Burn Care Lesson Guide PDF

NCM-N 118A LESSON GUIDE ON CARE OF CRITICALLY ILL CLIENTS EXPERIENCING SHOCK Intended Learning Outcomes: At the end of the 4-hours lecture, the students can: 1.Explain the changes within the body system that occur following a burn and prepare for immediate care of the burn patient. 2....

NCM-N 118A LESSON GUIDE ON CARE OF CRITICALLY ILL CLIENTS EXPERIENCING SHOCK Intended Learning Outcomes: At the end of the 4-hours lecture, the students can: 1.Explain the changes within the body system that occur following a burn and prepare for immediate care of the burn patient. 2.Evaluate the severity of a burn injury. Etiology of Burn Injury: 1. Heat 2. Radiation 3. Chemical 4. Electric current Size of Burn Injury is determined by using the following methods: 1. Wallace Rule of Nines - A quick and easy method that divides the body into sections, each accounting for approximately 9% (or a multiple thereof) of the TBSA. Use: Ideal for rapid assessment in emergency settings; Commonly used in initial triage and emergency care. 2. Lund and Browder Burn Assessment Chart -A more detailed and precise chart that accounts for age-specific body proportions. Use: Typically used in hospital settings or for more thorough burn assessments. Depth of Burn Injury: A. Superficial or 1st degree burn - Involves epidermal layer of the skin, leaving the skin intact - pink to red in color - sunburns and minor flash burns B. Partial thickness burn or 2nd degree burn- epidermal and dermal layers of the skin; hair follicles, sebaceous glands, and epidermal sweat glands remain intact.  Superficial partial- thickness burn - does not involve the entire depth of the dermis. - bright red in color and edematous - surface is moist and thin-walled, fluid-filled blisters appear within minutes - Very painful  Deep partial-thickness burn - Involves the entire dermis. - White and waxy and capillary refill may be decreased - Wet or dry and blisters can range from large and fluid filled to flat. - Less pain and decreased sensation C. Full-thickness burn or 3rd degree burn - burn involves all layers of the skin, including the hair follicles, sebaceous glands, and the epidermal sweat glands. - Very pale to bright red. - Little to no capillary refill and thrombosed blood vessels may be evident.  - Dry, firm, and may have a leathery feel and may also be referred to as eschar. Third degree burns develop in all three zones of burn injury: 3 Zones of burn injury: 1. Zone of coagulation - which is the deepest part of the burn. Cells are nonviable and the microcirculation is destroyed, leaving the skin dark colored and leathery. 2. Zone of stasis- viable and nonviable cells. Tissue destruction can occur even after the source of heat is removed. 3. Zone of Hyperemia - tissue with intact microvasculature that heals spontaneously within days. -appears pink, and capillary refill may be increased due to vasodilation induced by local inflammatory mediators Pathophysiology of Burn Management of Burn patient: 1. Dressing for minor burn injury - Moist environment to facilitate wound healing and it should prevent infection. - Topical ointment or cream directly to the clean wound, and covering the wound with a dressing. - Bacitracin ointment and silver sulfadiazine (Silvadene), - Topical agent must be reapplied frequently so the wound does not become dry. - Ointments containing vitamins A, D, and E are commonly used to dress minor burns of the face. 2. Major Burns - Multidisciplinary team with special training in burn care. - Specialists in physical and occupational therapy, respiratory therapy, social work, nutrition, psychology, and child life for children. - Management of a Burn Patient (Major Burns): 4 Phases 1. Resuscitation phase - Time of burn injury and ends with successful fluid resuscitation.  - Large-bore intravenous access for fluid administration. - Urinary catheter. - Nasogastric tube should be placed and suction applied to prevent aspiration. - Heart rate and blood pressure monitoring should be available.  a) Airway Management: Early Intubation.  b) Fluid Resuscitation: Avoid the development of hypovolemic shock  Goal: perfuse the organs  Nurses’ Roles: Administering fluids and continually monitoring and assessing the patient’s status.  Electrolyte status should be monitored closely.  Lactated Ringers Solution: Fluid of choice.  Balance between under resuscitation and over resuscitation. Inhalation Injury:  Exposure of the airways to heat or toxic substances, resulting in damage to the upper and lower airways.  Results in pulmonary edema, which predisposes the burn patient to pulmonary failure, infection, and long-term pulmonary complications.  