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What is Caring for the Patient with Burns to the Hands and Feet?

• A burn to the skin is an injury caused by exposure to heat (e.g., wet heat [hot liquid or steam], dry heat [flames, contact with hot surfaces]), radiation (including overexposure to ultraviolet [UV] rays), friction, electricity, or chemicals. The severity of a burn is assessed by the depth of the burn and the extent of the body’s surface that is injured, but burns to the hands and feet are nearly always considered complex injuries due to the potential for significant loss of mobility and function
• What: Burns are evaluated and classified based on the type (cause) of burn; the level of severity (e.g., depth); and the care required to control pain and prevent further loss of viable tissue, infection, and further injury (for more information about burn assessment, see What You Need to Know Before Caring for a Patient with Burns to the Hand and Feet, below)
• How: Emergency burn care, which includes elevating and cooling the affected area, is administered after patient’s circulation, airway, and breathing (CABs) have been stabilized. The burns are then evaluated and classified by depth and total body surface area [TBSA] affected. Ongoing care involves, at minimum, wound care, the administration of analgesia to control pain, and antimicrobial therapy to control infection. Surgery and functional rehabilitation therapy are often necessary in the treatment of partial- (second-degree) and full-thickness (third-degree) burns to the hands and feet
• Where and Who: The majority of burns to the hand and feet are considered complex injuries that require inpatient treatment in a hospital or at a specialty burn center. Wound care is provided by advanced practice clinicians and nurses who have undergone specialized training in burn care. Specialists in pain management, physical and occupational therapy, infection control, mental health, nutrition, and social work are often part of the collaborative effort required for effective care of patients with burns. In addition, patients with severe burns can receive psychosocial support to overcome negative self-image if the burns result in visible deformity or loss of function. Not all patients with burns to the hands or feet will require ongoing inpatient treatment—patients with superficial burns (i.e., burns affecting only the epidermis, such as a sunburn) may heal relatively quickly and with little medical intervention—but initial treatment at a hospital or burn clinic is recommended to prevent wound infection and to optimize recovery

What is the Desired Outcome of Caring for the Patient with Burns to the Hands and Feet?

• Care of the patient with burns to the hands and feet is provided with the goal of minimizing pain; reducing risk of infection, further injury, and disfigurement; promoting healing; and minimizing functional impairment

Why is Caring for the Patient with Burns to the Hands and Feet Important?

• The underlying muscles, tendons, bones, and nerves that control movement are easily damaged by burns to the hands and feet – areas of the body with thin dorsal skin and little subcutaneous tissue
• The skin on the palms (i.e., the palmar aspect of the hand) and soles (i.e., the plantar aspect of the foot) is thicker and more protective, but even minor burns to the palms and soles affect the patient’s ability to perform tasks that require gripping objects or bearing weight
• Burns to the hands and feet are prone to numerous complications including infection, necrosis, contractures, and compartment syndrome (i.e., impaired circulation due to excessive intramuscular pressure)
• Burns can result in functional impairment because use of the hands and feet is important to performing personal care activities and to productivity
• Disfigurement that results after burns to the hands and feet can cause the patient to lose self-confidence and develop a negative self-image

Facts and Figures

• Hand functionality is a major determinate of quality of life (QOL) in burn survivors. Unfortunately, hand contractures occur frequently following burns, resulting in both functional impairment and physical deformity. Correction of the contractures can require excision of scar tissue, surgical repair of the deformed tendons and muscles, and use of splints and physiotherapy (Sabapathy et al., 2010)
• Loss of use of the hand constitutes a 57% loss of function for the whole person (McCauley et al., 2009)

What You Need to Know Before Caring for the Patient with Burns to the Hands and Feet

