Whether you’re an ED, ICU, Burn Units Nurse, or a nursing student studying for NCLEX, burns along with their care and treatment are important to know. If you haven’t already, be sure to catch up on Nursing Fundamentals: A Guide to Burns, Part 1. Now let’s talk about burn staging, procedures, and complications of burns.
Burn Staging
There are three stages of burns, 1st degree, 2nd degree, and 3rd degree burns. But before we get into that, let’s remind ourselves of our multiple layers of skin. Starting from the skin that we all see on the outside, there’s the epidermis and then the dermis. After that comes the subcutaneous tissue (which includes fat), followed then by muscle and bone.
1st Degree Burns
First degree burns are defined by Stanford Medicine as superficial burns which, “affect only the epidermis, or outer layer of skin.” 1st degree burns will appear pink to red in color. They will not have any blisters, but edema (aka swelling) may be present. Examples of 1st degree burns include mild sunburns, partial scalds, and momentary contact with a hot object.
2nd Degree Burns
Second degree burns are defined by Stanford Medicine as partial thickness burns which, “involve the epidermis and part of the dermis layer of skin.” 2nd degree burns will appear red. They will have blisters and may be edematous (aka swollen). Examples of 2nd degree burns include scalds, contact with hot objects or flames, and chemical or grease burns.
3rd Degree Burns
Third degree burns are defined by Stanford Medicine as full thickness burns that, “destroy the epidermis and dermis. Third-degree burns may also damage the underlying bones, muscles, and tendons.” 3rd degree burns will appear white and dusty-like or black and charred-like. But it is important to keep in mind that if there are 3rd degree burns present, then there are likely also 1st and 2nd degree burns present. Which means you will see 3rd degree in the very center of the wound, then 2nd degree burns, and then 1st degree burns towards the edge of the wound. Where 3rd degree wounds are present, there will be no sensation since the burn is deeper than the nerve endings. But towards the edges of the wound, where the 1st and 2nd degree burns are, there will be pain/discomfort.
Burn Procedures
To help treat burns and aide in the healing process, there are a few different procedures that can be done. These include wound care, skin coverings, fasciotomy, and escharotomy.
Wound Care
Likely the most common treatment for burns, wound care. There are various types of wound care but in general, wound care refers to the non-surgical treatment of burns. For example, hyperbaric oxygen chambers may be used to increase oxygen to the burn area. This helps encourage new tissue development and healing of damaged tissue through increased oxygenation and therefore circulation.
Wound care also refers to the specific dressings and dressing changes that will be ordered by the provider, or a wound care nurse, to treat the burn. During dressing changes, it is important to use the exact supplies ordered. As this is what will help with healing and not stick into the wound, which can potentially cause further damage.
Debridement is another part of wound care. It removes dead skin cells and therefore helps the body focus its energy on the areas that are viable. Debridement is a procedure that is typically done mechanically with sharps, but it can also be done via hydrotherapy, and enzymatically. Prior to any form of debridement, it is important to pre-medicate your patient as this can be very painful.
Mechanical Debridement
Mechanical debridement is done using sharps, aka medical grade scissors and forceps. Necrotic (aka dead) tissue is then carefully cut away so that the beefy red healthy tissue underneath can heal better. This is usually a procedure that is done bedside by either a medical doctor or a certified wound care nurse.
Hydrotherapy Debridement
Hydrotherapy debridement is done using water, hence the prefix hydro. This can be done by having the patient take a bath or a shower, and use either water only, or water and a very mild cleansing soap, to carefully clean the burn site. Doing so will help soften the skin and cause the dead (aka necrotic) skin to fall off more naturally.
Enzymatic Debridement
Enzymatic debridement is a form of topical medication that will be ordered by the provider to help break down necrotic skin cells and ‘clean out’ the wound. This enzyme will be topically spread over the wound during dressing changes and can be wiped away and re-applied with the next dressing change.
Complications
Having full-thickness 3rd degree burn is extremely dangerous and difficult for the body to fully recover from. Not only will the patient be hospitalized and likely sent to a burn unit, but there are also many other potential complications that can occur secondary to the burn itself. These include serious infections, airway injury, fluid and electrolyte imbalances, and lastly immobility even when fully healed.
Infections
Skin is the first line of defense when protecting the body from infection and with burns, the skin is severely compromised. Meaning that the patient is now more susceptible to infection. Because of this, it is important to keep in mind proper infection control, see A Guide to Infection Control for more info.
Airway Injury
Depending on where the burn is and how it occurred, the airway can be compromised. Which as we know is a huge problem. If the patient was involved in some sort of fire, they likely have inhalation injury, and their lungs may be damaged. If the patient was burned with scalding water to the face and neck, then again, the airway could be physically compromised. Especially when the fluid begins to shift and the extreme edema (aka swelling) occurs.
Fluid and Electrolyte Imbalance
Which leads us to fluid shift and electrolyte imbalances. After a burn, your body will begin third-spacing, and accumulating extra-cellular fluid outside of the cell, where it shouldn’t be. Because of this, your cells will become dehydrated, dehydrating the whole body, and therefore throwing off your electrolyte balance. Which as we know, can be deadly for patients.
Immobility
Even after the patient is fully healed and out of the acute burn phase, they are going to be dealing with deep scarring and potential contractures to some extent for likely the rest of their life. The scarring isn’t only something the patient is going to have to learn how to adapt to psychosocially, it’s also something that causes pain, limits movement, and can lead to contractures. Contractures are the shortening and/or tightening of skin, muscles, and tendons that cause the area to contract permanently without the patient intentionally contracting. Because of this, the patient can lose a significant amount of mobility to the scarred area.
And that’s it! Now you know the different types of burns, phases of burn care, nursing interventions, staging of burns, burn procedures, and complications!
If you haven’t yet read Nursing Fundamentals: A Guide to Burns, Part 1, go read it now!
Do you treat burn patients? Comment below!
And don’t forget to brush up on the rest of your Nursing Fundamentals here!