Burns are a global public health problem, accounting for an estimated 180,000 deaths annually. The majority of these occur in low- to middle-income countries and almost two-thirds occur in the WHO African and Southeast Asia regions. Outcomes for burn clients have improved dramatically over the past 20 years, yet burns still cause substantial morbidity and mortality.
Burns are tissue damage that results from heat, overexposure to the sun or other radiation, or chemical or electrical contact. Burns can be minor medical problems or life-threatening emergencies. The skin location, the degree of temperature, and duration are contributing factors to the severity of the burn. There is a synergistic effect between the temperature and duration of exposure.
The basis of burn classification is depth. When examining a burn, there are four components needed to assess depth: appearance, blanching to pressure, pain, and sensation. Burns can be categorized by thickness according to the American Burn Criteria using those four elements.
- Partial thickness
- Superficial or fist-degree burns involve the epidermis of the skin only. It appears pink to red, there are no blisters, and it is dry. It is moderately painful. These burns heal without scarring within 5 to 10 days.
- Superficial partial-thickness or second-degree involves the superficial dermis. It appears red with blisters and is wet. The erythema blanches with pressure. The pain is severe. Healing typically occurs within 3 weeks with minimal scarring.
- Deep partial-thickness or third-degree burns involve the deeper dermis. It appears yellow or white, is dry, and does not blanch with pressure. There is minimal pain due to a decreased sensation. Healing occurs in 3 to 8 weeks with scarring present.
- Third-degree involves the full thickness of the skin and subcutaneous structures. It appears white or black/brown. With no pressure, blanching occurs. The burn is leathery and dry. There is minimal to no pain because of decreased sensation. Full-thickness burns heal by contracture and take greater than 8 weeks. Full-thickness burns require skin grafting.
- Fourth-degree shows charred skin with possible exposed bone.
- Fifth-degree has charred, white skin and exposed bone.
- Sixth-degree has loss of skin with exposed bone.
The skin is the body organ most commonly injured but internal burn injuries can also result from smoke inhalation. Most burns are caused by wet (hot fluids and steam) or dry heat and flames. Poverty and poor housing are known to be risk factors worldwide but every country has unique risk factors due to varied cultures and circumstances.
- Gender. Females have a slightly higher rate of death from burns compared to males according to the most recent data. This is associated with open-fire cooking or inherently unsafe cookstoves, which can ignite loose clothing.
- Age. Along with adult women, children are particularly vulnerable to burns. Burns is the fifth most common cause of non-fatal childhood injuries.
- Regional factors. Children under 5 years of age in the WHO African Region have over two times the incidence of burn deaths than children under 5 years of age worldwide. Boys under 5 years of age living in low- to middle-income countries of the WHO Eastern Mediterranean Region are almost two times as likely to die from burns as boys living in the WHO European Region.
- Socioeconomic factors. People living in low- and middle-income countries are at higher risk for burns than people living in high-income countries. Within all countries, however, burn correlates with socioeconomic status.
- Other risk factors. There are a number of other risk factors for burns, including occupations that increase exposure to fire, poverty, overcrowding and lack of proper safety measures, placement of young girls in household roles, underlying medical conditions, alcohol abuse, and smoking, easy access to chemicals used for assault, use of kerosene, and inadequate safety measures for liquefied petroleum gas and electricity.
The true epidemiology and trends in the burden of burn injuries globally are unclear, and there are marked differences in the estimates from modeling initiatives and results from population-proportional, cluster-randomized household surveys. Regardless, a detailed epidemiological understanding of the health, social, and economic burdens incurred is important as a foundation for advocacy, resource planning, and benchmarking interventions.
Burns from fire, heat, and hot substances are the fourth most common type of civilian trauma worldwide, following road traffic incidents, falls, and interpersonal violence. It is estimated that there are between 7 and 12 million people who sustain burn injuries that require medical care.
In India, over 1,000,000 people are moderately or severely burnt every year. Nearly 173,000 Bangladeshi children are moderately or severely burnt each year. In Bangladesh, Colombia, Egypt, and Pakistan, 17% of children with burns have a temporary disability and 18% have a permanent disability.
