Practice nursing care for Clients with Burns
The nurse who cares for a patient with a burn injury requires a high level of knowledge about the physiologic changes that occur after a burn, as well as astute assessment skills to detect subtle changes in the patient’s condition. In addition, the nurse must be able to provide sensitive, compassionate care to patients who are critically ill and must initiate rehabilitation early in the course of care. The nurse must also be able to communicate effectively with burn patients, distraught family members, and members of the entire interdisciplinary burn management team. This will ensure quality care, which increases the likelihood of the patient’s survival and promotes optimal quality of life.
Incidence of Burn Injury
The incidence of burn injuries has been declining during the past
several decades. Approximately 2 million people require medical attention for
burn injury in the
1. Prevention
2. Institution of lifesaving measures for the severely burned person
3. Prevention of disability and disfigurement through early, specialized, individualized treatment 4. Rehabilitation through reconstructive surgery and rehabilitative programs
Outlook for Survival and Recovery
Great strides in research have helped to increase the survival rate of burn victims. Mortality has fallen to levels never thought possible. Hunt et al. (2000) reported that survival following large burns based on total body surface area (TBSA) appears to have leveled off. Persons older than 70 years are surviving burns of 30% TBSA; those 60 to 70 years of age, 50% TBSA; those 20 to 30 years of age, 80% TBSA; and those 2 to 5 years of age, 75% TBSA. Research in areas such as fluid resuscitation, emergent burn treatment, inhalation injury treatment, and changes in wound care practice with early debridement and excision have contributed greatly to the decrease in burn deaths. Additionally, a better understanding of the importance of adequate nutritional support has contributed to increased survival rates. Very young and very old people have a high risk of death after burn injuries due to immature and stressed immunologic systems and pre-existing medical conditions, respectively. Chances of survival are greater in children older than age 5 and in adults younger than age 40. Inhalation injuries in combination with cutaneous burns worsen the prognosis. Outcome depends on the depth and extent of the burn as well as on the pre-injury health status and age of the patient. Acute care of patients with burn injuries has improved to the point at which survival is expected for most patients, and the burn team has shifted its focus to long-term outcomes for these patients.
Gerontologic Considerations
Reduced mobility, changes in vision, and decreased sensation in the feet and hands place elderly people at higher risk for burn injury; scalds and flames are the leading causes. These changes also place older people at risk for suffering a severe burn because they have difficulty in extinguishing the fire and removing themselves from the burn source. Morbidity and mortality rates associated with burns are usually greater in elderly patients than in younger patients. Thinning and loss of elasticity of the skin in the elderly predispose them to a deep injury from a thermal insult that might cause a less severe burn in a younger person. Moreover, chronic illnesses decrease the older person’s ability to withstand the multisystem stresses imposed by burn injury. An important goal of nurses in community and home settings is preventing burn injury, especially among the elderly. Nurses need to assess an elderly patient’s ability to perform activities of daily living safely, assist elderly patients and families to modify the environment to ensure safety, and make referrals as needed.
Pathophysiology of Burns
Burns are caused by a transfer of energy from a heat source to the body.
Heat may be transferred through conduction or electromagnetic radiation. Burns
are categorized as thermal (which includes electrical burns), radiation, or
chemical. Tissue destruction results from coagulation, protein denaturation, or ionization of cellular contents. The skin
and the mucosa of the upper airways are the sites of tissue destruction. Deep
tissues, including the viscera, can be damaged by electrical burns or through
prolonged contact with a heat source. Disruption of the skin can lead to
increased fluid loss, infection, hypothermia, scarring, compromised immunity,
and changes in function, appearance, and body image. The depth of the injury
depends on the temperature of the burning agent and the duration of contact
with the agent. For example, in the case of scald burns in adults, 1 second of
contact with hot tap water at
CLASSIFICATION OF BURNS
Burn injuries are described according to the depth of the injury and the extent of body surface area injured.
Burn Depth
Burns are classified according to the depth of tissue destruction as superficial partial-thickness injuries, deep partial-thickness injuries, or full-thickness injuries. Burn depth determines whether epithelialization will occur. Determining burn depth can be difficult even for the experienced burn care provider. See Chapter 56 for discussion and a diagram of the skin layers; see also Table 57-1. (The categories of superficial partial-thickness, deep partial-thickness, and full-thickness burns are similar to, but not the same as, first-, second-, and third-degree burns.) In a superficial partial-thickness burn, the epidermis is destroyed or injured and a portion of the dermis may be injured. The damaged skin may be painful and appear red and dry, as in sunburn, or it may blister. A deep partial-thickness burn involves destruction of the epidermis and upper layers of the dermis and injury to deeper portions of the dermis. The wound is painful, appears red, and exudes fluid. Capillary refill follows tissue blanching. Hair follicles remain intact. Deep partial-thickness burns take longer to heal and are more likely to result in hypertrophic scars. A full-thickness burn involves total destruction of epidermis and dermis and, in some cases, underlying tissue as well. Wound color ranges widely from white to red, brown, or black. The burned area is painless because nerve fibers are destroyed. The wound appears leathery; hair follicles and sweat glands are destroyed. The following factors are considered in determining the depth of the burn:
• How the injury occurred
• Causative agent, such as flame or scalding liquid
• Temperature of the burning agent
• Duration of contact with the agent
• Thickness of the skin
Extent of Body Surface Area Injured
Various methods are used to estimate the TBSA affected by burns; among
them are the rule of nines, the
RULE OF NINES An estimation of the TBSA involved in a burn is simplified by using the rule of nines. The rule of nines is a quick way to calculate the extent of burns. The system assigns percentages in multiples of nine to major body surfaces.
A more precise method of estimating the extent of a burn is the
PALM METHOD
In patients with scattered burns, a method to estimate the percentage of burn is the palm method. The size of the patient’s palm is approximately 1% of TBSA.
LOCAL AND SYSTEMIC RESPONSES TO BURNS
Burns that do not exceed 25% TBSA produce a primarily local response. Burns that exceed 25% TBSA may produce both a local and a systemic response and are considered major burn injuries. This systemic response is due to the release of cytokines and other mediators into the systemic circulation. The release of local mediators and changes in blood flow, tissue edema, and infection can cause progression of the burn injury. Pathophysiologic changes resulting from major burns during the initial burn-shock period include tissue hypoperfusion and organ hypofunction secondary to decreased cardiac output, followed by a hyperdynamic and hypermetabolic phase. The incidence, magnitude, and duration of pathophysiologic changes in urns are proportional to the extent of burn injury, with a maximal response seen in burns covering 60% or more TBSA. The initial systemic event after a major burn injury is hemodynamic instability, resulting from loss of capillary integrity and a subsequent shift of fluid, sodium, and protein from the intravascular space into the interstitial spaces. Figure 57-3 illustrates the pathophysiologic processes in acute major burns. Hemodynamic instability involves cardiovascular, fluid and electrolyte, blood volume, pulmonary, and other mechanisms.
Cardiovascular Response
Hypovolemia is the immediate consequence of fluid loss resulting in decreased perfusion and oxygen delivery. Cardiac output decreases before any significant change in blood volume is evident. As fluid loss continues and vascular volume decreases, cardiac output continues to fall and blood pressure drops. This is the onset of burn shock. In response, the sympathetic nervous system releases catecholamines, resulting in an increase in peripheral resistance (vasoconstriction) and an increase in pulse rate. Peripheral vasoconstriction further decreases cardiac output. Myocardial contractility may be suppressed by the release of inflammatory cytokine necrosis factor (Wolf, Prough & Herndon, 2002). Prompt fluid resuscitation maintains the blood pressure in the low-normal range and improves cardiac output. Despite adequate fluid resuscitation, cardiac filling pressures (central venous pressure, pulmonary artery pressure, and pulmonary artery wedge pressure) remain low during the burn-shock period. If inadequate fluid resuscitation occurs, distributive shock will occur (see Chap. 15). Generally, the greatest volume of fluid leak occurs in the first 24 to 36 hours after the burn, peaking by 6 to 8 hours. As the capillaries begin to regain their integrity, burn shock resolves and fluid returns to the vascular compartment. As fluid is reabsorbed from the interstitial tissue into the vascular compartment, blood volume increases. If renal and cardiac function is adequate, urinary output increases. Diuresis continues for several days to 2 weeks.
Burn Edema
Local swelling due to thermal injury is often extensive. Edema is defined as the presence of excessive fluid in the
tissue spaces (
Effects on Fluids, Electrolytes, and Blood Volume
Circulating blood volume decreases dramatically during burn shock. In
addition, evaporative fluid loss through the burn wound may reach 3 to
Other Systemic Responses
Renal function may be altered as a result of decreased blood volume.
Destruction of red blood cells at the injury site results in free hemoglobin in the urine. If muscle damage occurs (eg, from electrical burns), myoglobin
is released from the muscle cells and excreted by the kidney. Adequate fluid
volume replacement restores renal blood flow, increasing the glomerular filtration rate and urine volume. If there is
inadequate blood flow through the kidneys, the hemoglobin
and myoglobin occlude the renal tubules, resulting in
acute tubular necrosis and renal failure. The immunologic defenses
of the body are greatly altered by burn injury. Serious burn injury diminishes
resistance to infection. As a result, sepsis remains the leading cause of death
in thermally injured patients (Cioffi, 2001). The
loss of skin integrity is compounded by the release of abnormal inflammatory
factors, altered levels of immunoglobulins and serum
complement, impaired neutrophil function, and a
reduction in lymphocytes (lymphocytopenia). Research
suggests that burn injury results in loss of T-helper cell lymphocytes (
Management of the Patient With a Burn Injury
Burn care must be planned according to the burn depth and local response, the extent of the injury, and the presence of a systemic response. Burn care then proceeds through three phases: emergent/ resuscitative phase, acute/intermediate phase, and rehabilitation phase. Although priorities exist for each of the phases, the phases overlap, and assessment and management of specific problems and complications are not limited to these phases but take place throughout burn care. The three phases and the priorities for care are summarized in Table 57-2.
EMERGENT/RESUSCITATIVE PHASE OF BURN CARE
On-the-Scene Care
Anyone who encounters a burn victim for the first time may feel overwhelmed. The burned person’s appearance can be frightening at first. It can be difficult not to get caught up with the appearance of the person and instead to concentrate on the burn wounds. However, the burn wound is not the first priority at the scene: the first priority of on-the-scene care for a burn victim is to prevent injury to the rescuer. If needed, fire and emergency medical services should be requested at the first opportunity. Additional emergency procedures are highlighted in Chart.
AIRWAY, BREATHING, CIRCULATION
Although the local effects of a burn are the most evident, the systemic effects pose a greater threat to life. Therefore, it is important to remember the ABCs of all trauma care during the early postburn period:
• Airway
• Breathing
• Circulation; cervical spine immobilization for patients with high-voltage electrical injuries and if indicated for other injuries; cardiac monitoring for patients with all electrical injuries for at least 24 hours after cessation of dysrhythmia
Some practitioners include “DEF” in the trauma assessment: disability, exposure, and fluid resuscitation (Weibelhaus & Hansen, 2001). The circulatory system must also be assessed quickly. Apical pulse and blood pressure are monitored frequently. Tachycardia (abnormally rapid heart rate) and slight hypotension are expected soon after the burn. The neurologic status is assessed quickly in the patient with extensive burns. Often the burn patient is awake and alert initially, and vital information can be obtained at that time. A secondary head-to-toe survey of the patient is carried out to identify other potentially life-threatening injuries. (The E and F parameters of trauma assessment are discussed in detail later.) Preventing shock in a burn patient is imperative. Usually, rescue workers will cool the wound, establish an airway, supply oxygen, and insert at least one large-bore intravenous line.
