Learning Objectives
By the end of this section, you will be able to:
- Discuss the incidence and prevalence of burn injuries
- Discuss the pathophysiology, risk factors, and clinical manifestations of burns
- Describe the diagnostic tests used and laboratory values observed for burn injuries
- Apply nursing concepts and plan associated nursing care for the patient with burns
- Evaluate the efficacy of nursing care for patients with burns
- Describe the medical therapies that apply to burn injuries
A burn is an injury to the skin from heat or chemicals. It can occur due to a variety of reasons, including hot liquids, electricity, fire, or heat or sun exposure. Depending on the type and severity of the burn, a patient can have life-threatening or serious complications, such as secondary infections, hypovolemia, hypothermia, and sepsis. As a nurse, you must understand the different types of burns, assessment techniques, and appropriate nursing care.
Incidence and Prevalence
As of 2023, the World Health Organization estimated that, globally, approximately 180,000 deaths occur every year from burn injuries (World Health Organization, 2023). The American Burn Association reported in their 2018 update that approximately 486,000 burn injuries occur every year in the United States (American Burn Association, 2018). Thermal injury is the main cause overall, accounting for 86% of burns, whereas electrical (4%) and chemical (3%) burns make up only a small portion of burn injuries.
Injuries from flames and scald burns are the most common across the population. Flame burns are more common in adults; children (aged <5 years) are more likely to suffer scald injuries. Notably, burn occurrences disproportionately affect individuals from low- and middle-income backgrounds, particularly in regions with fewer economic resources (Schaefer & Szymanski, 2023).
Severity and Survival
Burns can range from minor to severe, with the mortality rate increasing along with the severity of the burn. Mortality ranges from 3% to 55% with more severe burns leading to death. For adults, severe burns are usually those that cover more than 20% of the body or total body surface area (TBSA). For children, a burn covering more than 10% of their TBSA is considered severe (Gauglitz & Williams, 2023).
All burns must be thoroughly assessed to determine thickness, the percentage of TBSA involved, and if there are any life-threatening complications. Methods of calculating TBSA are discussed later in this chapter. Nurses should follow the ABCDE assessment method when initially triaging and caring for a burn patient. The ABCDE method stands for (in order of priority):
- Airway: patency
- Breathing: oxygen saturation and respiratory rate
- Circulation: blood pressure, heart rate, and fluid resuscitation
- Disability: neurological status
- Exposure: temperature
For burns, ABC, followed by fluid resuscitation, take priority. More about the ABCDE can be found in the Chapter 33 Emergency Care chapter. For example, when using this method, the nurse would prioritize airway assessment and management ahead of any issues with circulation.
There are specialized burn injury hospitals and facilities throughout the country. However, not all patients come to burn centers for initial treatment. Therefore, a nurse in a typical emergency department should work with the health-care team to determine the severity of the patient’s burn injuries and discuss if the patient needs to be transferred to a burn facility (Gauglitz & Williams, 2023).
Link to Learning
The American Burn Association has a website where you can find burn center locations throughout the country.
Emergent Care
Following the ABCDE assessment method, the health-care team (i.e., nurse, respiratory therapist, health-care provider) will simultaneously assess the patient’s airway for patency and then address the patient’s breathing. Then, the team will assess the patient’s respiratory rate and oxygen saturation, along with any other compromising issues (e.g., smoke inhalation) to determine if the patient requires oxygen treatment. Depending on the severity of the burn injury, the health-care provider may have to intubate the patient and provide respiratory support with a ventilator.
After establishing the patient’s airway, the patient’s circulation would be assessed, and fluid resuscitation may be indicated; obtaining intravenous (IV) access and controlling areas of hemorrhage are top priorities in burn care. Fluid resuscitation is necessary for the body and skin’s hydration status because much of the vascular volume is lost through the skin with a burn. Adequate IV fluids are also needed to maintain vital signs within normal limits, including blood pressure support through intravascular volume. The nurse would then assess and address concerns related to disability or the patient’s neurological status. Lastly, the nurse would collaborate with the health-care team to determine exposure. Exposure includes assessing the patient’s temperature and skin, determining if warming measures are needed, assessing thickness of the burns, and calculating the TBSA (Gauglitz & Williams, 2023). For more information about the ABCDE triage method and interventions, see Chapter 33 Emergency Care.
