CPG Burns

Nurse Practitioner
CLINICAL PRACTICE GUIDELINE

Burns

Scope Outcomes
Nurse Practitioner Minor burn inuries Identify patients suitable for
NP CPG
Genera! Practitioner Chemical burns Identify patients not suitable
for NP CPG and redirect to
GP +/- NP.
"#$Nurse Practitioner Major burns reuirin! resuscitati"e
inter"entions
#urns complicated by inhalation injury
#urns complicated by electrical injury
Initia! Assessment an% Inter&entions Outcomes
Primar' sur&e'
assessment
$bnormal primary sur"ey
identified e%it CPG
$ir&ay
#reathin!
Circulation
(istor' Patient identified as not
suitable for NP CPG e%it
CPG
Nature of burn i.e. thermal' chemical'
electrical
MI() Mechanism' injuries sustained'
si!ns-"itals' treatment !i"en pre
hospital mana!ement
$bility to function/perform
$*+,s/occupation/social assessment
Past medical history-medications
$ller!ies-immunisations especially
tetanus
+ast food and fluids
Compensable status-
M-I)/.C/*-$/Pri"ate insurance
)ocuse% c!inica!
assessment
$ssess the si/e' location and depth .ound assessment either
epidermal or superficial
dermal burn

$bnormal findin!s identified
for NP CPG e%it CPG
usin! .allace,s 0rule of nines, 1 2 ' 3 4
-colour
-blisterin!
-sensation
-capillary return
-e%udates
-inflammation
Pain assessment Pain sca!e numeric* %epen%in+ on *etermine need for and type
of anal!esia nature and depth of burn' pain can be
mild to se"ere
$dministration of anal!esia 5eduction/relief of pain
Minimise/pre"ent possible
complications
Ana!+esia #
)irst Ai% ,- * ./ 6irst $id
5est
Immobilisation
7le"ation
Irri!ation &ith room temperature &ater
for up to 89 minutes
5emo"e je&ellery and clothin!
Clean &ith sterile sodium chloride

2
Healthscope Medical Centres acknowledges the Naturaliste Medical Group for the utilisation of this
Clinical Practice Guideline.

Nurse Practitioner
Burns

0or1in+ %ia+nosis an% In&esti+ations Outcomes
Ima+in+ No ima!in! reuired if Identify specific cause and
determine patient
mana!ement
- no concurrent injuries

Pat2o!o+' Not app!icab!e

Interpretation o3 resu!ts 4%ia+nostic 3eatures5 an% mana+ement Outcomes
%ecisions
Goa!s o3 Treatment Protect t2e 6oun% %urin+ t2e 2ea!in+
process
Pre"ent infection
Pro"ide pain relief
Pro&isiona! Dia+nosis Outcomes
Patient identified as suitable
for NP
CPG and dischar!ed safely

Epi%erma! Burn
Sunburn or minor 3!as2
inuries* minima!
e7posure time8
Epi%erma! in %ept2* re%*
PS minima!* 2ea!s 6it2in
9$:; %a's* no cosmetic
%e3ects
GP NP re"ie& &ith "ie& for dischar!e
*ressin! reuired as per amount of
e%udates' pain' contamination and
location
7%pected to heal spontaneously &ithin
:-2; days &ith minimal scarrin!
No dressin! unless protection reuired
1 8 ' ; 4
Patient education/health promotion +/-
GP if reuired.
6ollo& up appointment &ith GP NP +/-
GP if reuired.
Super3icia! Derma!
Burn
GP/NP re"ie& &ith "ie& for dischar!e Patient identified as suitable
for NP CPG and dischar!ed
safely

Patient referred to specialty
units
*ressin! reuired as per amount of
7pidermal and papillary
dermis in"ol"ement'
blisters present'
e%tremely painful &ith
e%posed ner"e endin!s'
heals in about 2; days'
e%udates' pain' contamination and
location
7%pected to ha"e more e%udates and
more absorbent dressin! more
appropriate.
*ressin! selection as per 0(u!!ested
*ressin!s, see $ppendices
Patient education/health promotion
6ollo& up appointment &ith GP or
referral for sur!ical consult or follo& up
&ith metropolitan hospital #urns Clinic
Mi% Derma! Burn NP re"ie& in consultation &ith GP &ith $ssessment by GP and
admission/transfer arran!ed.
+ar!er /one of necrosis'
+ar!e /one of stasis'
Can be painful'
*elayed capillary return'
#listers'
*ar< pin<
"ie& for transfer to hospital emer!ency
department
5e"ie& and maintain adeuate
anal!esia
Maintain hydration
*ocument fluid balance

