Burns: Phases, Nursing Care & Interventions

Proper nursing care and management are essential to ensure optimal healing when dealing with a burn injury. Unfortunately, every second of delay in treatment matters when it comes to the future outcome of burn injuries. That’s why understanding the many factors affecting wound healing and best practices for managing those wounds through nursing interventions are essential to successful results.

In this blog post, we will discuss burn injury nurse care and management – from recognizing different types of burns to assessing and treating impactful patient needs – to provide valuable insight into how nurses can efficiently cleanse and protect open wounds while promoting optimal healing.

What is a Burn?

Burn is a devastating and painful experience that can impact every aspect of a person’s life. It is an injury caused by heat, electricity, chemicals, or radiation exposure. Burn injuries can vary in severity, from minor burns that heal quickly, to life-threatening burns that require extensive medical treatment and rehabilitation. 

They can affect the skin, muscles, bones, and even internal organs, leading to scarring, disfigurement, and long-term physical and psychological effects.

Although burn injuries are common, they can be prevented with proper safety precautions and awareness. It is necessary to seek medical attention immediately if you or someone you know has suffered a burn injury, as prompt treatment can make all the difference in the healing process.

Classifications

First Degree Burns

First-degree burns are the mildest form of skin burn. They cause pain, redness, and swelling in the affected area. This type of burn usually heals within a few days without further treatment.

Second Degree Burns

Second-degree burns are more severe than first-degree, as they penetrate deeper into the skin layers. These types of burns cause pain, redness, swelling, and blistering. These burns can take many weeks to heal and may require medical treatment. Second-degree burns may take on the different forms below.

• Superficial partial thickness burns, which affect the epidermis and upper dermis, may appear pink or red, blistered, wet to the touch, and painful.
• Mid-dermal burns. These burns affect the lower dermis and may appear pale or splotchy, with white and red patches.
• Deep partial-thickness burns affect deeper layers of skin and can appear white or blackened in color, leathery in texture, and often painless due to nerve damage.

Third Degree Burns

Third-degree burns are the most serious and can cause severe damage to the skin tissues, nerves, muscles, and even bones. These types of burns usually result in permanent scarring of the affected area and may require skin grafting and reconstructive surgeries to repair the damage. 

Third-degree burns can be categorized into three different forms:

Full thickness destroys all skin layers including the epidermis, dermis, and occasionally deeper layers such as fat or muscle. These burns appear white or charred and leathery in texture and are often painless due to nerve damage.

Pathophysiology

Burns are one of the most frightening and painful injuries a person can experience. Beyond the immediate sensation of burning, however, a burn can lead to a range of serious pathologies. For instance, scar tissue can form at the site of the injury, which can restrict movement and potentially require surgical intervention.

Additionally, deep burns can damage the nerves at the site of the injury, causing not only intense pain but potentially numbness or even paralysis in the affected area. 

Infections are another possible complication of burns, as the damaged skin can become a breeding ground for harmful bacteria. 

Because of the complex and potentially severe pathologies that burn can cause, seeking professional medical attention as soon as possible after experiencing a burn is important.

What are the Systemic Responses to Burns?

Burns are injuries that can impact the body’s local and systemic parts. There are 3 main types of burns:

• Thermal
• Electrical
• Chemical.

The changes in tissue that occur after a burn trauma are crucial factors to consider. In extensive burns, fluid loss from damaged tissue will lead to decreased plasma levels and increased hematocrit levels, resulting in decreased cardiac output. This can cause widespread cellular hypoperfusion, which can have a damaging effect on multiple systems.

Local Response

• Zone of coagulation – This is the area of tissue that has sustained direct damage from the burn.
• Zone of Stasis: The zone of stasis is a zone of injury surrounding the coagulated area that can significantly increase in size due to secondary trauma, such as infection and shock.
• Zone of Hyperaemia – The zone of Hyperaemia is the area that experiences increased blood flow and inflammation due to the burn injury.

Systemic response

[ Once TBSA >30%, a systemic inflammatory reaction will occur.]

The body will respond to the burn trauma by releasing inflammatory mediators. These mediators can cause a host of systemic and metabolic changes, which can lead to multiple organ failure and sepsis.

What is the TBSA?

Once medical attention has been sought, one of the first steps in assessing a burn injury is to calculate its Total Body Surface Area (TBSA) affected. This calculation helps determine the percentage of the total skin area affected by the burn and provides valuable insight into how best to treat it.

Typically, TBSA assessment involves using a “rule of nines” to measure the burn. The rule of nines assigns percentages of TBSA to each body region, which can then be used to assess the amount of TBSA affected.

