Burn Care Nursing

Hot, intense and demanding, burn care nursing represents one of the profession's most challenging specialties, but nurses who gravitate to it tend to stay for years. "All the classes you take in nursing school, you utilize in a burn unit's psychology, communication skills and physiological aspects of caring for sick patients," said LaVelle Grubb, RN, a staff nurse and unit education coordinator at the 14-bed John S. Dunn, Sr. Burn Center at Memorial Hermann Hospital in Houston, Texas.

Grubb began her burn career as a volunteer reading to or visiting with patients at the Galveston, Texas, hospital where her mother worked as a burn nurse. The patients' disfigurement and dressings never bothered her.

Making up her mind on a nursing career at 12 years of age, she received her cap 35 years ago and immediately went to work in a burn unit, moving up to head nurse, before relocating to Houston and Memorial Hermann, where she has worked since 1982. Twenty-two years ago, she cared for Darrell Essary, a 20-year-old ironworker who had sustained an electrical burn over 33 percent of his body. About a year after his 53-day stay, he called Grubb and asked to volunteer on the unit. Essary found it so rewarding, he returned to school and became a registered nurse, for the past eight years working side-by-side with Grubb. He also established and facilitates an outpatient support group and a volunteer cadre of burn survivors who provide one-on-one peer support to hospitalized patients. "The burn may have been one of the best things that happened to me, as far as changing my life and giving me a whole new outlook," Essary said. "I've been offered other positions, but I haven�t been able to pull myself away from the bedside and working with burn patients." Essary is pursuing a master's degree and aims to become a nurse practitioner on the burn unit. He especially enjoys the unique relationships burn nurses establish with their patients. He involves patients in their care and knows the value of active rehabilitation. He often speaks from experience to motivate patients. The specialty requires a certain finesse. "Burn nursing is physically and psychologically demanding and is certainly not for everybody," said Mary-Liz Bilodeau, RN, MS, CCRN, CCNS, CS, BC, clinical nurse specialist and nurse practitioner at Massachusetts General Hospital in Boston. "But it is one of the most gratifying and satisfying areas of nursing."

Many burn units, such as the ones at Memorial Hermann and Massachusetts General, are set up to care for patients from initial injury, when their breathing is assisted by a ventilator and are needing total care, until they leave the hospital. "You see progress and the patient getting better and their pain going away," Grubb said. "By the time they are ready for discharge, you see a stable individual leaving, not someone depressed or crying." Mass General's unit even contains ambulatory services. "When the patients come back to the outpatient center and staff see them again, that does a lot for staff moral," said Bilodeau, who has worked with trauma and burn patients for 28 years. She provides care throughout the patients' stays and works with new and senior staff to advance their practice based on the latest research. At Memorial Hermann, RNs provide almost all of the care, from dressings to drawing blood to medications. Dressing changes and burn scrubs may take an hour for an experienced burn nurse but three hours for a critical-care nurse floating to the unit. Specially trained technicians change dressings at the University of Kansas Hospital's Burnett Burn Center in Kansas City, leaving nurses more time for monitoring fluids, protecting airways and other critical care. "It's very holistic, because you do everything for the patient. And you work as a team with different disciplines," said Rosie Thompson, RN, MS, clinical nurse specialist at the University of Kansas center. The care team includes nurses, physicians, respiratory therapists, physical and occupational therapists, psychologists and pain-management experts. Burn care nurses agree that pain control has improved from years past. Nurses use distraction and anti-anxiety drugs as well as powerful analgesics to keep patients comfortable. "It has a lot to do with your approach and the patient trusting you," Grubb said. "Once the patient sees that even though you are hurting them, you are helping them, then it all takes on a new aspect of care." Many burn patients suffer from mental illnesses or substance-abuse problems; some having received their burns in a suicide attempt. Even with pure accidents, patients worry about their appearance and future limitations and require psychological support. "Everyone truly works together," Bilodeau said. "There is not a lot of hierarchy in the burn world. Everyone's opinion is valued and sought after. That's how we help the patient get better." Patients typically stay one day for each one percent of burn. Nurses may care for patients at all stages of their recovery, one-on-one with a new patient or with two who have sustained less severe injuries or are becoming more independent. The variety of assignments helps prevent burnout, Grubb said. Working on a burn unit, kept at about 90 degrees due to patients� skin loss, can be draining. The nurses support each other and strive for balanced lives and activities outside the unit. "Everyone has their own way of dealing with the stress," Bilodeau said. "You have to put a little distance between yourself and some of these cases. It can wear you down." Nurses often become involved in survivor groups and professional organizations, such as the World Burn Congress and American Burn Association. Burn nurses also tend to reach out to the community with prevention efforts or fellow professionals to educate them about treatment advances. "Burns are 99 percent preventable," said Pam Pucci, RN, BSN, Trauma Burn Center nurse educator for the University of Michigan Health System in Ann Arbor. Pucci, a 17-year burn-care veteran, began a safety program four years ago for youths, after noting a 17 percent increase in admissions. She focuses on teaching youngsters who have started a fire in the past about the dangers associated with the behavior and the course of treatment if they are injured. "The recidivism rate for children who attend the program is zero," Pucci said. "They don't repeat the at-risk behavior." University research indicates that 36 percent of children who do not receive the training will set another fire. Pucci receives referrals from fire departments, courts, schools and parents. The team at Memorial Hermann has taught United States astronauts about burn care, in case of injury during a mission. While their teachings circle the earth, Memorial Hermann nurses continue providing daily care, their satisfaction soaring just knowing their actions and care have turned potentially tragic endings into new beginnings for their patients. "It is rewarding to see the difference I make in a patient's life, from the time they are real sick until discharge," Essary said. "And since I facilitate the support group, I get to see them come back and grow into a normal life with new relationships."

