Burn injuries: A guide for patients
University of Iowa Hospitals and Clinics Department of Nursing
You are recovering from a burn injury and may have many concerns. However, you can be assured that many of your needs are similar to those of others who have also experienced a burn injury. This booklet will answer some of your questions, reduce some of your fears, and provide you with information to help you plan for the future.
At The University of Iowa Hospitals and Clinics (UIHC) we use a team approach to your recovery and rehabilitation. The physicians, physicians assistant, nursing staff, dietitian, social worker, and physical therapists work together to help you get well. You will probably meet each of the team members during your hospital stay, but their involvement with you depends on your individual needs. Other staff members such as the occupational therapy counselor, psychology nurses, and chaplains are available if needed.
Burn depth
A superficial burn appears reddened and is painful. A superficial burn is often referred to as a first-degree burn.
Patients with burns to their face, neck, or lungs may require a
breathing tube, which is placed in their mouth
or nose.
A partial thickness burn appears red, moist, with blisters and is painful. A partial thickness burn is often referred to as a second-degree burn. Deep, partial thickness burns are often pale pink to white and are very painful. The deep, partial thickness burn may require skin grafting to improve function and to prevent excessive scarring. It is not uncommon for deep, partial thickness burns to convert to full thickness or third degree burns.
A full thickness burn, otherwise referred to as a third-degree burn, involves all layers of the skin. A full thickness burn appears dry and leathery and may be white, yellow, or brown in color. The nerve endings are destroyed in a full thickness burn, but the pain will continue. Skin grafting will be required to close this type of wound.
Size of burn
The percentage of the body burned is determined by one of several methods. At the UI Burn Treatment Center we determine the size of the burn injury based on the areas burned and the age of the patient. A special chart, the Lund Browder, allows us to determine the exact percentage of the body burned.
Type of burn
Burns are caused in a variety of circumstances, including exposure to direct heat or flames, flash explosions, steam blasts, and hot water. Contact with hot items, chemicals or electricity are also fairly common causes of the burn injury. Each injury will be a different size and depth and will have its own complications. In other words, every burn is different.
One very common complication, especially of flame injuries, is the inhalation injury. Breathing very hot air or smoke may cause damage to the upper breathing passages or to the lungs. Tissues become very swollen and secrete large amounts of fluid that may interfere with breathing. This can be a serious complication and must be treated very aggressively.
Severity of burn
Many factors which determine the severity of a burn injury. The size of the burn is a major factor, and also depth of the injury. The age of the patient is another very important factor. Body systems in very young patients or very old patients do not adjust to the burn injury as well as patients in other age groups. The general health of the patient before the burn injury, also plays a role in determining severity, as does the presence or absence of the inhalation injury.
First 48 hours
Upon arrival to the hospital, the injured person is admitted directly to the burn Treatment Center. During this time, vital body functions are assessed and treated. Breathing and circulation are maintained first. Patients with burns to their face, neck, or lungs may require a breathing tube, which is placed in their mouth or nose. This tube is connected to a ventilator to assist with breathing. Patients are unable to talk because of the tube through their mouth or nose. If a patient does not need to be placed on a ventilator, additional oxygen may be necessary to increase oxygen intake. A pulse oximeter may be placed on the patient to monitor the amount of oxygen in the blood.
An intravenous (IV) access line is also vital for proper treatment of the burned patient. Frequently, a patient will have more than one IV line. The IV delivers extra fluid and medication rapidly into the bloodstream. The extra fluid is needed to prevent dehydration and shock. As a result of the burn injury, the body releases chemicals that cause fluid to leave the blood vessels.
This fluid accumulates in and around the burn causing swelling. Fluid leaving the blood vessels also causes shock in burn patients. In forty-eight to seventy-two hours, this process will reverse-fluid comes back into the bloodstream and the swelling goes down. Medication is given in the IV line for pain and to maintain vital body function. Occasionally, what is known as an arterial line is placed in the wrist, groin, or foot of the patient. This specialized line is placed in an artery to record the patients blood pressure on a monitor. Blood samples can be easily and frequently drawn from this line in order to decrease multiple needle sticks.
The patient may be placed on a cardiac monitor to observe the heart rate and rhythm at all times. Alarms and limits are set on these monitors to notify the nurse immediately of any change.
A Foley catheter will be placed into the bladder to monitor kidney function so IV rates can be adjusted appropriately.
A nasogastric (NG) tube may be placed into the patients nose and down into the stomach to aid in removing stomach contents. This helps in preventing nausea and vomiting. Because of the stress of the burn injury, stomach activity decreases and the patient is unable to digest food or fluid. The patient should not be given anything to eat or drink during the first twenty-four hours. Later, during the hospitalization, this tube will be replaced with a small pliable tube to receive high protein-high calorie feedings.
As with any hospital admission, blood and urine samples will be obtained along with admission X-rays, EKGs, and photographs of the wounds. Photographs are taken upon admission to document the initial appearance and size of wounds.