Patient education and health promotion
3

Nurse Practitioner
Burns

Medication as per formulary
*ressin! selection as per 0(u!!ested
*ressin!s, see $ppendices

Deep Derma! Burn NP re"ie& in consultation &ith GP &ith $ssessment by GP &ith "ie&
for transfer
(ome blisterin!'
#lotchy red base'
*oes not blanch'
5educed sensation to
pinpric<'
(ur!ical correction
"ie& for transfer to metropolitan hospital
burns unit
anal!esia
Maintain hydration

*ressin!s as ad"ised

)u!! t2ic1ness NP re"ie& in consultation &ith "ie& to Identify patients not suitable
for NP CPG
#oth layers of s<in
destroyed' May affect
deeper structures'
*ense' &hite' &a%y or
charred appearance'
No sensation to pinpric<'
+eathery appearance
transfer to metropolitan hospital burns
unit
GP mana!ement +/- NP.

$ssessment by #urns =nit
and admission/transfer
arran!ed.
anal!esia
Maintain hydration

*ressin!s as ad"ised
Acute
Re3erra!
Criteria for specialised burns treatment
#urns !reater than 29> of )#($
(pecial areas ? face' hands' feet'
!enitalia' perineum and major joints
6ull thic<ness burns !reater than @> of
)#($
7lectrical or chemical burns
#urns &ith inhalation injury
Circumferential burns of limbs or chest
-ery youn! and "ery old
)hose &ith pre-e%istin! medical
disorders that could complicate
mana!ement' prolon! reco"ery or
increase mortality
#urns &ith associated trauma

8

Nurse Practitioner
Burns

Patient Disc2ar+e E%ucation Outcomes
02en to return <erba! instructions 3rom NP 7nsure patient understands
problem' treatment' follo& up
and is safe for dischar!e
home
NP/GP &ritten patient information

7nsure patient understands
home
)o!!o6 up
appointments <erba! instructions 3rom NP
.ritten instructions for NP/GP

Sa3et' $ppropriate dressin! fitted to burn 7nsure patient understands
home
Correct fittin! of aids ie. broad arm
slin!' referral for crutches from
pharmacy
Patients !reater than A9 yrs of a!e
-referral to physiotherapy

Speci3ic care <erba! instructions 3rom NP
.ritten information re!ardin! dressin!
chan!es and burn care
7nsure patient understands
home
Ot2er
Re3erra!s Re3erra!s ma' be ma%e 3or speci3ic patient problems or as reuired toB
- (il"er Chain
- social &or<
- physiotherapy
- dru! and alcohol
- counselor
- $bori!inal liaison officer

$ppropriate documentation
completed

Certi3icates Absence 3rom 6or1 certi3ic ates
.C certificate
Certificate of attendance
Letters 7nsures continuity of care
and referral to health care
team
)o local emer!ency departmentB
specialistB admittin! hospitalB allied
health

;

Nurse Practitioner
Burns

Me%ications Outcomes
Ana!+esia See separate Ana!+esia C!inica! Protoco! Patients +i&en ana!+esia
appropriate to aller!ies'
current medications and past
medical history
$nal!esia reuirements
determined by on!oin!
assessment of pain and
adeuate anal!esia
pro"ided
Patients &ith e%cessi"e pain
or pain unrelie"ed by
anal!esia need re"ie& by GP
<accination#
Immunisation
Tetanus Immuno+!obu!in intramuscu!ar
Inection
A%sorbe% %ip2t2eria an% tetanus to7oi%s

C$*)D 9.@m+ intramuscular Injection

Refer to Australian Immunisation Handbook t h
!dition " section on Immunisation for tetanus prone
wounds " for dosage regimen #dependent upon
pre$ious immunisation status and t%pe of e&posure'
Topica! a+ents

Super3icia! Burns= A!+asite an% 3i7amo!8
Re&ie6 6it2in . %a's

Partia! # 3u!! t2ic1ness burns= Acticoat> ?
co&er 6it2 Duo%erm>8 Re&ie6 6it2in . %a's
Intra&enous 3!ui%s

