Nursing Care & Interventions in the Client with Burn Injury

1. Nursing Care & Interventions in the Client with Burn Injury Keith Rischer RN, MA, CEN

2. Today’s 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

4. Depth of Burn Injury • Superficial-thickness • Epidermis only • Partial-thickness • Epidermis + partial Dermis • Full-thickness • Epidermis + all dermis + underlying tissue/muscle/bone

5. Assessment: Superficial-thickness • Pain • Redness • Heals in 3-5 days

6. Assessment: Partial-thickness • Red-blanch • No blanch with deeper burn • Blister and broken epidermis • Painful • Heal in 10-21 days

7. 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

11. Inhalation Injury: Assessment Severe cough Hoarseness Shortness of breath Anxiety Wheezing Dyspnea Disorientation Obtunded Coma • Facial burns • Singed nasal hairs • Stridor • CO Poisoning • HA • Nausea • Alterered LOC • Confusion • Coma Signs Symptoms

12. Burn Classification • Minor • <15% partial thickness • Moderate • 15-25% partial thickness • <10% full thickness • Severe • >25% partial thickness • >10% full thickness

13. ABA Burn Referral Guidelines • 2° Burns > 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 • ABG’s • 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…

16. Fluid Resuscitation • Nursing interventions • Large bore IV/central IV access • Lactated ringers • Nursing Assessment • I&O • Urine output • Daily weight • Oxygenation needs • Fluid overload • VS • Labs • Creatinine • Albumin • lytes

17. Nursing Diagnostic Priorities: First 48 Hours • Ineffective breathing pattern r/t… • Respiration pattern • Oxygenation • ABG’s • 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___ • Dilaudid…Onset___ Peak___ Duration___

18. Assessment Priorities: After 48 Hours • Cardiopulmonary • Pneumonia • Neuroendocrine • Increased metabolic demands • Immune (risk of infection) • Local • Systemic • VS • Altered LOC • u/o

19. 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 • > Catecholamines • > Glucocorticoids and glucose to insulin ratios • Metabolic alterations • > Gluconeogenesis • > Proteolysis • > Ureagenesis • < Lipolysis & Ketone utilization • Net Results of Changes • > Nitrogen losses • > Energy Expenditures and nutrition metabolism • Results • Hypermetabolic - catabolic state

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

25. Psychological Issues & Follow Up • Inpatient • PTSD • Disfigurement • Sexual issues • CD • Outpatient • Ongoing therapy • Support groups • Burn Camp