Nursing Care Interventions in the Client with Burn

Nursing Care & Interventions in the Client with Burn Injury Keith Rischer RN, MA, CEN 1

Today’s Objectives… Ø Ø Ø Ø Ø Compare and contrast the clinical manifestations of superficial, partial-thickness, and full-thickness burn injuries. Prioritize nursing care for the client during the emergent, acute, and rehabilitation phase of burn injury. Analyze assessment data to determine nursing diagnoses and formulate a plan of care for clients with burn injuries. Use laboratory data and clinical manifestations to determine the effectiveness of fluid resuscitation. Describe nursing management wound care and nutritional needs for the burn client. Evaluate assessment data to determine wound healing in the burn client. Identify pain management strategies for burn clients. Explain the positioning and range-of-motion interventions for the prevention of mobility problems in the client with burns. Discuss the potential psychosocial problems associated with burn injury. 2

Burn Injury: Patho Ø Skin • • Ø Ø Epidermis Dermis Purposes Skin destruction • • • Fluid/protein loss Sepsis Multi-system changes ü ü Dependant on age Health Depth of injury Body area involved 3

Depth of Burn Injury Ø Superficial-thickness • Ø Partial-thickness • Ø Epidermis only Epidermis + partial Dermis Full-thickness • Epidermis + all dermis + underlying tissue/muscle/bone 4

Assessment: Superficial-thickness Ø Ø Ø Pain Redness Heals in 3 -5 days 5

Assessment: Partial-thickness Ø Red-blanch • Ø Ø Ø No blanch with deeper burn Blister and broken epidermis Painful Heal in 10 -21 days 6

Assessment: Full-thickness Ø Ø Ø Ø Pale, white to red, yellow Charred eschar Leathery skin, dry surface Painless Edema present Signs of systemic shock may be present Needs grafting 7

Burns: Vascular Changes Ø Fluid shift • • Capillary leakage First 12 hours ü • Lasts 24 -36 hours Lyte & acid base imbalance Hypovolemia ü Hyperkalemia, hyponatremia ü Ø Fluid remobilization • Diuretic stage (48 -72 hours) Hyponatremia ü hypokalemia ü 8

Burns: Body System Assessment Ø Cardiac • • Ø Respiratory • • Ø Paralytic ileus Metabolic • • Ø Airway edema pulmonary cap. leakage GI • Ø HR increase CO decreased initially Increased due to catecholamines, cortisol and SNS Caloric needs double or triple Immune • • Diminished response Increased risk of infection 9

Burns: Emergency Management Ø Ø Ø Primary Survey Airway • Breathing • Circulation • C-Spine immobilization (when indicated) Secondary Survey • Complete head to toe exam • % of TBSA • Depth of burn • Part(s) of body burned • Rule out other serious or life threatening injuries 10

Inhalation Injury: Assessment CO Poisoning • HA • Nausea • Alterered LOC • Confusion • Coma Symptoms Signs Facial burns Singed nasal hairs Stridor Severe cough Hoarseness Shortness of breath Anxiety Wheezing Dyspnea Disorientation Obtunded Coma 11

Burn Classification Ø Ø Ø Minor • <15% partial thickness Moderate • 15 -25% partial thickness • <10% full thickness Severe • >25% partial thickness • >10% full thickness 12

ABA Burn Referral Guidelines Ø Ø 2° Burns > 10% TBSA Burns involving the face, hands, feet, genitalia, perineum, & major joints 3° Burns in any age group Electrical Burns • Ø lightning injuries Chemical Burns 13

Laboratory Findings: First 48 hours Ø Ø Ø Ø Hgb/Hct Glucose Sodium Potassium BUN/creatinine Albumin ABG’s • • p. O 2 p. CO 2 p. H CO 14

Nursing Diagnostic Priorities: First 48 Hours Decreased cardiac output r/t… Ø Deficient fluid volume r/t… Ø Ineffective tissue perfusion r/t… Ø Ineffective breathing pattern r/t… Ø Acute pain r/t… Ø 15

Fluid Resuscitation Ø Nursing interventions • • Ø Large bore IV/central IV access Lactated ringers Nursing Assessment • I&O ü • • • Urine output Daily weight Oxygenation needs Fluid overload VS Labs ü ü ü Creatinine Albumin lytes 16

Nursing Diagnostic Priorities: First 48 Hours Ø Ineffective breathing pattern r/t… • • Respiration pattern Oxygenation ü ABG’s – p. H: 7. 41…. 7. 29 – p 02: 73…. 55 – p. CO 2: 44…. 60 Ø Acute pain r/t… • Opiods IV Fentanyl. . . Onset___ Peak___ Duration___ ü Morphine… Onset___ Peak___ Duration___ ü Dilaudid…Onset___ Peak___ Duration___ ü 17

Assessment Priorities: After 48 Hours Ø Cardiopulmonary • Ø Neuroendocrine • Ø Pneumonia Increased metabolic demands Immune (risk of infection) • • Local Systemic ü VS ü Altered LOC ü u/o 18

Nursing Diagnostic Priorities: After 48 Hours Impaired skin integrity r/t… Ø Risk of infection r/t… Ø Imbalanced nutrition-less than body requirements r/t… Ø Impaired physical mobility r/t… Ø • • Ø ROM Early ambulation Disturbed body image r/t… 19

Impaired Skin Integrity-Wound Care Ø Debridement • Ø Wound dressings • • • Ø Hydrotherapy Antibiotic ointment Biologic Synthetic Skin grafts • • Autograft Artificial 20

Dressings: Topical Antibiotics Ø Silver Sulfadiazine • • Ø Most frequently used topical Gram negative/positive organisms Penetrates eschar well Applied with a gloved hand, tongue depressor or impregnated in gauze Bacitracin • • Acceptable for use with superficial burns Least expensive antimicrobial agent 21

Dressings Decrease pain Ø Absorb drainage Ø Preserve joint mobility and allow ROM Ø Provide protection and isolation of wound from environment Ø 22

Nutrition Ø Metabolic changes • Ø Hormone mediated > Catecholamines ü > Glucocorticoids and glucose to insulin ratios ü • • • Metabolic alterations > Gluconeogenesis ü > Proteolysis ü > Ureagenesis ü < Lipolysis & Ketone utilization ü Net Results of Changes Ø > Nitrogen losses > Energy Expenditures and nutrition metabolism Results • Hypermetabolic - catabolic state 23

Enteral Feedings Ø Preferred route • • Ø Parenteral (TPN) • • Ø Safety Better utilization of nutrients Gut integrity Lower cost Nonfunctional guts High risk for sepsis Objectives 24

Psychological Issues & Follow Up Ø Inpatient • • Ø PTSD Disfigurement Sexual issues CD Outpatient • • • Ongoing therapy Support groups Burn Camp 25