Burn Injury Nursing Care Management and Study Guide

A burn patient is a trauma patient first. Airway, breathing, and circulation come before the wound, and the wound itself keeps evolving for days. Your job is to read subtle changes early: a creeping desaturation, a falling urine output, a pulse you can no longer feel in a burned extremity. Know the physiology behind those changes and you will catch trouble before it becomes an emergency.

What is a Burn Injury

A burn is heat transferred from one site to another, destroying skin. Losing that barrier drives fluid loss, infection, hypothermia, scarring, compromised immunity, and lasting changes in function, appearance, and body image. Young children and the elderly carry higher morbidity and mortality than other age groups with the same injury, and inhalation injury on top of cutaneous burns worsens the prognosis. Severity depends on multiple factors that together let the burn team estimate survival and build the care plan.

Classification

Burns are classified by depth of tissue destruction.

Superficial partial-thickness burns destroy or injure the epidermis and may injure part of the dermis. Deep partial-thickness burns destroy the epidermis and upper dermis and injure the deeper dermis. Full-thickness burns destroy the epidermis and dermis entirely and, in some cases, the underlying tissue, muscle, and bone.

Pathophysiology

Tissue destruction comes from coagulation, protein denaturation, or ionization of cellular components. Burns under 20% of TBSA by the Rule of Nines produce a local response. Burns over 20% of TBSA produce a systemic response, driven by cytokines and other mediators released into the systemic circulation. Local mediators, shifting blood flow, tissue edema, and infection can all push the injury deeper over time.

Statistics and Epidemiology

Burns hit every age and socioeconomic group. An estimated 500,000 people are treated for minor burns each year. More than 40,000 are hospitalized annually, including 25,000 who need a specialized burn center. The remaining 5,000 hospitals see an average of three burns per year. Among burn-center admissions, 47% of injuries happened at home, 27% on the road, 8% were occupational, 5% recreational, and 13% from other sources. By mechanism, 40% are flame related, 30% scald, 4% electrical, 3% chemical, and the rest unspecified. Males carry greater than twice the risk of women. Contact burns peak at 20 to 40 years of age. The National Fire Protection Association reports 4,000 fire and burn deaths each year; of those 4,000, about 3,500 are from residential fires and 500 from other sources such as motor vehicle crashes, scalds, or electrical and chemical exposure. Overall mortality across all ages and all total body surface area burned is 4.9%.

Clinical Manifestations

The burn drives predictable shifts. Hypovolemia is the immediate consequence of fluid loss, cutting perfusion and oxygen delivery. Cardiac output falls before any measurable drop in blood volume. Edema forms rapidly. Circulating blood volume drops sharply during burn shock. Hyponatremia is common during the first week of the acute phase as water shifts from the interstitial space to the vascular space. Hyperkalemia appears immediately from massive cell destruction. Loss of skin leaves the patient unable to regulate temperature, so hypothermia follows.

Prevention

Teach patients and families to keep matches and lighters away from children, and never to leave children unattended near fire or in the bathroom or bathtub. Warn against smoking in bed, smoking near home oxygen, or falling asleep while smoking. Caution against throwing flammable liquids on a burning fire or using them to start one. Advise avoiding overhead and underground electrical wires when working outside, keeping hot irons and curling irons out of children's reach, and never running an electrical cord under carpets or rugs. Stay aware of loose clothing over a stove top while cooking. Keep a working fire extinguisher in the home and know how to use it.

Complications

Burn injuries progress without treatment. As edema increases, pressure on small vessels and nerves in the distal extremities obstructs blood flow and causes ischemia. Carbon monoxide inhalation produces tissue hypoxia. Pulmonary complications follow inhalation injury and can lead to respiratory failure.

