burn therapy, the management of a patient burned by flames, hot liquids, explosives, chemicals, or electric current. Partial-thickness burns may be first degree, involving only the epidermis, or second degree, involving the epidermis and dermis, whereas full-thickness or third-degree burns involve all skin layers. Second-degree burns covering more than 30% of the body and third-degree burns on the face and extremities, or more than 10% of the body surface, are critical. In the first 48 hours of a severe burn, vascular fluid, sodium chloride, and protein rapidly pass into the affected area, causing local edema, blister formation, hypovolemia, hypoproteinemia, hyponatremia, hyperkalemia, hypotension, and oliguria. The initial hypovolemic stage is followed by a shift of fluid in the opposite direction, resulting in diuresis, increased blood volume, and decreased serum electrolyte level. Potential complications in serious burns include circulatory collapse, renal damage, gastric atony, paralytic ileus, infections, septic shock, pneumonia, and stress ulcer (Curling’s ulcer), characterized by hematemesis and peritonitis. ▪ METHOD: The extent of the burn; its cause; its time of occurrence; and the patient’s age, weight, allergies, and any preexisting illness are all critical elements for the burn team to consider when providing care. If respiratory distress is present, endotracheal intubation or tracheostomy may be performed. Fluid intake and output are measured hourly; if a child excretes less than 1 mL/kg of urine or an adult less than 0.5 mL/kg, a diuretic or an increase in IV infusion of fluid may be necessary. Blood transfusions, steroid therapy, and antipyretics may be ordered; aspirin is contraindicated. Burned extremities are elevated, and contractures are prevented by using orthotics to keep affected areas properly aligned. The patient is weighed daily at the same time on the same scale, and, after the initial acute period, an adequate intake of a high-calorie, high-protein diet is encouraged. Tranquilizers may be given before wound care, but narcotics for pain usually are not needed after the acute phase. The patient is encouraged to stand for a few minutes every hour or every second hour and is generally able to walk in 7 to 10 days, but convalescence may be prolonged. Burn patients often are frightened, withdrawn, and disoriented initially, but after a few days they may become angry, depressed, or rebellious and need emotional support to help them cooperate with their treatment and rehabilitation. Extensive plastic surgery and repeated skin grafts may be required to restore function and the physical appearance of burn patients. ▪ INTERVENTIONS: The burn patient requires intensive, prolonged care to prevent complications and disfiguring contractures. A team approach to the complex care of this patient is imperative. For example, the nurse administers parenteral fluids and medication, implements wound care, closely monitors the patient’s condition, limits physical discomfort, provides emotional support and diversion, and encourages the family to visit regularly and become involved in the patient’s care. Physical therapists will initiate an aggressive therapy program; most burn patients need therapy at least twice daily. During the rehabilitation phase, physical therapy is critical to overcome the long-standing catabolic state and disuse atrophy. Occupational therapists can fabricate an orthosis to preserve range of motion and prevent or correct scar contractures. The burn team will meet regularly to ensure that the needs of the patient are met and that the treatment plan is coordinated in a way in which all disciplines can contribute their expertise to recovery. ▪ OUTCOME CRITERIA: The outcome for the severely burned patient depends greatly on the detailed, near-constant care required during the acute phase of treatment. Scarring may cause residual dysfunction and discouragement. Encouragement to participate fully in ongoing therapy and to continue treatments is essential.
