The skin is the largest organ in the body and serves as a barrier to the outside environment. It helps regulate temperature and offers a pathway for the senses, physical protection, and immunity. It also plays a role in metabolism by supporting bone mineralization by producing vitamin D and other nutrients. Lastly, it is of aesthetic importance because it offers our unique appearance, which impacts our psychosocial well-being.

Several layers comprise the skin, each with specific properties and functions. The two main layers of the skin are the epidermis and the dermis. The term epidermis derives from the Greek words epi (“on top of”) and derma (“skin”). The epithelial layer is stratified and exhibits progressive differentiation from a basal to a superficial direction. This process of constant renewal occurs by elongation and eventual flattening of cells as they rise to form the outer epithelial layer. These cells can migrate from the wound edge onto the wound bed that remains clean and moist.

The dermis is comprised entirely of living cells. Oil/sweat glands rise to the surface to eliminate waste. Blood vessels provide nutrients to the dermis tissue, hair follicles, and nerve endings. The subcutaneous fat layer lies below the dermis, and muscle lies below the fat. Muscle tissue provides contour, cushion, and insulation for the body. All of these structures are held together by collagen. Therefore an insult to the skin, such as a burn, potentially disrupts the integrity of these structures.

A burn injury can be benign or result in a catastrophic sequela of events within the body. The severity of this insult depends on the depth of the burn, the extent of injury/total body surface area (TBSA), and the mechanism of action. These factors influence how burn nurses address the immediate needs of their patients during initial management and definitive care.

Burn nurses understand two classification systems categorize burns; one system describes the burn wound as first-, second-, third-, and fourth-degree burns; the other classification system further defines the burn depth as superficial, partial-thickness, and full-thickness burns. These classifications of the burn wound enable the bedside nurse to focus efforts on salvaging viable tissue. Determinants affecting the burn depth include the skin’s thickness. Thinner skin found in infants, pediatrics, and the elderly results in deeper burns with less contact time. Insight into these care management needs prevents burn wound conversion caused by improper wound care, infectious processes, and inadequate resuscitation. So how do these classifications correlate?

First-degree burns are superficial burns that involve the epidermis. This type of injury presents as red, painful, and mildly edematous. There is no fluid loss with a first-degree burn; therefore this area is not calculated in the resuscitation formula. Although these areas typically heal without needing treatment, burn nurses are acutely aware that first-degree or superficial burns evolve and can result in a more profound injury.

Second-degree burns characterize as superficial partial-thickness or deep partial-thickness injuries. These injuries involve the entire epidermal layer and varying depths of the dermal layer. Superficial partial-thickness burns present as intact blisters or sloughing tissue revealing a painful supple, pink, and moist wound bed that easily blanches. A deep partial-thickness burn often presents less elasticity with variations of pink, red, and white wound beds that are moist or dry with delayed or no blanching. These burns can damage nerve endings, hair follicles, and glandular tissue. Because of the fluid loss occurring with a partial-thickness injury, these areas are calculated in the resuscitation formula. In addition, an aggressive approach to wound management helps prevent further complications.

Third-degree or full-thickness burns involve the entire epidermis and dermis and can extend into the subcutaneous tissue. These burn injuries are inelastic with leathery and dry (eschar) areas, often exposing coagulated vessels, and have varying color formations of white, black, or charred, tan, and even bright red (caused by hemoglobin entrapped in the skin). If circumferential, these areas will need releasing with an escharotomy (a surgical intervention used to restore circulation). These areas are included in resuscitation calculations and require surgical interventions to prevent complications. In addition, the extent of damage inhibits spontaneous healing.

Fourth-degree burns are the most severe injuries involving the entire epidermis, dermis, and subcutaneous tissue and extending into underlying vessels, nerves, muscles, tendons, and bones. These areas require surgical interventions to release pressure in affected compartments with a fasciotomy—further surgeries to remove all nonviable tissues can further complicate the recovery trajectory. Not only does the depth of the tissue injury affect the care, but the extent of the burn injury also plays a significant role in caring for burn patients. ^,

The extent of burn injury relates to TBSA. There are three standard methods used to determine the patient’s TBSA. The most usual method is the rule of nines. This technique divides the body into increments of nine. For example:

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  In an adult, the head represents 9%.

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  Each arm represents 9%.

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  Each leg represents 18%.

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  The anterior and posterior torso represent 18% each.

These calculations look very different for infants and pediatric patients because their heads have larger surface areas. For example, an infant’s head represents 18%, and the legs represent 14% each. As the child ages, typically every 1.5 years, clinicians subtract 1% from the head and add 0.5% to each leg until the child reaches adult calculations at around 14 years of age. Another widely used method is the palmar method. This method uses the patient’s palm (including fingers and thumb) to represent 1%. This method is valuable when calculating nonconfluent burns.

Burn centers use the Lund and Browder diagram as the gold standard in calculating TBSA because it accounts for age-specific nomograms, providing a more definitive burn diagnosis. ^, The mechanism of injury is another component dictating care.