@8AB So%ium C2!ori%e Intra&enous 3!ui%= C$
:@m! 3!us2 o3 Intra&enous cannu!ae D#-; or
In3usion at E$:-2r!' titrate% to patients
reFuirements

C!inica! au%it e&a!uation strate+ies
Une7pecte%
representation
5e"ie& Medical *irector Pro!ress Notes
Misse% prob!em Re$assessment o3 patient

Ge' to terms
NP$ Nurse Practitioner CPG$ C!inica! Practice Gui%e!ine
GP$ Genera! Practitioner 0C$ 0or1 co&er
PS$ Pain Score M<IT H Motor <e2ic!e Insurance Trust
S:$S;$ Sc2e%u!e o3 t2e %ru+ a%ministration act D<A$ Department o3 <eteran A33airs

@

Nurse Practitioner
Burns

Appen%ices
2. (u!!ested *ressin!s for the Mana!ement of Minor .ounds
3. Guidelines for the Mana!ement of a Minor #urn usin! 5etention *ressin!s
8. Care for the Minor 6acial #urn
;. Care for your #urn .ound usin! 5etention *ressin!
@. Care for your Eealed #urn
A. 5ule of Nines
:. Pain (cales

Re3erences an% e7istin+ CPGIs

Naturaliste Medical Group Nurse Practitioner Clinical Practice GuidelineF
#urns

Aut2ors2ip an% En%orsement
T2is +ui%e!ine 6as 6ritten b'=
+isa (choles - Nurse Practitioner
#road&ater Medical Practice G *unsborou!h Medical Practice

(i!natureF HHHHHHHHHHHHHHHHH

Re&ie6e% an% aut2orise% b'=

*r $ndre& +ill - General Practitioner


*r Mostyn Eamdorf -General Practitioner
GP *o&n (outhF Chair


*r (cott McGre!or - General Practitioner


Iarred (mith - Pharmacist
.est #usselton Pharmacy

*ate &rittenF Iune 3929
5e"ie& *ateF Iune 3922

A

Nurse Practitioner
Burns

Appen%i7 :8

SURGICAL DI<ISION H ROJAL PERT( (OSPITAL
(u!!ested dressin! for Mana!ement of the Minor #urn

J#I7C)I-7( J6 )57$)M7N)F
)o create a moist' &arm' constant en"ironment for &ound healin!
Promote autolysis
Increase patient comfort and reduce pain
7ncoura!e tissue !ro&th
5educe infection rates
Minimi/e interference to the patient,s lifestyle

G7N75IC
G5J=P(
)5$*7 N$M7( IN*IC$)IJN( $*-$N)$G7( *I($*-$N)$G7 *57((ING CE$NG7(
Eydrocolloid *uo*75M' (mall areas of partial to full Jcclusi"e Not transparent Prior to lea<in! from
Comfeel' Cutino"a
Eydro Chydrocellular
productD
thic<ness s<in loss $ssists autolytic Jffensi"e odour &ith beneath the dressin!
Presence of slou!h debridement hea"y' clouded
e%udate
3-@ days
+i!ht to moderate e%udate (elf adhesi"e If used for scar
Non-infected &ounds Promote !ranulation May macerate mana!ement 29-2;
days 5educe pain surroundin! s<in
Calcium
al!inate
Kaltostat' $l!oderm'
$l!isite M
Curasorb
Partial thic<ness s<in loss 5educe pain Ineffecti"e on dry Prior to e%udate
Minor bleedin! &ounds $bsorbs e%udate eschar lea<in! from beneath
dressin! Moderate to hea"y e%udate Eaemostatic Inacti"e on dry
properties &ounds *onor site dressin!
$ssists autolytic 5euires a secondary can be left sealed for
up to 2; days if clean
and dry
debridement dressin!
5etention
*ressin!
6i%omull stretch'
hyperfi%
(uperficial to partial 6acilitates joint Not transparent 8-2; days accordin!
thic<ness s<in loss mobility (pecific techniue to &ound assessment
Minor s<in lacerations $llo&s for normal reuired for easy
remo"al
Can be left for up to
Minimal to moderate hy!iene 2; days if clean and
dry e%udate 5educe friction at the
&ound surface
(il"er
*ressin!s
(il"er (ulphadia/ine
C((*D' $cticoat'
$"ance' Contreet'
$uacel sil"er'
acticoat absorbant
*eep partial to full thic<ness 5educes incidence of May cause stin!in! ((* ? *$I+L
s<in loss burn sepsis on superficial burns CE$NG7
7((7N)I$+ $ntimicrobial Can reduce mobility
(() is a preferred dressing for
patient transfer from rural areas
to ma*or referral centres
o"er small joints Product specific
(ome temporary information should be
sou!ht before use sil"er stainin! may
occur
Cost effecti"eness