In the United States, approximately 1.25 million people with burns present to the emergency department (ED) each year. Among these, 63,000 have minor burn injuries that are treated primarily in the ED, and an additional 6000 sustain major burn injuries that require hospital admission.
Tissue burn involves direct coagulation and microvascular reactions in the surrounding dermis that may result in the extension of the injury. Large injuries are associated with a systemic response caused by a loss of the skin barrier, the release of vasoactive mediators from the wound, and subsequent infection. This results in interstitial edema in distant organs and soft tissues, with an initial decrease in cardiac output and metabolic rate.
The classic description of the burn wound and surrounding tissues is a system of several circumferential zones radiating from primarily burned tissues.
- Zone of coagulation. A nonviable area of tissue at the epicenter of the burn.
- Zone of ischemia or stasis. Surrounding tissues (both deep and peripheral) to the coagulated areas, which are not devitalized initially but, due to microvascular insult, can progress irreversibly to necrosis over several days if not resuscitated properly.
- Zone of hyperemia. Peripheral tissues undergo vasodilatory changes due to neighboring inflammatory mediator release but are not injured thermally and remain viable.
Burn symptoms also include:
- White or charred skin
- Peeling skin
Burn wounds are evaluated according to their extent, depth, and circumferential components. Decisions regarding the type of monitoring, wound care, hospitalization, and transfer are made based on this information.
- The extent of the burn. Burn size or extent can be estimated in a number of ways. Perhaps the most accurate is the age-specific chart based on the Lund-Browder diagram that compensates for the changes in body proportions with growth. An alternative in adults is the “rule of nines”. This is less accurate in children because their body proportions are different from those of adults. For areas of irregular or nonconfluent burns, the palmar surface of the client’s hand can be used. The client’s palm is approximately 1% total body surface area (TBSA) and can be used for estimating patchy areas. The head/neck is 9% TBSA, each arm is 9% TBSA, the anterior thorax is 18% of TBSA, the posterior thorax is also 18% TBSA, each leg is 18% TBSA, and the perineum is 1% TBSA.
- Burn depths. Burn depth is classified as first, second, thor, or fourth degree.
- First-degree. These burns are usually red, dry, and painful. They begin sloughing off the next day.
- Second-degree. These are often red, wet, and very painful.
- Third-degree. These burns are generally leather in consistency, dry, insensate, and waxy. These wounds will not heal, except by contraction and limited epithelial migration with unstable cover. Burn blisters can overlie both second and third-degree burns.
- Fourth-degree. These involve underlying subcutaneous tissue, tendon, or bone.
How to calculate the Total Burn Surface Area (TBSA)
The Total Burn Surface Area (TBSA) is an important metric for determining the extent of burns on a patient’s body. The Rule of Nines is a popular method for calculating TBSA. The body is divided into segments using an imaginary border, with each segment representing 9% or multiples of 9% of the body surface area. The table below shows how adults and children scored using the Rule of Nines:
|Percentage for Adults
|Percentage for Children
|Head and neck
|Chest and abdomen
|Lower back and buttocks
To calculate the TBSA, the percentage of each burned segment is added together. For instance, if a patient has burns on their chest and abdomen (18%) and both arms (9% each), the TBSA would be 36% (18% + 9% + 9%). Nonetheless, it is essential to note that this method is not entirely accurate, and other factors, such as the depth and severity of the burn, should also be taken into account when determining treatment.
Most burns are small; clients with small burns are appropriately treated in an outpatient setting if the burns do not involve critical areas such as the face, hands, genitals, or feet. The best plan is to coordinate outpatient management with the burn unit’s team of healthcare providers, nurses, and therapists because their expertise may facilitate attaining optimal results.
- Client and family education. The client and family must be able to support an outpatient care plan. An adult caregiver should be available who can be with a child treated in the outpatient setting. A family member must be available who can perform the necessary wound cleansing, inspection, and dressing applications because most clients cannot do this themselves.