The mechanism of injury provides insight into impending problems the patient may encounter and enables bedside burn nurses to anticipate actions to improve patient outcomes. Types of burns include thermal, smoke inhalation, chemical, electrical, radiation, and cold injuries.

A thermal injury occurs when the skin comes in contact with fire, hot surfaces, hot liquids, or steam. The degree of tissue injury depends on the temperature and duration of exposure to the heat source. For example, at 155°F (68°C), the exposure time resulting in tissue damage is less than 1 second. Locally, the exposure immediately destroys cells, which in turn destroys the metabolic function of cells. However, this death does not occur uniformly; some cells die instantly, some are irreversibly injured, and others may survive with rapid and appropriate intervention. These affected areas are known as the Jackson zones of injury.

This theory categorizes the cutaneous burn injury into three distinct areas or zones that are readily identifiable as a bull’s-eye pattern:

• 1.

  Zone of coagulation . Typically, this is the centermost part of the bull’s-eye pattern. Full-thickness loss and coagulated blood vessels characterize this area. The tissue in this sphere is nonviable, signifying the area with the most prolonged contact with the heat source.

• 2.

  Zone of stasis . This area is labile, characterized by inflammation associated with decreased blood flow. This area may survive with appropriate treatment, but it converts with inadequate resuscitation or infection.

• 3.

  Zone of hyperemia . This is the most peripheral zone. Increased blood flow with limited inflammation characterize this area, which will likely heal without further complications.

An inhalation injury becomes suspect if the burn occurs in an enclosed space. When suspected, 100% oxygen via a nonrebreather mask is administered unless intubation is necessary. Three main categories encompass inhalation injuries: injury above the glottis, injury below the glottis, and systemic poisons. Injury above the glottis is thermal and results in potential upper-airway edema, causing the closure of the airway. Signs and symptoms prompting immediate intervention include singed facial hair (not alone but in addition to), stridor, hoarseness, tachypnea, inability to speak in complete sentences, and use of accessory muscles. Subglottic injuries from chemical byproducts are associated with prolonged exposure and inhalation of byproducts found in smoke (e.g., aldehydes, phosgene, ammonia), resulting in a genuine lung injury. Patients require intubation typically because of increased secretions, inactivation of ciliary function, ulcerations, and carbon deposits. ^, These deposits can form fibrin casts blocking small airways and impairing gas exchange. Other forms of inhalation injury include systemic poisons, such as carbon monoxide poisoning and cyanide poisoning.

Carbon monoxide is an odorless gas with a 200 times greater affinity to the hemoglobin molecule than oxygen. Carbon monoxide causes hypoperfusion of the brain, resulting in varying neurologic symptoms. When carbon monoxide is suspected, clinicians order a carboxyhemoglobin (COHb) level. The higher the COHb level, the more severe the neurologic symptoms are. Levels greater than 20 are associated with severe symptoms. Carbon monoxide binds with hemoglobin, impairing oxygen delivery to the tissues. The treatment for carbon monoxide poisoning is 100% oxygen. Bedside burn nurses should remain acutely aware that cyanide poisoning may also be present, along with carbon monoxide poisoning. ^,

Cyanide is a rapid systemic poison that causes cellular hypoxia and depletion of adenosine triphosphate, leading to metabolic acidosis. Patients with cyanide poisoning exhibit tachypnea and tachycardia in the early stages, followed by hypotension and bradycardia, manifesting cardiac failure in the late stages, along with neurologic symptoms consistent with carbon monoxide poisoning. Lab values highly suggestive of cyanide toxicity include the following:

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  High COHb level

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  Lactic acid level greater than 8 mmol/L (despite resuscitation)

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  High anion gap

Patients with cyanide poisoning do not respond to conventional treatment, so clinicians must treat them based on suspicion. Although clinicians will order a cyanide level, obtaining results often includes significant lag times. Most hospitals cannot complete cyanide testing, warranting a referral to an offsite lab. Treatment includes 5 g intravenous (IV) hydroxocobalamin over 15 minutes. Hydroxocobalamin binds with cyanide, forms cyanocobalamin, and is excreted through the kidneys, turning the urine red. Patients may also have a cherry red appearance without cutaneous burns; otherwise, this may be difficult to assess in extensive TBSA burns.

Chemical burns cause progressive tissue damage until the chemicals are deactivated. The most common chemicals fall under three main categories: acids, alkalis, and organic compounds. Factors affecting the extent and depth of injury include chemical composition, concentration, contact duration, and TBSA. Initial management principles include airway management, brushing off the powder chemicals, irrigating with copious amounts of water to stop the burning process, identifying the agent if possible, replacing intravascular volume, and maintaining normothermia. ^,

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  Acids (pH <7)

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    Acids cause damage by coagulation necrosis and protein precipitation, resulting in a leathery eschar that helps limit penetration deep into the tissue. They are found in bathroom cleansers and rust removers (e.g., hydrochloric acid, oxalic acid, phosphoric acid).

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    Hydrofluoric acid is weak but has a toxic fluoride ion that binds with free calcium in the blood. It can result in severe hypocalcemia, cardiac dysrhythmias, and death. We must provide another calcium source to attach to; otherwise, the chemical continues to cause tissue damage. They are used to cleanse metals. Treatment includes irrigation with water, then topical calcium gel or calcium infusions.