Type of Burn Injuries
Burns can occur from different heat sources, causing different types of burn injuries. The main types of burns are thermal, chemical, electrical, and radiation. A thermal burn is the most common type of burn and is caused by an external heat source, like flames, steam, or hot liquids. A chemical burn is caused by hazardous chemicals, like acids or strong detergents. An electrical burn is caused by exposure to electricity or electrical currents. A radiation burn occurs from exposure to radiation sources, such as sunlight or machines that emit radiation, during some cancer treatments (Warby & Maani, 2022). Burns are also classified by severity, ranking from least severe to most severe. These range from first-degree to sixth-degree burns and are further outlined in the following sections.
First-Degree Burns
A first-degree burn is the most superficial type of burn and is considered minor. It affects only the epidermis, or the outermost layer of the skin. First-degree burns are also called superficial thickness burns. An example of a first-degree burn would be a sunburn without any blisters, or one caused by touching a hot pot on the stove and quickly letting go (Warby & Maani, 2022).
Pathophysiology
First-degree burns affect only the skin’s epidermal, or outermost, layer. When a burn source affects the skin, it causes protein denaturation or breaking of the protein linkages of the epidermis. Collagen, which helps the skin’s elasticity, is also damaged. This causes the skin cells to die, a condition called necrosis (Pencle et al., 2022). After the burn injury occurs, three zones of injury arise: the zones of coagulation, statis, and hyperemia (Figure 14.5). The zone of coagulation is the central area of a burn where tissue has been irreversibly damaged and coagulated. The zone of stasis is the area surrounding a burn where the tissue has decreased perfusion, but the skin is still potentially viable. This is important for wound healing. Lastly, the zone of hyperemia is the outermost area of a burn where tissue is inflamed and has increased blood flow, typically recovering without intervention (Jeschke et al., 2020).
Clinical Manifestations
Clinical manifestations of first-degree burns include erythema, or redness, to the burned area, which can appear red or pink (Figure 14.6). Examples are a sunburn that does not blister or a minor burn from a stovetop. These burns may have minor skin swelling and are dry; they do not appear moist. First-degree burns will not form blisters and usually heal without scars. Pain associated with first-degree burns can be mild to moderate, depending on the area affected (Warby & Maani, 2022).
Assessment and Diagnostics
The nurse should assess the patient’s skin for the characteristics of a first-degree burn. The nurse should ask the patient how and when they were burned, what caused the burn (i.e., source), and if they have any pain (Pencle et al., 2022).
Diagnosis of first-degree burns is based on clinical presentation. In a light-skinned patient, the nurse would note pink to red skin; if the patient’s skin is darker, the burn may be reddish to brown. The burn will appear dry, without blisters, and only affects the top layer of skin. The nurse should also calculate the TBSA of first-degree burns using the Rule of Nines. The Rule of Nines is a quick tool that assigns a certain percentage to a body area, based on the surface area, so the person calculating can quickly estimate TBSA (Figure 14.7). Most first-degree burns are treated outside of the hospital setting and do not require additional diagnostic tests or laboratory and blood work (Pencle et al., 2022).
Nursing Care of the Patient with First-Degree Burns
When caring for a patient with a first-degree burn, it is important to understand how the burn occurred, the heat source, and the patient’s symptoms. The nurse will also assess and document the burn area(s) and calculate the TBSA affected by the burns, if extensive. The nurse will also provide pharmacological and nonpharmacological interventions and wound care education as ordered (Pencle et al., 2022). Nursing care for the patient presenting with a burn should follow these steps:
- Identify heat source and take the patient’s vital signs.
- Address airway and breathing problems, if any.
- Classify burns as first, second, or third degree.
- Calculate the TBSA.
- Provide remaining nursing interventions following the ABCDE model.
Interdisciplinary Plan of Care
Interdisciplinary Care of the Burn Patient
Team members may include:
- Burn surgeon: Leads the medical management, performs surgeries for debridement and grafting, and oversees overall treatment plan
- Interventions include surgical interventions, wound care, monitoring for complications, and coordinating with other team members for comprehensive care.
- Wound nurse or burn nurse: Provides specialized wound care, pain management, and education on burn care
- Interventions include dressing changes, administering medications, monitoring vital signs, and patient and family education on wound care and prevention of infection.
- Physical therapist: promotes mobility, prevents contractures, and enhances functional recovery
- Interventions include range of motion exercises, strength training, mobility aids, and positioning techniques to prevent deformities.
- Occupational therapist: Assists in regaining independence in daily activities and improving fine-motor skills
- Interventions include activities of daily living (ADLs) training, splinting, adaptive equipment, and techniques to improve dexterity and coordination.
- Social worker: Provides psychosocial support, resources for coping, and assistance with discharge planning
- Interventions include counseling, connecting with support groups, coordinating community resources, and addressing financial or housing concerns.
