Burns.pdf

Burns Care of Burn Wounds Wound Care for Patients with Burns First Degree Burn Second Degree Burn Third Degree Burn Phases of Wound Healing Defensive / Inflammatory Phase Starts at the time of the injury...

Burns Care of Burn Wounds Wound Care for Patients with Burns First Degree Burn Second Degree Burn Third Degree Burn Phases of Wound Healing Defensive / Inflammatory Phase Starts at the time of the injury Continues for 3-6 days Bleeding stops and removal of debris (phagocytosis) occurs Essential to healing process Proliferative Phase Day 3-21 Replacement of fibrin with collagen continues Strengthens wound bed Fibroblasts move from bloodstream into the wound, depositing fibrin Burns 1  Tissue becomes translucent red. Called granulation tissue. Very fragile and bleeds easily. Red means good. Remodeling / Maturation Phase Day 21 to 1-2 years Collagen fibers retract, reorganizing themselves and the scar strengthens If an abnormal amount of collagen appears, the result can be hypertrophic scar or keloid. Occurs more often in dark skinned people Mobility Phase Mobility and physical therapy are priorities to prevent scar tissue from impairing range of motion Wound Exudate Yellow exudate is creamy in appearance May have tinges of brown, green, or yellow depending on the causative organism Need to remove exudates Exudate is material such as fluid and dead phagocytic cells that have escaped from blood vessels during the inflammatory and diuresis process and deposited on tissue or tissue surfaces Exudate can be dead tissue sloughing off Can be a symptom of bacterial growth Often found in inflammatory phase Image Burns 2  Wound Necrosis Black Wound: Necrotic, black eschar Necrotic tissue MUST be removed for healing to occur (highlighted in transcript) Image Factors Affecting Wound Healing Nutrition Obesity Burns 3  Inhibits healing Impaired Blood Supply Drugs Wound Stress Diabetes Inhibits healing Aging Vasopressors (highlighted in transcript) Inhibits healing by impairing blood flow. Constrict blood flow from extremities Increase potential for shock, sepsis, or muscle wasting Burn wounds are much more complicated to care for than that of a normal post op wound Jackson’s Zones of Burn Wounds Zone of Hyperaemia (Outer zone) Took the least amount of damage Care is aimed at increasing blood supply and allowing the area where there is cell damage (not cell death) to completely recover Zone of stasis (middle zone) Some damaged cells, inflammation, and compromised supply of blood With early and ongoing burn wound care, may be full recovery to this area Zone of coagulation (inner zone) Where cell death or necrosis has occured Area of the greatest damage Burns 4  Zones can also go deeper If we have deep partial thickness, we can expect that the zone of stasis and hyperaemia are extending into the hypodermis Even if there is no cell damage there, if the inflammation continues, cell death into the zone of stasis may happen Wound Care Surgical Option Escharotomy vs Fasciotomy Escharotomy Removal of thick skin that may be necrotic, which overlays the wounds Done to release compression of tissue around the surrounding organs Fasciotomy If the surgical incision goes down into the muscle fascia, it is considered a fasciotomy. Done to remove necrotic tissue and release edema in compartment syndrome of the chest or extremities Allografting, autografting, xenografting Allografting Uses human skin harvested from cadavers Autografting Taken from patient’s own skin to cover burn wound Xenografting Taken from animal skin, usually a pig Surgical Debridement Important to remove all exudate or eschar to allow for granulation tissue to fill in the wound bed and the epithelial tissue to migrate across the surface of the wound Burns 5  Goal is wound closure in the first 5 days Wound Debridement Options Autolytic Uses body’s own enzymes and moisture to break down tissue Hydrocolloid and collagen dressings Enzymatic Using enzymes to break down tissue Santyl is a topical enzymatic Mechanical Wet to dry dressings and hydrotherapy Surgical / Sharp What we talked about above Wound Dressing Options Open Rare Unless it is likely that the wound will be covered by granulation tissue within 3-5 days, we typically prefer wet to dry dressings daily or BID Closed More often than not Biological or Biosynthetic Enhances body’s ability to form new skin over the wounds Allograft Taken out of freezer and applied within 15 mins to keep cells alive Burns 6  Remain on the patient for 1 week unless dressing