Thermal, electrical, or chemical trauma → tissue destruction; intensity and
duration of heat determine depth of destruction; prognosis depends on
location and % of total body surface area (TBSA) involved.


Extent of burn (rule of nines): Body divided into sections by % to quickly
assess TBSA involved; head and neck (9%), each arm (9%), anterior trunk
(18%), posterior trunk (18%), each leg (18%), perineum (1%)
■ Minor: 15%TBSA; face, hands, feet, and genitals not involved
■ Moderate: Partial thickness 15-25% or full thickness 10%
■ Major: Partial thickness 25%; full thickness 10%; burns of face, hands,
feet, or genitals, other complications

Depth of burn:
■ Partial-thickness (superficial): Includes epidermis, may include top layer of
dermis; erythema, pain, blanching with pressure
■ Partial-thickness (deep): Includes deeper layer of dermis; erythema,
hypersensitive to touch/air, moderate to severe pain, moist blebs, blisters
■ Full-thickness: Extends through dermis and may involve underlying
tissue; pale, white, or brown charred appearance (eschar), edema,
absence of pain but severe pain in surrounding tissue, burn odor
■ Inhalation injury: Facial burns, singed nostril hair, sooty sputum, voice
change, blisters in mouth or throat, dyspnea

Burn Phases

Emergent or Immediate Resuscitative Phase
Onset of injury to 5 or more days; usually 24-48hr; from fluid loss and edema
formation until diuresis begins

Acute Phase
Weeks or months; from mobilization of extracellular fluid to diuresis; burned
area is covered by skin grafts or until wounds heal

Rehabilitation Phase
Two wk to 2-3mo; major wound closure to achievement of maximal physical
and psychosocial adjustment; mature healing of skin may take 6mo-2yr

Signs and Symptoms

Emergent or immediate resuscitative phase: Shock from pain and
hypovolemia; fluid shift to interstitial and 3rd spaces; edema; adynamic
ileus; shivering related to heat loss, anxiety, pain; altered mental state
(hypoxia due to smoke inhalation, pain meds); ↑Hct; impairment of
immune system (↓WBC)

■ Acute phase: ↓Edema; necrotic tissue sloughs; granulation occurs in
partial-thickness burns (10-14 days)

■ Rehabilitation phase: Flat, pink new skin becomes raised and hyperemic
in 4-6wk and will cause joint flexion and fixation (contracture) if not
prevented; altered contour (slightly elevated and enlarged over


At the scene of burn: Put out flames; maintain airway, breathing,
circulation; first aid to prevent shock and respiratory distress; apply cool
water briefly to ↓trauma and pain (avoid ice → ↑damage); remove
clothing and jewelry to prevent constriction related to edema; leave
adherent clothing; cover with sterile/clean dressing (no ointments); rapid
sustained flushing of skin/eyes if chemical burn

In the hospital: May require intubation, O2, mechanical ventilator; extent
and depth of burns assessed; hemodynamic monitoring; fluid replaced
using an established formula (1/2 of fluids in first 8hr and other 1/2 over
next 16hr); prevention of electrolyte imbalance (hyper/hypokalemia and
hyper/hyponatremia); IV narcotic analgesics; wound care; tetanus toxoid;
ECG for electrical burns; meds to prevent Curling’s ulcer; ↑calorie, ↑protein
diet, vitamins and iron; pressure garments (↓scars); splints (↓contractures)

■ During rehabilitation: PT, OT, vocational education; reconstruction
(cosmetic, functional); counseling to manage

Nursing Care

Emergent or immediate resuscitative phase: Maintain respirations;
maintain patent airway (suction, endotracheal tube, mechanical ventilator);
monitor ABGs, O2 sat, breath sounds; place in Fowler’s position;
↑coughing; teach incentive spirometry; monitor fluid shift from
intravascular to interstitial space
Acute phase: Monitor fluid shift from interstitial to intravascular space

■ All Phases
■ Maintain fluid balance: Monitor S&S of fluid shifts, edema, daily
weight, I&O, hemodynamic status; give po fluids when ordered
■ Maintain circulation: Provide IV F&E, colloids as ordered, maintain
urinary output ≥30-50mL/hr, systolic BP ≥100mmHg, and pulse
■ Prevent infection: Assess for S&S of infection (↑T and ↑WBC, wound
bed and donor sites for purulent drainage, edema, redness); use
contact precautions; give systemic/topical antimicrobials/antibiotics;
provide surgical aseptic wound care as ordered
■ Manage pain: Give pain meds before procedures and routinely before
pain↑; use nonpharmacological interventions (distraction); use lifting
sheet; keep room temperature 80-85F, humidity 40%, prevent drafts
Maintain nutrition: NPO initially, high-calorie, high-protein diet with
supplements when able, tube feedings or parenteral nutrition
■ Provide emotional support: Address fear, grief, altered role, body image
(explain that edema will subside in 2-4 days); explain all care
■ Maintain bowel function: Assess bowel function, maintain NGT to
decompression (↓N&V, aspiration, ileus formation)
■ Ongoing care: Assist with hydrotherapy, debridement, grafting; plan for
rest; maintain mobility and prevent contractures (positioning, splints,
ambulation, ROM); teach use of pressure garments and skin lubrication;
↑self-care activities when able

Rehabilitation phase: Continue monitoring for infection and providing
nutritional support until skin coverage is achieved; protect new skin from
injury; teach: self-care, wound care; reassure appearance will continue to
improve over time; refer to support group.
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