Adult Health Nursing Week 9 - Integumentary System - Burns, 2024 PDF

Adult Health Nursing –II Week-9 Integumentary System Burns Nurse. Jule Lindsay RN, BScN, MN Objectives Define terminologies Etiologies Assessment Signs and symptoms Medications Diagnostic tests Nutritional requirements Health Teachings Community Resources 2 3 Ø Occur when there is injury to the skin...

Adult Health Nursing –II Week-9 Integumentary System Burns Nurse. Jule Lindsay RN, BScN, MN Objectives Define terminologies Etiologies Assessment Signs and symptoms Medications Diagnostic tests Nutritional requirements Health Teachings Community Resources 2 3 Ø Occur when there is injury to the skin or Burns other tissues of the body caused by heat, chemicals, electrical current, or radiation Ø The patient with a burn injury may have a multitude of problems Ø Most burn accidents are preventable 4 Definition A burn is an injury to the skin or other organic tissue primarily caused by heat or due to radiation, radioactivity, electricity, friction or contact with chemicals. Thermal (heat) burns occur when some or all the cells in the skin or other tissues are destroyed by: hot liquids (scalds) 5 q Thermal burns Types of Burn Injury q Chemical burns q Smoke inhalation injury q Electrical burns q Cold thermal injury 6 Cardiogenic Shock Definition Systolic or diastolic dysfunction Systolic dysfunction is the heart’s inability to pump the blood forward. ↓ filling of the heart will result in ↓ stroke volume Compromised cardiac output (CO) Classification of Burn Injury § Severity of injury is determined by Ø Depth of burn Ø Extent of burn in percent of TBSA Ø Location of burn Ø Age of patient, pre-burn medical history, and circumstances or complicating factors 7 Cross Section of Skin 8 Classification of Burn Injury Depth of Burn § Burns are defined by degrees (first, second, third, and fourth) § ABA classifies burns according to depth of skin destruction Ø Partial-thickness burn Ø Full-thickness burn 9 Classification of Burn Injury Depth of Burn § Superficial partial-thickness burn Ø Involves epidermis Ø First degree § Deep partial-thickness burn Ø Involves dermis Ø Second degree § Full-thickness burn Ø Involves all skin elements, nerve endings, fat, muscle, bone Ø Thirds and fourth degree 10 11 Classification of Burn Injury Extent of Burn Two common tools for determining the total body surface area Ø Lund-Browder chart § Considered more accurate Ø Rule of Nines § Used for initial assessment Ø Sage Burn Diagram (www.sagediagram.com) Lund-Browder Chart 12 Rule of Nines Chart 13 Classification of Burn Injury Location of Burn Severity of burn injury is determined by location of burn wound Ø Face, neck, chest § Respiratory obstruction from edema, eschar Ø Hands, feet, joints, eyes § Self-care difficult Ø Ears, nose, buttocks, perineum § High risk for infection 14 15 Classification of Burn Injury Location of Burn § Circumferential burns of extremities can cause circulation problems distal to burn § Possible nerve damage to affected extremity Ø Patients may also develop compartment syndrome 16 Classification of Burn Injury Patient Risk Factors § Preexisting heart, lung, or kidney disease contribute to poorer prognosis § Diabetes and peripheral vascular disease put patient at high risk for delayed healing 17 Classification of Burn Injury Patient Risk Factors § Physical weakness make it challenging for patient to recover Ø Alcohol or drug use Ø Malnutrition § Concurrent fractures, head injuries, or other trauma leads to a more difficult time recovering 18 Prehospital Care § Remove person from source of burn and stop burning process § Rescuer must protect themselves from being injured § Electrical and chemical injuries Ø Remove patient from contact with source 19 Prehospital Care § Small thermal burns Ø Cover with clean, cool, tap water-dampened towel Ø Cooling within 1 minute helps minimize depth of injury § Large thermal burns Ø If unresponsive—circulation, airway, breathing Ø If responsive—Airway, breathing, circulation 20 Prehospital Care § Large thermal burns Ø Cool burns for no more than 10 minutes Ø Do not immerse in cool