NURSING ALERT Breathing must be assessed and a patent airway established immediately during the initial minutes of emergency care. Immediate therapy is directed toward establishing an airway and administering humidified 100% oxygen. If such a high concentration of oxygen is not available under emergency conditions, oxygen by mask or nasal cannula is given initially. If qualified personnel and equipment are available and if the victim has severe respiratory distress or airway edema, the rescuers can insert an endotracheal tube and initiate manual ventilation.
NURSING ALERT No food or fluid is given by mouth, and the patient is placed in a position that will prevent aspiration of vomitus because nausea and vomiting typically occur due to paralytic ileus resulting from the stress of injury.
Emergency Medical Management
The patient is transported to the nearest emergency department. The hospital and physician are alerted that the patient is en route to the emergency department so that life-saving measures can be initiated immediately by a trained team. Initial priorities in the emergency department remain airway, breathing, and circulation. For mild pulmonary injury, inspired air is humidified and the patient is encouraged to cough so that secretions can be removed by suctioning. For more severe situations, it is necessary to remove secretions by bronchial suctioning and to administer bronchodilators and mucolytic agents. If edema of the airway develops, endotracheal intubation may be necessary. Continuous positive airway pressure and mechanical ventilation may also be required to achieve adequate oxygenation. After adequate respiratory status and circulatory status have been established, the patient is assessed for cervical spinal injuries or head injury if the patient was involved in an explosion, a fall, a jump, or an electrical injury. Once the patient’s condition is stable, attention is directed to the burn wound itself. All clothing and jewelry are removed. For chemical burns, flushing of the exposed areas is continued. The patient is checked for contact lenses. These are removed immediately if chemicals have contacted the eyes or if facial burns have occurred. It is important to validate an account of the burn scenario provided by the patient, witnesses at the scene, and paramedics. Information needs to include time of the burn injury, source of the burn, place where the burn occurred, how the burn was treated at the scene, and any history of falling with the injury. A history of preexisting diseases, allergies, and medications and the use of drugs, alcohol, and tobacco is obtained at this point to plan care. A large-bore (16- or 18-gauge) intravenous catheter should be inserted in a non-burned area (if not inserted earlier). Most patients have a central venous catheter inserted so that large amounts of intravenous fluids can be given quickly and central venous pressures can be monitored. If the burn exceeds 25% TBSA or if the patient is nauseated, a nasogastric tube should be inserted and connected to suction to prevent vomiting due to paralytic ileus (absence of peristalsis). The physician evaluates the patient’s general condition, assesses the burn, determines the priorities of care, and directs the individualized plan of treatment, which is divided into systemic management and local care of the burned area. Nonsterile gloves, caps, and gowns are worn by personnel while assessing the exposed burned areas. Clean technique is maintained while assessing burn wounds. Assessment of both the TBSA burned and the depth of the burn is completed after soot and debris have been gently cleansed from the burn wound. Careful attention is paid to keeping the burn patient warm during wound assessment and cleansing. Assessment is repeated frequently throughout burn wound care. Photographs may be taken of the burn areas initially and periodically throughout treatment; in this way, the initial injury and burn wound can be documented. Such documentation is invaluable for insurance and legal claims. Clean sheets are placed under and over the patient to protect the area from contamination, maintain body temperature, and reduce pain caused by air currents passing over exposed nerve endings. An indwelling urinary catheter is inserted to permit more accurate monitoring of urine output and renal function for patients with moderate to severe burns. Baseline height, weight, arterial blood gases, hematocrit, electrolyte values, blood alcohol level, drug panel, urinalysis, and chest x-rays are obtained. If the patient is elderly or has an electrical burn, a baseline electrocardiogram is obtained. Because burns are contaminated wounds, tetanus prophylaxis is administered if the patient’s immunization status is not current or is unknown. Although the major focus of care during the emergent phase is physical stabilization, the nurse must also attend to the patient’s and family’s psychological needs. Burn injury is a crisis, causing variable emotional responses. The patient’s and family’s coping abilities and available supports are assessed. Circumstances surrounding the burn injury should be considered when providing care. Individualized psychosocial support must be given to the patient and family. Because the emergent burn patient is usually anxious and in pain, those in attendance should provide reassurance and support, explanations of procedures, and adequate pain relief. Because poor tissue perfusion accompanies burn injuries, only intravenous pain medication (usually morphine) is given, titrated for the patient. If the patient wishes to see a spiritual advisor, one is notified.
TRANSFER TO A BURN CENTER
· Don’t apply ice, iced water, lotions, moisturisers, oil, ointments, creams or powders to the burn. Butter or flour can make the damage worse.
· Call an ambulance if the burn is to your child’s face, airway, hands or genitals, or if the burn is larger than the size of your child’s hand.
· Go to a doctor or hospital if the burn is the size of a 20-cent piece or larger, or if it’s deep, raw, angry or blistered. Also go if the pain persists or is severe, or you’re not sure how bad the burn is.
The depth and extent of the burn are considered in determining whether the patient should be transferred to a burn center. Patients with major burns, those who are at the extremes of the age continuum, those with coexisting health problems that may affect recovery, and those with circumstances that increase their risk for acute and long-term complications are transferred to a burn center. Chart 57-4 lists the American Burn Association’s criteria for burn center referral after initial assessment and management. If the patient is to be transported to a burn center, the following measures are instituted before transfer:
• A secure intravenous catheter is inserted with lactated Ringer’s solution infusing at the rate required to maintain a urine output of at least 30 mL per hour.
• A patent airway is ensured.
• Adequate pain relief is attained.
• Adequate peripheral circulation is established in any burned extremity.
•Wounds are covered with a clean, dry sheet, and the patient is kept comfortably warm.
All assessments and treatments are documented, and this information is provided to the burn center personnel. The transferring facility must relay accurate intake and output totals to burn center personnel so that adequate fluid resuscitation measures continue.
MANAGEMENT OF FLUID LOSS AND SHOCK
Next to handling respiratory difficulties, the most urgent need is preventing irreversible shock by replacing lost fluids and electrolytes. As mentioned previously, survival of burn victims depends on adequate fluid resuscitation. Table 57-3 summarizes the fluid and electrolyte changes in the emergent phase of burn care. Intravenous lines and an indwelling catheter must be in place before implementing fluid resuscitation. Baseline weight and laboratory test results are obtained as well. These parameters must be monitored closely in the immediate post-burn (resuscitation) period. Controversy continues regarding the definition of adequate resuscitation and the optimal fluid type for resuscitation. Refinement of resuscitation techniques remains an active area of burn research.
Fluid Replacement Therapy.
The total volume and rate of intravenous fluid replacement are gauged by
the patient’s response. The adequacy of fluid resuscitation is determined by
following urine output totals, an index of renal perfusion. Output totals of 30
to 50 mL/hour have been used as goals. Other
indicators of adequate fluid replacement are a systolic blood pressure
exceeding
Fluid Requirements.
The projected fluid requirements for the first 24 hours are calculated by the clinician based on the extent of the burn injury. Some combination of fluid categories may be used: colloids (whole blood, plasma, and plasma expanders) and crystalloids/electrolytes (physiologic sodium chloride or lactated Ringer’s solution). Adequate fluid resuscitation results in slightly decreased blood volume levels during the first 24 post-burn hours and restores plasma levels to normal by the end of 48 hours. Oral resuscitation can be successful in adults with less than 20% TBSA and children with less than 10% to 15% TBSA. Formulas have been developed for estimating fluid loss based on the estimated percentage of burned TBSA and the weight of the patient. Length of time since burn injury occurred is also very important in calculating estimated fluid needs. Formulas must be adjusted so that initiation of fluid replacement reflects the time of injury. Resuscitation formulas are approximations only and are individualized to meet the requirements of each patient. The various formulas are discussed below and summarized in. As early as 1978, the NIH Consensus Development Conference on Supportive Therapy in Burn Care established that salt and water are required in burn patients, but that colloid may or may not be useful during the first 24 to 48 post-burn hours. The consensus formula provides for the volume of balanced salt solution to be administered in the first 24 hours in a range of 2 to 4 mL/kg per percent burn. In general, 2 mL/kg per percent burn of lactated Ringer’s solution may be used initially for adults. This is the most common fluid replacement formula in use today. As with the other formulas, half of the calculated total should be given over the first 8 post-burn hours, and the other half should be given over the next 16 hours. The rate and volume of the infusion must be regulated according to the patient’s response by changing the hourly infusion rates. Fluid boluses are recommended only in the presence of marked hypotension, not low urine output. Typical fluid rate changes should involve an increase or decrease in flow rate by no more than 25% to 33% (Yowler & Fratianne, 2000). Studies demonstrate that with large burns, there is a failure of the sodium-potassium pump (a physiologic mechanism involved in fluid–electrolyte balance) at the cellular level. Thus, patients with very large burns may need proportionately more milliliters of fluid per percent of burn than those with smaller burns. Also, patients with electrical injury, pulmonary injury, and delayed fluid resuscitation and those who were burned while intoxicated may need additional fluids. The following example illustrates use of the formula in a 70-kg (168-lb) patient with a 50% TBSA burn: 1. Consensus formula: 2 to 4 mL/kg/% TBSA 2. 2 Ч 70 Ч 50 = 7,000 mL/24 hours 3. Plan to administer: First 8 hours = 3,500 mL, or 437 mL/ hour; next 16 hours = 3,500 mL, or 219 mL/hour Most fluid replacement formulas use isotonic electrolyte solutions. Regardless of which standard replacement formula is used, the patient receives approximately the same fluid volume and sodium replacement during the first 48 hours. Another fluid replacement method requires hypertonic electrolyte solutions. This method uses concentrated solutions of sodium chloride and lactate (a balanced salt solution) so that the resulting fluid has a concentration of 250 to 300 mEq of sodium. The rationale for this replacement method is that by increasing serum osmolality, fluid will be pulled back into the vascular space from the interstitial space. Reduced systemic and pulmonary edema has been reported after administering hypertonic solutions.
Gerontologic Considerations
Decreased function of the cardiovascular, renal, and pulmonary systems increases the need for close observation of elderly patients with even relatively minor burns during the emergent and acute phases. Acute renal failure is much more common in elderly patients than in those younger than age 40. The margin of difference between hypovolemia and fluid overload is very small. Suppressed immunologic response, a high incidence of malnutrition, and an inability to withstand metabolic stressors (eg, a cold environment) further compromise the elderly person’s ability to heal. As a result of these issues in elderly patients who sustain burn injury, close monitoring and prompt treatment of complications are mandatory.
