1ST SEMESTER
A.Y. 2024 – 2025
|NCM 118
PRE- FINAL NCM 118
BURN
D. Burn depth
1. Superficial-thickness burn (Fig. 46-3)
Description:
Cell destruction of the layers of the skin caused by heat,
friction, electricity, radiation, or chemicals.
B. Burn size
1. Small burns: The response of the body to injury is
localized to the injured area.
2.Large or extensive burns:
a. Major or extensive burns consist of 25% or
more of the total body surface area for an adult and 10%
or more of the total body sur- face for a child.
b. The response of the body to the injury is
systemic
c. The burn affects all major system s of
the body.
d. Electrical burns often have surface injury that
is small but intern al injuries maybe extensive
C. Estimating the extent of injury
a. Involves injury to the epidermis, the blood supply to the
dermis still intact.
b. Mild to severe erythema (pink to red) is present, but no
blisters.
c. Skin branches with pressure.
d. Burn is painful, with tingling sensation, and The pain is
eased by cooling.
e. Discom fort lasts about 48 hours, healing g occurs in
about 3 to 6 days.
f. No scarring occurs, and skin grafts are not
required.
2. Superficial partial thickness burn (Fig. 46-4)
a. Involves injury deeper into the dermis; the blood supply
is reduced.
b. large blisters may cover an extensive area.
c. Edem a is present.
d. Mottled pink to red base and broken epidermis, with a
wet, shin y, and weeping surface, are characteristic.
e. Burn is painful and sensitive to cold air.
f. Heals in 10 to 21 days with no scarring, but some minor
pigmen t changes may occur.
g. Grafts may be used if the healing process is
prolonged.
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3. Deep partial thickness burn (Fig. 46-5)
d. Injured surface appears dry.
e. Edem a is present under the eschar.
f. Sensation is reduced or absent because of
nerve ending destruction.
g. Healing g m ay take weeks to month s and
depends on establishing an adequate blood
supply.
h. Burn requires rem oval of eschar and split- or
full-thickness skin grafting.
I. Scarring and wound contractures are likely to
develop.
5. Deep full-thickness burn (Fig. 46-7)
a. Extends deeper into the skin derm is
b Blister form action usually does not occur because the
dead tissue layer is thick and sticks to underlying viable
derm is.
c. Wound surface is red and dry with white areas
in deeper parts.
d. May or m ay not blanch, and edema is
moderate.
e. Can convert to full thickness burn if tissue
dam age increases with infection, hypoxia, or ischemia.
f. Generally heals in 3 to 6 weeks, but scar formotion results and skin grafting may be
necessary.
4. Full-thickness burn (Fig. 46-6)
a.
A.Injury extends beyond the skin into underlying fascia
and tissues, and muscle, bone, and
tendons are damaged.
b. Injured area appears black, and sensation is
completely absent.
c. Eschar is hard and inelastic.
d. There is lack of pain because nerve endings
have been destroyed.
e. Healing takes months and grafts are required.
E. Age and general health
a. Involves injury and destruction of the epidermis and the
dermis; the wound will not heal by reepithelialization and
grafting may be required.
b. Appears as a dry, hard, leathery eschar (burn crust or
dead tissue must slough off or be removed from the
wound before healing can occur)
c. Appears waxy white, deep red, yellow, brown,
or black
1. Mortality rates are higher for children younger than 4
years of age, particularly for children from birth to 1 year
of age, and for clients older than 65 years.
2. Debilitating disorders, such as cardiac, respiratory,
endocrine, and renal disorders, negatively influence the
client’s response to injury and treatment.
3. Mortality rate is higher when the client has a preexisting disorder at the time of the burn injury.
F. Burn location
1. Burn s of the head, neck, and chest are associated
with pulmonary com plications.
2. Burn s of the face are associated with corneal
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abrasion.
3. Burn s of the ear are associated with auricular
chondritis.
4. Han ds and joints require intensive therapy to
prevent disability.
5. The perineal area is prone to auto contamination
by urine and feces.
6. Circumferential burn s of the extremities can produce a tourniquet-like effect and lead to vascular
compromise (compartment syndrome).
