yourself from potential exposure. Chemical burns to the eyes should be continuously irrigated. If only one eye is affected, be careful not to contaminate the unaffected eye. If contact lenses are in place, remove with a clean gloved hand. Irrigate the eye by running normal saline through I.V. tubing when both eyes are affected. 22
• Electrical . Assess pulses distal to the burn. Monitor the patient for myoglobinuria (myoglobin released from injured muscle tissue and hemoglobin from damaged red blood cells). Initiate fluid resuscitation and insert an indwelling urinary catheter. Be prepared to administer I.V. mannitol, an osmotic diuretic, to maintain urine output, and I.V. sodium bicarbonate to alkalinize the urine. 21,22
• Inhalation . Obtain an arterial blood gas analysis, COHgb level, and chest X-ray. Be prepared if fiber-optic bronchoscopy or endotracheal intubation is needed. 21

A good start

As you can see, Abe's initial care faithfully mirrored the information contained in this manuscript. Abe's story and progress will continue to unfold in a second article, discussing his care in the BICU, skin grafting, and in-hospital rehabilitation.

Classification of burns by depth of injury

• Superficial or epidermal burns caused by the sun or low-intensity heat flashes damage only the epidermis. These burns cause erythema, skin blanching on pressure, mild pain and edema, and no blisters or vesicles, although after 24 hours the skin may blister and peel. Symptoms include hyperesthesia, mild pain, and tingling. Healing typically takes 3 to 6 days without scarring.
• Partial-thickness burns caused by chemicals, flame, or hot liquids damage the epidermis and part of the dermis. They are characterized as either superficial or deep . These burns appear as fluid-filled vesicles that are red and shiny (and wet if the vesicles have ruptured). Symptoms include edema, hyperesthesia, pain caused by nerve injury, and sensitivity to cold air. Healing typically takes 10 to 21 days for superficial partial-thickness burns, which involve part of the dermis, and 2 to 6 weeks for deep partial-thickness burns, which involve more of the dermis.
• Full-thickness burns are caused by prolonged exposure to chemicals, electrical current, flame, hot liquids, or tar. Full-thickness burns will expose adipose tissue beneath the dermis layer of skin. The skin appears dry, waxy, white, leathery, or hard. Signs and symptoms include anesthesia, possible hematuria, possible entrance and exit wounds from an electrical burn, and shock. Skin grafting is often required for healing, and patients may lose function of extremities or digits, or need amputation.
• Deep full-thickness burns are deep and potentially life-threatening injuries that extend through the skin into underlying tissues such as fascia, muscle, and/or bone. Deep full-thickness burns are typically caused by prolonged exposure to fire, hot liquids, chemicals, or exposure to a burst of intense electricity or ultraviolet rays.

Sources: Coffee T. Care of patients with burns. In: Ignatavicius DD, Workman ML, eds. Medical-Surgical Nursing: Patient-Centered Collaborative Care . 8th ed. St. Louis, MO: Saunders Elsevier; 2016.

Rice PL, Orgill DP. Classification of burns. UptoDate. 2016. www.uptodate.com .

Should the patient go to a burn center? 1

Patients who should be referred to a burn center include:

• All burn patients under age 1 year.
• All burn patients ages 1 to 2 years with burns over 5% or more of TBSA.
• Patients of any age with full-thickness burns of any size.
• Patients over age 2 years with partial-thickness burns greater than 10% of TBSA.
• Patients with burns of special areas such as the face, hands, feet, genitalia, perineum, or major joints.
• Patients with electrical burns, including lightning injuries.
• Patients with chemical burns.
• Patients with inhalation injury resulting from a fire or hot liquid burn.
• Patients with circumferential burns of the limbs or chest.
• Patients with preexisting medical disorders that could complicate burn management, prolong recovery, or affect mortality.
• Patients with burns and concomitant trauma.
• Children with burns who are suspected to be victims of child abuse.
• Patients whose burns require treatment that exceeds the capabilities of the referring facility.
• Patients with septic burn wounds.

A look at the AVPU scale

This scale, a shortened form of the GCS, can be used to determine a patient's level of consciousness.

Alert: patient is alert, awake, responds to voice, and/or is oriented to time, place, and person. Nurses can obtain subjective information from the patient.

Verbal: The patient opens his or her eyes to verbal stimuli, but is not fully oriented to time, place, or person; or only becomes aroused after verbal stimuli.

Painful: The patient responds to painful or noxious stimuli, such as nailbed pressure, but does not respond to verbal stimuli; patient difficult to arouse.

Unresponsive: The patient is nonverbal and does not respond to painful stimuli; unconscious.

