Goals of burn care are to maintain the patient's physiologic stability, repair skin integrity, prevent infection, and promote maximal functioning and psychosocial health. Reintegration of the patient into the home/school/work/community environment is important. A particular focus is care immediately after a burn occurs. Competent care at that time can dramatically improve the success of overall treatment.
Burn severity and percent of total body surface area affects the type of care you'll provide. Burn severity is determined by the burn's depth and extent and other factors, such as age, complications, and coexisting illnesses. (See Evaluating burn severity, .) Effective pain management during procedures is imperative.
Infection of a burn can increase wound depth, cause skin graft rejection, slow healing, increase pain, and prolong hospitalization. It can even lead to death. To help prevent infection, use strict aseptic technique during care; dress the burn site as ordered; monitor and rotate intravenous (I.V.) lines regularly; and carefully assess the burn extent, body system functions, and the patient's emotional status. Other interventions—such as careful positioning and regular exercise for burned extremities—help maintain joint function, prevent contractures, and minimize deformity. (See Positioning the patient to prevent deformity, .)
Repair of skin integrity requires aggressive wound debridement followed by maintenance of a clean wound bed until the wound heals or is covered with a skin graft.
A sterile field is required, and all equipment and supplies used in the dressing should be sterile. Sterile towels to set up the sterile field 
ordered pain medication normal saline solution fluffed gauze pads sterile bowl blunt scissors tissue forceps ordered topical medication burn gauze roller gauze fine-mesh gauze elastic gauze elastic netting or tape cotton-tipped applicators three pairs of sterile gloves two sterile gowns two masks surgical cap shoe covers heat lamps bath blanket impervious plastic trash bag.
Warm normal saline solution by immersing unopened bottles in warm water. Check expiration dates on packaging. Assemble equipment on the dressing table. Make sure the treatment area has adequate light to allow accurate wound assessment. Open equipment packages using aseptic technique. Arrange supplies on a sterile field in order of use.
Low exposure
To prevent cross-contamination, plan to dress the cleanest areas first and the dirtiest or most contaminated areas last. To help prevent excessive pain or cross-contamination, you may need to perform the dressing in stages to avoid exposing all wounds at the same time.
Verify the physician/clinician orders.
Identify the patient with at least two patient identifiers, according to facility policy.
Assess the patient's level of pain per facility policy.
Administer ordered oral pain analgesic about 20 minutes before beginning wound care and/or I.V. analgesic immediately before the procedure to maximize patient comfort and cooperation.
Explain the procedure to the patient and provide privacy.
Turn on overhead heat lamps to keep the patient warm. Make sure they don't overheat the patient.
Pour warmed normal saline solution into the sterile bowl in the sterile field.
Perform hand hygiene.
Removing a dressing without hydrotherapy
Put on a gown, a mask, and sterile gloves.
Remove dressing layers down to the innermost layer by cutting the outer dressings with sterile blunt scissors.
If the inner layer appears dry, soak it with warm normal saline solution to ease removal.
Remove the inner dressing with sterile tissue forceps or your sterile gloved hand.
Take out the trash
Because soiled dressings harbor infectious microorganisms, dispose of dressings carefully in the impervious plastic trash bag according to facility policy. Dispose of your gloves and perform hand hygiene.
Put on a new pair of sterile gloves. Using gauze pads moistened with normal saline solution, gently remove exudate and old topical medication. Move from the center of the wound outward.
Carefully remove all loose eschar with sterile forceps and scissors if ordered. (See “Mechanical and chemical debridement,” page 515.)
What's in the margin?
Assess wound condition. Note the location, size of wound, and tissue description. The wound should appear clean, with no debris, loose tissue, purulence, inflammation, or darkened margins.
Before applying a new dressing, remove your gown and gloves. Discard them according to your facility policy, perform hand hygiene, and put on new barrier attire with sterile gloves.
Soak fine-mesh gauze and the elastic gauze dressing in a large sterile basin containing the ordered solution (for example, saline or silver nitrate).
Wring out the fine-mesh gauze until it's moist but not dripping and apply it to the wound. Warn the patient that he may feel transient pain when you apply the dressing.
Wring out the elastic gauze dressing and position it to hold the fine-mesh gauze in place.
Roll an elastic gauze dressing over these two dressings to keep them intact.
Warm and cozy—but not wet
Cover the patient with a warm cotton bath blanket to prevent chills. Change the blanket if it becomes damp. Use an overhead heat lamp if necessary.
