Week 4-NUPD 701 2 - Care of Burned Patients PDF

CARE OF THE PATIENT WHO HAS BEEN BURNED WEEK 4: NUPD701  OBJECTIVES 1 2 3 4 5 6 Apply the nursing Describe the Reflect and explore...

CARE OF THE PATIENT WHO HAS BEEN BURNED WEEK 4: NUPD701  OBJECTIVES 1 2 3 4 5 6 Apply the nursing Describe the Reflect and explore Explain the Explore how Apply empirical and process to a patient nursing assessment your personal psychosocial and empirical and aesthetic knowing with burn injuries. and management values and beliefs follow-up/aftercare aesthetic knowing to a patient with of a patient with in relation to the aspects of burns. influences nurses burns. burns. metalanguage and nursing (metaparadigms) of practice. nursing. Traumatic Burn Injury Types: THERMAL (FLAME, SCALD, FLASH, COLD, RADIATION) Oil, fire ELECTRICAL (LOW AND HIGH VOLTAGE) Nerve damage (tissue ischemia) CHEMICAL (ACIDS & ALKALI CARBON MONOXIDE/INHALATION INJURY (ABOVE AND BELOW THE GLOTTIS) Check levels in blood and how they were exposed Functions of the Skin: Intact Healthy Skin Protection Thermoregulation Sensor for pain, heat, touch & cold Helps regulate metabolism Burn=loss of structural integrity Compromised immunity Hypothermia Increased fluid loss Infection Changes in appearance (body image) The Skin Layers Epidermis Dermis Subcutaneous tissue Muscle/tendon/bone  Physiology Epidermis Dermis Provides a ‘waterproof’ layer and Connective tissue -gives skin protects the body from invasion toughness and durability of pathogens ‘waterproof’ allows water vapor Contains: to be retained (moisture) Nerve endings - sensitive to pain and temperature Blood vessels Sebaceous and sweat glands IMPORTANT: the normal function will be impaired when damaged by a burning agent How deep is it? Superficial No medical treatment Deep Partial thickness Blisters ( fluid shift) Full thickness  Superficial Full thickness Red Painful Contact with high temperatures Brisk capillary refill Appearance varies No blisters White, waxy Heal in approximately 7 days Charred brown Dry, leather like vessels Deep Partial thickness No blisters Red or pink Reduced sensation resulting in minimum Wet surface with or without blisters feeling of pain Extremely painful No capillary refill Brisk capillary refill Skin grafting needed to minimize scaring Blisters present or wet waxy surface and deformities. Heals in approximately 14 days (Williams, 2009, p. 56) Depth and Characteristics Practice identifying depth of burn Superficial burn: affects the epidermis Practice identifying depth of burn Partial thickness burn: affects the dermis (there is third spacing here as the fluids shift from intravascular to tissues then into a trans-cellular space  Practice identifying depth of burn thickness burn: affects the epidermis, dermis and subcutaneous layer. can see here how these different type of full thickness burns take on different appearances What do we need to consider: plan of care Extent of Injury – size and depth Details of Injury – where, what, when Where is the injury What caused it When did it happen – rule out amount of fluid loss Time of Injury Health History Co morbities Extent of damage: estimated total body surface area (TBSA) Lund Browder More accurate assessment of TBSA Different charts for children & adults as body surface sizes are different Each part of the body is broken up into percentages (Williams, 2009) Surface Area Graphic Evaluation (SAGE) Diagram Extent of damage: estimated total body surface area (TBSA) Palmar Surface Uses the palmar surface of the client’s hand including fingers is approximately 0.8-1.0% of the total body surface area (TBSA) It is an estimate, sometimes used in relatively small burns (Williams, 2009) E Rule of Nines xtent of damage: estimated total body surface area (TBSA) Quick and easy method to Note the had is 4.5% in front assess burns and 4.5% back Less accurate than Lund- Browder Body surface is divided into area of 9% of multiples of 9, with 1% for genitalia/perineum We will be using the Rule of Nines to calculate TBSA (Williams, 2009) Rule of Nines  Calculating TBSA with the Rule of Nines Based on this picture….calculate the total body surface area affected  Phases of Burn Management EMERGENT ACUTE REHABILITATION From onset of burn, up to 5 days Usually begins 36-48 hours after Planning starts on admission, but injury when fluid shift resolves technical rehab starts with wound Average length is 72 hours closure and ends when patient Begins with mobilization of fluid reaches their optimum level of Emergent phase begins with fluid loss and edema from interstitial back into the functioning intravascular space followed by Pt is not in fluid overload diuresis Patient centered care: Albumin low and sodium low Psychosocial preparation and Care is directed towards Watch potassium when shifting support assessment and maintenance Fluid/lytes are shifting from intravascular to Home care management interstitial spaces because capillary Urine out put key sign of Self management education permeability has increased….serous fluid then improvement albumin Home and community 30 – 50 ml/hr resources Treatment to prevent Hypovolemic shock Phases Emergent phase Remember that after burn injury there are vascular and cellular responses Fluids are shifting from intravascular to interstitial and even transcellular spaces because capillary permeability has increased….serous fluid then albumin Client’s who have burn injuries appear very swollen ….because the fluid is in the tissues not in the vascular space…..therefore they are at high risk for hypovolemic shock Emergent phase – fluid shifts Increased Capillary permeability Generalized dehydration Reduced blood volume and hemo-concentration Decreased urine output Trauma causes release of potassium into ECF: = hyperkalemia Na+ traps in edema fluid: hyponatremia Metabolic acidosis Fluid shifting: “third spacing” Fluid shift occurs as the blood vessels close to the burn dilate and leak fluids into the interstitial space Is a continuous leak of plasma from vascular space into interstitial space Causes decreased blood volume and blood pressure The impaired fluid and electrolyte balance leads to loss of plasma fluids & proteins = decreased blood volume & decreased blood pressure EDEMA develops as plasma and electrolytes escape into the interstitial space Results in: a profound disruption of fluid and electrolyte balance & acid-base balance Monitoring labs During the emergent phase of burn injuries monitor: ABGs (inhalation injuries, or exposure to substances that affect the airway) Carboxyhemoglobin (inhalation injuries….Carbon monoxide poisoning) Complete blood count (WBCs, Hemoglobin, Hematocrit) Electrolytes (sodium, potassium) Glucose Albumin Renal function tests (BUN, Creatinine) Urine (specific gravity)  ABGs - pH is decreased d/t metabolic acidosis Carboxyhemoglobin – elevated (impairs oxygen uploading at the tissue level) Hemoglobin & Hematocrit – elevated d/t fluid volume loss Prior to WBC – first rises then drops if immune system is unable to sustain defense (left shift) fluid Na – decreased, trapped in edema fluid and lost through plasma resuscitatio leakage K – elevated as result of disruptions of the sodium potassium pump, n tissue destruction & RBC hemolysis Glucose – elevated d/t stress response and altered uptake across injured tissue Albumin- Low, protein is lost through the wound and vascular membranes d/t increased permeability BUN & Cr – elevated d/t fluid lossd/t fluid loss Urine (specific gravity) -elevated d/t decreased blood flow, urine is concentrated and inadequate output Interventions: Emergent Phase Establish or maintain airway Ensure breathing is stabilized Maintain circulation status by starting fluid resuscitation (TBSA >20%) Ensure BP > 90 systolic HR