The patient is first stabilized in the admission area, and then taken to the hydrotherapy room. There all wounds are cleansed, broken blisters are debrided, and hair is shaved within two to three inches of the burn wound. Burns that circle around the torso, leg, or arm completely (otherwise known as circumferential) may act as a tourniquet on the limb and obstruct blood flow. If the blood flow is obstructed, an escharotomy (cut) is made through the burned tissue to allow a release of pressure. After cleansing with soap and water, antibiotic bandages are applied.
What to expect during hospitalization
Wound care
The patient is placed in a special cart that allows for cleansing of the burned area. Cleansing of the wound is completed using a soap and water. The nurse may use special equipment to remove damaged tissue at this time.
The patient is given pain medication prior to and during the hydrotherapy procedures. Hydrotherapy with the application of wound bandages is done every morning. Antibiotic solutions may be applied to the bandages each evening.
Debridement
The greatest danger to the burn patient is the presence of non-living tissue. Bacterial germs may live in this dead tissue causing a delay in wound healing and may cause a life-threatening infection.
Skin grafting
After debridement, skin grafting (autografting) may be done if the burn injury is not too extensive. Skin grafting may be postponed until the debrided tissue is healthier. Skin grafting involves taking skin from an unburned part of the patients body (donor site) and placing it on the burn wound. More than one surgical procedure may be necessary depending upon the extent and location of the burns. If more than one surgery is necessary, temporary skin coverage is needed to protect the wound until final grafting or healing takes place.
Temporary skin coverage may be provided by either Homografts or Xenografts. Homografts and Xenografts are thin grafts resembling autografts that are surgically placed on the burn injured areas. Temporary coverage of the wounds decreases pain and helps protect wounds from bacterial infection. These grafts adhere to the wounds but are removed when the burn wound is ready for autografting.
Most full thickness and sometimes partial thickness burn injuries require debridement and skin grafting. When the skin is ready for skin grafting, the autograft is meshed and stretched to cover a burned area larger than the donor site. The skin is stapled in place and covered with a netting or clear thin dressing.
Bulky, wet bandages soaked with an antibiotic solution are then applied. These bandages are soaked every four to six hours. The bandage is left in place and the graft is left undisturbed. The graft begins to grow and adhere within 48 hours. At the end of four to five days, the graft should be adherent. New skin grafts are fragile and advancement of the dressing will be determined by the medical staff.
Movement, bleeding, infection, and poor nutrition can interfere with the graft taking hold. This is why activity may be limited and splints applied to the grafted area. The donor site will heal in approximately two weeks. The grafted area and donor site may form scars.
If the skin graft is not successful or there is more dead tissue to be debrided, the patient will return to the operating room for further skin grafting until all wounds are covered. The overall number of surgeries is determined by the extent of the injury.
Pain control, itching, therapy, and nutrition
Pain control
Burn wounds of any degree are painful. The medical staff work to make pain management specific to each persons reaction to pain. Morphine is given through an IV during the first twenty-four to forty-eight hours after admission and surgery. Oral narcotics are used following this forty-eight hour period. Pain medication is administered throughout the day to the patient.
Although therapy may be painful for the patient, it should never be avoided because it is essential for recovery. In addition, relaxation therapy, distraction, and imagery
Your body needs time to build up skin that can
withstand pressure. The length of time will vary with each individual. For some it may take several months and for others a year or more. Gradually, as your skin thickens and toughens, it will become less sensitive. You will be able to go about your normal
routine with less fear of bruising.
can be used as a supplement to pain medication.
Itching
As burn wounds heal, many patients experience itching and dryness of donor and grafted areas because these areas do not produce the necessary oils to lubricate the skin. The oil-producing glands have been destroyed from the initial injury to these areas. The skin may be dry, flaky, and itchy. Moisturizing lotions should be applied several times a day to those healed areas. An anti-itch medication may be prescribed to decrease the itching.
Physical therapy and occupational therapy
Patients admitted to the Burn Treatment Center are evaluated by the occupational therapist and physical therapist. Burn injury places the patient at risk for scarring, contractures, and loss of joint and muscle function. These therapists and nursing staff work with patients and families to decrease these complications and to maximize recovery.
Positioning - proper positioning of all body parts is begun at the time of admission. The purpose of good body position is to decrease tightening of joints and tissues and to prevent loss of normal range of motion. Skin that has been burned looses its normal elasticity (ability to stretch). Burned areas must continue to be stretched through positioning and exercise in order to avoid permanent loss of elasticity.
A patient may be required to give up use of a pillow to ensure proper positioning for the neck and back. Arms and legs are elevated and placed in a straight position. Burned hands are often splinted to decrease loss of function. These positions may not be comfortable for the patient but are necessary to improve function in the injured areas.
Splints
A splint is a device used to keep a body part in a fixed position. This fixed position keeps the body in the proper position for later movement. Splints can be made of plastic, metal, or plaster. Splints may also be used after surgery in order to immobilize a grafted area (for example, the arm and shoulder). The patient may be required to wear splints twenty-four hours a day.