Nursing Management: Emergent/Resuscitative Phase
Assessment data obtained by prehospital providers (rescuers such as emergency medical technicians) are shared with the physician and nurse in the emergency department. Nursing assessment in the emergent phase of burn injury focuses on the major priorities for any trauma patient; the burn wound is a secondary consideration. Aseptic management of the burn wounds and invasive lines continues. The nurse monitors vital signs frequently. Respiratory status is monitored closely, and apical, carotid, and femoral pulses are evaluated. Cardiac monitoring is indicated if the patient has a history of cardiac disease, electrical injury, or respiratory problems, or if the pulse is dysrhythmic or the rate is abnormally slow or rapid. If all extremities are burned, determining blood pressure may be difficult. A sterile dressing applied under the blood pressure cuff will protect the wound from contamination. Because increasing edema makes blood pressure difficult to auscultate, a Doppler (ultrasound) device or a noninvasive electronic blood pressure device may be helpful. In severe burns, an arterial catheter is used for blood pressure measurement and for collecting blood specimens. Peripheral pulses of burned extremities are checked hourly; the Doppler device is useful for this. Elevation of burned extremities is crucial to decrease edema. Elevation of the lower extremities on pillows and of the upper extremities on pillows or by suspension using intravenous poles may be helpful. Large-bore intravenous catheters and an indwelling urinary catheter are inserted, and the nurse’s assessment includes monitoring fluid intake and output. Urine output, an indicator of renal perfusion, is monitored carefully and measured hourly. The amount of urine first obtained when the urinary catheter was inserted is recorded. This may assist in determining the extent of preburn renal function and fluid status. Urine specific gravity, pH, and glucose, acetone, protein, and hemoglobin levels are assessed frequently. Burgundy-colored urine suggests the presence of hemochromogen and myoglobin resulting from muscle damage. This is associated with deep burns caused by electrical injury or prolonged contact with flames. Glucosuria, a common finding in the early postburn hours, results from the release of stored glucose from the liver in response to stress. Although not responsible for calculating the patient’s fluid requirements, the nurse needs to know the maximum volume of fluid the patient should receive. Infusion pumps and rate controllers are used to deliver a complex regimen of prescribed intravenous fluids. Administering and monitoring intravenous therapy are major nursing responsibilities. Body temperature, body weight, preburn weight, and history of allergies, tetanus immunization, past medical and surgical problems, current illnesses, and use of medications are assessed. A headto- toe assessment is performed, focusing on signs and symptoms of concomitant illness, injury, or developing complications. Patients with facial burns should have their eyes examined for potential injury to the corneas. An ophthalmologist is consulted for complete assessment via fluorescent staining. Assessing the extent of the burn wound continues and is facilitated with anatomic diagrams (described previously). In addition, the nurse works with the physician to assess the depth of the wound and areas of full- and partial-thickness injury. Assessment of the circumstances surrounding the injury is important. Obtaining a history of the burn injury can help to plan the care for the patient. Assessment should include the time of injury, mechanism of burn, whether the burn occurred in a closed space, the possibility of inhalation of noxious chemicals, and any related trauma. The neurologic assessment focuses on the patient’s level of consciousness, psychological status, pain and anxiety levels, and behavior. The patient’s and family’s understanding of the injury and treatment is assessed as well. Nursing care of the patient during the emergent/resuscitative phase of burn injury is detailed in the Plan of Nursing Care.
NURSING ALERT
Formulas are only a guide. The patient’s response, evidenced by heart rate, blood pressure, and urine output, is the primary determinant of actual fluid therapy and must be assessed at least hourly. Patient outcomes are improved by optimal fluid resuscitation.
ACUTE OR INTERMEDIATE PHASE OF BURN CARE
The acute or intermediate phase of burn care follows the emergent/ resuscitative
phase and begins 48 to 72 hours after the burn injury. During this phase,
attention is directed toward continued assessment and maintenance of
respiratory and circulatory status, fluid and electrolyte balance, and
gastrointestinal function. Infection prevention, burn wound care (ie, wound cleaning, topical antibacterial therapy, wound
dressing, dressing changes, wound dйbridement, and wound grafting), pain management, and nutritional support are
priorities at this stage and will be discussed in detail. Airway obstruction
caused by upper airway edema can take as long as 48
hours to develop. Changes detected by x-ray and arterial blood gases may occur
as the effects of resuscitative fluid and the chemical reaction of smoke
ingredients with lung tissues become apparent. The arterial blood gas values
and other parameters determine the need for intubation
or mechanical ventilation. As capillaries regain integrity, at 48 or more postburn hours, fluid moves from the interstitial to the
intravascular compartment and diuresis begins. If
cardiac or renal function is inadequate, for instance in the elderly patient or
in the patient with preexisting cardiac disease,
fluid overload occurs and symptoms of congestive heart failure may result (see
Chap. 30). Early detection allows for early intervention and carefully
calculated fluid intake. Vasoactive medications,
diuretics, and fluid restriction may be used to support circulatory function
and prevent congestive heart failure and pulmonary edema.
Cautious administration of fluids and electrolytes continues during this phase
of burn care because of the shifts in fluid from the interstitial to
intravascular compartments, losses of fluid from large burn wounds, and the
patient’s physiologic responses to the burn injury. Blood components are
administered as needed to treat blood loss and anemia.
Fever is common in burn patients after burn shock resolves. A resetting of the
core body temperature in severely burned patients results in a body temperature
a few degrees higher than normal for several weeks after the burn. Bacteremia and septicemia also
cause fever in many patients. Acetaminophen (Tylenol) and hypothermia blankets
may be required to maintain body temperature in a range of 37.2° to
Infection Prevention
Despite aseptic precautions and the use of topical antimicrobial agents, the burn wound is an excellent medium for bacterial growth and proliferation. Bacteria such as Staphylococcus, Proteus, Pseudomonas, Escherichia coli, and Klebsiella find optimal conditions for growth within the burn wound. The burn eschar is a nonviable crust with no blood supply; therefore, neither polymorphonuclear leukocytes or antibodies nor systemic antibiotics can reach the area. Phenomenal numbers of bacteria—more than 1 billion per gram of tissue—may appear and subsequently spread to the bloodstream or release their toxins, which reach distant sites. Staphylococci and enterococci are the organisms responsible for more than 50% of nosocomial bloodstream infections in patients with burn injuries. Fungi such as Candida albicans also grow easily in burn wounds. When the burn wound is healing through spontaneous reepithelialization or is being prepared for skin grafting, it must be protected from sepsis. Burn wound sepsis has these characteristics: • 105 bacteria per gram of tissue • Inflammation • Sludging and thrombosis of dermal blood vessels The primary source of bacterial infection appears to be the patient’s intestinal tract, the source of most microbes. The intestinal mucosa normally serves as a barrier to keep the internal environment free from a variety of pathogens. After a severe burn injury, the intestinal mucosal barrier becomes markedly permeable. Because of this impaired intestinal mucosal barrier, the disturbed microbial flora and endotoxins found in the intestinal lumen pass freely into the systemic circulation, finally causing infection. If the intestinal mucosa receives some type of protection against permeability change, infection could be avoided. Early enteral feeding is one step to help avoid this increased intestinal permeability and prevent early endotoxin translocation (Cioffi, 2000; Peng, Yuan & Ziao, 2001). Infection impedes burn wound healing by promoting excessive inflammation and damaging tissue. A major secondary source of pathogenic microbes is the environment. Infection control is a major role of the burn team in providing appropriate burn wound care. Cap, gown, mask, and gloves are worn while caring for the patient with open burn wounds. Clean technique is used when caring directly for burn wounds. Tissue specimens are obtained for culture regularly to monitor colonization of the wound by microbial organisms. These may be swab, surface, or tissue biopsy cultures. Swab or surface cultures are noninvasive, simple, and painless. However, data obtained from such cultures apply only to the area sampled; therefore, invasive wound biopsy cultures may be required. Antibiotics are seldom prescribed prophylactically because of the risk of promoting resistant strains of bacteria. Systemic antibiotics are administered when there is documentation of burn wound sepsis or other positive cultures such as urine, sputum, or blood. Sensitivity of the organisms to the prescribed antibiotics should be determined before administration. Several parenteral antimicrobial agents may be given together to treat the infection. Careful attention is paid to antibiotic use in the burn unit because inappropriate use of antibiotics significantly affects the microbial flora present in the unit.
Wound Cleaning
Various measures are used to clean the burn wound.
Hydrotherapy in the form of shower carts, individual showers, and bed baths can be
used to clean the wounds. Total immersion hydrotherapy is performed in some
settings. Because of the high risk of infection and sepsis, the use of plastic
liners and thorough decontamination of hydrotherapy equipment and wound care
areas are necessary to prevent cross-contamination. Tap water alone can be used
for burn wound cleansing. The temperature of the water is maintained at
Topical Antibacterial Therapy
There is general agreement that some form of antimicrobial therapy applied to the burn wound is the best method of local care in extensive burn injury. Topical antibacterial therapy does not sterilize the burn wound; it simply reduces the number of bacteria so that the overall microbial population can be controlled by the body’s host defense mechanisms. Topical therapy promotes conversion of the open, dirty wound to a closed, clean one. Criteria for choosing a topical agent include the following:
• It is effective against gram-negative organisms, Pseudomonas aeruginosa, Staphylococcus aureus, and even fungi.
• It is clinically effective.
• It penetrates the eschar but is not systemically toxic.
• It does not lose its effectiveness, allowing another infection to develop.
• It is cost-effective, available, and acceptable to the patient.
• It is easy to apply, minimizing nursing care time.
The three most commonly used topical agents are silver sulfadiazine (Silvadene), silver nitrate, and mafenide acetate (Sulfamylon). These agents are described in Table 57-5. Many other topical agents are available, including povidone–iodine ointment 10% (Betadine), gentamicin sulfate, nitrofurazone (Furacin), Dakin’s solution, acetic acid, miconazole, and chlortrimazole. Bacitracin may be used for facial burns or on skin grafts initially. A newer product used in burn wound care is Acticoat Antimicrobial Barrier dressing. Acticoat is a silver-coated dressing approved for treatment of burn wounds and donor sites. This dressing is kept moist with water for a controlled, sustained release of silver over the wound to provide an antimicrobial barrier. Acticoat has been shown to have a better antimicrobial performance than the traditional silver-based products commonly used in burn wound treatment. Acticoat is also cost-effective. The dressing can be left in place for up to 5 days, decreasing patient discomfort, the cost of dressing supplies, and nursing time for dressing changes. The dressing has been shown clinically to be very effective for prevention of burn wound infection (Yin, Langford & Burrell, 1999). No single topical medication is universally effective. Using different agents at different times in the postburn period may be necessary. Bacteriologic cultures are required to monitor the effect of topical medications. Prudent use and alternation of antimicrobial agents result in less resistant strains of bacteria, greater effectiveness of the agents, and a decreased risk of sepsis. Before a topical agent is reapplied, the previously applied topical agent must be thoroughly removed. The number of times the dressings are changed and soaked is planned to promote optimal therapeutic use of the topical agent.
Wound Dressing
When the wound is clean, the burned areas are patted dry and the prescribed topical agent is applied; the wound is then covered with several layers of dressings. A light dressing is used over joint areas to allow for motion (unless the particular area has a graft and motion is contraindicated). A light dressing is also applied over areas for which a splint has been designed to conform to the body contour for proper positioning. Circumferential dressings should be applied distally to proximally. If the hand or foot is burned, the fingers and toes should be wrapped individually to promote adequate healing. Burns to the face may be left open to air once they have been cleaned and the topical agent has been applied. Careful attention must be given to burns left exposed to ensure that they do not dry out and convert to a deeper burn. Close communication and cooperation among the patient, surgeon, nurse, and other health care team members are essential for optimal burn wound care. Different wound areas on a given patient may require a variety of wound care techniques. Diagrams posted at the bedside are useful to inform staff of the current prescription for wound care, splints to be applied over dressings, and the exercise regimen to be followed before dressings are reapplied.
OCCLUSIVE METHOD
There is a role for occlusive dressings in treating specific wounds. An occlusive dressing is a thin gauze that is impregnated with a topical antimicrobial agent or that is applied after topical antimicrobial application. Occlusive dressings are most often used over areas with new skin grafts. Their purpose is to protect the graft, promoting an optimal condition for its adherence to the recipient site. Ideally, these dressings remain in place for 3 to 5 days, at which time they are removed for examination of the graft. When these dressings are applied, precautions are taken to prevent two body surfaces from touching, such as fingers or toes, ear and scalp, the areas under the breasts, any point of flexion, or between the genital folds. Functional body alignment positions are maintained by using splints or by careful positioning of the patient.
