General Assessment of a Patient with Burns

Original Editor - Carin Hunter
Top Contributors - Jess Bell, Carin Hunter, Tarina van der Stockt, Kim Jackson, Rucha Gadgil and Ahmed M Diab

Burn Assessment

Each individual with a burn injury is unique. Management should always be tailored to the individual and their specific context. This requires a detailed and accurate initial assessment. Investing time in the initial evaluation helps ensure the best possible immediate care, reduces the risk of long-term complications, and maximises a patient's functional recovery. By conducting a comprehensive assessment, the multidisciplinary team can become familiar with the patient's long-term goals and align therapy to these objectives. This, in turn, enhances patient engagement with the treatment plan.

Sharing initial assessment findings with relevant members of the multidiciplinary team helps to streamline subsequent assessments and facilitates continuity of care, both during rehabilitation and upon transition to community settings. This approach minimises patient frustration and ensures accurate transmission of relevant information throughout the treatment journey.

Goal Setting

The multidisciplinary team should assess a patient and set goals using the SMART goal method with each patient. SMART goals are specific, measurable, attainable, realistic and time-bound.

Short-term rehabilitation goals might include:

• preventing respiratory complications
• controlling oedema
• maintaing joint range of motion
• maintaing strength
• preventing excessive scarring

Risk factors to consider:

• injury factors:
  • inhalation injury
  • burn area - systemic inflammatory reaction syndrome involving the lungs
  • depth of burn
  • scarring
• patient factors
  • reduced ambulation and mobility
  • increased bed rest
  • increased pain
  • pre-existing co-morbidities
• treatment factors
  • skin reconstruction surgery
  • invasive monitoring and procedures
  • management in critical care

Functional long-term goals might include:

1. achieving functional independence
2. improving participation in society
3. maintaining / enhancing psychological well-being
4. establishing / achieving return to work plan

Key Aspects of the Subjective Assessment of a Patient with a Burn Injury

The following sections discuss essential components to include when examining a patient with a burn injury.

1. Inhalation Injury

During the subjective assessment, clinicians should carefully observe for signs of inhalation injury, especially in cases where there is a history of exposure to fire and smoke within enclosed spaces, coupled with diminished levels of consciousness. Physical indicators may include charring around the mouth and nostrils, singed nasal hairs, presence of soot in sputum and upper airways, alterations in voice quality, and the presence of wheezing. f any signs of inhalation injury are noted, a qualified member of staff must conduct an inhalation injury examination. This ensures the prompt initiation of appropriate treatment measures.

2. Total Body Surface Area

There are many methods on conducting a Total Body Surface Area (TBSA) assessment. The most accurate method is the Rules of Nines and Lund and Brower method. Another commonly used method is the Palmer Surface Method, whereby the patients palm size, (representing 1% TBSA) is used to estimate the total burns coverage. Please note, when assessing the burnt area, oedema should not be included.

When conducting the TBSA assessment, there are two main considerations:

1. The Parkland Formula for fluid resuscitation
2. When a patient has more than 20–25% TBSA a systemic inflammatory reaction is seen which is known to affect all body organs. This poses a risk for the respiratory system.

Please see Introduction to Burns for more information regarding TBSA Assessment.

3. Burn Type and Depth

It is important to regularly re-examine the extent of tissue destruction as it can change up to 48 hours post burn. It is uncommon for a burn to present uniformly with a singe depth throughout. Quick administration of first aid can influence the type and depth to a large extent.

4. Burn Site and Impact

The burn site can have a large impact of the potential functional outcome and the trauma associated with the injury. There are four High Impact areas associated with burns and this requires an awareness of the clinician assessing as these areas require specialised treatment.

High Impact Areas:

1. Hands
2. Face
3. Perineum
4. Joints

5. Current History

When conducting the current history questioning, please be aware of the emotional trauma that could be associated with a burn injury. If there is a family member or witness around, they can also be asked to fill in areas of the history that either the patient cannot recall, or that they are battling emotionally to elaborate on.