7. Circumferential thorax burns lead to inadequate
chest wall expansion and pulmonary insufficiency.
XX. Inhalation Injuries
A. Smoke inhalation injury
1. Description: Respiratory injury that occurs when
The victim inhales products of combustion during a fire.
The airway is a priority concern in an inhalation
injury.
2. Assessment
a. Facial burns
b. Erythema
c. Swelling of oropharynx and nasopharynx
d. Singed nasal hairs
e. Flaring nostrils
f. Stridor, wheezing, and dyspnea
g. Hoarse voice
h. Sooty (carbonaceous) sputum and cough
I. Tachycardia
j. Agitation and anxiety
2. Assessment (Table 46-5)
B. Carbon monoxide poisoning
1. Description
a. Carbon monoxide is a colorless, odorless, and tasteless
gas that has an affinity for hem o- globin 200 times greater
than that of oxygen.
b. Oxygen molecules are displaced, and carbon monoxide
reversibly
binds
to
hemoglobin
to
form
carboxyhemoglobin.
c. Tissue hypoxia occurs.
C. Direct thermal heat injury
1. Description
a. Thermal heat injury can occur to the lower
airways by the inhalation of steam or explosive gases or
the aspiration of scalding liquids.
b. Injury can occur to the upper airways, which
appear erythematous and edematous, with
mucosal blisters and ulcerations.
c. Mucosal edema can lead to upper airway
obstruction, especially during the first 24 to
48 hours.
d. All clients with head or neck burns should be
monitored closely for the development of
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airway obstruction and are considered immediately for
endotracheal intubation if obstruction occurs.
2. Assessment
a. Erythema and edema of the upper airways
b. Mucosal blisters and ulcerations
XXII. Management of the Burn Injury
XXI. Pathophysiology of Burns
A. Following a burn, vasoactive substances are released
from the injured tissue, and these substances cause an
increase in capillary permeability, allowing the plasm a
to seep into the surrounding tissues.
B. The direct injury to the vessels increases capillary
permeability (capillary permeability decreases 18 to 26
hours after the burn but does not normalize until 2 to 3
weeks following the injury).
C. Extensive burns result in generalized body edema
and a decrease in circulating intravascular blood volume.
D. The fluid losses result in a decrease in organ
perfusion.
E. The heart rate increases, cardiac output decreases,
and blood pressure drops.
F. Initially, hyponatremia and hyperkalemia occur.
G. The hematocrit level increases as a result of plasm a
loss; this initial increase falls to below norm al by the
third to fourth day after the burn as a result of red blood
cell dam age and loss at the time of injury.
H. Initially, the body shunts blood from the kidneys,
causing oliguria; then the body begins to reabsorb fluid,
and diuresis of the excess fluid occurs over the next days
to weeks.
I. Blood flow to the gastrointestinal tract is diminished,
leading to intestinal ileus and gastrointestinal
dysfunction.
J. Immune system function is depressed, resulting in
immunosuppression and thus increasing the risk of
infection and sepsis.
K. Pulmonary hypertension can develop, resulting in a
decrease in the arterial oxygen tension level and a
decrease in lung compliance.
L. Evaporative fluid losses through the burn wound are
greater than norm al, and the losses continue until
complete wound closure occurs.
M. If the intravascular space is not replenished with
intravenously administered fluids, hypovolemic shock
and ultimately death occur.
A. Resuscitation/ emergent phase
1. Prehospital care
a. Begins at the scene of the accident and ends
when emergency care is obtained
b. Remove the victim from the source of
the burn.
c. Assess the ABCs—airway–breathing–circulation.
d. Assess for associated trauma, including inhalation
injury
e. Conserve body heat.
f. Cover burns with sterile or clean cloths.
g. Remove constricting jewelry and clothing.
h. Insert intravenous (IV) access.
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I. Tran sport to the emergency department.
2. Emergency department care is a continuation of care
administered at the scene of the injury.
o. Prepare the client for an escharotomy or fasciotomy as
prescribed.