Assessment and Diagnostic Findings

Several methods estimate the TBSA burned. The Rule of Nines is the quick adult method: divide the body into multiples of nine and sum the burned parts as a percent of total body surface area. The Lund and Browder method accounts for the percentage of surface area of different body parts (especially head and legs) relative to age. The Palmer method uses the patient's palm: the palm without the digits is roughly 1% of TBSA, and the palm without the fingers equals 0.5% TBSA, a general measure for all ages.

Medical Management

Sequence matters in burn care.

Alert the hospital and physician that the patient is en route so lifesaving measures start on arrival. In the ED, priorities stay airway, breathing, and circulation. Give 100% humidified oxygen and encourage coughing to clear secretions. Remove all clothing and jewelry and flush chemical burns. Insert a large-bore (16 or 18 gauge) IV catheter in a non-burned area. If the burn exceeds 20% to 25% TBSA, place a nasogastric tube to low intermittent suction, since large burns cause nausea. Lay clean sheets over and under the patient to protect the wound from contamination, hold body temperature, and reduce the pain of air moving over exposed nerve endings. Gauge total volume and rate of IV fluid replacement by the patient's response, guided by the resuscitation formula.

Nursing Management

Nursing Assessment

The burn wound is secondary; assess the patient as you would any trauma patient, with aseptic management of wounds and invasive lines continuing throughout.

Establish the circumstances: time of injury, mechanism, whether it happened in a closed space, possible inhalation of noxious chemicals, and any associated trauma. Monitor vital signs frequently and watch respiratory status closely; evaluate apical, carotid, and femoral pulses, especially around circumferential burns to an extremity. Start cardiac monitoring if the patient has a cardiac or respiratory history or an electrical injury. Check peripheral pulses on burned extremities hourly, using Doppler as needed. Measure fluid intake (IV) and output (urinary catheter) hourly, and note the urine volume present when the catheter goes in, which reflects preburn renal function and fluid status. Obtain a history covering body temperature, current and preburn weight, allergies, tetanus immunization, past medical and surgical problems, current illnesses, and medications. Arrange corneal injury assessment for facial burns. Keep reassessing burn extent and depth, identifying full- and partial-thickness areas. Assess neurologic status (consciousness, psychological state, pain and anxiety) and the patient's and family's understanding, support system, and coping skills.

Acute Phase

The acute or intermediate phase begins 48 to 72 hours after the burn. Wound care and pain control are the priorities. Focus on hemodynamic shifts, wound healing, pain, psychosocial response, and early detection of complications. Measure vital signs frequently, with respiratory and fluid status the top priority. Assess peripheral pulses often for the first few days to catch restricted blood flow. Watch hourly fluid intake and urine output along with blood pressure and cardiac rhythm, and report changes to the burn surgeon promptly. For inhalation injury, monitor level of consciousness, pulmonary function, and ability to ventilate; if the patient is intubated and ventilated, frequent suctioning and airway assessment are priorities.

Rehabilitation Phase

Rehabilitation starts immediately after the burn. Wound healing, psychosocial support, and restoring maximum function are the priorities, while fluid and electrolyte balance and nutrition stay important. Early on, gather information about educational level, occupation, leisure activities, cultural background, religion, and family interactions. Assess self-concept, mental status, emotional response to the injury and hospitalization, intellectual functioning, prior hospitalizations, response to pain and pain relief, and sleep pattern. Reassess against rehab goals: range of motion of affected joints, ADL function, early skin breakdown from splints or positioning devices, signs of neuropathy, activity tolerance, and the quality of healing skin. Document participation and self-care in ambulation, eating, wound cleaning, and applying pressure wraps. Keep assessment continuous to catch complications early, including postoperative checks after primary excision.

Diagnosis

Common nursing diagnoses include impaired gas exchange related to carbon monoxide poisoning, smoke inhalation, and upper airway obstruction; ineffective airway clearance related to edema and smoke inhalation; fluid volume deficit related to increased capillary permeability and evaporative wound losses; hypothermia related to loss of skin microcirculation and open wounds; pain related to tissue and nerve injury; and anxiety related to fear and the emotional impact of the injury.

