Burns can be caused by heat, hot liquids, strong chemicals, electricity and radiation.  They are measured by the amount of body surface that has been burned, the burn degree, and their depth or thickness.  Burns are classified in stages as first, second, third or forth degree, depending on how deeply the layers of skin (dermis and epidermis) are damaged.  The size of the area of the body affected by a burn or scald plays a large part in determining whether it is classified as a major or minor injury.  Nursing care of the burn patient includes maintaining a patent airway and monitoring respiratory function, restoring hemodynamic stability, alleviating pain, preventing complications including common infections, giving emotional support to the patient and family, and providing information about condition, prognosis and treatment.

          A burn that causes reddening of the skin but no blistering is a first-degree burn.  This type of burn is painful but does not leave a scar.  Treatment of a first-degree burn is treated with a topical ointment to keep the injured area from drying out and cracking as it heals.  These burns take a week to ten days to heal and seldom leave a scar.  Accidentally touching a hot burner, getting too much tropical sun, and holding a scalding hot pot are all ways you can get first-degree burns.

          A burn that causes blisters is a second-degree burn.  Typically this burn is divided into superficial and deep second degree burns.  A superficial second-degree burn involves only the most superficial dermis.  It presents with blistering or sloughing of overlying skin, causing a red, painful wound.  Normally the burn blanches but shows good capillary refill.  Hairs cannot be pulled out easily.  Healing occurs within 14 days, typically without scarring and without requiring surgical intervention.  A deep second degree burn involves more of the epidermis.  It may present as blisters, or a wound with white or a deep red base.  Sensation is usually decreased.  Healing takes more than 14 days.  Incidence of hypertrophic scarring correlates with the length of the healing phase greater than two weeks.  Therefore, debriding and grafting is recommended by 2-3 weeks.

          A third-degree burn penetrates the entire thickness of skin layers and permanently destroys tissues.  It presents as a white, black or mottled hard, dry wound, from which hairs are easily pulled out.  No pain is present with a third degree burn.  Third-degree burns come from situations like the ones you read about in the paper.  Fireman rushing from burning buildings, people rolling on the ground with their clothes on fire, pots of boiling water spilling on vulnerable skin and accidents involving electrical outlets are  examples of a third degree burn.  

        Fourth degree burns injure and expose muscle, bone, and tendons, and may require amputation of extremities.  If left without surgical intervention the eschar will eventually separate by the formation of a layer of granulation tissue.  Potential risks of not debriding and grafting include sepsis, hypertrophic scarring and increased pain.  Treatment includes replacing lost body fluids, removing destroyed tissue and charred skin, preventing infection and grafting skin to replace the burned skin.  Physical therapy is usually necessary to restore the function of the affected area.  A fourth-degree burn results most often from the direct exposure of skin to open flame.

          Depending on the location affected and the degree of severity, a burn victim may experience a wide number of potentially fatal complications including shock, infection, electrolyte imbalance and respiratory distress.  Beyond physical complications, burns can also result in severe psychological and emotional distress due to scarring and deformity.  For a patient with a severe burn injury, as with any trauma patient, prompt and accurate assessment is crucial.  The initial assessment of the patient therefore involves ensuring that airway, ventilation and circulation are not compromised.  Based on the initial assessment, a plan of care is developed and documented for each patient.  The Burn Team undertakes monitoring of the patient’s condition and review of the plan of care on an ongoing basis including formal case management meetings. 

          Necrotic burnt tissue provides an environment for the proliferation of microorganisms exposing the patient to the risk of infection, delayed healing and complications.  As such, meticulous attention is paid to the management of the burn wound.  Burn wound management is based on the principles that burn wound dressings are applied to provide a local environment which optimizes healing and minimizes discomfort.  Burn wound care is complex, time-consuming and a painful procedure, particularly for those patients with an extensive burn injury.  And so, nursing staff who are experienced in the management of severe burn injury undertake burn care and dressing changes.  Burn wound care necessitates significant commitment of nursing time.  Dressing for major burns may take two hours or more and require two or more nursing staff. 

          Severe burn injury causes severe pain.  The nature of burn care frequently involves protracted surgical and non-surgical procedures which cause episodes of increased pain.  Commonly patients experience longstanding pain or ongoing parasthetic (itching) sensations in their wounds for many years following injury.  Pain management is an integral part of caring for the burnt patient.  Contemporary burn nursing practice involves the provision of nursing care in a highly complex clinical and technological environment requiring a high level of clinical competence and the possession of a repertoire of observation, administration, management and technical skills.  As such, burn nursing is recognized as a nursing specialty.  

          Nursing staff constitute the largest component of the multidisciplinary burn team and assume 24-hour responsibility for patient safety and well-being.  Nursing personnel contribute to positive patient outcomes through the provision of holistic care to patients with severe burn injury and their families, from initial presentation through all phases of acute and ongoing care.  Coordination of the multidisciplinary Burn Team is usually a nursing responsibility during the acute care phase.  Finally, burn unit nursing staff are integrally involved in the perioperative management of the burn patient, including the provision of nursing care during burn surgery.  






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