Nursing Management: Burns

Chapter 25


Nursing Management


Burns


Judy Knighton




Learning Outcomes



1. Relate the causes of and prevention strategies for burn injuries.


2. Differentiate between partial-thickness and full-thickness burns.


3. Apply the tools used to determine the severity of burns.


4. Compare the pathophysiology, clinical manifestations, complications, and collaborative management throughout the three burn phases.


5. Compare the fluid and electrolyte shifts during the emergent and acute burn phases.


6. Differentiate the nutritional needs of the burn patient throughout the three burn phases.


7. Compare the various burn wound care techniques and surgical options for partial-thickness versus full-thickness burn wounds.


8. Prioritize nursing interventions in the management of the burn patient’s physiologic and psychosocial needs.


9. Examine the various physiologic and psychosocial aspects of burn rehabilitation.


10. Design a plan of care to prepare the burn patient and caregiver for discharge.



Key Terms















Reviewed by Cecilia M. Bidigare, RN, MSN, Associate Professor of Nursing, Sinclair Community College, Beavercreek, Ohio; and Patricia S. Regojo, RN, MSN, Nurse Manager, Burn Center, Temple University Hospital, Philadelphia, Pennsylvania.


The focus of this chapter is the care of patients who have experienced a burn. A burn is an injury to the tissues of the body caused by heat, chemicals, electric current, or radiation. The resulting effects are influenced by the temperature of the burning agent, duration of contact time, and type of tissue that is injured.


An estimated 450,000 Americans seek medical care each year for burns.1,2 Approximately 45,000 people are hospitalized, one half of whom require care in specialized burn centers. About 3500 Americans die annually as a direct result of their injuries. The highest fatality rates occur in children ages 4 years and younger and adults over age 65. Around the world, nearly 11 million people need medical attention annually for burn injuries, and about 300,000 die.3


Although burn incidence has decreased over the past 20 years, burn injuries still occur too frequently and mainly to people at a lower socioeconomic level. Most burn incidents should be viewed as preventable. Today, the focus of burn prevention programs has shifted from blaming individuals and changing behaviors to making legislative changes and collecting global burn data to address the unique prevention needs of developing countries.4



image eNursing Care Plan 25-1   Patient With a Thermal Burn Injury




Patient Goals














Outcomes (NOC) Interventions (NIC) and Rationales




Fluid/Electrolyte Management


Emergent Phase



• Monitor hemodynamic status, including central venous pressure, to determine fluid status.


• Monitor laboratory results relevant to fluid balance (e.g., hematocrit, blood urea nitrogen [BUN], albumin, total protein, serum osmolality, and urine specific gravity levels) to detect changes in fluid/electrolyte balance.


• Keep an accurate record of intake and output to monitor fluid loss and gain.


• Maintain IV solution containing electrolyte(s) at constant flow rate (as appropriate) to prevent fluid overload or excessive electrolyte levels.


• Monitor for manifestations of electrolyte imbalance to detect early changes in electrolyte balance.


• Weigh patient daily and monitor trends to detect early changes in fluid balance.


• Consult physician if signs and symptoms of fluid and/or electrolyte imbalance persist or worsen to provide additional therapy as needed.


Acute Phase




image





Patient Goals














Outcomes (NOC) Interventions (NIC) and Rationales





Pain Management


Emergent Phase



• Provide optimal pain relief with prescribed analgesics to manage pain.


• Use pain control measures before pain becomes severe to avoid pain escalation.


• Assure pretreatment analgesia prior to painful procedures to prevent breakthrough pain.


• Teach the use of nonpharmacologic techniques (e.g., biofeedback, hypnosis, relaxation, guided imagery, music therapy, distraction) before, after, and, if possible, during painful activities; before pain occurs or increases; and along with other pain relief measures to provide the most complete pain relief possible.


• Evaluate the effectiveness of the pain control measures used through ongoing assessment of the pain experience.


• Observe for nonverbal cues of discomfort (e.g., grimacing, guarding, increase in heart rate or blood pressure), especially in those unable to communicate effectively.


• Institute and modify pain control measures on the basis of the patient’s response.


Acute Phase



Rehabilitative Phase




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Patient Goals














Outcomes (NOC) Interventions (NIC) and Rationales








image




Patient Goals














Outcomes (NOC) Interventions (NIC) and Rationales






Nutrition Therapy


Emergent Phase



Acute Phase



Rehabilitative Phase




image




Patient Goals














Outcomes (NOC) Interventions (NIC) and Rationales








image


*Nursing diagnoses listed in order of priority.