Planning and Goals

Set goals for adequate tissue oxygenation, a patent airway and adequate airway clearance, restored fluid and electrolyte balance with perfusion of vital organs, adequate body temperature, pain control, and minimized patient and family anxiety.

Nursing Priorities

1. Maintain patent airway and respiratory function.
2. Restore hemodynamic stability and circulating volume.
3. Alleviate pain.
4. Prevent complications.
5. Provide emotional support for the patient and significant other (SO).
6. Provide information about condition, prognosis, and treatment.

Nursing Interventions

Promoting gas exchange and airway clearance. Provide humidified oxygen and monitor arterial blood gases (ABGs), pulse oximetry, and carboxyhemoglobin levels. Assess breath sounds and respiratory rate, rhythm, depth, and symmetry; watch for hypoxia. Look for signs of inhalation injury: blistered lips or buccal mucosa, singed nostrils, burns of the face, neck, or chest, increasing hoarseness, or soot in sputum or secretions. Report labored or shallow respirations or signs of hypoxia to the physician immediately and prepare to assist with intubation and escharotomies. Monitor the ventilated patient closely. Run aggressive pulmonary care: turning, coughing, deep breathing, forceful inspiration with spirometry, and tracheal suctioning. Position to clear secretions, keep the airway patent, and promote chest expansion, using an artificial airway as needed.

Restoring fluid and electrolyte balance. Monitor vital signs, hourly urine output, central venous pressure (CVP), pulmonary artery pressure, and cardiac output. Report signs of hypovolemia or fluid overload. Maintain IV lines and fluids at prescribed rates, and document intake, output, and daily weight. Elevate the head of the bed and burned extremities. Monitor serum electrolytes (sodium, potassium, calcium, phosphorus, bicarbonate) and recognize developing imbalances. Notify the physician immediately of decreased urine output, falling blood pressure or central/pulmonary pressures, or rising pulse.

Maintaining normal body temperature. Provide a warm environment with a heat shield, space blanket, heat lights, or blankets. Assess core temperature frequently. Work quickly when wounds must be exposed to minimize heat loss.

Minimizing pain and anxiety. Use a pain scale (1 to 10) and distinguish restlessness from pain versus hypoxia. Give IV opioid analgesics as prescribed, assess the response, and watch for respiratory depression in patients who are not ventilated. Provide emotional support, reassurance, and simple explanations of procedures. Assess understanding, coping strategies, family dynamics, and anxiety, and respond individually. Give antianxiety medication if the patient stays highly anxious and agitated after psychological support.

Monitoring and managing potential complications. For acute respiratory failure, assess for increasing dyspnea, stridor, and changing respiratory patterns; monitor pulse oximetry and ABGs for problematic oxygen saturation and rising CO2; monitor chest x-rays; watch for cerebral hypoxia (restlessness, confusion); report deteriorating respiratory status immediately and assist with intubation or escharotomy. For distributive shock, monitor for early signs (decreased urine output, cardiac output, pulmonary artery pressure, pulmonary capillary wedge pressure, blood pressure, or rising pulse) or progressive edema, and give fluid resuscitation as ordered. For acute renal failure, report abnormal urine output and quality, BUN and creatinine, and urine hemoglobin or myoglobin, and give increased fluids as prescribed. For compartment syndrome, assess peripheral pulses hourly with Doppler and neurovascular status hourly (warmth, capillary refill, sensation, movement), remove the blood pressure cuff after each reading, elevate burned extremities, report any extremity pain or loss of pulse or sensation, and prepare to assist with escharotomies. For paralytic ileus, keep the nasogastric tube on low intermittent suction until bowel sounds return and auscultate for distention. For Curling's ulcer, check gastric aspirate for blood and pH and stools for occult blood, and give antacids and histamine blockers (ranitidine [Zantac]) as prescribed.

