Burns, Trauma, Wound Care and Local Infection

Burn Injury Assessment, Systemic Complications, and Emergent Care

Caring for a client with burn injuries requires the practical nurse to collect focused data promptly and understand the systemic impact of thermal damage. Burns are categorized by depth. Superficial burns involve only the epidermis, presenting with dry, red skin that blanches with pressure and causes pain. Superficial partial-thickness burns involve the epidermis and upper dermis and typically have moist blisters and marked pain; deep partial-thickness burns extend farther into the dermis and may have reduced sensation. Full-thickness burns destroy all skin layers as well as the underlying nerve endings. Because the nerve endings are destroyed, full-thickness burn areas are insensate to light touch and appear leathery, white, brown, or charred. For an adult client, the Rule of Nines assigns 9% to the head and neck together, 9% to each entire arm, 18% to the anterior trunk, 18% to the posterior trunk, 18% to each entire leg, and 1% to the perineum.

In the emergent phase following a severe burn, physiological stability is the primary focus. After airway and breathing needs are addressed, a major concern is hypovolemic shock, which is caused by increased capillary permeability and massive fluid shifts. During this period, damaged cells release potassium, placing the client at high risk for hyperkalemia. To evaluate whether fluid replacement is effective, the practical nurse monitors hourly urine output and reports the findings to the registered nurse. For most adults with major burns, a urine output of at least 0.5 mL/kg/hr serves as an important clinical indicator of adequate fluid resuscitation.

Airway preservation remains an immediate life-safety priority. Inhalation injury must be suspected if the practical nurse collects data revealing facial burns, singed nasal hairs, carbonaceous sputum, or hoarseness. Any of these findings must be reported promptly to the registered nurse. If stridor is heard, it indicates life-threatening upper-airway obstruction, requiring the practical nurse to call for immediate help and notify the registered nurse. Furthermore, carbon monoxide poisoning is an invisible danger because carbon monoxide has a much higher affinity for hemoglobin than oxygen. Standard pulse oximetry cannot distinguish oxyhemoglobin from carboxyhemoglobin, so its reading may be falsely reassuring and cannot rule out carbon monoxide poisoning. If carbon monoxide poisoning is suspected, the practical nurse immediately alerts the RN and assists with prompt administration of 100% oxygen, usually by nonrebreather mask, under an order or emergency protocol and within state scope.

Ongoing practical nursing care centers on preventing contractures, supporting healing, and stopping infection. For a client with anterior neck burns, the practical nurse avoids placing pillows under the client's head, which helps prevent disfiguring and disabling flexion contractures. Nutritional needs are intense; the practical nurse reinforces teaching that clients recovering from severe burns require a high-calorie, high-protein diet to provide the fuel necessary for tissue repair. To prevent infection, the practical nurse adheres to strict hand hygiene, uses prescribed aseptic wound-care technique, and follows facility infection-control precautions. Candidates should note that protective isolation is not routinely required for clients with severe burns.