The goals of burn care are to:
– maintain physiologic stability.
– repair skin integrity.
– prevent infection.
– promote maximal function and psychosocial health.
Criteria for admission to burn unit (American Burn Association)
1. Partial-thickness burns of greater than 10% of the total body surface area
2. Burns that involve the face, hands, feet, genitalia, perineum, or major joints
3. Third-degree burns in any age group
4. Electrical burns, including lightning injury , chemical burns
5. Inhalation injury
6. Burn injury in patients with preexisting medical disorders that could complicate management
7. Any patients with burns and concomitant trauma (such as fractures) in which the burn injury
poses the greatest risk of morbidity or mortality
8. Burned children in hospitals without qualified personnel or equipment for the care of children
9. Burn injury in patients who will require special social, emotional, or rehabilitative intervention
Its important to do strict sterile burn dressing to prevent infection as burn infection could increase wound depth, cause rejection of skin graft, worsen pain, prolong hospitalization and even could lead to death.
To help prevent infection:
– strict aseptic technique must be used during care.
– dress burn site as ordered.
– monitor and rotate IV line regularly.
– carefully assess the burn extent.
– assess body system function.
– assess patient emotional status.
– change dressing twice daily or as ordered.
– using topical antibiotics as ordered.
1. first degree burn ( superficial burn):
Pink area or red with minimal edema, sensitive to touch
2. second degree burn:
a. partial thickness burn affecting dermal and epidermal layer) : Blisters; mottled appearance, red an blanches with pressure.
b. deep partial thickness burn:
Blisters (easily unroofed); wet or waxy dry; variable color (patchy to cheesy white to red); does not blanch with pressure.
3. third degree burn (full thickness burn):
Appear red, waxy white, brown or black, red skin remain red when touched, skin leathery (dry and inelastic) with extensive subcutaneous edema, skin insensitive to touch, hair fall easily.
Equipment needed for burn dressing nursing care plan:
– normal saline solution.
– sterile fluffed gauze pads.
– sterile 4x4gauze pads.
– sterile bowl.
– sterile scissors.
– sterile tissue forceps.
– ordered topical medication.
– sterile burn gauze.
– sterile roller gauze.
– sterile elastic netting or tape.
– sterile cotton tipped applicator or tongue depressor.
– ordered pain medication.
– surgical cap.
– heat lamp.
– plastic trash bag.
Optional: splints, vest dressing. Sterile razor or clippers.
Preparation of equipment:
# Warm normal saline solution by immersing unopened bottle in warm water.
# assemble equipment on the dressing table.
# make sure the treatment area has adequate light to allow accurate wound assessment.
# open equipment packages using sterile technique.
# arrange supplies on a sterile field in order of use.
# To prevent cross contamination clean from cleanest to dirtiest.
# if burn in large body areas perform dressing in stages to avoid exposing all body parts.
1. administer the ordered pain medication about 20 minutes before beginning wound care to maximize patient comfort and cooperation.
2. explain the procedure to the patient and provide privacy.
3. turn on overhead heat lamp to keep patient worm, make sure that it will not overheat the patient.
4. pour warmed normal saline solution into sterile bowl in the sterile field
5. wash your hands.
Removing a dressing without hydrotherapy:
– put on gown and mask.
1. remove dressing layers down to the inner most layer by cutting the outer dressing with sterile blunt scissors.
2. if inner layer appears dry soak it with warm normal saline solution to ease removal.
3. remove the inner dressing with tissue forceps or sterile gloved hand.
4. because soiled dressing harbor infectious microorganisms, dispose the dressing carefully in impervious plastic trash bag according to your facility policy, dispose of your gloves and wash your hands.
5. put on new pairs of sterile gloves using gauze pads moistened with normal saline solutions, gently remove any exudate and old topical medications
6. carefully remove all loose eschar with sterile forceps and scissors if ordered.
7. assess wound condition. The wound should appear clean with no debris, loose tissue, purulence, inflammation or darkened margins.
8. before applying a new dressing remove your gown, gloves and mask. Discard them properly, and put on a clean mask, surgical cap, gown and sterile gloves.
Applying a wet dressing:
1. soak fine- mesh gauze and the elastic gauze in large sterile basin containing the ordered solution for example silver nitrate.
2. wring out the fine mesh gauze until its moist but not dripping and apply it to the wound warn the patient that he may feel transient pain when dressing applied.
3. Roll an elastic gauze dressing over these two dressings to keep them intact.
4. cover the patient with a cotton bath blanket to prevent chills, change the blanket if it becomes damp, use an overhead heat lamp if necessary.
5. Change the dressing frequently, as ordered to keep the wound moist, especially if using silver nitrate as it may damage the skin tissue if it become dry.
Some protocols call for irrigating dressing with solution at least every 4 hours, through small opening into outer dressing.
Apply dry dressing with a topical medication:
1. remove old dressing and clean the wound.
2. apply ordered medication to the wound in a thin layer, with your sterile gloved hand or tongue depressor, then apply several layers of burn gauze to contain medication but allow exudate to escape.
3. remember to cut the dry dressing to fit only the wound areas don’t cover unburned areas.
4. cover the entire dressing with roller gauze and secure it with elastic netting or tape.