Source: Emergency Medical Paramedic. AVPU. 2013. www.emergencymedicalparamedic.com/avpu .

burns; ICU; nursing assessment; severe burn injuries; trauma

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Fatima, a single 32-year-old Muslim refugee female, has been living in the United State for six months with her two kids in a garage. She was cooking dinner to break her fast during Ramadan when a gas leak resulted in a explosion. Her kids were out playing in the front yard when they heard the explosion. Her eldest daughter immediately ran to her neighbor’s house and asked them to call 911. Upon arrival to the scene, firefighters rescued Fatima and emergency medical technicians (EMTs) were able to remove her burned clothing and hijab. She was conscious, alert and oriented, but sustained significant burn injuries to her face, neck, anterior torso, bilateral upper and lower extremities, and posterior trunk. As a result, the patient was intubated with 100% oxygen enroute to the hospital for airway protection due to inhalation injury and edema with facial burns. The EMTs started an 18 gauge in the left forearm and initiated an intravenous (IV) 1000 mL bolus of Lactated Ringer’s (LR).

Emergency Department (ED)

The EMTs radioed in their ETA at 10 minutes out and the West Hills trauma medical term and burn nurses were informed. Initial assessment at the hospital revealed a young woman that was orally intubated with bilateral clear breath sounds.

Vital signs were as followed:

• Heart Rate: 120
• Blood Pressure: 160/90 (113)
• Temperature: 98.4 F, 36.9 C
• Pain: 4 points on CPOT
• Respirations: 18 (AC ventilation)

The sustained burns to the face, neck, anterior torso, bilateral upper and lower extremities, and posterior trunk were classified as third degree burns to 51% of her total body surface area (TBSA). A chest X-ray confirmed accurate placement of the ET tube. Fluid resuscitation was continued in the ED with LR. The following initial pending labs were drawn: CBC, carboxyhemoglobin, electrolytes, and ABGs. A foley catheter was inserted to monitor renal function (Hinkle & Cheever, 2014).

Burn Intensive Care Unit (BICU)

Fatima was transferred to the BICU where fluid resuscitation was continued. Her reported height and weight in the ED was 157 cm and 50 kg. The Parkland Formula (4mL x % TBSA x kg = total fluid for the first 24 hours) was calculated to a total of 10,200 mL/24 hours (Mehta & Tudor, 2019). The first half of the fluids were administered within the first eight hours totaling 5,100 mL. The second half of the fluid was given over 318.8 mL/hour for a total of 16 hours.

Vitals signs were as followed:

• Heart Rate: 115
• Blood Pressure: 100/80 (90)
• Temperature: 96.o F, 35.6 C
• Pain: 3 points on CPOT
• Respirations: 17 (AC ventilation)

Hourly vital signs were documented. A continuous Dilaudid drip of 1 mg/hr was provided for pain management (Unbound Medicine, 2017). Fatima was assessed for any signs and symptoms of respiratory distress (labored breathing, pallor, hypotension, tachycardia, wheezing). A nasogastric tube (NG) tube was placed for nutritional needs. Urine output during was 40 mL/hr. The lab results revealed the following: K+ 5.3 mEq/L, Na+ 130 mEq/L, Cl+ 111 mEq/L, and glucose 120 mg/dL. Fatima was in a metabolic acidotic state. Her carboxyblin was at 11%.

While in the BICU, Fatima recieved multidisciplinary care from nutrition services, respiratory therapy, spiritual care services, physical therapy, social work, case management, nursing, and the physician team. Once the patient was stable, she underwent serial surgical debridement. The health care team members proposed a porcine xenograft as part of Fatima’s plan of care; however, due to conflicting Islamic religious beliefs the plan of care was revised. After consulting with Fatima and the Mullah (Islamic spiritual leader) they both agreed to a Halal bovine xenograft for treatment. It is important to note that the patient with continue to undergo wound preparation procedures over the next couple of weeks. Due to the %TBSA, the team and Fatima decided to culture epidermal autographs for the optimal skin/wound healing. The nurses and physicians continued to provide aseptic would and graft care (Hinkle & Cheever, 2014).

