Overview of Burn Injuries

A student nurse is caring for a patient with severe thermal burns. Which statement made by the student nurse to the charge nurse indicates that additional teaching is needed?

"I will check my patient hourly to make sure that he does not experience an inflammatory response from his burns."

A family member of a patient with a severe facial burn asks the nurse why the patient's face is swollen. Which statement made by the nurse is appropriate?

"Swelling is an expected inflammatory response of the body to a burn injury.

Introduction

A burn is an injury caused by heat, chemicals, electric current, or radiation. Approximately 11 million individuals seek medical care each year for burns. The type and extent of the burn is important to understand when helping patients with burns survive their injuries.

Summary

A burn is an injury caused by heat, chemicals, electric current, smoke inhalation, or radiation. Although burns are often classified by degree (first, second, third, or fourth), the American Burn Association recommends that burns be classified according to depth of skin destruction (partial-thickness and full-thickness). Use of the rule of nines and the Lund-Browder chart can assist in determining the extent of a burn injury. The inflammatory response is the body's natural response to a tissue injury, such as a burn. It works to neutralize and dilute the inflammatory agent, remove necrotic skin, and establish an environment suitable for healing and repair. The manifestations of a burn vary based on the type of burn and its severity. Symptoms can range from minor skin discomfort to loss of consciousness and cardiac arrest. Patients with significant burn injuries should be referred to burn centers for care and treatment.

Full-thickness skin destruction: Third- and fourth-degree burns: Structures involved

All skin elements and local nerve endings destroyed. Coagulation necrosis present. Surgical intervention required for healing.

A nurse is caring for a patient with a first-degree thermal burn injury. Which symptom can the nurse expect to see on assessment? Insensitivity to pain Cherry-red skin color Blanching with pressure Edema of surrounding tissue NOT SURE

Blanching with pressure

Match the cause of the burn injury to its clinical manifestations.

Burn odor, visible contact point, impaired circulation to area: Electrical Coughing, increasing hoarseness, singed nasal or facial hair: Smoke inhalation Moist blisters, hypersensitive to touch or air, blanching with pressure: Thermal (partial-thickness, second-degree) Dry, leathery eschar; charred appearance; impaired sensation when touched: Thermal (full-thickness)

Clinical manifestations of chemical

Burning Redness, swelling of injured tissue Degeneration of exposed tissue Discoloration of injured skin Localized pain Edema of surrounding tissue Decreased muscle coordination or paralysis

Chemical

Chemical burns are caused by contact with acids, alkalis, and other organic compounds such as petroleum products. The most commonly affected area is the eye.

A nurse is caring for a patient with thermal burns. Which pathophysiologic reactions result in the patient being at risk for burn shock?

Decreased blood volume and increased systemic vascular resistance Fluids leak out of the intravascular space during a thermal burn injury. This results in a decrease in blood volume and a compensatory increase in systemic vascular resistance.

The treatment of a burn is dictated by the severity of the burn. Severity of a burn is determined by the following criteria:

Depth of burn Extent of burn calculated as percentage of total body surface area (TBSA) Location of burn (burns in certain areas are more severe) Patient risk factors (age, medical history) These elements will affect the ability of the patient to heal and recover from the burn injury.

Which factors determine the severity of a burn?

Depth of burn Location of burn Medical history of the patient Extent of burn calculated as percentage of total body surface area

Full-thickness skin destruction: Third- and fourth-degree burns: Appearance

Dry, waxy, white, leathery, or hard skin; thrombosed vessels; lack of pain because of nerve destruction; may involve muscles, tendons, and bones

A nurse is caring for a patient with a chemical burn injury. Which symptom can the nurse expect to find on assessment?

Edema of surrounding tissue

Electrical

Electrical burns are the result of intense heat generated by an electrical current. The severity of the burn depends on several factors including the amount of voltage and the body surface area that was in contact with the electrical current.

Partial-thickness skin destruction: Deep (second-degree) burn: Structures involved

Epidermis and dermis involved to varying depths. Skin elements, from which epithelial regeneration occurs, remain viable.

Partial-thickness skin destruction: Superficial (first-degree) burn: Appearance

Erythema, blanching on pressure, pain and mild swelling, no vesicles or blisters (although skin may blister or peel after 24 hours)

Partial-thickness skin destruction: Deep (second-degree) burn": Possible cause

Flame, flash, scald, contact with hot objects, chemicals, tar, cement, electrical current

Full-thickness skin destruction: Third- and fourth-degree burns": Possible cause

Flame, scald, chemical, tar, cement, electrical current

Partial-thickness skin destruction: Deep (second-degree) burn: Appearance

Fluid-filled vesicles that are red, shiny, or wet (if vesicles have ruptured); severe pain caused by nerve injury; mild to moderate edema

Match the type of burn with the source of the burn injury

Hydrochloric acid: Chemical Boiling water: Thermal Exposed outlet wire: Electrical

Clinical manifestations of electrical

Leathery, white, or charred skin Burn odor Loss of consciousness Impaired touch sensation Minimal or absent pain Dysrhythmias or cardiac arrest Visible contact points Diminished peripheral circulation in injured extremity Fractures or dislocations from force of current

What is the proper classification for a thermal burn involving only the epidermis and superficial structures of the dermis?