- Wound cleansing. Gently clean the wound of debris and exudate on a regular basis. This usually requires the daily removal of accumulated exudate and topical medications. Clients may clean the burn with lukewarm tap water and mild soap if the wound is a small superficial burn. Gently cleanse the wound with a gauze or clean washcloth, inspect for signs of infection, pat dry with a clean towel, and re-dress the client.
- Wound dressing. Wound dressing, whether one is using topical medication or a wound membrane, should provide four benefits, including prevention of wound desiccation, control of pain, reduction of wound colonization and infection, and prevention of added trauma to the wound. Most topical dressings have a viscous carrier that prevents wound desiccation and a broader antibacterial spectrum that reduces wound colonization. The addition of a gauze wrap minimizes the soiling of both clothing and unburned skin and protects the wound from the external environment.
- Pain control. An oral narcotic medication administered 30 to 60 minutes prior to a planned dressing change provides adequate pain control.
- Excision and grafting. Early excision and closure of full-thickness wounds change the natural history of burn injury, avoiding the otherwise common occurrence of wound sepsis. Wound size is the most important factor in determining the need for early operation because this correlates with the physiological threat of the injury. If wounds involve more than 50% TBSA, achieving immediate autograft closure is often impossible.
- Skin substitutes. Temporary skin substitutes provide protection from mechanical trauma, a vapor barrier, and a physical barrier to bacteria. These membranes contribute to a moist wound environment with a low bacterial density that is consistent with optimal wound healing. Split-thickness human allograft remains the optimal temporary skin cover.
- Resuscitative fluid management. The Parkland formula advocated the guideline for the total volume of the first 24 hours of resuscitation (with Ringer lactate solution) at approximately 4 mL/kg body weight per percentage burn TBSA. With this formula, half the volume is given in the first 8 hours postburn, with the remaining volume delivered over 16 hours. Hourly urine output is a well-established parameter for guiding fluid management. The rate of fluid administration should be titrated to a urine output of 0.5 mL/kg/hr or approximately 30 to 50 mL/hr in most adults and older children. In small children, the goal should be approximately 1 mL/kg/hr.
Clients with acute burns require significant and costly interprofessional care that includes nurses, advanced practitioners, surgeons, pharmacists, physical and occupational therapists, and social workers. Proper initial management of a client with serious burns can have a significant impact on their long-term health outcomes.
Primary assessment of clients with burns starts with airway patency and cervical spine protection. Breathing, central and peripheral circulation, and cardiac status are assessed; any disability, deficit, or gross deformity is stabilized; and clothing is removed to assess the extent of burns and concurrent injuries.
- Areas of numbness, tingling or burning pain
- Changes in vision or decreased visual acuity
- History of impairments and other medical conditions
- Lack of safety practices
- Engaging in risky behavior
- Exposure to violence or abuse
- Decreased or absent urinary output
- Decreased or absent bowel sounds
- Generalized tissue edema
- Weight loss
- Nausea and vomiting
- Changes in orientation, affect, or behavior
- Decreased deep tendon reflexes
- Guarding behavior
- Thoracic excursion in chest burns
- Upper airway stridor, wheezes
- Breath sounds such as crackles, stridor, rhonchi
- Tissue trauma according to the degree of burn injury
- Singed nasal hairs, dry and red mucous membranes
- Risk for ineffective airway clearance related to tracheobronchial obstruction, trauma, or pulmonary edema
- Risk for deficient fluid volume related to loss of fluid through burn wounds and hypermetabolic state
- Acute pain related to destruction of skin tissues and edema formation
- Risk for infection related to destruction of the skin barrier or suppressed inflammatory response
- Ineffective peripheral tissue perfusion related to circumferential burns of extremities with edema
- Imbalance nutrition: less than body requirements related to hypermetabolic state, protein catabolism, or anorexia
- Impaired physical mobility related to neuromuscular impairment, pain, limb immobilization
- Impaired skin integrity related to disruption of skin surface
- Fear/Anxiety related to the threat of death/disfigurement, a memory of the traumatic event, or hospitalization
- Disturbed body image related to disfigurement and pain
- Deficient knowledge related to lack of exposure or unfamiliarity with resources
Nursing Desired Outcomes
- The client will maintain a patent airway and respiratory function.