Important aspects to cover:

• History of the incident
  • Specific attention paid to the mechanism of injury
• First aid
  • An accurate account of what treatment was given?
  • On site medication administered needs to be explained clearly with amounts and times given as this could react with the medication administered on admission to hospital
  • If no adequate first aid was administered, suspect deeper burn injury
• Falls
  • Is there any indication that the patient fell?
  • What height did they fall from?
  • Suspect a possible head  injury, sprain or fracture
• Electrical injury
  • What voltage was involved?
  • Which parts of the body was in contact with earth?
  • Suspect nerve or deep muscle injury with high voltage current  
• Explosions
  • Suspect a fall, high velocity injury or possible tympanic membrane injury, as the latter would cause a loss of  hearing and difficulty communicating
• Passage to hospital and time to admission

6. Medical and Surgical History

• Pain medication
• Debridement
• Escharectomy
• Flaps/grafts
• Any particular MDT instructions to be followed

7. Past History

• Include any medical history
• Previous surgical interventions
• Medication
  • Amount
  • Duration on medication
  • Condition controlled or uncontrolled

8. Social History

• Basic activities of daily living. These vary from person to person, some examples:
  • Dressing
  • Bathing
  • Eating
  • Shopping
  • Driving
  • Home maintenance
• Past physical function
  • General mobility
  • Stair mobility
  • Lifting
• Past physical fitness
  • Strength
  • Flexibility
  • Endurance
  • Balance
• Social support and home situation
• Occupation
  • Particularly important for hand burns

Psychosocial Factors/ Yellow Flags

• Self-image
• Coping style
• Mental health
• Emotional behaviour  

Key Aspects of the Objective Assessment of a Patient with a Burn Injury

The following sections discuss the key components of the objective assessment for a patient with a burn injury.

1. Pain Intensity Assessment

Visual Analogue Scale

Observational behavioural pain assessment scales should be used to Measure pain in children aged 0 to 4 years e.g.

• Visual Analogue Scale (VAS) and the Wong-Baker FACES pain rating scale
  • Visual analogue scale can have the faces used alongside but also has numbers assigned below the faces which the patient uses to indicate their pain scores.
  • VAS can be used from age 12 upwards and is suitable for adults.
  • Wong-Baker FACES consists of 6 pain assessment cards that vary from a smile to sad to crying facial expressions representing pain behavior rating and is supervised by the Chinese Association for the Study of Pain (CASP). The patient chooses the best card to represent the pain intensity.
  • Faces pain rating scale can be used in children aged 5 years and older.
• The FLACC scale
  • 5 categories:
    • Face
    • Legs
    • Activity
    • Cry
    • Consolability
  • each of which accounts for scores of 0 to 2. With 10 as the full mark, 0 to 3, 4 to 7 and 8 to 10 scores represent no/light pain, moderate pain and acute pain, respectively

• COMFORT scale
  • 6 categories including
    • Alertness
    • Calmness/agitation
    • Crying
    • Physical movement
    • Muscle tone
    • Facial tension
  • With a full mark of 30, each category is scored on a 1 to 5 scale. In practice, suggestive information is offered according to the sum of the scores among the 6 categories. The higher scores one obtains, the more violent the pain (Table S1). Necessary pain interventional therapies shall be taken if the scores add up to more than 17
• Pain Observation Scale for Young Children (POCIS)
  • used for pain behavioral assessment with points ranging from 0 to 7, in which 0, 1 to 2, 3 to 4 and 5 to 7 are recorded as no pain, slight pain, moderate pain and severe pain, respectively, with 7 categories each contributing 0 or 1 point towards the overall score

For more information regarding Pain Assessment Tools please see:

• British Pain Society Outcome Measures
• Physiopedia page on Outcome Measures

2. Burn Outcome Measures

When treating patients in a multidisciplinary team, it is useful to use outcome measures that can be retested as the condition progresses. Some examples:

1. Burn Specific Health Scale -Brief (BSHS-B): Examine the  physical and psychosocial functioning of burn patients and their quality of life.
2. Burns Scar Index (Vancouver Scar Scale)
3. Burns Specific Pain Anxiety Scale

3. Inhalation Assessment

Physical signs are not the most reliable and accurate tools for assessment but they can contribute to the whole assessment of the patient. Physical signs should be included with clinical tests, regular re-assessment and correct initial management.