  • Pediatric pearls:

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      Any pediatric exposure to hydrofluoric acid is considered an emergency.

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      Hypocalcemia onset is rapid and severe.

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      Oral ingestion is often fatal.

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      Cal-Brite (air conditioner [A/C] coil cleaner) is pink, which is hydrofluoric acid; it looks exactly like amoxicillin. Nu-Brite (A/C coil cleaner) is blue, and this one is an alkali.

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  Alkalis (pH >7)

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    Alkalis cause tissue damage by liquefaction necrosis and protein denaturation; these chemicals melt any tissue in its path, resulting in the deeper spread of the chemical and quicker burn progression. Oven, drain, and toilet bowl cleaners consist of alkali agents. Calcium hydroxide, wet cement, is a strong alkali. Anhydrous ammonia is another alkali that can cause damage.

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  Organic compounds: petroleum products, phenols, creosote

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    Organic compounds cause cutaneous damage by dissolving fat in cell membranes. Once absorbed, it can harm multiple organs, including the kidneys and liver. ^,

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  Chemical injuries to the eyes

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    Chemical injuries to the eyes cause severe lacrimation, conjunctivitis, and progressive damage to the cornea, which can lead to blindness. Patients with chemical injuries to the eyes typically present with swelling and spasms of the eyelids. Alkalis are often associated with criminal assaults. Water or saline irrigation is the emergency treatment of choice and helps minimize tissue damage. It is imperative to consult ophthalmology on all chemical injuries to the eyes.

Electricity causes damage from the body’s conduction from current flow, arc flash, secondary ignition of clothing, thermal contact burns, and associated injuries. Two types of electrical currents are direct and alternating. Factors affecting the extent and depth of damage include the type of current, voltage, duration of contact, current pathway, thermal injury from secondary ignition of clothes, and concomitant injuries. Initial management principles include stopping the burning process, airway management, cardiac monitoring, Advanced Cardiac Life Support protocol if indicated, evaluating for multiple contact points with high voltage replacing intravascular volume, assessing perfusion and compartment pressures to determine whether an intervention is required, and maintaining normothermia.

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  When a victim encounters an electrical current, the flexor muscles contract, causing the hands to clench and maintain contact with the electrical source. Low-voltage electricity causes few physical findings, but the delayed onset of migratory pain, neurologic findings, and psychological effects can be debilitating. High-voltage current heats tissues immediately, resulting in deep-tissue necrosis, which may not be visible other than the charred contact points. Findings suggesting electrical conduction injury include:

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    Loss of consciousness

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    Paralysis or mummified extremity

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    Loss of peripheral pulses

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    Surface burns occurring in flexor regions (antecubital, axillary, inguinal, and popliteal burns)

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    Myoglobinuria

  • Burn nursing pearls :

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      With high-voltage electrical burns, look for areas of thermal burns under rings, belts, and contact points in the scalp (even with intact hair), behind their ears, between fingers and toes, in their axillae, and between buttocks.

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      As body piercings have become more acceptable, patients should be evaluated closely for hidden piercings that could have a significant injury.

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      Assess for blood in the mouth (may result from the patient biting the tongue in high-voltage injuries).

Very low radiation levels are found within our environment, constantly exposing every person to some level. This exposure increases when there is proximity or exposure to x-ray machines and computed tomography scanners. Exposure during treatment from any of these machines can result in radiation injury. Other radiotherapy devices contain highly radioactive elements that can also create radiation injury.

Of course, there is also the possibility that masses of people may suffer radiation injury and exposure should there ever be an attack from a nuclear weapon or a nuclear spill or leak. The most important thing for a bedside burn nurse to remember when treating a victim of radiation exposure is to protect oneself. Using personal protective equipment (PPE) helps prevent skin contamination with any radioisotope.

A Geiger-Muller counter is the most helpful instrument after a radiation accident. It allows the caregiver to immediately detect contaminated sites and helps determine the efficiency of decontamination. However, it does not determine the total dose of radiation.

All patients should be treated as potentially contaminated until being scanned with a Geiger-Muller counter. These are available in most radiology departments. If the scan is negative, then the patient does not require external decontamination.

The burn nurse should obtain a thorough history to determine the level of contamination. Rapid removal from the area is necessary if being treated at the scene. Immediate decontamination, including removing possible contaminated clothing and thoroughly irrigating all affected areas with water, should be the priority. This irrigation should continue until a survey with a radiation detector indicates minimal residual radiation or at least a steady-state condition.

Strict adherence to facility protocols must be reinforced, along with periodic radiation training and skill checkoffs, to ensure each member of the burn team understands their own responsibility and role in the event of this type of incident.

Exposure to a cold environment without proper protection can result in cold injuries that can be severe. Also referred to as frostbite, the extent of these injuries may require amputation, but a more significant issue could be systemic hypothermia, which can be rapidly fatal. Therefore restoring normothermia must occur first; then, the focus can shift to treating the cold injury. Heat injuries create a different sequela from cold injuries, so the approach to care must be different.

