Burn Injury Management PDF

Management of Patients With Burn Injury Chapter 57 1 Learning Objectives On completion of this chapter, the learner will be able to: 1. Identify the incidence and factors that...

Management of Patients With Burn Injury Chapter 57 1 Learning Objectives On completion of this chapter, the learner will be able to: 1. Identify the incidence and factors that affect severity of burn injury in the United States. 2. Describe the local and systemic effects of a major burn injury. 3. Use the nursing process as a framework for care of the patient in the emergent/resuscitative, acute/intermediate, and rehabilitative phases of a burn injury. 4. Compare priorities of care, including fluid replacement, wound management and 2 psychosocial support, and potential complications  Introduction All adults will experience a burn injury at some point in their lives. Burn injuries are painful, costly, disfiguring, require intensive and extensive rehabilitation therapy, and may be associated with long-term disability. Larger burns are associated with morbidity and mortality. A burn injury can affect people of all ages and socioeconomic groups. Patients with burns have particularly prolonged lengths of hospital stay. Men have more than twice the incidence of burn injury than women. The overall mortality rate at all ages groups is 2.9% 3 Incidence The causes of burns were classified as: -41%, was reported as flame -35% were scalds -10% were from direct source contact -3% were electrical -3% were chemical contact -3% were inhalation - 5% related to other causes 4 Gerontologic Considerations Mortality associated with burns are greater in older adult patients than in younger patients when comparing injuries with similar severity (15%). The skin of the older adult is thinner and less elastic, which affects the depth of injury and its ability to heal. Complications associated with burn injuries are also highest in patients 60 years and older (pneumonia, respiratory failure, septicemia, cellulitis, wound infection, kidney injury, arrhythmias, and other hospital- acquired infections). 5 Prevention Most of burns are preventable 6  Outlook for survival & recovery Multiple factors determine the severity of each burn injury: -Age of the patient -Depth of the burn -Extent of surface area of the body burned -The presence of inhalation injury -Presence of other injuries -Location of the injury in areas -The presence of comorbid conditions. 7 Severity of Burn 1. Age: Young children and older adults have increased morbidity and mortality when compared to other age groups 2. Burn depth: according to the depth of tissue destruction 8  9 10 11 12 13 14 Outlook for Survival and Recovery 3. Extent of body surface area injured: -Rule of Nine -Lund & Browder method -Palmer method 15 16 17 18  19 Pathophysiology Burn injuries are some of the worst traumatic injuries. 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. The depth of the injury depends on the temperature of the burning agent and the duration of contact with the agent. 20 Pathophysiology 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. 21 22  23 Pathophysiology Burns that exceed one third of the TBSA are considered major burn injuries and produce both a local and a systemic inflammatory response. The initial systemic event after a major burn injury is hemodynamic instability, which results from loss of capillary integrity and a subsequent shift of fluid, sodium, and protein from the intravascular space into the interstitial space, producing hypovolemic shock. 24 Pathophysiology 25 Pathophysiology Cardiovascular alterations Fluids & electrolytes alterations -Edema -Compartment syndrome -Escharotomy -Fasciotomy -Hyperkalemia -Hyponatremia 26 Pathophysiology 1. Cardiovascular Alterations: -An immediate decrease in cardiac output that precedes the loss of plasma volume. -As a compensatory response to intravascular fluid loss, an increase in peripheral resistance (vasoconstriction) and an increase in pulse rate that further decreases tissue perfusion. -Hypovolemia due to plasma volume loss 27 Pathophysiology -Then the workload of the heart and oxygen demand increase -As capillary leakage continues, vascular volume, cardiac output, and blood pressure decrease -This is the onset of early burn shock -Burn shock is initially a type of hypovolemic shock secondary to intravascular volume loss 28  Pathophysiology 2. Fluid and Electrolyte Alterations: -A superficial burn will cause localized edema to form within 4 hours -A deeper burn will continue to form edema up to 18 hours post injury. -Treatments for edema may include elevation of the extremity 29 Pathophysiology In severe cases, cutting of the eschar (i.e., Devitalized tissue) via escharotomy (i.e., Surgical incision through eschar), or decompression of edema formation via fasciotomy (i.e., Surgical incision through fascia to relieve constricted muscle) to restore tissue perfusion Reabsorption of edema begins about 4 hours post injury and is complete approximately 4 days postburn injury. 