Partial-thickness burn

Burn injuries that should result in referral of the patient to a burn center include the following:

Partial-thickness burns extending over 10% of TBSA Burns that involve the face, hands, feet, genitalia, perineum, or major joints or that extend all the way around a portion of the body Full-thickness burns in any age group Electrical burns, including lightning injury Chemical burns Inhalation injury Burn injury in a patient with any preexisting medical conditions that could complicate treatment, prolong recovery, or affect patient mortality Burn injury to any patient with trauma (such as fractures) when the burn injury poses the greatest risk of morbidity or mortality (If the trauma poses the greater immediate risk, the patient may be initially stabilized in a trauma center before being transferred to a burn unit.) Burn injury to a child when a hospital lacks qualified personnel or equipment to care for children Burn injury in patients who will require special social, emotional, or rehabilitative intervention Burn injury suspected of being caused by abuse

clinical manifestations of thermal

Partial-thickness/first-degree: redness, pain, moderate to severe tenderness, minimal edema, blanching with pressure Partial-thickness/second-degree: moist blebs and blisters; mottled white, pink to cherry-red; hypersensitive to touch or air; moderate to severe pain; blanching with pressure Full-thickness/third- and fourth-degree: dry, leathery eschar (scab or dead skin); waxy white, dark brown, or charred appearance; strong burn odor; impaired sensation when touched; absence of pain with severe pain in surrounding tissues; lack of blanching with pressure

Radiation

Radiation burns are caused by exposure to radiation. The radiation types of greatest concern are thermal radiation, radiofrequency energy, ultraviolet (UV) light, and ionizing radiation. Sunburn, caused by UV radiation, is a common type of radiation burn. Another type is significant exposure to x-ray during diagnostic medical imaging or radiotherapy.

Clinical manifestations of smoke inhalation

Rapid, shallow respirations Increasing hoarseness Coughing Singed nasal or facial hair Darkened oral or nasal membranes Smoky breath Productive cough with black, gray, or bloody sputum Difficulty swallowing Dizziness Headache Cherry-red skin color (late sign of carbon monoxide poisoning) Decreased oxygen saturation Dysrhythmias

Smoke Inhalation

Smoke inhalation burns are caused by inhaling noxious chemicals or hot air that results in damage to the respiratory tract.

Partial-thickness skin destruction: Superficial (first-degree) burn: Structures Involved

Superficial epidermal damage with hyperemia. Tactile and pain sensation intact.

Partial-thickness skin destruction: Superficial (first-degree) burn: Possible Cause

Superficial sunburn, quick heat flash, radiation

Clinical manifestations of radiation

Symptoms similar to those seen in thermal burns Burns from radiation therapy may not appear until weeks after treatment and can cause:Hair loss on affected areaDry or wet peeling skin (desquamation)Decreased sweatingEdemaUlcerationsBleedingSkin cell death The extent of damage from radiation therapy depends on the total radiation dose, the size of the area treated, cellular fractionation, and the type of radiation used.

The Lund-Browder chart may also be used to calculate

TBSA. The Lund-Browder chart is considered more accurate than the rule of nines because it takes the age of the patient into consideration in the calculation of TBSA.

When calculating the total body surface area (TBSA) affected by a burn, the nurse knows that the Lund-Browder chart is considered more accurate than the rule of nines for which reason?

The Lund-Browder chart considers the age of the patient in calculation of TBSA.

A nurse is caring for a patient who spilled boiling soup on her legs. Which type of burn will the nurse see?

Thermal

Thermal

Thermal burns are caused by flame, flash, scald, or contact with hot objects. The severity of the burn depends on the temperature of the burning agent and how long it was in contact with the skin.

It is estimated that each year, approximately 486,000 Americans will receive medical treatment for

burns, and 40,000 Americans will be hospitalized because of burn injuries—most of which will be caused by a fire.

Smoke inhalation during a fire can also cause

carbon monoxide poisoning. When too much carbon monoxide is inhaled, the body replaces the oxygen in the red blood cells with carbon monoxide. This prevents oxygen from reaching tissues and organs. Traditional pulse oximeters measure functional arterial oxyhemoglobin saturation. The pulse oximeter can differentiate only between deoxygenated (or reduced) hemoglobin and saturated hemoglobin. Carboxyhemoglobin "appears" like these, so the patient's oxygen saturation may appear normal—but the traditional pulse oximeter is incapable of distinguishing between normal hemoglobin and carboxyhemoglobin. This patient may truly be hypoxemic. Patients who are at risk for, or who are suspected to have carbon monoxide poisoning, should be monitored by using a CO-oximeter.

Approximately 73% of burn injuries occur in the

home

At the time of a major burn injury, capillary permeability is

increased. Fluids and electrolytes begin to leak into the interstitium, causing edema and decreased blood volume. Hematocrit increases, which results in increased blood viscosity. The combination of decreased blood volume and increased viscosity results in increased systemic vascular resistance. Burn shock, a type of hypovolemic shock, can occur. Burn shock can result in death if not treated.

The inflammatory response is the body's

natural response to a tissue injury, such as a burn. It works to neutralize and dilute the inflammatory agent, remove necrotic skin, and establish an environment suitable for healing and repair.

Patients being treated for cancer with radiation therapy are at a high risk for

radiation burns. Cardiac catheterizations and other interventional radiology treatments can put patients at risk as well, especially if there are complications extending the radiation exposure. The nurse must perform careful and frequent skin assessments and provide prophylactic skin care measures.

The extent of a burn injury is one of the criteria used to determine the

severity of a burn. One commonly used tool for determining the TBSA affected by a burn is the rule of nines, which uses multiples of nine to estimate the TBSA and guide treatment decisions such as fluid resuscitation. Note that first-degree burns, equivalent to sunburn, are not included when TBSA is calculated.

Most hospitalized patients with burns in the United States have which type of burn injury?

thermal