The bedside burn nurse must understand the pathophysiology of hypothermia. Initially, the patient may feel a generalized cold sensation with uncontrollable shivering. After this, confusion, lethargy, and impaired coordination of body movements may ensue. As the core temperature drops, shivering stops, and the patient grows somnolent with respiratory depression and profound bradycardia. Death results from hypoventilation and systolic cardiac arrest. Hypovolemia is present as even mild hypothermia creates diuresis, and volume may decrease rapidly. Noting a brisk urine flow should not be an adequate indicator of hypovolemia. Stabilization in the initial resuscitation phase is key.

Initially, clinicians must assess and intervene with life-threatening complications related to airway patency, breathing, circulation, disabilities, and exposure. Ensuring the patient has and maintains a patent airway is vital in airway management. Evaluate for upper-airway compromise in patients with deep facial burns, carbonaceous material around the nose and mouth, singed facial hair, red oral mucosa, vomit, blood, loose teeth, and stridor and hoarseness because these can indicate upper-airway swelling.

For patients burned in an enclosed space with suspected inhalation injury, they should be placed on 100% nonrebreather and continuously reassessed. C-spine immobilization must be maintained until cleared.

For patients’ breathing, assess rate, rhythm, and depth of respirations; symmetric equal chest excursion; and equal breath sounds upon auscultation. Elevate patients’ head of bed (unless contraindicated) and promote deep breathing and coughing. If patients are anxious, tachypneic, using accessory muscles, or have a decreased level of consciousness, then assess their need for further interventions. If respiratory deterioration or airway patency changes occur, the burn nurse must alert clinicians for intubation.

Once intubated, use a landmark not affected by swelling to measure the depth of the endotracheal tube (ETT), such as the teeth or gumline. All ETTs must be secured with a commercial device or cloth tape circumferentially around the head because the adhesive tape will not adhere to facial burns, so burn nurses must continuously assess and reassess ETT placement.

• Burn nursing pearls:

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    Other factors affecting the airway and breathing are the need for large resuscitation fluid volumes and circumferential full-thickness burns to the torso.

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    Full-thickness burns to the torso can impede ventilation, warranting escharotomies.

• Pediatric pearls:

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    Pediatric patients have small cone-shaped, easily occluded airways.

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    Pediatric patients with an ETT should have a two-point securement device circumferentially around the head.

When assessing burn patients’ circulatory status, nurses should expect them to have a heart rate ranging from 100 to 120 beats per minute. The elevated heart rate is caused by the massive release of circulating catecholamines and increased capillary permeability. The increased capillary permeability results in plasma seeping from the vasculature to the interstitial space, which can cause edema formation; therefore prehospital IV fluids should continue until calculating the TBSA in the secondary survey.

Lactated Ringer’s solution is the fluid of choice because it most mimics fluid loss. Administer this fluid through two large-bore IV lines until more definitive access can be obtained. Elevate circumferentially burned extremities to relieve edema formation. Nursing responsibilities for all circumferential, partial-thickness, and full-thickness burns require hourly pulse checks. Full-thickness circumferential burns impede blood flow to extremities, warranting escharotomies.

Next, assess for disabilities by evaluating patients’ neurologic status. AVPU (alert, response to verbal stimuli, response to painful stimuli, or unresponsive) determines responsiveness. Assess pupils to ensure they are equal and reactive to light. Assess extremities for movement. Expose patients and assess for any concomitant trauma needing immediate attention. Once stabilization occurs, the nurse can move to the secondary survey.

The secondary survey consists of obtaining a complete history (allergies, medications, past medical history, last meal, and tetanus status), head-to-toe assessment, vital signs, determining the %TBSA, insertion of an indwelling urinary catheter, obtaining baseline labs and initial radiographic studies, treating pain and anxiety, and initial wound care. Once a thorough head-to-toe assessment is complete, the burn severity is assessed, including the depth, areas affected, and the extent of the burn injury. This information enables the multidisciplinary team to determine adjusted fluid needs.

Fluid resuscitation is an art and poses unique challenges for the burn nurse. These challenges result from an insensible fluid loss at the injury site, increased capillary permeability, and a massive release of inflammatory and vasoactive mediators resulting in a systemic response. If not treated initially, the cascade of events leads to hypovolemia, cardiac depression (loss of preload), and increased intravascular resistance resulting in burn shock.

The most commonly used formula for fluid resuscitation is the consensus formula: 2 to 4 mL/kg/%TBSA with one-half of the volume given over the first 8 hours and the remaining volume given over the next 16 hours.

• Pediatric pearls:

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    Children under 30 kg require the addition of maintenance fluids; the fluid of choice is 5% dextrose in lactated Ringer’s solution.

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    Use of the 4-2-1 formula is commonly used to achieve a maintenance fluid rate, which is not titrated.

