Nursing Care & Interventions in the Client

with Burn Injury

Keith Rischer RN, MA, CEN

1
 Today’s Objectives…

 Compare and contrast the clinical manifestations of superficial, partial-

thickness, and full-thickness burn injuries.
 Prioritize nursing care for the client during the emergent, acute, and
rehabilitation phase of burn injury.
 Analyze assessment data to determine nursing diagnoses and
formulate a plan of care for clients with burn injuries.
 Use laboratory data and clinical manifestations to determine the
effectiveness of fluid resuscitation.
 Describe nursing management wound care and nutritional needs for
the burn client.
 Evaluate assessment data to determine wound healing in the burn
client.
 Identify pain management strategies for burn clients.
 Explain the positioning and range-of-motion interventions for the
prevention of mobility problems in the client with burns.
 Discuss the potential psychosocial problems associated with burn
injury.

2
 Burn Injury: Patho

 Skin
• Epidermis
• Dermis
 Purposes
 Skin destruction
• Fluid/protein loss
• Sepsis
• Multi-system changes
 Dependant on age
 Health
 Depth of injury
 Body area involved

3
 Depth of Burn Injury

 Superficial-thickness
• Epidermis only
 Partial-thickness
• Epidermis + partial
Dermis
 Full-thickness
• Epidermis + all dermis
+ underlying
tissue/muscle/bone

4
 Assessment: Superficial-thickness

 Pain
 Redness
 Heals in 3-5 days

5
 Assessment: Partial-thickness

 Red-blanch
• No blanch with deeper burn
 Blister and broken
epidermis
 Painful
 Heal in 10-21 days

6
 Assessment: Full-thickness

 Pale, white to red, yellow

 Charred eschar
 Leathery skin, dry surface
 Painless
 Edema present
 Signs of systemic shock
may be present
 Needs grafting

7
 Burns: Vascular Changes

 Fluid shift
• Capillary leakage
• First 12 hours
 Lasts 24-36 hours
• Lyte & acid base imbalance
 Hypovolemia
 Hyperkalemia, hyponatremia
 Fluid remobilization
• Diuretic stage (48-72 hours)
 Hyponatremia
 hypokalemia

8
 Burns: Body System Assessment

 Cardiac
• HR increase
• CO decreased initially
 Respiratory
• Airway edema
• pulmonary cap. leakage
 GI
• Paralytic ileus
 Metabolic
• Increased due to catecholamines, cortisol and SNS
• Caloric needs double or triple
 Immune
• Diminished response
• Increased risk of infection 9
 Burns: Emergency Management
 Primary Survey
 Airway
• Breathing
• Circulation
• C-Spine immobilization
(when indicated)

 Secondary Survey
• Complete head to toe exam
• % of TBSA
• Depth of burn
• Part(s) of body burned
• Rule out other serious or life
threatening injuries

10
 Inhalation Injury: Assessment

Facial burns Severe cough

Singed nasal hairs Hoarseness
Stridor Shortness of breath
Anxiety

Symptoms
Signs

CO Poisoning Wheezing
•HA Dyspnea
•Nausea Disorientation
•Alterered LOC Obtunded
• Confusion Coma
• Coma
11
 Burn Classification

 Minor
• <15% partial thickness
 Moderate
• 15-25% partial
thickness
• <10% full thickness
 Severe
• >25% partial thickness
• >10% full thickness

12
 ABA Burn Referral Guidelines
 2° Burns > 10% TBSA
 Burns involving the
face, hands, feet,
genitalia, perineum, &
major joints
 3° Burns in any age
group
 Electrical Burns
• lightning injuries
 Chemical Burns

13
 Laboratory Findings: First 48 hours

 Hgb/Hct
 Glucose
 Sodium
 Potassium
 BUN/creatinine
 Albumin
 ABG’s
• pO2
• pCO2
• pH
• CO

14
 Nursing Diagnostic Priorities: First 48 Hours

 Decreased cardiac output r/t…

 Deficient fluid volume r/t…
 Ineffective tissue perfusion r/t…
 Ineffective breathing pattern r/t…
 Acute pain r/t…

15
 Fluid Resuscitation
 Nursing interventions
• Large bore IV/central IV access
• Lactated ringers

 Nursing Assessment
• I&O
 Urine output
• Daily weight
• Oxygenation needs
• Fluid overload
• VS
• Labs
 Creatinine
 Albumin
 lytes
16
 Nursing Diagnostic Priorities: First 48 Hours

 Ineffective breathing pattern r/t…

• Respiration pattern
• Oxygenation
 ABG’s
– pH: 7.41….7.29
– p02: 73….55
– pCO2: 44….60
 Acute pain r/t…
• Opiods IV
 Fentanyl... Onset___ Peak___ Duration___
 Morphine… Onset___ Peak___ Duration___
 Dilaudid…Onset___ Peak___ Duration___

17
 Assessment Priorities: After 48 Hours
 Cardiopulmonary
• Pneumonia
 Neuroendocrine
• Increased metabolic demands
 Immune (risk of infection)
• Local
• Systemic
 VS
 Altered LOC
 u/o

18
 Nursing Diagnostic Priorities: After 48 Hours

 Impaired skin integrity r/t…

 Risk of infection r/t…
 Imbalanced nutrition-less than body
requirements r/t…
 Impaired physical mobility r/t…
• ROM
• Early ambulation
 Disturbed body image r/t…
19
 Impaired Skin Integrity-Wound Care

 Debridement
• Hydrotherapy
 Wound dressings
• Antibiotic ointment
• Biologic
• Synthetic
 Skin grafts
• Autograft
• Artificial

20
 Dressings: Topical Antibiotics

 Silver Sulfadiazine
• Most frequently used topical
• Gram negative/positive organisms
• Penetrates eschar well
• Applied with a gloved hand, tongue depressor
or impregnated in gauze
 Bacitracin
• Acceptable for use with superficial burns
• Least expensive antimicrobial agent

21
 Dressings

 Decrease pain
 Absorb drainage
 Preserve joint mobility
and allow ROM
 Provide protection and
isolation of wound from
environment

22
 Nutrition

 Metabolic changes  Net Results of

• Hormone mediated Changes
 > Catecholamines • > Nitrogen losses
 > Glucocorticoids and
glucose to insulin ratios
• > Energy Expenditures
and nutrition metabolism
• Metabolic alterations
 > Gluconeogenesis  Results
 > Proteolysis • Hypermetabolic -
 > Ureagenesis catabolic state
 < Lipolysis & Ketone
utilization

23
 Enteral Feedings

 Preferred route
• Safety
• Better utilization of nutrients
• Gut integrity
• Lower cost
 Parenteral (TPN)
• Nonfunctional guts
• High risk for sepsis
 Objectives
24
 Psychological Issues & Follow Up

 Inpatient
• PTSD
• Disfigurement
• Sexual issues
• CD
 Outpatient
• Ongoing therapy
• Support groups
• Burn Camp

25