Pneumonia PDF

Pneumonia Pneumonia: is an inflammation of the lung parenchyma caused by various microorganisms, including bacteria, mycobacteria,fungi,and viruses Pneumonitis:is a more general term that describes an inflammatory process in Exc...

Pneumonia Pneumonia: is an inflammation of the lung parenchyma caused by various microorganisms, including bacteria, mycobacteria,fungi,and viruses Pneumonitis:is a more general term that describes an inflammatory process in Exce5s mucu$ the lung tissue that may predispose orInflamed bronchiole in alveoi (air place the patient at risk for microbial invasion. Classifications and of Pneumonia according to the American Thoracic Society.: A. Health care-associated pneumonia (HCAP) -Pneumonia is an infection obtained during a visit to an outpatient clinic,nursing home,or long-term care facility.occurring in a nonhospitalized patient with extensive health care contact with one or more of the following: ·Hospitalization for ≥2 days in an acute care facility within 90 days of infection ·Residence in a nursing home or long-term care facility ·Antibiotic therapy,chemotherapy,or wound care within 30 days of current infection ·Hemodialysis treatment at a hospital or clinic ·Home infusion therapy or home wound care 177 ·Family member with infection due to multidrug- resistant bacteria 177.HCAP was conceived as a specific category in order to identify patients at increased risk for multidrug- resistant organisms (MDRO) - Initial antibiotic treatment of HCAP is often different from that for CAP due to the possibility of MDROs B. Community-acquired pneumonia(CAP): a common infectious disease,occurs either in the community setting(outside of the healtheare system,including hospitals,nursing homes,outpatient clinics,or any other healthcare facility).or occurs within the first 48 hours after hospitalization of patients who do not meet the criteria for health care-associated pneumonia (HCAP). -Causative organisms of CAP include Streptococcus pneumoniae, Gram-negative bacilli,Haemophilus influenzae,and Legionella. C. Hospital-acquired pneumonia (HAP): -Develops 48 hours or more after hospitalization and does not appear to be incubating at the time of admission. -It is associated with a high mortality rate because of the virulence of the organisms,the resistance to antibiotics,and the patient's underlying disorder. -It is the most common cause of death among all patients with hospital-acquired infection. -The common organisms responsible for HAP include 178  the Enterobacter species,Escherichia coli,Haemophilu influenzae, Klebsiella pneumoniae,Pseudomonas aeruginosa.Most patients with HAP are colonized by multiple organisms. -Pseudomonal pneumonia occurs in patients who are debilitated, those with altered mental status,and those with prolonged intubation or with tracheostomy.Staphylococcal pneumonia can 178  occur through inhalation of the organism or spread through the hematogenous route. Predispose factors to HAP: ·impaired host defenses (e.g.,severe acute or chronic illness) ·a variety of comorbid conditions(supine positioning and aspiration,Coma,Malnutrition,prolonged hospitalization, hypotension,metabolic disorders. ·Hospitalized patients are also exposed to potential bacteria from other sources(e.g.Respiratory therapy devices and equipment, transmission of pathogens by the hands of health care personnel). ·Numerous intervention-related factors also may play a role in the development of HAP(e.g.,therapeutic agents leading to central nervous system depression with decreased ventilation, impaired removal of secretions,or potential aspiration; prolonged or complicated thoracoabdominal procedures,which may impair mucociliary function and cellular host defenses,ET intubation [VAP];prolonged or inappropriate use of antibiotics; the use of nasogastric tubes).In addition,patients with compromised immune systems are at particular risk. D.Ventilator-associated pneumonia (VAP): ·VAP can be considered a subtype of HAP,as the only differentiating factor is the presence of an ET tube. -It occurs within 96 hours of the onset of mechanical ventilation, usually due to antibiotic-sensitive bacteria that colonize the 179  patient prior to hospital admission. -Prevention of VAP by the five key elements of the VAP bundle interventions: 179  ·Elevation of the head of the bed (30°to 45°) ·Daily “sedation vacations”and assessment of readiness to extubate ·Peptic ulcer disease prophylaxis ·Deep venous thrombosis (DVT)prophylaxis ·Daily oral care with chlorhexidine (0.12%oral rinses) Pneumonia in the Immunocompromised Host (PCP) -Common causative organisms include Pneumocystis pneumonia (PCP),fungal pneumonias,and Mycobacterium tuberculosis. It occurs with the use of corticosteroids or other immunosuppressive agents,chemotherapy,nutritional depletion,the use of broad-spectrum antimicrobial agents,acquired immune deficiency syndrome (AIDS), genetic immune disorders,and long-term mechanical ventilation. -The clinical manifestation in PCP has a subtle onset,with progressive dyspnea,fever,and a nonproductive cough. Aspiration Pneumonia It results from the entry of endogenous or exogenous substances into the lower airway -The most common form of aspiration pneumonia is bacterial infection from aspiration of bacteria that normally reside in the upper airways. -It may occur in the community or hospital setting. -Common pathogens are anaerobes,S,aureus,Streptococcus 180 species, and gram-negative bacilli -Causes of aspiration pneumonia: ·Bacteria may be aspirated into the lung. Gastric contents ·Exogenous chemical contents. 180  ·lrritating gases.This type of aspiration or ingestion may impair the lung defenses,cause inflammatory changes,lead to bacterial growth and a resulting in development of pneumonia. Pathophysiology ·Normally,the upper airway prevents potentially infectious particles from reaching the sterile lower respiratory tract.Patients with pneumonia caused by infectious agents often have an acute or chronic underlying disease that impairs host defenses. · Pneumonia affects both ventilation and diffusion.An inflammatory reaction can occur in the alveoli,producing an exudate that interferes with the difusion of oxygen and carbon dioxide.White blood cells, mostly neutrophils,also migrate into the alvcoli and fill the normally air-filled spaces.Areas of the lung are not adequately ventilated because of secretions and mucosal edema that cause partial occlusion of the bronchi or alveoli,with a resultant decrease in alveolar oxygen tension. ·Bronchospasm may also occur in patients with reactive airway disease.Because of hypoventilation,a ventilation- perfusion (V./Q.) mismatch occurs in the affected area of the lung. ·Venous blood entering the pulmonary circulation passes through the under ventilated area and travels to the left side of the heart poorly oxygenated.The mixing of oxygenated and unoxygenated or poorly 181 oxygenated blood eventually results in arterial hypoxemia. 