Most centers use nurse-driven fluid protocols. These nurse-driven protocols outline specific monitoring parameters for IV fluid adjustments, such as urine output and labs, including arterial blood gas (ABG), complete blood count, lactic acid, basic metabolic panel, prothrombin time, partial thromboplastin time, and fibrinogen. Advanced hemodynamic monitoring (central venous pressure, cardiac output and cardiac index, stroke volume [SV]/SV variation/SV index, systemic vascular resistance) provides additional guidance for fluid titration. Because of fluid shifts and edema formation, initiation of intraabdominal pressure monitoring often occurs.

Urine output goals vary. Adults and teens should have urine output of 0.5 ml/kg/h, and pediatric patients less than or equal to 30 kg should have 0.5 to 1 mL/kg/h. In contrast, all high-voltage electrical burns with evidence of myoglobinuria should have 1 to 1.5 mL/kg/h.

Because no superior parameter is used to monitor resuscitation, burn nurses manage and adjust patients’ IV resuscitation based on a culmination of data. The resuscitation formula is a guide only used as a starting point. Burn nurses must understand the need for specific baseline labs to identify trends to assist resuscitation titration.

Specific laboratory components used during resuscitation are hemoglobin and hematocrit (patients often present with hemoconcentration from plasma seeping from the intravascular area to the interstitial space), base deficit (if extremely negative, associated with global hypoperfusion and dehydration), lactic acid (high levels indicate tissue hypoperfusion), and pH and HCO ₃ (can signify metabolic acidosis in patients requiring more resuscitation fluid). Physician notifications throughout the nurse-driven protocol ensure physician awareness of patients’ clinical response.

The rationale for physician notification is to protect the patient from developing complications associated with fluid resuscitation. Evidence supports this practice as timely titrations prevent complications from over- and underresuscitation.

Overresuscitation increases patients’ risk of developing orbital, extremity, and abdominal compartment syndrome from diffuse tissue edema. Interventions addressing these complications include monitoring hourly urine output, hourly pulse checks, and optimal positioning to minimize edema formation by elevating the head of the bed and extremities and trending labs. Additional measures include initiating colloids, intraabdominal pressure monitoring, and starting continuous renal replacement therapy (CRRT).

Not only does overresuscitation present challenges, but underresuscitation can also be detrimental, resulting in wound conversion, acute renal failure, and even burn shock. Strategies to prevent these complications include early initiation and continual monitoring of resuscitative efforts and nurse-driven fluid protocols, as these have significantly decreased inconsistencies with underresuscitation.

Other care considerations during the secondary survey include the placement of a nasogastric tube for intubated patients, urinary catheter placement, and continuous monitoring of extremities with circumferential full-thickness burns. In addition, the development of ventilatory compromise remains high in patients with circumferential torso burns, warranting close monitoring.

Clinicians will perform a bronchoscopy to assess airway and lung-tissue damage in ventilated patients with suspected inhalation injuries. This diagnostic is done shortly after admission and as needed to remove carbonaceous material and thick secretions to promote optimal oxygenation. Vent management for these patients involves placing them on various modes of ventilation. The most common ventilator mode is assist-control with low tidal volume (6–8 mL/kg). However, the respiratory therapist manages the ventilator; the burn nurse must be able to readily identify and appropriately assess common issues and situations associated with mechanical ventilation, including ETT management such as dislodgement, obstruction related to excessive secretions, intermittently suction to remove excess secretions and mucus, troubleshooting vent alarms, and interpreting ABGs. These skill sets are imperative for the burn nurse who is continuously at the bedside of these patients. In addition, recognizing subtle and obvious signs of deterioration provides the nurse with objective data to promptly collaborate with the multidisciplinary team and care for these patients.

Heat loss in the acute phase occurs from convection, evaporation, radiation, and conduction. Maintaining patients’ temperature is a priority. In burn patients with thermal injuries of 20% TBSA or greater, the loss of skin reduces blood flow to the damaged tissue and deepens the burn depth. Systemic complications occur at core temperatures less than 95°F (35°C), such as ventricular arrhythmia, respiratory depression, coagulopathy, and loss of peripheral vasomotor tone.

Keeping the ambient temperature at or above 85°F assists in maintaining normothermia. When environmental warming is insufficient, implementing other measures is indicated. Noninvasive warming measures include heated ceiling tiles, Bair Huggers, fluid warmers, and heating blankets. Other invasive adjuncts may be required. Invasive measures include esophageal warming probes and central venous heat exchange systems. Maintaining normothermia is extremely challenging during the initial burn wound cleaning and evaluation.

Burn patients are at an increased risk of infection. The goal during the initial cleaning is to remove nonviable burn tissue and any other debride on the skin/hair. The initial cleaning includes washing burns on the face with mild soap (avoiding the eyes) and burn areas to the rest of the body with a diluted chlorohexidine solution. Next, rinse these areas with either a filtered or sterile water system. Nurses must also wash nonburned regions because soot is often present. After completing the initial cleaning, swabbing with a chlorohexidine wand provides added antimicrobial coverage. Once these areas dry, wrap patients in sterile gauze to provide protection. Most centers moisten these dressings with a prescribed antimicrobial solution. If patients are at risk for hypothermia, another option is to apply polyhexamethylene biguanide–impregnated gauze to all areas except the face.

