Med-Surg - Integumentary System, part 8: Nursing Care of Burns

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Hi. I'm Cathy with Level Up RN. In this video, I will be discussing the nursing care of burn patients, which is a topic that is highly tested on in nursing school. At the end of the video, I'm going to give you guys a little quiz to test your knowledge of some of the key points I'll be covering, so definitely stay tuned for that. And if you have our Level Up RN Medical-Surgical Nursing Flashcards, definitely pull those out so you can follow along with me, and pay close attention to the bold red text on these cards because those are going to represent the most important facts that you are very likely to see show up on a nursing school exam.

Nursing care of a burn patient is divided into three phases. We have the emergent phase, the acute phase, and the rehabilitative phase. So the emergent phase begins at the time of injury and lasts for about 24 to 48 hours. Our focus during this time is on maintaining the patient's airway, providing fluid resuscitation, and preserving organ functioning. The acute phase begins once fluid resuscitation is complete and ends when we have wound closure. Our focus during this time is on infection control, wound healing, nutrition, and mobility. The rehabilitative phase begins once we have wound closure and ends when the patient achieves maximal function. Our focus during this phase is on psychosocial adjustment as well as the prevention of contractures and reconstructive procedures. So during this video, we will really be focused on the emergent phase as well as the acute phase. During the emergent phase, we, of course, want to stop the burning process and maintain the patient's airway. We would administer oxygen as ordered and assess the patient for signs of inhalation injury, which includes singed eyebrows or singed nasal hair as well as sooty sputum. We are going to provide IV fluid resuscitation using a large-bore catheter in order to prevent hypovolemia. We're going to administer IV opioid analgesics and keep our patient warm. We're going to keep our patient NPO and insert an NG tube, and then we are also going to insert a Foley catheter so we can closely monitor our patient's urine output. And then we also need to administer a tetanus vaccine if the patient is not up to date on their tetanus vaccinations or if their status is unknown.

In terms of assessing the percentage of the patient's body that is burned, we would use the rule of nines for adults. For pediatric patients, there are more reliable methods, such as the Lund-Browder chart. The rule of nines divides the body's surface area into percentages. So the entire head is 9%, so if just the back of the head is burned, then that would be 4.5%. The entire trunk is 36%, so if just the anterior chest is burned, that would be 18%, and if the back of the trunk is burned, that would be 18% as well. Each upper extremity is 9%, so again, if just the anterior right arm is burned, that would be 4.5%. And then each lower extremity is 18%, so if just the back of one leg is burned, that would be 9%. And then the perineum is 1%. Let's now talk about the depth of the burn injury and what characteristics may be present at each of the depths. As a heads-up, I am going to be showing some photographs of burn injuries, so if that is disturbing for you, then you'll definitely want to skip to the next section of this video.

With a superficial or first-degree burn, damage is limited to the epidermis. The skin will be pink or red in color, mild edema may be present, but there will not be any blisters. An example of a superficial burn is a sunburn, as shown here. With a superficial partial-thickness burn or second-degree burn, we have damage to the upper layer of the dermis. Characteristics at this depth include a red or pink color, mild to moderate edema, and the presence of blisters. With a deep partial-thickness burn, which is still a second-degree burn, damage extends deep into the dermis. Characteristics at this depth include a red or white color, moderate edema, and soft, dry eschar. With a full-thickness or third-degree burn, damage extends into the subcutaneous tissue. Characteristics at this depth include severe edema, no blisters, and hard and inelastic eschar. Also of note, at this depth, nerve endings have been destroyed, so the patient may not have pain at the affected area. And then finally, with a deep full-thickness burn or a fourth-degree burn, damage extends beyond the subcutaneous tissue into the muscle, tendon, or bone. The affected area will be black with hard and inelastic eschar, edema and blisters will not be present, and the patient will not have pain at the affected area because, again, those nerve endings have been destroyed at this depth of injury.

Fluid resuscitation is critical during the emergent phase of burn care, and we want to provide enough fluids to maintain a urine output of 0.5 milliliters per kilogram per hour for adult patients, so the Parkland formula is used to calculate the amount of lactated Ringer's we need to provide the patient within the first 24 hours. So with this formula, we take 4 milliliters of lactated Ringer's, we multiply this by the patient's weight in kilograms, and then multiply that times the percentage of the patient's body that has been affected by the burn using the rule of nines that we went over before. So for example, if we have a 60-kilogram patient and 36% of their body has been affected by the burn, then we would calculate the amount of fluids the patient requires by taking 4 times the patient's weight in kilograms, so that's 60, and then multiply that by the percentage of their body affected, so 36%, and we get 8,640 milliliters. So that's the amount we need to give over 24 hours. Half of this amount needs to be given in the first 8 hours, and then the remaining amount is given over the next 16 hours.

After fluid resuscitation, we move into the acute phase of burn care, where wound healing is definitely a priority. In terms of wound care, any necrotic tissue will need to be debrided, and the patient may require skin grafts as well. Following surgery to place a skin graft, you should elevate and immobilize the area and definitely monitor for signs and symptoms of infection. Two key topical antibiotics that are often used with burn injuries include silver sulfadiazine, as well as mafenide acetate. Mafenide acetate can penetrate eschar in the wound as opposed to silver sulfadiazine, which cannot. Mafenide acetate carries the risk for metabolic acidosis, and with silver sulfadiazine, a key side effect is transient neutropenia. Preventing infection is also very important, so we will want to administer antibiotics as ordered. We want to use aseptic technique when caring for our patient's wounds. We want to restrict visitors per the facility's policy and not allow any fresh plants or flowers in the patient's room. In order to prevent contractures, we should assist the patient with passive and/or active range-of-motion exercises, and then we also need to make sure our patient is getting adequate nutrition. They will require additional protein and additional calories to help facilitate wound healing, so some patients may require total parenteral nutrition, or TPN, as well.

All right. It's quiz time. I've got three questions for you. One of the questions would definitely be easier if you have a calculator, so if you want to pause the video and go grab a calculator, that may be helpful to you. All right. Question number one. Singed eyebrows and sooty sputum are indicative of blank in a burn victim. The answer is inhalation injury. Question number two. What vaccination should be provided to the patient during the emergent phase of burn care? The answer is the tetanus vaccine. And question number three. This is the one you may want a calculator for. Using the Parkland formula, how much lactated Ringer's should be administered in the first 24 hours to a 100-kilogram patient with burns affecting 18% of their body? The answer is 7,200 milliliters. So you take 4 times 100 times 18, and that gives you 7,200 milliliters that needs to be administered in the first 24 hours.

All right. That is it for this video. I hope you have found it super helpful. Take care, and good luck with studying.

In order to prevent contractures, we want to assist the patient with passive and/or active range-of-- and we should not allow any fresh flowers or plants in the patient's wound. In their wound? In their room. Also, don't put flowers in their wound, please.