Restoring normal fluid balance. Monitor IV and oral intake using infusion pumps, measure intake, output, and daily weight, and report changes in blood pressure or pulse rate.

Preventing infection. Provide a clean, safe environment and protect the patient from cross-contamination (visitors, other patients, staff, equipment). Scrutinize the wound for early signs of infection. Monitor culture results and white blood cell counts. Use clean technique for wound care and aseptic technique for invasive procedures, with meticulous hand hygiene before and after contact. Caution the patient against touching wounds or dressings, wash unburned areas, and change linens regularly.

Maintaining adequate nutrition. Start oral fluids slowly when bowel sounds return and record tolerance; if vomiting and distention do not occur, advance gradually to a normal diet or tube feedings. With a dietitian, plan a protein- and calorie-rich diet the patient will accept, and encourage family to bring favorite nutritious foods. Provide supplements if prescribed. Document caloric intake and insert a feeding tube if oral intake cannot meet caloric goals, noting residual volumes. Weigh the patient daily and graph the trend.

Promoting skin integrity. Assess wound status and support the patient through painful wound care. Coordinate dressing changes. Assess each burn for size, color, odor, eschar, exudate, epithelial buds (small pearl-like clusters of cells on the wound surface), bleeding, granulation tissue, graft take, donor-site healing, and the condition of surrounding skin, and report significant changes. Keep the team informed of current wound care procedures. Support and encourage the patient and family to take part in dressing changes, and assess their strengths early in preparing for discharge.

Relieving pain and discomfort. Assess pain frequently and give analgesics and anxiolytics before pain becomes severe, documenting the response. Encourage analgesic use before painful procedures. Teach relaxation techniques, give the patient some control over wound care and analgesia, and reassure often. Use guided imagery, distraction, hypnosis, music therapy, and virtual reality. Assess sleep daily and give sedatives if prescribed. Work quickly through treatments and dressing changes. During healing, promote comfort with oral antipruritic agents, a cool environment, frequent skin lubrication with water or a silica-based lotion, exercise and splinting to prevent contracture, and diversional activities.

Promoting physical mobility. Prevent complications of immobility (atelectasis, pneumonia, edema, pressure ulcers, contractures) with deep breathing, turning, and proper repositioning. Encourage early sitting and ambulation; when the legs are involved, apply elastic pressure bandages before bringing the patient upright. Work aggressively to prevent contractures and hypertrophic scarring for a year or more after wound closure. Begin passive and active range-of-motion exercises from admission until after grafting, within prescribed limits. Apply splints or functional devices for contracture control and monitor for vascular insufficiency, nerve compression, and skin breakdown.

Strengthening coping strategies. Help the patient build effective coping: set clear behavior expectations, promote truthful communication to build trust, practice coping strategies, and give positive reinforcement. Demonstrate acceptance and enlist an uninvolved person for the patient to vent to without fear of retaliation. Include the patient in care decisions, encourage individuality and preferences, and set realistic self-care expectations.

Supporting patient and family processes. Address verbal and nonverbal concerns of patient and family, instruct family in how to support the patient, and make psychological or social work referrals as needed. Provide information about burn care and the expected course. Begin patient and family education during burn management, matching teaching to learning style and ability and removing barriers to learning. Stay sensitive to changing family dynamics.