• Understanding of how to assess and determine the severity of the burn is important. Burn severity is assessed by the type (cause), extent, depth, and location of the burn 
• The extent of the burn refers to the TBSA affected. TBSA can be calculated using the Chart for Estimating Area of Burns (also known as the Lund and Browder Chart, which, although first developed in 1944, remains the most widely accepted method for estimating the extent of burn injuries). According to the Lund and Browder burn assessment chart, each hand comprises approximately 2.5% of TBSA and each foot comprises 3.5%. These percentages include the entire surface of each hand or foot. To calculate burns that affect only the plantar, palmar, or dorsal surface, the clinician would divide the percentage in half (e.g., burn to the plantar surface of the foot = 1.75% TBSA). Note: First-degree burns, as defined below, are not included in the percentage of TBSA because they do not cause an open wound (Lund et al., 1944)
• The depth of damage to burned body tissues is categorized as one of the following:
• First-degree (or superficial) burns are those limited to the outer layer of skin, which typically appears red and swollen. Superficial burns present as simple erythema and usually heal without scarring
• Second-degree (or partial-thickness or dermal injury) burns involve the dermis (i.e., the second layer of skin). The skin is usually red, splotchy, swollen, and blistered. Second-degree burns are subdivided into superficial-partial-thickness burns (i.e., destruction of the epidermis and upper dermis; usually the result of contact with scalding liquid or brief contact with a hot surface) and deep-partial-thickness burns (i.e., destruction of the epidermis through the lower dermis; usually the result of longer contact with a heated surface). Under optimal conditions, partial-thickness burns heal within several weeks, but can leave a scar
• Third-degree (or full thickness) burns extend through the entire dermis. The affected areas can be stiff and white or brown in color. Treatment usually involves excision of the affected areas. Scarring, contractures, and amputation can result
• Fourth-degree burns extend into underlying muscle, fat, and bone and where blood vessels and nerve endings are usually destroyed, causing permanent damage. The affected areas can be blackened and covered with eschar. Treatment involves excision and amputation of the affected extremity
• McCauley (2000) classified burn scar contractures by their severity, as follows:
• Grade I is characterized by symptomatic tightness without range of motion limitations or structural abnormalities
• Grade II is defined by mild decrease in range of motion without significant impact on activities of daily living (ADLs) or structural abnormalities
• Grade III is characterized by functional deficit with early structural deformity
• Grade IV indicates loss of hand function with significant structural deformity, and is further classified into
• Type A: Consisting of flexion contractures
• Type B: Consisting of extension contractures
• Type C: Consisting of both flexion and extension contractures
• Knowledge of physical assessment, skin/wound assessment, pain assessment, burn care, and infection control protocols is important
• Prior to caring for the patient with burns to the hands and feet:
• Review facility protocol for wound and burn care, if one is available
• Review the treating clinician’s orders regarding assessment and treatment
• Verify completion of facility informed consent documents. If burn care is performed under emergency conditions, the universally accepted standards of care for the medical condition offer implied consent
• Review the patient’s medical history/medical record for any allergies (e.g., to latex, medications, or other substances); use alternative materials as appropriate
• Gather the following materials:
• Skin assessment form (e.g., Lund and Browder Chart), if available
• Facility-approved pain assessment tool, if available
• Nonsterile gloves for cleaning wound. Additional personal protective equipment (PPE; e.g., gloves, gown, mask) may be needed if exposure to body fluids is anticipated
• Sterile gloves for applying dressing
• Sterile normal saline for irrigation
• Sterile tongue depressor
• Sterile cotton-tipped swabs
• Sterile 4 x 4 gauze, rolled gauze, and tape
• Sterile dressings appropriate to depth of the burn (e.g., biosynthetic wound dressing), as prescribed
• Material for cool compresses (e.g., sterile gauze, cool saline)
• Splint and pillows and/or towel for repositioning
• Topical antimicrobial ointment (e.g., sulfadiazine 1%, mafenide acetate), as prescribed
• Analgesia/anxiolytic/sedation, as prescribed
• Systemic antibiotic, as prescribed