Dressing Changes
Dressings are changed in the patient’s unit, hydrotherapy room, or treatment area approximately 20 minutes after an analgesic agent is administered. They may also be changed in the operating room after the patient is anesthetized. A mask, goggles, hair cover, disposable plastic apron or cover gown, and gloves are worn by health care personnel when removing the dressings. The outer dressings are slit with blunt scissors, and the soiled dressings are removed and disposed of in accordance with established procedures for contaminated materials. Dressings that adhere to the wound can be removed more comfortably if they are moistened with tap water or if the patient is allowed to soak for a few moments in the tub. The remaining dressings are carefully and gently removed. The patient may participate in removing the dressings, providing some degree of control over this painful procedure. The wounds are then cleaned and dйbrided to remove debris, any remaining topical agent, exudate, and dead skin. Sterile scissors and forceps may be used to trim loose eschar and encourage separation of devitalized skin. During this procedure, the wound and surrounding skin are carefully inspected. The color, odor, size, exudate, signs of re-epithelialization, and other characteristics of the wound and the eschar and any changes from the previous dressing change are noted.
Wound Debridement
As debris accumulates on the wound surface, it can retard keratinocyte migration, thus delaying the epithelialization process. Dйbridement, another facet of burn wound care, has two goals:
• To remove tissue contaminated by bacteria and foreign bodies, thereby protecting the patient from invasion of bacteria
• To remove devitalized tissue or burn eschar in preparation for grafting and wound healing
There are three types of debridement—natural, mechanical, and surgical.
NATURAL DEBRIDEMENT
With natural dйbridement, the dead tissue separates from the underlying viable tissue spontaneously. After partial- and full-thickness burns, bacteria that are present at the interface of the burned tissue and the viable tissue underneath gradually liquefy the fibrils of collagen that hold the eschar in place for the first or second postburn week. Proteolytic and other natural enzymes cause this phenomenon. Using antibacterial topical agents, however, tends to slow this natural process of eschar separation. It is advantageous to the patient to speed this process through other means, such as mechanical or surgical dйbridement, thereby reducing the time during which bacterial invasion and other iatrogenic problems may arise.
MECHANICAL DEBRIDEMENT
Mechanical debridement involves using surgical scissors and forceps to separate and remove the eschar. This technique can be performed by skilled physicians, nurses, or physical therapists and is usually done with daily dressing changes and wound cleaning procedures. Dйbridement by these means is carried out to the point of pain and bleeding. Hemostatic agents or pressure can be used to stop bleeding from small vessels. Dressings are also useful dйbriding agents. Coarse-mesh dressings applied dry or wet-to-dry (applied wet and allowed to dry) will slowly dйbride the wound of exudate and eschar when they are removed. Topical enzymatic dйbridement agents are available to promote dйbridement of the burn wounds. Because such agents do not have antimicrobial properties, they should be used with topical antibacterial therapy to protect the patient from bacterial invasion.
SURGICAL DEBRIDEMENT
Early surgical excision to remove devitalized tissue along with early burn wound closure is now being recognized as one of the most important factors contributing to survival in a patient with a major burn injury. Aggressive surgical wound closure has reduced the incidence of burn wound sepsis, thus improving survival rates (Gibran & Heimbach, 2000). Early excision is carried out before the natural separation of eschar is allowed to occur. Surgical debridement is an operative procedure involving either primary excision (surgical removal of tissue) of the full thickness of the skin down to the fascia (tangential excision) or shaving the burned skin layers gradually down to freely bleeding, viable tissue. Surgical excision is initiated early in burn wound management. This may be performed a few days after the burn or as soon as the patient is hemodynamically stable and edema has decreased. Ideally, the wound is then covered immediately with a skin graft, if needed, and an occlusive dressing. If the wound bed is not ready for a skin graft at the time of excision, a temporary biologic dressing may be used until a skin graft can be applied during subsequent surgery. The use of surgical excision carries with it risks and complications, especially with large burns. The procedure creates a high risk of extensive blood loss (as much as 100 to 125 mL of blood per percent body surface excised) and lengthy operating and anesthesia time. However, when conducted in a timely and efficient manner, surgical excision results in shorter hospital stays and possibly a decreased risk of complications from invasive burn wound sepsis.
Gerontologic Considerations
Eschar separation in full-thickness burns is typically delayed in elderly patients, and older patients are frequently poor risks for surgical excision. Therefore, prolonged hospitalization, immobilization, and associated problems may be common. If the elderly patient can tolerate surgery, early excision with skin grafting is the treatment of choice because it decreases the mortality rate in this population. Prevention of complications of prolonged hospitalization, immobility, and surgery is essential in the care of the elderly burn patient.
Grafting the Burn Wound
If wounds are deep (full-thickness) or extensive, spontaneous reepithelialization is not possible. Therefore, coverage of the burn wound is necessary until coverage with a graft of the patient’s own skin (autograft) is possible. The purposes of wound coverage are to decrease the risk for infection; prevent further loss of protein, fluid, and electrolytes through the wound; and minimize heat loss through evaporation. Several methods of wound coverage are available; some are temporary until grafting with permanent coverage is possible. Wound coverage may consist of biologic, biosynthetic, synthetic, and autologous methods or a combination of these approaches. The main areas for skin grafting include the face (for cosmetic and psychological reasons); functional areas, such as the hands and feet; and areas that involve joints. Grafting permits earlier functional ability and reducescontractures (shrinkage of burn scar through collagen maturation). When burns are very extensive, the chest and abdomen may be grafted first to reduce the burn surface. Granulation tissue fills the space created by the wound, creates a barrier to bacteria, and serves as a bed for epithelial cell growth. Richly vascular granulation tissue is pink, firm, shiny, and free of exudate and debris. It should have a bacterial count of less than 100,000 per gram of tissue to optimize graft take. If the wound is not ready for skin grafting, the burn wound is excised and allowed to granulate. Once the wound is excised, a wound covering is applied to keep the wound bed moist and promote the granulation process.
BIOLOGIC DRESSINGS (HOMOGRAFTS AND HETEROGRAFTS)
Biologic dressings have several uses. In extensive burns, they save lives by providing temporary wound closure and protecting the granulation tissue until autografting is possible. Biologic dressings are commonly used in patients with large areas of burn and little remaining normal skin donor sites. Biologic dressings may also be used to debride wounds after eschar separation. With each biologic dressing change, dйbridement occurs. Once the biologic dressing appears to be “taking,” or adhering to the granulating surface with minimal underlying exudation, the patient is ready for an autograft. Biologic dressings also provide temporary immediate coverage for clean, superficial burns and decrease the wound’s evaporative water and protein loss. They decrease pain by protecting nerve endings and are an effective barrier against water loss and entry of bacteria. When applied to superficial partial-thickness wounds, they seem to speed healing. Biologic materials can be left open or covered. They stay in place for varying lengths of time but are removed in instances of infection or rejection. Biologic dressings consist of homografts (or allografts) and heterografts (or xenografts). Homografts are skin obtained from living or recently deceased humans. The amniotic membrane (amnion) from the human placenta may also be used as a biologic dressing. Heterografts consist of skin taken from animals (usually pigs). Most biologic dressings are used as temporary coverings of burn wounds and are eventually rejected because of the body’s immune reaction to them as foreign. Homografts tend to be the most expensive biologic dressings. They are available from skin banks in fresh and cryopreserved (frozen) forms. Homografts are thought to provide the best infection control of all the biologic or biosynthetic dressings available. Revascularization occurs within 48 hours, and the graft may be left in place for several weeks. Cost, availability, and the possibility of transmission of disease limit the use of homografts. Amnion is less expensive and is available in hospitals with burn centers and specialized tissue banks, which obtain and process it in cooperation with obstetric services. However, amnion grafts do not become vascularized by the patient’s vessels and can be left in place only for short periods. Pigskin is available from commercial suppliers. It is available fresh, frozen, or lyophilized (freeze-dried) for longer shelf life. Pigskin impregnated with a topical antibacterial agent such as silver nitrate is also available. Pigskin is widely used for temporary covering of clean wounds such as superficial partial-thickness wounds and donor sites. Although pigskin does not vascularize, it will adhere to clean superficial wounds and provides excellent pain control while the underlying wound epithelializes.
BIOSYNTHETIC AND SYNTHETIC DRESSINGS
Problems with availability, sterility, and cost have prompted the search for biosynthetic and synthetic skin substitutes, which may eventually replace biologic dressings as temporary wound coverings. Currently the most widely used synthetic dressing isBiobrane, which is composed of a nylon, Silastic membrane combined with a collagen derivative. The material is semitransparent and sterile. It has an indefinite shelf life and is less costly than homograft or pigskin. Like biologic dressings, Biobrane protects the wound from fluid loss and bacterial invasion. Biobrane adheres to the wound fibrin, which binds to the nylon–collagen material. Within 5 days, cells migrate into the nylon mesh. Generally, adherence to the wound surface correlates directly with low bacterial counts. When the Biobrane dressing adheres to the wound, the wound remains stable and the Biobrane can remain in place for 3 to 4 weeks. Biobrane dressings (Fig. 57-4) readily adhere to donor sites and meticulously clean dйbrided partial-thickness wounds; they will remain until spontaneous epithelialization and wound healing occur. Biobrane can be laid on top of a wide-meshed autograft to protect the wound until the autograft epithelium grows out to close the interstices. As the Biobrane gradually separates, it is trimmed, leaving a healed wound. Biobrane is also useful for intermediate or long-term closure of a surgically excised wound until an autograft becomes available. Like biologic dressings, Biobrane should not be used over grossly contaminated or necrotic wounds. Removal of Biobrane after several weeks is similar to but easier than removal of a vascularized allograft and leaves a bleeding granulation bed that readily accepts an autograft. Another fairly new temporary wound covering is BCG Matrix. This dressing combines beta-glucan, a complex carbohydrate, with collagen in a meshed reinforced wound dressing. Beta-glucan is known to stimulate macrophages, which are vital in the inflammatory process of healing. BCG Matrix is a temporary wound covering intended for use with partial-thickness burns and donor sites. It is applied immediately after cleaning and dйbridement. If the burn wound surface remains free of infection, BCG Matrix can be left in place until healing is complete. Several other synthetic dressings are available for burn wound care. Op-Site, a thin, transparent, polyurethane elastic film, can be used to cover clean partial-thickness wounds and donor sites. This dressing is occlusive and waterproof but permeable to water vapor and air; this permeability not only provides protection from microbial contamination but also allows for the exchange of gases, which occurs much more quickly in a moist environment. Other synthetic dressings used for burn wounds include Tegaderm, N-Terface, and DuoDerm. Burns that are between superficial and deep partial thickness in depth can be treated with a promising new temporary biologic covering, TransCyte, a material composed of human newborn fibroblasts, which are cultured on the nylon mesh of Biobrane. The thin silicone membrane bonded to the mesh provides a moisture vapor barrier for the wound. TransCyte is used to treat burns in which the depth is indeterminate. TransCyte delivers a variety of biologically active proteins, which may benefit the wound healing process. Research has shown that wounds treated with TransCyte healed more quickly and with less hypertrophic scarring than burns treated with the traditional silver sulfadiazine protocols (Noordenbos, Dore & Hansbrough, 1999).
DERMAL SUBSTITUTES
In an attempt to develop the ideal burn wound covering product, dermal substitutes have been created. Two such products are Integra Artificial Skin and Alloderm. Artificial skin (Integra) is the newest type of dermal substitute. A dermal analog, Integra is composed of two main layers. The epidermal layer, consisting of Silastic, acts as a bacterial barrier and prevents water loss from the dermis. The dermal layer is composed of animal collagen. It interfaces with the open wound surface and allows migration of fibroblasts and capillaries into the material. This “neodermis” becomes a permanent structure. The artificial dermis is biodegraded and reabsorbed. The outer silicone membrane is removed 2 to 3 weeks after application and is replaced with the patient’s own skin in the form of a thin epidermal skin graft. Long-term effects of Integra include minimal contracture formation. The graft site is very pliable, almost eliminating the need for repeated cosmetic surgery. Most importantly, Integra has resulted in less hypertrophic scarring (Fig. 57-5), thus eliminating the need for compression devices once the burn wound has healed. The use of Integra is increasing the survivability of burns and improving the functional and cosmetic qualities of the healed burn (Winfrey, Cochran & Hegarty, 1999). Another promising dermal substitute is Alloderm. It is processed dermis from human cadaver skin, which can be used as the dermal layer for skin grafts. When a donor site (the area from which skin is taken to provide a skin graft for another part of the body) is harvested for an autologous skin graft, both the epidermal and dermal layers of skin are removed from the donor site. Alloderm provides a permanent dermal layer replacement. Its use allows the burn surgeon to harvest a thinner skin graft consisting of the epidermal layer only. The patient’s epidermal layer is placed directly over the dermal base (Alloderm). The new graft is then treated according to the burn unit’s protocol. Use of Alloderm has also resulted in less scarring and contractures with healed grafts; donor sites heal much more quickly than conventional donor sites because only the epidermal layer has been harvested. This is important when donor sites are limited because of extensive burns (Luterman, 2000).
