Module 8 Burn Management PDF

Republic of the Philippines TARLAC STATE UNIVERSITY COLLEGE OF SCIENCE DEPARTMENT OF NURSING Lucinda Campus, Brgy. Ungot, TarlacCityP...

Republic of the Philippines TARLAC STATE UNIVERSITY COLLEGE OF SCIENCE DEPARTMENT OF NURSING Lucinda Campus, Brgy. Ungot, TarlacCityPhilippines 2300 Tel.no.: (045) 493-1865 Fax: (045) 982-0110 website: www.tsu.edu.ph Awarded Level 2 Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines Inc (AACCUP) -------------------------------------------------------------------------------------------------------------------- INSTRUCTIONAL MODULE: COURSE: NCM 112: CARE OF CLIENTS WITH PROBLEMS IN FLUIDS AND ELECTROLYTES Developer and their Background: Prof. Merlie Q. Espiritu,RN,MAN Email add: merlieespiritu04@gmail [email protected] … COURSE DESCRIPTION: This course deals with concepts, principles, theories and techniques of nursing care management of at risk and sick adult clients in any setting with alteration/problems in oxygenation, fluid and electrolytes, infectious, inflammatory and immunologic responses, cellular aberrations, acute and chronic. The learners are expected to provide nursing care plan to at risk and sick adult clients utilizing the nursing process. COURSE OUTLINE: Week 10 & 12 UNIT II: Fluid and Electrolyte Imbalances in Renal Disorders Week 13 &14 UNIT III. : Fluid and Electrolytes Imbalances of Patient with Burn Injury Week 15 & 17 UNIT IV: Fluid and Electrolytes Imbalances of Patient with Neurogenic Disorders Week 18 Final Examination WEEK 13 and 14: MANAGEMENT OF PATIENT WITH BURN INJURY WITH FLUIDS, ELECTROLYTES AND ACID-BASE IMBALANCES AND FLUID REPLACEMENT RATIONALE: This module will help the students to learn the concepts, theories, and principles of fluid and electrolyte imbalances in caring for patients with burn injury with fluids, electrolytes and acid-base imbalances and fluid replacement. It will also guide and equip student nurses to apply their knowledge and skills in the formulation of a comprehensive plan of care. INSTRUCTION TO THE USERS: The student(s) will answer the given activities; preparatory activities entail assessment of the student's understanding and knowledge about the concepts, theories, and principles of fluid and electrolyte imbalances in caring for patients with burns. Developmental activities comprise applications, discussions, and analysis coming from the concepts learned. Closure activities consist of case studies, critical thinking exercises, and evaluation examinations. Learning objectives: At the end of this module, the nursing student will be able to; 1. Learn the different concepts, theories and principles of renal replacement therapy and burn injury 2. Discuss the pathologic responses in body fluids and electrolytes imbalances in acute renal failure and burn injury 3. Apply concepts and principles in the assessment of patient with fluids and electrolytes Balance in renal replacement and burn injury 4. Determine the various assessment procedures and diagnostic procedures. 5. Demonstrate safe, appropriate and holistic care utilizing the nursing process. 4. Conceptualize and formulate a particular nursing care in the plan of care to a given patient with consideration to the ethico-legal and moral standards of nursing practice. 5. Provide safe and quality and appropriate nursing interventions and actions holistically and comprehensively. 6. Evaluate client’s responses based on the plan of care given. 7. Ensure completeness of documentation of client’s responses based on the nursing care rendered with integrity, safety, accessibility and security of information. INTRODUCTION: BURNS INCIDENCES:  Burns are a global public health problem, accounting for an estimated 180 000 deaths annually. The majority of these occur in low- and middle-income countries and almost two thirds occur in the WHO African and South-East Asia Regions.   In many high-income countries, burn death rates have been decreasing, and the rate of child deaths from burns is currently over 7 times higher in low- and middle-income countries than in high-income countries.   Non-fatal burns are a leading cause of morbidity, including prolonged hospitalization, disfigurement and disability, often with resulting stigma and rejection.   Burns are among the leading causes of disability-adjusted life-years (DALYs) lost in low- and middle-income countries.  Hospitalization for burns varies by country and is influenced by health service payment programmes, but among countries studied hospitalization trends are going towards shorter stays and an increased proportion of burns being treated in specialized burn centers. (WHO 2023). Prevention: WHO 2023 Prevention strategies should address the hazards for specific burn injuries, education for vulnerable populations and training of communities in first aid. An effective burn prevention plan should be multi-sectoral and include broad efforts to:  Improve awareness   Develop and enforce effective policy  Describe burden and identify risk factors  Set research priorities with promotion of promising interventions  Provide burn prevention programmes  Strengthen burn care  Strengthen capacities to carry out all the above. World Health Organization (WHO, 2023) several specific recommendations for individuals, communities and public health officials to reduce burn risk.  Enclose fires and limit the height of open flames in domestic environments.  Promote safer cook stoves and less hazardous fuels and educate regarding loose clothing.  Apply safety regulations to housing designs and materials and encourage home inspections.  Improve the design of cook stoves, particularly with regard to stability and prevention of access by children.  Lower the temperature in hot water taps.  Promote fire safety education and the use of smoke detectors, fire sprinklers and fire- escape systems in homes.  Promote the introduction of and compliance with industrial safety regulations, and the use of fire-retardant fabrics for children’s sleepwear.  Avoid smoking in bed and encourage the use of child-resistant lighters.  Promote legislation mandating the production of fire-safe cigarettes.  Improve treatment of epilepsy, particularly in developing countries.  Encourage further development of burn-care systems, including the training of health-care providers in the appropriate triage and management of people with burns.  Support the development and distribution of fire-retardant aprons to be used while cooking around an open flame or kerosene stove. First Aid: WHO 2023 What to do What not to do  Stop the burning process by removing  Do not start first aid before ensuring your clothing and irrigating the burns. own safety (switch off electrical current,  Extinguish flames by allowing the patient to wear gloves for chemicals etc.) roll on the ground, or by applying a blanket,  Do not apply paste, oil, haldi (turmeric) or or by using water or other fire-extinguishing raw cotton to the burn. liquids.  Do not apply ice because it deepens the  Use cool running water to reduce the injury. temperature of the burn.  Avoid prolonged cooling with water  In chemical burns, remove or dilute the because it will lead to hypothermia. chemical agent by irrigating with large  Do not open blisters until topical volumes of water. antimicrobials can be applied, such as by a  Wrap the patient in a clean cloth or sheet health-care provider. and transport to the nearest appropriate  Do not apply any material directly to the facility for medical care. wound as it might become infected.   