181  N.B: If a substantial portion of one or more lobes is involved,the disease is referred to as lobar pneumonia.The term bronchopneumonia is used to describe pneumonia that is distributed in a patchy fashion,having originated in one or more localized areas within the bronchi and extending to the adjacent surrounding Bronchopneumonia Lobar pn lung parenchyma. Bronchopneumonia is more common than lobar pneumonia. Table 1:Risk Factors and Preventive Measures for Pneumonia Risk Factor Preventive Measure 1.Conditions that produce mucus or -Promote coughing and expectoration of bronchial obstruction and interfere with secretions normal lung drainage (e.g.,cancer; -Encourage smoking cessation cigarette smoking,chronic obstructive pulmonary disease) 2.Patients who are immunosuppressed or -Initiate special precautions against neutropenic (low neutrophil count) infection 3.Smoking -Encourage smoking cessation 4.Prolonged immobility and shallow -Reposition breathing pattern -Promote lung expansion exercises and coughing -Initiate suctioning and chest physical therapy if indicated 182 5.Nothing-by-mouth (NPO)status; ·Promote frequent oral hygiene. placement of nasogastric,orogastric,or -Minimize risk for aspiration by checking 182  endotracheal tube placement of tube and proper positioning of patient Table 1:continued 6.Depressed cough reflex,Aspiration of ·Reposition frequently to prevent foreign material as in unconscious aspiration patients,Abnormal swallowing -administer medications particularly those mechanism that increase risk for aspiration. -Perform suctioning and chest physical therapy if indicated 7.Supine positioning in patients unable to -Elevate head of bed at least 30 degrees protect their airway 8.Antibiotic therapy -Monitor patients receiving antibiotic therapy for signs and symptoms of pneumonia 9.Alcohol intoxication -Encourage avoid or reduced alcohol intake 10.Transmission of organisms from health -Use strict hand hygiene and gloves care providers -Implement health care provider education 11.General anesthetic,sedative,or opioid -Observe the respiratory rate and depth preparations that promote respiratory during recovery from general anesthesia depression, and before giving medications. -Ifrespiratory depression is apparent, withhold the medication and contact the primary provider 183 Clinical Manifestations of pneumonia: ·A sudden onset of chills,rapidly rising fever (38.5°to 40.5°℃. ·Pleuritic chest pain that is aggravated by deep breathing and coughing. ·Tachypnea(25 to 45 breaths/min).Other signs of respiratory distress (eg.shortness of breath and the use of accessory muscles in respiration) ·The predominant symptoms may be headache,low-grade fever, myalgia,rash,and pharyngitis,nasal congestion,sore throat. ·After a few days,mucopurulent sputum is expectorated. ·In severe pneumonia,the cheeks are flushed,and the lips and nail beds demonstrate central cyanosis. Orthopnea ·poor appetite. ·The patient is diaphoretic and tires easily. ·Sputum is often purulent;and may blood-tinged sputum may be expectorated. Assessment and Diagnostic Findings:The diagnosis of pneumonia performed through:.History -Physical examination. ·Chest x-ray. -Blood culture (bloodstream invasion [bacteremia]occurs 184  frequently). - Sputum examination ·Bronchoscopy is often used in patients with acute severe infections,immune compromised and mechanically ventilated. ·Arterial Blood Gases (ABG). 184 Prevention of pneumonia: -Pneumococcal vaccination,there are two types of pneumococcal vaccine recommended for adults: 1.A pneumococcal conjugate vaccine(PCV13)which protects against 13 types of pneumococcal bacteria.It is recommended for conditions that weaken the immune system,such as:HIV infection, organ transplantation,leukemia,lymphoma,chronic kidney disease,or with cerebrospinal fluid leak or with cochlear implants. 2.A pneumococcal polysaccharide vaccine (PPSV23).It is a newer vaccine that protects against 23 types of pneumococcal bacteria.It is recommended for those who smoke cigarettes,alcoholism,have chronic heart,lung,or liver disease. 3.Other preventive measures see table 1 Medical Management of pneumonia (Pharmacologic Therapy): 1.Prescribing appropriate antibiotics for bacterial pneumonias. Guidelines are used to guide antibiotic choice: -The resistance patterns. -prevalence of causative organisms. -Patient risk factors. -Treatment setting (inpatient vs.outpatient) -Costs and availability of newer antibiotic agents must all be considered. 185  -Antibiotics may be monotherapy or combination therapy. Patients with known multidrug Patients with known multidrug resistance resistance Monotherapy with ceftriaxone, A three-drug combination therapy may be ampicillin/sulbactam,levofloxacin, used;an antipseudomonal cephalosporin or or ertapenem is used. ceftazidime or antipseudomonal carbapenem Or piperacillin/tazobactamplus, aminoglycoside plus,linezolid or vancomycin -The patient's status must be assessed 72 hours after the initiation of therapy,and antibiotics should be discontinued or modified based on the culture results. 2.Assisting the patient to get adequate rest and hydration. 3.Managing complications if they occur. 4.In some patients,supplemental oxygenation may be prescribed. treatment is usually initiated with a broad-spectrum IV Complications of pneumonia: a.Hypotension b.Sepsis and septic shock c.Respiratory Failure d.Pleural Effusion e.Atelectasis f.Delirium Nursing process Nursing Assessment *Nursing assessment include assess of the sign and symptoms of pneumonia fever,chills,or night sweats in a 186 patient who also has 186  respiratory symptoms should alert the nurse to the possibility of bacterial pneumonia ·Respiratory assessment identifies the clinical manifestations of pneumonia:pleunitic-type pain,fatigue,tachypnea,the use of accessory muscles for breathing,bradycardia.coughing,and purulent sputum. ·The nurse monitors the patient for the following:changes in temperature and pulse;amount,odor,and color of secretions; frequency and severity of cough;degree of tachypnea or shortness of breath;changes in physical assessment findings and changes in the chest x-ray findings. Diagnosis Nursing Diagnosis: o Impaired/ineffective airway clearance related to presence of tracheobronchial secretions o Fatigue and activity intolerance related to impaired/decreased respiratory function. o Risk for hypovolemia related to fever and a rapid respiratory rate o Impaired nutritional status. o Lack of knowledge about the treatment regimen and preventive measures. Planning and Goals 187 - Improved airway patency. -Increased activity. Maintenance of proper fluid volume. -Maintenance of adequate nutition. 187  - An understanding of the treatment protocol and preventive measures. -Absence of complications Nursing Interventions 1.Improving airway patency: ·The nurse encourages hydration (2 to 3 L/day)to loosen pulmonary secretions. ·Humidification through a high-humidity facemask to deliver warm,humidified air to the tracheobronchial tree,helps liquefy secretions,and relieves tracheobronchial irritation. ·The nurse encourages the patient to perform an effective,directed cough,which includes correct positioning,a deep inspiratory maneuver. *Postural drainage and chest physiotherapy(CPT)are important in loosening and mobilizing secretions.The nurse frequently positions the patient properly to drain the involved lung segments then chest physiotherapy must perform(the chest is percussed and vibrated). The nurse monitors the patient for cough and sputum production after the completion of CPT.Also,after each position change,the nurse encourages the patient to breathe deeply and cough.If the patient is too weak to cough effectively,the nurse may need to remove the mucus by nasotracheal suctioning. 