is soiled Specific training that nurses have in order to work with these patients and complete these dressing changes VAC Also common with burn injuries Goal is wound closure in the first 5 days Wound Care Ongoing Pressure or Ace Wraps Minimalize hypertrophic or keloid scar formation Overgrowths of skin that can be restrictive to joints or disfiguring will inhibit mobility and the patient’s ability to return to previous levels of function Physical or occupational therapy In collaboration between floor nurses, wound care nurses, PT and OT are important to achieve optimal quality of life after a burn Goal is to minimize scaring and return to optimal level of functioning Image Burns 7  Pain Management Burn victims are exposed to high levels of pain and wound care can lead to PTSD Sometimes multiple times a day they can have debridement's, dressing changes, and painful therapies Managing their pain is difficult Give multimodal types of medications to ease some of the distress Short acting and long acting sedatives and opioids as specific times leading up to wound care Therapeutic communication and creative distractions also help Music is the most common distraction used Other options include VR simulations Wound care is a large part of a burn nurse’s role and it is an expectation to be an advocate for your patients comfort and emotional needs Tissue Integrity Tissue Integrity Supports Critical Life Functions Temperature Regulation Conservation of Fluid Protection of underlying tissue Excretion of toxins Neurosensory The integumentary system is the largest organ system in the body Burns 8  Impaired Tissue Integrity Specifically focused on damage to the epidermal and dermal layers Deeper damage to skin will result in disruption of the role of the underlying tissue Burn Injury Caused by heat generated by exposure to one of the following Thermal Involve flames, steam or hot liquid OA and young are highest risk of thermal burns Young because impulsive, lack of fear, and have not yet learned OA because of decreased sensory acuity (hearing, seeing, feeling temperatures) Chemicals Usually related to acids and alkaline chemicals Even when rinsed well can create a deep invasive burn for hours after contact Largely work related Farming and environmental services Federal regulations have labeling requirements for those that can cause burns Read labels is important Radiation Most commonly sunburns, burns following radiation therapy, and contact with radioactive substance Burns 9  Avoiding extended exposure to direct sunlight, sunscreen, and protective clothing can minimize risk of radiation burns Occupational training is also necessary to minimize the risk to employees and patients involved in radioactive treatments Electrical Contact with direct electrical sources and are ALWAYS considered major burns Classification of Burns Depth Superficial First degree (Minor) Localized pain with redness and eventual peeling of the dead epidermis cells Common sunburn Partial Thickness Second Degree (Moderate) Superficial Destruction of the epidermis and the upper third of the dermis Damage to sebaceous glands, nerves, and possible some capillaries Deep Destruction of the epidermis and the entire dermis Damage includes sebaceous glands, nerves, some capillaries, tendons, and sweat glands Full Thickness Third degree (Major) Burns 10  Destruction of the epidermis, dermis, and subcutaneous tissue Muscles, fat, collagen, and arterioles may all be destroyed Important to note that nerve damage may be so severe that the patient will not have any pain at all Classification of Extent of Burns Expressed as a percentage of total body surface area (TBSA) Rule of Nines (Important to remember the chart and to be able to calculate) Quick Assessment Only use with partial and full thickness Will vary depending on age and size of patient Benefits is that it’s quick. Mostly used by emergency medical services and in the emergency department Different versions for children and infants Image Lund and Broder Burn Assessment Chart (Do not memorize this one) Burns 11  Less useful for EMS / Emergency Care Setting Commonly used in critical care More Accurate Specific to ages Decision to Transfer to Burn Center The American Burn Association Guidelines on who should receive treatment at a burn center are as follows 1) Individuals who have partial thickness burns on more than 10% of their total body surface area 2) Individuals who have burns involving the face, hands, feet, genitals, perineum, or major joints 3) Any