Introduction

Burn injuries can have devastating physical and psychological effects on individuals. Nursing management of burn injuries encompasses a comprehensive approach aimed at preventing complications, promoting wound healing, managing pain, and providing emotional support to patients and their families. Here, we discuss the essential aspects of nursing management for burn injuries.

Burns are classified based on their depth and severity, typically categorized into four main types:

1. First-Degree Burns:
   • Superficial burns that only affect the outer layer of the skin (epidermis).
   • Characterized by redness, pain, and mild swelling.
   • Common causes include brief exposure to heat, sunburns, or minor scalds.
   • Usually heal within a few days without significant scarring.
2. Second-Degree Burns:
   • Partial-thickness burns that extend through the epidermis into the underlying dermis.
   • Manifest as painful, red, blistered skin with swelling and moist appearance.
   • Can result from prolonged exposure to heat, hot liquids, or chemicals.
   • May take several weeks to heal and have a higher risk of scarring and infection.
3. Third-Degree Burns:
   • Full-thickness burns that damage both the epidermis and dermis, extending into the underlying tissues.
   • Present with charred, white, brown, or blackened skin that may appear leathery or waxy.
   • Often painless due to nerve damage, but surrounding areas may be painful.
   • Require immediate medical attention and often necessitate surgical intervention, skin grafting, or specialized wound care.
4. Fourth-Degree Burns:
   • Deep tissue burns that extend beyond the skin layers into muscle, tendon, or bone.
   • Characterized by extensive tissue destruction and necrosis.
   • Often result from prolonged exposure to high-temperature flames, electrical currents, or chemical agents.
   • Require urgent medical intervention and may lead to long-term disability or limb loss.

The nursing priorities for patients with burn injuries are as follows:

1. Ensure and maintain a clear airway and adequate breathing.
2. Administer appropriate fluid resuscitation to prevent dehydration and shock.
3. Provide effective pain management.
4. Implement infection control measures to prevent wound and systemic infections.
5. Assess and manage burn wounds to promote healing.
6. Provide necessary nutritional support to meet increased metabolic demands.

Assessment and Triage:

Assess for the following subjective and objective data:

1. Redness or discoloration of the skin at the burn site
2. Pain or tenderness at the burn site
3. Swelling or blister formation
4. Peeling or shedding of skin
5. Presence of open wounds or raw skin
6. Charred or blackened skin in severe burns
7. Difficulty breathing or coughing if the burn involves the airways
8. Nausea or vomiting
9. Weakness or dizziness
10. Increased heart rate
11. Decreased urine output
12. Signs of infection, such as increased redness, swelling, or pus
13. Changes in mental status or confusion
14. Smoke inhalation-related symptoms, such as hoarseness, cough, or difficulty swallowing

Assess for factors related to the cause of burn injury:

1. Neuromuscular impairment, pain/discomfort, decreased strength, and endurance
2. Restrictive therapies, limb immobilization; contractures
3. Disruption of the skin surface with the destruction of skin layers (partial-/full-thickness burn) requiring grafting
4. Traumatic event, dependent patient role; disfigurement, pain
5. Tracheobronchial obstruction: mucosal edema and loss of ciliary action (smoke inhalation); circumferential full-thickness burns of the neck, thorax, and chest, with compression of the airway or limited chest excursion
6. Trauma: direct upper-airway injury by flame, steam, hot air, and chemicals/gases
7. Situational crises: hospitalization/isolation procedures, interpersonal transmission, and contagion, the memory of the trauma experience, threat of death and/or disfigurement
8. Hypermetabolic state (can be as much as 50%–60% higher than normal proportional to the severity of injury)
9. Protein catabolism
10. Destruction of skin/tissues; edema formation
11. Manipulation of injured tissues, e.g., wound debridement
12. Inadequate primary defenses: the destruction of the skin barrier, traumatized tissues
13. Inadequate secondary defenses: decreased Hb, suppressed inflammatory response.