188  The nurse also administers oxygen therapy 2.Promoting rest and conserving energy: -The nurse encourages the patient to assume a comfortable position to promote rest and breathing (eg,semi fowler position)also 188  should change positions frequently to enhance secretion clearance and pulmonary ventilation and perfusion. -Patients must be instructed to avoid overexertion and to engage in only moderate activity during the initial phases of treatment 3.Promoting fluid intake -The respiratory rate of patients with pneumonia increases because of the increased workload imposed by labored breathing and fever.An increased respiratory rate leads to an increase in insensible fluid loss during exhalation and can lead to dehydration.So,the nurse encourages the patient to increase fluid intake(at least 2 L/day)unless contraindicated.Hydration must be achieved more slowly and with careful monitoring in patients with preexisting conditions such as heart failure. 4.Managing nutrition: -Many patients with shortness of breath and fatigue have a decreased appetite and consume only fluids.Fluids with electrolytes may help provide calories and electrolytes.Oral nutritional supplement may be used to supplement calories. -The nurse encourages the patient to have small,frequent meals. -IV fluids and nutrients may be given if necessary. 5.Promoting patients 'knowledge: 189 -The nurse educates the patient and family about the cause of pneumonia,management of symptoms,signs and symptoms that should be reported to the physician or the nurse,and the need for follow-up, The nurse also provides information about factors(both patient risk factors and extemal factors)that may have contributed to the 189  development of pneumonia and strategies to promote recovery and prevent recurrence. -If the patient is hospitalized,they are instructed about the purpose and importance of management strategies that have been implemented and about the importance of adhering to therm during and after the hospital stay. -Explanations should be given simply and in language that the patient can understand.If possible,written instructions and information should be provided,and alternative formats should be provided for patients with hearing or vision loss,if necessary. -Because of the severity of symptoms,the patient may require that instructions and explanations be repeated several times. 6.Monitoring and managing potential complications: a. Continuing Symptoms After Initiation of Therapy. ·The patient is observed for response to antibiotic therapy;patients usually begin to respond to treatment within 24 to 48 hours after antibiotic therapy is initiated. ·If the patient started taking antibiotics before evaluation by culture and sensitivity of the causative organisms,antibiotics may need to  be changed once the results are available. b. Shock and Respiratory Failure. ·The nurse assesses the patient's vital signs,pulse oximetry values,and hemodynamic monitoring parameters.  "The nurse reports sign of deteriorating patient status and assists in administering IV fluids and medications presenbed to combat shock ·Intubation and mechanical ventilation may be requred if respiratory failure occurs c. Pleural Effusion, ·If pleural effusion develops,thoracentesis is performed to remove fluid.the nurse assists in the procedure and explains it to the patient d. Delirium ·Delirium may be related to hypoxemia,fever,dehydration or developing sepsis.Ensuring patient safety is important nursing interventions. 7.Educating Patients About Self-Care. Patient education is crucial regardless of the setting,and the proper administration of antibiotics is important. ·A seamless system of care must be maintained for the patient from hospital to home;this includes communication between the nurses caring for the patient in both settings. ·The nurse educates the patient about proper administration of antibiotics and potential side effects. ·The patient should be educated about symptoms that require contacting the primary provider:difficulty 191  breathing,worsening cough,recurrent/increasing fever,and medication intolerance. ·The nurse encourages breathing exercises to promote secretion clearance and volume expansion. 191  The outpatient should be contacted by the health care team or instructed to contact the primary provider 24 to 48 hours after starting therapy. ·The nurse instruct patient about a follow-up chest x-ray and physical examination ·The nurse encourages the patient who smokes to stop smoking. ·The patient is instructed to avoid stress,fatigue,sudden changes in temperature,and excessive alcohol intake. ·The nurse reviews with the patient the principles of adequate nutrition and rest,because one episode of pneumonia may make a patient susceptible to recurring respiratory tract infections. Evaluation Expected patient outcomes may include the following: a.Demonstrates improved airway patency,as evidenced by adequate oxygenation by pulse oximetry or arterial blood gas analysis, normal temperature,normal breath sounds,and effective coughing b.Rests and conserves energy by limiting activities and remaining in bed while symptomatic and then slowly increasing activities 192  c.Maintains adequate hydration,as evidenced by an adequate fluid intake and urine output and normal skin turgor d.Consumes adequate dietary intake,as evidenced by maintenance or increase in body weight without excess fluid gain e.Verbalizes increased knowledge about management strategies 192 、 f Adherrs to management strategies 8.Echibits no complications Definition of (COPD): Chronic obstructive pulmonary disease describes(COPD)is an umbrella tern for chronic lung diseases that have limited airflow in and out of the lungs in which airflow in the lungs is obstructed. Resistance to inspiration is decreased,whereas resistance to expiration is increased,so that the expiratory phase of respiration is prolonged Overview Chronic obstructive pulmonary is a preventable and treatable disease with some significant extra-pulmonary effects.Chronic bronchitis and emphysema are types of COPD usually occur in male patient above 50 years and heavy cigarette smoker.Asthma,once classified as a type of COPD,is now considered a distinct restrictive rather than obstructive disorder. Chronic bronchitis Chronic bronchitis affects the lung parenchyma characterized by excessive mucus production with a productive cough for at least 3 months each year for 2 consecutive years. Causes of chronic bronchitis: 1.Smoking 2.Air pollution 3.Genetic factors Pathophysiology: 1.The bronchial tree becomes inflamed from inhaled 196 irritants (e.g smoking),and impaired ciliary function reduces the ability to remove the irritants. 196 2.The mucus-producing glands in the airways become hypertrophied, producing excessive thick,tenacious mucus,which obstructs airways and traps air(Fig.1). 3.Alveoli may become damaged and fibrosed,resulting in altered function of the alveolar macrophages.As a result,the patient becomes more susceptible to respiratory infection. Normal bronchus Chronic bronchus Smooth muscle -Inflammation Increased number Open airway of mucus gland Mucus gland causIng chronic cough Figure(1)Pathophysiology of chronic bronchitis Signs and symptomsof chronic bronchitis 1.The earliest symptom is a chronic productive cough(sputum may become gray,white,or yellow) 2.Bronchospasm and wheezing may occur. 3.Dyspnea on exertion. 