Initial management:

• Quick transportation to the emergency room
• Conscious
• Patent airway
• Chest radiograph
• Arterial blood gases

Physical Signs

• Soot stained sputum
• Stridor (Noisy breathing due to an obstructed airway)
• Wheezing
• Facial burns
• Singed nasal hairs
• Anxiety
• Cough
• Stupor
• Dyspnoea
• Hoarse vocal quality  
• Singed facial / nasal hair  
• Oedema
• Erythema (Superficial reddening of the skin, usually in patches, as a result of injury  or irritation causing dilatation of the blood capillaries)
• Inspiratory and end expiratory crackles on auscultation  
• Chest x-ray changes
• Signs of Hypoxia
  • Headache
  • Shortness of breath
  • Fast heartbeat
  • Coughing
  • Wheezing
  • Confusion
  • Bluish color in skin, fingernails, and lips **R-Baux score to predict the probability of death after burn injury was calculated for each patient by the following formula: R-Baux score =(TBSA+AGE+[17xR]) {R=1 if patient has inhalation injury and R=0 if not}

Bronchoscopy Assessment:

• Bronchoscopy assists with rapid diagnosis of inhalation injury and grading it be unavailable to the clinician and is considered the gold standard
• Inhalation Injury signs on bronchoscopy:
  • Erythema
  • Edema (which may be seen as a blunting of the carina)
  • Mucosal blisters
  • Erosions
  • Hemorrhages
  • Bronchial secretions
  • Soot deposits
• Indirect laryngoscopy permits visual assessment to the level of the vocal cords and can be a useful, albeit limited, tool should

Three determinants of injury severity

• Duration of smoke exposure
• Temperature of the inhaled smoke
• Composition of the smoke

For the latest recommendations please see:

• A Critical Update of the Assessment and Acute Management of Patients with Severe Burns
• Inhalation Injury in the Burned Patient

4. Oedema Assessment

When assessing oedema, the subjective component includes when the swelling began and any changes in the oedema with position. The objective assessment needs to be carefully carried out so there is a reduced risk on infection and no increase in pain. It is good to know how to assess oedema by stage and by size.

Stage of Oedema	Appearance of Oedema
Stage 1	Soft, may pit on pressure
Stage 2	Firm, rubbery, non-pitting
Stage 3	Hard, fibrosed

Oedema Classification Table

The most commonly used tools to measure oedema are:

1. Volume measurements (with a water volumeter)
2. Girth measurements (with a tape measure).
3. Pitting edema assessment (based on the depth and duration of the indentation).

For more information on how to conduct these measurements, please see Oedema Assessment

5. Physical Assessment

When conducting a physical assessment, it is often helpful to break up the assessment into two section. Firstly the upper limbs, lower limbs and trunk, secondly, general functional mobility. When conducting a physical assessment, it is important to consider complicating factors such as prolonged bed rest, high levels of pain and pre-existing co morbidities.

• Limbs and Trunk
  • Assessment of:
    • Joint range of motion
    • Muscle Strength
    • Muscle Length
  • Limiting factors:
    • Pain
    • Muscle length
    • Trans-articular burns
    • Scar contracture
    • Individual  specificity of the burn
• General Functional Mobility
  • The mobility assessment should only be carried out once the patient is medically stable and the focus is:
    1. Prevention of complications associated with prolonged bed rest.
    2. Restoration of function & independence.
  • Factors to be assessed:
    • Functional transfers
    • Gait
    • Endurance
    • Balance
  • Factors to consider:  
    • Posture
    • Activities of daily living
    • Demands of vocational roles
    • Cardiovascular response to mobilisation  
    • Neurological status
    • Concomitant injuries/weight-bearing status