water or cover with ice Ø Remove burned clothing Ø Wrap in dry, clean sheet or blanket 21 Prehospital Phase § Chemical burns Ø Remove chemical particles or powder Ø Flush area with water § Inhalation injury Ø Watch for signs of respiratory distress Ø Treat quickly and efficiently Ø 100% humidified oxygen if CO poisoning is suspected 22 Phases of Burn Management Ø Emergent (resuscitative) Ø Acute (wound healing) Ø Rehabilitative (restorative) 23 24 Emergent Phase § Emergent (resuscitative) phase is time required to resolve immediate problems resulting from injury § Up to 72 hours § Main concerns Ø Hypovolemic shock Ø Edema § Ends when fluid mobilization and diuresis begins 25 Emergent Phase Clinical Manifestations § Shock from hypovolemia § Pain § Blisters § Paralytic ileus § Shivering § Altered mental status 26 Emergent Phase Complications Cardiovascular system Ø Dysrhythmias and hypovolemic shock Ø Impaired circulation to extremities with circumferential burns- if untreated can lead to § Tissue ischemia § Paresthesia § Necrosis 27 Emergent Phase Complications Cardiovascular system Ø Impaired microcirculation and increased viscosity results in sludging Corrected by adequate fluid replacement Ø Venous thromboembolism (VTE) Prophylaxis with anticoagulants 28 Emergent Phase Complications Respiratory system Ø Upper airway burns § May occur with or without smoke inhalation Ø Lower airway injury 29 Emergent Phase Complications Respiratory system Ø Need fiberoptic bronchoscopy and carboxyhemoglobin blood levels Ø Watch for signs of respiratory distress Chest x-ray may appear normal on admission; changes can occur over next 24 to 48 hours Ø ABGs may be within normal range on admission and change over time 30 Emergent Phase Complications Other cardiopulmonary problems Ø Patients with preexisting heart or lung disease are at increased risk § Heart failure § Pulmonary edema § Pneumonia 31 Emergent Phase Complications Urinary system Ø Acute tubular necrosis (ATN) Ø Decreases blood flow to kidneys causes renal ischemia 32 Emergent Phase Nursing/Interprofessional Management Airway management Ø Early endotracheal intubation Ø Escharotomies of the chest Ø Fiberoptic bronchoscopy Ø Humidified air and 100% oxygen Ø High fowler’s position Ø Suctioning, chest PT Ø Bronchodilators 35 Emergent Phase Nursing/Interprofessional Management Fluid therapy Ø 2 large-bore IV lines for greater than 15% TBSA Ø For burns greater than 20% TBSA central line may be considered Ø Arterial line placed if frequent ABGs or invasive BP monitoring needed Ø Parkland (Baxter) formula for fluid replacement 36 Emergent Phase Nursing/Interprofessional Management Wound care Ø Cleansing and gentle debridement § Can be done on a shower cart, in a shower, or on a bed or stretcher Ø Surgical debridement § May need to be done in the OR § Necrotic skin is removed § Releasing escharotomies and fasciotomies may be done 37 Hydrotherapy Cart Shower 38 Debriding Full–Thickness Burn 39 Emergent Phase Nursing/Interprofessional Management Wound care Ø Shower § Once-daily shower § Dressing change in morning and evening Ø Newer antimicrobial dressings can be left in place from 3 to 14 days 40 Emergent Phase Nursing/Interprofessional Management Wound care Ø Infection can cause further tissue injury and possible sepsis § Source of infection is patient’s own flora § Skin, respiratory, GI 41 Emergent Phase Nursing/Interprofessional Management Wound care Ø Open method § Burn is covered with topical antimicrobial § No dressing over wound § Usually limited to the care of facial burns 42 Emergent Phase Nursing/Interprofessional Management Wound care Ø Multiple dressing changes or closed method § Sterile gauze dressings are laid over topical antimicrobial § Dressings may be changed from every 12 hours to once every 14 days 43 Application of Silver Sulfadiazine to Moistened Gauze 44 Emergent Phase Nursing/Interprofessional Management Wound care Ø When open burns wounds are exposed, staff should wear PPE § Disposable hats § Masks § Gowns § Gloves Ø Use sterile gloves to apply antimicrobial ointment and sterile dressings 45 Emergent Phase Nursing/Interprofessional