Types of Patients VII: Burns

And no, we're not talking about the Scottish poet.

Burns patients often suffer an extreme amount of pain. Not surprisingly, they often describe it as a "searing" pain, ever present and exaggerated by air, alleviated by being immersed in water or covered with salve. In fact, rule of thumb is, if a burn doesn't hurt it is either very superficial or just the opposite: deep and serious. The reason for the latter is that the burn has destroyed nerve endings, representing a deep and potentially debilitating wound.

Alleviating pain with narcotics is a nursing priority, but, as I tell many burns patients, we can take away some of the pain, but it is unlikely we can take away all of the pain. Heavy sedation is necessary for seriously burned patients. We do not do this in the ER; we prefer our patients to be able to recognize their surroundings and talk about what is happening to them. Heavy sedation can be done in a burns unit. We air-transport these patients to Harborview, the trauma center in Seattle.

All burns occur because of heat, but the heat source differentiates different types of burns and also specialized treatment. Thermal burns occur because of direct contact with something hot, like fire, steam, hot oil. Radiation burns result from exposure to radiation, like sunburn. Chemical burns are the result of direct contact with acidic substances, like lye. Finally, inhalation burns are caused by breathing in super-heated fumes from fire, burning chemicals, or even steam.

The first nursing priority for a burns patient is, like all others, A for airway. Specifically, did the burn occur in an environment or a condition that could have affected the airway. The mucousal lining of the airway (i.e., the mouth, nares, pharynx, and trachea) can be easily damaged by each of the types of burns mentioned above. Swelling of or seeping fluids from the damaged airway structures, can occlude the airway. The nurse should be keenly observant of burnt facial hair, lips, nose hair, etc., which may be a telltale sign of complications with the airway.

The second priority is B for breathing. Has the burn caused difficulty breathing? Did the person inhale smoke, steam, burning chemicals? High-flow oxygen may be necessary to help oxygen transport through bronchi, bronchioles, and air sacs that have been impaired.

The third priority is C for circulation. Important here is the issue of fluids. Because skin, the largest organ of the body, is also the main protectorate of everything underneath it, losing it to a burn represents not only an impairment of skin integrity but also loss of insulation and fluid retention. Large and serious burns can result in relative dehydration of the patient in a very short time. Fluid resuscitation (i.e., the administration of massive amounts of IV fluid) may be necessary to avoid hypotension and cardiac dysrhythmias.

Attention to the ABCs is equally augmented by two factors: (1) how much of the surface of the body has been burned, and (2) how deep the burns are.

Nurses need to quickly determine the former by using the Rule of Nines. Basically, for a normal size adult, each section of the body constitutes 9% of total body surface area. A circumferential burn of the arm would be 9%; a burn expanding over the back would be 9%; a circumferential burn of the thigh would be 9%, etc. Nurses initially should guestimate; later and more precise measurement will determine long-term therapy.

The degree of the burn also determines treatment. 1st degree burns are superficial (e.g., a sun burn) and do not often require fluid resuscitation. These burns may or may not blister, and dead skin will eventually slough off. 2nd degree burns (partial thickness burns) go deeper, blister, and may require debridement (i.e., removal of damaged skin layers). These burns will usually leave scarring.

3rd degree or full thickness burns, go completely through the epidermis and dermis layers and can burn into muscle, nerve, even bone. These burns definitely require debridement, the patient requires fluid resuscitation, and depending upon how large an area is burned, the patient probably requires treatment in a specialized burns unit.

Two additional nursing considerations are infection potential and emotional responses. Because the skin protects us from infection, interrupting it with a burn requires a tetanus booster as well as potentially antibiotic therapy. And because burns can often be disfiguring (either through physical loss of structures or through scarring) burns patients may require emotional care as well. The ER nurse can initiate both infection control and emotional therapy.

Robert Burns's Auld Lang Syne is about remembering the previous year and all its friends and events, and turning over a new leaf. Sort of what burns do; the dead skin falls away, and the patient may very well have a reminder of what happened.

Unfortunately.