30  31 Pathophysiology Immediately after burn injury, hyperkalemia (excessive potassium) may result from massive cell destruction. Hypokalemia (potassium depletion) may occur later with fluid shifts and inadequate potassium replacement. Hyponatremia (serum sodium depletion) may be present from plasma loss or may occur during the first week of the acute phase, as water shifts from the interstitial space and returns to the vascular space 32 Pathophysiology Other laboratory findings: -The early hematocrit may be elevated due to destruction of some red blood cells -Abnormalities in coagulation, including a decrease in platelets (thrombocytopenia) -Prolonged clotting and prothrombin times also occur 33 34  35 Pathophysiology 3. Pulmonary alterations -Inhalation of thermal or smoke -Indicators of possible inhalation injury include: 1. Injury occurring in an enclosed space 2. Burns of the face or neck 3. Singed nasal hair 4. Hoarseness, high-pitched voice change, stridor 5. Soot in sputum 6. Dyspnea or tachypnea 7. Signs of reduced oxygen levels (hypoxemia) 8. Erythema and blistering of the oral or pharyngeal mucosa 36  Pathophysiology 4. Kidney alterations: -Decrease blood flow,… -Adequate fluid volume replacement can restore renal blood flow -If muscle damage occurs (e.g., From electrical burns), myoglobin is released from the muscle cells and excreted by the kidneys causing the urine to be red -If there is inadequate blood flow through the kidneys, the hemoglobin and myoglobin occlude the renal tubules, resulting in acute 37 tubular necrosis and kidney failure. Pathophysiology 5. Immunologic Alterations: -The patient is continually exposed to the environment. (skin the largest barrier) -Increased risk for sepsis 6. Thermoregulatory Alterations: -Exhibit low body temperatures in the early hours after injury. -Hypothermia on admission is associated with increases in mortality , ventilator days, length of stay, and infection rates. 38  Pathophysiology 7. Gastrointestinal Alterations: -Indicators of GI organ ischemia include increasing serum lactate and feeding intolerance. -Three of the most common GI alterations in patients with burns are paralytic ileus (absence of intestinal peristalsis), Curling’s ulcer, and translocation of bacteria. -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. These signs suggest gastric or duodenal erosion (Curling’s ulcer) 39 Pathophysiology -Patients with large TBSA burns are at risk for life-threatening abdominal compartment syndrome (ACS) due to large volumes of fluid required for resuscitation -Increased pressure in the abdominal cavity contributes to GI tract and abdominal organ ischemia 40  Management of Burn Injury- on the scene (emergent/resuscitative phase) From onset of injury to completion of fluid resuscitation The first step in management is to remove the patient from the source of injury Stop the burning process while preventing injury to the rescuer. Establishing an airway, supplying oxygen (100% oxygen if co poisoning is suspected) Inserting at least one large-bore IV catheter for fluid administration Covering the wound with a clean, dry cloth or gauze ABCDE care 41 Management of Burn Injury-Medical management (emergent/resuscitative phase) 1. The patient is transported to the nearest emergency department (ED) 2. Initial priorities in the ED remain airway, breathing, and circulation (100% O2, encourage cough). 3. Fluid resuscitation is initiated in burns greater than 20% TBSA. 4. Peripheral IV access may be obtained 5. Thermal & chemical burn: 2 ml of RL* wt*% TBSA 6. Electrical burn: 4 ml of RL *wt*% TBSA. 7. The calculated resuscitation fluids administered over 24 hours. The half amount at the first 8 hours. 42  Management of Burn Injury- (emergent/resuscitative phase) 8. adequate respiratory function and circulatory status have been established 9. All clothing and jewelry are removed 10. The patient’s temperature must be monitored because hypothermia 11. An indwelling urinary catheter is inserted to permit accurate monitoring of urine output. 