Evaluation of Burnt Patient PDF

Evaluation of burnt patient Definition : − It's an observational study of a subject carrying out a specific task. − It's a continuing process of collecting and organization relevant information in order to plan and implement an effective treatment. Goals of evaluation: 1. To determine th...

Evaluation of burnt patient Definition : − It's an observational study of a subject carrying out a specific task. − It's a continuing process of collecting and organization relevant information in order to plan and implement an effective treatment. Goals of evaluation: 1. To determine the patient's present status. 2. To plan a treatment program. 3. To identify the rehabilitation goals. 4. To anticipate the patient's potential problems by assessing all necessary information available. 5. To provide diagnostic information. 6. To determine the status of the patient at the time of discharge and the type of follow up plan. Types of evaluation : Informal Standardized Formal (General over view of (Grading performance e.g. (Functional tests) the pt.) e.g. Ms. test) Initial evaluation Progress evaluation Discharge evaluation (re-evaluation) 1  Sources of information to Evaluate the Burn patient 1. Medical chart. 2. Physician. 3. Nurse. 4. Pt's family. 5. Patient. 6. Other member of burn team. Components of evaluation : 1. Patient demographic data and history. 2. Burn severity index. 3. Edema and limb circumference 4. Sensory assessment. 5. Muscle strength assessment. 6. Joint ROM assessment. 7. Flexibility assessment. 8. Mobility and ambulation assessment 9. Endurance assessment. 10.Function activities assessment. 11.Neurological and psychological factors. 1- Patient demographic data and history : Personal Past history Present history Special history history 2 Personal history : Name, Age, Sex, Occupation, Wight, height, address, serial number, medical record number, room number, name of referring physician. Past history : Any previous disease , trauma, surgery and burn Vision and hearing acuity. Balance and co-ordination. Neuromuscular or skeletal deficits Present history :  Date of burn.  Date of evaluation.  Date of admission.  Date of initial P.T.  Date of operation.  Type of skin graft: ( Donor site or Recipient site) Special history: − Percentage, extent & depth of burn. − Associated injury e.g. -----------------------------,--------------------------------,------------------- − Position of patient. 2- Burn severity index: It is the variables that are associated with increased burned patient mortality rate. These variables are:- 1) age 2) gender (sex) 3) Burn wound assessment 4) Extent of burn 5) Depth of burn 6) Location of burn 7) Respiratory status ( inhalation injury) 3  both extrem ages are associated with high mortality rate.) Children develoelop more scar contracture (why?) young children have incomplete 2- gender (sex) thermoregulatory system. old pepole have decrease the ability to recover from burn relation between burn occurs in males depth, extent & due to reduction of fluids more than females and decrease level of blood location of oxygenation with burn. but the risk of death in wound. and the presence of females is moredue to comorditity with qld pepole psychological status. 3- Burn wound may be another cause. assessment 1- age 4- Extent of burn (TBSA / BBSA) The percentage of total body burn is an important information for:- Either major 1) Calculate the patient resuscitation There is a direct or minor burn relation between the {(2 or 4) ml x kg bodyweight x % BBSA & the number BBSA} + 2000 ml saline of contractures of which 50% to be administered in the developed initial 8 hours In the 1980s, a burn that 2) Obtaining survival statistic involved 60% to 70% (TBSA) was often fatal but now patients are 3) Estimating treatment program time routinely surviving 80% to 90% TBSA burn injuries. 4 There are many methods to calculate the TBSA:- a) rule of nine b) lund & browder chart c) entire palmer surface - When calculating burn area, erythema should not be included. This may take a few hours to fade, so some overestimation is inevitable if the burn is estimated acutely. - It is important that all of the burn is exposed and assessed. - During assessment, the environment should be kept warm, and small segments of skin exposed sequentially to reduce heat loss. Pigmented skin can be difficult to assess, and in such cases it may be necessary to remove all the loose epidermal layers to calculate burn size. a. Rule of nine - it used for adults only - it is used in emergency triage - it divides the body to (11) segments each one = 9% what is the triage? The answer:- ------------------------------------------------------------------ ------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------ 5 b. Lund & browder chart - This chart, if used correctly, is the most accurate method. - It compensates for the variation in body shape with age and therefore can give an accurate assessment of burns area in children. c. Entire palmer surface -This method used the patient's hand-size to estimate the percent TBSA of small burns. -The entire palmer surface of the patient own hand = 1 % N.B: In very large burns, it is often easier to measure the area of skin that is un-burnt and then subtract this from 100%. 