AUTOGRAFTS
Autografts remain the preferred material for definitive burn wound closure following excision. Autografts are the ideal means of covering burn wounds because the grafts are the patient’s own skin and thus are not rejected by the patient’s immune system. They can be split-thickness, full-thickness, pedicle flaps, or epithelial grafts. Full-thickness and pedicle flaps are commonly used for reconstructive surgery, months or years after the initial injury. Split-thickness autografts can be applied in sheets or in postage stamp–like pieces, or they can be expanded by meshing so that they can cover 1.5 to 9 times more than a given donor site area. Skin meshers enable the surgeon to cut tiny slits into a sheet of donor skin, making it possible to cover large areas with smaller amounts of donor skin. These expanded grafts adhere to the recipient site more easily than sheet grafts and prevent the accumulation of blood, serum, air, or purulent material under the graft. However, any kind of graft other than a sheet graft will contribute to scar formation as it heals. Using expanded grafts may be necessary in large wounds but should be viewed as a compromise in terms of cosmesis. If blood, serum, air, fat, or necrotic tissue lies between the recipient site and the graft, there may be partial or total loss of the graft. Infection and mishandling of the graft, as well as trauma during dressing changes, account for most other instances of graft loss. Using split-thickness grafts allows the remaining donor site to retain sweat glands and hair follicles and minimizes donor site healing time. Use of cultured epithelial autograft (CEA) is common at several burn centers. This involves a biopsy of the patient’s skin in an unburned area. Keratinocytes are then isolated and epithelial cells are cultured in a laboratory. The original epithelial cell sample can multiply to 10,000 times its original size over 30 days. These cells are then attached to the burn wound. Varying degrees of success have been reported, and results are encouraging. However, the disadvantages of the CEA are that the grafts are thin and fragile and can shear easily. Research has shown that the outcomes of use of CEA are not as positive as once thought. The quality of burn scars is better, but patients have longer hospital stays and higher hospital costs and require more surgical procedures than those treated by traditional methods. In addition, patients require more reconstructive procedures in the first 1 to 2 years postinjury. Therefore, CEA use is very limited and reserved for burn patients whose donor sites are limited (Noordenbos et al.).
Care of the Patient with an Autograft.
Occlusive dressings are commonly used initially after grafting to immobilize the graft. Occupational therapists may be helpful in constructing splints to immobilize newly grafted areas to prevent dislodging the graft. Homografts, heterografts, or synthetic dressings may also be used to protect grafts. The graft may be left open with skin staples to immobilize it, which allows close observation of progress. The first dressing change is usually performed 3 to 5 days after surgery, or earlier in the case of purulent drainage or a foul odor. If the graft is dislodged, sterile saline compresses will help prevent drying of the graft until the physician reapplies it. The patient is positioned and turned carefully to avoid disturbing the graft or putting pressure on the graft site. If an extremity has been grafted, it is elevated to minimize edema. The patient begins exercising the grafted area 5 to 7 days after grafting.
Care of Donor Site.
A moist gauze dressing is applied at the time of surgery to maintain pressure and to stop any oozing. A thrombostatic agent such as thrombin or epinephrine may be applied directly to the site as well. The donor site may be treated in several ways, from single-layer gauze impregnated with petrolatum, scarlet red, or bismuth to new biosynthetic dressings such as Biobrane or BCG Matrix. Some burn centers are using the Acticoat dressing on donor sites. Despite the type of donor site covering, donor sites must remain clean, dry, and free from pressure. Because a donor site is usually a partial-thickness wound, it will heal spontaneously within 7 to 14 days with proper care. Donor sites are painful, and additional pain management must be a part of the patient’s care.
Pain Management
Pain is inevitable during recovery from any burn injury. Pain in the burn patient has been described as a tormenting consequence of burn injury and wound healing (Jonsson, Holmsten, Dahlstrom & Jonsson, 1998). Burn pain is thought to have both nociceptive and neuropathic pain components. Management of the often-severe pain is one of the most difficult challenges facing the burn team. Many factors contribute to the burn patient’s pain experience. These factors include but are not limited to the severity of the pain, the adequacy of the health care provider’s assessment of the pain, the appropriateness and adequacy of pharmacologic treatment of pain, the multiple procedures involved in burn care (ie, wound care, rehabilitative exercises), and appropriate evaluation of the effectiveness of pain relief measures. The outstanding features of burn pain are its intensity and long duration. Further, necessary wound care carries with it the anticipation of pain and anxiety. In partial-thickness burns, the nerve endings are exposed, resulting in excruciating pain with exposure to air currents. Although nerve endings are destroyed in full-thickness burns, the margins of the burn wound are hypersensitive to pain, and there is pain in adjacent structures. Healing of full-thickness burns creates significant discomfort as regenerating nerve endings become entrapped in scar formation. Most severe burns are a combination of partialthickness and full-thickness burns. Burn patients have been described as having three types of pain: background or resting pain, procedural pain, and breakthrough pain. Background pain is pain that exists on a 24-hour basis. Procedural pain is pain caused by procedures such as burn wound care or range of motion exercises. Breakthrough pain occurs when blood levels of analgesic agents fall below the level required to control background pain. The patient’s pain level must be assessed throughout the day because each type of pain is different and various pain management strategies may be needed to address different types of pain (McCaffrey & Pasaro, 1999). The primary pain from the burn itself is intense in the initial acute postburn phase. In the next few weeks thereafter, until the skin heals or skin grafts are applied and heal, the pain intensity remains high because of treatment-induced pain. Wound cleaning, dressing changes, dйbridement, and physical therapy can all cause intense pain. Donor sites may be intensely painful for several days. Discomfort related to tissue healing, such as itching, tingling, and tightness of contracting skin and joints, adds to the duration, if not the intensity, of pain over weeks or months. Because pain cannot be eliminated short of complete anesthesia, the goal is to minimize the pain with analgesic agents to an acceptable goal set by the patient. Opioid administration via the intravenous (IV) route, particularly in the emergent and acute phases of burn management, remains the mainstay for pharmacologic management of burn pain. Use of opioids is complicated by the fluctuation in the bioavailability of drugs, protein binding of the drug, and the drug clearance related to the hemodynamic and fluid volume shifts that occur with a burn injury. Absorption of the opioid also may be affected. Titrating analgesic agents to obtain pain relief while minimizing side effects is crucial. The burn patient’s requirements for analgesia are often high, but fear of addiction on the part of the patient and health care provider hamper adequate opioid administration. Morphine sulfate remains the analgesic of choice for treatment of acute burn pain. It is titrated to obtain pain relief based on the patient’s self-report of pain using a standardized pain rating scale. Fentanyl is another useful opioid for burn pain, particularly procedural burn pain. It has been shown to be effective for management of intense pain of short duration. Fentanyl has a rapid onset, high potency, and short duration, all of which make it effective for use with burn wound procedures. Appropriate cardiac and respiratory monitoring must be carried out during its administration. Patient-controlled analgesia (PCA), in which a pump is used to administer a continuous infusion of an opioid, maintains a steady level of opioid for pain relief. Use of continuous infusion requires close monitoring of the patient’s responses. Sustained-release opioids, such as MS Contin or oxycodone (OxyContin), have also been used successfully in the treatment of burn pain. These medications can effectively treat the resting pain that is often associated with burn injury. Additional medications must be prescribed with these medications to cover breakthrough pain. Some burn units use self-administered nitrous oxide during burn wound procedures. Proper ventilation and monitoring equipment and availability of qualified personnel to administer nitrous oxide limit its use. Anxiety and pain go hand in hand for burn patients. The entire burn experience can produce severe anxiety, which can, in turn, exacerbate pain. Therefore, the ideal pain management regimen must incorporate the treatment of pain and anxiety and must be individualized for each patient. Sedation with anxiolytic medications such as lorazepam (Ativan) and midazolam (Versed) may be indicated in addition to the administration of opioids. The use of nonpharmacologic measures has also proven effective in the management of burn pain. These measures include relaxation techniques, deep breathing exercises, distraction, guided imagery, hypnosis, therapeutic touch, humor, information giving, and music therapy (McCaffrey & Pasaro, 1999). Music therapy has gained interest recently in the treatment of pain. Researchers have found that music affects both the physiologic and psychological aspects of the pain experience. Music diverts the patient’s attention from the painful stimulus; provides reality orientation, distraction, and sensory stimulation; and allows for patient self-expression (Fratianne et al., 2001; Prensner et al., 2001).
Nutritional Support
Burn injuries produce profound metabolic abnormalities fueled by the exaggerated stress response to the injury.
The body’s response has been classified as hyperdynamic,
hypermetabolic, and hypercatabolic.
Hypermetabolism can affect morbidity and mortality by
increasing the risk of infection and slowing the healing rate. Patients’
metabolic demands vary with the extent of the burn injury. Hypermetabolism
is evident immediately after a burn injury. The degree of the response depends
on the size of the burn and the patient’s age, body composition, size, and
genetic response to insult. Persistent hypermetabolism
may last up to 1 year after burn injury (Hart et al., 2000). Major metabolic
abnormalities seen after a burn injury include increased catabolic hormones (cortisol and catechols);
decreased anabolic hormones (human growth factor and testosterone); a marked
increase in the metabolic rate; a sustained increase in body temperature; a
marked increase in glucose demands; rapid skeletal muscle breakdown with amino acids
serving as the energy source; lack of ketosis, indicating that fat is not a
major source of calories; and catabolism that does not respond to nutrient
intake (Demling & Seigne,
2000). Therefore, it is essential to control the stress response by increasing
the anabolic process through adequate nutrition and increased muscle activity,
decreasing heat loss from wounds, and maintaining a warm environment.
Controlling secondary stress, such as pain and anxiety, also helps to control
the stress response. The most important of these interventions is to provide
adequate nutrition and calories to decrease catabolism. Nutritional support
with optimized protein intake can decrease protein losses by approximately 50%
(Cioffi, 2000). Healing of the burn wound consumes
large quantities of energy. Effective nutrition management depends on how well
the energy expenditure due to the burn injury can be estimated and matched with
appropriate amounts of micronutrients, carbohydrates, lipids, and protein. The
goal of nutritional support is to promote a state of positive nitrogen balance
by optimizing nutrition to match nutrient utilization. The nutritional support
required is based on the patient’s preburn status and
the TBSA burned. Several formulas exist for estimating the daily metabolic
expenditure and caloric requirements of patients with burn injuries. The most
commonly used formulas include the Curreiri formula,
which uses body weight and percent burn, and a variation of the Harris-Bennedict equation, which determines basal energy
requirements based on stress and burn size (Demling
& Seigne, 2000). Protein requirements may range
from 1.5 to
DISORDERS OF WOUND HEALING
Disorders of wound healing in the burn patient result from excessive abnormal healing or inadequate new tissue formation. Hypertrophic scarring and keloid formation result from excessive abnormal healing.