4. Minor burns
a. Administer pain medication as prescribed.
b. Instruct the client in the use of oral analgesics
as prescribed.
c. Administer tetanus prophylaxis as prescribed.
d. Administer wound care as prescribed, which may
include cleansing, debriding loose tissue, and removing
any dam aging agents, followed by the application of
topical antimicrobial cream and a sterile dressing.
e. Instruct the client in follow-up care, including active
range-of-motion exercises and wound care treatments
B. Resuscitative phase
1. Fluid resuscitation (Table 46-7)
3. Major burns
a. Evaluate the degree and extent of the burn and treat lifethreatening conditions.
b. Ensure a patent airway and administer 100% oxygen as
prescribed.
c. Monitor for respiratory distress and assess the need for
intubation.
d. Assess the oropharynx for blisters and erythema; assess
vocal quality and for singed nasal hairs and auscultate
lung sounds.
e. Monitor arterial blood gases and carboxyhemoglobin
levels
f. For an inhalation injury, administer 100% oxygen via a
tight-fitting nonrebreather face mask as prescribed until
the carboxyhemoglobin level falls below 15%.
g. Initiate peripheral IV access to non-burned
skin proximal to any extremity burn or prepare for the
insertion of a central venous line as prescribed.
h. Assess for hypovolemia and prepare to administer
fluids intravenously to maintain fluid balance.
I. Monitor vital signs closely.
j. Insert a Foley catheter as prescribed and manage fluid
resuscitation with goal to maintain urine output at 30 to
50 m L/hour.
k. Maintain NPO (nothing by mouth) status.
l. Insert a nasogastric tube as prescribed to remove
gastric secretions and prevent aspiration.
m. Administer tetanus prophylaxis as prescribed.
n. Administer pain medication, as prescribed,
by the IV route.
a. The amount of fluid administered depends
on how much IV fluid per hour is required
to maintain a urinary output of 30 to
50 m L/hour.
b. Successful fluid resuscitation is evaluated by stable
vital signs, an adequate urine output, palpable peripheral
pulses, and intact level of consciousness and thought
processes.
c. IV fluid replacement may be titrated (adjusted) on the
basis of urinary output plus serum electrolyte levels to
meet the perfusion needs of the client with burns.
d. If the hemoglobin and hematocrit levels decrease or if
the urinary output exceeds 50 m L/hour, the rate of IV
fluid administration may be decreased.
Urinary output is the most reliable and most sensitive noninvasive assessment parameter for cardiac
out-put and tissue perfusion.
2. Interventions
a. Monitor for tracheal or laryngeal edema and administer
respiratory treatments as prescribed; intubation and
mechanical ventilation are instituted with respiratory
burns before com plications develop, if needed.
b. Monitor pulse oximetry and prepare for arterial blood
gases and carboxyhemoglobin levels if inhalation injury
is suspected.
c. Elevate the head of the bed to 30 degrees or more for
bur s of the face and head.
d. Monitor for fluid overload and pulmonary
edema.
e. Initiate electrocardiographic monitoring.
f. Monitor temperature and assess for infection.
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g. Initiate protective isolation techniques.
maintain strict hand washing; use sterile sheets and linen
s when caring for the client. and use gloves, cap, m asks,
shoe covers, scrub clothes, and plastic aprons.
h. Clip body hair around wound margins.
I. Monitor daily weights, expecting a weight
gain of 6-to-9-kilogram s (15 to 20 pounds) in the first 72
hours.
j. Monitor gastric output and pH levels and for gastric
discom fort and bleeding, indicating a stress ulcer.
k. Administer antacids, H2 receptor antagonists, and
antiulcer medications as prescribed to prevent a stress
ulcer.
l. Auscultate bowel sounds for ileus and monitor for
abdominal distention and gastrointestinal dysfunction.
m. Monitor stools for occult blood.
n. Obtain urine specimen form myoglobin and
hemoglobin levels.
o. Monitor IV fluids and hourly intake and out-put to
determine the adequacy of fluid replacement therapy;
notify the health care provider (HCP) if urine output is
less than 30 or greater than 50 m L/hour. Monitor
serum laboratory, including g electrolytes
and complete blood count.