- Nutritionist: Ensures optimal nutritional support for wound healing and overall recovery
- Interventions include nutritional assessment, high-protein diet plans, vitamin and mineral supplementation, and monitoring for malnutrition.
- Psychologist/psychiatrist: Addresses mental health issues such as anxiety, depression, and post-traumatic stress disorder (PTSD) related to the burn injury.
- Interventions include psychological assessments, therapy sessions, support groups, and medication management if needed.
- Respiratory therapist: Manages respiratory complications, especially in patients with inhalation injuries
- Interventions include monitoring respiratory status, providing oxygen therapy, ventilator support, and pulmonary rehabilitation exercises.
Recognizing and Analyzing Cues
When recognizing cues, the patient may report that they received a burn to their skin. Additionally, the nurse may notice a pink to red or brown area that appears dry and mildly swollen. Some skin conditions, like birthmarks, can be mistaken for burns, so the nurse should ask the patient about all areas. Also, the nurse analyzes these clues by asking the patient how they received a burn, when the burn occurred, and their pain level. If the patient can speak, the nurse can use the numeric pain scale. If the patient is unconscious or nonverbal, the nurse can assess the patient’s vital signs (e.g., tachycardia or tachypnea) in conjunction with the approved facility pain scale, such as FACES or Pain Assessment in Advanced Dementia (PAINAD) Scale. The nurse should also ask the patient if they have tried any over-the-counter remedies or taken any medications for pain relief (Pencle et al., 2022).
Prioritizing Hypotheses, Generating Solutions, and Taking Action
The priority nursing hypothesis for first-degree burns is impaired skin integrity related to the burn injury. When generating solutions, the nurse can determine pharmacological and nonpharmacological interventions to promote impaired skin integrity with the outcome of the burn healing. First-degree burns are considered minor and can be treated mainly using the “Cs” of burn care (Schaefer & Szymanski, 2023):
- Cooling: In small areas, tap water or saline solution may help to prevent the burn from progressing burning and to reduce pain.
- Cleaning: Burns should be cleaned using a mild soap and water or a mild antibacterial wash. Large blisters are generally debrided. Small blisters and blisters involving the palms or soles are left intact.
- Covering: The burn may be covered using an absorbent dressing or specialized burn dressing over a topical antibiotic ointment or cream. A pharmacological intervention would be applying topical medications, such as silver sulfadiazine or aloe vera; an example of a nonpharmacological intervention is topical petroleum ointment.
- Comfort: For pain, over-the-counter pain medications (e.g., acetaminophen, ibuprofen) or prescription pain medications can be used. Some burned areas may be supported using splints, which may provide some comfort to the patient.
If the burn was due to sun exposure, the nurse educates the patient on preventive skin care, like applying sunscreen and avoiding sunlight during the hotter hours of the day.
Evaluation of Nursing Care for the Patient with First-Degree Burns
The nurse will evaluate the effectiveness of the pharmacological and nonpharmacological interventions related to impaired skin integrity. The nurse would expect a first-degree burn to fully heal within 5 to 10 days (Warby & Maani, 2022).
Evaluating Outcomes
The desired outcome is that the patient will not experience any signs of impaired skin integrity related to the burn injury. In a light-skinned person, the area would not be red or pink; in a dark-skinned person, erythema is not always apparent. In all patients, there should be no signs of infection. The skin would be completely healed, without a permanent scar in most cases. The patient would also note they have little to no pain to the area (Pencle et al., 2022).
Medical Therapies and Related Care
First-degree burns usually heal without complications. However, the health-care provider may refer the patient to wound care, if needed. Usually, this would be needed if the wound is not healing as expected or appears to become infected. Depending on the location of the burn, the patient may need home health assistance with wound care if they live at home alone. The nurse would recommend a referral to either home health or a case manager to coordinate wound care (Pencle et al., 2022).
Second-Degree Burns
A second-degree burn is a type of partial-thickness burn involving the epidermis and the dermis, which appears as red and blistering and can be very painful (Warby & Maani, 2022). Second-degree burns most often occur from hot liquids (e.g., hot grease, microwaved water), chemicals, or radiation.
Pathophysiology
Second-degree burns affect the skin’s epidermis and part of the dermis. They can affect the superficial dermis or penetrate deeper. Similar to first-degree burns, protein denaturation—breaking of the protein bonds—occurs and collagen is damaged. Depending on how far the burn extends into the dermis, the skin can lose fluid and have decreased thermal regulation and sensation. With larger burns, covering greater than 20% of a person’s body surface area, the body may produce a systemic inflammatory response, whereby fluid loss and shifts occur throughout the body. This can lead to septic or hypovolemic shock (Schaefer & Tannan, 2023).