Monitoring and managing potential complications (ongoing). For heart failure, assess for fluid overload, decreased cardiac output, oliguria, jugular vein distention, edema, or onset of S3 or S4 sounds. For pulmonary edema, assess for rising CVP, pulmonary artery and wedge pressures, and crackles; report promptly, position with the head elevated unless contraindicated, and give medications and oxygen as prescribed. For sepsis, watch for increased temperature, increased pulse, widened pulse pressure, and flushed, dry skin in unburned areas (early signs); note trends, obtain wound and blood cultures, and give scheduled antibiotics on time. For acute respiratory failure and ARDS, monitor for dyspnea, changing respiratory pattern, and adventitious sounds, and assess for decreased tidal volume and lung compliance on mechanical ventilation; the hallmark of ARDS onset is hypoxemia on 100% oxygen with decreased lung compliance and significant shunting. For visceral damage from electrical burns, monitor the ECG and report dysrhythmias, attend to pain from deep muscle ischemia, and watch for blood loss and hypovolemia after any fasciotomy. For contractures, provide early aggressive physical and occupational therapy. For impaired psychological adaptation, obtain a psychological or psychiatric referral as soon as major coping problems appear.

Promoting activity tolerance. Schedule care to allow uninterrupted sleep and give hypnotics as prescribed. Communicate the plan to family and caregivers. Reduce metabolic stress by relieving pain, preventing chilling or fever, and protecting all body systems to conserve energy; monitor fatigue, pain, and fever to set the daily activity level. Incorporate physical therapy to prevent muscle atrophy and maintain mobility, and build activity tolerance with diversional activities of increasing duration.

Improving body image and self-concept. Listen to the patient's concerns and offer realistic support, referring to a support group for coping with loss. Assess psychosocial reactions and build a plan to help the patient manage feelings. Help the patient practice responses to people who stare or ask about the injury. Support through small gestures (a birthday cake, combing hair before visitors, cosmetic resources), and teach the patient to direct attention from a disfigured body to the self within. Coordinate consultants (psychologists, social workers, vocational counselors, teachers) during rehabilitation.

Teaching self-care. Throughout every phase, prepare the patient and family for care at home with verbal and written instructions on wound care, complication prevention, pain management, and nutrition. Review specific exercises and the use of elastic pressure garments and splints in writing. Teach them to recognize and report abnormal signs. Help them identify and acquire needed supplies and equipment, encourage and support followup wound care, and refer patients with inadequate support to home care resources. Reassess periodically to modify home instructions or plan reconstructive surgery.

Evaluation

Expected outcomes include absence of dyspnea, respiratory rate between 12 and 20 breaths/min, lungs clear on auscultation, arterial oxygen saturation greater than 96% by pulse oximetry, ABG levels within normal limits, a patent airway, minimal colorless thin respiratory secretions, urine output between 0.5 and 1.0 mL/kg/h, blood pressure higher than 90/60 mmHg, heart rate less than 120 bpm, and body temperature between 36.1°C and 38.3°C.

Gerontologic Considerations

Older adults are at higher risk for burns from reduced coordination, strength, sensation, and vision. Predisposing factors and health history complicate their care. Limited pulmonary function affects airway exchange, lung elasticity, and ventilation, further worsened by a smoking history. Decreased cardiac function and coronary artery disease raise complication risk, and malnutrition, diabetes mellitus, or other endocrine disorders add nutritional challenges that require close monitoring. Orientation may vary on admission or over the course of care, making pain and anxiety harder to assess. Thinner, less elastic skin deepens injury and slows healing.

Discharge and Home Care Guidelines

Teach the patient and family to wash small, clean, open wounds daily with mild soap and water and apply the prescribed topical agent or dressing. Provide careful written and verbal instruction on pain management, nutrition, complication prevention, specific exercises, and the use of pressure garments and splints. Patients treated at a burn center usually return to the burn clinic periodically for evaluation, modified instructions, and reconstructive surgery planning. Refer patients who cannot manage their own care or who have inadequate support systems for home care.

Documentation Guidelines

Document breath sounds and character of secretions; respiratory rate, pulse oximetry and O2 saturation, and vital signs; the plan of care and who was involved in planning; the teaching plan; the patient's response to interventions, teaching, and actions; use of respiratory devices or adjuncts; conditions that may interfere with oxygen supply; intake and output, fluid balance, weight changes, and urine specific gravity; progress toward desired outcomes; and any modifications to the plan of care.