Coordinated national programs in developed countries have focused on child-resistant lighters, nonflammable children’s clothing, tap water anti-scald devices, fire-safe cigarettes, stricter building codes, hardwired smoke detectors and alarms, and fire sprinklers. As a nurse, you can advocate for burn risk reduction strategies in the home and at work, and you can teach workers to reduce burn injuries in both settings (Tables 25-1 and 25-2).





Types of Burn Injury


Thermal Burns


Thermal burns, caused by flame, flash, scald, or contact with hot objects, are the most common type of burn injury (Fig. 25-1). The severity of the injury depends on the temperature of the burning agent and the duration of contact time. Scald injuries can occur in the bathroom or while cooking. Flash, flame, or contact burns can occur while cooking, smoking, burning leaves in the backyard, or using gasoline or hot oil.


image
FIG. 25-1 Types of burn injury. A, Partial-thickness thermal hand burn. B, Full-thickness thermal hand burn. C, Full-thickness scald burn to the buttock and lower back secondary to immersion in hot water.



Smoke and Inhalation Injury


Smoke and inhalation injuries from breathing hot air or noxious chemicals can cause damage to the respiratory tract. Three types of smoke and inhalation injuries can occur: metabolic asphyxiation, upper airway injury, and lower airway injury. Because smoke inhalation injuries are a major predictor of mortality in burn patients, rapid assessment is critical.5




Upper Airway Injury.


Upper airway injury results from an inhalation injury to the mouth, oropharynx, and/or larynx. The injury may be caused by thermal burns or the inhalation of hot air, steam, or smoke. Mucosal burns of the oropharynx and the larynx are manifested by redness, blistering, and edema (Table 25-3). The swelling can be massive and the onset rapid. Flame burns to the neck and the chest may make breathing more difficult because of the burn eschar, which becomes tight and constricting from the underlying edema. Swelling from scald burns to the face and the neck can also be lethal, as can external pressure from edema pressing on the airway. Mechanical obstruction can occur quickly, presenting a true medical emergency.



Carefully assess the patient for facial burns, singed nasal hair, hoarseness, painful swallowing, darkened oral and nasal membranes, carbonaceous sputum, history of being burned in an enclosed space, and clothing burns around the chest and neck.




Electrical Burns


Electrical burns result from intense heat generated from an electric current. Direct damage to nerves and vessels, causing tissue anoxia and death, can also occur. The severity of the electrical injury depends on the amount of voltage, tissue resistance, current pathways, surface area in contact with the current, and length of time that the current flow was sustained (Fig. 25-2). Tissue densities offer various amounts of resistance to electric current. For example, fat and bone offer the most resistance, whereas nerves and blood vessels offer the least resistance. Current that passes through vital organs (e.g., brain, heart, kidneys) produces more life-threatening sequelae than that which passes through other tissues. In addition, electric sparks may ignite the patient’s clothing, causing a flash injury.


image
FIG. 25-2 Electrical injury produces heat coagulation of blood supply and contact area as electric current passes through the skin. A, Back and buttock (arrows). B, Leg (arrow).

As with inhalation injury, perform a rapid assessment of the patient with electrical injury. Transfer to a burn center is indicated. The severity of an electrical injury can be difficult to determine, since most of the damage is below the skin (known as the iceberg effect). Determination of electric current contact points and history of the injury may help determine the probable path of the current and potential areas of injury. Contact with electric current can cause muscle contractions strong enough to fracture the long bones and vertebrae. Another reason to suspect long bone or spinal fractures is a fall resulting from the electrical injury. For this reason, all patients with electrical burns should be considered at risk for a potential cervical spine injury. Cervical spine immobilization must be used during transport and subsequent diagnostic testing completed to rule out any injury.


Electrical injury puts the patient at risk for dysrhythmias or cardiac arrest, severe metabolic acidosis, and myoglobinuria. The electric shock event can cause immediate cardiac standstill or ventricular fibrillation. Delayed cardiac dysrhythmias or arrest may also occur without warning during the first 24 hours after injury. Myoglobin from injured muscle tissue and hemoglobin from damaged red blood cells (RBCs) are released into the circulation whenever massive muscle and blood vessel damage occurs. The released myoglobin pigments travel to the kidneys and can block the renal tubules, which can result in acute tubular necrosis (ATN) and acute kidney injury (see Chapter 47).