Avoid application of topical medication until the patient has been placed under appropriate medical care. Overview: BURN: - Involve destruction of the epidermis, dermis, or subcutaneous layers of skin - Can be permanently disfiguring and incapacitating both emotionally and physically, and possibly life-threatening - Associated imbalances: result from alterations in skin integrity and internal body membranes, and from effect of heat on body water and solute losses that result from cellular destruction. - Type and severity of imbalance depend on burn type and depth of percentage of bodv surface area (BSA) involved, and burn phase. Causes:  Thermal bums (most common): result from exposure to several sources - Dry heat such as flames - Moist heat, such as steam and hot liquids - Frostbite (because effects are similar to those of thermal bums)  Mechanical bums: caused by the friction or abrasion that occurs when skin is rubbed harshly against a coarse surface  Electrical bums: possible after contact with one of multiple causes - Faulty electrical wiring - High-voltage power lines - Immersion in water that has been electrified - Lightning strikes  Chemical burns: result from direct contact, ingestion, inhalation or injection of various substances - Acids - Alkali - Vesicants  Radiation bums: typically associated with sunburn or radiation therapy (cancer treatment) BURN SEVERITY DETERMINATION: Each burn injury is determined by multiple factors. - Age of the patient; depth of the burn; - Amount of surface area of the body that is burned; - Presence of inhalation injury; - Presence of other injuries; - Location of the injury in areas such as the face, the perineum, hands, or feet; and the presence of comorbid conditions  More than 40% TBSA burned are at high risk for mortality and morbidity (Jeschke et al., 2015). 1. Superficial Dry, red, easily blanching, sometimes painful  Example: Sunburn NOT counted in calculations of total burn surface area (TBSA) Adapted from: American Burn Association (2022) 2. Superficial Partial Thickness Moist, red, blanching, blisters, very painful Counted in calculations of total burn surface area (TBSA) Adapted from: American Burn Association (2022) 3. Deep Partial Thickness Drier, more pale, less blanching, less pain Counted in calculations of total burn surface area (TBSA)  Adapted from: American Burn Association (2022) 4. Full Thickness Dry, leathery texture, variable color (white, brown, black), loss of pin prick sensation Counted in calculations of total burn surface area (TBSA) Adapted from: American Burn Association (2022) BURN DEPTH - Burns are classified according to the depth of tissue destruction. 1. First-degree burns are superficial injuries that involve only the outermost layer of skin. - These burns are erythematous, but the epidermis is intact; if rubbed, the burned tissue does not separate from the underlying dermis. This is known as a negative Nikolsky’s sign. - A typical first-degree burn is a sunburn or superficial scald. 2. Second-degree burns involve the entire epidermis and varying portions of the dermis. - painful and are typically associated with blister formation. - Healing time depends on the depth of dermal injury and typically ranges from 2 to 3 weeks.  - Hair follicles and skin appendages remain intact. 3. Third-degree (full-thickness) burns involve total destruction of the epidermis, dermis, and, in some cases, damage of underlying tissue. - Wound color ranges widely from pale white to red, brown, or charred. - Burned area lacks sensation because nerve fibers are damaged. -Wound appears leathery and dry due to the destruction of the microcirculation; hair follicles and sweat glands are destroyed. - Severity of this burn is often deceiving to patients because they have no pain in the injury area. 4. Fourth-degree burns (deep burn necrosis) are those injuries that extend into deep tissue, muscle, or bone (Kearns, Cairns, Holmes, et al., 2013).  Factors are considered in determining the depth of a burn: 1. How the injury occurred, 2. Causative agent (such as flame or scalding liquid), 3. Temperature and duration of contact with the causative agent, 4. Thickness of the skin at the injury site. Source: Brunner & Suddarth’s 2022; Medical-Surgical Nursing, 15ed. Figure 57-1 Third-degree (full-thickness) burn to arm and upper back with surrounding second- degree (partial-thickness) burn. Used with permission from University of Texas Medical Branch, Galveston, TX. Source: Hinkle & Cheever (2022) Brunner & Suddarth’s ;Medical-Surgical Nursing, 15ed Figure 57-2 Fourth-degree burn to second digit. Used with permission from University of Texas Medical Branch, Galveston, TX. Source: Hinkle & Cheever (2022) Brunner & Suddarth’s ;Medical-Surgical Nursing, 15ed EXTENT OF BODY SURFACE AREA INJURED  Methods are used to estimate the TBSA affected by burns; 1. Rule of nines, 2. Lund and Browder method, 3. Palmer method. 1. Rule of Nines: - most common method used to estimate the extent of burns in adults is the rule of nines - This system is based on anatomic regions, each representing approximately 9% of the TBSA, allowing clinicians to quickly obtain an estimate of burn size. - If a portion of an anatomic area is burned, the TBSA is calculated accordingly E.g.: If approximately half of one arm were burned, the TBSA burned would be 4.5% (Kearns et al., 2013). Figure 57-3 The rule of nines. Estimated percentage of total body surface area (TBSA) in the adult is calculated by sectioning the body surface into areas with a numerical value related to nine. (Note: The anterior and posterior head total 9% of TBSA.)  Source: Adapted from: Hinkle & Cheever (2022) Brunner & Suddarth’s ;Medical-Surgical Nursing, 15ed Adapted from;: American Burn Association,(2022) American Burn Association Criteria for Referral to a Burn Center  Partial-thickness burns covering 10% of total body surface area or greater Burns involving the face, hands, feet, genitalia, perineum, or major joints  Third-degree burns - Electrical burns, including lightning injury - Chemical burns - Inhalation injury  Burn injury in patients with pre-existing medical disorders  Any patients with burns and concomitant trauma  Children with burn injuries in facilities that do not specialize in pediatric care  Patients who will require special social, emotional, or long-term rehabilitation Adapted from American Burn Association. (2011). Advanced burn life support (ABLS) course provider manual 2011. Chicago, IL: Author. 2. Lund and Browder Method - A more precise method of estimating the extent of a burn is the Lund and Browder method (Kearns et al., 2013), which recognizes the percentage of surface area of various anatomic parts, especially the head and legs, as it relates to the age of the patient.  - By dividing the body into very small areas and providing an estimate of the proportion of TBSA accounted for by each body part, clinicians can obtain a reliable estimate of TBSA burned. - Initial evaluation is made on arrival of the patient to the hospital and should be revised within the first 72 hours, because demarcation of the wound and its depth present themselves more clearly by this time. Adapted from: Hinkle & Cheever (2022) Brunner & Suddarth’s ;Medical-Surgical Nursing, 15ed. 3. Palmer Method- - In patients with scattered burns, or very large burns with minimal sparing, the palmer method is an expeditious method to determine extent of injury. - The size of the patient’s hand, including the fingers, is approximately 1% of that patient’s TBSA (ABA, 2018). PATHOPHYSIOLOGY: - Burn injuries are very traumatic injuries as the initial injury can evolve and worsen over time. - Burn injury is the result of a chemical injury or heat transfer from one site to another, causing tissue destruction through coagulation, protein denaturation, or ionization of cellular contents.  - Burn wound is not homogenous; rather, tissue necrosis occurs at the center of the injury with regions of tissue viability toward the periphery. - The central area of the wound is termed the zone of coagulation due to the characteristic coagulation necrosis of cells that occurs. - The surrounding zone, the zone of stasis, describes an area of injured cells that may remain viable but, with persistent ischemia, will undergo necrosis within 24 to 48 hours. - The outermost zone, the zone of hyperemia, sustains minimal injury and may fully recover spontaneously over time. Figure 57-4 Zones of burn injury. Each burned area has three zones of injury. The zone of coagulation (the innermost area, where cellular death occurs) sustains the most damage. The zone of stasis (the middle area) has a compromised blood supply, inflammation, and tissue injury. The zone of hyperemia (the outermost area) sustains the least damage. Source: Hinkle & Cheeves 2022; Brunner & Suddarth’s Medical-Surgical Nursing, 15ed. - The skin and the mucosa of the upper airways are the most common sites of tissue destruction, although deep tissues, including the viscera, can be damaged by electrical burns or by prolonged contact with a heat or chemical source. - Release of local mediators and changes in blood flow, tissue edema, and infection can cause progression of the burn injury. - Potential mechanism of burn injury is radiation exposure. Radiation injuries produce Two detrimental effects; 1. Thermal effect, which results in cutaneous burn injuries. 