Before and during wound care, medicate patients for anticipatory and procedural pain. IV pain medication is the best route. Burn nurses are acutely aware that anxiety can exacerbate pain, so they advocate treating anxiety with IV benzodiazepines.

• Pediatric pearl:

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    Because of the larger surface area–to-weight ratio, small infants lose heat more rapidly than adults; they cannot shiver and rely on nonshivering thermogenesis by metabolizing brown fat for heat production.

• Burn pearl:

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    Patients with less than 5% TBSA burn are at little to no risk of developing hypothermia resulting from the burn injury.

Completing the primary and secondary survey components for the seasoned burn nurse occurs seamlessly. It is second nature to anticipate, adapt, and intervene to maintain stability and improve patient outcomes.

Patient conditions warranting urgent interventions are the presence of circumferential full-thickness burns to the torso and extremities. As fluids shift and edema forms, escharotomies are necessary to prevent further complications because full-thickness burns act as a tourniquet as the eschar tissue loses its elasticity, impeding the blood flow essential for perfusion. In full-thickness burns of the torso, nurses will notice difficulty bagging the patient, inability to obtain tidal volumes on the vent, and increased peak airway pressures.

Full-thickness burns to extremities result in pain, pallor, paresthesia, paralysis, and a decrease or absence of distal pulses. If these assessment findings occur, then the bedside nurse should immediately collaborate with the providers to set up for escharotomies.

• Burn pearl:

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    Supplies include sterile gown and gloves, betadine or specified prep solution, application of grounding pads, sterile cauterizing pens, and setup of the electric cautery machine.

If the escharotomy is successful, patients with circumferential torso burns will exhibit a decrease in peak airway pressures and an increase in tidal volumes. Patients with extremity escharotomies will experience the return of pulses and capillary refill. Burn nursing responsibilities include monitoring for incisional bleeding and continuing to elevate extremities to reduce further edema formation. Clinicians may cover escharotomy incisions with a biologic dressing or opt for just kerlix moistened with a prescribed solution. Application of dressings will decrease the risk of infection.

• Burn pearl:

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    When the extent of the burn injury involves the muscle compartment, this depth injury necessitates a fasciotomy achieved with the same equipment.

Not only are nurses focusing on burn management principles needed during the initial phase, but recognizing nonaccidental burns is also essential. Burn nurses must consider the possibility when caring for vulnerable populations such as the elderly, disabled, and pediatrics. In addition, burns can be a means of covering up abuse-related injuries. Scalds are young children’s most common cause of nonaccidental burn trauma. Signs of nonaccidental burns include but are not limited to the following: the story not matching the injury, symmetric pattern, uniform depth with lines of demarcations, marks of household appliances, delayed care, and infected burn wounds. Physical signs of nonburn trauma include but are not limited to depressed fontanelles in infants, fractures, dislocations, abdominal tenderness, dehydration, or malnutrition.

Psychosocial aspects indicative of nonaccidental burn trauma include:

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  History being incompatible with examination findings

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  A child who is passive, introverted, and fearful

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  Lack of parental concern

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  Unrelated adult presenting the child

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  A child who is already involved with social services

Nurses should always collaborate with the provider to obtain a detailed history, examine the patient, photograph injuries, and interview parents and caregivers individually. Completion of ordered labs and diagnostic studies is essential in early management. In cases of suspected nonaccidental trauma, case managers notify the appropriate authorities. Documentation (including photographic images) provides substantial evidence for authorities to act on the patient’s behalf. All health care team members play a vital role in ensuring a safe discharge plan.

Burns of 20% TBSA or greater trigger a release of massive amounts of catecholamines and inflammatory mediators, resulting in an immunologic derangement. This systemic response leads to multiorgan dysfunction or failure lasting for months, even years, following a catastrophic burn injury. Therefore burn nurses must be mindful of these changes and adapt interventions as needed.

The respiratory system is affected by direct thermal damage (upper-airway edema), inhalation of toxic chemicals (lower-airway injury), and carbon monoxide/cyanide poisoning. It is essential to recognize that cyanide poisoning necessitates the infusion of IV hydroxocobalamin. Other mechanisms affecting the lower airway can manifest complications, including excessive secretions, alveolar damage, and pulmonary edema.

These pulmonary changes necessitate the need for intubation. For patients on the ventilator, burn nurses preemptively elevate the head of the bed, perform inline suctioning, and promote early mobility to mobilize secretions. ^, These maneuvers help decrease the sequelae of events associated with ventilation, such as ventilator-associated pneumonia and acute respiratory distress syndrome.

Cardiovascular effects result from a release of catecholamines (norepinephrine, dopamine, and epinephrine) and inflammatory mediators (cytokines, histamine, nitric oxide, tumor necrosis factor [TNF]). This systemic surge leads to tachycardia, increased capillary permeability, and massive fluid shifts resulting in decreased preload, cardiac output, and low mean arterial pressures. If left untreated, burn shock ensues; therefore adequate fluid resuscitation is vital in the acute phases to ameliorate the potential for burn shock.