Clinical Manifestations
Clinical manifestation of second-degree or partial-thickness burns includes erythema, blisters, and a wet appearance (Figure 14.8). The skin may swell and skin erythema will be blanchable with pressure. Blanching occurs when the skin temporarily turns white after pressure is applied. Second-degree burns usually produce moderate to severe pain. This is because the patient’s epidermis and dermis are damaged and nerve endings can be exposed and destroyed (Warby & Maani, 2022).
Assessment and Diagnostics
The nurse should assess the patient’s skin for the characteristics of a second-degree burn. The nurse gathers valuable information from the patient, detailing how and when the burn occurred, the heat source, and the patient’s pain level (Pencle et al., 2022).
Assessment and diagnosis of burns are based on visualization of the skin and clinical presentation. The nurse would note the level of involvement of the patient’s epidermal and dermal layers. The nurse would calculate the TBSA of second-degree burns to determine the percentage of the patient’s body that is affected by burns (Schaefer & Szymanski, 2022).
Depending on the extent of the burns, the patient may require inpatient treatment. Additional laboratory and diagnostic tests may be ordered, including a CBC, comprehensive metabolic panel (CMP), arterial blood gases analysis, and other diagnostic tests. These tests assess the patient’s overall condition, including oxygenation, kidney function, infection and other responses. If a smoke inhalation injury is suspected, chest X-rays and electrocardiograms (ECGs) may be ordered as well. The chest x-ray may show lung injury, whereas the ECG can show slight changes to cardiac function (Rice & Orgill, 2023).
Nursing Care of the Patient with Second-Degree Burns
When caring for a patient with a second-degree burn, the nurse must recognize and analyze patient cues. The nurse will carefully prioritize nursing hypotheses and generate both pharmacological and nonpharmacological solutions.
Recognizing and Analyzing Cues
The nurse will first start by recognizing patient cues and gathering relevant information. The nurse should obtain a history of the burn, take the patient’s vital signs, and assess the patient’s pain level, which will likely be moderate to severe. When assessing the burns, the nurse would look for the characteristics of a second-degree burns. The nurse would then analyze these cues to determine a priority nursing hypothesis.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
After the nurse has gathered and analyzed cues, they will determine the priority nursing hypothesis. Typically, the priority nursing hypothesis is impaired skin integrity for second-degree burns. However, if the extent of the burns covers a large percentage of the patient’s body or if their vital signs are unstable, other nursing hypotheses may be a priority, like airway, breathing, or circulation issues. The nurse would follow the ABCDE assessment method when prioritizing. For example, if the patient has experienced smoke inhalation, impaired gas exchange might be the priority nursing hypothesis over impaired skin integrity (Rice & Orgill, 2023).
The nurse should then generate solutions for the priority hypothesis of impaired skin integrity by providing pharmacological and nonpharmacological interventions. Some solutions are wound care, pain control, and infection prevention. Any clothing or jewelry should be removed from areas near the burn. The nurse would then cool the patient’s skin by either applying water or a saline solution and gauze. This prevents the burn injury area from extending deeper and supports skin cell repair. The nurse would then cleanse the burn with an antibacterial wash. If the health-care provider orders it, the nurse may remove larger blisters by gently applying pressure with gauze while leaving smaller ones intact. The nurse will then apply a topical ointment, like silver sulfadiazine or mupirocin, as ordered, and a nonadherent dressing to the burn areas, serving as barriers and protectants (Schaefer & Szymanski, 2022).
The nurse can also provide pain relief with ordered pain medications, such as IV morphine or other opioids. Ideally, the nurse would administer pain medications at least 30 minutes before providing burn care or completing dressing changes, because second-degree burns can be extremely painful. The nurse would assess the patient’s burn injuries during dressing changes, ensuring there are no signs and symptoms of infection, and alert the health-care provider of any changes. Symptoms of infection may include fever, increased erythema, or yellow and foul-smelling discharge from the wound. Depending on the TBSA percentage of burns, the nurse may also need to provide IV fluid replacement. Burns covering a larger portion of the patient’s body can lead to hypovolemia or fluid volume deficit (Rice & Orgill, 2023).
Evaluation of Nursing Care for the Patient with Second-Degree Burns
Next, the nurse will evaluate the effectiveness of interventions related to impaired skin integrity. Second-degree (or partial-thickness) burns usually heal within 3 weeks, and scarring is minimal (Warby & Maani, 2022).
