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Nursing Care & Interventions in the Client with Burn Injury
Keith Rischer RN, MA, CEN More than 1.55 million burn injuries in U.S. and Canada each year. 6,000 die each year : majority die from smoke and flame in house fires Second leading cause of accidental death in children age 1-4 & third leading cause of injury & death ages 1-18 Direct cost of treatment is over 1 billion $ a year Indirect costs of these injuries amount to several billion dollars per year Individually: Pain Loss of earning Transportation Litigation Disability
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Today’s Objectives… 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.
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Burn Injury: Patho Skin Purposes Skin destruction Epidermis Dermis
Fluid/protein loss Sepsis Multi-system changes Dependant on age Health Depth of injury Body area involved Sources: Sunburn-epidermis only to full thickness involving all layers of skin Flames Hot Liquids – keep hot water heaters less than 130 degrees Skin Epidermis…superficial layer-very thin 0.15mm Dermis…thicker mm Made of collagen,elastic fibers, sensory nerve fibers, hair follicle, sebasceous glands WITH INJURY-SKIN CAN REGENERATE AS LONG AS PARTS OF DERMIS PRESENT Purposes P rotective barrier against injury and bacteria Fluid and lyte balance Excretory organ-sweat DESTRUCTION CAN TOLERATE TEMPS OF 104 without injury…at 158 skin destruction rapid
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Depth of Burn Injury Superficial-thickness Partial-thickness
Epidermis only Partial-thickness Epidermis + partial Dermis Full-thickness Epidermis + all dermis + underlying tissue/muscle/bone Severity burn determined by extent of body surface area-depth Differences in skin thickness in various parts of body Thin in eyelids, ears, nose genitals, tops of hands and feet Elderly have thinner skin Superficial-thickness Least damage Peeling of dead skin occurs for 2-3 days-heals in 3-5 days no scar Partial-thickness Pink or mottled Hyperestesia Blister and broken epidermis Wet surface Painful Heal in days Deep partial thickness may require grafting Full-thickness
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Assessment: Superficial-thickness
Pain Redness Heals in 3-5 days
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Assessment: Partial-thickness
Red-blanch No blanch with deeper burn Blister and broken epidermis Painful Heal in days
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Assessment: Full-thickness
Pale, white to red, yellow Charred eschar Leathery skin, dry surface Painless Edema present Signs of systemic shock may be present Needs grafting
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Burns: Vascular Changes
Fluid shift Capillary leakage First 12 hours Lasts hours Lyte & acid base imbalance Hypovolemia Hyperkalemia, hyponatremia Fluid remobilization Diuretic stage (48-72 hours) Hyponatremia hypokalemia Fluid shift Circulatory disruption after injury…blood flow decreases or ceases…macrophages release mediators that cause blood vessel constriction Capillary leakage Blood vessels dilate and leak fluid into interstitial space of plasma and proteins Amount of fluid shift depends on extent of injury Hyper K+ due to cell damage Sodium retained as aldosterone increases, but is diluted by the interstitial fluid shift Fluid remobilization Capillary leak stop After 24 hours Diuretic phase….edema shifts back to vascular space…blood volume increases leading to increased renal blood flow and diuresis unless renal damage Hyponatremia…increased renal excretion Hypokalemia…K+ moves back into cells and excreted in u/o
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Burns: Body System Assessment
Cardiac HR increase CO decreased initially Respiratory Airway edema pulmonary cap. leakage GI Paralytic ileus Metabolic Increased due to catecholamines, cortisol and SNS Caloric needs double or triple Immune Diminished response Increased risk of infection Cardiac HR increase CO decreased initially Respiratory…flames not the issue-superheated air-steam-smoke GI Metabolic Immune
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Burns: Emergency Management
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 HISTORY QUESTIONS FOR ASSESSMENT IN ED Age Mechanism of injury Cause of burn Did injury occur in a closed space ? Smoke inhalation ? Noxious chemicals ? Related trauma
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Inhalation Injury: Assessment
Facial burns Singed nasal hairs Stridor CO Poisoning HA Nausea Alterered LOC Confusion Coma Severe cough Hoarseness Shortness of breath Anxiety Wheezing Dyspnea Disorientation Obtunded Coma Signs Symptoms Present in 20-50% of those admitted to burn centers
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Burn Classification Minor <15% partial thickness Moderate
<10% full thickness Severe >25% partial thickness >10% full thickness
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ABA Burn Referral Guidelines
2° Burns > 10% TBSA Burns involving the face, hands, feet, genitalia, perineum, & major joints 3° Burns in any age group Electrical Burns lightning injuries Chemical Burns Burn injury with preexisting medical disorders that complicate management, recovery, or mortality Burns + Trauma Hospitals that are not equipped/qualified to care for children with burns Require special social/emotional support
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Laboratory Findings: First 48 hours
Hgb/Hct Glucose Sodium Potassium BUN/creatinine Albumin ABG’s pO2 pCO2 pH CO Hgb/Hct…elevated due to fluid loss Glucose…elevated due to stress response Sodium…decr-dilutiuonal Potassium…incr-tissue destruction Albumin…decr lost through wound and vascular membrane ABG’s pO2…decr pCO2…incr due to resp injury pH…decr-metabolic acidosis CO…elevated-smoke inhalation
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Nursing Diagnostic Priorities: First 48 Hours
Decreased cardiac output r/t… Deficient fluid volume r/t… Ineffective tissue perfusion r/t… Ineffective breathing pattern r/t… Acute pain r/t… Decreased cardiac output r/t…altered stroke volume from increase in capillary permeability Deficient fluid volume r/t…active fluid volume loss, lyte imbalance Ineffective tissue perfusion(cerebral, CV, renal, GI) r/t… hypovolemis from extravascuilar fluid shifts, decreased CO Ineffective breathing pattern r/t…resp distress from upper airway edema, pulmonary edema Acute pain r/t…biologic injury, damaged or exposed nerve endings
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Fluid Resuscitation Nursing interventions Nursing Assessment
Large bore IV/central IV access Lactated ringers Nursing Assessment I&O Urine output Daily weight Oxygenation needs Fluid overload VS Labs Creatinine Albumin lytes Decreased cardiac output r/t… Deficient fluid volume r/t… Ineffective tissue perfusion r/t… NEED LARGE FLUID LOADS IN FIRST 24 HOURS FOR SEVERE BURNS WHY Permeable capillaries Hypovolemia Decreased cardiac output WHO TBSA > 20% < 2 y.o. or > 60 y.o.