Presence of soot  c) Escharotomy - Physician uses a scalpel or electrocautery to cut through the eschar, which releases tension and permits blood flow to the area. Nurse’s role: monitoring the patient for blood loss and assessing for further signs of compartment syndrome.  d) Pain Management: Intravenously administered narcotics; Continuous infusions of morphine or fentanyl are common. Nurse’s Role: continually assesses the patient for pain using developmentally appropriate pain and sedation scales. 2. Acute Phase- Begins 24 to 72 hours post burn injury. Wound Management:  Areas of first and second-degree burns can be managed with wound care.  Deep second-degree burns can heal without surgical intervention unless the wound becomes necrotic due to impaired circulation or infection.  Third-degree, or full thickness, burns require surgical intervention to heal.  Autografting:   Involves removing thin slices of unburned skin from an unburned “donor” site and placing it on top of the excised burn wound.  Donor skin can be placed directly onto the burn (sheet graft) or meshed to increase the burn surface area covered.  Cadaver skin (allograft) is often used to cover excised skin or widely meshed autograft. Major Burn Dressing:  Silver sulfadiazine or other silver-coated dressings.  Bacitracin or vitamin A, D, and E cream  Fresh skin graft is covered with a moist dressing such as impregnated mesh gauze or silver impregnated dressings. The dressing is covered with bulky gauze and wrapped securely. Nurses’ Role: Nursing concerns regarding comfort and wound care following excision and grafting of a burn wound. Wound Management:  Preventing and Managing Infection Nurse’s Role: Nurses must know what infection precautions should be taken to protect this patient and other patients in the burn unit.  Infection control practices are very important, especially when treating patients with large burns or who are at increased risk due to age, weakened immune systems, or chronic disease.  Feeding should begin slowly to assess the patient’s tolerance. 3. Rehabilitation phase –  Begins when the patient is no longer acutely ill and most of the burn wounds are covered.  Continues post discharge as the patient regains function and recovers emotionally. Nurse’s Role: Support the patient’s physical and emotional healing.  Prepare the patient and family for discharge and ensuring that the patient is connected to resources in his or her home community to facilitate continued healing.  Wound and Scar Management Nurses Role: Educate about signs and symptoms of infection and should seek prompt medical treatment.  Avoid unnecessary exposure to people with colds or infections and maintaining up-to-date immunizations.  Hypertrophic scarring can be prevented or greatly reduced by the application of pressure garments.  The burn patient may be required to wear pressure garments continuously for up to 2 years following injury.  The patient is educated about the importance of wearing the garments continuously during this time and how to protect fragile skin under the garments with lubrication. Wound Contractures: Occur as a result of scar formation over joints, which limit joint movement.  Nurse works with physical and occupational therapy to ensure the patient is exercising and appropriate body positioning is maintained using splints and other devices.  Nurses Role: Assess the patient’s compliance. Pain During the Rehabilitation Phase:  Oral opioids, acetaminophen, or nonsteroidal anti-inflammatory medications provide adequate pain relief for most patients.  Pain and anxiety medications should be tapered during the rehabilitation phase.  Nurses Role: Educate on non-pharmacological therapies to decrease pain and anxiety. 4. Reintegration phase  The burn team begins to prepare the patient for reintegration into society prior to discharge.  The patient fears rejection and ridicule from acquaintances and strangers seeing the burn scars for the first time. Nurses’ Role:  Encouraging the patient and family to be independent prior to discharge.  Work with the patient’s community to ease social reintegration.  Assesses the patient’s coping abilities during outpatient clinic visits.  Assesses the family’s ability to care for the patient at home and provides the family with references for local services that can ease the transition. Nursing Diagnosis for Burn Patients Ineffective airway clearance related to inhalation injury Impaired gas exchange related to inhalation injury Deficient fluid volume related to third-spacing of fluids Pain related to burn injury Impaired skin integrity related to burn injury Anxiety related to sudden change in health status Body image disturbance related to change in physical appearance Risk for infection related to inadequate defense mechanisms Risk for imbalanced nutrition less than body requirements due to increased metabolic needs following burn injury