Evaluating Outcomes
When evaluating outcomes related to impaired skin integrity, the nurse determines if their interventions were effective. First, the nurse would expect the patient’s pain level to be tolerable prior to dressing changes. They would assess this by asking the patient their pain level (using an appropriate pain assessment tool) before, during, and after wound care. Nurses can also look for physiological clues that can indicate pain for unconscious patients, like tachycardia or tachypnea. As the burn heals, the nurse would expect the patient’s pain to reduce over time. The nurse would expect the burn to begin healing and show no signs of infection; the burn should appear pink, and dry, with healing blisters. Depending on the timing of the desired outcome, the nurse would expect the patient’s burn to almost be completely healed within 3 weeks. There may be some scarring present (Schaefer & Szymanski, 2022).
Medical Therapies and Related Care
Usually, second-degree burns heal within 3 weeks. Depending on the extent of the patient’s burns and related injuries, the nurse may need to collaborate on patient care with other health-care team members. If the patient had smoke inhalation, collaborative care with a respiratory therapist and pulmonologist will be needed. To aid with wound care, a referral for a wound care nurse and other specialists may be placed by the primary care provider. To promote wound healing, a nutritionist may be consulted for dietary recommendations. If a secondary infection develops, the health-care provider may order a consultation with an infectious disease specialist and/or a pharmacist. Lastly, if the patient is discharged and needs help with wound care at home, an order for home health, case management, or wound care clinic may be needed.
Third-Degree Burns
A third-degree burn involves the epidermis, dermis, and subcutaneous structures and appears white or black, dry, and leathery. Because third-degree burns involve all layers of the skin, they are also referred to as full-thickness burns. These burns require immediate medical attention because they can be life-threatening (Warby & Maani, 2022). Common causes of third-degree burns are extremely harsh chemicals, flames, or scalding liquids.
Pathophysiology
Third-degree burns affect the entire epidermis and dermis of the skin, extending into the subcutaneous tissue. These burns may also extend to and damage the underlying bones, tendons, muscles, and nerves. Because the nerve endings in the skin are destroyed by the burn, patients do not have pain. Third-degree burns are severe, no matter the size, and require treatment at a specialized burn center and skin grafting (Warby & Maani, 2022). They can also lead to fluid loss and decreased thermal regulation, depending on the percentage of the body the burn covers (Schaefer & Tannan, 2023).
Clinical Manifestations
Third-degree (or full-thickness) burns can appear white, black, or brown, look dry or leathery, and be nonblanchable. They may produce eschar, which is a piece of dead tissue that is cast off from the surface of the skin, particularly after a burn injury. It is usually a dark color and can be hard or soft, depending on the type and cause of the injury. The patient will not have pain, due to the destruction of nerve ending in the skin, and there may be exposed bone, tendon, or muscle tissue (Warby & Maani, 2022) (Figure 14.9).
Assessment and Diagnostics
The nurse should assess the patient’s skin for the characteristics of a first-degree burn and assess the patient’s pain level. Many patients with third-degree burns also have second-degree burns, so they may experience pain. Therefore, the nurse should still assess the patients for pain using the appropriate tool for the patient’s level of consciousness.
Diagnosis of third-degree burns is based on presentation and appearance. The health-care provider may order additional bloodwork and testing based on the extent of the burn injuries, the source of the burn, and whether the patient experienced smoke inhalation. Additional tests may include a CBC, CMP, arterial blood gas analysis, and other diagnostic tests. If the patient received the burn from an electrical shock, they would require an initial ECG and continuous ECG monitoring (Rice & Orgill, 2023). The health-care provider reviews the WBC count for indicators of infection and kidney function, and hemoglobin and hematocrit for fluid volume status. Arterial blood gases provide an accurate picture of the patient’s respiratory status; thus, arterial blood samples are used to measure the levels of oxygen, carbon dioxide, and blood pH, and these indicate how well the lungs are oxygenating the blood and removing carbon dioxide.
Nursing Care of the Patient with Third-Degree Burns
When caring for patients with third-degree burns, the nurse should be able to differentiate among the degrees, based on the patient cues and assessment. They would then determine appropriate nursing care.
Life-Stage Context
Burns in the Older Adult
For older patients, consider asking them more relevant information to how they received the burn. Did they forget to use a mitt when removing a hot pan from the oven? Did they leave an electric blanket on their bed, causing a burn due to sensory issues? Sometimes the exact cause of the burn can lead down the path to other potential patient conditions to assess, like dementia or neuropathy.
Recognizing and Analyzing Cues
The nurse will first start the nursing process by gathering information and recognizing cues. The nurse will follow the ABCDE assessment method to identify and address any areas of immediate concern first. During this assessment process, the nurse should ask questions about how and when the patient received the burn, what heat source was involved, and any associated symptoms. The nurse will also complete their initial vital signs assessment, have the patient rate their pain, and assess the skin.