I remember turning on the hot water tap in the bathtub that evening in 1968 before bending over to wash my hair. I was 16 and had long hair then, and I wanted it to look good for school the next day. As I knelt down, everything went black, for it was at that moment that I had an epileptic seizure and fell into the tub, hitting my head on the unforgiving porcelain.

At some point, I regained enough consciousness to begin struggling to escape the scalding water that was pouring out of the faucet. The noise alerted my father, who came to my rescue, only to find me lying semi-comatose in the tub, my skin red and shriveled. My mom phoned for help, and I was rushed by ambulance to our local hospital with burns over 40% of my body.

Though the hospital lacked a burn unit, the action taken by the ED staff was similar to the way in which burn victims should be approached today: They treated me as a trauma patient—which is what burn patients are. As such, burn patients require the same initial treatment.1 From a nursing perspective, that means assessing airway, breathing, and circulation (the ABCs), providing adequate fluid resuscitation, and evaluating and treating the wound.

Treat the patient, not just the burn

According to the American Burn Association, there are more than 1 million burn injuries and 4,500 fire and burn deaths annually in the United States. It's estimated that 700,000 of the injured are taken to the ED and 45,000 are hospitalized each year. Half of those who are admitted go to the 125 specialized burn centers around the country, and the rest to the nation's 5,000 other hospitals.1,2

Among the most common burns are those caused by scalds,3 which is what I'd experienced in a major way; so major, in fact, that I required skin graft surgery. But before that procedure took place, my care began as every trauma patient's should, with a primary survey. Perform one whenever you care for a burn patient who is being seen for the first time or in whom the extent of injury is unknown. First and foremost, treat the patient, not just the burn. Rapidly assess the ABCs and look for signs of an airway obstruction or other life-threatening conditions, which may cause death more quickly than a burn injury would.4 Focusing solely on the burn wound and not the whole patient may cause you to miss such signs.

Suspect inhalation injury if you observe singed facial hair, carbonaceous sputum, soot in the oropharynx, hoarseness, neck or face burns, or stridor—an ominous sign. When in doubt, intubate early; it's much more difficult once the patient's airway becomes swollen from smoke inhalation.1 Laryngeal edema is progressive in the first 18 – 24 hours of inhalation injury.

In patients with major burns, start an IV to replace fluid loss. Fluid replacement will also become an important part of your care later—up to 48 hours after injury. But more on that in a bit.

When the patient is stabilized, perform a more thorough secondary survey, which includes assessing the depth and extent of the burn.1 Expose the wound completely, if possible; it's important, however, to leave any clothing adhering to the burn in place. To reduce the risk of hypothermia, provide a warm environment for the patient while these tasks are being performed.5

You'll need to grade the burns so that the ED physician can decide whether to admit the patient to the hospital, treat her as an outpatient, or transport her to a special burn center without delay.6 Determine the depth of the burn by using the degree scale described in the table on pages 56 and 57. Then calculate the total body surface area (TBSA) affected.

