The management of non-complex burns within the community
Fowler A. Nursing Times. 2003; 99(25): 49-51.
- Superficial burns and superficial partial thickness buns can be managed at home or as an outpatient. More severe burns should be managed at a specialist burns unit in the hospital.
- If a superficial partial thickness burn does not demonstrate signs of healing after 10 days of treatment then it should be referred to a specialist burns or plastic surgery unit as it may have become infected or be deeper than first suspected.
- To provide practical guidelines for the management of superficial burns and superficial partial thickness burns. Follow up to previous article on assessment and classification of burns.
A full assessment of a patient with burns injuries should include:
- The patient’s general health.
- Significant past medical health, eg heart or respiratory problems.
- Burns injury – history, type, cause, depth and percentage.
- Pulse, blood pressure, temperature, respirations and weight.
- Children may require narcotic analgesia to facilitate assessment and wound management.
- Patients with burns to the upper limbs may benefit from immobilization and elevation using a sling to help reduce oedema and relieve pain.
- Assess the need for prophylactic tetanus.
Referral to a specialist centre
- If the patient is going to be referred to a specialist centre then avoid any topical creams such as silver sulphadiazine as this may alter the appearance of the wound. It is also an expensive means of temporarily covering a wound.
- If a secondary dressing is required for transfer, patient comfort or wound protection then paraffin impregnated gauze with an absorbent pad could be used or even film wrap.
Immediate burn management
- Cooling process – the first treatment for a burn injury is to stop the burn process by using cool water for at least 10 minutes and up to 20 minutes (usually until the burning sensation stops). This cools the area, reduces pain and stops progression to a deeper burn.
- Circumstances where cool water should not be used are facial burns or certain chemical burns involving metallic sodium or metallic potassium. Never use ice or iced water as this can make the burn injury worse resulting in a deeper wound due to reduced blood flow.
Management of simple erythema
- Patients with simple erythema may have pain and be anxious about moving body parts. The management of these cases is the same as simple sunburn.
- Increase the patient’s oral fluid intake.
- Apply aloe vera gel or sun tan lotion containing aloe vera. Aloe vera gel alleviates pain and moisturises the area. Beware of sensitivities to preservatives such as parabens.
- A thin hydrocolloid film or foam dressing could be applied to avoid friction, eg under clothes.
- The burn should be reviewed after 48 hours by phone, in clinic or home visit. If the burn blisters then the patient will need re-assessing.
- Patients with partial thickness burns will need analgesia and reassurance and the wound will need to be covered with a protective dressing that can absorb any exudate.
- Any loose skin over the wound can be debrided and cleansed with warm tap water, sterile saline or water in line with local infection control policies. A low or non-adherent pad should be applied and the dressing should be left intact for 48-72 hours. The wound should be left covered, clean and dry.
- A thin hydrocolloid dressing may be applied to wounds with low exudate levels and is useful for children with superficial burns. This enables easy inspection as the wound can be viewed through the dressing and does not need to be removed before the 48-72 hour period. The dressing is also waterproof.
Management of blisters
- There is no national consensus on blister management. In the case of small non-complex burns it is acceptable to leave them intact. If the blister pops then the loose skin should be cut off and the wound covered with a low or non-adherent dressing.
- Blisters act as a protective layer against infection, but if they are large or impeding movement it may be easier to incise and drain them and absorb the resultant exudate.
First review at 48-72 hours
- The patient’s general health and wound should be reviewed at 48-72 hours after the injury.
- The initial inflammatory period subsides when the period of maximum exudate has ended and local oedema has subsided.
- At each review it is important to assess the patient’s pain and how they are managing the wound at home.
- Epithelialising wounds require a moist, warm and protective environment to heal.
- Dressings should be chosen dependent on the size, site and depth of the burn.
- A low or non-adherent dressing and a secondary dressing or hydrocolloid are often used on burn wounds. Hydrocolloids are often used in the community as they provide an ideal healing environment and can be left on for up to a week.
Management of deep burns
- Small deeper burns covered with eschar may be managed conservatively if the patient if unfit for or refuses to have a skin graft.
- The patient may be managed in the community with support from the local burns or plastic surgery unit or from community staff with outreach support from burns or plastic surgery units.
- The aim is to rehydrate the wound by promoting natural autolysis or debridement.
- A choice of hydrogels or antibacterial agents can be used dependent on the wound’s appearance and aim of treatment, the patient’s condition and preferred treatment.
Mobility and Movement
- The patients’ dressings should not inhibit their movement.
- Burns on the hand can be managed by placing the hand in a polythene bag that will allow movement and regular inspection.
- To prevent the bag sticking to the wound 5mls of silver sulphadiazine cream or silicone oil can be put into the bag to act as a lubricant. The bag should be changed twice daily.
- Good infection control, nutritional intake and wound management will promote healing. If any scabs are present at the wound site they should be left in place as removal may lead to visible scarring. If necessary a hydrogel could be used to rehydrate the area.
- Advice and information will help to allay patient fears, such as to avoid trauma and refrain from exposing the scar to direct sunlight as it is more vulnerable to sunburn.
- Massage the area with a skin cream to moisturise the scar and prevent friction or abrasions. Dry, flaky skin is more liable to itch and break down. Patients can be checked at 4-6 weeks following healing to check the scar and allay any anxieties.
Follow up and after care
- Patients may be referred to a burns unit at any time if they need assessment for scar management, psychological or functional support.
- Patients may forget instructions about wound management when they are in pain or upset over a traumatic injury. Key information should be provided on wound management, dressings and scarring and advice on where to go for ongoing support or what to do in the event of an adverse event.