4.Expiration is prolonged secondary to obstructed air passages. 5.Cyanosis secondary to hypoxemia may be noted,especially after severe coughing. 197 6.Fever which may or may not be present. 197  Complications:.Right-sided heart failure results from tachyeardia in response to hypovemia which causes edema in the extremities. -Renal failure,and hyponatremia caused by fluid overload late in disease. Medical Diagnosis: Initially,results of the physical examination.chest radiography,and pulmonary function tests may be normal.As the disease progresses. these findings become increasingly abnormal. 1.Complete blood count,electrolyte levels. 2.Microscopic examination of the sputum 3.Physical eramination: thonchi and wheezes on auscultation, prolonged expiration,jugular vein distention,and pedal edema 4.Chest X-ray: possibly hyperinflation. 5.Pulmonary function tests (PFTs):particularly spirometry is used to determine the severity of the airflow limitation,assess the response to medications,and follow disease progression.The most important values measured during spirometry are the forced expiratory volume in one second (FEVi,and the forced vital capacity (FVC). 6.ABG(arterial blood gas)analysis usually reveals hypoxemia and respiratory acidosis. 7.ECG:may show atrial arhythmias;right ventricular hypertrophy. Treatments 1.An inhaled anticholinergic and an inhaled beta2-adrenergic agonist are the mainstay of therapy;they re delivered by  metered dose inhaler (MDI)as shown in figure (2)or nebulizer to enlarge the airways. 2.Aminophy line or another methy kanthine is given orally or I.V.to relax bronchial spasms. 198 3.An antibiotic is used to prevent or treat infection. 4.An inhaled or oral steroid is used to decrease the inflammatory response, thus decreasing bronchial edema during acute exacerbations. 5.Diuretics for edema 6.Oxygen for hypoxemia Fig.(2)Examples of metered dose inhaler Emphysema Is a chronic ireversible disease characterized by abnormal distention of the alveoli.The alveolar walls and capillary beds also show marked destruction,resulting in decreased elastic recoil properties of lungs 199 Causes of emphysema; 1.Chronic bronchitis (99%) 2.Bronchial asthma 3.Congenital (alphal antitrypsin deficiency),.Trypsin destruct alveolar tissue (elastic fibers);alpha 1 antitrypsin destruct the trypsin. Pathophysiology: 1.Emphysema affects the alveolar membranes,causing destruction of the alveolar walls and loss of elastic recoil.This also causes damage to adjacent pulmonary capillaries. 2.Because of the loss of elastic recoil,passive expiration is impaired and air is trapped in the alveoli. 3.Reduction in pulmonary capillaries reduces gas exchange. 4.As the disease progresses,large air spaces within the lung tissue (bullae)or adjacent to the pleurae (blebs)may be seen over the lung surface.These sacs can rupture,allowing air to enter the thorax (pneumothorax)with each respiration.Emergency thoracentesis is performed to remove the air from the thoracic cavity. Signs and symptoms 1.Exertional dyspnea. 2.Chronic productive cough of muco-purulent sputum. 3.Pursed-lip breathing,hyperventilation and prolonged expiration. 4.Characteristic patient positioning(tripod position)that is leaning slightly forward with arms resting on the sides of the chair as 200  shown in fig (3). 5.Lung auscultation reveals decreased breath sounds,wheezing,and crackles 6.Heart sounds are diminished or muffled 200 7.Visual inspection shows a barrel-chest and using the accessory muscles of respiration(muscles in the jaw and neck and intercostal muscles). 8.Respiratory function is markedly impaired. Typical Posture of a Person with COPD Fig(3)Tripod position Complications: 1.Recurrent respiratory tract infections 2.Corpulmonale 3.Respiratory failure. Diagnosis ·Physical examination: hyper resonance on percussion,decreased breath sounds,expiratory prolongation,and quiet heart sounds. ·Chest X-ray: in advanced disease,flattened diaphragm, hyperinflation of lungs,enlarged anteroposterior chest diameter. ·Pulmonary function tests:marked decrease in overall ?A1 function, including increased total lung capacity and residual volume and decreased vital capacity and forced expiratory volume ?A1  ·Arterial blood gas (ABG)analysis:usually reveals hypoxemia and respiratory acidosis ·Electrocardiogram (ECG):signs of right ventricular hypertroplhy late in disease ·Red blood cell count: increased hemoglobin level late in disease when persistent severe hypoxia is present -Sputum analysis typically is ordered. -Testing for alpha-1 antitrypsin (AAT)deficiency:especially in a nonsmoker or have a strong family history of COPD. Medical Management -Smoking cessation is encouraged. -Bronchodilators to dilate airways by decreasing edema and spasms and improving gas exchange. -Supplemental oxygen at low-flow may be prescribed -Antibiotics. -Corticosteroids on a limited basis to assist with brochodilatation and removal of secretions. -Chest physiotherapy to increase ventilation as deep breathing, coughing,chest percussion,vibration,and postural drainage. Surgical Management: 1.Bullectomy:remove one or more very large bullae from the lungs. 2.Lung Volume Reduction Surgery:remove damaged tissue 202 from the lungs. 3.Lung Transplant 202 Nursing Process for the Client with (COPD) Assessment 1.Assess the client's respiratory status,including respiratory effort, rate,and pattern.-Deternine whether the client has diminished breath sounds and prolonged expiration.Observe for evidence of dyspnea at rest,as well as accentuated accessory neck muscles and barrel-shaped chest. 2.Check the characteristics of secretions:consistency,quantity, color,or odor.Other important assessment data are the client's ability to expectorate secretions, 3.Observe signs and symptoms of chest infection. 4.In addition to the history,nurses review the results of available diagnostic tests. Nursing diagnoses 1.Ineffective breathing pattern Related to decreased energy or increased fatigue 2.Ineffective airway clearance Related to the presence of bronchoconstriction,increased mucus production,and ineffective cough 3.Impaired gas exchange Related to prolonged expiration,loss of lung tissue elasticity,and atelectasis 4.Activity intolerance related to fatigue,hypoxemia. 5.Self-care deficits related to fatigue secondary to insufficient 203 ventilation. Expected Outcome 1.Client will maintain a patent airway and adequate airway clearance. 2.Client will maintain optimal gas exchange. 203 3.Client will exhibit improvement in activity tolerance. 4,Independence self-care activities. Achieving Airway Clearance 1.Monitor the patient for dyspnea and hypoxemia. 2.Administer bronchodilators by nebulizer or MDI as indicated 3.Confirm relief of bronchospasm by measuring improvement in forced expiratory volume (FEV1)as well as by assessing the degree of dyspnea and making sure that it has lessened. 4.Increase fluid intake to 3 L/day if not contraindicated (as in heart failure). 5.Humidify of inspired air.These measures keep secretions moist and easier to expectorate. 6.Instruct client for early signs of infection:increased sputum production,changes in sputum color and consistency,fever,increased coughing,and increased dyspnea. 6.Encourage patient to eliminate or reduce all pulmonary irritants particularly cigarette smoking. 7.Recommend yearly influenza vaccines and pneumococcal vaccines every 5 years to reduce the risk of these infections. 