The nurse must then analyze the patient cues. For example, if the patient is having difficulty breathing, they may have smoke inhalation. Alternatively, the burn may have restricted the patient’s breathing, or the patient may be anxious; the nurse will need to determine the correct option. The nurse should also be looking for cues consistent with third-degree burns. For example, if the burn is black, dry, and leathery, and the patient denies pain at the burn injury site, these cues are consistent with a third-degree burn. Other findings might indicate a different severity of burn (Gauglitz & Williams, 2023).
Prioritizing Hypotheses, Generating Solutions, and Taking Action
After the nurse has analyzed cues, they will determine the priority nursing hypothesis following the ABCDE assessment method. If the patient has received burns to a large portion of their body or experienced smoke inhalation, the priority nursing hypotheses would be related to oxygen exchange or depleted fluid volume. However, typically, the priority nursing hypothesis for third-degree burns not covering a large portion of the patient’s body is impaired skin integrity. The priority nursing interventions are dependent on the TBSA of burns (Rice & Orgill, 2023).
After the nurse determines the priority nursing hypothesis, they will generate solutions. Solutions related to impaired skin integrity are wound care, infection prevention, and care coordination with plastic surgery. Typically, patients do not have pain with third-degree burns, but pain medications may be needed for wound care; the nurse must consider this as a possible solution. A short-term outcome for impaired skin integrity may be preventing wound infection and compartment syndrome. The nurse would potentially set a long-term expected outcome of the patient’s burn injury healing after 8 or more weeks (Schaefer & Szymanski, 2022).
The nurse then will act on the interventions they identified. If the patient is not already at a burn injury center, they should be transferred to a specialized burn center to provide quality care and resources. In the meantime, the nurse should work with the health-care provider to cleanse the wound and debride or remove dead tissue, and apply topical antimicrobial ointments. Depending on the extent of the burn injury, the nurse will also assess for signs of compartment syndrome around the burn site. This includes the taking patient’s pulse and assessing skin color, along with any reports of numbness, tingling, or pain. If the nurse identifies signs of impending compartment syndrome, such as severe pain, pulselessness, swelling, or numbness and tingling, they should notify the health-care provider immediately. The nurse also must collaborate on patient care with other members of the health-care team because third-degree burns can require extensive debridement, which involves removal of damaged tissue around a wound to allow for new tissue to more easily grow. The nurse may need to coordinate consultations with general surgery, plastic surgery, and other surgical specialties, depending on the size and depth of the burn (Schaefer & Nunez Lopez, 2023).
As with other burns, the nurse would assess for signs and symptoms of infection and alert the health-care provider of any changes. Some common symptoms of infection include fever, increased erythema, or yellow and foul-smelling discharge from the burn. Depending on the TBSA percentage of burns, the nurse may also need to provide IV fluid replacement, because burns covering a larger portion of the patient’s body can lead to hypovolemia or fluid volume deficit (Rice & Orgill, 2023).
Evaluation of Nursing Care for the Patient with Third-Degree Burns
After the nurse has implemented their nursing care, they will evaluate the effectiveness of their actions. The nurse can evaluate both short- and long-term goals related to impaired skin integrity. Short-term goals may be to prevent infection and prevent any signs of compartment syndrome. A long-term goal may be for the wound to completely heal, which may take months to years, and will likely leave a permanent scar (Warby & Maani, 2022).
Evaluating Outcomes
For a short-term (and long-term) goal, the nurse would expect the patient’s burn injury to show no signs and symptoms of infection. The patient may also require surgeries to help debride and cleanse the wound to prevent infection and promote healing. The nurse will also note no signs of compartment syndrome: no swelling, no decreased pulses to the affected area(s), or other signs. A short-term goal would be for the patient’s WBC count to remain within normal range, indicating no signs of infection. A long-term goal would be evaluated after 8 weeks, when the nurse would expect the burn to be almost completely healed (Schaefer & Nunez Lopez, 2023).
Medical Therapies and Related Care
Typically, third-degree, or full-thickness, burns take at least 8 weeks to heal and may take even longer. The patient will require care from a collaborative health-care team. The nurse expects the patient to need referrals to wound care, plastic surgery, and potentially orthopedics if any underlying bone is involved. If the patient experiences smoke inhalation, the nurse should expect additional health-care team members to be involved in the patient’s care, like a pulmonologist and respiratory therapist. Additionally, if a secondary infection develops, an infectious disease consultation may be ordered along with a nutritionist to promote wound healing. Once the patient is ready to be discharged home or another care facility, the nurse can potentially expect referrals for case management, home health, and wound care.