If in doubt contact 5JL$+ P75)E EJ(PI)$+ C9MDN33; 33;; Plastic 5e!istrar Con pa!eD of the Clinical Nurse (pecialist for the Plastic (ur!ery and #urns Con pa!eD or
Plastic *ressin!s Clinic on 7%tF ;3399 direct fa%F C9MD N33; :9@N

Compiled in 2NNA byF # (perrin! CN' CPlastic *ressin! ClinicsD 5oyal Perth Eospital
5e"isedF 399A

$uthorised byF 6 .ood *irector of #urns =nit

:

Nurse Practitioner
Burns

Appen%i7 -8

Consi%er re3erra! to a specia!ise% Burns Centre i3 t2e burn 3a!!s into one o3 t2e
3o!!o6in+ cate+ories= Bo%' Sur3ace Area= K :@B a%u!t patientL K CB c2i!% # !ess :E mont2s
o3 a+e # 2an%s # 3ace # 3eet # perineum # maor oint in&o!&ement # circum3erentia! burns # 3u!!
t2ic1ness burns # e!ectrica! burns # c2emica! burns # an' in3ecte% burns

GUIDELINES )OR T(E MANAGEMENT O) MINOR BURN INMURJ USING RETENTION
DRESSINGS 4ie N)i7omu!! Stretc2I or N('pa3i7I5

APPLICATION O) DRESSING=

2. $nal!esic reuirementsF
a. consider reuirements for initial treatment Cmay reuire intra"enous / intramuscular
narcoticD.
b. once dressin! is intact oral anal!esia should be adeuate' if not reassess.

3. .ash the burn &ound under runnin! &ater.

8. *ebride blisters' e%cept palm and sole' &hich need to be slit Ccreate an ellipseD to
allo& for
adeuate decompression and to pre"ent the blister re-occurrin!.

;. 7nsure the surroundin! s<in is dry - the dressin! &ill not adhere to moist s<in.

@. $pply the retention dressin! to the surface of the &ound - no interface !au/e/cream
is
reuired. $llo& an o"erlap of 3cm of retention dressin! on to intact s<in.

A. If co"erin! a joint surface' apply &ith the line of the stretch of the non-&o"en fabric
follo&in! the line of fle%ion of the joint. *J NJ) ()57)CE .I)E
$PP+IC$)IJN.

:. .hen joinin! t&o pieces of retention dressin! o"er the &ound surface allo& no more than
3cm o"erlap of the dressin!. J"erlap can reduce the effecti"eness of the dressin! by
pre"entin! moisture "apour permeability.

M. *ischar!e patient &ith information sheet on care of and remo"al of the dressin!.

N. 5e"ie& in 3 - @ days.

29.If 0blisters, form beneath the retention dressin! they can be treated &ithout remo"in! all of
the dressin!. (imply cut a&ay the retention dressin! co"erin! the blistered area. )he
blistered s<in &ill come a&ay &ith the dressin! releasin! the e%udate. )he ra& area
remainin! is then treated as the burn area &as initially ie clean' dry and apply a patch of
retention dressin! &ith an o"erlap of no !reater than 3cm
M

Nurse Practitioner
Burns

Appen%i7 .8

CARE O) T(E MINOR )ACIAL BURN

2. .ash your face carefully t&ice each day &ith a simple non-perfumed soap and &ater' &hen
sho&erin! or bathin!.

3. Men should sha"e each day to reduce the ris< of infection.

8. 5emo"e any loose tissue and crustin! &hile sho&erin!.

;. Gently pat &ith a clean to&el. $pply a thin smear of emollient-based ointment to all burn
areas e%cept for the eyelids.