Renal system effects are secondary to decreased cardiac output, leading to decreased renal perfusion and acute kidney injury. Deep thermal injuries and high-voltage electrical injuries release damaged red blood cells (releasing hemoglobin molecules) and skeletal muscle cells (releasing myoglobin), causing red-brown pigmented urine leading to renal failure. Bedside nurses recognize that decreased or pigmented urine necessitates increasing resuscitation fluid. Initiating CRRT may need to be implemented for renal protection.

The neurologic system is affected by systemic poisons. These poisons cause decreased perfusion to the brain, leading to short- and long-term deficits. Other neurologic management aspects include pain control, sedation, and delirium management. Burn nurses recognize the need for a multimodal approach to pain and anxiety and address complex psychological needs related to acute stress and posttraumatic stress disorder (PTSD).

The gastrointestinal system effects result from a disruption of the intestinal epithelial barrier causing intestinal permeability and leading to the translocation of bacteria. Patients are also prone to developing Curling ulcers caused by decreased mucous production. In addition, the colon can become edematous with increased resuscitation requirements resulting in intraabdominal compartment syndrome. Therefore nurses provide stress-ulcer prophylaxis, initiate intraabdominal pressure monitoring, and begin nutrition supplementation when hemodynamically stable. ^,

The endocrine system effects occur from a massive release of stress hormones, such as cortisol, leading to insulin resistance. In addition, hypermetabolism causes metabolic rates to exceed twice the typical rates, leading to catabolism. To combat these effects, burn nurses must maintain blood glucose levels of less than 180 and initiate early nutrition v ia the oral, gastric, or postpyloric route. ^,

The musculoskeletal system effects also occur from hypermetabolism, resulting in muscle wasting. Other aspects affecting the musculoskeletal system include burn scars and contracture formation.

• Burn pearl:

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    The institution of early nutrition is instrumental in mitigating the effects of hypermetabolism, whereas early mobility, splinting, and pharmacologic adjuncts, such as oxandrolone and pressure garments, enhance musculoskeletal recovery.

• Pediatric pearl:

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    Pediatric patients can experience bone-growth delays for up to 2 years postinjury.

The hepatic system effects are variable and based on the severity of the burn injury. A severe burn affects vitamin metabolism and hormone synthesis and alters the coagulation cascade. Decreases in antithrombin III and proteins C and S increase the risk of thrombosis, whereas the risk of developing disseminated intravascular coagulation heightens because of this hypercoagulable state. Therefore burn nurses understand the need to replace vitamins and administer heparin and clotting factors as needed.

Burn patients have a high susceptibility to developing infectious processes and sepsis. Sepsis manifests in burn patients through changes in their temperature, progressive tachycardia, thrombocytopenia, hyperglycemia, feeding intolerance, and documented infection. Early excision and grafting have been instrumental in decreasing the incidence of sepsis and wound infections. Nurses also play a vital role in infection prevention, reducing associated complications.

Infection prevention principles include limiting unnecessary traffic, preventing hypothermia by maintaining ambient room temperatures, enforcing stringent hand hygiene, using nonpermeable PPE during all patient encounters, and providing aseptic wound care at the bedside. It is also crucial to have robust infection prevention programs and staff engagement to prevent hospital-associated conditions.

Central line–associated bloodstream infection prevention includes using central line bundles for insertion, using chlorohexidine-impregnated dressings over central lines through intact skin, using silver-impregnated dressings over central lines placed through burn tissue, scrubbing the hub, and performing standardized line maintenance.

Essential catheter-associated urinary tract infection prevention includes stringent cleansing practices and nurse-driven catheter removal protocols. Some centers using silver-impregnated urinary catheters.

Ventilator-associated pneumonia prevention is vital. Most centers institute early mobility protocols, sedation vacations, spontaneous awakening and breathing trials, and other adjuncts to assist with pulmonary toileting.

As the primary caregiver at the bedside, the burn nurse holds a substantial responsibility in contributing to the care and management of the burn wound throughout hospitalization. Therefore the burn nurse needs to understand the phases of burn wound healing to understand better, anticipate needs, and plan care accordingly.

Burns are unique from other types of wounds. For instance, systemic inflammation is more significant in a burn injury than a chronic wound. Though the stages are similar, the physiologic characteristics manifest differently for each. The three phases a burn transitions through are the inflammatory, proliferative, and remodeling phases.

An initial immune response characterizes the inflammatory phase. This results from localized vasodilation and fluid extravasation as neutrophils and monocytes are recruited to the injured site, thus helping prevent infection during the healing process—edema results from leaking capillaries. Also during the inflammatory phase, necrotic tissue is degraded and engulfed by macrophages.

As this phase progresses, there is an overlap with the proliferative phase. Its name indicates that rapid cell growth and change characterize this phase. Cytokines and growth factors activate keratinocytes and fibroblasts. The keratinocytes migrate over the wound bed to assist in the closure and restoration of the vascular network, which is a vital step in the wound-healing process. The final phase is the remodeling phase, where scar maturation occurs. As collagen and elastin are deposited and continuously reformed, the transition of the cell types occurs, and wound contracture occurs. This transitioning and changing of fibroblasts to myofibroblasts ultimately determine the scar’s pliability once it matures. For final wound healing to occur, there must be modulation between the process of apoptosis of keratinocytes and inflammatory cells, which also contributes to the overall final appearance of the wound.