• Why is it critical to initiate fluid resuscitation in burn patients?
• How would you address Fatima’s cultural beliefs and what type of support systems could be integrated into the patient’s plan of care?
• Fatima had a 51 %TBSA, why is it important to calculate the TBSA in burn patients?
• Burn patients tend to have third-spacing and re at an increased risk for shock and hypothermia. Therefore, it is critical to administer isotonic fluids (preferably Lactated Ringer’s) to replace the fluid loss. Continually assess the patient for signs and symptoms of hypovolemia and ensure they have adequate cardiac output and tissue perfusion.
• As the nurse, it is vital to educate themselves about the patient’s Islamic values, beliefs, and preferences. Attempt to reach out to family members or the community members within the same Mosque. In addition, ensure that a spiritual team is on board. Lastly, communicate with the patient and family to address their wishes, cultural, and religious beliefs in the overall plan of care.
• %TBSA helps determine the amount of fluid resuscitation and the extent of care that is needed. There is an increase chance of mortality with %TBSA greater than 50 because of the increased number of organs involved.

Critical Illness, brain Dysfunction, and Survivorship Center. (2019). Assess, prevent and manage pain. Retrieved from https://www.icudelirium.org/medical-professionals/assess-prevent-and-manage-pain

Hinkle, J.L., & Cheever, K.H. (2014). Brunner & Suddarth’s textbook of medical surgical nursing. Philadelphia, PA: Lippincott Williams & Wilkins

Litt, J.S. (2018). Evaluation and management of the burn patient: A case study and review. Missouri Medicine, 115 (5), 443-446. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6205272/

Mehta, M & Tudor, G.J. (2019) Parkland formula. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK537190/

Strauss, S. & Gillespie, G.L. (2018). Initial assessment and management of burn patients. American Nurse Association, 13 (6). Retrieved from https://www.americannursetoday.com/initial-assessment-mgmt-burn-patients/

Unbound Medicine, Inc. (2017). Nursing Central (1.31). [Mobile application software]. Retrieved from https://itunes.apple.com/us/app/nursing-central/id300420397?mt=8

University of Wisconsin Hospitals and Clinics. (2019). Emergency Medicine. UW Health. Retrieved from https://www.uwhealth.org/emergency-room/assessing-burns-and-planning-resuscitation-the-rule-of-nines/12698

Nursing Case Studies by and for Student Nurses Copyright © by jaimehannans is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

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Burn Injury Case Study (60 min)

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Mr. Travis is a 32 year old male who presents to the ED after sustaining severe 2nd and 3rd degree burns in a house fire.  The below diagram estimates his wounds. He weighs 85 kg and is 5’11”.

Using the Rule of Nines, estimate the Total Body Surface Area Burned (TBSA %).

• Half of the head/neck – 4.5%
• Top half of front torso – 9%
• Top half of back – 9%
• Full top half of right arm – 4.5%
• Full top half of left leg – 9%
• Half of front abdomen – 4.5%
• Half of lower back – 4.5%
• TOTAL – 45%

Calculate the total fluid volume required for resuscitation in the first 24 hours using the Parkland Burn Formula.

• 4 x 45% x 85 kg = 15,300 mL in 24 hours
• Give ½ in the first 8 hours = Start fluids at 956 mL/hr

What is the TOP nursing priority for Mr. Travis?

• Fluid resuscitation to prevent hypovolemic shock
• Mr. Travis’s vitals are: BP 90/48, HR 108, Temp 97.2, Pain 10/10.

You note circumferential burns around the Right Upper Arm and soot around the mouth with singed nose hairs, plus some facial swelling.

What are your main concerns for complication(s)?

• Airway due to possible/likely inhalation burns and airway swelling
• Compartment syndrome due to circumferential burns around right arm

Physiologically, explain the alterations in Mr. Travis’s vital signs.

• He is likely hypovolemic due to the loss of fluids from the burns, hence the low BP and high HR
• He is hypothermic because of his inability to regulate temperature due to skin loss

How will you know if fluid resuscitation is effective?

• Fluid resuscitation should be titrated to urine output of at least 0.5 mL/kg/hr or 30-50 mL/hr
• If excess urine output, slow fluids
• If not enough, speed up fluids
• Mr. Travis is intubated for airway protection and taken to the OR for surgical debridement of his burns. He is then transferred to the Burn ICU

What are priorities for daily care of Mr. Travis?

• Infection prevention and meticulous wound care – sterile dressing changes
• Pain control – PCA if able
• Manage ventilator and respiratory needs until able to be extubated
• Maintain temperature and hemodynamics

Mr. Travis will need skin grafts. How will you explain autologous skin grafts to Mr. Travis and his family?

• Autologous skin grafts are performed by taking a slice of healthy tissue from somewhere else on the patient’s body, for example, his right thigh that isn’t burned, and then running it through a meshing device.
• This allows it to be stretched over the wound and secured in place, then the skin will grow in around the graft.

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This nursing case study course is designed to help nursing students build critical thinking.  Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process.  To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy  to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs.  If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding.  In the end, that is what nursing case studies are all about – growing in your clinical judgement.

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