How to Care for the Patient with Burns to the Hands and Feet

• Perform hand hygiene and don non-sterile gloves

• If you are first responder on the scene, promptly assess the patient’s CABs and employ basic life support measures, as needed, until the emergency medical transport team arrives. Always assess for the possibility of inhalation burns (i.e., burns injury due to inhalation of smoke, toxins, or heated air by checking for burns around the nose and mouth, labored breathing, and airway compromise). Provide emergency burn care to maintain cardiopulmonary stability and halt tissue damage
• Using aseptic technique, insert an intravenous catheter to administer fluids and analgesia, as ordered
• Irrigate the affected hand/foot with cool normal saline or apply normal saline-soaked gauze to the burn to halt tissue damage, reduce inflammation, provide pain relief, and remove surface debris
• Proceed with burn care after the patient has been stabilized
• Identify the patient using facility protocol
• Introduce yourself and assess the coping ability of the patient and family and for knowledge deficits and anxiety regarding the burn and care associated with the injury
• Determine if the patient/family requires special considerations regarding communication (e.g., due to illiteracy, language barriers, or deafness); make arrangements to meet these needs if they are present
• Use professional certified medical interpreters, either in person or via phone, when language barriers exist
• Explain the procedures to be implemented and their purpose; answer any questions and provide emotional support as needed
• Assess the patient’s general health status, including his/her pain level using a facility-approved pain assessment tool
• If appropriate, premedicate patient with prescribed analgesia/anxiolytic/sedative; allow for therapeutic level to be reached prior to administering wound care
• Use the splint, pillows, and/or towel to elevate and immobilize the affected hand/foot to minimize edema, as ordered
• Assess and classify the injury. Obtain information from the patient/family regarding how the burn occurred and the causative agent (e.g., hot liquid, flame)
• Cool the burn by applying cooled (not cold) normal-saline-soaked gauze to the damaged tissue
• This step reduces inflammation and pain when soaked gauze is applied immediately after the burn is received. Subsequent irrigation should be performed using a room temperature solution
• Using aseptic technique to minimize risk of infection, provide wound care appropriate to the depth of the burn and according to clinician’s orders
• Cleanse the foot/hand with gauze and or cotton-tipped swabs dipped in room temperature normal saline
• Gently remove (debride) loose, necrotic skin and assist the treating clinician with sharp or extensive debridement
• After cleansing and debridement, note the appearance of the wound to assess for injury
• Dispose of soiled materials and remove nonsterile gloves; perform hand hygiene
• Open sterile packages, including onto sterile surface—the inner lining of a sterile package is commonly used for this purpose
• Open the container for the topical antimicrobial ointment
• Don sterile gloves
• Use the sterile tongue depressor to collect the required amount of topical ointment from the container and apply the medication to all portions of the injured tissue
• Depending on the treating clinician’s order, leave the wound open to air or lightly cover it with a gauze dressing, secured with tape
• For partial-thickness burns, apply occlusive (e.g., biosynthetic wound dressing, petrolatum gauze) or antibiotic dressing (e.g., silver sulfadiazine or mafenide acetate)
• For full-thickness wounds, apply antibiotic dressing (preferably mafenide acetate, which has the greatest antimicrobial effect)
• For superficial burns, apply lotion or aloe vera gel to superficial burns with intact skin to maintain skin hydration and soothe discomfort
• Avoid dressing the wound more than once daily unless the wound becomes infected or produces a significant volume of exudate
• More frequent dressing changes offer no additional benefit and are painful for the patient
• Position the patient’s hands and feet so that nothing rests against the injured tissue
• Administer prescribed systemic antibiotic if infection develops
• Dispose of used procedure materials per facility protocol and perform hand hygiene
• Frequently assess for pain using facility protocol and administer prescribed analgesia (e.g., morphine, acetaminophen)
• Assist with completion of facility preoperative protocols if patient requires surgery
• Assist the patient daily with ambulation, ADLs, and with repositioning to maintain functional ability, promote independence, and minimize risk of developing pressure ulcers and contractures
• Monitor for complications and administer treatment, as ordered
• Monitor for infection (e.g., increasing pain, edema, exudate). Administer systemic antibiotic, as prescribed
• Monitor for poor intake. Encourage adequate intake of food and fluids, and administer nutritional supplements, as ordered
• Monitor for compartment syndrome. Check circulation to the hand/foot hourly for the first 48 hours after initial treatment by checking capillary refill and peripheral pulses. If circulation is compromised (e.g., cool fingers/toes, decreased capillary refill), notify the treating clinician and help prepare the patient for surgery (see Red Flags , below)
• Document the following in the patient’s medical record:
• Date and time of assessment/wound care
• Assessment findings, including
• classification of burn (e.g., degree and/or grade)
• wound appearance (e.g., color, size, odor, drainage, depth, evidence of healing)
• The patient’s pain level, if analgesia/anxiolytic/sedation was administered, patient’s response to medication, and if other comfort measures were used
• Details of wound care provided (e.g., dressings and topical agents applied)
• Patient tolerance of the procedure
• Unexpected outcomes and nursing interventions employed
• Patient/family education

