Definition
It refers to admitting a patient with burns directly to the unit to resolve the immediate problems resulting from burn injury.
Purposes
- To correct fluid and electrolyte imbalances.
- To initiate life saving measures without delay.
- To prevent infection.
- To manage pain.
Initial management of a major burn patient
- Perform ABCDEF primary survey.
A-Airway with cervical spine control
B-Breathing
C-Circulation
D-Neurological disability
E-Exposure with environmental control
F-Fluid resuscitation - Assess burn size and depth.
- Establish good intravenous access and give fluids.
- Give analgesia.
- Catheterize patient or establish fluid balance monitoring.
- Take baseline blood samples for investigation.
- Dress wound.
- Perform secondary survey, reassess, and exclude or treat associated injuries.
- Arrange safe transfer to specialist burns facility.
Procedure
| Nursing action | Rationale | |
| 1. | Receive patient in the unit especially prepared for the purpose. | |
| 2. | The initial management of a severely burnt patient is similar to that of any trauma patient. A modified “advanced trauma life support” primary survey is performed, with particular emphasis on assessment of the airway and breathing. | |
| 3. | History taking | |
| Collect history about the incident such as the cause of burns, that is chemical, thermal, electrical or radiation. | Helps to know about the cause of burns and plan management during initial period. | |
| Collect data about the time of occurrence of burns, level of consciousness at the scene, whether injury occurred in an enclosed or open space, presence of associated trauma, etc. | Helps in planning management during initial period. | |
| Collect data regarding duration of exposure in case of electrical, chemical, or radiation burns. | Helps to identify type, extent, and depth of bums. | |
| Assess the patient for depth, size and location of the burns. | ||
| 4. | Assess percentage of burns by “Rule 9”. For example: A person sustained burns of the chest, abdomen and right arm. The percentage of body burned will correspond to chest (anterior trunk) = 9.0% Abdomen= 9.0% Front right arm= 4.5% Back right arm= 4.5% Total = 27%; the person sustained 27% burns | Helps in planning treatment and calculating fluid to administered. |
| 5. | A-Airway Assess for compromised airway. Protect the cervical spine unless evident that it is not injured. Assist the physician in establishing a patent airway by means of intubation as necessary. | Swelling of the upper airway interferes with patency of airway and breathing. Clients with head and neck burn injury need immediate endotracheal intubation. |
| B-Breathing Ensure adequate breathing by providing 100% oxygen if indicated as suspected inhalation injury. | ||
| C-Circulation Establish intravenous access with two large bore cannulas Withdraw necessary quantity of blood for checking full blood count, urea and electrolytes, blood group and clotting screen. | | |
| D-Neurological disability Assess for responsiveness with the Glasgow coma scale. | Patient may appear confused due to hypovolemia or hypoxia. | |
| E-Exposure with environment control. Examine the patient (including the back) to get an accurate estimate of the burn area and to check for any concomitant injuries.Cover the patient appropriately using sterile linen and keep warm. | Provides baseline data. Burn patients, especially children, easily become hypothermic. This will lead to hypoperfusion and deepening of burn wounds. | |
| F-Fluid resuscitation The resuscitation regimen should be determined and begun based on the estimation of burn area and calculated accordingly. Initiate IV infusion through peripheral line. Assist for cut down, if indicated.Catheterize the patient. Children’s urine output can be monitored with external catchment devices or by weighing nappies provided the injury is <20% of total body area. | Maintains circulatory blood volume. A urinary catheter is mandatory in all adults with injuries covering >20% of total body surface area to monitor urine output. | |
| 6. | Meet patient’s needs based on priority: Remove saturated clothing (chemical or scald burns).Cool the tar burn. Copiously irrigate a chemical burn. Remove any jewelry present on patient. | |
| 7. | In chemical burns, assess for: Knowledge of offending agent. Concentration. Duration of exposure. | Determines the extent of injury. |
| 8. | In case of electrical injuries, assess for: Electrical source. Type of current. Current voltage. | Determines the extent of injury. |
| 9. | Administer narcotic agents through IV line as prescribed by the physician. All patients with large burns should receive intravenous morphine at a dose appropriate to body weight. The need for further doses should be assessed within 30 minutes. | Reduces pain. Oral method of drug administration is not used due to gastrointestinal dysfunction. |
| 10. | Assess general health of the patient with debilitating illnesses such as cardiac, pulmonary, endocrine and renal disease. Perform a secondary survey after the initial emergency management. | To identify and treat concomitant injuries. |
| 11. | Initiate nasogastric feeding (withhold feed if paralytic ileus is present). Perform adequate dressing of the wound maintain strict aseptic techniques. | Maintains nutritional status. Prevents and reduces the risk of aspiration. |
| 12. | Maintain strict isolation and follow aseptic technique in caring for patient. | Prevents spread of infection. |
| 13. | Check vital signs frequently. | Helps to identify deviation from normal. |
| 14. | Assess for baseline laboratory studies such as: Blood glucose. BUN. Serum creatinine. Serum electrolytes. Hematocrit level. Chest X-ray. ABG (inhalation injury). | Identifies development of complications at an early stage. |
| 15. | Monitor ECG continuously, especially in high voltage electrical injury and major burns. | Patients are at risk of developing dysrhythmias in high voltage electrical injury and in major burns. |
| 16. | Administer tetanus toxoid for patients who have not been immunized. If immunized, tetanus booster dose should be given according to physician’s order. | |
| 17. | Record the time of admission and document procedures done in nurse’s records. | Acts as a communication between staff members. |
Special consideration
- Inform police in medicolegal case.
- Use caution when patient is biohazard with hepatitis B and HIV infection.
- Inform family by giving periodical information about patient’s condition and progress.
- Assess patient for known allergies.
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
- Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
- Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
- Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
- AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
- Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/
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