p. Elevate circumferential burn s of the extremities on
pillows above the level of the heart to reduce dependent
edema if no obvious fractures are present; diuretics
increase the risk of hypovolemia and are generally
avoided as a means of decreasing edema.
q. Monitor pulses and capillary refill of the affected
extremities and assess perfusion of the distal extremity
with a circumferential burn.
r. Prepare to obtain chest x-rays and other radiographs to
rule out fractures or associated trauma.
s. Keep the room temperature warm.
t. Place the client on an air-fluidized bed or other special
mattress and use a bed cradle to keep sheets off the
client’s skin.
3. Pain management
a. Administer opioid analgesics as prescribed by
the IV route.
b. Avoid administering medication by the oral route
because of the possibility of gastrointestinal dysfunction.
c. Medicate the client as prescribed and before
painful procedures.
a. Proper nutrition is essential to promote wound healing
and prevent infection.
b. The basal metabolic rate is 40 to 100 times higher than
norm al with a burn injury.
c. Maintain NPO status until bowel sounds are
heard, and then advance to clear liquids as prescribed.
d. Dietary consultation may be prescribed. Nutrition may
be provided via enteral tube feeding or parenteral nutrition
through a central line.
e. Provide a diet high in protein, carbohydrates, fats, and
vitamins, with major bur s requiring more than 5000
calories daily.
f. Monitor calorie intake and daily weights.
5. Escharotomy
a. A lengthwise incision is made through the
burn eschar to relieve constriction and pressure and to
improve circulation.
b. Escharotomy is performed for circulatory compromise
caused by circumferential burns.
c. Escharotomy can be perform ed at the bedside without
anesthesia because nerve endings have been destroyed by
the burn injury.
d. Escharotomy may be necessary on the thorax
to improve ventilation.
e. Following the escharotomy, assess pulses, color,
movement, and sensation of affected extremity and
control any bleeding with
pressure.
f. Pack the incision gently with fine mesh gauze
as prescribed after escharotomy.
g. Apply topical antimicrobial agents to the area
as prescribed.
6. Fasciotomy
a. An incision is made extending through the
subcutaneous tissue and fascia.
b. The procedure is performed if adequate tissue perfusion
does not return following an escharotomy.
c. Fasciotomy is performed in the operating room with the
client under general anesthesia.
d. Following the procedure, assess pulses, color,
movement, and sensation of affected extremity and
control any bleeding with pressure.
Avoid the intramuscular or subcutaneous medication route for medication administration because
absorption through the soft tissue is unreliable when
hypovolemia and large fluid shifts occur.
4. Nutrition
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e. Apply topical antimicrobial agents and dressings to
the area, as prescribed.
2. Wound coverings
C. Acute phase
1. Continue with protective isolation techniques.
2. Provide wound care as prescribed and prepare for
wound closure.
3. Provide pain management.
4. Provide adequate nutrition as prescribed.
5. Prepare the client for rehabilitation.
D. Woun d care (Table 46-8)
1. Description: Cleansing, debridement, and dressing of
burn wounds
2. Hydrotherapy
a. Wounds are cleansed by showering on a special table
or washing small areas of wound at bedside.
b. Hydrotherapy occurs for 30 minutes or less to prevent
increased sodium loss through the burn wound, heat loss,
pain, and stress.
c. Client should be premedicated before procedure.
d. Hydrotherapy is not used for clients who are
hemodynamically unstable or those with new skin grafts.
e. Care is taken to minimize bleeding and maintain body
temperature during the procedure.
f. Prescribed antimicrobial agents are applied
after hydrotherapy.
3. Debridement
a. Debridement is rem oval of eschar or necrotic tissue to
prevent bacterial proliferation under the eschar and to
promote wound healing.
b. Debridement may be mechanical, enzymatic, or
surgical.
c. Deep partial-thickness burns or deep full- thickness
burn s: Wound is cleansed and debrided, and topical
antimicrobial agents are applied once or twice daily.