Scars
One of the most devastating sequelae of a burn injury is the formation of hypertrophic scars. Clinicians cannot reliably predict or prevent the formation of hypertrophic scars. Hypertrophic scars are more common in children, in people with dark skin, and in areas of stretch or motion. The pathophysiology behind these scars is not completely understood, but they are characterized by an overabundant matrix formation, especially collagen. Hypertrophic scars and wound contractures are more likely to occur if the initial burn injury extends below the level of the deep dermis. Healing of such deep wounds results in the replacement of normal integument with highly metabolically active tissues that lack the normal architecture of the skin. In the collagen layer beneath the epithelium, many fibroblasts proliferate gradually. Myofibroblasts, cells that have the ability to contract, are also present in immature wounds. As the myofibroblasts contract, the collagen fibers, which normally lie in flat bundles, tend to form a wavy pattern. Eventually the collagen bundles take on a supercoiled appearance and collagen nodules develop. The scar becomes red (because of its hypervascular nature), raised, and hard. Burn personnel must be proactive in the prevention and management of scar formation. Compression measures are instituted early in burn wound treatment. Ace wraps are used initially to help promote adequate circulation, but they can also be used as the first form of compression. Scar management occurs mainly in the rehabilitative phase, after the wounds are closed. Hypertrophic scarring may cause severe contracture across involved joints. Therefore, prevention and management of this type of scarring is essential (see “Prevention of Hypertrophic Scarring” in the rehabilitation phase discussion). However, these scars are limited to the area of injury and gradually regress over time.
Keloids
A large, heaped-up mass of scar tissue, a keloid, may develop and extend beyond the wound surface. Keloids tend to be found in people with darkly pigmented skin, tend to grow outside of wound margins, and are likely to recur after surgical excision.
Failure to Heal
Failure of the wound to heal may result from many factors, including infection and inadequate nutrition. A serum albumin level of less than 2 g/dL is usually a factor in impaired healing in the burn patient.
Contractures
Contractures are another concern as wounds heal. The burn wound tissue shortens because of the force exerted by the fibroblasts and the flexion of muscles in natural wound healing. An opposing force provided by splints, traction, and purposeful movement and positioning must be used to counteract deformity in burns affecting joints.
NURSING PROCESS: CARE OF THE PATIENT DURING THE ACUTE PHASE
Assessment
Continued assessment of the burn patient during the early weeks after the burn injury focuses on hemodynamic alterations, wound healing, pain and psychosocial responses, and early detection of complications. Assessment of respiratory and fluid status remains the highest priority for detection of potential complications. The nurse assesses vital signs frequently. Continued assessment of peripheral pulses is essential for the first few postburn days while edema continues to increase, potentially damaging peripheral nerves and restricting blood flow. Observation of the electrocardiogram may give clues to cardiac dysrhythmias resulting from potassium imbalance, preexisting cardiac disease, or the effects of electrical injury or burn shock. Assessment of residual gastric volumes and pH in the patient with a nasogastric tube is also important. Blood in the gastric fluid or the stools must also be noted and reported. Assessment of the burn wound requires an experienced eye, hand, and sense of smell. Important wound assessment features include size, color, odor, eschar, exudate, abscess formation under the eschar, epithelial buds (small pearl-like clusters of cells on the wound surface), bleeding, granulation tissue appearance, status of grafts and donor sites, and quality of surrounding skin. Any significant changes in the wound are reported to the physician, because they usually indicate burn wound or systemic sepsis and require immediate intervention. Other significant and ongoing assessments focus on pain and psychosocial responses, daily body weights, caloric intake, general hydration, and serum electrolyte, hemoglobin, and hematocrit levels. Assessment for excessive bleeding from blood vessels adjacent to areas of surgical exploration and dйbridement is necessary as well. The Plan of Nursing Care provides an outline of nursing activities in the acute phase of burn care.
Diagnosis
NURSING DIAGNOSES
Based on the assessment data, priority nursing diagnoses in the acute phase of burn care may include the following:
• Excessive fluid volume related to resumption of capillary integrity and fluid shift from the interstitial to intravascular compartment
• Risk for infection related to loss of skin barrier and impaired immune response
• Imbalanced nutrition, less than body requirements, related to hypermetabolism and wound healing needs
• Impaired skin integrity related to open burn wounds
• Acute pain related to exposed nerves, wound healing, and treatments
• Impaired physical mobility related to burn wound edema, pain, and joint contractures
• Ineffective coping related to fear and anxiety, grieving, and forced dependence on health care providers
• Interrupted family processes related to burn injury
• Deficient knowledge about the course of burn treatment
COLLABORATIVE PROBLEMS/ POTENTIAL COMPLICATIONS
Based on the assessment data, potential complications that may develop in the acute phase of burn care may include:
• Heart failure and pulmonary edema
• Sepsis
• Acute respiratory failure
• Acute respiratory distress syndrome
• Visceral damage (electrical burns)
Planning and Goals
The major goals for the patient may include restoration of normal fluid balance, absence of infection, attainment of anabolic state and normal weight, improved skin integrity, reduction of pain and discomfort, optimal physical mobility, adequate patient and family coping, adequate patient and family knowledge of burn treatment, and absence of complications. Achieving these goals requires a collaborative, interdisciplinary approach to patient management.
Nursing Interventions
RESTORING
To reduce the risk of fluid overload and consequent congestive heart failure, the nurse closely monitors IV and oral fluid intake, using IV infusion pumps to minimize the risk of rapid fluid infusion. To monitor changes in fluid status, careful intake and output and daily weights are obtained. Changes in pulmonary artery, wedge, and central venous pressures, as well as in blood pressure and pulse rate, are reported to the physician. Low-dose dopamine to increase renal perfusion and diuretics may be prescribed to promote increased urine output. The nurse’s role is to administer these medications as prescribed and to monitor the patient’s response.
PREVENTING INFECTION
A major part of the nurse’s role during the acute phase of burn care is detecting and preventing infection. The nurse is responsible for providing a clean and safe environment and for closely scrutinizing the burn wound to detect early signs of infection. Culture results and white blood cell counts are monitored. Clean technique is used for wound care procedures. Aseptic technique is used for any invasive procedures, such as insertion of IV lines and urinary catheters or tracheal suctioning. Meticulous hand hygiene before and after each patient contact is also an essential component of preventing infection, even though gloves are worn to provide care. The nurse protects the patient from sources of contamination, including other patients, staff members, visitors, and equipment. Invasive lines and tubing must be routinely changed according to recommendations of the Centers for Disease Control and Prevention. Tube feeding reservoirs, ventilator circuits, and drainage containers are replaced regularly. Fresh flowers, plants, or fresh fruit baskets are not permitted in the patient’s room because of the risk of microorganism growth. Visitors are screened to avoid exposing the immunocompromised burn patient to pathogens. Patients can inadvertently promote migration of microorganisms from one burned area to another by touching their wounds or dressings. Bed linens also can spread infection through either colonization with wound microorganisms or fecal contamination. Regularly bathing unburned areas and changing linens can help prevent infection.
MAINTAINING ADEQUATE NUTRITION
Oral fluids should be initiated slowly when bowel sounds resume. The patient’s tolerance is noted. If vomiting and distention do not occur, fluids may be increased gradually and the patient may advance to a normal diet or to tube feedings. The nurse collaborates with the dietitian or nutrition support team to plan a protein- and calorie-rich diet that is acceptable to the patient. Family members may be encouraged to bring nutritious and favorite foods to the hospital. Milkshakes and sandwiches made with meat, peanut butter, and cheese may be offered as snacks between meals and late in the evening. Nutritional supplements such as Ensure and Resource may be provided. Caloric intake must be documented. Vitamin and mineral supplements may be prescribed. If caloric goals cannot be met by oral feeding, a feeding tube is inserted and used for continuous or bolus feedings of specific formulas. The volume of residual gastric secretions should be checked to ensure absorption. Parenteral nutrition may also be required but should be used only if gastrointestinal function is compromised (see Chap. 36). Patients should be weighed each day and their weights graphed. Patients can use this information to set goals for their own nutritional intake and to monitor weight loss and gain. Ideally, the patient will lose no more than 5% of preburn weight if aggressive nutritional management is implemented. The patient with anorexia requires encouragement and support from the nurse to increase food intake. The patient’s surroundings should be as pleasant as possible at mealtime. Catering to food preferences and offering high-protein, high-vitamin snacks are ways of encouraging the patient to increase intake.
PROMOTING SKIN INTEGRITY
Wound care is usually the single most time-consuming element of burn care after the emergent phase. The physician will prescribe the desired topical antibacterial agents and specific biologic, biosynthetic, or synthetic wound coverings and will plan for surgical excision and grafting. The nurse needs to make astute assessments of wound status, to use creative approaches to wound dressing, and to support the patient during the emotionally distressing and very painful experience of wound care. The nurse serves as the coordinator of the complex aspects of wound care and dressing changes for the patient. The nurse must be aware of the rationale and nursing implications for the various wound management approaches. Nursing functions include assessing and recording any changes or progress in wound healing and keeping all members of the health care team informed of changes in the wound or treatment. A diagram, updated daily by the nurse responsible for the patient’s care, helps to inform all those concerned about the latest wound care procedures in use for the patient. The nurse also assists the patient and family by providing instruction, support, and encouragement to take an active part in dressing changes and wound care when appropriate. Discharge planning needs for wound care are anticipated early in the course of burn management, and the strengths of the patient and family are assessed and used in preparing for eventual discharge and home care.
RELIEVING PAIN AND DISCOMFORT
Pain measures discussed earlier are continued during the acute phase of burn recovery. Analgesic agents and anxiolytic medications are administered as prescribed. Frequent assessment of pain and discomfort is essential. To increase its effectiveness, analgesic medication is provided before the pain becomes severe. Nursing interventions such as teaching the patient relaxation techniques, giving the patient some control over wound care and analgesia, and providing frequent reassurance are helpful. Guided imagery may be effective in altering the patient’s perceptions of and responses to pain. Other pain-relieving approaches include distraction through video programs or video games, hypnosis, biofeedback, and behavioral modification. The nurse works quickly to complete treatments and dressing changes to reduce pain and discomfort. The patient is encouraged to take analgesic medications before painful procedures. The patient’s response to the medication and other interventions is assessed and documented. Healing burn wounds are typically described by patients as itchy and tight. Oral antipruritic agents, a cool environment, frequent lubrication of the skin with water or a silica-based lotion, exercise and splinting to prevent skin contracture, and diversional activities all help to promote comfort in this phase.
PROMOTING PHYSICAL MOBILITY
An early priority is to prevent complications resulting from immobility. Deep breathing, turning, and proper repositioning are essential nursing practices that prevent atelectasis and pneumonia, control edema, and prevent pressure ulcers and contractures. These interventions are modified to meet the patient’s needs. Low-air-loss and rotation beds may be useful, and early sitting and ambulation are encouraged. Whenever the lower extremities are burned, elastic pressure bandages should be applied before the patient is placed in an upright position. These bandages promote venous return and minimize swelling. The burn wound is in a dynamic state for a year or more after wound closure. During this time, aggressive efforts must be made to prevent contracture and hypertrophic scarring. Both passive and active range-of-motion exercises are initiated from the day of admission and are continued after grafting, within prescribed limitations. Splints or functional devices may be applied to extremities for contracture control. The nurse monitors the splinted areas for signs of vascular insufficiency and nerve compression.