Other Tests, Treatments, or Procedures That May be Necessary Before or After Caring for the Patient with Burns to the Hands and Feet

• Request referrals, as appropriate, to
• a registered dietitian for nutritional supplementation; nutritional consult may be considered because patients with complex injuries, especially young children, older adults, and individuals with underlying health problems, should increase their nutritional intake to promote wound healing
• physical and occupational therapy for functional limitation of hands/feet resulting from disuse, mobility impairment, or contractures
• a mental health specialist for counseling regarding disability or disfigurement, and to a social worker for local resources for support groups
• plastic surgeon for surgical reconstruction
• A tetanus shot may be administered if the patient’s vaccinations are not current
• Wound culture will be ordered if infection is suspected

What to Expect After Caring for the Patient with Burns to the Hands and Feet

• Optimal care is provided by a multidisciplinary team of clinicians, resulting in effective pain control, prevention of infection, functional recovery, and positive coping

Red Flags

•  Signs and symptoms of wound infection include sudden increase in body temperature, tenderness, pain, and swelling, delayed healing, discolored granulation tissue, and foul odor
•  Circumferential burns (i.e., burns that encircle digits or limbs) can result in compartment syndrome and tissue necrosis. Treatment consists of surgical decompression (i.e., escharotomy) of the affected hand, foot, or digits
•  Full-thickness burns of the hand and feet generally require surgical intervention. Procedures include debridement, split-thickness and full-thickness skin grafts, escharotomy, and amputation

What Do I Need to Tell the Patient/Patient’s Family?

• Inform patients that extensive rehabilitation is often necessary following severe burn injury to hands or feet. Encourage the patient to continue to adhere to the treatment regimen which can consist of dressing changes, physical therapy, medication, pain management, and nutritional support

References

1. Barillo, D. J. (2003). Management of burns to the hand. Wounds, 15(1), 4-9.

2. Cutting, K. F., & White, R. J. (2005). Criteria for identifying wound infection – revisited. Ostomy/Wound Management, 51(1), 28-34.

3. Lund, C., & Browder, N. (1944). The estimation of areas of burns. Surgery, Gynecology & Obstetrics, 79; 352-358.

4. Mann, E. A. (2011). Burn wound care. In D. L. Wiegand (Ed.), AACN procedure manual for critical care (6th ed., pp. 1097-1107). St. Louis, MO: Elsevier Saunders

5. McCahill, B. (2011). Nursing the patient with burn injury. In C. Booker & M. Nicol (Eds.), Alexander’s nursing practice (4th ed., p. 784). Edinburgh: Churchill Livingstone/Elsevier.

6. McCauley, R. L. (2000). Reconstruction of the pediatric burned hand. Hand Clinics, 16(2), 249-259.

7. McCauley, R. L. (2009). Reconstruction of the pediatric burned hand. Hand Clinics, 25(4), 543-550.

8. Parsons, L. (2010). Burns. In J. Kowalak (Ed.) Lippincott manual of nursing practice (9th ed, pp. 1172-1189). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins.

9. Sabapathy, S. R., Bajantri, B., & Bharathi, R. R. (2010). Management of post burn hand deformities. Indian Journal of Plastic Surgery, 43(Suppl), S72-S79.

Reviewer(s)

Kathleen Walsh, RN, MSN, CCRN, Cinahl Information Systems, Glendale, California

Nursing Practice Council, Glendale Adventist Medical Center, Glendale, California

Original document: 2011 Dec 02