Classification of Burn Injury


The treatment of burns is related to the severity of the injury.6 Severity is determined by (1) depth of burn, (2) extent of burn calculated in percent of total body surface area (TBSA), (3) location of burn, and (4) patient risk factors (e.g., age, past medical history). The American Burn Association (ABA) has established referral criteria to determine which burn injuries should be treated in burn centers with specialized facilities (Table 25-4). The majority of patients with minor burn injuries can be managed in community hospitals.7




Depth of Burn


Burn injury involves the destruction of the integumentary system. The skin is divided into three layers: epidermis, dermis, and subcutaneous tissue (Fig. 25-3). The epidermis, or nonvascular protective outer layer of the skin, is approximately as thick as a sheet of paper. (The structure and function of the skin are discussed in Chapter 23.)


image
FIG. 25-3 Cross section of skin indicating the depth of burn and structures involved.

The dermis, which lies below the epidermis, is approximately 30 to 45 times thicker than the epidermis. The dermis contains connective tissues with blood vessels, hair follicles, nerve endings, sweat glands, and sebaceous glands.


Under the dermis lies the subcutaneous tissue, which contains major vascular networks, fat, nerves, and lymphatics. The subcutaneous tissue acts as a heat insulator for underlying structures, including muscles, tendons, bones, and internal organs.


Burns continue to be defined by degrees: first, second, third, and fourth degree. The ABA recommends a more precise definition and classifies burns according to depth of skin destruction: partial-thickness burns and full-thickness burns (see Fig. 25-3). Skin-reproducing (re-epithelializing) cells are located along the shafts of the hair follicles, sweat glands, and oil glands. If significant damage occurs to the dermis (i.e., a full-thickness burn), not enough skin cells remain to regenerate new skin. A permanent, alternative source of skin needs to be found. Table 25-5 compares the various burn classifications according to the depth of injury.




Extent of Burn


Two commonly used guides for determining the TBSA affected or the extent of a burn wound are the Lund-Browder chart (Fig. 25-4, A) and the Rule of Nines (Fig. 25-4, B). (First-degree burns, equivalent to a sunburn, are not included when calculating TBSA.) The Lund-Browder chart is considered more accurate because it considers the patient’s age in proportion to relative body-area size. The Rule of Nines is often used for initial assessment of a burn patient because it is easy to remember. For irregular- or odd-shaped burns, the patient’s hand (including the fingers) is approximately 1% TBSA. The Sage Burn Diagram is a free, Internet-based tool for estimating TBSA burned (www.sagediagram.com).


image
FIG. 25-4 A, Lund-Browder chart. By convention, areas of partial-thickness injury are colored in blue and areas of full-thickness injury in red. Superficial partial-thickness burns are not calculated. B, Rule of Nines chart.


Location of Burn


The severity of the burn injury is also determined by the location of the burn wound. Burns to the face and neck and circumferential burns to the chest or back may interfere with breathing as a result of mechanical obstruction from edema or leathery, devitalized burn tissue (eschar). These burns may also indicate possible inhalation injury and respiratory mucosal damage.


Burns to the hands, feet, joints, and eyes are of concern because they make self-care difficult and may jeopardize future function. Burns to the hands and feet are challenging to manage because of superficial vascular and nerve supply systems that need to be protected while the burn wounds are healing.


Burns to the ears and the nose are susceptible to infection because of poor blood supply to the cartilage. Burns to the buttocks or perineum are highly susceptible to infection from urine or feces contamination. Circumferential burns to the extremities can cause circulation problems distal to the burn, with possible nerve damage to the affected extremity. Patients may also develop compartment syndrome (see Chapter 63) from direct heat damage to the muscles, swelling, and/or preburn vascular problems.



Patient Risk Factors


Any patient with preexisting cardiovascular, respiratory, or renal disease has a poorer prognosis for recovery because of the tremendous demands placed on the body by a burn injury. The patient with diabetes mellitus or peripheral vascular disease is at high risk for poor healing, especially with foot and leg burns.8 General physical debilitation from any chronic disease, including alcoholism, drug abuse, or malnutrition, makes it challenging for the patient to fully recover from a burn injury. In addition, the burn patient who has also sustained fractures, head injuries, or other trauma has a more difficult time recovering.