individuals who have full thickness burns 4) Individuals with electrical, chemical, and inhalation injuries 5) Any child in a facility without adequate trained personnel 6) Individuals or other trauma 7) Individuals who require special emotional interventions Also safe to assume that any patient with circumferential burns on the extremities and/or chest must also be evaluated at a burn center Nursing Care: Nursing Diagnosis Ineffective airway clearance Impaired gas exchange Risk for aspiration Risk for infection Burns 12  Alteration in tissue perfusion Impaired thermoregulation Impaired mobility Fluid volume deficit Ineffective renal perfusion Acute pain Ineffective coping Hopelessness Fear / Anxiety Disturbed Body Image Deficient Knowledge Respiratory Injury from Burns Causes Hot Air / Hot Steam Effect: Laryngeal obstruction / Bronchospasm Smoke / Hot Particles / Aspiration Effect: Mucosal Slough / Infection / Bronchiolar Plugging / Atelectasis / Bronchospasm Irritant Gases Effect: Pneumonia / Pulmonary Edema / Alveolar Capillary Defect Assessment Facial / Neck Trauma Singed Nasal / Facial Hair Stridor / Hoarseness Burns 13  Difficulty Swallowing / Excessive Secretions Respiratory Distress Patient may be drooling or coughing excessive amounts of clear mucous. Obvious respiratory distress is an indication of a deeper injury Always be suspicious of respiratory damage. Often there will be no obvious burns to the nasal passaged or mouth, but inhalation of smoke alone can cause respiratory failure. It is often delayed and subtle Goal of care is to prevent hypoxia / pneumonia, constriction of chest muscles throughout the emergent and acute phases of a burn injury. With ongoing assessments, we continue the suspicion of inhalation injury or trauma such as fractured ribs that punctured the lung, and that could be causing respiratory distress. ARDS is another common complication of inhalation injury due to fluid buildup in the alveoli. Must continue assessing for swelling in the chest cavity and rigidity of the chest muscles that may require surgical intervention Carbon monoxide poisoning will require high O2 delivery, possible under pressure since hemoglobin is having a difficult time binding with oxygen. The only way to diagnose carbon monoxide poisoning is to obtain a carboxyhemoglobin lab as well as trending ABG’s. A pulse ox recognizes carbon monoxide the same way as O2, and will give you a false reading Oxygen should be used in the early phases of burn treatment regardless of what O2 saturation measures. Wait for ABG’s to get a true sense of oxygenation Nursing Care / Emergent and Acute Oxygenation Direct Injury Acute Respiratory Distress Syndrome (ARDS) Carbon Monoxide Poisoning Pneumonia Burns 14  Hypoventilation (ARDS / Injury / Muscle Contractures) Systems Involved with Burns Integumentary Skin loss Sensory Loss Decreased Temperature Cardiovascular Third Spacing Decreased Blood Pressure Increased Pulse Decreased RBC Decreased Cardiac Output Decreased Tissue Perfusion Cardiac issues related to hypovolemic shock, dysrhythmias and possible cardiac arrest related to fluid loss and electrolyte imbalances, most notably with shifts in potassium Respiratory Hypoxia Increased Respirations Rhonchi Decreased Ciliary Movement Airway obstruction GI Hyperacidity Ileus Burns 15  Melena Hematemesis Increased Abdominal Girth Urinary Decreased Glomerular Filtration Rate Increased Creatinine Increased BUN Increased Specific Gravity Increased Uric Acid Myoglobinuria Impacted in the early phases of burn due to reduced blood flow. Urine output decreases, BUN increases, and you may see dark shades of urine which can further obstruct the urinary system and cause renal failure Immune Decreased T Cell Decreased B Cell Increased WBC Decreased Proteins Phagocytosis Metabolism Increased Catabolism Decreased Anerobism Weight Loss Acidosis Hyperglycemia Burns 16  Nursing Care: Emergent Phase Assessment Stop burn process Airway management Fluid resuscitation Cover wounds to maintain body temperature Pain management Emotional Support Decision needs to be made to send patient to burn center Typically lasts 24 hours Focus of this phase is to stop the burn process, maintain airway and oxygenation, prevent shock through fluid resuscitation, and provide comfort and emotional support A decision will be made by healthcare team in regards for transferring this patient to a burn or trauma center Pain management is very important in all phases of burn care. Pain meds for burn tend to be in higher