STRENGTHENING COPING STRATEGIES
In the acute phase of burn care, the patient is facing the reality of the burn trauma and is grieving over obvious losses. Depression, regression, and manipulative behavior are common responses of patients who have burn injuries. Withdrawal from participation in required treatments and regression must be viewed with an understanding that such behavior helps the patient cope with an enormously stressful event. Much of the patient’s energy goes into maintaining vital physical functions and wound healing in the early postburn weeks, leaving little emotional energy for coping in a more effective manner. Nurses can assist patients to develop effective coping strategies by setting specific expectations for behavior, promoting truthful communication to build trust, helping patients practice appropriate strategies, and giving positive reinforcement when appropriate. Most importantly, the nurse and all members of the health care team must demonstrate acceptance of the patient. The patient frequently vents feelings of anger. At times the anger may be directed inward because of a sense of guilt, perhaps for causing the fire or even for surviving when loved ones perished. The anger may reach outward toward those who escaped unharmed or to those who are now providing care. One way to help the patient handle these emotions is to enlist someone to whom the patient can vent feelings without fear of retaliation. A nurse, social worker, psychiatric liaison nurse, or clergy member who is not involved in direct care activities may fill this role successfully. Burn patients are very dependent on health care team members during the long period of acute illness. However, even when physically unable to contribute much to self-care, they can be included in decisions regarding care and encouraged to assert their individuality in terms of preferences and recognition of their unique identities. As patients improve in mobility and strength, the nurse works with them to set realistic expectations for self-care, including self-feeding, assistance with wound care procedures, exercise, and planning for the future. Many patients respond positively to the use of contractual agreements and other strategies that recognize their independence and their specific role as part of the health care team moving toward the goal of self-care.
SUPPORTING PATIENT AND FAMILY PROCESSES
Family functioning is disrupted with burn injury. One of the nurse’s responsibilities is to support the patient and family and to address their spoken and unspoken concerns. Family members need to be instructed about ways that they can support the patient as adaptation to burn trauma occurs. The family also needs support by the health care team. The burn injury has tremendous psychological, economic, and practical impact on the patient and family. Referrals for social services or psychological counseling should be made as appropriate. This support continues into the rehabilitation phase. Burn patients are commonly sent to burn centers far from home. Because burn injuries are not anticipated, family roles are disrupted. Therefore, both the patient and the family need thorough information about the patient’s burn care and expected course of treatment. Patient and family education begins at the initiation of burn management. Barriers to learning are assessed and considered in teaching. The preferred learning styles of both the patient and family are assessed. This information is used to tailor teaching activities. The nurse assesses the ability of the patient and family to grasp and cope with the information. Verbal information is supplemented by videos, models, or printed materials if available. Patient and family education is a priority in the rehabilitation phase.
MONITORING AND MANAGING POTENTIAL COMPLICATIONS
Heart Failure and Pulmonary Edema
The patient is assessed for fluid overload, which may occur as fluid is mobilized from the interstitial compartment back into the intravascular compartment. If the cardiac and renal systems can not compensate for the excess vascular volume, congestive heart failure and pulmonary edema may result. The patient is assessed for signs of heart failure, including decreased cardiac output, oliguria, jugular vein distention, edema, and the onset of an S3 or S4 heart sound. Increasing central venous, pulmonary artery, and wedge pressures indicate increased fluid volume. Crackles in the lungs and increased difficulty with respiration may indicate a fluid buildup in the lungs, which is reported promptly to the physician. In the meantime, the patient is positioned comfortably, with the head of the bed raised (if not contraindicated because of other treatments or injuries) to promote lung expansion and gas exchange. Management of this complication includes providing supplemental oxygen, administering IV diuretic agents, carefully assessing the patient’s response, and providing vasoactive medications, if indicated.
Sepsis
The signs of early systemic sepsis are subtle and require a high index of suspicion and very close monitoring of changes in the patient’s status. Early signs of sepsis may include increased temperature, increased pulse rate, widened pulse pressure, and flushed dry skin in unburned areas. As with many observations of the burn patient, one needs to look for patterns or trends in the data. (See Chap. 15 for a more detailed discussion of septic shock.) Wound and blood cultures are performed as prescribed, and results are reported to the physician immediately. The nurse also observes for and reports early signs of sepsis and promptly intervenes, administering prescribed IV fluids and antibiotics to prevent septic shock, a complication with a high mortality rate. Antibiotics must be given as scheduled to maintain proper blood concentrations. Serum antibiotic levels are monitored for evidence of maximal effectiveness, and the patient is monitored for toxic side effects.
Acute Respiratory Failure and Acute Respiratory Distress Syndrome
The patient’s respiratory status is monitored closely for increased difficulty breathing, change in respiratory pattern, and onset of adventitious (abnormal) sounds. Typically at this stage, signs and symptoms of injury to the respiratory tract become apparent. Respiratory failure may follow. As described previously, signs of hypoxia (decreased O2 to the tissues), decreased breath sounds, wheezing, tachypnea, stridor, and sputum tinged with soot (or in some cases containing sloughed tracheal tissue) are among the many possible findings. Patients receiving mechanical ventilation must be assessed for a decrease in tidal volume and lung compliance. The key sign of the onset of ARDS is hypoxemia while receiving 100% oxygen, decreased lung compliance, and significant shunting. The physician should be notified immediately of deteriorating respiratory status. Medical management of the patient with acute respiratory failure requires intubation and mechanical ventilation (if not already in use). If ARDS has developed, higher oxygen levels, positive endexpiratory pressure, and pressure support are used with mechanical ventilation to promote gas exchange across the alveolar–capillary membrane.
Visceral Damage
The nurse must be alert to signs of necrosis of visceral organs due to electrical injury. Tissues affected are usually between the entrance and exit wounds of the electrical burn. All patients with electrical burns should undergo electrocardiographic monitoring, with dysrhythmias being reported to the physician. Careful attention must also be paid to signs or reports of pain related to deep muscle ischemia. To minimize the severity of complications, visceral ischemia must be detected as early as possible. The physician can perform fasciotomies to relieve the swelling and ischemia in the muscles and fascia and to promote oxygenation of the injured tissues. Because of the deep incisions involved with fasciotomies, the patient must be monitored carefully for signs of excessive blood loss and hypovolemia.
Evaluation
EXPECTED PATIENT OUTCOMES
Expected patient outcomes may include:
1. Achieves optimal fluid balance a. Maintains intake and output and body weight that correlate with expected pattern b. Exhibits vital signs and central venous, pulmonary artery, and pulmonary artery wedge pressures within designated limits c. Demonstrates increased urine output in response to diuretic and vasoactive medications d. Has heart rate less than 110 beats/min in normal sinus rhythm
2. Has no localized or systemic infection a. Has wound culture results showing minimal bacteria b. Has normal urine and sputum culture results
3. Demonstrates anabolic nutritional status a. Gains weight daily after initial loss secondary to fluid diuresis and no oral intake of food or fluid b. Shows no signs of protein, vitamin, or mineral deficiencies c. Meets required nutritional needs entirely by oral intake d. Participates in selecting diet containing prescribed nutrients e. Exhibits normal serum protein levels
4. Demonstrates improved skin integrity a. Sustains generally intact skin that remains free of infection, pressure, and injury b. Demonstrates remaining open wound areas that are pink, re-epithelializing, and free of infection c. Demonstrates donor graft sites that are clean and healing d. Has healed wounds that are soft and smooth e. Demonstrates skin that is lubricated and elastic
5. Has minimal pain a. Requests analgesic agents for specific wound care procedures or physical therapy activities b. Reports minimal pain c. Gives no physiologic, verbal, or nonverbal cues that pain is moderate or severe d. Uses pain control measures such as nitrous oxide, relaxation, imagery, and distraction techniques to cope with and alleviate pain and discomfort e. Can sleep without being disturbed by pain f. Reports skin is comfortable, with no itching or tightness
6. Demonstrates optimal physical mobility a. Improves range of motion of joints daily b. Demonstrates preinjury range of motion of all joints c. Has no signs of calcification around the joints d. Participates in activities of daily living
7. Uses appropriate coping strategies to deal with postburn problems a. Verbalizes reactions to burns, therapeutic procedures, losses b. Identifies coping strategies used effectively in previous stressful situations c. Accepts dependency on health care providers during acute phase d. Verbalizes realistic view of problems resulting from burn injury and plans for future e. Cooperates with health care providers in required therapy f. Participates in decision making regarding care g. Resolves grief over losses resulting from burn injury and circumstances surrounding injury (eg, death of others, damage to home or other property) h. States realistic objectives for plastic surgery, further medical intervention, and results i. Verbalizes realistic abilities and goals j. Displays hopeful attitude toward future
8. Relates appropriately in patient/family processes a. Patient and family verbalize feelings regarding change in family interactions b. Family emotionally supports the patient during the hospitalization c. Family states that own needs are met
9. Patient and family verbalize understanding of the treatment course a. States rationale for different aspects of treatment b. States realistic time period for recovery
10. Absence of complications a. Lungs clear on auscultation b. Exhibits no dyspnea or orthopnea and can breathe easily when standing, sitting, and lying down c. Exhibits no S3 or S4 heart sounds or jugular venous distention d. Exhibits urine output; central venous, pulmonary artery, and pulmonary artery wedge pressures; and cardiac output within normal or acceptable limits e. Exhibits normal blood, sputum, and urine culture results f. Maintains arterial blood gas values within normal or acceptable limits g. Has normal lung compliance h. Has no visceral organ damage i. Has stable cardiac rhythm
REHABILITATION PHASE OF BURN CARE
Although long-term aspects of burn care are discussed last in this chapter, rehabilitation begins immediately after the burn has occurred—as early as the emergent period—and often extends for years after injury. In the aftermath of the acute stages of injury, the burn patient increasingly focuses on the alterations in self-image and lifestyle that may occur. Wound healing, psychosocial support, and restoring maximal functional activity remain priorities. The focus on maintaining fluid and electrolyte balance and improving nutritional status continues. Reconstructive surgery to improve body appearance and function may be needed. Burn injuries can have a major impact on quality of life. Changes in physical activity and social, psychological, and employment status may occur. Therefore, psychological and vocational counseling and referral to support groups may be helpful to promote recovery and quality of life. Family members also need support and guidance in assisting the patient to return to optimal health.
Prevention of Hypertrophic Scarring
The wound is in a dynamic state for 1.5 to 2 years after the burn occurs. If appropriate measures are instituted during this active period, the scar tissue loses its redness and softens. Healed areas that are prone to hypertrophic scarring require the patient to wear a pressure garment (Fig. 57-6). These devices are especially useful for partial-thickness wounds that required more than 2 weeks to heal and for the edges of grafted skin. Applying elastic pressure garments loosens collagen bundles and encourages parallel orientation of the collagen to the skin surface, with the disappearance of the dermal nodules. As pressure continues over time, there is a restructuring of the collagen and a decrease in vascularity and cellularity (Serghiou, Young, Ott et al., 2002). The physical therapist, occupational therapist, or a representative of the manufacturer of elastic pressure garments measures the patient for correct fit. While awaiting the arrival of the garment, soft, tubular, knitted elastic pressure bandages can be used to help desensitize the patient’s skin, protect healing areas, apply pressure, and promote venous return. Patients must be instructed about the need for lubrication and protection of the healing skin and the need for pressure garments for at least a year after the injury. A program including elastic pressure garments, splints, and exercise under the supervision of an experienced physical and occupational therapy team is recommended for optimal functional and cosmetic results.
NURSING PROCESS: CARE OF THE PATIENT DURING THE REHABILITATION PHASE
Assessment
Information about the patient’s educational level, occupation, leisure activities, cultural background, religion, and family interactions is obtained early. The patient’s self-concept, mental status, emotional response to the injury and hospitalization, level of intellectual functioning, previous hospitalizations, response to pain and pain relief measures, and sleep pattern are also essential components of a comprehensive assessment. Information about the patient’s general self-concept, self-esteem, and coping strategies in the past will be valuable in addressing emotional needs. Ongoing physical assessments related to rehabilitation goals include range of motion of affected joints, functional abilities in activities of daily living, early signs of skin breakdown from splints or positioning devices, evidence of neuropathies (neurologic damage), activity tolerance, and quality or condition of healing skin. The patient’s participation in care and ability to demonstrate self-care in such areas as ambulation, eating, wound cleaning, and applying pressure wraps are documented on a regular basis. In addition to these assessment parameters, specific complications and treatments require additional specific assessments; for example, the patient undergoing primary excision requires postoperative assessment. Recovery from burn injury involves every system of the body. Therefore, assessment of the burn patient must be comprehensive and continuous. Priorities will vary at different points during the rehabilitation phase. Understanding the pathophysiologic responses to burn injury forms the framework for detecting early progress or signs and symptoms of complications. Early detection leads to early intervention and enhances the potential for successful rehabilitation.