To estimate the TBSA affected in adults, use the rule of nines method. Under this rule, an adult's head and neck account for 9% of TBSA, each arm is 9%, each leg is 18%, the front and back of the torso are 18% each, and the perineum is 1%. (A diagram is available at www.nda.ox.ac.uk/wfsa/html/u10/u1010p01.htm..) One caveat: The rule of nines can't be used for children because a child's body proportions are different from that of an adult.1 For children, use the Lund-Browder classification, available at www.nda.ox.ac.uk/wfsa/html/u10/u1010p02.htm.. Because it takes age-related body proportions into consideration, this method of classification will help you make a more accurate assessment of a child's burns.

Your care will vary by injury severity

The American Burn Association advises that patients with partial thickness burns greater than 10% of the TBSA, those suffering third-degree burns, and those with burns of the face, hands, feet, genitalia, perineum, or major joints be referred to a burn unit.7 If a patient is going to be transported to a burn center, cover the burn with a clean, dry sheet, because airflow over the affected areas can be painful. In cases such as this, do not use any creams, which can impede visualization of the wound after the patient is transferred.1

Most burn injuries seen in the ED, however, are relatively minor.7 The first step in treating burns without blistering or deep skin damage is to use a lotion to keep the skin moist. Clean burns that have blistered with a mild antimicrobial soap, such as 4% chlorhexidine topical (Hibiclens, Hibistat), and irrigate the affected area copiously with water. Next, shave any hair that's within three to four inches of the wound to reduce the risk of infection and allow for better inspection of the injury.

Intact blisters and loose, nonviable tissue will need to be debrided. Apply an antibiotic ointment or cream, such as silver sulfadiazine (Silvadene, Thermazene, others), to prevent infection after debriding.3 Don't use silver sulfadiazine for patients who have facial burns or who are allergic to sulfa drugs; use bacitracin (Baciguent) or another antibiotic instead. Apply these medications twice a day, and cover the wound with a clean, non-stick gauze dressing like Telfa.6 Another option is to apply one of the new, jelly-like hydrocolloid dressings (Tegasorb, DuoDerm, others). Leave it in place for about 72 hours and then change it every five to seven days.

Although many patients get considerable relief from the application of antibiotic ointment or cream, some may need pain-killing drugs or, in extreme cases, narcotics.

If your patient suffered major burns, as I did, she's at risk of developing hypovolemia from massive fluid shifts that occur in the first 24 – 48 hours following the burn injury. Prepare to begin aggressive fluid resuscitation if the patient's injury covers more than 20% of TBSA or if she has burns on the face or hands, which could keep her from drinking enough fluids. If possible, place two large-bore IV catheters through unburned skin. If you must place an IV in a burned area, thread the cannula far enough into the vein so that the swelling that occurs later won't push the hub out, causing infiltration.1

Fluid resuscitation is typically accomplished using the Consensus Formula, a combination of the Parkland and the modified Brooke formulas. It calls for infusing lactated Ringer's solution over the first 24 hours after the burn injury. The recommended quantity is 2 – 4 ml/kg body weight per percent of TBSA, giving half the amount over the first eight hours and the rest over the next 16 hours.

As an example, the fluid needs of a 185-pound man with burns over 35% of his body would be calculated as such: 2 – 4 ml 2 81 kg 2 35% = 5,670 – 11,340 ml.

Regulate fluid by monitoring hourly urine output. For an adult, you should administer the solution at a rate sufficient to maintain urine output of 30 – 50 ml/hr, or 0.5 ml/kg/hr for an adult and 1 ml/kg/hr for children who weigh less than 30 kg. Don't increase fluids in an attempt to keep urine output above the recommended range because this can lead to increased intracranial pressure, pulmonary edema, and heart failure.1

Another concern is that in some burn patients, chest expansion is restricted because of burns around the chest wall, making breathing difficult. This condition may require escharotomy, which involves cutting through the burned tissue until healthy tissue is reached. Escharotomy may also be needed for circumferential burns—those around the arms, legs, fingers, or toes; the procedure can save these body parts by releasing the fluid that has built up underneath the burned areas.6

An important part of burn management is providing adequate pain relief.6 Morphine is the gold standard. The typical adult dosage is 3 – 5 mg IV, repeated at five- to 10-minute intervals until pain is controlled.1 For children, the dose is 0.1 – 0.2 mg/kg/dose every two to four hours as needed. If the patient can't tolerate morphine, fentanyl (Sublimaze) is an alternative.