6 5) Depth of burn The depth of burn is related to the amount of energy delivered in the injury and to the relative thickness of the skin (the dermis is thinner in very young and very old people). Increase the burn wound depth leads to increase the severity & mortality rate due to :- - Decrease the probability of spontaneous healing. - Increase scar tissue contractures formation. - Increase the loss in ROM. Assessment of burn depth Assessing burn depth can be difficult. The patient's history will give clues to the expected depth: a flash burn is likely to be superficial, whereas a burn from a flame that was not rapidly extinguished will probably be deep. On direct examination, there are four elements that should be assessed bleeding on needle prick, sensation, appearance, and blanching to pressure. 7 ❖ Bleeding—Test bleeding with a 21 gauge needle. Brisk bleeding on superficial pricking indicates the burn is superficial or superficial dermal. Delayed bleeding on a deeper prick suggests a deep dermal burn, while no bleeding suggests a full thickness burn. ❖ Sensation—Test sensation with a needle also. Pain equates with a superficial or superficial dermal burn, non-painful sensation equates with deep dermal injury, while full thickness injuries are insensate. However, this test is often inaccurate as edema also blunts sensation. ❖ Appearance and blanching—Assessing burn depth by appearance is often difficult as burns may be covered with soot or dirt. Blisters should be de-roofed to assess the base. Capillary refill should be assessed by pressing with a sterile cotton bud (such as a bacteriology swab):- A red, moist wound that obviously blanches and then rapidly refills is superficial A pale, dry but blanching wound that regains its color slowly is superficial dermal Deep dermal injuries have a mottled cherry red color that does not blanch (fixed capillary staining). The blood is fixed within damaged capillaries in the deep dermal plexus A dry, leathery or waxy, hard wound that does not blanch is full thickness. With extensive burns, full thickness burns can often be mistaken for un-burnt skin in appearance. Most burns are a mixture of different depths. Assessment of depth is important for planning treatment, as more superficial burns tend to heal spontaneously whereas deeper burns need surgical intervention, but is not necessary for calculating resuscitation formulas. Therefore, in acute situations lengthy depth assessment is inappropriate. A burn is a dynamic wound, and its depth will change depending on the effectiveness of resuscitation. Initial estimates need to be reviewed later. 6) location of burnt wound The anatomical locations is important key to anticipate contracture development. 8  Burn at skin creases or near to the joint surface is more susceptible to develop scar contractures, decrease ROM & increase functional loss. Common anatomical sites of burn scar contractures:- Eye lids Mouth commcommissur Ant. & post. es Axillary folds Ant. neck Anti-cubital space Lateral trunk forearm Wrist flexion crease perineum s palmer & Dorsal surfaces of hands & fingers Popliteal space Dorsal & planter Tendon achilles surfaces of the feet Factors contributing to scar contracture formation 1. Length of hospitalization. 2. IC length stay. 3. Number of skin graft operations. 4. Number of joint surface areas requiring skin grafting. 5. Amount of septic. 9 7) Respiratory state:- − Inhalation injury have a direct relationship with mortality rate. − Inhalation injury affects the patient endurance capacity. − It can be suspected in the following cases:- 1) Victim injured in closed space. 2) Flame burn in face & anterior trunk. 3) Coughing with profuse expectoration. 4) Horsens of voice. 3- Edema and limb circumference Edema assessment 1- by observation by comparsion to the sound limb 2- by palpation to determin the type of edema (pitting or non-pitting) 3- by measuerment Water displacement method, Round measurement ,Ring method 10 a- Water displacement method (volumetric method). − Water displacement is used to measure limb volume and is based on Archimedes' Principle, which states that the water volume displaced is equal to the volume of the object immersed in the water. − it's used mainly for hands &feet's & sterilized water must be used. − But it is difficult to be used in acute stage as it requires putting the affected limb in dependant position which may be painful because of vascular compression − Steps of measurement:- fill the pool to the refarreal point ask the patient to put the healthy limb in the pool (careful positiong of the extermity is essential with using bony land mark as a referance.) 