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Nursing Diagnostic Priorities: First 48 Hours
Ineffective breathing pattern r/t… Respiration pattern Oxygenation ABG’s pH: 7.41….7.29 p02: 73….55 pCO2: 44….60 Acute pain r/t… Opiods IV Fentanyl... Onset___ Peak___ Duration___ Morphine… Onset___ Peak___ Duration___ Dilaudid…Onset___ Peak___ Duration___ Ineffective breathing pattern r/t… Upper airway edema pronounced first 8-12 hours and after aggressive fluid resuscitation Damaged lung tissue sloughed as well Opiods-No IM…why??? Fentanyl... Onset___ 2Peak__3-5_ Duration_30-60__ Morphine… Onset___rapid Peak__20_ Duration___4-5 hours Dilaudid…Onset__15_ Peak__15-30_ Duration_2-3 hours__
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Assessment Priorities: After 48 Hours
Cardiopulmonary Pneumonia Neuroendocrine Increased metabolic demands Immune (risk of infection) Local Systemic VS Altered LOC u/o Cardiopulmonary Neuroendocrine…5000 calories needed daily Immune Local Systemic
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Nursing Diagnostic Priorities: After 48 Hours
Impaired skin integrity r/t… Risk of infection r/t… Imbalanced nutrition-less than body requirements r/t… Impaired physical mobility r/t… ROM Early ambulation Disturbed body image r/t… Impaired skin integrity r/t…burn wound Risk of infection r/t…inadequate defenses, malnutrition IV abx….topical abx Imbalanced nutrition-less than body requirements r/t…increased metabolic rate, reduced calorie intake Impaired physical mobility r/t…open burn wounds, pain Disturbed body image r/t…changes in physical appearance
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Impaired Skin Integrity-Wound Care
Debridement Hydrotherapy Wound dressings Antibiotic ointment Biologic Synthetic Skin grafts Autograft Artificial OBJECTIVES Prevent conversion Remove devitalized tissue Promote healthy granulation tissue growth Minimize infection risk Completion of healing process following autograft Control scar formation Auto skin grafts A donor site will be painful for 5 to 10 days until it heals
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Dressings: Topical Antibiotics
Silver Sulfadiazine 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 Used on partial to full thickness burn areas Avoid the eyes Apply by “buttering” a layer on the burn wound or impregnate in a roll of gauze Patients over 60years or >40% TBSA require twice daily dressing changes, Alternating with Sulfamylon Can cause a drop in WBC , if less than 3,000 we switch to Xeroform with Bacitracin
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Dressings Decrease pain Absorb drainage
Preserve joint mobility and allow ROM Provide protection and isolation of wound from environment Biosynthetic wound dressing gloves
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Nutrition Metabolic changes Net Results of Changes Results
Hormone mediated > Catecholamines > Glucocorticoids and glucose to insulin ratios Metabolic alterations > Gluconeogenesis > Proteolysis > Ureagenesis < Lipolysis & Ketone utilization Net Results of Changes > Nitrogen losses > Energy Expenditures and nutrition metabolism Results Hypermetabolic - catabolic state 5000 calories-high protein
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Enteral Feedings Preferred route Parenteral (TPN) Objectives Safety
Better utilization of nutrients Gut integrity Lower cost Parenteral (TPN) Nonfunctional guts High risk for sepsis Objectives TPN Use for patients with nonfunctional guts Supplement enteral feedings High risk for line sepsis GOALS Nitrogen balance Prealbumin Maintain weight
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Psychological Issues & Follow Up
Inpatient PTSD Disfigurement Sexual issues CD Outpatient Ongoing therapy Support groups Burn Camp
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