2. Damage to the cellular deoxyribonucleic acid (dna), which may be localized or affect the whole body. Morbidity and mortality are dose dependent. - Depth of a burn injury depends on the temperature of the burning agent and the duration of contact with the agent. - In adults, exposure to temperatures of 54°C (130°F) for 30 seconds will result in burn injury.  = At 60°C (140°F), tissue destruction occurs in 5 seconds (this is a common setting for home water heaters; = At 71°C (160°F) or higher, a full thickness burn occurs instantaneously (ABA, 2011). - Major burn injuries -affect more than 30% TBSA, produce both local and systemic effects characterized by burn wound edema, generalized edema formation in noninjured tissue, increased metabolic rate (hyper-metabolism), hyperdynamic circulation, increased oxygen and glucose consumption, catabolism of muscle and bone, immune dysfunction, insulin resistance, and impaired organ perfusion (Flores, Stockton, Roberts, et al., 2015; Snell et al., 2013). - Severe injuries- encompass changes in pathophysiology of all body systems. = Initially, these responses are compensatory adaptive responses to the burn injury, but quickly become counterproductive events negatively impacting recovery (Abdullahi & Jeschke, 2014). = seen in trauma, but the magnitude, duration, and severity are significantly higher with burn injuries. ELECTRICAL BURNS Electrical injuries are devastating and complex burns. - Heat generated by electricity is directly responsible for tissue damage, but unlike most thermal burns, visual examination is not predictive of burn size and severity. - It is helpful to know the circumstances of the injury to anticipate potential tissue damage and complications. Mechanisms of Injury: 1. Flash Injury- An electrical flash generates light and heat. Injury is caused by the heat generated to exposed areas, or by flames from ignition of clothing. - thermal burns and have fewer complications; patients with flash injuries have shorter lengths of hospital stay than those with conductive injuries. 2. Conductive Injury - occur when the current overcomes the skin’s resistance and travels through the body. - amount and severity of tissue damage is directly proportional to the strength of the current (voltage), duration of contact with the source, which organs lay along the pathway of current, and whether the current is direct or alternating. - Conduction of electricity through the nerves and vessels and along the outside of bones generates heat, causing damage to adjacent tissues and direct injury to the peripheral nerves. - Deep muscle injury may be present without injury to superficial muscles, masking the true extent of the injury. - Electrical current immediately contracts muscles as it travels through the body causing possible skeletal and joint injuries in high-voltage contact. 3. Lightning Injury- can result from a direct strike, a high-voltage DC injury that is usually fatal, or a side flash wherein the current discharges from an object nearby through the air to an adjacent object or person. - Side flashes are the most common cause of injury and result in immediate deep polarization of the entire myocardium with possible cardiac arrest. - -Respiratory arrest is also expected because electric current can temporarily inactivate the brain’s respiratory center. Management 1. Resuscitation fluid calculations based on total body surface area. 2. Serum creatinine kinase levels are useful in determining the degree of muscle injury in the early phases of care. - Myoglobinuria (excess of myoglobin in the urine) -common with muscle damage, may cause kidney failure if not treated. - caused by muscle breakdown, releasing a high amount of myoglobin in the blood. Myoglobinuria can lead to acute kidney injury. 3. IV fluid administration titrated to a higher target of urine output per hour than usual may be indicated until the urine is no longer red. - Common practice to add 50 mEq of sodium bicarbonate per liter of IV fluid in an effort to assist in alkalinizing the urine. 4. Serum myoglobin and urine myoglobin levels may be monitored as indicators of the need for continued resuscitation. Surgical treatment of an electrical injury- is as complex as the injury itself. - Vasculature is commonly affected; thus, progressive tissue necrosis occurs over time. - Sequential surgical debridement - using caution to preserve viable tissue..Cardiovascular Alterations: - Immediate decrease in cardiac output that precedes the loss of plasma volume, - Vasoconstriction compensatory responses secondary to plasma volume loss, the workload of the heart and oxygen demand increase. - Hypovolemia is the immediate consequence of ensuing plasma volume loss and results in decreased perfusion and oxygen delivery. = As fluid loss continues due to capillary leakage, and vascular volume decreases, cardiac output continues to decrease and the blood pressure drops (onset of burn shock). = systemic inflammation causes the release of free oxygen radicals that increase capillary permeability, causing increased plasma loss and subsequent peripheral edema. = As a compensatory response to intravascular fluid loss, the sympathetic nervous system releases catecholamine, resulting in an increase in peripheral resistance (vasoconstriction) and an increase in pulse rate that decreases tissue perfusion. Pathophysiologic Changes with Severe Burns: Source: Hinckle & Cheeves (2022) Brunner & Suddarth’s ;Medical-Surgical Nursing, 15ed. Management: - Prompt, appropriate fluid resuscitation maintains the blood pressure in the low to normal range and improves cardiac output. Note: Despite adequate fluid resuscitation, cardiac filling pressures (central venous pressure, pulmonary artery pressure, and pulmonary artery wedge pressure) remain low during the initial burn shock period.  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.  Intrinsic diuresis will begin and continue for several days to 2 weeks in the previously healthy adult. Fluid and Electrolyte Alterations - Edema forms rapidly after a burn injury. - A superficial burn will cause edema to form within 4 hours, whereas a deeper burn will continue to form edema up to 18 hours post-injury. - Caused by increased perfusion to the injured area in the presence of increased capillary permeability and reflects the amount of microvascular and lymphatic damage to the tissue. - In burns greater than 30% TBSA, inflammatory mediators stimulate local and systemic reactions resulting in extensive shift of intravascular fluid, electrolytes, and proteins into the surrounding interstitium. (Snell et al., 2013). Concept Mastery Alert For patients in the emergent/resuscitative phase, nurses should do a primary survey and monitor circulation. As the taut, burned tissue becomes unyielding to the edema underneath its surface, it begins to act like a tourniquet, especially if the burn is  circumferential. As edema increases, pressure on small blood vessels in the distal extremities causes an obstruction of blood flow and consequent tissue ischemia and compartment syndrome. Patients in the acute/intermediate phase must be closely monitored for the development of venous thromboembolism (VTE). Treatment for Edema 1. Elevation of the extremity or, in severe cases, cutting of the eschar (devitalized tissue) via escharotomy (surgical incision through eschar) or decompression of edema formation via fasciotomy (surgical incision through fascia to relieve constricted muscle) to restore tissue perfusion (Figure 57-6) Figure 57-5 Escharotomy of forearm. Used with permission from University of Texas Medical Branch, Galveston, TX. Source: Hinkle & Cheeves (2022) Brunner & Suddarth’s Medical-Surgical Nursing, 15ed. Figure 57-6 Fasciotomy of upper arm. Used with permission from University of Texas Medical Branch, Galveston, TX. Source: Hinkle & Cheeves (2022) Brunner & Suddarth’s Medical-Surgical Nursing, 15ed. 2. Reabsorption of edema begins at about 4 hours post-injury and is complete by 4 days post-burn injury. The rate of reabsorption depends on the depth of injury to the tissue. Although adequate fluid resuscitation is paramount to maintaining tissue perfusion, excessive fluid administration increases edema formation in both burned and unburned tissue causing ischemia and necrosis. 