Airway Management:

Assessment of the patient’s airway, breathing, and circulation is critical in managing burn injuries. Here are the nursing interventions and actions:

1. Airway, Breathing, and Circulation Assessment:
   • Assess the patient’s airway patency, breathing effort, and circulation status. Pay close attention to signs of smoke inhalation and pulmonary damage, such as singed nasal hairs, mucosal burns, voice changes, coughing, wheezing, soot in the mouth or nose, and darkened sputum.
   • Recognize that exposure to burning materials can lead to inhalation injury, which may compromise respiratory function.
2. Obtain Comprehensive History:
   • Gather information about the nature of the injury, including the burning agents involved, duration of exposure, and whether the incident occurred in closed or open spaces. Preexisting respiratory conditions and smoking history should also be noted, as they increase the risk of respiratory complications.
3. Assess Gag and Swallow Reflexes:
   • Evaluate the patient’s ability to gag and swallow. Look for signs of difficulty swallowing, drooling, hoarseness, and wheezy cough, which may indicate inhalation injury.
4. Monitor Respiratory Status:
   • Monitor the patient’s respiratory rate, rhythm, and depth regularly. Watch for signs of respiratory distress, such as tachypnea, use of accessory muscles, cyanosis, and changes in sputum color.
   • Auscultate lung sounds for abnormal findings such as stridor, wheezing, crackles, diminished breath sounds, and a brassy cough, which may indicate airway obstruction or respiratory distress.
5. Assess Skin Color Changes:
   • Note any changes in skin color, including pallor or a cherry-red hue in unburned skin, which may suggest hypoxemia or carbon monoxide poisoning.
6. Evaluate Mental Status Changes:
   • Monitor the patient for changes in behavior or mentation, such as restlessness, agitation, or altered level of consciousness. These changes may indicate developing hypoxia and require prompt intervention.
7. Monitor Fluid Balance:
   • Keep track of the patient’s fluid balance over a 24-hour period, noting any variations or changes. Inhalation injury increases fluid demands due to obligatory edema, and excess fluid replacement can lead to pulmonary edema.
8. Obtain Laboratory Tests:
   • Draw blood samples for a complete blood count, type and crossmatch, electrolyte levels, glucose, blood urea nitrogen, creatinine, and arterial blood gas analysis. These tests provide baseline data and help guide treatment decisions.

Fluid Resuscitation:

• Calculate fluid resuscitation requirements based on the extent and depth of the burn injury using established formulas (e.g., Parkland formula).
• Initiate early fluid resuscitation to prevent hypovolemic shock and maintain tissue perfusion.
• Monitor fluid balance closely, adjusting fluid rates based on the patient’s hemodynamic status, urine output, and laboratory values.

Wound Care:

.Patients with burn injuries often experience a break in skin integrity due to the loss of skin, leading to various complications such as infection, impaired wound healing, and fluid/electrolyte imbalances. Additionally, the loss of skin and underlying tissues can result in decreased blood flow to the affected area, further complicating the healing process. Here are nursing interventions and actions for managing burn wounds:

1. Wound Assessment:
   • Assess and document the size, color, and depth of the wound, including any necrotic tissue and the condition of the surrounding skin. This provides crucial information for determining the need for skin grafting and evaluating circulation in the area.
2. Evaluation of Grafted Areas:
   • Evaluate the color and healing progress of grafted and donor sites. Monitor for signs of healing or complications, such as infection or graft failure, to guide further management.
3. Burn Care and Infection Control:
   • Provide appropriate burn care and infection control measures to prepare the tissues for grafting and reduce the risk of infection or graft failure.
4. Wound Covering Maintenance:
   • Maintain wound coverings as indicated, ensuring proper protection and support for newly grafted areas. This may involve elevating the grafted area when possible and keeping the skin free from pressure to promote circulation and prevent ischemia.
5. Dressing Care:
   • Keep dressings over newly grafted areas and donor sites, using materials such as mesh, petroleum, or nonadhesive dressings. These dressings protect healing tissue and promote optimal graft adherence.
6. Skin Care:
   • Wash sites with mild soap, rinse, and lubricate with cream several times daily after dressings are removed and healing is accomplished. Special care is needed to maintain flexibility in newly grafted skin and healed donor sites.
7. Bleb Aspiration:
   • Aspirate blebs under sheet grafts using a sterile needle or roll with a sterile swab. Removing fluid-filled blebs prevents graft adherence issues and reduces the risk of graft failure.
8. Preparation for Surgical Grafting:
   • Prepare for or assist with surgical grafting procedures, including homografts, heterografts, cultured epithelial autografts (CEA), and artificial skin (Integra). These procedures provide temporary or permanent coverage for burn wounds and promote healing.