Exercise program - Once the patients condition has improved, vigorous daily therapy begins. The physical and occupational therapist develops an exercise program for each specific need. When appropriate, the patient is encouraged to walk, perform self-cares, feed him or herself, and use the bathroom. The Burn Treatment Center has one exercise room equipped with a variety of modern exercise devices. Exercises may be necessary for several months after discharge from the hospital.
Nutrition
During the first twenty-four to forty-eight hours of hospitalization, the stomach and intestines may reject food and liquids. This is normal and usually subsides within two to three days. At the same time, the body begins to use energy at a very rapid rate. The body requires a large amount of calories, protein, and fluids to heal burns, grafts, and donor sites.
The healthy adult needs 1,500 to 2000 calories a day while the burned adult may need twice that amount.
To help meet these increased nutritional needs, a patient is encouraged to drink fluids containing calories and protein. Milk is offered throughout the day. Special burn malts that are high in calories and protein are also given. A patient is served three highprotein, high-calorie meals each day. It is important to note that since water has no protein or calories, water is not routinely given to patients because it fills them up but does not address their need for extra nutrition. Whenever possible, patient are instructed to feed themselves. Although this may be difficult or uncomfortable, self-feeding promotes a sense of self reliance and also provides mild exercise for the arms and hands.
Often the patients food intake is recorded to assist the dietitian in determining if the patient is receiving adequate calories and protein. Family members are welcome to participate in this part of the patients care, and the dietitian or nurse will instruct them in this task.
Frequently, a patient loses his appetite or is unable to eat or drink enough to meet daily calorie and protein requirements. When this occurs, a small, soft nasogastric tube (NG) is inserted through the nose and down into the stomach. Special formula is given through the tube every hour. When the patients appetite returns and calorie intake is adequate, the NG tube is removed.
Caring for your burn after hospitalization
A rehabilitation facility may be necessary depending on the severity of the burn. These facilities can further your rehabilitation needs once your acute care needs have been met. If you transfer to a rehabilitation unit, your therapist will design and occupational/physical therapy schedule to meet your needs. Your social worker will meet with you to arrange your discharge--either to go home or to a rehabilitation facility, depending on your needs.
Your newly healed skin will require some special care and consideration when you return home.
Bathing
You may continue to bathe in your usual manner, however, soaking in a bath tub is not recommended. Using a clean soft towel and gently washing instead of vigorously rubbing will lessen any discomfort of bathing.
Dry Skin
The dry scaly appearance of your skin results from damage or destruction of the oil-producing glands. Some of these glands will begin to function again, but until that time you will need to use some artificial lubricant.
Itching
Itching usually accompanies the dry, scaly, healed skin. Avoid vigorous scratching because this may break your delicate skin and leave open areas to heal. Reapply lotion or mineral oil as needed.
Bruises
Now that your burns have healed, you have a new layer of skin that is thinner and more sensitive and delicate than the rest of your body. These areas will bruise easily and must be protected against burns and sharp objects.
Dont wear tight clothing or shoes that can cause pressure and blistering.
Your body needs time to build up skin that can withstand pressure. The length of time will vary with each individual. For some it may take several months and for others a year or more. Gradually, as your skin thickens and toughens, it will become less sensitive. You will be able to go about your normal routine with less fear of bruising.
Blisters
Blisters commonly occur in healed or grafted areas and are no cause for alarm. Friction from linen, rubbing, and bumping against objects will cause blisters. Standing for long periods of time without appropriate support may also cause blistering. If blisters occur, you can obtain instructions on how to care for them in the burn clinic or from your physician.
Cold
Because your new skin is thinner, it will be more sensitive to cold. Slight tingling and numbness may be experienced, especially in hands and feet, when the weather is cold. You can decrease your discomfort by wearing warm clothing and avoiding exposure to the cold.
Appearance
Your healed burn will continue to change over the next several months. You can expect some discoloration and scarring in the normal course of events.
Scarring
Discoloration is generally associated with scarring. Initially it is very difficult to tell how much scarring will be permanent.
Scarring from first-degree burns and light second-degree burns may disappear within a few months. Areas of deep second degree and third-degree burns may continue to build up scar tissue for at least two years. At this point, some of your scars may start to gradually disappear. You can also expect some of them to be permanent.
Although not all burn wounds will look like these examples, you can see that scarring varies from person to person and with different depths of injury. Scars usually progress over a period of time. You can expect them to look the worst between 4 and 8 months post burn and then gradually regress over 6 to 12 months.
Exercise
As your skin heals, scar tissue will develop and your skin will tend to contract, causing tightness of muscles. You may notice a stiffness and slight pulling in the joints upon rising from sleep or after being inactive for long periods during the day. You will find that movement of the joints gradually decreases the stiffness. Regular exercise helps prevent arms and legs from becoming fixed in a rigid position.
Diet
Nutrition is as important to your health after you leave the hospital as during recovery from a burn injury. It is important to maintain a good weight for your height. Choose foods rich in protein to complete healing and maintain good tissue structure.
Vitamins and minerals are essential for healing and maintaining normal body functions. Try to use a variety of foods since different foods have different nutrients. Control the amount of fat added to foods to help prevent excessive weight gain.
Exercise Critical Care Nursing Division