3. Immediately after burn injury, hyperkalemia may result from massive cell destruction. - Hypokalemia may occur later with fluid shifts and inadequate potassium replacement. - Serum sodium levels vary in response to fluid resuscitation. =Hyponatremia -present as a result of plasma loss or may also occur during the first week of the acute phase, as water shifts from the interstitial space and returns to the vascular space. 4. At the time of burn injury, some RBC may be destroyed and others damaged, resulting in anemia. - Hematocrit may be elevated due to plasma loss. - Abnormalities in coagulation, including a decrease in platelets (thrombocytopenia) and prolonged clotting and prothrombin times. Pulmonary Alterations - Inhalation injury is caused by inhalation of thermal and/or chemical irritants. - Inhalation injuries are categorized as upper airway injury (above the glottis) or lower airway injury (below the glottis).  - Injuries above the vocal cords can be thermal or chemical, whereas injuries below the vocal cords are usually chemical (ABA, 2011). - Approximately 2% to 14% of patients admitted to burn centers have an inhalation injury (ABA, 2018). 1. Upper airway injury is obstructive and is caused by severe upper airway edema from direct thermal injury or secondary edema from face or neck burns in the early post- burn period. Protective intubation is often warranted to maintain patency of the airway (ABA, 2018; Jones et al.,2017). Because of the cooling effect of rapid vaporization in the oropharynx, direct heat injury does not normally occur below the level of the glottis. 2. Lower Airway Injury - Inhalation injury below the glottis results from inhaling the products of incomplete combustion or noxious gases and is often the source of death at the scene of a fire. - Smoke inhalation injuries cause loss of ciliary action, trigger an inflammatory response causing hypersecretion, and produce severe mucosal edema and possibly bronchospasm. - A reduction in alveolar surfactant production produces atelectasis (collapse of alveoli) in the parenchyma. - Expectoration of carbon particles in the sputum is the cardinal sign of this injury. - Aggressive pulmonary toilet is critical to maintain airway patency and clear resulting viscous sputum. - Contributing Factors: Noxious gases, such as carbon monoxide (CO) and hydrogen cyanide. CO poisoning is a factor in most fatalities at the scene of a fire as it combines with hemoglobin and displaces oxygen to form carboxyhemoglobin. Kidney Alterations - Kidney function may be altered as a result of decreased blood volume post-burn injury due to the compensatory response to intravascular volume loss. - Adequate fluid volume replacement can restore renal blood flow, increasing the glomerular filtration rate and urine volume. - Destruction of RBC at the injury site results in free haemoglobin in the urine. If muscle damage occurs (from electrical burns), myoglobin is released from the muscle cells and excreted by the kidneys causing the urine to be red. - Inadequate blood flow through the kidneys caused by the hemoglobin and myoglobin occluding the renal tubules, acute tubular necrosis and acute kidney injury will occur. - Increased abdominal pressure from the injury can also cause kidney ischemia. Immunologic Alterations: - immunologic defenses of the body are greatly altered by a burn injury. - Skin is the largest barrier to infection, and when it is compromised, the patient is continually exposed to the environment. - produces systemic release of cytokines and other substances that cause leukocyte and endothelial cell dysfunction. - Burn center provide an infection-controlled environment to protect the patient and minimize exposure to potentially harmful organisms. Thermoregulatory Alterations - Integumentary loss results in an inability to regulate body temperature.  - Patients with burn injuries may exhibit low body temperatures in the early hours after injury. Hostler, Weaver, Ziembicki, et al. (2013) found that hypothermia (core temperature less than 36.5°C [97.7°F]), on admission of patients to the hospital was an independent predictor of mortality. - Intraoperative hypothermia, exacerbated by exposure during prolonged surgeries, combined with general anesthesia’s blunting of metabolic and neurologic hypothermic responses, also poses challenges to successfully treating patients with major burns (Davis, Rodriquez, Quintana, et al., 2013). Gastrointestinal Alterations - Predisposed to altered GI motility. - Impaired enteric nerve and smooth muscle function, inflammation, surgery, medications such as vasopressors, and inadequate tissue perfusion are some causes of GI dysfunction. - Indicators of GI organ ischemia include increased bladder pressure, increasing serum lactate, and feeding intolerance (Trexler, Lundy, Chung, et al., 2014). - Three most common GI alterations: 1. paralytic ileus (absence of intestinal peristalsis), 2. Curling’s ulcer, 3. translocation of bacteria. - Decreased peristalsis and bowel sounds are manifestations of paralytic ileus. - Gastric distention and nausea may lead to vomiting - gastric decompression is advised. - Gastric bleeding secondary to massive physiologic stress may be signaled by occult blood in the stool, regurgitation of “coffee ground” material from the stomach, or bloody vomitus (signs suggest gastric or duodenal erosion (Curling’s ulcer). - Large TBSA burns are also at risk for life-threatening ACS due to large volumes of fluid required for resuscitation, fluid shifts to the interstitium causing edema formation, and decreased abdominal wall compliance due to eschar formation. Increased pressure in the abdominal cavity contributes to GI tract and abdominal organ ischemia. MANAGEMENT OF BURN INJURY: Categorized into three phases of care: A. Emergent/Resuscitative Phase: On-the-Scene Care 1. Remove the patient from the source of injury and stop the burning process while preventing injury to the rescuer. 2. Establishing an airway - supplying oxygen (100% oxygen if carbon monoxide poisoning) 3. Inserting at least one large-bore iv line, 4. Covering the wound with a clean, dry cloth or gauze. Continuous irrigation of chemical injury must begin immediately.  An immediate primary survey of the patient is carried out to assess the ABCDEs: - Airway (A) with consideration given to protecting the cervical spine, gas exchange or - Breathing (B), - Circulatory and cardiac status (C), - Disability (D) including neurologic deficit, - Expose and examine (E) while maintaining a warm environment (ABA, 2018).  