Pain Management:

• Assess and reassess the patient’s pain using standardized pain assessment tools
• Administer analgesics promptly to relieve pain and minimize suffering.
• Utilize multimodal analgesia techniques, including pharmacological and non-pharmacological interventions, to optimize pain control.
• Educate patients on relaxation techniques, guided imagery, and distraction methods to cope with pain.

Infection Prevention:

• Implement strict infection control measures to prevent wound contamination and nosocomial infections.
• Adhere to aseptic techniques during wound care procedures.
• Administer prophylactic antibiotics as indicated, especially for large burns or high-risk patients.
• Monitor for signs of infection, such as increased pain, erythema, warmth, or purulent drainage, and initiate prompt treatment.

Nutritional Support:

Patients with burn injuries are at risk of malnutrition due to increased metabolic demands, physical stress, and decreased appetite. Adequate nutrition is crucial for healing and tissue repair. Here are nursing interventions and actions for managing malnutrition in patients with burn injuries:

1. Bowel Sounds Assessment:
   • Auscultate bowel sounds to assess for hypoactive or absent bowel sounds, which may indicate ileus. Oral feedings can be initiated once ileus subsides within 36-48 hours postburn.
2. Food Preferences:
   • Ascertain the patient’s food likes and dislikes and encourage significant others to bring food from home if appropriate. This provides a sense of control and enhances participation in care, potentially improving food intake.
3. Monitoring Body Composition:
   • Monitor muscle mass and subcutaneous fat to assess nutritional status. Utilize indirect calorimetry if available for more accurate estimation of body reserves or losses and to evaluate the effectiveness of therapy.
4. Caloric Intake and Weight Monitoring:
   • Maintain a strict calorie count and weigh the patient daily. Adjust the prescribed dietary formulas based on the percentage of open body surface area and wound healing progress to ensure appropriate caloric intake for healing.
5. Laboratory Studies:
   • Monitor laboratory studies including serum albumin, prealbumin, creatinine, transferrin, and urine urea nitrogen to assess nutritional status and guide interventions.
6. Glucose Monitoring:
   • Perform fingerstick glucose and urine testing as indicated to monitor glucose levels and assess metabolic status.
7. Meal Frequency:
   • Provide small, frequent meals and snacks to prevent gastric discomfort and enhance food intake.
8. Nutrient-rich Choices:
   • Encourage the patient to view diet as a part of treatment and choose foods and beverages high in calories and protein to meet metabolic needs and promote wound healing.
9. Meal Positioning:
   • Encourage the patient to sit up for meals and socialize with others. Sitting helps prevent aspiration and aids digestion, while socialization promotes relaxation and may enhance food intake.

Psychosocial Support:

• Provide emotional support and counseling to patients and their families throughout the recovery process.
• Encourage open communication and address concerns regarding body image, functional limitations, and psychological distress.
• Collaborate with interdisciplinary team members, including psychologists, social workers, and support groups, to address psychosocial needs effectively.

Rehabilitation and Scar Management:

• Initiate early mobilization and physical therapy to prevent contractures and optimize functional outcomes.
• Implement scar management techniques, such as pressure garments, silicone gel sheets, and scar massage, to minimize scarring and improve cosmesis.
• Monitor for signs of hypertrophic scarring or keloid formation and intervene promptly with appropriate treatments.

Discharge Planning and Follow-up:

• Develop a comprehensive discharge plan tailored to the patient’s individual needs and resources.
• Provide education on wound care, medication management, signs of complications, and follow-up appointments.
• Arrange for outpatient services, including home health care, outpatient rehabilitation, and community support services, as needed.

Nursing Implementations

Conclusion

Nursing management of burn injuries requires a holistic and multidisciplinary approach to address the complex needs of patients physically, psychologically, and emotionally. By providing comprehensive care, nurses play a pivotal role in optimizing outcomes and promoting the recovery and rehabilitation of individuals with burn injuries.

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