does, more often, and used together to achieve a tolerable amount of pain Nursing Care: Emergent and Acute Perfusion Fluid resuscitation begins with EMS Initiate 2 large bore IVS Initial fluid is warmed isotonic (LR / NS) started at 500 ml/hr until weight and TBSA is known Followed by colloid (albumin) Burns 17  Hourly urine output used to assess effectiveness of fluid resuscitation (0.5-1 ml/kg/hr) Parkland Formula for Adult Fluid Resuscitation Volume of Isotonic Fluid = 4mL x weight(kg) x TBSA 1/2 of the result in the first 8 hours The next half over the next 16 hours Really focus of fluid resuscitation, you NEED good IV access. If IV access is a challenge, then intraosseous in a site without burn is preferred and a central line will likely be inserted upon arrival to allow fluid resuscitation and pressure monitoring Parkland Formula Volume of Isotonic Fluid = 4mL x weight(kg) x TBSA 1/2 of the result in the first 8 hours The next half over the next 16 hours Assessing Fluid Resuscitation 0.5-1ml/kg/hr Acute Stage Wound Care Nutrition Therapy Infection Prevention Pain Management Burns 18  Emergent phase is approximately the first 24 hours or through the end of fluid replacement Acute stage begins with the start of diuresis and ends with closure of the burn wound Diuresis in terms of a burn patient is used to describe the fluid loss that happens when the vascular system becomes permeable, and the fluids shift into other parts of the body and drain through the patients wounds The Acute Stage is heavily focused on wound care, nutrition, infection prevention, and pain management Following this fluid loss there are severe electrolyte imbalances which lead to damage of other systems of the body Serial labs such as: CBC, BMP, and ABG are needed to assess damage to the entire body Renal failure, cardiac dysrhythmias and respiratory distress are just a few of the issues CBC Elevated WBC since the body is trying to protect itself Elevated Hct which happens when the vascular system is dry because it’s more concentrated Decreased Hemoglobin due to loss of volume Chemistry Panel Normal Sodium Expect to change depending on what stage these labs were taken Normal Potassium (maybe low) Expect to change depending on what stage these labs were taken Burns 19  Elevated Glucose Normal for any kind of stressor to the body Elevated Creatine Kinase Trauma to the tissues Elevated BUN Patient is dehydrated and alerting us to early renal issues Low Total Protein Always low in burn patients due to massive tissue damage Nutrition is very important. Expect enteral and parenteral nutrition in burn care. It is typically initiated very early on Low Albumin Hypo/HyperKalemia Expected and common with burn patients. Expect to be out of range Nursing Care: Emergent and Acute Perfusion Compartment Syndrome (when pressure within the limb cuts off circulation) Common with circumferential limb injuries Treatment to relieve the pressure Escharotomy Using a blade, they go down the middle/side of the extremity or chest cavity. Skin will separate and there will be oozing / fluid loss following this procedure Saves limbs Burns 20  In case of chest cavity edema, relieving the pressure allows you to adequately ventilate the patient Rehabilitative Stage Scar and Contracture Prevention Rehabilitation Returning to work Family and Social Roles Occupational and Physical Therapy Due to decreased ability to fight infection, extensive wounds, immobility, a foley, and central venous catheter use, Sepsis is a MAJOR complication of burn injuries that we see in late acute and early rehab phases Tetanus immunization is often administered in the ER Literature shows much improved outcomes if antibiotics are given prophylactically. Sepsis causes an increased mortality rate and renal failure rates in burn patients during these phases Nurse specific interventions aimed at preventing these complications are vital Early removal of foley and central venous catheter Complications and Nursing Interventions Preventing Infection Promoting Fluid Volume Effective Pain Management Protecting Skin Integrity Maintaining Physical Mobility Burns 21  Promote Balanced Nutrition Facilitate Empowerment Overview 3 Phases of Burn Care Emergent Acute Rehabilitative Respiratory Distress Signs & Symptoms and Interventions Burn Wound Assessment Superficial Partial Full TBSA% Burn Center Transfer Fluid Resuscitation and Assessing Adequate Fluid Intake Wound Care Debridement Methods Phases of Wound Healing Factors Affecting Wound Healing Burns 22