12. Intubated patients should have a nasogastric tube inserted to decompress the stomach and prevent vomiting (20-25% TBSA) 13. Daily body weight and lab investigations should be obtained 43 Nursing Management NURSING DIAGNOSIS: Impaired gas exchange associated with carbon monoxide (CO) poisoning, smoke inhalation, and upper airway obstruction GOAL: Maintenance of adequate tissue oxygenation Nursing Interventions: -Provide 100% humidified oxygen -Assess breath sounds, and respiratory rate, rhythm, depth and symmetry of chest excursion. -Observe for the following: Erythema, Singed nasal hairs, Burns of face, neck, or chest -Monitor arterial blood gas values -Prepare to assist with intubation 44  Nursing Management NURSING DIAGNOSIS: Impaired airway clearance associated with exposure to smoke GOAL: Maintain patent airway and adequate airway clearance Nursing Interventions: -Maintain patent airway through proper patient positioning -Provide humidified oxygen as prescribed -Encourage patient to turn, cough, and deep breathe. 45 Nursing Management NURSING DIAGNOSIS: Hypovolaemia associated with increased capillary permeability and evaporative losses from the burn wound GOAL: Restoration of optimal fluid and electrolyte balance and perfusion of vital organs Nursing Interventions: -Monitor vital signs, hemodynamics, and urine output -Maintain IV lines and regulate fluids -Observe for symptoms of deficiency or excess of serum (K, Na, Ca, HCO3) -Elevate head of patient’s bed and burned extremities -Notify primary provider immediately of decreased urine output 46  Nursing Management NURSING DIAGNOSIS: Hypothermia associated with loss of skin microcirculation and open wounds GOAL: Maintenance of adequate body temperature Nursing Interventions: -Assess core body temperature frequently -Provide a warm environment -Work quickly when wounds must be exposed 47 Nursing Management NURSING DIAGNOSIS: Acute pain associated with chemical or physical injury GOAL: Control of pain Nursing Interventions: -Use pain intensity scale to assess pain level. -Administer IV antispasmodic agents as prescribed -Provide emotional support and reassurance. 48  Acute/ intermediate phase It follows the emergent/resuscitative phase and begins 48 to 72 hours after the burn injury. The attention is directed toward continued assessment and maintenance of: - Respiratory and circulatory status - Fluid and electrolyte balance - GI and kidney function. - Infection prevention and control - Burn wound care - Pain management - Early positioning/mobility are priorities in the acute/intermediate stage of recovery. 49 Medical Management Infection prevention Wound cleaning (hygiene) Wound dressing Wound debridement The goals of debridement (the removal of devitalized tissue) are: - Removal of devitalized tissue or burn eschar in preparation for grafting and wound healing. -Removal of tissue contaminated by bacteria Wound grafting Pain management 50 Nursing management Restoring Normal Fluid Balance: IVF Preventing Infection: aseptic techniques, antibiotics Modulating Hypermetabolism: high calorie, high protein diet Promoting Skin Integrity: dressing, skin care Relieving Pain and Discomfort Promoting Physical Mobility: physical therapy Strengthening Coping Strategies Supporting Patient and Family Processes 51 Monitoring and Managing Potential Complications Acute Respiratory Failure and Acute Respiratory Distress Syndrome Heart Failure and Pulmonary Edema Sepsis Delirium 52  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 The ultimate goal is to return patients to the highest level of function possible within the context of their injuries. 53 Rehabilitation phase Complications in rehabilitation phase: -Neuropathies and nerve entrapment: electrical, large and deep burn -Wound breakdown and/or pressure injury formation: inadequate nutrition -Hypertrophic scaring: Partial- and full-thickness burns -Contractures: Partial- and full-thickness burns -Joint disability: Burn wound, burn scar, and contractures -Complex pain: Trauma and burns 54  Rehabilitation Phase Care of the Patient during the Rehabilitation Phase: 1. Activity intolerance associated with pain with exercise, limited joint mobility, muscle wasting, and limited endurance 2. Disturbed body image associated with altered physical appearance and self-concept 3. Impaired mobility due to contractures or hypertrophic scarring 4. Lack of knowledge about postdischarge home care and recovery needs 55