Burn Care
The goals of burn care are to maintain the patient’s physiologic stability, repair skin integrity, prevent infection, and promote maximal functioning and psychosocial health. Competent care immediately after a burn occurs can dramatically improve the success of overall treatment. (See Burn care at the scene.)
Every burn victim should be evaluated initially as a trauma patient. Focus on maintaining the patient’s airway, breathing, and circulation. When the burn is caused by a chemical agent, the priority is to remove the offending agent and irrigate the affected area with water. Next, do a head-to-toe assessment followed by efforts to stop the burn and contain the injury. Burn severity is determined by the depth and extent of the burn and the presence of other factors, such as age, complications, coexisting illnesses, and the possibility of abuse. (See Estimating burn surfaces in adults and children and Evaluating burn severity, pages 98, 99.)
To promote stability, you’ll need to carefully monitor your patient’s respiratory status, especially if he has suffered smoke inhalation. Be aware that a patient with burns involving more than 20% of his total body surface area usually needs fluid resuscitation, which aims to support the body’s compensatory mechanisms without overwhelming them.1 Expect to give fluids (such as lactated Ringer’s solution) to keep the patient’s urine output at 0.5 to 1 mL/kg/hour for children and 1 to 1.5 mL/kg/hour for adults, and expect to monitor blood pressure and heart rate.1 You’ll also need to control body temperature because skin loss interferes with temperature regulation. Use warm fluids, heat lamps, and hyperthermia blankets, as appropriate, to keep the patient’s temperature above 97° F (36.1° C), if possible. Additionally, you’ll frequently review laboratory values such as serum electrolyte levels to detect early changes in the patient’s condition.
Infection can increase wound depth, cause rejection of skin grafts, slow healing, worsen pain, prolong hospitalization, and even lead to death. To help prevent infection, use strict sterile technique during care, dress the burn site as ordered, monitor and rotate IV lines regularly, and carefully assess the burn extent, body system functions, and the patient’s emotional status.
Early positioning after a burn is extremely important to prevent contractures. Careful positioning and regular exercise for burned extremities help maintain joint function and minimize deformity. When the extremities aren’t being exercised, they should be maintained in maximal extension, using splints, if necessary. Particular attention should be focused on the hands and neck because they are the most prone to rapid contracture.2 (See Positioning the burn patient to prevent deformity, page 100.)
Early excision and debridement of the wound in the first 48 hours has been shown to decrease blood loss and reduce the duration of the health care facility stay; however, this procedure should be used only on wounds that are clearly full-thickness burns.
Equipment
Normal saline solution ▪ sterile bowl ▪ sterile scissors ▪ tissue forceps ▪ ordered topical medication ▪ burn gauze ▪ roller gauze ▪ elastic netting or tape ▪ fine-mesh gauze ▪ elastic gauze ▪ cotton-tipped applicators or sterile tongue depressor ▪ ordered pain medication ▪ sterile gloves ▪ sterile gown ▪ mask ▪ surgical cap ▪ heat lamps ▪ impervious plastic trash bag ▪ cotton bath blanket ▪ 4″ × 4″ sterile gauze pad ▪ Optional: moisture chambers for eyes.
A sterile field is required, and all equipment and supplies used in the dressing should be sterile.
Preparation of Equipment
Warm normal saline solution by immersing unopened bottles in warm water. Gather equipment on the dressing table. Make sure the treatment area has adequate light to allow accurate wound assessment. Open equipment packages using sterile technique. Arrange supplies on a sterile field in order of use.
Implementation
Verify the doctor’s orders.
Confirm the patient’s identity using at least two patient identifiers according to your facility’s policy.3
Explain the procedure to the patient and provide privacy.
Assess the patient’s pain. If ordered, administer an analgesic to increase the patient’s comfort and tolerance levels. Oral analgesics should be given at an appropriate time before the procedure, depending on the medication’s onset and peak of action. An IV analgesic may be given immediately before the procedure.5
Turn on overhead heat lamps to keep the patient warm. Make sure that they don’t overheat the patient.
Pour warmed normal saline solution into the sterile bowl in the sterile field.
Removing A Dressing Without Hydrotherapy
Remove old dressing layers down to the innermost layer by cutting the outer dressings with sterile blunt scissors. Lay open the dressings.
If the innermost layer appears dry, soak it with warm normal saline solution to ease removal.
Remove the inner dressing with sterile tissue forceps or your gloved hand.
Dispose of the dressings in the impervious plastic trash bag, according to your facility’s policy, because soiled dressings harbor infectious organisms.
Burn Care at the Scene
By acting promptly when a burn injury occurs, you can improve a patient’s chance of uncomplicated recovery. Emergency care at the scene should include steps to stop the burn from worsening; assessment of the patient’s airway, breathing, and circulation (ABCs); a call for help from an emergency medical team; and emotional and physiologic support for the patient.
Stop the Burning Process
If the victim is on fire, tell him to fall to the ground and roll to put out the flames. (If he panics and runs, air will fuel the flames, worsening the burn and increasing the risk of inhalation injury.) Or, if you can, wrap the victim in a blanket or other large covering to smother the flames and protect the burned area from dirt. Keep his head outside the blanket so that he doesn’t breathe toxic fumes. As soon as the flames are out, unwrap the patient so that the heat can dissipate.
Cool the burned area with any nonflammable liquid to decrease pain and stop the burn from growing deeper or larger.
If possible, remove any potential sources of heat, such as jewelry, belt buckles, and some types of clothing. In addition to adding to the burning process, these items may cause constriction as edema develops. If the patient’s clothing adheres to his skin, don’t try to remove it. Rather, cut around it.
Cover the wound with a clean, dry, sheet or other smooth, nonfuzzy material.
Assess the Damage
Assess the patient’s ABCs, and perform cardiopulmonary resuscitation, if necessary. Then check for other serious injuries, such as fractures, spinal cord injury, lacerations, blunt trauma, and head contusions.
Estimate the extent and depth of the burns. If flames caused the burns and the injury occurred in a closed space, assess for signs of inhalation injury: singed nasal hairs, burns on the face or mouth, soot-stained sputum, coughing or hoarseness, wheezing, or respiratory distress. Also assess for signs of carbon monoxide poisoning: dizziness, nausea, headache, and seizures.
Call for help as quickly as possible. Send someone to contact the emergency medical service (EMS).
If the patient is conscious and alert, try to get a brief medical history as soon as possible.
Reassure the patient that help is on the way. Provide emotional support by staying with him, answering questions, and explaining what’s being done for him.
When help arrives, give the EMS a report on the patient’s status.
