24/02/2015
Burn Injury: An Introduction to
Burn Wound Care
Jennifer Hyson RN
Clinical Nurse Educator
Capital Health
Overview
Burn Injury Review
• Types (Cause)
• Severity
• Extent (TBSA)
• Classification (Depth)
Burn Wound Care
• Goals
• Burn Care and Dressings
• Skin Grafts/Donor Site Care
Types (cause) of Burn Injuries
Thermal
• Dry heat
• Moist heat
• Direct contact
• Extreme cold
Chemical
• Acids
• Alkalis
Electrical
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Thermal Burns
• Dry heat
• Moist heat
• Contact
• Frostbite
Chemical Burns
• Acids and Alkalis
• Damage to skin proportional to type, amount
and strength of substance, duration of contact
and mechanism of action
• Treatment depends on specific chemical
Electrical Burns
• Small portion of the burn population
• Entry and exit points
• Difficult to assess injury because much of it is
internal
• Damage may show up later as heart arrhythmia,
eye injury or bleed
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Burn Severity
• Classified as Minor or Major
• Severity Factors
▫ Extent
▫ Depth
▫ Age
▫ Part of the body burned
▫ Past medical history
Burn Severity: Extent
Calculation of the total body surface area [TBSA]
• Palm Method
• Rule of Nines
• Lund and Browder
Rule of Nines
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Lund and Browder Method
Burn Severity: Depth
Factors that influence depth:
• Intensity
• Duration
• Thickness of the skin
Burn Depth Terminology
Older Terminology
Newer Terminology
First Degree
Superficial
Second Degree
Superficial Partial Thickness
Deep Partial Thickness
Full Thickness
Third Degree
Fourth Degree
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Superficial
First Degree
• Damage to the
epithelium
• Red and dry
• Blanches with
pressure
• No blisters
• Tender/painful
• Heals in 3 to 5 days
Superficial Partial Thickness
Second Degree
• Destruction of
epidermis, superficial
damage to dermis
• Epidermal
appendages intact
• Red, wet, blisters
• Blanches with
pressure
• Extremely painful
• Heals in 14-21 days
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Deep Partial Thickness
Second Degree
• Destruction of
epidermis, damage to
dermis
• Some epidermal
appendages intact
• Less moist, pale
• No/delayed blanching
• Deep pressure
sensation/No pinprick
sensation
• Prolonged healing
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Full Thickness
Third Degree
• Complete destruction
of epidermis, dermis
and epidermal
appendages
• Dry, leathery
• Mottled, brown, red
• No sensation/pain
• Requires excision and
grafting
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Full Thickness
Fourth Degree
• Complete destruction of epidermis, dermis
and epidermal appendages
• Involves connective tissue, muscle and bone
• Dry
• Black or brown
• No pain
• Limited movement of limb/digits
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Burn Wound Care
Goals of Wound Care
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Prevention of conversion
Removal of devitalized tissue
Preparation of healthy granulation tissue
Minimize systemic infection
Completion of the auto grafting process
Limiting scars/contractures
Wound Care Procedure
Before you begin:
• Prepare supplies and environment
• Premedicate patient
• Wear the proper PPE
• Keep in mind patient allergies
General principles:
• Dressing removal and cleansing = clean
technique
• Dressing application = sterile technique
• Wound cleansing includes debridement
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Wound Care Procedure
During the dressing:
• Assess vital signs
• Assess wound for healing
• Assess wound for infection
• Assess distal circulation
• Passive or active ROM
Superficial burns (first degree)
Wound Care
• Bath or shower
• Moisturizing agent
• May apply dressing for comfort
Superficial Partial Thickness
Second Degree
Wound Care
• Cleanse with warm N/S
• Non adherent dressing
• Cover with gauze
Keep in mind:
• Budding
• Soak dressings that have adhered to wound
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Deep Partial Thickness/Full
Thickness
Deep seconds & third degree
Wound Care
• Cleanse with warm N/S
• Apply gauze coated with 1% silver sulphdiazine
• Cover with protective/absorbent layer
Keep in mind:
• Do not apply SSD to intact skin or less severe
burns
• Manage exudate
Full Thickness
Fourth Degree
Wound Care
• Cleanse with warm N/S
• Cover exposed bone, tendon with hydrogel
• Cover with Jelonet and gauze
Eshcarotomy Care
• Cleanse with
warm N/S
• Cover with
thick strips of
Jelonet
• Manage
exudate
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Care of Facial Burns
• Warm N/S soaks followed by gentle wiping
action
• Remove any devitalized tissue
• Apply thin layer of polysporin ung QID
• If male, shave daily using SSD and a disposable
razor
Keep in mind:
• Watch for pressure areas on back of head, ears
• No pillow for neck burns
Hand and Foot Dressings
Important Points:
• Wrap each digit separately
• Use enough kling to secure the dressing and still
allow for movement of the fingers and toes
• Monitor distal circulation
• Keep arms and legs elevated on pillows
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Skin Grafts & Donor Sites
Skin Grafting
Types of Skin Grafts
• Autograft
• Allograft
Graft Care
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Bedrest 5-7 days PO
Initial dressing taken down by physician
Dressing are removed gently
With sterile q-tips reapply any loose graft
Cleanse the area gently with NS
Apply jelonet cut to size
Cover with gauze, and an outer dressing and
secure with kerlix (where possible) or tape
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Donor Site Care
• Covered in foam dressing for 7-10 days
• Frequently assessed for bleeding and reinforced
within the first 24hr
• Assess for signs of infection
• Painful
• Remove gently on 10th day (or as ordered)
▫ Cleanse with NS
▫ Cover with Vaseline mesh dressing (Jelonet)
▫ Cut back Jelonet with scissors as wound heals and Jelonet
releases
• Once wound has closed coat with lanolin or
available moisturizer daily
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Questions
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