Management Wound care Ø Allograft Ø Homograft skin § From skin donor cadavers § Used with newer biosynthetic options 46 Emergent Phase Nursing/Interprofessional Management Drug therapy Ø Tetanus immunization § Given routinely to all burn patients 47 Emergent Phase Nursing/Interprofessional Management Drug therapy Ø Antimicrobial agents § Topical agents Ø Silver sulfadiazine Ø Mafenide acetate § Systemic antibiotics are not usually used in controlling burn wound flora Ø Started when diagnosis of sepsis is made 48 Emergent Phase Nursing/Interprofessional Management Drug therapy Ø VTE prophylaxis § Low-molecular-weight heparin or low-dose unfractionated heparin is started § Those with high bleeding risk, VTE prophylaxis with intermittent pneumatic compression devices, or graduated compression stockings recommended 49 Emergent Phase Nursing/Interprofessional Management Nutritional therapy Ø Nutrition takes priority once fluid replacement needs addressed Ø Early and aggressive nutritional support within hours of burn injury § Decreases complications and mortality § Optimizes burn wound healing § Minimizes negative effects of hypermetabolism and catabolism 50 Emergent Phase Nursing/Interprofessional Management Nutritional therapy Ø Hypermetabolic state § Resting metabolic expenditure may be increased by 50% to 100% above normal § Core temperature is increased § Catecholamines increased, stimulate catabolism 51 Acute Phase § Begins with mobilization of extracellular fluid and subsequent diuresis § Ends when Ø Partial thickness wounds are healed or Ø Full thickness burns are covered by skin grafts 52 Acute Phase Clinical Manifestations Partial-thickness wounds form eschar Ø Once eschar is removed, re-epithelialization begins Full-thickness burn wounds require Ø Surgical debridement Ø Skin grafting 53 Acute Phase Laboratory Values Sodium Ø Hyponatremia can develop from § Excessive GI suction § Diarrhea Ø Water intoxication § From excess water intake § Offer juices, nutritional supplements 54 Acute Phase Complications Infection Ø Burn wound colonized by patient’s own flora Ø WBCs have functional deficit and patient is immunosuppressed Ø Partial-thickness burns can convert to full-thickness wounds in the presence of infection 55 Acute Phase Complications Infection Watch for signs and symptoms § § § § Hypothermia or hyperthermia Increased heart and respiratory rate Decreased BP Decreased urine output Causative organism of sepsis usually gram-negative bacteria § Obtain cultures § Lactate level 56 Acute Phase Complications Cardiovascular and respiratory systems Ø Same complications can be present in emergent phase and may continue into acute phase Ø In addition, new problems might arise, requiring timely intervention 57 Acute Phase Complications Neurologic system Ø No physical symptoms unless severe hypoxia from respiratory injuries or complications from electrical injuries occur Ø Disorientation Ø Combative Ø Hallucinations Ø Frequent nightmare-like episodes 58 Acute Phase Complications Neurologic system Ø Delirium § § § § More acute at night Occurs more often in older adults Usually, transient Complications and sequelae can last for years 59 Acute Phase Complications Musculoskeletal system Ø Limited ROM Ø Skin and joint contractures Gastrointestinal system Ø Paralytic ileus Ø Diarrhea Ø Constipation Ø Curling’s ulcer 60 61 Endocrine system Ø Increased blood glucose levels § Increased mobilization of glycogen stores § gluconeogenesis Ø Increased insulin production § Insulin effectiveness decreased due to insulin insensitivity Ø Hyperglycemia may also be caused by high caloric intake needed Acute Phase Nursing/Interprofessional Management § Wound care § Excision and grafting § Pain management § Physical and occupational therapy § Nutritional therapy 62 Acute Phase Nursing/Interprofessional Management Wound care Ø Ongoing observation Ø Assessment Ø Cleansing Ø Debridement Ø Dressing reapplication 63 Acute Phase Nursing/Interprofessional Management Wound care Ø Enzymatic debridement § Speeds up removal of dead tissue from healthy wound bed Ø Cleanse with soap and water or normal saline