@. )a<e special care of the eyes' applyin! eye ointment' as directed by your doctor' to the eye
lids.

A. $fter eatin! or drin<in!' apply an oily cream such as 0lanoline, to the lips to pre"ent them
from becomin! dry and crac<ed. )his helps to reduce infection.

:. It is necessary to ta<e special care of burns to the ears' by !ently cleanin! the ears &hile
sho&erin! and applyin! a thin smear of an emollient based ointment to pre"ent dryin!.
Pressure on the ears &hile they are healin! may reduce the blood supply causin! further
dama!e to the s<in and increasin! the ris< of infection.

M. )he burn may cause the face to s&ell. (ittin! up on t&o or more pillo&s at ni!ht &ill help to
reduce facial s&ellin!.

N. If your &ound increases in pain or you are concerned about the s&ellin!' contact the clinic
for re"ie& by the nurse.

29. 5etention dressin!s such as ,6i%omull (tretch, and 0Eyperfi%, are not recommended
for use on facial burns

Appen%i7 ;= Patient In3ormation S2eet
N

Nurse Practitioner
Burns

CARE )OR JOUR BURN 0OUND USING RETENTION DRESSING

0(ILE (EALING
2. .ash t&ice daily o"er the dressin! &ith simple soap and &ater.
5emo"e
any crustin! or yello&/!reen fluid that may collect
3. *ry thorou!hly usin! a to&el to pat dry
8. If soa<ed in &ater for o"er @ minutes the dressin! and &ound bill
become
so!!y and increase the ris< of infection
;. $"oid acti"ities that may cause injury to the &ound and lead to
bleedin! or
infection' e! di!!in! in sand' s&immin!' !ardenin!' mechanical
repairs
@. If your &ound becomes red and hot &ith an increase in pain or
s&ellin!
beneath the dressin!' or if it blisters then return for re"ie& of the
&ound
A. *J NJ) 57MJ-7 )E7 *57((ING. It &ill not come off easily
&ith &ater.
$ttempts to remo"e it &ill cause pain and dama!e the healin! tissue.

REMO<ING T(E RETENTION DRESSING
Please remo"e the dressin! onF
HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH

Carefully follo& these instructionsF
2. Coat the dressin! in oil Coli"e' peanut' baby' "e!etableD ma<in! sure
the
dressin! is &ell soa<ed.
3. .rap the dressin! in plastic food &rap and banda!e if necessary to
pre"ent
oil from stainin! your clothin! or bed linen or co"er &ith an old
clean )-shirt
or soc<.
8. +ea"e plastic food &rap in place for a minimum of ; hours. )his
can be
o"erni!ht.
;. .ash carefully in sho&er/bath to remo"e the dressin!
@. (imply co"er a!ain in fresh plastic food &rap to pre"ent ra& areas
from
dryin! and hold in place &ith banda!es or clothes
A. Lour &ound can no& be easily assessed &hen you arri"e

Multidisciplinary #urn Mana!ement 5oyal Perth Eospital Ian 399;

Appen%i7 C= Patient In3ormation S2eet
29

Nurse Practitioner
Burns

CARING )OR JOUR (EALED BURN

Jnce the s<in has healed it &ill be fra!ile and need care and protection

2. 5etention dressin! may be used to protect the surface for a period after
healin!. )he retention dressin! can be left in place until it comes off by
itself. If it !ets dirty' you may &ish to chan!e it before it comes off
naturally. It is usually stays on for about @-: days. If at 3 &ee<s post
healin! the scar is a concern to you please ma<e a follo&-up
appointment.

3. Protect yourself from the sun by usin! sun bloc< C(P6 89+D. Eats and
protecti"e clothin! are a must.

)he pi!ment cells need time ? one to t&o years - to reco"er

8. )he !lands in the s<in ta<e time to reco"er. Moisturisin! creams need to
be applied re!ularly Cat least t&ice dailyD and continued for se"eral
&ee<s. Massa!e the moisturi/in! cream into the s<in. It pre"ents dryin!
and crac<in!. It can also help to reduce itchin! and increase comfort.
$"oid hi!hly perfumed creams or creams that ha"e alcohol base.

$ppropriate creams are a"ailable from the supermar<et or local chemist
at competiti"e prices. 7d (orbolene' +anoline or $ueous Cream.