A reminder: Burn patients who haven't had a tetanus booster in five years will need to be immunized.

Surgery is required for the worst burns

There are several treatment options for major burns, depending upon their severity. Partial thickness burns, which damage the epidermis and a small part of the underlying dermis, can heal on their own when treated with cleaning and bandaging.

Surgery is required for burns that damage both the epidermis and most of the dermis. Surgery replaces damaged skin with a graft of healthy skin or a skin substitute. If burn wounds requiring surgery are not treated, the body attempts to close them by forming scar tissue. Over time, the scar tissue contracts, leading to disfigurement and loss of motion in nearby joints.

In the grafting of burn wounds, surgeons use healthy skin from another part of the patient's body as a permanent treatment—a process called autografting. An alternative is to transplant skin from a cadaver, known as an allograft, or from an animal, such as a pig, called a xenograft. Allografts and xenografts are temporary coverings; within several weeks, both types will be rejected and must be replaced with an autograft.8

Burns that are extensive or in a sensitive area, such as the face, may benefit from the surgical placement of grafting material made with animal tissue, such as Biobrane or Integra. In recent years, the FDA has also approved temporary skin substitutes made with human tissue, such as OrCel and TransCyte, which promote faster healing.8

Skin substitutes weren't around when my burns were being treated; I had extensive grafting surgery instead. Initially, skin was grafted from my legs to my back, neck, and part of my chest. Even with medication, the pain was severe and remained that way for quite some time. Twice a day, I went to physical therapy and soaked in the tub, of all places. I had to keep moving, and water exercises helped my joints. I'm told it was touch and go for a few weeks—my natural defenses have caused me to block out memories of the unpleasant events.

After three months, I went home to my family, only to return to the hospital for more surgery two months later. A year later, I had still more surgery. I badly wanted to resume competing on my school's swim team, and eventually I was able to do that. I went on with my life, graduating from high school, college, and nursing school. I even worked in a burn unit for a time.

Twenty years ago, burns covering half the body were routinely fatal, so I was lucky. Today, because of advances in resuscitation, wound care, infection control, and grafting, patients with burns covering 90% of their bodies can survive.3 My surgeon worked miracles, but I know he couldn't have done it without the benefit of a team of nurses and the knowledge, assessment skills, emotional support, and teaching they brought to my care.

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Classifying burns

The severity of a burn can be graded by using the degree scale, which classifies burns according to their depth and helps to determine treatment.

Superficial:

Often called first-degree, these burns damage only the epidermis, or outer layer of the skin. They're pink to red and painful. There's some edema, but no blisters or eschar. Dead skin may peel away two to three days after the burn.

Superficial partial thickness:

One of two types of second-degree burns, these extend into the upper dermal layer and leave the skin pink to red. Because nerve endings are exposed, any stimulation causes intense pain. There is mild to moderate edema and the burn will blister, but there is no eschar.

Deep partial thickness:

This more severe type of second-degree burn, extending into the deeper layers of derma, leaves the skin red to pale, with moderate edema. Blisters are rare but there will be soft, dry eschar. The patient will experience pain, but not as much as in a superficial partial thickness burn because some of the nerve endings have been destroyed.

Full thickness:

Also known as third-degree burns, these leave the skin black, brown, yellow, white, or red. Edema is severe. The burn penetrates the derma and sometimes reaches into subcutaneous fat. Pain is minimal because the nerve endings are almost completely destroyed. There are no blisters, but there is hard, inelastic eschar.

Deep full thickness:

These fourth-degree burns are the most serious. The burn extends through the skin into the underlying fascia and may even damage the tendons and bone. The skin is black with no edema, and the eschar is hard and inelastic. Because nerve endings have been destroyed, pain is minimal.

SOURCE: Ignatavicius, D. A., Workman, M. L., & Mishler, M. A. (Eds.). (1999). Medical-surgical nursing across the health care continuum (3rd ed.), (pp. 1754 – 1758). Philadelphia: W. B. Saunders.

 

Burn Care Nursing

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