In general, burns that affect less than 20% TBSA are considered minor injuries; between 20-50% is moderate; and greater than 50% are severe. IV fluids are typically necessary for burns more significant than 20% TBSA to prevent dehydration and other complications.

At What Temperature Do Burns Occur?

The American Academy of Pediatrics suggests that hot tap water [HTW] should not exceed 49°C (120°F) to avoid accidental burns in young children. 

Research indicates that at 52°C (125°F), full-thickness skin burns can form within two minutes, and a temperature of 54°C (130°F) may cause them in just 30 seconds. 

Hence, it is essential to maintain a safe hot tap water temperature to protect children from accidental burns.

The Effects of Burns

The effects of a burn injury can vary widely, depending on the type and harshness of the burn. In mild cases, redness and inflammation may be present, which can cause swelling, itching, and pain. 

For deeper burns, these symptoms may worsen to blisters or even further tissue damage. Skin grafting and other treatments may be necessary in severe cases to minimize scarring and other lasting effects.

The Burn Rehabilitation Team

Once the severity and location of the burn have been determined, a burn rehabilitation team can begin to assess and treat any additional impactful patient needs. This team typically comprises nurses, physical therapists (PTs), occupational therapists (OTs), and other healthcare professionals working together to ensure that all aspects of wound healing are being addressed.

Burn Care Management

Burn Care Management: Burn care management requires a multidisciplinary approach to address all aspects of wound healing, infection prevention, and scarring. With the help of a burn rehabilitation team consisting of nurses, physical therapists (PTs), occupational therapists (OTs), and other healthcare professionals, patients can be guided through the three phases of burn care: emergent, acute, and rehabilitative. Such as following

Scar Management

Scars caused by a burn injury can be uncomfortable and unsightly; scar management is essential to recovery from a burn injury. Scar massage, compression garments, topical treatments, and other modalities may reduce scarring or improve its appearance. Psychological support may also be necessary for helping patients cope with the visible effects of burns.

Burn Center Referral

Burn center referrals may be necessary for severe or complex burns to provide the patient with comprehensive care. Patients will receive wound care, pain management, and psychological support from a multidisciplinary team of experts during their stay at these specialized centers. Burn centers also offer additional resources such as physical therapy and scar management programs to help patients regain optimal function.

You can visit the AmeriBurn website for more details.

With the proper care and support, most people can recover from a burn injury without lasting effects. However, it is essential to seek a medical lookout if you or someone else experiences a burn injury so that proper treatment can begin immediately. Early intervention can significantly improve the outcome of a burn injury and reduce the risk of long-term complications such as scarring and infection.

Phases of Burn Care

Burn care management is divided into three phases: emergent, acute, and rehabilitative. During these stages, the main concerns are fluid replacement, wound healing, and psychological support for the patient. Once they have been taken away from the source of the burn, healthcare personnel assesses their ABCs (airway, breathing, and circulation) and then start implementing steps to provide care.

PHASE 1: [Emergent Phase/Resuscitative]

The resuscitative (emergent) phase of burn management begins at the time of injury. This phase is focused on addressing any fatal issues caused by the burn. A thorough assessment of the patient’s burns will determine the treatment plan (see “Burns Assessment” on Picmonic). This includes allocating for hypovolemic shock and edema formation.

Injury to Return of Capillary Permeability

Shortly after the burn, damage to capillaries can cause fluid and electrolyte shifts from the vasculature into interstitial tissues. As a result, vascular volume loss occurs due to second-spacing (fluid in interstitial tissue) and third-spacing (blisters/edema). Capillary permeability is restored with adequate fluid replacement; once interstitial fluid returns to the vasculature, edema dissipates, and diuresis begins.

48-72 hours

The emergent phase usually lasts 48-72 hours from the time of injury; the beginning of diuresis marks its end.

IV Fluid Replacement

Patients who have suffered burns to more than 15% of their Total Body Surface Area (TBSA) will require two large bore intravenous access sites to infuse a substantial volume of fluid. 

The Parkland (Braxton) formula calculates fluid requirements, and crystalloid or colloidal solutions like Lactated Ringer’s/albumin are administered accordingly. The rate of fluid administration is monitored and adjusted every hour based on the patient’s response, which includes urine output and vital signs.

PHASE 2: Acute Phase: 

The acute phase of burn care begins once the patient is stabilized in the emergent phase. This stage focuses on wound healing, infection prevention, and preventing scarring.

Debridement

During the acute phase, the burn wounds must be debrided (cleaned) to remove necrotic tissue that could harbor infection or impede wound healing. This is typically done through surgical excision of dead tissue, though other methods such as whirlpool therapy, may also be used.