1 record the measurement. aske the pt. to out his/her extermity from the pool then refill the pool to the same refarreal point then aske the pt. to put the affected limb 2 recored the measurement now substract the both measurement write the number in ml. 3 11 b- Round measurement. Girth measurements are one alternative to water displacement volumetric. Girth measurements are simple, efficient and clinically useful. By taking measurements at fixed points on an edematous limb (e.g., every 5 cm), it is easy to see where the changes in girth are occurring with intervention. Do the measurement by using sterilized tap to record changes in the limb circumference and compare it with the other side. There are many ways of used assessment but the most common assessment are 7 point measurement 5 point measurement The measurement is taken at (7) The measurement is taken at (5) points points One at a fixed land mark & three One at a fixed land mark & two points above it & three points points above it & two points below it below it (on a fixed intervals). (on a fixed intervals) The measurement done every (5 The measurement done every (7.5 cm) on the edematous limb cm) on the edematous limb Or every (2.5 cm) for the edematous hand or feet. Steps of measurement:- 1) Put pt. in appropriate position 2) Determine a fixed land mark for the upper limb it can be the medial or lateral epicondyles of the humerus or olecrannon. for the hand ulnar or radial styloid process or one of the hand flexion creases. for the L.L the landmark can be medial or lateral epicondyles of the femur, Lateral or Medial malleolus. 12  3) Apply rounded measurement by the tap on the landmark point & record the number 4) From the land mark up & down to take measurements at fixed intervals on an edematous limb and record the number for each level 5) Do the same for the other limb 6) Compare between the obtained measurements. c- Ring method :It is an objective method but it used for the neck only. 4- Sensory assessment − Sensory assessment is done by pinprick to test the cutaneous sensation, − Sensory assessment is done also to all areas near to the burn ( even if not affected) specially in deep burns to detect any suspected nerve lesion. − it is used mainly to determine the depth of the burn injury  In 2nd degree burn ( painful ) use pinprick to determine the amount of pain.  b. In 3rd degree burn( painless) use pinprick to determine the depth of burn. − In electrical burn, massive edema or associated injury, the sensory assessment should include assessment to superficial and deep sensation + reflexes. 5- Joint ROM assessment: − It is important for determination of progression or regression of the patient activity. 13 − It is done by using either electronic or standard goniometer. − Causes of limitation are pain , edema, inelastic eschar and disuse of the affected part. 6- Muscle strength assessment − Ms. Test is usually done through Functional or group muscle test (especially if the burn patient functioned at a normal level before the injury ) − individual muscle test is done only in case of sever edema and electric burn or if particular injury is Suspected − Pain , edema and anxiety cause a non physiological decrease in muscle strength. − TENSIOMETER can be used to detect the Ms. Strength. 7- Endurance assessment − Cardiovascular endurance is limited due to systemic & catabolic effect of burn injury ( as there is increase to ATP lyses during wound healing to allow building of collagen & to compensate heat loss) − Apoptosis cause lyses to Ms. Protein so decrease heart endurance. − Aerobic capacity of Pt. is affected by bed rest, immobilization & pain. − Ask Pt. to ambulate as early as possible. 8-Mobility and ambulation assessment − It is the degree to which the patient is able to move about freely in bed or during transfer. 14  − Changing the position in bed is important to decrease tissue damage (bed sores). − Location of burn may inhibit ambulation. − Deviation in gait are related to pain, burn in planter aspect, affection of tendon Achilles or popliteal space. − Permission to patient to walk after burn injury is a medical decision. 9- Posture assessment − Burn affect both relaxed position & upright position especially in early hospitalization. − Patient tend to take fetal position or abnormal position according to the location of burnt area. − Factors that affect position of the patient : 1. Site of burn 2. Pain 3. Scar formation 10- Functional activities assessment − Assess patient's ability to perform ADL (eating, dressing, bathing, bed mobility, toilet activity & school or work activity) Give the patient score according to the following:- 3 Dependent 2 Requires assistance 1 Has difficulty but does by self 0 Normal − Hand dominance should be recorded. − Encourage the patient to use the affected hand. − Assistive device may be required to complete patient's activity. 15