Diagnosis
NURSING DIAGNOSES
Based on the assessment data, priority nursing diagnoses in the longterm rehabilitation phase of burn care may include the following:
• Activity intolerance related to pain on exercise, limited joint mobility, muscle wasting, and limited endurance
• Disturbed body image related to altered physical appearance and self-concept
• Deficient knowledge about postdischarge home care and follow-up needs
COLLABORATIVE PROBLEMS/ POTENTIAL COMPLICATIONS
Based on the assessment data, potential complications that may develop in the rehabilitation phase include: • Contractures •Inadequate psychological adaptation to burn injury
Planning and Goals
The major goals for the patient include increased participation in activities of daily living; increased understanding of the injury, treatment, and planned follow-up care; adaptation and adjustment to alterations in body image, self-concept, and lifestyle; and absence of complications.
Nursing Interventions
PROMOTING ACTIVITY TOLERANCE
Nursing interventions that must be carried out according to a strict regimen and the pain that accompanies movement take their toll on a burn patient. The patient may become confused and disoriented and lack the energy to participate optimally in care. The nurse must schedule care in such a way that the patient has periods of uninterrupted sleep. A good time for planned patient rest is after the stress of dressing changes and exercise, while pain interventions and sedatives may still be effective. This plan must be communicated to family members and other care providers. Burn patients may have insomnia related to frequent nightmares about the burn injury or to other fears and anxieties about the outcome of the injury. The nurse listens to and reassures the patient and administers hypnotic agents, as prescribed, to promote sleep. Reducing metabolic stress by relieving pain, preventing chilling or fever, and promoting the physical integrity of all body systems will help the patient conserve energy for therapeutic activities and wound healing. The nurse incorporates physical therapy exercises in the patient’s care to prevent muscle atrophy and to maintain the mobility required for daily activities. The patient’s activity tolerance, strength, and endurance will gradually increase if activity occurs over increasingly longer periods. Fatigue, fever, and pain tolerance are monitored and used to determine the amount of activity to be encouraged on a daily basis. Activities such as family visits and recreational or play therapy (eg, video games, radio, TV) can provide diversion, improve the patient’s outlook, and increase tolerance for physical activity.
IMPROVING BODY IMAGE AND SELF-CONCEPT
Burn patients frequently suffer profound losses. These include not only a loss of body image due to disfigurement but also losses of personal property, homes, loved ones, and ability to work. They lack the benefit of anticipatory grief often seen in a patient approaching surgery or a person dealing with the terminal illness of a loved one. As care progresses, the patient who is recovering from burns becomes aware of daily improvement and begins to exhibit basic concerns: Will I be disfigured? How long will I be in the hospital? What about my job and family? Will I ever be independent again? How can I pay for my care? Was my burn the result of my carelessness? As the patient expresses such concerns, the nurse must take time to listen and to provide realistic support. The nurse can refer patients to a support group, such as those usually available at regional burn centers or through organizations such as the Phoenix Society. Through participation in such groups, patients will meet others with similar experiences and learn coping strategies to help them deal with their losses. Interaction with other burn survivors allows the patient to see that adaptation to the burn injury is possible. If a support group is not available, visits from burn survivors can be helpful to the patient coping with such a traumatic injury. A major responsibility of the nurse is to assess constantly the patient’s psychosocial reactions. What are the patient’s fears and concerns? Does the patient fear loss of control of care, independence, or sanity itself? Is the patient afraid of rejection by family and loved ones? Does he or she fear being unable to cope with pain or physical appearance? Does the patient have concerns about sexuality, including sexual function? Being aware of these anxieties and understanding the basis of the patient’s fears enable the nurse to provide support and to cooperate with other members of the health care team in developing a plan to help the patient deal with these feelings. When caring for burn patients, the nurse needs to be aware that there are prejudices and misunderstandings in society about those who are viewed as different. Opportunities and accommodations available to others are often denied those who are disfigured. Such amenities include social participation, employment, prestige, various roles, and status. The health care team must actively promote a healthy body image and self-concept in burn survivors so that they can accept or challenge others’ perceptions of those who are disfigured. Survivors themselves must show others who they are, how they function, and how they want to be treated. The nurse can help patients practice their responses to people who may stare or inquire about their injury once they are discharged from the hospital. The nurse can help patients build self-esteem by recognizing their uniqueness—for example, with small gestures such as providing a birthday cake, combing the patient’s hair before visiting hours, giving information about the availability of a cosmetician to enhance appearance, and teaching the patient ways to direct attention away from a disfigured body to the self within. Consultants such as psychologists, social workers, vocational counselors, and teachers are valuable participants in assisting burn patients to regain their self-esteem.
MONITORING AND MANAGING POTENTIAL COMPLICATIONS
Contractures
With early and aggressive physical and occupational therapy, contractures are rarely a long-term complication. However, surgical intervention is indicated if a full range of motion in the burn patient is not achieved.
Impaired Psychological Adaptation to the Burn Injury
Some patients, particularly those with limited coping skills or psychological function or a history of psychiatric problems before the burn injury, may not achieve adequate psychological adaptation to the burn injury. Psychological counseling or psychiatric referral may be made to assess the patient’s emotional status, to help the patient develop coping skills, and to intervene if major psychological issues or ineffective coping is identified.
PROMOTING HOME AND COMMUNITY-BASED CARE
Teaching Patients Self-Care
As the inpatient phase of recovery becomes shorter, the focus of rehabilitative interventions is directed toward outpatient care or care in a rehabilitation center. In the long term, much of the care of healing burns will be performed by the patient and others at home. Throughout the phases of burn care, efforts are made to prepare the patient and family for the care that will continue at home. Thus, they are instructed about the measures and procedures that they will need to perform. For example, patients commonly have small areas of clean, open wounds that are healing slowly. They are instructed to wash these areas daily with mild soap and water and to apply the prescribed topical agent or dressing. In addition to instructions about wound care, patients and families require careful written and verbal instructions about prevention of complications, pain management, and nutrition. Information about specific exercises and use of pressure garments and splints is reviewed with both the patient and family; written instructions are provided for reference. They are taught to recognize abnormal signs and instructed to report them to the physician. All of this information will enable patients to progress successfully through the rehabilitative phase of burn management. The patient and family are assisted in planning for the patient’s continued care by identifying and acquiring supplies and equipment that are needed at home.
Continuing Care
Follow-up care by an interdisciplinary burn care team will be necessary. Preparations should begin during the early stages of care. Patients who receive care in a burn center usually return to the burn clinic or center periodically for evaluation by the burn team, modification of home care instructions, and planning for reconstructive surgery. Other patients receive ongoing care from the general or plastic surgeon who cared for them during the acute phase of their management. Still other patients require the services of a rehabilitation center and may be transferred to such a center for aggressive rehabilitation before going home. Many patients require outpatient physical or occupational therapy, often several times weekly. It is often the nurse who is responsible for coordinating all aspects of care and ensuring that the patient’s needs are met. Such coordination is an important aspect in assisting a burn victim to achieve independence. Patients who return home after a severe burn injury, those who cannot manage their own burn care, and those with inadequate support systems will need referral for home care. During visits to the patient at home, the home care nurse assesses the patient’s physical and psychological status as well as the adequacy of the home setting for safe and adequate care. The nurse monitors the patient’s progress and adherence to the plan of care and notes any problems that interfere with the patient’s ability to carry out the care. During the visit, the nurse assists the patient and family with wound care and exercises. Patients with severe or persistent depression or difficulty adjusting to changes in their social and/or occupational roles are identified and referred to the burn team for possible referral to a psychologist, psychiatrist, or vocational counselor. The burn team or home care nurse identifies community resources that may be helpful for the patient and family. Several burn patient support groups and other organizations throughout the United States offer services for burn victims. They provide caring people (often recovered burn victims) who can visit a burn patient in the hospital or home or telephone the patient and family periodically to provide support and counseling about skin care, cosmetics, and problems related to psychosocial adjustment. Such organizations, and many regional burn centers, sponsor group meetings and social functions at which outpatients are welcome. Some also provide school-reentry programs and are active in burn prevention activities. If more information is needed regarding burn prevention, the American Burn Association can help locate the nearest burn center and offer current burn prevention tips. Because so much attention is given to the burn wound and the treatments that are necessary to treat the burn wound and to prevent complications, the patient, family, and health care providers may inadvertently ignore the patient’s ongoing needs for health promotion and screening. Thus, the patient and family are reminded of the importance of periodic health screening and preventive care (eg, gynecologic examinations, dental care).
Evaluation
EXPECTED PATIENT OUTCOMES
Expected patient outcomes may include:
1. Demonstrates activity tolerance required for desired daily activities a. Obtains sufficient sleep daily b. Reports absence of nightmares or sleep disturbances c. Shows gradually increasing tolerance and endurance in physical activities d. Can concentrate during conversations e. Has energy available to sustain desired daily activities
2. Adapts to altered body image a. Verbalizes accurate description of alterations in body image and accepts physical appearance b. Demonstrates interest in resources that may improve body appearance and function c. Uses cosmetics, wigs, and prostheses as desired to achieve acceptable appearance d. Socializes with significant others, peers, and usual social group e. Seeks and achieves return to role in family, school, and community as a contributing member
3. Demonstrates knowledge of required self-care and followup care a. Describes surgical procedures and treatments accurately b. Verbalizes detailed plan for follow-up care c. Demonstrates ability to perform wound care and prescribed exercises d. Returns for follow-up appointments as scheduled e. Identifies resource people and agencies to contact for specific problems
4. Exhibits no complications a. Demonstrates full range of motion b. Shows no signs of withdrawal or depression c. Displays no psychotic behaviors
Burn Care in the Home
More and more burns are being treated exclusively in outpatient settings, including wound clinics, physicians’ offices, and emergency department clinics. The outpatient setting is appropriate for the care of minor burns and most moderate burns. However, a number of factors must be considered in determining the appropriate site of care. These factors include the age of the patient, the extent and depth of the burn, the availability of family support systems and community resources to assist the patient, the patient’s adherence to the prescribed plan of care, and the distance from home to the outpatient setting. Initially, looking at and touching the burn wound may be difficult and even frightening to some family members and patients. However, with encouragement and support, most can handle burn wound care with little need for daily professional care. Instructions, both verbal and written, are given to the patient about burn wound care, pain management strategies, the need for adequate nutrition, and the importance of exercise and rest. Instruction is also given about signs and symptoms of infection that should be reported to the physician. The importance of notifying the physician about complications early and of keeping follow-up appointments is emphasized to the patient and family.
Gerontologic Considerations
Nursing assessment of the elderly burn patient should include particular attention to pulmonary function, response to fluid resuscitation, and signs of mental confusion or disorientation. A careful history of preburn medications and preexisting illnesses is essential. Nursing care promotes early mobilization, aggressive pulmonary care, and attention to preventing complications. Because of lowered resistance, burn wound sepsis and lethal systemic septicemia are more likely in elderly patients. Moreover, fever may not be present in the elderly to signal such events. Therefore, surveillance for other signs of infection becomes even more important. Rehabilitation must take into account preexisting functional abilities and limitations, such as arthritis and low activity tolerance. Elderly patients commonly lack family members who can provide home care, so social services and community nursing services must be contacted to provide optimal care and supervision after hospital discharge.