This easy study guide helps nursing students and NCLEX reviewees better understand the types of burns, their causes, pathophysiology, and the nursing interventions.
Definition of Burns
Burns are an injury to the skin, layers of the skin, or tissue damage. This can lead to damage to the skin integrity and may lead to serious complications.
Causes of Burns
There are different causes of burns and it depends on the energy source. It is important to remember these energy sources when reviewing for the NCLEX:
- Heat/Thermal: Examples are fire, steam, and hot liquid. This the most common cause of burns.
- Electrical: When a person is electrocuted, the electric currents pass through the body and damages the tissues. The burn damage from electricity is usually under the skin, and not seen superficially, which is known as the “iceberg effect”. Watch out for heart problems, dysrhythmia, bone fractures, and renal failure.
- Chemical: When chemical substances come in contact with the skin, this causes burns. There are two types of chemical burns – alkaline and acidic. Alkali-based chemicals are harder to treat as compared to acidic chemical burns. Examples of chemicals that may cause burns are car battery acid, ammonia, bleach, or pool chlorination products.
- Cold: Prolonged exposure to cold may cause burns, an example of this is frostbite.
- Radiation: Sources of radiation burn are prolonged exposure to the sun and the radiation treatment of chemotherapy. Examples of these are ultraviolet light, thermal radiation, radiofrequency energy, and ionizing radiation.
- Friction: Frictions are also considered burns, this results from a forceful abrasion or friction to the skin. This is usually seen in people in car accidents, road rash, or those who experienced rope burn.
It is important to take note that burn severity depends on a lot of factors. It may depend on the depth of damage to the skin, the surface percentage of burnt skin, the patient’s age, existing medical illness, location of the burn, and if the patient experienced inhalation injury. If the burn patient has burns extended deep to the dermis and epidermis, this may cause more serious problems.
The Layers of the Skin
Before reviewing the four classifications of burns, let us first refresh our memory on the skin layers.
- Epidermis: The top layer is called the epidermis, it is the skin that we can touch and see. It is responsible for protecting our whole body from environmental hazards and preventing infection.
- Dermis: Below the epidermis is the dermis layer. The dermis contains nerve endings, blood vessels, and sweat glands. the dermis contains cells that help create new skin. That is why burn patients who have burns deep in the dermis may need skin grafts because the dermis is unable to create skin cells.
- Hypodermis/Subcutaneous Tissues: Below the dermis is the subcutaneous tissues also known as the hypodermis. It contains fat tissues, arteries, and veins. The subcutaneous tissue is responsible for insulating the bones, muscles, and organs in the body, in short, this layer is important in regulating the body temperature. Patients who have burns extending down to the subcutaneous tissue may have problems with the regulation of body temperature.
Classification of Burns (Degree-Type)
1. First Degree / Superficial Burn
This burn affects the epidermis, which means it is a superficial burn and is the less severe of all burn types. The best example of first-degree burns is a sunburn. The skin appears to be pink or very red, warm to the touch, and painful.
First-degree burns usually heal in 7 days and there is no scarring or blister formation. With a superficial burn, the capillary refill is faster, which means the burn hasn’t caused too much damage.
2. Second Degree / Partial Thickness
Second-degree burns affect both the epidermis and dermis. This can be deep partial-thickness or superficial thickness, depending on the extent of the burn to the dermis. A second-degree burn often appears as red, pink, blistered, moist in the burnt area, swollen, and scab-like tissue. It is more painful than a superficial burn, but nerve sensations are still not affected. If the second-degree burn is severe, the patient may need skin grafting.
3. Third Degree / Full Thickness
In third-degree burns, this affects all three layers of the skin – epidermis, dermis, and subcutaneous fat. The sweat glands, hair follicles, and nerves are damaged too. Pain is not present in third-degree burns because of the decreased pain sensation to the receptors. Third-degree burns appear waxy white, stiff, and leathery. It is important to remember that the skin cannot heal in third-degree burns and the patient is going to need skin grafting.
4. Fourth Degree / Deep Full Thickness
This is the most severe form of burn, which affects all layers of the skin and may extend up to the bones, muscles, and ligaments. The pain sensation is gone and fourth-degree burns will appear black or charred with eschar.
Important Note: Eschars are dead cells and tissues that fall and shed from the skin. This is usually seen in third-degree and fourth-degree burn patients. It looks brown, tan, black, or crusty. This is dangerous, and the patient may need the procedure called escharotomy (cutting off the eschars to relieve the pressure).
What Is the Rule of Nines?
The rule of nines is the calculation used to determine the extent of burn on the total body surface (or the extent of burns in the area of the body). The rule of nines is important to determine because this will help in the treatment such as fluid replacement.
The surface of the body is divided into nine surfaces starting from the top working the way downward. To summarize the rule of nines, here’s what you need to remember:
- Head and Neck: 9% (4.5% each for back and front)
- Right Arm: 9% (4.5% each for back and front)
- Left Arm: 9% (4.5% each for back and front)
- Trunk: 36% (18% each for back and front)
- Perineum: 1%
- Right Leg: 18% (9% each for back and front)
- Left Leg: 18% (9% each for back and front)
For example, a patient has the front head and neck burnt (equals 4.5%) plus front and back right arm burnt (equals 9%). The total body surface area burned is 13.5%.
For patients with burn injury, the nursing interventions will depend on the parts of the body burn and the classification. Here are the nursing interventions the nurse should remember:
- Fluid replacement: to prevent hypovolemic shock and electrolyte imbalance
- Monitor for hypovolemic shock: Monitor for decreased blood pressure, increased heart rate, and decreased cardiac output
- Monitor hourly urine output: This is to determine if the patient receives proper hydration. The desired hourly urine output is 30ml/hr.
- Monitor glucose levels, GI function. bowel sounds, and vomiting: The patient may experience Curling’s ulcer and may need an NGT tube to remove GI fluids and has.
- Diet: As long as normal GI function is established, place the patient on a high calorie, high protein, and high carbohydrate diet. During burn damage, the caloric intake is high, which means more calories are required to compensate for the burn.
- Monitor respiratory system, signs of infection, and temperature.
- Ensure proper wound care.
Here’s an Exclusive Burns Lecture for Nclex by Megan McClintock from Pocket Prof Apps. This is a nice discussion of important information about burns for nursing students. Watch it now!