8.Encourage client to cough and clear secretions;suction as needed. 9.Chest physiotherapy as postural drainage,intermittent 204  positive- pressure breathing Improving Breathing Patterns 1.Inspiratory muscle training and breathing retraining may help improve breathing patterns. 2.Training in diaphragmatic breathing reduces the respiratory rate, increases alveolar ventilation,and sometimes helps expel as much air as possible during expiration. 204  3.Pursed-lip breathing helps slow expiration,prevent collapse of small airways,and control the rate and depth of respiration;it also promotes relaxation 4.High fowler's position promotes better lung expansion;turning side to side promotes aeration of lung lobes. 5.Administer oxygen as prescribed.Clients with COPD chronically retain CO2 and depend on hypoxic drive as the stimulus for breathing;accurate oxygen administration is essential for preventing cessation of breathing. 6.Monitor level of consciousness and mental status. Improving Activity Tolerance 1.Evaluate the patient's activity tolerance and limitations and use teaching strategies to promote independent activities of daily living. 2.Instruct the patient to perform exercise training to strengthen the muscles of the upper and lower extremities and to improve exercise tolerance and endurance. 3.Recommend use of walking aids,if appropriate,to improve activity levels and ambulation. 4.Consult with other health care professionals (rehabilitation therapist, occupational therapist,physical therapist)as needed. Monitoring and Managing Complications 1.Assess patient for complications(respiratory failure,respiratory 205 infection,and atelectasis). 2.Monitor for cognitive changes,increasing dyspnea,tachypnea,and tachycardia. 3.Monitor pulse oximetry values and administer oxygen as prescribed 205 4.Instruct patient and family about signs and symptoms of infection or other complications and to report changes in physical or cognitive status. 6.Encourage patient to be immunized against influenza and streptococcus pneumonia. 7.Caution patient to avoid significant air pollution and to avoid exposure to high outdoor temperatures with high humidity. 8.If a rapid onset of shortness of breath occurs,quickly evaluate the patient for potential pneumothorax by assessing the symmetry of chest movement,differences in breath sounds,and pulse oximetry. Teaching Patients Self-Care ·Provide instructions about self-management;assess the knowledge of patients and family members about therapeutic regimen. ·Teach patients and family members'early signs and symptoms of infection and other complications so that they seek appropriate health care promptly. ·Instruct patient to avoid extremes of heat and cold and air pollutants (eg,fumes,smoke,dust,talcum,lint,and aerosol sprays).High altitudes aggravate hypoxemia. 206 ·Encourage patient to adopt a lifestyle of moderate activity,ideally in a climate with minimal shifts in temperature and humidity;patient should avoid emotional disturbances and stressful situations;patient should be encouraged to stop smoking. ·Review educational information and have patient demonstrate correct metered-dose inhaler(MDl)use before discharge,during follow-up visits,and during home visits. 206  Introduction: Bum is an injury to skin that causes not only pain but may end with defommity and also it can be too severe to be life threatening accident.It has high incidence in both sexes in all ages among all sociocconomic groups all over the world because it has so many reasons and usually occurs suddenly Although its prevention is easy,it still not applicable most of the time because it is mostly accidental. Anatomy of skin,figure no.1: The skin consists of three layers:the epidermis,dermis and the subcutaneous tissue(outer/superficial to inner/deeper). 1.The epidermis consists of live cells covered by a layer of a dead cell.The outer layer usually is replaced every 3 to 4 days. 2.The dermal layer is the largest portion of the skin.It contains blood and lymph vessels,nerves, sweat and sebaceous glands and 3.The subcutaneous/subdermal layer is an adipose tissue.Then the next structure under skin is the muscles. Hair covers all the skin except for the palms and the soles. Nails are keratin(an insoluble fibrous protein)cover the dorsal surface of the fingers and toes. S y sqummoye celle Bmsol ceils. Epidermi Melanoeyte s Dar mis Swe glend Subcutis Ly mph ves Fat cells Hair folllcleSWeat aland Blo6d vessel Figure no.I,Anatomy of skin 209  1.Protection: Skin covers almost all the skin and it is very effective against invasion of bacterial infection,micro-organisms or other foreign bodies. It is a barrier to the environmental factors such as chemical,sunlight, insect bites,wind,bun and trauma. 2.Sensation; The skin contains receptors of nerve endings which allow the sensation of environment and stimulants as pain,light,touch,pressure. 3.Water balance: It prevents the excessive water and electrolytes loss. There is an insensible water loss (perspiration)by evaporation because the skin is not completely impermeable and the daily amount is approximately 600 ml,but it varies according to body temperature. On the other hand,prolonged immersion in water causes swelling as a result of osmosis.Water being pulled into skin cells. 4.Temperature regulation: Body heat resulting from nutrients metabolism. Heat loss through the skin occurs by radiation,conduction and convection according to the degree of body heat and the environment (increase heat leads to vasodilatation,increase blood flow and vice versa). Another body temperature regulator is sweating.It occurs when body core temperature exceeds 37°C regardless skin temperatures. 210  Sweating is evaporated by body heat that is lost (decrease)by increase evaporation of sweating. 5.Vitamin production: Exposure to ultraviolet sun rays can convert substances necesary for synthesizing vitamin D(from subcutaneous fat). 210  6.Immune response function: Several dermal cells are component of immune system. 7.Psychological satisfaction: It gives the body the normal appearance,while if burn or trauma, skin is affected.The change body image and affect psychological condition. Definition of burn; It is massive tissue destruction,from coagulation,protein denaturation or ionization of cellular contents caused by contact with energy sources. Causes of burn: 1.Thermal causes: a.Dry heat: As fires,hot fumes,direct contact with heaters or any hot surfaces. b.Moist heat: As in contact with hot liquids. N.B: Frost bite has the same effect similar to excessive dry and moist heat so it considered a thermal injury. 2.Mechanical burns: Friction or abrasions on harshly rubbing of skin against coarse surface in case of motorcycle accident (road rash)as friction produce high energy. 3.Electrical burns: a. Any contact with faulty electrical wiring,or immersion 211 in water that has been electrified. b.Light strikes:it is a very dangerous type because of the risk of intemal damages. 211  It also has a unique character of having inlet (wide irregular edges, more damage and more necrotic tissues)and exit(smaller,regular edges,less damage less necrotic tissues). The severity of electrical burn effect depends mostly on tissue resistance e.g.fat offer the most resistance,nerves and blood vessels offer the least resistance. In addition electrical currents may catch person's clothes causing addition thermal injury,it also causing tetanic muscle contractions which can cause bone fracture,cardiac arrest,dysthythmias and metabolic acidosis. The immediate effect on the heart is cardiac standstill or fibrillation. 