Phases of Burn Care Phase Duration Priorities Emergent/resuscitative From onset of  Primary survey: A, B, C, D, E injury to  Prevention of shock completion of  Prevention of respiratory distress fluid  Detection and treatment of resuscitation concomitant injuries  Wound assessment and initial care Acute/intermediate From beginning  Wound care and closure of diuresis to  Prevention or treatment of near completion complications, including infection of wound closure  Nutritional support Rehabilitation From major  Prevention and treatment of wound closure to scars and contractures return to  Physical, occupational, and individual’s vocational rehabilitation optimal level of  Functional and cosmetic physical and reconstruction psychosocial  Psychosocial counseling adjustment Adapted from American Burn Association. (2018). Advanced burn life support (ABLS) course provider manual 2018. Chicago, IL: Author; Serghiou, M. A., Ott, S., Source: Hinkle & Cheeves (2022) Brunner & Suddarth’s Medical-Surgical Nursing, 15ed. QUALITY AND SAFETY NURSING ALERT: Airway patency and breathing must be assessed during the initial minutes of emergency care. Immediate therapy is directed toward establishing a patent airway and giving humidified 100% oxygen. If qualified personnel and equipment are available and the victim has severe respiratory distress and/or airway edema, the rescuers must insert an endotracheal tube and initiate mechanical ventilation. QUALITY AND SAFETY 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 may occur and protection of the airway is always a priority. Medical Management: I. Initial priorities in the ED remain airway, breathing, and circulation. - For mild pulmonary injury, 100% humidified oxygen is given, and encourage the patient to cough so that secretions can be expectorated or removed by suctioning. - For more severe situations- remove secretions by bronchial suctioning and to give bronchodilators and mucolytic agents. Emergency Procedures at the Burn Scene 1. Extinguish the flames or remove from source. When clothing catches fire, the flames can be extinguished if the person drops to the floor or ground and rolls (“stop, drop, and roll”); anything available to smother the flames, such as a blanket, rug, or coat, may be used. - older adult, or others with impaired mobility, could be instructed to “stop, sit, and pat” to prevent concomitant musculoskeletal injuries.  - Standing still forces the person to breathe flames and smoke, and running fans the flames. If the burn source is electrical, the electrical source must be disconnected safely before moving the patient. 2. Cool the burn. After the flames are extinguished, the burned area and adherent clothing are soaked with cool water, briefly, to cool the wound and halt the burning process. -- Never apply ice directly to the burn, never wrap the person in ice, and never use cold soaks or dressings for longer than several minutes; such procedures may worsen tissue damage and lead to hypothermia in people with large burns. - Remove restrictive objects. If possible, remove clothing immediately. - Adherent clothing may be left in place once cooled. - Other clothing and all jewelry, including all piercings, should be removed to allow for assessment and to prevent constriction secondary to rapidly developing edema. 3. Cover the wound - cover as quickly as possible to minimize bacterial contamination, maintain body temperature, and decrease pain by preventing air currents from coming in contact with the injured surface. - Any clean, dry cloth can be used as an emergency dressing. - Ointments and salves should not be used. Other than the dressing, no medication or material should be applied to the burn wound at the scene. 4. Irrigate chemical burns. Chemical burns resulting from contact with a corrosive material are irrigated immediately. - brush off the chemical agent, remove clothes immediately, and rinse all areas of the body that have come in contact with the chemical. - Rinsing can occur in the shower or any other source of continuous running water. - If a chemical gets in or near the eyes, the eyes should be flushed with cool, clean water immediately. - Outcomes for the patient with chemical burns are significantly improved by rapid, sustained flushing of the injury at the scene. Adapted from American Burn Association. (2018). Advanced burn life support (ABLS) course provider manual 2018. Chicago, IL: The secondary survey focuses on obtaining a history, the completion of the total body systems assessment, initial fluid resuscitation, and provision of psychosocial support of the conscious patient (ABA, 2018). I. Medical Management: 1. Initial priorities in the ED remain airway, breathing, and circulation. For mild pulmonary injury, 100% humidified oxygen is given, and the patient is encouraged to cough so that secretions can be expectorated or removed by suctioning. For more severe situations, it may be necessary to remove secretions by bronchial suctioning and administer bronchodilators and mucolytic agents. 2. Continuous monitoring of airway patency is critical; a previously stable airway may rapidly deteriorate as edema increases and toxic effects of smoke inhalation become apparent. II. Fluid resuscitation is initiated in burns greater than 20% TBSA - to maintain adequate organ perfusion. - Baseline weight and laboratory test results – must be monitored closely in the immediate post-burn (resuscitation) period.  - Shock, ischemic complications, and multiple organ dysfunction syndrome (MODS) occur with under-resuscitation. - Heart failure and pulmonary edema occur with over-resuscitation. - Peripheral IV access may be initially obtained- larger burns, central venous access is - recommended due to the large volumes required. - TBSA is calculated and fluid resuscitation with lactated Ringers (LR) should be initiated using ABA fluid resuscitation formulas. - Lactated Ringers solution (LR) - crystalloid of choice because its pH and osmolality most closely resemble human plasma. The ABA (2018) fluid resuscitation formula for adults within 24 hours post thermal or chemical burn is as follows:  2 mL LR × patient’s weight in kilograms × %TBSA second-, third-, and fourth-degree burns  For adults with electrical burns: 4 mL LR × patient’s weight in kilograms × %TBSA second-, third-, and fourth-degree burns  Timing is one of the most important considerations in calculating fluid needs in the first 24 hours post burn. = The starting point is the time of injury —not the time of arrival to the treating facility (ABA, 2018).  Regulation: = One half of the total calculated volume is given in the first 8 hours post- burn injury. = The second half of the calculated volume is given over the next 16 hours. Note: These formulas are only guidelines. It is imperative that the rate of infusion be titrated hourly as indicated by physiologic monitoring of the patient’s response. Each patient has a unique injury and optimum results require individualized treatments based on patient response (Gillenwater & Garner, 2017).  For adults: (ABA 2018) Urine output: 0.5 to 1 mL/kg/h is used as an indication of appropriate resuscitation in thermal and chemical injuries, Urine output: 75 to 100 mL/h for electrical injuries.  Chemical burns flushing of the exposed areas with copious amounts of clean water is continued.  Eyes are examined promptly for injury to the corneas.  Temperature must be monitored because hypothermia may develop rapidly and manipulation of the environment may be necessary. Temperature less than 35°C (95°F) causes vasoconstriction, which may increase tissue ischemia and necrosis.  An indwelling urinary catheter is inserted to permit accurate monitoring of urine output and as a measure of kidney function and fluid needs for patients with moderate to severe burns.  Burn exceeds 20% to 25% TBSA, a nasogastric tube is inserted and connected to low intermittent suction. All patients who are intubated should have a nasogastric tube inserted to decompress the stomach, and to prevent vomiting and aspiration.  Clean sheets are placed under and over the patient to protect the burn wound from contamination, maintain body temperature, and reduce pain caused by air currents passing over exposed nerve endings.   Baseline height, weight, arterial blood gases, hematocrit, serum electrolytes, blood alcohol level, drug panel, urinalysis, and chest x-rays,  ECG and continuous cardiac monitoring. QUALITY AND SAFETY NURSING ALERT  Blood pressure cuff can be placed around a patient’s burned extremity. The cuff must be of the correct size with accommodations made for edema. CIRCULATION (RESUSCITATION) 1. Patients with burns less than 20% BSA can be effectively resuscitated from burn shock using oral solutions; many patients with burns up to 40% TBSA can also be safely resuscitated. A. There are many formulas for oral rehydration solutions, but all include clean water, glucose, and electrolytes. Adapted from ABA 2022; “Guidelines for Burn Care Under Austere Conditions” B. Adults and children > 2 years should be allowed to take sips from a cup frequently, with the goal of consuming approximately 8 to 10 ounces every 10 to 15 minutes. C. Very young children < 2 years should be given a teaspoon of fluid every 1 to 2 minutes. D. Oral fluids should be given in amounts tolerated by the patient, accepting the occasional episode of nausea and vomiting as inevitable but not a reason to discontinue oral therapy. 