E. Wound closure
1. Description
a. Wound closure prevents infection and loss
of fluid.
b. Closure promotes healing.
c. Closure prevents contractures.
d. Wound closure is performed usually on day 5
to 21 following the injury, depending on the extent of the
burn.
3. Autografting
a. Autografting provides perm anent wound
coverage.
b. Autografting is the surgical rem oval of a thin layer of
the client’s own unburned skin, which then is applied to
the excised burn wound.
c. Autografting is performed in the operatingroom under
anesthesia.
d. Monitor for bleeding following the graft procedure
because bleeding beneath an autograft can prevent
adherence.
e. If prescribed, small amounts of blood or serum can be
rem oved by gently rolling the fluid from the center of the
graft to the periphery with a sterile gauze pad, where it
can be absorbed.
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f. For large accumulation s of blood, the HCP may
aspirate the blood using a small-gauge needle and syringe.
g. Autografts are immobilized following surgery for 3 to
7 days to allow time to adhere and attached to the wound
bed.
h. Position the client for immobilization and
elevation of the graft site to prevent movement and
shearing of the graft.
4. Care of the graft site
a. Elevate and immobilize the graft site.
b. Keep the site free from pressure.
c. Avoid weight-bearing.
d. When the graft takes, if prescribed, roll a cotton-tipped
applicator over the graft to remove exudate, because
exudate can lead to infection and prevent graft adherence.
e. Monitor for foul-smelling drainage, increased
temperature, increased white blood cell count, hematoma
formation, and fluid accumulation.
f. Instruct the client to avoid using fabric softeners and
harsh detergents in the laundry.
g. Instruct the client to lubricate the healing skin with
prescribed agents.
h. Instruct the client to protect the affected area
from sunlight.
I. Instruct the client to use splints and support garments as
prescribed.
5. Care of the donor site
a. Method of care varies, depending on the
HCP’s preference.
b. Non adherent gauze dressing may be applied at the time
of the surgery to maintain pressure and stop any oozing,
covering the site decreases discom fort from exposed
nerve endings; always check the surgeon’s
preference.
c. The HCP m ay prescribe site treatment with gauze
impregnated with petrolatum or with
a biosynthetic dressing.
d. Keep the donor site clean, dry, and free from
pressure.
e. Prevent the client from scratching the donor
site.
f. Apply lubricating lotions to soften the area and
reduce the itching after the donor site is healed
G. Rehabilitative phase (see Table 46-6)
1. Description: Rehabilitation is the final phase of
burn care.
2. Goals
a. Promote wound healing.
b. Minimize deformities.
c. Increase strength and function.
d. Provide emotional support.
Priority nursing action
BURN INJURY care in the emergency department
1. Assess for airway patency.
2. Administer oxygen as prescribed.
3. Obtain vital signs.
4. Initiate an intravenous (IV) line and begin fluid
replacement as prescribed.
5. Elevate the extremities if no fractures are
obvious.
6. Keep the client warm and place the client on
NPO (nothing by mouth) status.
The primary goal for a burn injury is to maintain a
patent airway, administer IVfluids to prevent
hypovolemic shock, and preserve vital organ
functioning. Therefore, the priority actions
are to assess for airway patency and to maintain a
patent airway. The nurse then prepares to
administer oxygen. The type of oxygen delivery
system is prescribed by the health care provider.
Oxygen is necessary to perfuse tissues and
organs. Vital signs should be assessed so that a
baseline is obtained, which is needed for
comparison of subsequent vital signs once fluid
resuscitation is initiated. The nurse then initiates
an IV line and begins fluid replacement as
prescribed. The extremities are elevated (if no
obvious fractures are present) to assist in
preventing shock. The client is kept warm (using
sterile linens) and is placed on NPO status because
of the altered gastrointestinal function that occurs
as a result of the burn injury. A Foley catheter
maybe inserted so that the response to the fluid
resuscitation can be carefully monitored. Once
these actions are taken, the nurse performs a
complete assessment, stays with the client, and
monitors the client closely. In addition, tetanus
toxoid may be prescribed for prophylaxis
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