CYWHS Nursing & Midwifery Clinical Standards

Burn Wound Assessment

The CYWHS recommends all Nursing and Midwifery Clinical Standards are accessed
only via the CGER intranet. The CYWHS cannot ensure that a pre-printed or paper copy
is the current endorsed version.

Document Number cs2006_41

Publication Date 2 April 2007
Functional Group - Sub Group Individual Health Care – Care Planning and
Delivery’
Summary Correct assessment of burn wound depth is
essential in determining appropriate treatment
and dressing products
Replaces Burns Dressing- Bactigras/Soft white paraffin
impregnated gauze (Vaseline gauze) 1636,
Burns Dressing- Hydrocolloid dressing 1634,
Burns Dressing- Silver Sulphadizine cream 1630,
Burns Dressing- Transparent Film 1635, Burns
Dressing –Hypafix 1623
Lead Writer L Quinn – Burns CN
Lead Writer Contact c/o Burn service ext 18193, pg 5876
Others Involved In Writing S McRae – Burns CNC, H Harris – Newland CN,
S Khurana – Burns Consultant, J Hoyle – Stomal
Therapist, A Sparnon – Burns Consultant, B
Anderson – Newland NUH, J Hartwig – Paed
Surg Project Nurse
Accreditation Action Group Responsible Leadership and Management / Research
Executive Director Responsible Regional Director - Nursing and Midwifery
Applies to WCH
Review Date 1 January 2010
Minimum Competency Level Accredited EN
Key Words Burn, wound, assessment, dressing, hypafix,
bactigras, hydrocolloid, paraffin, silver
sulphadizine cream, transparent film
Status Active
Endorsed by Clinical Standards Reference Group
Endorsement Date 28 March 2007
Board of Directors

Compliance with this clinical standard is mandatory

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 CYWHS Nursing & Midwifery Clinical Standard
Burn Wound Assessment
The CYWHS recommends all Nursing and Midwifery Clinical Standards are accessed
only via the CGER intranet. The CYWHS cannot ensure that a pre-printed or paper copy
is the current endorsed version.

This Clinical Standard was printed on

Introduction
Burns are a common form of trauma.1% of the population of Australia and Zealand
(200,000) suffer burns each year.1

There are five classifications of burn depth:

• Epidermal
• Superficial Dermal
• Mid Dermal
• Deep Dermal
• Full Thickness

Accurate assessment of burn depth on admission is important in making decisions

about dressings and surgery.9

Definition(s)
Epidermal:

• Appearance - pink or red erythema with no blisters.

• Capillary return – Rapid <2 seconds.
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 • Sensation - painful.
• Outcome – will heal in 3-5 days with no resulting cosmetic blemish.
• Most common cause is sunburn.
• May require hospitalisation for pain management.
• Pure erythema is not included in estimation of TBSA. Differentiation between
erythema and superficial dermal burn may be difficult in the first few hours
following the burn injury.

Superficial Dermal

• Appearance – Wet, pale pink or blotchy with blisters, when blister is debrided
the dermis will be exposed, potentially increasing depth of tissue loss.
Epidermis may not lift off for 12 to 24 hours increasing risk of inaccurate
assessment of burn as superficial epidermal.
• Capillary return – Brisk <2 seconds.
• Sensation – Very painful as sensory nerves are exposed.
• Outcome – Will heal in 7-10 days as epidermal appendages remain intact.
Minimal or no scarring but a colour defect may remain.

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Mid Dermal:

• Appearance – Red, dark pink, white with blisters.

• Capillary return – Sluggish, varies with depth.
• Sensation – Adequate.
• Outcome – Will heal in 10 to 14 days, except in the very young and elderly
where the dermis is thin and depth of burn is invariably deeper.
• This type of burn injury is highly susceptible to conversion to a deeper
thickness wound. Factors that may deepen wound include inadequate first
aid, co-morbidities, poor resuscitation, inappropriate wound management or
dressing choice, patient age, vasoconstriction from over cooling,
hypovolaemia, oedema and infection.

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Deep Dermal:

• Appearance – Blotchy red due to extravasation of haemoglobin, or mottled or

waxy and white. Will sometimes have blisters.
• Capillary return – Absent.
• Sensation – To pressure but not pain, dermal nerve endings are lost. The
presence of sensation to touch usually indicates the burn is a deep dermal
injury opposed to full thickness.
• Outcome – 2-3 weeks, as epidermis, dermis and epidermal appendages are
lost. If infected may convert to full thickness injury requiring grafting.
• There is a marked decrease in blood flow making the wound very prone to
conversion to a deeper injury and to infection.

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Full Thickness:

• Appearance – White, charred, black, tan, no blisters.

• Capillary return – Absent.
• Sensation – Absent.
• Outcome – Large areas will not heal without surgical intervention, small areas
may heal from the edges after several weeks. This wound will not re-
epithelialise and whatever area of the wound is not closed by wound
contraction will require skin grafting.
• Epidermis, dermis and epidermal appendages are destroyed, injury may
involve fascia, muscle and bone.

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Indications
Each depth of burn requires different treatment approaches and therefore
appropriate dressing products.

Contraindications

• The burn wound is a dynamic living environment that will alter depending on
both intrinsic factors (such as release of inflammatory mediators, bacterial
proliferation) and extrinsic factors (such as dehydration, systemic
hypotension, cooling)
• It is therefore important to review the wound at regular intervals until healing.

Equipment
• Refer to Burn Wound Management standard

Process

Hand hygiene must be performed at the beginning of all procedures and universal
precautions utilised where there is a risk of exposure to body fluids.

Burn assessment should be undertaken by an experienced Burns nurse in

conjunction with Medical Officer or Burns CN/CNC

• Refer to Burn Wound Management standard.

• Assess depth of burn wound using burn depth principles.
• Select dressing product -refer to Burn Guidelines.
• Complete dressing as per Burn Wound Management standard.

Associated Links
Burn wound management standard

Split skin graft standard

Burns dressing – facial burns

Burns guidelines www.wch.sa.gov.au/services/az/divisions/psurg/burns/index.html

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References
1. Australian and New Zealand Burn Association Ltd 2005, Emergency
management of severe burns – course manual, 9th Edition.
2. Carrougher, G 1998, ‘Burn wound assessment and topical treatment’ in Burn
care and therapy, Mosby, St. Louis, pp 133-166.
3. Clarke, M 2002, ‘Paediatric Burn Injuries’, Seminar,[monograph cited on the
internet 11/6/2006] Available on URL
http://surgclerk.med.utoronto.ca/Phase2/Paediatric/PaediatricBurns.htm
4. Demling, R and DeSanti, L 2004, ‘Managing the burn Wound’ [monograph
cited on the internet 10/6/06]. Available on URL http://www.burnsurgery.org
5. Heittiaratchy, S and Papini, R 2004, ‘Initial management of a major burn :II –
Assessment and resuscitation, BMJ, Vol 329, pp 101-103.
6. Lybarger, P and Kadilak, P 2001, ‘Thermal Injury’ in Critical Care Nursing of
infants and children 2nd ed Curley, M and Maloney-Harmon, P (Ed)
Saunders, Philadelphia, pp 981-996.
7. Williams, W 2002, ‘Pathophysiology of the burn wound’ in Total Burn Care
2nd Edition Herndon D, Saunders, London, pp. 514-522
8. Photos accessed from Women’s and Children’s Burn Database.

Disclaimer Copyright

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