Decades ago, early excision and autografting were introduced as an approach to burn wound management. For most of what we know historically about burn wound management, nonsurgical interventions were the standards of care before this new method. Early excision and surgical debridement decrease the risk of blood loss, infection, length of hospital stay, and mortality and increase graft take. This aggressive approach to burn wound management soon evolved into the standard of care most burn clinicians practice today.

Split-thickness skin grafting is the gold standard for burn wound closure and offers the most timely and permanent option for coverage available.

Patients with more extensive burns and limited donor availability may require temporary coverage to prepare the wound bed better to receive a graft. Options for this include allografts (tissues taken from another human, either living or deceased) and xenografts (tissues taken from another species).

Various products, techniques, and approaches to finalizing burn wound closure have also evolved over the past few decades. For example, the use of cultured epidermal products, dermal templates, synthetic materials, and, more recently, autologous suspension of keratinocytes have broadened the capability of the burn surgeon to close the burn wound more rapidly and definitively while, at the same time, sparing donor skin. Also in recent development is the integration of stem cells and growth factors into products that promote revascularization, another critical component of burn wound healing.

Burn nursing care of patients receiving any of these treatments requires an in-depth understanding of the product used, knowledge of the action of the product’s components, and their effect on burn wound healing. This knowledge allows the nurse to proactively anticipate patients’ needs related to their burn wound and how to maintain the burn wound dressing best.

Various materials and topical agents are available and are used in varying degrees by many burn centers. However, some centers still use a great deal of silver sulfadiazine cream and mafenide acetate cream with gauze, while other centers use silver contact layers or gels.

Other dressing options, such as hydrogels, hydrocolloids, collagen-based dressings, foam, silver, and other antimicrobial-coated and-impregnated dressings, as well as cell-based therapies, are among the many options for burn wound treatment. In addition, adjunctive therapies, such as negative-pressure wound therapy (NPWT) and hydrosurgical debridement and cleansing, have migrated into the burn wound armamentarium of care. It is incumbent on bedside nurses to understand all these burn wound treatment options and learn what responsibility they bear to administer them within their practice.

The immediate postoperative time point is a crucial one for the bedside burn nurse. The nurse must look for many assessment findings and remain aware until the patient stabilizes. In addition, the nurse should anticipate that the patient will be cold, so implement warming measures immediately upon returning to the room (i.e., warming blankets, overbed warmers, warm IV fluids, and keeping ambient temperature higher than normal). The goal of care is to keep the patient from shivering. Shivering increases energy expenditure and wastes calories needed for healing.

Also, with warming, peripheral capillaries will begin to ooze, so some bleeding is to be expected. In some cases, a bleeder may erupt. If not thoroughly cauterized, a tiny vessel may bleed or burst open once warming occurs. Regardless, the bedside burn nurse must be alert to excessive bleeding and address the issue accordingly. Sometimes, light pressure held on the area for a time will allow the bleeding to subside. Other times, if it remains persistent, the surgeon should be contacted.

Understandably, the patient will be in some amount of pain, so the bedside burn nurse should anticipate the need for pain medication. Close monitoring of nonventilated patients for any signs of respiratory depression is required. Oxygen supplementation and even a narcotic antagonist must be readily available.

The burn nurse must gauge response to pain medication and document according to facility requirements. Use of restraints may be necessary immediately postop if the patient is combative or confused so that lines of access or other indwelling tubes are protected. It is essential to notify the physician if this is an issue and provide proper orders and documentation to restrain the patient.

The burn nurse must closely monitor vital signs to rule out any signs of hypovolemia or impending shock, and monitor urine output with consideration for all fluids or medications received in the operating room. The nurse must monitor oxygen saturation continuously and treat symptoms of fluid overload or respiratory depression immediately.

Donor sites immediately postop are moist, tender, and may bleed. Therefore protecting the dressing and managing the level of exudate are of utmost importance.

Treating donor site pain should be an urgent consideration immediately postop. As the donor site heals, it may become tight and pruritic. If located on an extremity and the patient becomes upright to ambulate, blood often rushes to the site and can become a very dark purplish color. It is necessary to explain that this is only temporary caused by the extremity being in a dependent position. As the donor site heals, it is important to keep it well moisturized.

In rare cases, donor sites may convert to a deeper wound if they become infected or do not heal. Donor site conversion requires further surgery and very likely skin grafting to achieve final closure. Other complications the bedside burn nurse may be vigilant toward are hematomas beneath skin grafting, which could separate the graft from the wound bed, and areas of pressure resulting from splinting or improper positioning can all result in graft failure. In addition, sheer and friction can result in graft loss when positioning the patient in bed or transferring to a chair or bedside commode. Again, the bedside burn nurse is the first line of defense in mitigating these complications.