Burn Treatment Pharmacology and Diagnostics NUR 203 Module

Burn Treatment: Pharmacology and Diagnostics NUR 203 Module F Continued Kathleen Williams, MSN, CRNP

Treatment Priorities �Stop the Burning Process �Apply Oxygen �Intubate when indicated by history of assessment findings; airway may occlude secondary to exposure up to 48 hours post burn incident �Determine the need to continually assess for any indications of respiratory impairment due to circumferential chest burn �Set up and assist with escharotomy when indicated �Place NG tube and Foley catheter

Treatment Priorities - Continued �Administer Morphine for pain �Obtain patient weight �Calculate fluid replacement accurately and initiate fluid resuscitation after placing two (2) large bore intravenous catheters (14 G - 16 G) or central venous access, (If use central access, best in femoral area) �Obtain information regarding medications, allergies, status of tetanus, and pre-existing diseases �Ascertain the treatment status; early treatment consultation or treat and transfer

Stop the Burning Process: �THERMAL BURN �Smother or douse the flames �CHEMICAL BURN �Flush with H 2 O (water); brush dry chemical off first �ELECTRICAL BURN �Interrupt current

Nursing Diagnosis � Ineffective Airway Clearance and Impaired Gas Exchange related to tracheal edema or interstitial edema secondary to inhalation injury and/or circumferential torso eschar manifested by hypoxemia and hypercapnia � Deficient fluid volume secondary to fluid shifts into the interstitium and evaporative loss of fluids from the injured skin � Risk for hypothermia related to loss of skin and/or external cooling � Ineffective tissue perfusion related to compression and impaired vascular circulation in extremities with circumferential burns � Acute pain related to burn trauma

Nursing Diagnosis - Continued � Risk for infection related to loss of skin, impaired immune response, and invasive therapies � Risk for injury: gastrointestinal bleeding related to stress response � Imbalanced Nutrition; Less than body requirements related to ileus and increased metabolic demands secondary to physiological stress and wound healing � Impaired Physical Mobility and self care deficit related to burn injury, therapeutic splinting, and immobilization requirements after skin graft, and/or contractures. � Risk for ineffective individual coping and disabled family coping related to acute stress of critical injury and potential life threatening crisis

Diagnostic Studies: �Laboratory Studies �CBC �ABG’s �Carboxyhemoglobin �Electrolytes �BUN �Urinalysis �Glucose in all children and known diabetics

Diagnostic Studies- Continued �Chest xray �ECG with all electrical burns or if there is any question of pre-existing cardiac problems

Pharmacological Agents: Initial Fluid Resuscitation is done according to ABLS Fluid Resuscitation Formulas. INFUSED according to calculations done using an estimation of a victims fluid needs related to the extent of the burn and body size and age. Calculation of fluids for the first 24 hours: Adults: 2 -4 ml/RL x Kg body weight x percent burn Children: 3 -4 ml RL x Kg body weight x percent burn One half of the estimated volume to be infused in the first 24 hours is administered in the first 8 hours post burn. The remaining half of the estimated rescitation volume should be administered over the subsequent 16 hours of the first post burn day. The volume of fluid to be administered is further adjusted according to the individual patient’s response to the burn and the treatment regimen. The second 24 hours requires intense monitoring of the patient and their physiological response to the burn. Colloid containing fluids can be utilized to keep volume loading at a minimum. Urinary output is monitored and electrolyte free water is also administered to the adult to maintain adequate urine output (30 -50 ml/hr) while monitoring serum sodium levels to keep them at no less than post 24 hour resuscitation levels (i. e. 130 m. Eq/L) Adults: a. 0. 3 – 0. 5 ml colloid- containing fluid x Kg body weight x % BSA burn physiologic concentration in NS) b. Electrolyte –free fluid to maintain adequate urinary output (Albumin diluted to Children: a. 0. 3 – 0. 5 ml colloid-containing fluid x Kg body weight x % burn ( Albumin diluted to physiologic concentration in (NS) b. Half Normal Saline (1/2 NS) to maintain adequate urinary output More specific calculations should be done according to ABLS protocol as soon as possible! See Box 20 -1 in Sole, p 636.

Pharmacological Agents: � Pain Management: This is often difficult to do in burn patients. Specific protocols are usually in place for burn patients due to the quantities of analgesics required for pain control. Patients are often under medicated if the standard dosing schedule is used. �Opiates are the most common analgesics used to treat burn pain. Subcutaneous or Intramuscular injections are ineffective in the resuscitative phase because of the impaired circulation in the soft tissue. � Morphine is the drug of choice and Intravenous (IV) is the route of choice � Anxiety: Anxiety is a complicating factor in burn treatment. Anxiety further exacerbates the patient’s pain response. This treatment requires individualization of the treatment. �Anxiolytics are commonly administered in the acute

Pharmacological Agents: �Infection Control: burn Patient’s are at high risk of infection related to disruption of normal skin integrity and altered immune response. �Topical the are used in the wound care of burn patient’s �Clotrimazole cream or Nystatin �Mafenide acetate (Sulfamylon) �Silver-coated dressings (Acticoat, Aquacel Ag, Mepilex Ag, Tegaderm Ag) �Silver Nitrate �Silver Sulfadiazine (SSD, Silvadene) �Oral �Intravenous

Pharmacological � Wound Care Dressings; there are many biologicals used for burn management at different stages of burn treatment. � Non Pharmacological Interventions to Wound Care: �Negative pressure wound therapy (NPWT) or vacuumed- assisted closure (VAC) devices can be used for the treatment of grafts, partial-thickness burns and deep surgical wounds � Surgical Excision and Grafting �Biological dressings are used on the donor sites for grafts used in treatment of burns. Many examples are available. � Bio. Brane this dressing is placed on a wound and it peels away as the wound heals, so as the edges rise and peel back the nurse trims away the dressing until it is all healed � Vigilon Colloidal Suspension � Silver Coated dressings Acticoat, Mepilex Ag, for example are silver coated flexible dressings that provide continuous release of silver ions for 3 -14 days while dressing is moist.