Nursing Care

1
Nursing Care Interventions in the Client with
Burn Injury

• Keith Rischer RN, MA, CEN

2
Todays Objectives

• Compare and contrast the clinical manifestations
  of superficial, partial-thickness, and
  full-thickness burn injuries.
• Prioritize nursing care for the client during the
  emergent, acute, and rehabilitation phase of burn
  injury.
• Analyze assessment data to determine nursing
  diagnoses and formulate a plan of care for
  clients with burn injuries.
• Use laboratory data and clinical manifestations
  to determine the effectiveness of fluid
  resuscitation.
• Describe nursing management wound care and
  nutritional needs for the burn client.
• Evaluate assessment data to determine wound
  healing in the burn client.
• Identify pain management strategies for burn
  clients.
• Explain the positioning and range-of-motion
  interventions for the prevention of mobility
  problems in the client with burns.
• Discuss the potential psychosocial problems
  associated with burn injury.

3
Burn Injury Patho

• Skin
• Epidermis
• Dermis
• Purposes
• Skin destruction
• Fluid/protein loss
• Sepsis
• Multi-system changes
• Dependant on age
• Health
• Depth of injury
• Body area involved

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Depth of Burn Injury

• Superficial-thickness
• Epidermis only
• Partial-thickness
• Epidermis partial Dermis
• Full-thickness
• Epidermis all dermis underlying
  tissue/muscle/bone

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Assessment Superficial-thickness

• Pain
• Redness
• Heals in 3-5 days

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Assessment Partial-thickness

• Red-blanch
• No blanch with deeper burn
• Blister and broken epidermis
• Painful
• Heal in 10-21 days

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Assessment Full-thickness

• Pale, white to red, yellow
• Charred eschar
• Leathery skin, dry surface
• Painless
• Edema present
• Signs of systemic shock may be present
• Needs grafting

8
Burns Vascular Changes

• Fluid shift
• Capillary leakage
• First 12 hours
• Lasts 24-36 hours
• Lyte acid base imbalance
• Hypovolemia
• Hyperkalemia, hyponatremia
• Fluid remobilization
• Diuretic stage (48-72 hours)
• Hyponatremia
• hypokalemia

9
Burns Body System Assessment

• Cardiac
• HR increase
• CO decreased initially
• Respiratory
• Airway edema
• pulmonary cap. leakage
• GI
• Paralytic ileus
• Metabolic
• Increased due to catecholamines, cortisol and SNS
• Caloric needs double or triple
• Immune
• Diminished response
• Increased risk of infection

10
Burns Emergency Management

• Primary Survey
• Airway
• Breathing
• Circulation
• C-Spine immobilization (when indicated)
• Secondary Survey
• Complete head to toe exam
• of TBSA
• Depth of burn
• Part(s) of body burned
• Rule out other serious or life threatening
  injuries

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Inhalation Injury Assessment
Severe cough Hoarseness Shortness of
breath Anxiety Wheezing Dyspnea Disorientation Obt
unded Coma

• Facial burns
• Singed nasal hairs
• Stridor
• CO Poisoning
• HA
• Nausea
• Alterered LOC
• Confusion
• Coma

Signs
Symptoms
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Burn Classification

• Minor
• lt15 partial thickness
• Moderate
• 15-25 partial thickness
• lt10 full thickness
• Severe
• gt25 partial thickness
• gt10 full thickness

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ABA Burn Referral Guidelines

• 2 Burns gt 10 TBSA
• Burns involving the face, hands, feet, genitalia,
  perineum, major joints
• 3 Burns in any age group
• Electrical Burns
• lightning injuries
• Chemical Burns

14
Laboratory Findings First 48 hours

• Hgb/Hct
• Glucose
• Sodium
• Potassium
• BUN/creatinine
• Albumin
• ABGs
• pO2
• pCO2
• pH
• CO

15
Nursing Diagnostic Priorities First 48 Hours

• Decreased cardiac output r/t
• Deficient fluid volume r/t
• Ineffective tissue perfusion r/t
• Ineffective breathing pattern r/t
• Acute pain r/t

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Fluid Resuscitation

• Nursing interventions
• Large bore IV/central IV access
• Lactated ringers
• Nursing Assessment
• IO
• Urine output
• Daily weight
• Oxygenation needs
• Fluid overload
• VS
• Labs
• Creatinine
• Albumin
• lytes

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Nursing Diagnostic Priorities First 48 Hours

• Ineffective breathing pattern r/t
• Respiration pattern
• Oxygenation
• ABGs
• pH 7.41.7.29
• p02 73.55
• pCO2 44.60
• Acute pain r/t
• Opiods IV
• Fentanyl... Onset___ Peak___ Duration___
• Morphine Onset___ Peak___ Duration___
• DilaudidOnset___ Peak___ Duration___

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Assessment Priorities After 48 Hours

• Cardiopulmonary
• Pneumonia
• Neuroendocrine
• Increased metabolic demands
• Immune (risk of infection)
• Local
• Systemic
• VS
• Altered LOC
• u/o

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Nursing Diagnostic Priorities After 48 Hours

• Impaired skin integrity r/t
• Risk of infection r/t
• Imbalanced nutrition-less than body requirements
  r/t
• Impaired physical mobility r/t
• ROM
• Early ambulation
• Disturbed body image r/t

20
Impaired Skin Integrity-Wound Care

• Debridement
• Hydrotherapy
• Wound dressings
• Antibiotic ointment
• Biologic
• Synthetic
• Skin grafts
• Autograft
• Artificial

21
Dressings Topical Antibiotics

• Silver Sulfadiazine
• Most frequently used topical
• Gram negative/positive organisms
• Penetrates eschar well
• Applied with a gloved hand, tongue depressor or
  impregnated in gauze
• Bacitracin
• Acceptable for use with superficial burns
• Least expensive antimicrobial agent

22
Dressings

• Decrease pain
• Absorb drainage
• Preserve joint mobility and allow ROM
• Provide protection and isolation of wound from
  environment

23
Nutrition

• Metabolic changes
• Hormone mediated
• gt Catecholamines
• gt Glucocorticoids and glucose to insulin ratios
• Metabolic alterations
• gt Gluconeogenesis
• gt Proteolysis
• gt Ureagenesis
• lt Lipolysis Ketone utilization

• Net Results of Changes
• gt Nitrogen losses
• gt Energy Expenditures and nutrition metabolism
• Results
• Hypermetabolic - catabolic state

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Enteral Feedings

• Preferred route
• Safety
• Better utilization of nutrients
• Gut integrity
• Lower cost
• Parenteral (TPN)
• Nonfunctional guts
• High risk for sepsis
• Objectives

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Psychological Issues Follow Up

• Inpatient
• PTSD
• Disfigurement
• Sexual issues
• CD
• Outpatient
• Ongoing therapy
• Support groups
• Burn Camp