Grafting/Flap Reconstruction

Once most dead tissue has been removed, skin grafts or flap reconstruction may be necessary to speed up healing and reconstruct any damaged areas. Grafted skin must be taken from a healthy body area (donor site) and placed on top of the burnt area (recipient site). Careful selection of donor and recipient sites is essential for successful grafting.

PHASE / STAGE 3: Rehabilitative/Recovery Phase

The rehabilitative (recovery) phase of burn care begins once the wound has healed and is ready for closure. During this phase, the patient will receive physical and occupational therapies to regain their optimal level of function.

Physical Therapy

Physical therapy helps patients regain strength and motion in affected areas of their body. Initial exercises may include passive range-of-motion to reduce joint stiffness and splinting/bracing for burn contractures (tissue shortening). As strength returns, active movements like stretching, gait training, and strengthening exercises will also be implemented.

Occupational Therapy

Occupational therapy helps patients learn how to perform activities of daily living (ADLs) such as dressing, eating, hygiene, etc. with the least difficulty. The therapist may also provide adaptive equipment such as prostheses or wheelchairs to help the patient become more independent.

Psychological Support

Psychological support is essential for a burn patient’s recovery, as they may be dealing with feelings of depression and anxiety due to the trauma of their injuries. Mental health professionals can provide individual or group therapy, relaxation techniques, biofeedback, and other treatments to help them cope.

Burns In Nursing Management: Emergent/Resuscitative Phase

Assessment

• Mainly focus on the major priorities of any trauma patient; burn wound care is a secondary consideration though sterile management and monitoring of such wounds and invasive tubes must be maintained.
• Assess the circumstances around the injury: time of the incident, cause of the burn, the possibility of inhalation of hazardous chemicals, and associated traumas.
• Monitor vitals regularly; maintain a close watch over respiratory condition; pay particular attention to apical, carotid, and femoral pulses in areas with circumferential burns to extremities.
• Check peripheral pulses on burned limbs hourly; use Doppler as necessary.
• Track fluid intake (IV fluids) and output (urinary catheter) per hour; note the amount of urine accumulated upon insertion (indicating pre-burn renal function and fluid status).
• If appropriate, Install cardiac monitoring (e.g., history of heart or lung issues or electrical injury).
• Assess body temperature, weight, past weight before the burn, allergies, tetanus immunization, prior medical/surgical issues, existing illnesses, and use of medications.
• Arrange for patients with facial burns to have their corneas examined. Keep assessing the extent of burn damage, depth of wounds, and complete/partial thickness injury. Gauge patient’s neurological condition: consciousness level, psychological state, pain/anxiety levels, behavior.
• Examine comprehension of injury and treatment by the patient and family; assess available support systems and coping skills.

Nursing Interventions For the Resuscitation Phase of burn injury

Nursing care for a patient with a burn injury needs to be accurate and effective.

Promoting Gas Exchange and Airway Clearance

• Provide humidified oxygen and observe ABGs, pulse oximetry, and carboxyhemoglobin levels. Monitor for signs of inhalation injury such as blistering lips or buccal mucosa, singed nostrils, facial or chest burns, hoarseness, or soot in respiratory secretions.
• Report labored breathing, decreased depth of respirations, or hypoxia to the physician immediately–be prepared for intubation and escharotomies.
• Regularly monitor patients who are on mechanical ventilation.
• Encourage aggressive pulmonary care measures, such as turning, deep breathing, coughing, periodic forceful inspiration using spirometry, and tracheal suctioning.
• Ensure proper positioning to promote secretions removal, patent airway, and optimal chest expansion; use artificial airways if necessary.

Restoring fluid and Electrolyte Balance

• Monitor urine output and electrolytes closely.
• Administer IV fluids as indicated to replace ongoing losses from wound exudate, third-spacing of fluid, and evaporative losses from the burning surface.
• Elevate the head of the bed and burn extremities.
• Administer antibiotics as ordered for systemic infection or sepsis prophylaxis.
• Alert your physician right away if there is a decrease in urine output, blood pressure, or central venous, pulmonary artery, or pulmonary artery wedge pressures; or an increase in pulse rate.

Maintaining Normal Body Temperature

• Keep the patient warm, and provide blankets or warming devices as ordered.
• Monitor temperatures closely; keep the temperature at the normal range (98.6-100°F) if possible.
• Monitor for shivering and hypothermia.
• Administer heated humidified oxygen to prevent drying of the airway secretions in inhalation injury patients.