Ø Cover with antimicrobial creams Ø When fully debrided, cover with protective, greasy-based gauze 64 Acute Phase Nursing/Interprofessional Management Wound care Appropriate coverage of graft § Greasy gauze next to graft followed by saline moistened middle and dry outer dressings § Unmeshed sheet graft used for facial grafts Ø Grafts are left open Ø Complication: Blebs 65 Acute Phase Nursing/Interprofessional Management Excision and grafting Ø Eschar is excised down to subcutaneous tissue or fascia Ø Hemostasis is achieved Ø Autograft is placed on clean, viable tissue Ø Donor skin is taken with a dermatome Ø Choice of dressings varies 66 Acute Phase Nursing/Interprofessional Management Excision and grafting Ø Grafts are attached with § Fibrin sealant § Sutures or staples § Negative pressure wound therapy Ø With early excision, function is restored, scar tissue minimized 67 Split-Thickness Sheet Skin Graft to Hand 68 Donor Site Being Harvested 69 Covering Donor Site With Hydrophilic Foam Dressing 70 Healed Donor Site 71 Application of Cultured Epithelial Autograft 72 Healed Cultured Epithelial Autograft 73 Acute Phase Nursing/Interprofessional Management Pain management Patients experience two kinds of pain Continuous background pain Ø IV administration of an opioid Ø Or slow-release, twice-a-day oral opioid Ø Patient-controlled analgesia Ø Anxiolytics and adjuvant analgesics Treatment-induced pain Ø Pre-medicate with analgesic and anxiolytic Ø Nondrug strategies may also be used 74 Acute Phase Nursing/Interprofessional Management Pain management Nondrug strategies § Relaxation breathing § Visualization, guided imagery § Hypnosis § Biofeedback § Music therapy 75 Acute Phase Nursing/Interprofessional Management Physical and occupational therapy Ø Good time for exercise is during dressing changes Ø Passive and active ROM Ø Splints should be custom-fitted 76 Acute Phase Nursing/Interprofessional Management Nutritional therapy Ø Caloric needs should be calculated by dietitian Ø High-protein, high-carbohydrate foods Ø Antioxidant protocol may be beneficial Ø Monitor laboratory values Ø Weigh weekly 77 Rehabilitation Phase The rehabilitation phase begins when Ø Wounds have nearly healed Ø Patient is engaging in some level of self-care 78 Rehabilitation Phase Pathophysiologic Changes § Burn wounds heal either by spontaneous re-epithelialization or by skin grafting § Layers of keratinocytes begin rebuilding the tissue structure § Collagen fibers add strength to weakened areas 79 Rehabilitation Phase Complications Skin and joint contractures Ø Most common complications during rehab phase Ø Develops because of shortening of scar tissue in flexor tissues of joint Ø Proper positioning, splinting, and exercise should be used to minimize contracture. 80 Contracture of the Neck 81 Rehabilitation Phase Nursing/Interprofessional Management Encourage both patient and caregiver to take part in care Ø Skills for wound care Ø Dressing changes Ø Scar management, moisturizing, sun protection Reconstructive surgery is often done after a major burn 82 Rehabilitation Phase Nursing/Interprofessional Management Ø Ongoing pain management Ø Nutritional needs Ø PT and OT routines Ø Encouragement and reassurance 83 Gerontologic Considerations Normal aging process puts the patient at risk for injury because of Ø Unsteady gait Ø Limited eyesight Ø Decreased hearing Ø Skin drier and more wrinkled Ø Thinner dermis, reduced blood flow 84 Emotional Needs of the Patient and Caregivers § Many emotional and psychologic needs § Assess circumstances of burn injury § Burn survivors often have guilt, fear of dying, and frustrations § New fears may occur during recovery 85 Emotional Needs of Patient and Family Ø Self-esteem may be adversely affected Ø Address spiritual and cultural needs Ø Issue of sexuality must be met with honesty Ø Caregiver and patient support groups 86 Special Needs of Nursing Staff Ø You may find it difficult to cope with deformities of burn injury Ø Know you provide care that makes a critical difference Ø Ongoing support services or debriefings may be helpful Ø Practice good self-care 87 88 Thank you 89