2. For patients with burns >20%, IV resuscitation, if supplies permit, should be utilized using the Parkland formula. (Adapted from ABA 2022; “Guidelines for Burn Care Under Austere Conditions” In resource-constrained environments, IV resuscitation may need to be restricted to survivable burns >40%. A. Total mL 24 hour fluid requirement = 4mL LR x Kg body weight x %TBSA B. Give ½ during the first 8 hours post injury and ½ during the following 16 hours C. Example: 4mL x 70 Kg patient x 50% TBSA = 14,000mL  D. Give 7000mL during first 8 hours (875mL/hour) and 7000mL during following 16 hours (437.5mL/hour) E. Monitor hourly urine output: 30-50mL/hour for adults, 1m/Kg/hour for children F. Other endpoints of resuscitation as able: Vital signs, Hct, Lactate, Base Deficit G. Increase/decrease fluids by 10-20% each hour according to urine output. Beware of abdominal compartment syndrome if fluid rate gets to 6mL/Kg/hour. If the patient is not responding to increases crystalloid volume consider 5% Albumin or FFP. If means of communication available, contact a burn surgeon for assistance or consider re-triage of resources. Nursing Management 1. Cardiac monitoring- cardiac disease, electrical injury, or respiratory conditions. 2. Vital signs and hemodynamic status such as tachycardia and tachypnea. - Burned extremities- A clean dressing applied under the blood pressure cuff protects the wound from contamination. - Increasing edema makes blood pressure difficult to auscultate, a Doppler (ultrasound) device or a noninvasive electronic blood pressure device. - Severe burns - arterial catheter is used for blood pressure measurement and for collecting blood specimens. - Peripheral pulses of burned extremities are checked frequently, either by palpation or the use of a Doppler if necessary. 3. Elevation of burned extremities above the level of the heart to decrease edema. 4. Large-bore IV catheters (14 to 18 gauge) and an indwelling urinary catheter are inserted and hourly assessment of intake and urine output. 5. Red-colored urine- presence of hemochromogens from damage to red blood cells and myoglobin resulting from muscle damage. 6. Glycosuria - common finding in the early post-burn hours, results from the release of liver glycogen stores in response to stress. 7. Assists with calculating the patient’s expected fluid requirements and monitoring the patient’s response to fluid resuscitation. Nursing responsibilities: - Administration of fluids, - strict monitoring of fluid intake and output, - monitoring patient response, and notifying the treatment team of significant assessment findings and any abnormal laboratory values. - A head-to-toe assessment is performed, focusing on signs and symptoms of concomitant illness, associated injury, or developing complications. - Assessing the extent of the burn wound using the rule of nines or facilitated with anatomic diagrams is performed. - Assess the initial areas of full- and partial thickness injury. B. ACUTE/INTERMEDIATE PHASE - begins 48 to 72 hours after the burn injury. - Assessment and maintenance of respiratory and circulatory status, fluid and electrolyte balance, and GI and kidney function. - Infection prevention - burn wound care (wound cleaning and débridement, topical antibacterial therapy, application of dressings, and wound grafting), - Pain management - modulation of the hypermetabolic response, and early positioning/mobility. Medical Management - Airway obstruction- caused by upper airway edema can take as long as 48 hours to develop. 1. Monitoring of arterial blood gases with carboxyhemoglobin levels, and direct observation of the airway by fiberoptic bronchoscopy (Dries & Endorf, 2013). 2. To lessen the effects of upper airway edema, elevation of the patient’s head of the bed. - Stridor and dyspnea are ominous- late signs of impending airway obstruction. 3. Early protective intubation to maintain airway patency should be considered as obstruction may occur very rapidly. 4. Late pulmonary complications secondary to inhalation injuries- mucosal sloughing of the airway and casts formed from cellular debris, which can lead to obstruction, increased secretions, inflammation, atelectasis, airway ulceration, pulmonary edema, and tissue hypoxia (Snell et al., 2013). - Pneumonia, acute lung injury (ALI), and ARDS. - Ventilator-associated pneumonia (VAP) - complication of hospitalized and mechanically ventilated, and exacerbated in patient with an inhalation injury. - It affects as many as 10% to 20% of patients on mechanical ventilation longer than 48 hours. 5. As capillaries regain integrity, 48 or more hours after the burn, fluid moves from the interstitial to the intravascular compartment and intrinsic diuresis begins. 6. If cardiac or kidney function is inadequate, fluid overload may occur and symptoms of heart failure may result. 7. Administration of fluids and electrolytes continues - due to fluid shifts, evaporative fluid loss from large burn wounds, and the patient’s physiologic responses to the burn injury. 8. Blood components are given as needed to treat surgical blood loss and anemia. 9. Hyperthermia- common in patients after burn shock resolves. - A resetting of the core body temperature - severely burned results in a body temperature a few degrees higher than normal for several weeks after the burn. This can be compounded by body temperature increases from sepsis. 10. Central venous, peripheral arterial, or specialty catheters - for monitoring hemodynamics. - burned areas of the body are avoided as insertion sites for invasive lines. 11. Early excision – necrotic tissue is removed and underlying viable tissue is preserved. - Early excision of dead tissue with wound closure and/or application of biologic or synthetic wound covering reduces the effects of inflammatory mediators that cause pathophysiologic abnormalities (Rousseau et al., 2014). Infection Prevention - Loss of the barrier function of the skin for protection against invasive microorganisms; - Necrotic tissue in burn eschar combines with serum proteins to produce an environment conducive to bacterial growth; - Effects of thermal injury compromise both cell-mediated and systemic intrinsic immunity Note: Pathogens can be transmitted directly by health care staff through contact or droplets, or indirectly through the environment or equipment (Meyerson et al., 2015). Therefore, the nurse prioritizes infection prevention in the plan of care. - Causative agents of burn infections may include bacteria, fungi, or viruses.  - Infection impedes burn wound healing by promoting excessive inflammation and damaging tissue. - Clinical signs of infection- progressive erythema, warmth, tenderness, and malodorous exudate. A multiple-strategy approach is crucial in prevention and control of burn wound infections,(Mayhall, 2012): 1. Use of barrier techniques (e.g., gowns, gloves, eye protection, and masks if needed) 2. Environmental cleaning with periodic cultures of patient care equipment (with special attention to hydrotherapy equipment) 3. Application of appropriate topical antimicrobial agents 4. Appropriate use of systemic antibiotic and antifungal agents (careful use and close monitoring of culture sensitivities are needed due to increasing challenges of antibiotic resistance in health care environments) 5. Early excision and closure of the burn wound 6. Control of hyperglycemia (with insulin as indicated, even in a patient without a prior diagnosis of diabetes) 7. Culture on admission to screen for the presence of methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci. - Wounds are generally cultured on admission, with each surgical case, and for clinical suspicion of infection. - Antimicrobial therapy is tailored to culture results. Wound Cleaning 1. Proper management of burn wounds is required to prevent wound deterioration. Goal of wound care: To remove nonviable tissue and wound exudate, and eliminate previously applied topical agents. 1. Gentle cleaning with mild soap, water, and a washcloth can prevent infection by decreasing bacteria and debris on the wound surface. - Hair in and around the burn area, except the eyebrows, should be clipped short or shaved. - Hemodynamically unstable- wounds washed at the bedside, whereas patients who are ambulatory may shower. 