Minimizing Pain and Anxiety

• Assess pain level frequently and adjust medications as necessary.
• Provide diversional activities to help patients cope with anxiety or fear associated with injury.
• Encourage the patient to practice deep-breathing exercises or relaxation techniques.
• Encourage family members to be present during care and support the patient.

Monitoring and Managing Potential Complications

Acute respiratory failure:

• Observe for symptoms of increasing dyspnea, stridor, and disruption inspiration.
• Measure oxygen saturation and blood gas levels regularly to identify any rising CO2.
• Review chest x-rays.
• Watch out for indications of cerebral hypoxia (e.g., restlessness, confusion).
• Promptly inform the physician of the deteriorating condition.
• Assist with intubation or escharotomy where necessary.

Distributive shock: Monitor for early indications of shock, such as decreased urine output, cardiac output, pulmonary artery pressure, pulmonary capillary wedge pressure, BP, etc., or buildup of edema; deliver fluid resuscitation as prescribed in response to physical readings; perseveringly track fluid status.

Acute renal failure: Record and report abnormal levels of urine production/quality and BUN/creatinine in the blood; take note of hemoglobin or myoglobin in the urine; offer heightened fluids according to instructions.

Compartment syndrome: Track peripheral pulse using Doppler at hourly intervals; evaluate the neurovascular state of extremities every hour (warmth, capillary refill, sensation, and mobility); take off BP cuff after each evaluation; raise burned extremities; keep an eye for any ache, loss of peripheral pulse/sensation; be ready to help with escharotomies.

Paralytic ileus: Place the nasogastric tube on low intermittent suction until the resumption of bowel sounds; listen to the abdomen regularly for distention and sounds from the intestine.

Curling’s ulcer:

• Assess gastric aspirate for blood and pH level.
• Test stools for hidden blood.
• Give antacids and H2 blockers (e.g., ranitidine) as advised.

Burns Nursing Management: Acute/ Intermediate Phase

The acute or intermediate phase starts 48 to 72 hours after the burn injury. At this stage, burn wound care and pain control are priorities.

Assessment

• Evaluate the degree of burn injury and continue to assess for changes in depth.
• Inspect wounds for signs of infection; monitor temperature, pulse, and respiration; check the oropharynx for burns or singeing.
• Assess wound dressings and note the amount of drainage.
• Check peripheral pulses hourly as indicated; measure capillary refill time (CRT).
• Monitor vital signs, daily weight, and levels of consciousness.
• Assess for edema and hemodynamic stability.
• Check respiratory status; review ABGs or pulse oximetry readings.
• Evaluate the patient’s nutritional status, anorexia, nausea, vomiting, diarrhea, and abdominal distention.

Nursing Interventions For Acute Phase

Restoring Normal Fluid Balance

• Monitor input and output daily. Measure intake and production of intravenous fluids, gastric suction, drainage from the wound, nasogastric tubes, and urine catheters; expect more significant losses than the average for burn patients because of increased metabolic demands.
• Monitor laboratory values such as hematocrit (HCT), hemoglobin (Hgb), electrolytes, blood urea nitrogen (BUN), creatinine, and glucose; report significant deviations to a physician.

Wound Care Management

• Perform dressings according to prescribed procedures.
• Document the type of dressing used, amount of exudate present (amounts vary from scant amounts to profuse amounts on the wound surface), bleeding, granulation tissue formation, the success rate of grafts, and other pertinent information.

Pain Management

• Assess pain level to determine opioid (narcotic) requirements; discuss the need for pain relief with the physician before administering analgesic medications.
• Monitor the patient for signs of addiction or dependency on narcotics.
• Use noninvasive techniques such as massage, heat/cold application, and relaxation exercises to supplement opioids and provide additional comfort.
• Develop a plan with the patient to use the least amount of medication possible while providing adequate relief from pain.

Initiating Comfort Measures

• Support the patient’s efforts in self-care activities.
• Offer emotional support in coping with disfiguring effects of burn injury; refer for counseling if needed.
• Encourage interaction among family members and friends who can help the patient cope during hospitalization.

Preventing Skin Breakdown and Contractures

• Identify factors that can lead to skin breakdown by assessing for malnutrition, dehydration, incontinence, immobility, or any other condition affecting skin integrity.
• Prevent potential complications of immobility (atelectasis, pneumonia, edema, pressure ulcers, and contractures) through deep breathing exercises, turning the patient regularly, and proper repositioning.
• Modify interventions as needed for the patient’s situation.
• Encourage early sitting and ambulation after injury when possible; apply elastic pressure bandages to extremities if legs are involved before helping them into an upright position. Make aggressive efforts to prevent contractures and hypertrophic scarring of burned areas.