4.Chemical burns: Direct contact with strong acid,alkaline or inhalation of toxic substance or chlorine especially when clothes absorbed the chermicals. In inhalation of toxic gases it cause respiratory tissue damage but this risk decrease as a result of cooling of the gas before reaching the lungs.The most toxic inhaled gases are: a.Carbon monoxide (Co):odorless gas result from burning substances, faster in combination with hemoglobin than oxygen causing carboxyhemoglobin.Poisoning and asphyxiation is suspected so 100 % humidified oxygen is needed. b.Inhalation of hot air,steam,smoke:Causing mechanical 212 obstruction in oropharyenx and larynx from edema.Singed(bumed)dark nasal hair,darkness of oral and nasal mucosal membrane is suspected. 5.Radiation burns ; a,Prolonged exposure to sun rays(midday)in fragilk sensitive persons without sun screen protection. 212  b.Exposure to unplanned radiotherapy or diagnostic radiation. Pathophysiological changes in burn: -It includes local and systemic effect. -If the burn not exceed 25% of total body surface area (TBSA) only produce local effect,but if it exceeds this percent it will produce local and systemic effect because burn release chemical mediators such as cytokines which cause local and generalized effects: 1.Local effect: It is similar to local inflammatory process in: a.Vasodilatation causing redness and blanching with pressure. b.Leukocytes adherence to burn area causing inflammatory process. c.Increase capillary permeability producing wound edema which cause shifting of fluid in the interstitial space causing blister and edema. Edema is usually maximized after 24 hours and it begins to be resolved gradually 1 to 2 days post burn till complete resolving in 7 to 10 days post injury it could be reduced by avoiding excessive fluid replacement during the early post burn period. 213  2.General effects Figure no.2,: Pathophysiological Changes During Hypermetabollc/hyperdynamic Phase of Burn (>48 hrs) 碱 d a st atus bra ma r p esoxe ixedeiae ·Tachycardia · · u dysfunction ·Pulmonary edema · c g · -Altered ·B A ho m r onchorrhe a rat ry dis t ress contractilit tSvO₂ ro · 。SVR~ · Pneumonia n 卫饰 ·t ulob ler ula r fi l a tion rate d taboli c function ·i ar func t it n d g clearan c e li Live lood flo w inhammatary Tespansu ·1Gluco eo gene sis i Coagulation factors ·High energy expenditure *Albuminemia (1O₂consumption &1CO₂production) MInus sucli t a olism recsais t n c e -hyperglycemia Eon maefbW Persistence of generalized edema with>25%body burn ↓Hematopoiesis ·Anemia ·Immunoparesis ·Osteoporosis ea paaeege a.Cardiovascular response: Hypovolemia resuling from fluid lost(from the intravascular system)in edema that causes decrease tissue perfusion and decrease cardiac output which cause drop in blood pressure (burn shock). Sympathetic nervous system releasing catecholamine causing vasoconstriction and tachycardia. In circumscribed bun(circular around part of the body,edema act like a tourniquet. This edema increases,pressure on small blood vessels and nerves in the distal extremities causes an obstruction of blood flow and consequent ischemia,this is called compartment syndrome. The physician may need to perform an escharotomy,a surgical incision into the eschar(devitalized tissue resulting from a burn)to relieve the constricting(pressure)effect of the burned tissue. b.Pulmonary response: Bronchoconstriction caused by releasing of histamine. Upper airway injury resulting from direct heat or edema as mechanical obstruction Lower airway injury below glottis cause hypersecretion of mucous, sever mucosal edema and bronchospasm and lung collapse may occur and formation of carboxyhemoglobin (inhalation of CO₂smoke +Hb). Indicators of pulmonary affection in response to burn: 215 1.History indicating that bum occurred in a closed area. 2.Burns of face and neck 3.Singed nasal hair. 4.Hoarseness,voice changes,dry cough,striders,black and bloody sputum. 5.Tachypnea and manifestations of hypoxia. 215 c.Renal response: Decreased intravascular blood volume will decrease renal tubular perfusion. Destruction of red blood cells by effect of burn which excreted by the kidney. Muscle damage causes myoglobin released and also excreted by the kidney which can cause occlusion of the renal tubules and acute tubular necrosis and renal failure. d.The immunological response: Loss of skin barrier and presence of eschar is a favorable media for bacterial growth Abnormal inflammatory response decrease delivery of antibiotics, white blood cells and oxygen to the injured area. As a result of cells destruction,decrease of serum albumin and immunoglobulin. Burn wound sepsis: ·After colonization/invasion of the burn surface by bacteria,it may progress to invasion of adjacent non burned tissue. It can develop into systemic septicemia. e.Gastrointestinal response: 216  As a result of sympathetic nervous system response to trauma peristalsis decrease and gastric distention,nausea,vomiting and paralytic ileus may develop. Ischemia of gastric mucosa,burn stress,diminishes or absence of oral intake increase risk of duodenal and gastric ulcer. f.Hematological changes: Thrombocytopenia (decrease platelet). 216  Anemia resulting from destruction of red blood,blood loss during bum injury,diagnostic and therapeutic procedures. g.Skin changes: Loose of skin causing inability to regulate body temperature (low body temperature in the early stage)then as hyper metabolism occurs it causes hyperthermia burn patients for much of post burn period even in absence of infection. h.Metabolic response: Due to burn inflammatory process,catecholamine(chemical mediator)released and causing hypermetobolic response. Healing of large surface area requires much energy. The adult burn patient may require 3,000 to 5,000 calories per day which differs according to burn body surface area. i.Fluid and electrolytes response: Fluid accumulation lasts 3 to 48 hours after burn injury in which fluid shift from intravascular to interstitial space(third space shift) causing edema which reaches its maximum extent within 8 hours afterburn injury. Because of capillary damage in bum response,it alters permeability of vessels causing escaping of plasma,liquid and protein shifting to interstitial space. Because of this shift less liquid is available to dilute blood, hemoconcentration and increase hemoglobin and hematocrit. 217  Injured tissue causing release of acids(lactic acid from tissue destruction)causing drop in the PH level causing metabolic acidosis. 217  Electrolytes imbalance mainly: 1.Potassium; ·Hyperkalemia resulting from massive cellular trauma,metabolic acidosis or renal failure.Potassium released into the extra cellular fluid in the first days post burn injury. 2.Sodium; ·Hyponatremia result from increase loss of sodium and water from the cell.Large amount of sodium trapped in edematous fluid early after burm injury. ·Late after burn hypematremia can result from aggressive use of hypertonic sodium solutions during fluid replacement therapy. Classification and degrees of burn: It can be classified according to: A.Depth of burn. B.Extent ofburn C.Location of burn This classification explained as: A.Classification of burn according to depth,figure no.3: 1.Superficial partial thickness (first degree):it is similar to sunburn. Only the epidermis is injured.Although the burn is red and painful,it heals in 5-10 days,usually spontaneously with symptomatic treatment. 