;. In some scars pressure therapy is helpful. Pressure !arments may be
considered. )he need for further scar treatment &ill be assessed by your
GP.

Multidisciplinary #urn Mana!ement 5oyal Perth Eospital Ian 399;

22

Nurse Practitioner
Burns

Appen%i7 D8 Ru!e o3 nines

23

Nurse Practitioner
Burns

Appen%i7 98

P$IN (C$+7(

<isua! ana!o+ue sca!e 4<AS5

Numerica! ratin+ sca!e 4NRS5

)aces ratin+ sca!e 4)RS5

28

Nurse Practitioner
Burns

Be2a&ioura! ratin+ sca!e= )or patients unab!e to pro&i%e a se!3$report o3 pain
)ace @ : - Score=
6ace muscles
rela%ed
6acial muscle
tension' fro&n'
!rimace
6reuent to constant
fro&n' clenched ja&
: - Score=
Rest!essness @
Ouiet' rela%ed
appearance' normal
mo"ement
Jccasional restless
mo"ement' shiftin!
position
6reuent restless
mo"ement may include
e%tremities or head
)unctiona! acti&it' scoreO
CCou!h/mo"ementD
$ ? No limitation
# ? Mild limitation
C ? (e"ere limitation
: - Score=
Musc!e toneP @
Normal muscle tone Increased tone'
fle%ion of fin!ers and
toes
5i!id tone
P 5elati"e to baseline
: - Score=
<oca!isationPP @
No abnormal sounds Jccasional moans'
cries' &himpers and
!runts
6reuent or continuous
moans' cries'
&himpers or !runts
: - Score=
Conso!abi!it' @
Content' rela%ed 5eassured by touch'
distractible
*ifficult to comfort by
touch or tal<
Be2a&ioura! pain assessment sca!e tota! 4@H:@5 #:@

Q $ssess muscle tone in patients &ith spinal cord lesion or injury at a le"el abo"e the
lesion injury. $ssess
patients &ith hemiple!ia on the unaffected side.
QQ )his item cannot be measured in patients &ith artificial air&ays.

Pain ratin+ sca!es instructions

Subecti&e pain score
$ll patients are to ha"e a functional acti"ity score recorded in addition to the chosen subjecti"e score.
<isua! ana!o+ue sca!e 4<AS5
Instruct the patient to point to the position on the line bet&een the faces to indicate ho& much pain they are
currently feelin!. )he far left end indicates 0No pain, and the far ri!ht end indicates 0.orst pain e"er,.
Numerica! ratin+ sca!e 4NRS5
Instruct the patient to choose a number from 9 to 29 that best describes their current pain. 9 &ould mean 0No
pain, and 29 &ould mean 0.orst possible pain,.
)aces ratin+ sca!e 4)RS5
$dults &ho ha"e difficulty usin! the numbers on the "isual/numerical ratin! scales can be assisted &ith the use
of the si% facial e%pressions su!!estin! "arious pain intensities. $s< the patient to choose the face that best
describes ho& they feel. )he far left face indicates 0No hurt, and the far ri! ht face indicates 0Eurts &orst,.
*ocument number belo& the face chosen.
Be2a&ioura! ratin+ sca!e
)he beha"ioural pain assessment scale is desi!ned for use &ith non-"erbal patients unable to pro"ide self-reports of
pain.
5ate each of the fi"e measurement cate!ories C9'2 or 3D.
$dd these to!ether.
*ocument the total pain score out of 29.
)unctiona! acti&it' score
)his is an acti"ity-related score. $s< your patient to perform an acti"ity related to their painful area Cfor
e%ample' deep breathe and cou!h for thoracic injury or mo"e affected le! for lo&er limb painD.
Jbser"e your patient durin! the chosen acti"ity and score $' # or C.
$ ? No limitation meanin! the patient,s acti"ity is unrestricted by pain
# ? Mild limitation means the patient,s acti"ity is mild to moderately restricted by pain
C - (e"ere limitation means the patient ability to perform the acti"ity is se"erely limited by pain

Q5elati"e to baseline refers to any restriction abo"e any pre?e%istin! condition the patient may already ha"e.
2;

CPG Burns

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Nurse Practitioner

CLINICAL PRACTICE GUIDELINE

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