Toxic Epidermal Necrolysis and Stevens-Johnson Syndrome
Although not occurring from a burn injury, there are two disorders that can resemble partial-thickness burns and are often treated in similar ways. Both Stevens-Johnson Syndrome (SJS) and toxic epidermal necrolysis (TEN) are abrupt, rare skin reactions that involve loss of skin and sometimes mucosal membranes. In 80% of cases, medications cause these rare and life-threatening reactions. Some common medications that can cause these reactions include cephalosporins, allopurinol, phenytoin, among others (Oakley & Krishnamurthy, 2023).
Pathophysiology
The exact pathophysiology of SJS and TEN is unknown. The main theory is that the causative medication binds to the major histocompatibility complex type 1, causing a T-cell–mediated reaction. Another theory is that release of granulysin (a protein) and CD8+ cells may lead to keratinocyte death and skin blistering (Bendetti, 2022).
The skin cell death that occurs causes the patient’s skin to blister and slough off, which looks similar to a second-degree burn injury. Thus, patients with SJS or TEN are often treated at burn centers and burn units, because management is similar (Bendetti, 2022).
Clinical Manifestations
Usually, patients with SJS or TEN will present with fever and feeling generally unwell. They may also have upper respiratory symptoms. Over the course of a few days, they will develop a blistering skin rash, which can include mucosal membranes like the lips, mouth, and the gastrointestinal tract. Patients with TEN will likely develop widespread target-appearing, painful, blister-like erosions. Patients with SJS will have a similar, more localized, rash. Patients may also report a headache and sore throat. Because SJS and TEN can affect other body systems like the liver and kidneys, patients may also report symptoms related to the affected body system. Some symptoms may include nausea, vomiting, shortness of breath, or leg swelling (Oakley & Krishnamurthy, 2023). Multiorgan dysfunction syndrome (MODS) is also a possibility and is discussed in Chapter 23 Shock and Sepsis.
Assessment and Diagnostics
The skin of patients with SJS or TEN will appear similar to that of patients with second-degree burns. The widespread rash looks like a target, and painful bister-like erosions often develop. The nurse should obtain the patient’s history of illness and a personal history, including when their symptoms started, and ask the patient if they have started any new medications (Oakley & Krishnamurthy, 2023).
After the initial workup, the health-care provider may order laboratory tests, like a CBC, CMP, and liver and renal function panels. Patients with SJS or TEN usually have anemia, neutropenia, elevated transaminase levels, hyponatremia, and other abnormal laboratory values. To rule out other potential causes, the provider may order a skin biopsy and additional pulmonary or cardiac diagnostic tests, such as bronchoscopies, chest x-rays, and ECGs (Oakley & Krishnamurthy, 2023).
Nursing Care of the Patient with TEN or SJS
When caring for a patient with SJS or TEN, the nurse must recognize and analyze patient cues. Symptoms usually start with fever and malaise, with skin blistering appearing a few days later. The patient may have started taking a new medication or is taking one of the medications associated with developing TEN or SJS. The nurse will provide both pharmacological and nonpharmacological interventions to assist with symptom relief and treatment.
Recognizing and Analyzing Cues
The nurse will recognize cues by identifying relevant information and will start by asking the patient about symptom onset and current medications. The nurse will then take the patient’s vital signs, ask about the patient’s pain level, and assess the patient’s skin. The patient’s skin will likely have widespread blistering erosions that look like targets or bullseyes. The erosions can also affect the patient’s mucosal membranes, like the mouth and lips, or the palms and soles of the feet; the nurse should examine these areas as well (Oakley & Krishnamurthy, 2023).
Prioritizing Hypotheses, Generating Solutions, and Taking Action
The nurse will determine the priority nursing hypothesis, which may be different for the acute and rehabilitation phases of SJS and TEN. However, the priority hypothesis is typically impaired skin integrity. If there is airway involvement, that takes priority, based on the ABCDE triage method. The nurse can generate pharmacological and nonpharmacological interventions to promote skin healing and prevent infection.
Of importance, the nurse would discontinue the administration of the medication causing SJS or TEN. The nurse can also provide daily skin care as ordered, which can include gently removing necrotic tissue, cleansing the wounds, and applying nonadherent dressings (Hanson & Bettencourt, 2020). The nurse should also assess for signs and symptoms of infection and collect wound cultures every 2 days of the skin lesions. If infection is present, the nurse would notify the health-care provider and administer antibiotics as ordered. The nurse should also frequently assess the patient’s pain and provide pain medications as needed for pain relief. Depending on the condition of the patient, the health-care provider might include fluid replacement, monitor laboratory values, and provide supplemental oxygen, nutrition, and temperature control (Oakley & Krishnamurthy, 2023).