Assisting Patient and Family Processes

• Support and address the verbal as well as nonverbal worries of the patient and their family. Guide the family on how they can best support their loved one.
• Make necessary referrals to psychology or social services professionals if required. Give detailed information about burn care and its expected course of treatment. Include patients in care decisions, showing acceptance for their individuality and preferences; set realistic expectations for self-care.
• Encourage truthful communication to build trust, helping patients practice coping strategies with positive reinforcement when appropriate.
• Engage a neutral individual for the patient to express their emotions without worrying about repercussions.

Monitoring and Managing Potential Complications

• Heart failure:  Watch for indications of fluid overload, including decreased cardiac output, diminished urine output, swelling in the jugular vein, edema, or newly developing S3 or S4 heart sounds.
• Pulmonary edema:  Assess the patient’s CVP, pulmonary artery, and wedge pressures regularly, looking out for any changes; report them immediately. Make sure the patient is comfortable with their head elevated unless contraindicated. Administer medications and oxygen as directed and evaluate their response. Monitor for crackles too.
• Sepsis: Monitor the temperature, pulse rate, and widened pulse pressure in unburned areas, along with any flushed, dry skin (all of which are early signs). Additionally, take wound and blood cultures as needed. Be sure to provide antibiotics on schedule.

Acute respiratory failure & acute respiratory distress syndrome 

• (ARDS): Monitor the respiratory status for dyspnea, a change in the breathing pattern, and adventitious sounds. Keep an eye out for decreased tidal volume and lung compliance in patients on mechanical ventilation; notify the physician immediately of any changes.
• Visceral damage (from electrical burns):  Please monitor the electrocardiogram (ECG) and inform us of irregular heart rhythms. Also, please note any pain related to profound muscle ischemia and report it promptly. Early detection of these issues can minimize their severity. 
• After a fasciotomy, the patient should be monitored for excessive blood loss and hypovolemia, as this procedure may be necessary to relieve swelling and ischemia in the muscles and fascia.

Burns Nursing Management: Rehabilitation Phase

During rehabilitation, we focus on healing the emotional scars and the physical wound for long-term results. The rehabilitation phase can take several years for certain patients. Some critical factors in this phase are:

• Continued wound care and management to promote proper healing
• Pain reduction through medications, massage, and other comfort measures
• Exercises to improve strength, range of motion, and scar mobility
• Counseling or therapy for coping with emotional trauma
• Psychosocial support to help the patient adjust to physical changes related to burn injury
• Education about body image, self-esteem, and lifestyle changes.

The rehabilitation phase is an essential yet often overlooked step in burn care. It is necessary to help the patient cope with physical and emotional losses and readjust to life after a burn injury. Long-term follow-up by an interdisciplinary team of healthcare professionals can ensure success in this phase.

Follow-up Care and Education

In addition to the rehabilitation phase, follow-up care is essential to monitor for signs of infection or other complications. Patient education should also be provided on adequately caring for the wound, managing pain, and promoting overall health. 

Follow-up appointments should include the following:

• Evaluations of the wound and dressing changes as needed.
• Monitoring of vital signs.
• Assessment for any complications.

Patient education can focus on proper wound care techniques, nutrition to promote healing, relaxation exercises to reduce stress, and tips for emotional coping.

Why Do Burns Cause Hyperkalemia?

Burns can range from mild to severe, depending on the extent and depth of the injury. While the most visible consequence of burns is damage to the skin, they can also seriously affect the body’s internal functions. One such effect is the risk of developing hyperkalemia, a condition characterized by high potassium levels in the blood. 

Hyperkalemia can be life-threatening and cause adverse cardiac events. Research suggests that burns can cause hyperkalemia due to the release of potassium from the damaged cells into the bloodstream. 

This can result in difficulty for the kidneys to remove excess potassium from the body, leading to a buildup of potassium in the blood. Understanding the relationship between burns and hyperkalemia is crucial for healthcare professionals in managing and treating burn injuries effectively.

Final Words

In conclusion, a burn injury is a highly traumatic experience requiring specialized care to ensure positive outcomes. The nursing process should include assessing the patient’s physical and psychosocial needs. Initiating comfort measures, preventive interventions and assisting patient and family processes helps provide holistic care during hospitalization. 

Monitoring for potential complications and providing follow-up care is essential to burn management. Providing comprehensive care throughout the entire continuum of burn treatment increases the chances for successful recovery.

References:

https://www.ncbi.nlm.nih.gov/books/NBK430795/

https://www.rch.org.au/trauma-service/manual/Burns/#:~:text=Zone%20of%20coagulation%20%E2%80%93%20this%20is,penumbra%20of%20potentially%20salvageable%20tissue.