Phases of Burn Management


Burn management can be organized chronologically into three phases: emergent (resuscitative), acute (wound healing), and rehabilitative (restorative). Overlap in care does exist. For example, the emergent phase begins at the time of the burn injury, and care often begins in the prehospital phase, depending on the skill level of providers at the scene. Planning for rehabilitation begins on the day of the burn injury or admission to the burn center. Formal rehabilitation begins as soon as functional assessments can be performed. Wound care is the primary focus of the acute phase, but wound care also takes place in both the emergent and rehabilitation phases.



Prehospital Care


At the scene of the injury, priority is given to removing the person from the source of the burn and stopping the burning process. Rescuers must also protect themselves from being injured. In the case of electrical and chemical injuries, initial management involves removal of the patient from contact with the electrical or chemical source.


Small thermal burns (10% or less of TBSA) should be covered with a clean, cool, tap water–dampened towel for the patient’s comfort and protection until medical care is available.9 Cooling of the injured area (if small) within 1 minute helps minimize the depth of the injury. If the burn is large (greater than 10% TBSA) or an electrical or inhalation burn is suspected, first focus your attention on the ABCs:



To prevent hypothermia, cool large burns for no more than 10 minutes. Do not immerse the burned body part in cool water because it may cause extensive heat loss. Never cover a burn with ice, since this can cause hypothermia and vasoconstriction of blood vessels, thus further reducing blood flow to the injury. Gently remove as much burned clothing as possible to prevent further tissue damage. Leave adherent clothing in place until the patient is transferred to a hospital. Wrap the patient in a dry, clean sheet or blanket to prevent further contamination of the wound and to provide warmth.


Chemical burns are best treated by quickly removing any chemical particles or powder from the skin. Remove all clothing containing the chemical because the burning process continues while the chemical is in contact with the skin. Flush the affected area with copious amounts of water to irrigate the skin anywhere from 20 minutes to 2 hours postexposure. Tap water is acceptable for flushing eyes exposed to chemicals. Tissue destruction may continue for up to 72 hours after contact with some chemicals.


Observe patients with inhalation injuries closely for signs of respiratory distress. These patients need to be treated quickly and efficiently if they are to survive. If CO poisoning is suspected, treat the patient with 100% humidified O2. Patients who have both body burns and an inhalation injury must be transferred to the nearest burn center.


Always remember that the burn patient may also have sustained other injuries that could take priority over the burn itself. Individuals involved in the prehospital phase of burn care must adequately communicate the circumstances of the injury to hospital providers. This is especially important when the patient’s injury involves being trapped in a closed space, exposure to hazardous chemicals or electricity, or a possible traumatic injury (e.g., fall).


Prehospital care and emergency management are presented in tables that describe thermal burns (Table 25-6), inhalation injury (Table 25-7), electrical burns (Table 25-8), and chemical burns (Table 25-9).



image TABLE 25-6


EMERGENCY MANAGEMENT
Thermal Burns













Etiology Assessment Findings Interventions






Initial


• Assess airway, breathing, and circulation.


• Stabilize cervical spine.


• Assess for inhalation injury.


• Provide supplemental O2 as needed.


• Anticipate endotracheal intubation and mechanical ventilation with circumferential full-thickness burns to the neck and chest or large TBSA burn.


• Monitor vital signs, level of consciousness, respiratory status, O2 saturation, and heart rhythm.


• Remove nonadherent clothing, shoes, watches, jewelry, glasses or contact lenses (if face was exposed).


• Cover burned areas with dry dressings or clean sheet.


• Establish IV access with two large-bore catheters if burn >15% TBSA.


• Begin fluid replacement.


• Insert indwelling urinary catheter if burn >15% TBSA.


• Elevate burned limbs above heart to decrease edema.


• Administer IV analgesia and assess effectiveness frequently.


• Identify and treat other associated injuries (e.g., fractures, head injury).




image


TBSA, Total body surface area.



image TABLE 25-7


EMERGENCY MANAGEMENT
Inhalation Injury












Etiology Assessment Findings Interventions


Related posts:

  1. Introduction
  2. Nursing Management: Sexually Transmitted Infections
  3. Nursing Management: Integumentary Problems
  4. Fluid, Electrolyte, and Acid-Base Imbalances

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Nov 17, 2016 | Posted by in NURSING | Comments Off on Nursing Management: Burns

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