- The client will demonstrate hemodynamic stability and restored circulating volume.
- The client will report a reduction or alleviation of pain.
- The client will be free of complications.
- The client will achieve timely wound healing.
- The client will maintain palpable peripheral pulses of equal quality and strength.
- The client will demonstrate nutritional intake adequate to meet metabolic needs.
- The client will maintain a position of function and strength of affected limbs.
- The client will report anxiety and fear are reduced to a manageable level.
- The client will verbalize acceptance of self in the situation.
- The client will verbalize understanding of therapeutic needs.
- Assess circulation. Edema formation and tissue destruction signal the need to assess peripheral circulation more frequently for the first 24 to 36 hours in affected areas, especially if there is a circumferential injury. The nurse should assess skin color and temperature, sensation, peripheral pulses, and capillary refill.
- Perform effective wound care routinely. Wound care is essential to prevent infection and should be performed immediately after completing primary and secondary assessments and any life or limb-threatening conditions are treated. After pre-medicating the client with a narcotic analgesic, the affected area is washed thoroughly using water and skin disinfectants. Debris found on the wound is cleansed and large ruptured blisters are debrided. An antibacterial ointment may be applied and a non-adherent gauze may cover any open areas.
- Provide early fluid resuscitation. Most burn centers use a modified Parkland formula to calculate total fluid volume requirements. Half of the volume calculated is given in the first 8 hours post-burn injury, 25% in the second 8 hours, and the final 25% in the last 8 hours. Rapid and aggressive fluid resuscitation is needed to replace intravascular volume and maintain end-organ perfusion. Although crystalloids like lactated Ringer are the preferred volume-replacement therapy, some clients will require colloids to retain as much fluid as possible inside the vessels.
- Reduce pain and anxiety. Pain at the secondary assessment will vary based on injury depth and the amount of nerve involvement. A variety of nonpharmacologic interventions can reduce pain and allow the members of the healthcare team to provide treatments and therapies. The affected extremities should be elevated above the level of the heart to decrease edema and subsequent pain. The client should be pre-medicated prior to dressing changes or other procedures that may require mobility of the affected area.
- Provide emotional support. Psychosocial and the resulting responses to burn trauma may vary. The nurse should be prepared to provide emotional support throughout the resuscitation process. Talk the client through interventions to gain their trust and promote rapport. The client’s feelings should be acknowledged and no judgemental comments must be given.
- Monitor for signs of infection. Early recognition of wound infection through daily assessment helps limit mortality and morbidity. When removing dressings, the nurse should assess for changes in wound exudate (color, amount, and odor(, signs of cellulitis (inflammation or erythema of the surrounding tissue), increased wound pain, and loss of previously healed skin. Untreated wound infection can progress to deeper wound infection, leading to sepsis.
- Assist in the rehabilitation of the burn client. As a burn wound heals, continual contraction of the scar creates most chronic problems. Rehabilitation from the time of admission helps prevent contractures and diminishes the need for reconstructive surgery. Proper positioning helps protect the client’s wounds, decrease edema, and counteract scar contraction. Positions usually involve placing extremities in a functional position and joints in extension. Splinting of affected areas begins as soon as possible after the injury. Splinting helps protect joints and skin grafts and achieve anatomic positioning to prevent contracture formation. An active, progressive exercise program is essential to prevent permanent burn scar contracture and to maintain a normal range of motion in affected joints.
- The client achieved homeostasis.
- The client reported pain is controlled or reduced.
- The client displayed prevention of complications.
- The client dealt with the current situation realistically.
- The client understood their condition, prognosis, and therapeutic regimen.
- The client adhered to the plan in place to meet needs after discharge.
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