2.Partial thickness (second degree):it involve the epidermis and part of the dermis layer of skin it is classified as: a.Superficial partial thickness:very painful,red in color with clear blister,blanches with pressure.heals within 14 days 218 b.Deep parial thickness:painful,yellow or white.Less blanching. May be blistering.It takes more than 3 wecks to heal,may need debridement 218 3.Full thickness (third degree):destruction of all layers of the skin and consequently is painless(due to nerve damage).The tissue appears stiff,white or brown with no blanching or it may be charred/black (lifeless).If not debrided,this type of burn injury leads to sepsis, extensive scarring,and contractures.It may reach muscle and bone. Figure no.3,Classification of bum according to depth B.Classification of burn according to extend of body surface area; 1.Rule of nines:The percentage of burn injury.The system divides the body into multiples of nine.The sum total of these parts equals the total body surface area,figure no.4. 219  9 36 9 9 3 9W 2 9 9m 9 18 18 18 18 % 17 17 5 5-9 10-7 ADULT (RUL OF NINE S Figure no.4,Rule of nines. 219 2.Palm method:In patients with scattered burns,or for a quick pre. hospital assessment.The size of the patient's one open palm is approximately 1%of the TBSA.The paticnt's palm without the fingers is equivalent to 0.5%TBSA,figure no.5. Figure no.5.Palm method 3. Lund and Browder method:it recognizes percentage of surface area of burn according to the anatomical parts in relation to the age,figure no.6. Burn Assessment Lund &Browder Chart LUNO ANO BNOWDER CHANTS nNONE, Superficial Deep REGION % HEAD NECK ANT.TRUNK POST,TRUNK RIGHT ARM LEFTARM BUTTOCKS GENITALIA RIGHT LEG LEETLEG TOTAL BURN AELATIVS PERCENTAGE OF BODY SUNFACE ANEA AFFECTED BY GHOWIH AREA AGE O 1 5 10 15 ADULT 多 A* OF HEAO 9除 8 6 学 5 4号 ,3 B-B OF ONE TIHGH 2% 3'% 4号 4年 4% 220 G-×OF QNE LEO 2% 22 2% 3 3% 3% Figure no.6.Lund and Browder method 220  - The initial evaluation is made on the patient arrival to hospital and it revised daily because of changes that may occur. Factors affecting burn process: 1.How injury occurred. 2.Causative agent (e.g.hot water,flame,fire,electricity…etc). 3.Temperature of the burming agent. 4.Duration of exposure to burning agent. 5.Degree or thickness of the skin and resistance of body structure. 6.How burn occur. 7.Age and body built of the patient. 8.Medical condition of the patient. Management of burn: A.Emergency/resuscitation phase of burn case. B.Acute/immediate phase of burn care. C.Rehabilitation phase of burn care. Treatment explained as: A.Emergency/resuscitation phase (from time of burn to 48 hours of burn): 1)Care on the scene of burn(the first priority is to prevent injury of rescuer and victim): -Call fire force 180 and emergency medical services 123. -Stop burn process:as by“stop,drop,and roll”…etc. -Remove the victim away from site of injury. -Cool the burn with running water and never apply ice directly to the burn. -Flush chemical burns and affected clothes with running water only. 221 -Remove all clothes (on and near burn area),assistive devices and jewelry. -Cover the burn with clean cloth or dressing - Assess ABCDEs; a.A:Airway with protecting cervical spine. b.B:Breathing and gas exchange c.C:Circulatory and cardiac status d.D:Disability including neurologic deficit e.E:Examination expose the body for assessment while maintaining a warm environment -Care with CAB technique if needed -Secondary head to toe assessment to detect any other life- threatening problems. -If cervical spine injury is suspected in case of falling as in electrical injuries,support head and neck and use logrolling technique before moving the patient. -Position patient correctly to prevent aspiration(head on one side). -Keep patient NPO. -Assess neurogenic status especially in extensive burned patient ( often patient is alert) -Obtain history of the burn,witness,patient history especially medical surgical,pharmacological,sensitivity history. 2)When ambulance arrives: 222 -Support neck with cervical collar if suspected cervical injury. -In pulmonary injury or inhalation bums: a.Administration of 100%humidified oxygen. b.Encourage patient to cough. 222  c.Suction is done to expectorate secretions or given bronchodilators and mucolytic then suction. d.If airway edema is developed,endotracheal (oral or nasal). -Insertion of large bore(16~18 gauge)intravenous catheter. -Insertion of nasogastric tube for gastric suction. -For the health personal wearing non-sterile gloves,caps and gowns and using clean technique during assessment. -Assessment of TBSA and burn depth after cleaning the wound. -Keep patient warm. -Photos may be taken for documentation. -Cover patient with clean linen to prevent contamination,maintain body temperature and to reduce pain caused by air current. - Insertion of indwelling urinary catheter to monitor urinary output. -Measure weight,height arterial blood gases,hematocrit, hemoglobin.electrolytes,blood alcohol value,urine analysis and chest X ray is required. -Electrocardio gram in patient with electrical burn. -Administering tetanus toxoid prophylaxis. -Care of patient and family psychologically(reassurance and support)and explanations are given to improve coping. -Administer pain medication as ordered. -Spiritual care is provided. 3)Arrival to burn center: √Ensure patent airway. √Check vital signs  √If necessary,a blood pressure cuff can be placed around a patient's burned extremity.The cuff must be of the correct size with accommodations made for bulky dressings. √Intravenous lactated Ringers infusion is given to maintain urine output at least 30 ml per hour. √Adequate pain reliving medication is given. √Ensure adequate peripheral circulation in the burn extremity by neurovascular assessment. √Care of burn according to its type and degree. √Cover wound by clean and dry sheet and keep patient warm. √Documentation of all previous assessment and care measurements. 4)Management of fluid loss and shock: -The volume and route depends on patient's condition including: √Total urinary output (30-50 ml/hour). √Systolic blood pressure more than 100 mm Hg,pulse rate less than 110 b/m. √Hematocrit (HT)hemoglobin(Hb)levels. √Sodium and potassium levels. √TBSA and degree of burn -Some combining fluid categories may be used colloids (whole blood,plasma,plasma expanders)crystalloids /electrolytes 224  (sodium chloride,lactated Ringers solutions). -Oral fluid may be given to adult patient with less than 25%of TBSA. -Formulas used for fluid replacement if TBSA 25%or more: a)For the first day: 1.(2-4)×TBSA×body weight)is given in the first 24 hours. 224 2. Maximum of 10,000 mL over 24 hours. 3. If the bums excceding 50%TBSA are calculated cqual 50%TBSA to avoid fluid overload, 4.Most commonly given is crystalloids to replace Na,K mainly lactated Ringer's,normal saline and glucose 5% 5.Half of the calculated total should be given over the first 8 post- bum hours,and the other half should be given over the next 16 hours. 