Change dressings as ordered, to keep the wound moist, especially if you're using silver nitrate. Silver nitrate becomes ineffective and the silver ions may damage tissue if dressings become dry. (To maintain moisture, some protocols call for irrigating the dressing with solution at least every 4 hours through small slits cut into the outer dressing.)
Remove old dressings, dispose of properly, and clean the wound (as described previously).
Apply ordered medication to the wound in a thin layer (about 2 to 4 mm thick) with your sterile gloved hand. If the area is large and painful, the medication may be applied to the gauze first, then laid onto the burn surface. Place several layers of burn gauze on top to contain the medication but allow exudate to escape.
Cut to fit
Don't cover unburned areas.
Cover the entire dressing with roller gauze and secure it with elastic netting or tape.
Apply dressings from the distal to the proximal area to stimulate circulation and prevent constriction. Wrap the burn gauze once around the patient's arm or leg so the edges overlap slightly. Continue wrapping in this way until the gauze covers the wound.
Apply a dry roller gauze dressing to hold the bottom layers in place. Secure with elastic netting or tape. Elastic/ace bandages may be ordered for the lower extremities to help maintain venous blood return.
Wrap each finger separately with a single layer of a 4'' × 4'' gauze pad to allow the patient to use his hands and to prevent webbing contractures.
Put gauze between each toe as appropriate to prevent webbing contractures.
Place the hand/foot in a functional position and secure this position using a dressing. Apply splints if ordered.
Apply the ordered medication to the wound in a thin layer. Then cover the entire burned area with sheets of burn gauze.
Wrap the area with roller gauze or apply a specialty vest dressing to hold the burn gauze in place.
Netting a good result
Secure the dressing with elastic netting or tape. Make sure the dressing doesn't restrict respiratory motion, especially in very young or elderly patients and in those with circumferential injuries (injuries to the body's periphery).
If the patient has scalp burns, clip or shave the hair around the burn as ordered. Clip other hair until it's about 20 (5 cm) long to prevent contamination of burned scalp areas.
Shave facial hair if it comes in contact with burned areas.
Typically, facial burns are managed with milder topical agents (such as triple antibiotic ointment) and are left open to air. If dressings are required, make sure they don't cover the patient's eyes, nostrils, or mouth.
Clip hair around the affected ear.
Remove exudate and crusts with cotton-tipped applicators dipped in normal saline solution.
Place a 4'' × 4'' layer of gauze behind the auricle to prevent webbing.
Apply the ordered medication to 4'' × 4'' gauze pads and place the pads over the burned area. Before securing the dressing with a roller bandage, position the patient's ears normally to avoid damaging the auricular cartilage. The ears may be left open after topical medication is applied.
Examine the ear canals for patency.
Assess the patient's hearing ability.
Clean the area around the eyes and eyelids with a cotton-tipped applicator and normal saline solution every 4 to 6 hours, or as needed, to remove crusts and drainage.
Administer ordered eye ointments or drops.
If the eyes can't be closed, apply lubricating ointments or drops as ordered.
Be sure to close the patient's eyes before applying eye pads to prevent corneal abrasion. Don't apply topical ointments near the eyes without a doctor's order.
Check the nostrils for signs of inhalation injury, including inflamed mucosa, singed hairs inside the nostrils, and soot.
Up the chimney
Clean the nostrils with cotton-tipped applicators dipped in normal saline solution. Remove crusts.
Apply ordered ointments.
If the patient has a nasogastric tube, use tracheostomy ties to secure the tube or bridle type device that doesn't require external ties/tape. Be sure to check the ties frequently for tightness resulting from swelling of facial tissue. Clean the area around the tube every 4 to 6 hours.
Assess/document level of pain again after dressing wounds to determine effectiveness of pain medications and tolerance of the procedure.
Perform dressing changes in stages to prevent cross-contamination and excessive exposure, which increases pain. Change sterile gloves for each stage.
Wound condition
Thorough assessment and documentation of the wound's appearance are essential to detect infection and other complications. A purulent wound or green-gray exudate indicates infection; an overly dry wound suggests dehydration; and a wound with a swollen, red edge suggests cellulitis. Suspect a fungal infection if the wound is white and powdery. Healthy granulation tissue appears clean, pinkish, faintly shiny, free of exudate, and bleeds easily.
Because blisters protect underlying tissue, leave them intact unless they impede joint motion, become infected, or cause patient discomfort.
Keep in mind that the patient with healing burns has increased nutritional needs. He'll require extra protein and carbohydrates to accommodate an almost doubled basal metabolism.
Begin discharge planning as soon as the patient enters the facility to help him (and his family) make a smooth transition from facility to home. (See Documenting burn care.)
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