Burns, wounds and pressure injuries

Burn depth

Watch: Pain doesn't track severity: the deepest burns can be painless. Face, hands, feet, genitals or a major joint: especially serious.

Adult rule of nines

Children: Use the age-adjusted Lund-Browder chart. The client's palm plus fingers is about 1%. Superficial burns don't count in the size.

Inhalation injury: airway first

• Suspect it after a fire in a closed space.
• Clues: singed eyebrows or nose hairs, burned lips, face or neck burns; a hoarse voice, wheezing, trouble breathing, dark sooty sputum.
• Airway swelling can close the airway; lung damage can take 2 to 3 days to show.
• Give oxygen when carbon monoxide is possible.

Emergency care

• Stop the burning, keeping rescuers safe. Electrical injury: power off before you approach.
• Early burn deaths come from airway or inhalation injury, other trauma, and shock: look for each.
• Small burns: cool water for at least 20 minutes, never ice. Large burns: cool only if still hot.
• Clean, dry cover; elevate burned limbs. No butter or ointments on a severe burn, no breaking blisters, nothing by mouth.

Fluid resuscitation

• Start IV fluid early through a large-bore catheter, two for burns over 20%, in unburned skin when possible. Keep the client warm.
• The formula estimates the total fluid for the first 24 hours from the time of burn, counting only partial- and full-thickness burns.
• Adult thermal burns (a federal guide): 2 mL lactated Ringer's × kg × percent burned; children 3, electrical 4. Starting estimates, not set doses; some references use 4 for adults, so follow the order.
• Then adjust the rate to perfusion, urine output and response. Too little harms organs; too much causes dangerous swelling.

Pressure injury stages

What it is: Skin or deeper tissue damage, usually over a bony spot or under a device, from pressure alone or with shear.

Preventing pressure injuries

• Braden Scale: lower score, higher risk. 15 to 18 mild, 13 to 14 moderate, 10 to 12 high, 9 or below severe. Score on admission, then regularly.
• Turn on an individual plan; two hours isn't universal.
• Float the heels. Head of the bed at 30 degrees or lower when you can, to reduce shear.
• Move clients up with friction-reducing or mechanical equipment and enough trained staff, per policy; never drag them. Keep skin clean and dry.

Wound drainage

How wounds heal

• Four phases: hemostasis, inflammation, proliferation, maturation. Closure time varies with the wound, perfusion, infection and other illness.
• Healthy granulation is pink, moist, painless and bumpy. Dark red tissue that bleeds easily, or a shiny white or yellow film, suggests infection.
• Report slough and eschar. Stable, dry heel eschar stays until circulation is checked.
• Measure length head to toe, width and depth in centimeters, by one consistent method.

Drains and staples

• Wound vac: foam sealed under film, with suction. Keep the seal intact.
• Bulb drain: empty and measure, then compress the bulb before closing it. Pin it below the wound, with slack.
• Report drainage that increases or changes.
• Sutures or staples: provider order, inspect first, then remove every other one first, checking healing as you go.

Cleansing and dressings

Every change: Cleanse with normal saline; avoid hydrogen peroxide, iodine and acetic acid, which can harm tissue. Keep the bed moist, not wet. Give pain medicine before a painful change.