6.Rate of infusion according to patient condition. b)For the second day: 1.(TBSA body weight)is given in the second 24 hours of burn. 2.Most commonly given crystalloids and colloids according to patient laboratory investigations of Na,K,Hb,Albumin and protein mainly lactated Ringer's,normal saline,glucose 5%,albumin,blood,packed RBCs,plasma…etc. 3.One third of the calculated total should be given every 8 hours. B.Acute/immediate phase(from 48 to 72 hours of burn): -Assessing any delayed effect of the bun(e.g.airway obstruction …ect) -Capillaries regain integrity at 48 hours or more post burn fluids moves from interstitial to intravascular space;diuresis begins with decrease edema level. -Continuing administering of fluid and electrolytes as needed is important. Fever is common in burn patient after shock is relived 225 because of resistance of core temperature regulation,but temperature not exceed 38oc except in case of septic burn wound acetaminophen (Tylenol/paracetamol)and hypothermic blanket are used to reduce temperature,general care includes: 225 1)Infection prevention. -Using strict aseptic technique in dressing. -Systemie and local prophylactic antibiotics are given. -Clean environment and using universal precautions. -Wound culture is the indicator for early detection of infection and proper antibiotic. 2)Wound dressing: -Hydrotherapy is used to facilitate removal of old dressing,chance for EOM exercises and soothing effect. -Hydrotherapy in the form of shower,bed baths and tub bath. -Hydrotherapy should be limited to a 20-to 30-minute period to prevent chilling or additional metabolic stress. -The temperature of water is maintained at body temperature (37° C)to avoid shivering or coldness. -Patting by a sterile towel for dryness after shower. - Intact blister left intact but water may be aspirated by needle. -After cleansing and applying the topical agent,Vaseline dressing is applied to avoid adherence on the burned area. -Dressing layers on the joint area should be but be light to facilitate mobility. -When circumferential (circular)dressing is applied to fingers and toes layers of Vaseline dressing is used to separate them to avoid adhesion. 226 3)Topical antibacterial therapy: -Selection criteria for topical agent includes :- 1.Effective against gram positive and gram negative organisms. 226 2.Penetrates Escher but systemically nontoxic. 3.Cost effective,available and accepted by the patient. 4.Easy in application,minimize nursing care time. -No single topical medication is universally effective;combination may be necessary after wound culture. -Topical antibacterial agent as silver sulfadiazine (Silvadene),silver nitrate,mafenide acetate (Sulfamylon),povidone iodine ointnent 10%(Betadine),gentamicin sulfate,nitrofurazone (Furacin)…etc. 4)Burn wound dressing: -Under aseptic technique after about 20 minute of given analgesics under close observation after hydrotherapy,dressing could be open (exposed)or close(occlusive)methods: a.Open(exposed)method, in which the wound is left uncovered after dressing and applying the topical medications. 1.Safe time,effort,staff and supplies. 2.Causes less pain during wound care 3.Facilitates early continuous wound inspection. 4.Allow wound dryness. 5.Useful for face and perianal area burn. 6.Increase loss of water and body heat by evaporation. 7.Increase risk of infection,trauma,pain and burn wound adhesion. 8.Difficult in exercise and transference. 9.Chance for burned area adhesion as in burned fingers. 10.Affect psychological condition of patient. b.Closed or occlusive method, in which the wound is covered after dressing and applying the topical medications: 1.Maintains moist wound. 2.Promotes maintenance of body temperature. 227 3.Decreases risk of infection,trauma and pain. 4.Easy transference of patient 5,Keeps bumed area separated as in fingers burn. 6.Reduces pain during position changes. 7.Useful for burn extremities. 8.Need more time,effort,supplies and staff. 9,More difficult in continuous wound assessment. 10.Improve psychological condition as patient not see the burn all the time. 5)wound debridement : -Debris(dead tissues)accumulates on wound surface which delaying epithelialization process, enhance bacterial growth, debridement could be: a.Natural:spontaneous separation of dead tissue. b.Mechanical:using surgical scissors and forceps or friction on hydrotherapy and dressing. c.Surgical:by surgical excision early in burn wound closure which reduces risk of sepsis. 6)Grafting burn wound: -Occurs in deep extensive burn when spontaneous revitalization is not possible,it includes: 1.Autograft:from the patient himself. 2.Homograft (allograft):from human skin or human placental. 228 3.Heterograft(xenograft):from animals usually pigs (rejected may occur because of immunologic response). 4.Skin(Dernal)Substitutes:alternative synthetic materials to substitutes skin to cover the wound and promote healing.It consists 228 of 2 layers dermal and epidernal with animal collagen.It is applied until enough skin is available for grafting purposes. 5.Biosynthetic and synthetic dressing:as biobrane(nylon,silastic with collagen derivative which remain 3 to 4 weeks.Its advantages in its sterility and availability. 7)Pain management: -Elevation of buned extremities above the level of the heart to decrease edema. -Gentle dressing and positioning. -Adequate dressing bandages. -Emotional support. -Gentle,simple and gradual exercise. -Intravenous opioid administration could be used in emergency management but fear of addiction and other problems is high, morphine sulfate is the analgesic of choice so many forms could be used including nonpharmacological measures e.g.music therapy could be effective,progressive relaxation technique…etc 8)Nutritional support :- -Because of change of metabolic rate,risk of infection,burn stress and alteration(increase)catabolic hormones e.g.cortisone decrease anabolic hormones e.g.human growth factor so adequate nutrition is strictly required. 229  -Depending on TBSA,patient condition and associated conditions: a.Daily:protein 1.5 to 4.0 gm/kg of body weight mainly for burn healing and tissue repair. b.Lipids are importance for wound healing,cellular integrity,and absorption of fat-soluble vitamins 229 c.Carbohydrates are included to meet caloric requirements as high as 5.000 calories per day and to spare protein,which is essential for wound healing. d.Minerals,vitamins also required according patient's condition. C.Rehabilitation phase :- -It begins immediately after occurrence of burn often extends for years after injury it focus on alteration of physical condition,self- image and life style. -It includes: Wound care and care of disability if present. ·Psychosocial support. ·Diet planning,exercise program and maintenance of daily living activities. ·Family education and support. ·Prevention,early detection and proper treatment of complication. ·Referral to proper rehabilitation specialists,psychotherapist, physiotherapy specialist and social referral if needed. Disorders/complications of wound healing: 1.Scares:areas of fibrous tissue replace normal skin after burn healing. 2.Keloids:A large,heaped-up mass of scar tissue. 230 3.Failure to heal:burn not heal;may due to infection,inadequate nutrition. 4.Contracture:burn wound tissue shortens because of the force exerted by the fibroblasts and the flexion of muscles in natural wound healing. 230