2. Strategies for the prevention of cross-contamination - use of plastic liners, water filters, and thorough decontamination of equipment. 3. During bathing, patient participation is encouraged to promote exercise of the extremities. 4. At the time of wound cleaning, all skin is inspected for any signs of redness, breakdown, or local infection. 5. Provides the nurse an opportunity for patient education. 6. Encouraging family presence during wound care can improve patient and family satisfaction, nursing communication, and optimize patient outcomes. 7. During treatment, the patient is continuously assessed for signs of hypothermia. - water temperature is maintained at 37.8°C (100°F), and the temperature of the room should be maintained between 26.6° and 29.4°C (80° and 85°F) to prevent hypothermia. 8. Other assessment considerations - fatigue, changes in hemodynamic status, and pain unrelieved by analgesic medications or relaxation techniques. Topical Antibacterial Therapy Goal: To provide a dressing with the following characteristics:  1. Is effective against gram-positive and gram-negative organisms and fungi 2. Penetrates the eschar but is not systemically toxic 3. Is cost-effective, available, and acceptable to the patient 4. Is easy to apply and remove, and decreases the frequency of dressing changes, decreases pain, and minimizes nursing time QUALITY AND SAFETY NURSING ALERT: Prudent use and alternation of antimicrobial agents can result in reduction of resistant strains of bacteria, greater effectiveness of the agents, and a decreased risk of sepsis. Wound Dressing: - After the prescribed topical agents are applied, the wound is covered with several layers of dry dressings with lighter dressing over joints to allow for mobility. - Dressings may need to be modified to accommodate splints or other positioning devices. - Circumferential dressings should always be applied distally to proximally in order to promote return of excess fluid to the central circulation. - If the hand or foot is burned, the fingers and toes should be wrapped individually to promote mobility and function while 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 is required to ensure that the topical agent does not come in contact with the eyes or mouth. A light dressing can be applied to the face to absorb excess exudates if needed. - Occlusive dressings, gauze, and a topical antimicrobial agent - used over areas with new skin grafts; a. to protect the new graft b. promote an optimal condition for its adherence to the recipient site. = Surgical dressings remain in place for 3 to 5 days, - are removed for examination of the graft. = When occlusive 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 regular repositioning of the patient. QUALITY AND SAFETY NURSING ALERT Dressings can impede circulation if they are wrapped too tightly. The peripheral pulses must be checked frequently and burned extremities elevated. If the patient’s pulse is diminished, this is a critical situation and must be addressed immediately. Overview of Select Topical Antimicrobial Agents Used for Burn Wounds: Wound Débridement - removal of devitalized tissue. Goals: 1. Removal of devitalized tissue or burn eschar in preparation for grafting and wound healing 2. Removal of tissue contaminated by bacteria and foreign bodies, thereby protecting the patient from invasion of bacteria Types of Débridement: 1. Natural Débridement - devitalized tissue separates from the underlying viable tissue spontaneously.  - Bacteria present at the interface of the burned tissue and the viable tissue gradually liquefy the fibrils of collagen that hold the eschar in place. - Collagen is a protein present in skin, tendon, bone, cartilage, and connective tissue. 2. Mechanical Débridement - involves the use of surgical tools to separate and remove the eschar. - usually done with daily dressing changes. - If bleeding occurs, hemostatic agents or pressure can be applied to achieve hemostasis. - Dressing changes and wound cleaning aid the removal of wound debris. Wet-to-dry dressings are not advocated in burn care because of the possibility of removing viable cells along with necrotic tissue. 3. Chemical Débridement -Topical enzymatic agents are available to promote débridement of burn wounds.. - Heavy metals such as silver can deactivate débriding agents; therefore, caution is necessary to ensure that the topical antimicrobial agent does not interfere with the chemical débridement. - Alternating topical medications with dressing changes may also be considered. 4. Surgical Débridement - - Early surgical excision to remove devitalized tissue along with early burn wound closure is recognized as one of the most important factors contributing to survival in a patient with a major burn injury. - Surgical débridement is carried out before the natural separation of eschar occurs. - may be performed as soon as possible after the burn, once the patient is hemodynamically stable and edema has decreased. - Wound Grafting: Deep partial- or full-thickness burns: a. decrease the risk of infection; b. prevent further loss of protein, fluid, and electrolytes through the wound; c. minimize evaporative heat loss Autografts: - Autografting remains the preferred autologous method for definitive burn wound closure after excision. - Autografts are the ideal means of covering burn wounds because the grafts are the patient’s own skin; therefore are not rejected by the patient’s immune system. - If blood, serum, air, fat, or necrotic tissue is present between the recipient site and the graft, there may be partial or total loss of the graft. - Infection, mishandling of the graft, sheer injury with mobilization or trauma during dressing changes account for most other instances of graft loss. - Use of split-thickness grafts allows the remaining donor site to retain sweat glands and hair follicles, minimizing healing time.  Figure 57-7 Split-thickness sheet graft. Used with permission from University of Texas Medical Branch, Galveston, TX. Figure 57-8 Split-thickness meshed graft. Used with permission from University of Texas Medical Branch, Galveston, TX.  Cultured epithelial autograft (CEA) has emerged as an important procedure in the management of massive burns.  In burns that cover more than 90% TBSA, CEA an option because the availability of nonburned skin as donor sites will not be sufficient for grafting.  CEA involves obtaining full-thickness biopsies of the patient’s unburned skin that are cultured to promote growth of keratinocytes. The final product is available approximately 3 weeks later for grafting. Figure 57-9 Application of cultured epithelial autologous grafts. Used with permission from University of Texas Medical Branch, Galveston, TX. Care of the Graft Site: 1. Protection is key in caring for skin grafts postoperatively. 2. Occlusive dressings are commonly used initially after grafting to immobilize the graft and support a humid environment. 3. First dressing change - 2 to 5 days after surgery, or earlier in the case of clinical signs of infection or bleeding. 4. Infection, bleeding beneath the graft, and shearing forces are the most common reasons for graft loss in the early postoperative period. 5. The patient is positioned and turned carefully to avoid disturbing the graft or putting pressure on the graft site. 6. If an extremity has been grafted, it is elevated to minimize edema. 7. Patient may begin exercising the grafted area 5 to 7 days after surgery. This may vary with individual burn center’s protocols. Care of the Donor Site: - donor site is a clean wound created in a surgical environment. - After the donor skin is excised, a hemostatic agent such as thrombin or epinephrine may be applied directly to the site to promote hemostasis. - A myriad of dressings are available to cover donor sites. - Donor sites must remain clean, dry, and free from pressure. Because a donor site is usually a partial-thickness wound, it is very painful and an additional potential site of infection. - With proper care, the donor site should heal spontaneously within 7 to 14 days in a previously healthy, nonsmoking adult. Biosynthetic and Synthetic Dressings - widely used synthetic dressing is Biobrane® a dual-layer dressing of nylon and silicone (Jeschke, Finnerty, Shahrokhi, et al., 2013).  - Material is porous, semi-transparent, and sterile. Figure 57-10 Biobrane® applied to hand and forearm. Used with permission from University of Texas Medical Branch, Galveston, TX. Pain Management - nature of the injury may expose nerve endings; and the patient may require multiple débridements, surgeries, and treatments. - provide a long-acting analgesic agent that will provide even coverage for this long-term discomfort. - Use escalating doses when initiating the medication to reach the level of pain control that is acceptable to the patient and facilitates participation in their recovery. Nursing management: 1. Restoring fluid balance - daily weights and careful calculation of intake and output measurement 2. Preventing infection - providing a clean environment, including the promotion of protective isolation interventions. 3. Modulating hypermetabolism- collaborates with the dietitian or nutrition support team to develop a plan that meets the needs of the patient. 4. Promoting skin integrity - make astute assessments of wound status, use creative approaches to wound dressings, and support the patient during the emotionally distressing and significantly painful experience of wound care. 5. Relieving pain and discomfort- Frequent assessment of pain is required, and analgesic and anxiolytic medications are given as prescribed. - Oral antipruritic agents, environmental conditions, frequent lubrication of the skin with water or silica-based lotion, and diversion activities all help to promote comfort 6. Promoting mobility- Deep breathing, turning, and proper positioning are essential nursing practices that prevent atelectasis and pneumonia, control edema, and prevent pressure ulcers and contractures.  7. Strengthening coping strategies - enlist someone to whom the patient can express feelings without fear of retaliation. - set realistic expectations for self-care and planning for the future. 8. Supporting patient and family processes - providing support to the patient and family as they adapt to the burn injury. 9. Monitoring and managing complications- Acute respiratory failure and Acute respiratory distress syndrome- respiratory status is monitored closely for increased difficulty in breathing, change in respiratory pattern, or onset of adventitious (abnormal) breath sounds. C. Rehabilitation Phase - Rehabilitation begins immediately after the burn has occurred and often extends for years after the initial injury. - Burn rehabilitation is comprehensive, complex, and requires a multidisciplinary approach to optimize the patient’s physical and psychosocial recovery related to the injury. I. Psychological Support - A patient’s outlook, motivation, and support system are important to their overall well- being and ability to progress. - Life-altering nature of burn injuries almost always causes temporary or permanent impairment of psychosocial adaptation. - Early consultation with mental health professionals will assist to best meet individual needs, which may include pharmaceutical interventions with concurrent counseling. TABLE 62-5 Complications in Rehabilitation Phase of Burn Care: II: Abnormal Wound Healing  - Partial-thickness wounds involving the epidermis and superficial dermis tend to heal without scarring. - Deeper wounds will likely develop scarring of variable degrees. - Normal scarring occurs in a superficial tissue injury and begins forming within 7 to 10 days post-injury and progresses over the next 6 to 12 months. III: Hypertrophic and Keloid Scars - Hypertrophic scars form within the boundaries of the initial wound and push outward on the perimeter of the wound. - Common areas - over joints and in the younger population. -Scar becomes red (hypervascular nature), raised, and hard. - Keloid scars are irregularly formed and extend beyond the margins of the original wound. - large, nodular, and ropelike, often causing itching and tenderness. - more common in dark-pigmented skin, uncommon in children and older adults, and have familial tendencies. - Prevention and Treatment of Scars: 1. Compression is introduced early in burn wound treatment. 2. Elastic bandage wraps are used initially to help promote adequate circulation, BUT they can also be used as the first form of compression for scar management, followed by elasticized tubular bandages until the patient can be measured for a customized garment. NURSING INTERVENTIONS: 1. Promoting activity tolerance - physical and occupational therapy exercises in the patient’s care to prevent muscle atrophy and to maintain the mobility required for daily activities. 2. Improving body image and self-concept - social participation, employment, prestige, various roles, and status. - actively promote a healthy body image and self-concept in patients with burn injuries so that they can accept or challenge others’ perceptions of those who are disfigured or disabled. 3. Promoting physical mobility through preventing - Contractures or hypertrophic scar formation - With early and aggressive physical and occupational therapy, contractures or hypertrophic scars are rarely a long-term complication. 4. Monitoring and managing potential complications - Impaired psychological adaptation to the burn Injury. - Psychological counselling or psychiatric referral - 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. 5. Educating the patient about self-care - wound care, dressing changes, pain management, nutrition, prevention of complications, and other care needs. - Information and written instructions are provided about specific exercises and the use of pressure garments and splints. 6. Continuing and transitional care - After discharge, patients should receive follow-up from a burn center when possible for periodic evaluation by the burn team, modification of outpatient treatment plan, and evaluation for reconstructive surgery.  Critical Thinking Activities: Complete the following flow chart illustrating the pathophysiologic sequence of reactions that result from a systemic response to a burn injury. Part 2: Scenario 1 A 55-year-old man is hospitalized for a smoke inhalation injury with a 15% TBSA burn to his upper torso and extremities. He has been placed on 100% oxygen per non- rebreather mask and started on a morphine drip for pain control. He awakens when verbally stimulated, but he does not consistently follow directions. Questions: 1. What potential complications should be considered for this patient given his smoke inhalation injury and burns, and how might these complications influence his overall treatment plan and recovery? 2. Which evidence-based tools should you use to assess the patient’s neurologic and pulmonary status, and his response to pain management? 3. What evidence-based nursing interventions should be integrated into the plan of care to support his pulmonary status and to manage the distress associated with his burn and high oxygen requirement? Scenario 2 A 65-year-old man was admitted overnight to the burn unit with an 18% partial- thickness scald burn. The day after admission, in the early afternoon, you note that the patient’s heart rate has increased to 160 bpm, temperature is 38.7°C (101.7°F), and his capillary refill time has increased to greater than 2 seconds. Questions: 1. What are the potential underlying causes of the patient's elevated heart rate, increased temperature, and prolonged capillary refill time following his admission to the burn unit, and how might these signs indicate complications such as infection, fluid status, or systemic response to his burn injury? 1. After alerting the charge nurse, what interventions do you anticipate? 2. What are your priority interventions? Enumerate. References: Hinkle & Cheeves (2022), Brunner and Suddarth, Textbook of Medical-Surgical Nursing, 15th edition, Vol. 1 and 2 Brunner & Suddarth’s 2021.Textbook in Medical- Surgical Nursing 10th edition Vol. 1&2 I. Willis, Laura, 2020. Lippincott Williams & Wilkins, Fluids and Electrolytes Made Incredibly Easy,7th edition. Norris,2021, Porth’s Pathophysiology Concepts of Altered Health States, 10 th edition