Clinical Safety and Procedures (QSEN)
Wound Care and Dressing Changes for Burn Patients
Purpose: To guide health-care providers in performing wound care and dressing changes for burn patients to prevent infection and promote healing.
QSEN Competencies: Patient-Centered Care, Safety, Evidence-Based Practice (EBP), Teamwork and Collaboration
Steps:
- Gather supplies
- Ensure all necessary supplies are available: sterile gloves, dressing materials, normal saline or wound cleanser, antibiotic ointment (if prescribed), and pain management medications.
- Hand hygiene and PPE (Safety)
- Perform hand hygiene thoroughly.
- Don sterile gloves and other appropriate PPE to maintain a sterile field.
- Assess the wound (Patient-Centered Care, Safety)
- Inspect the burn wound for signs of infection, such as increased redness, swelling, warmth, or purulent discharge.
- Note the color, size, and depth of the burn.
- Administer pain relief (Patient-Centered Care)
- Provide prescribed analgesics prior to the dressing change to manage pain and minimize discomfort.
- Clean the wound (Safety, EBP)
- Gently clean the wound with sterile normal saline or an appropriate wound cleanser.
- Use a gentle technique to avoid causing further trauma to the wound bed.
- Apply antibiotic ointment (EBP):
- Apply a thin layer of antibiotic ointment to the burn wound, if prescribed, to prevent infection.
- Apply the dressing (Safety, EBP)
- Cover the wound with a nonadherent dressing to protect the area and promote a moist healing environment.
- Secure the dressing with appropriate bandaging materials, ensuring it is snug but not constricting.
- Dispose of used materials (Safety)
- Safely dispose of used dressing materials and gloves in accordance with infection control protocols.
- Perform hand hygiene after disposing of materials.
- Document the procedure (Teamwork and Collaboration, Safety):
- Record the details of the wound care procedure in the patient’s medical record, including wound appearance, any signs of infection, patient’s pain level, and the type of dressing applied.
- Educate the patient and family (Patient-Centered Care, Teamwork and Collaboration)
- Provide education on wound care and signs of infection to the patient and their family.
- Ensure they understand the importance of keeping the wound clean and dry and when to seek medical attention.
Evaluation of Nursing Care for the Patient with TEN and SJS
The nurse should evaluate the effectiveness of the pharmacological and nonpharmacological interventions related to impaired skin integrity. The course of SJS and TEN is divided into acute and rehabilitation phases, for which expected patient outcomes are different. The acute phase is the period when the patient is hospitalized, and the rehabilitation phase is the period after the patient is discharged from the hospital.
Evaluating Outcomes
When evaluating outcomes related to impaired skin integrity, the nurse would expect the patient’s wounds to heal without any signs of infection. The patient’s pain should also be controlled to a tolerable level. The nurse would expect the patient’s laboratory values and thermoregulation to return to normal, with no fluid imbalances present (Oakley & Krishnamurthy, 2023).
Medical Therapies and Related Care
Care from a large interdisciplinary team is required for patients with SJS or TEN because these conditions affect multiple organ systems. Some specialists on the health-care team may include an intensivist and pulmonologist, dermatologist, urologist, gynecologist, ophthalmologist, and plastic surgeon. The patient will also need referrals to supportive services like wound care, nutrition, physical therapy, occupational therapy, and psychology (Oakley & Krishnamurthy, 2023).
Rehabilitation and Psychological Care for SJS or TEN
Patients with SJS and TEN usually require care in an intensive care setting and burn unit initially. This is because SJS and TEN affect multiple organ systems, requiring close patient monitoring. Once the patient has recovered from the acute phase, they will require rehabilitation. Rehabilitation can be completed either inpatient or outpatient, depending on the patient’s ambulatory status at discharge. Patients who are not ambulatory will be transferred to an inpatient rehabilitation facility. Patients will require an extended period of physical and occupational therapy to gain strength and complete ADLs independently. The patient may also require pain management and care coordination for follow-up appointments and ongoing care (Shanbhag et al., 2020).
Additionally, patients with SJS and TENS will need psychological support because the illness can cause stress and PTSD. Patients may require a psychiatric evaluation and medications to help with stress symptoms. The nurse will help collaborate with inpatient psychiatric care while the patient is in the hospital and outpatient care when the patient is discharged (Shanbhag et al., 2020).