Burn care

1. Burn care Nursing2003,March 報告人：開刀房　何秀美 報告日期:95年8月23日

2. Here’s what you need to know KNOWING HOW TO care for a patient with burn injuries in the first crucial hours after injury may shorten her hospital stay and help her recover more fully.

3. BASICS • First you assess her airway,breathing, and circulation. Look for signs of a compromised airway and inhalation injury • Use pulse oximetry to monitor • Obtain an arterial blood gas analysis to provide a baseline. • Need tetanus antitoxin(If vaccine booster in more than 10 years) • cool compresses. (Never use ice, which causes vasoconstriction and may i n crease tissue injury.)

4. BASICS • Draw blood for a baseline complete blood cell count and electrolyte levels • renal failure, which can occur after b urn injury, especially if the patient receives nephrotoxic drugs such as antibiotics Obtain baseline blood urea nitrogen and creatinine levels to monitor • Monitor her for hypothermia.

5. Signs and symptoms that alertyou to possible inhalation injury • burns to the face, head, ears,neck, or chest • singed facial hair, nostrils, or lips • blistering on the face or mouth • irritated or tearing eyes • carbonaceous (sooty) sputum • dyspnea or tachypnea • coughing, wheezing, or stridor • reddened and edematous oral mucosa • hoarseness .(hoarseness could indicate edema and airway obstruction.

6. Assessing burns secondary systems survey, you’ll assess burn wounds. 1.Thepalm method provides a rough estimate in the field. The surface area of an adult’s palm is equal to 0.5% to 1% of her BSA. 2.Therule of nines is another method . In this system, the body is divided into groups equal to about 9% of BSA (for example,the head and neck count as 9% ofBSA), 3.The two-dimensional Lund -Browderclassification Each section of the body has its own percentage figure according to patient age. Patients with extensive burns(more than 15% of total BSA) need fluid resuscitation to maintain vital organ perfusion and hemodynamic stability

7. Classifying depth of burn injurySuperficial (first degree) • Only epidermis involved • Skin is pink,red,painful, and dry, with no blistering. • These burns heal in 3 to 5 days and rarely leave scars. • Use emollients to prevent skin from drying and cracking. • Don’t count these burns in percentage of total body surface area. • Because the epidermal barrier remains intact, the risk of infection is minimal.

8. Classifying depth of burn injury Partial thickness (second degree) • Epidermis and dermis involved • Skin is bright red, pearl-pink, painful, wet, blistered, and edematous. Rapid heat and fluid loss may occur with large burns. • Burns heal in 10 days to 2 weeks. • Use atopical agent or temporary biologic cover. Skin grafts may be needed. • Monitor for infection. • Don’t break blisters. • Incidence of scarring depends on depth of burn.

9. Classifying depth of burn injury Full thickness (third degree) • Epidermis and dermis destroyed • Fascia, muscle, and bone may be affected.* • Skin is leathery; dry; painful at edge of burn, otherwise painless; edematous; charred; and white, beige ,brown, or black. Massive fluid and heat loss may occur with large burns. • Burns heal in weeks to months; less time is needed if skin is grafted. • Excise dead skin and apply skin graft orequivalent. Topical antimicrobial agents may be applied to decrease infection risk. • Monitor for infection. • These burns are prone to contracture formation and scarring. Very deep burns involving underlying subcutaneous tissue, tendon, or bone may be considered fourth -degree burns.

10. Keeping pain under control • Full thickness burns typically are painless because of damaged sensory nerves • partial-thickness burn sare extremely painful because some nerves are intact. • Wound care with dressing changes exercising, doing range-of-motion exercises, skin contractures, and stretching also can cause intense pain • Morphine usually is the drug of choice for managing burn pain. • continuous morphine infusion by a patient-controlled analgesia pump. Patient Administer bolus doses of morphine for break through pain. • Adjunctive techniques for pain management include relaxation therapy, diversion

11. Wound care fundamentals • Burn injuries suppress the immune system, increasing the risk of infection and other complications. • Provide daily wound care to prevent infection, maintain function,and promote healing. • Before removing a dressing, prevent it from sticking to the wound by soaking it with sterile 0.9%sodium chloride or sterile water for afew minutes. • Let the patient remove the dressing herself if patient’s able • Wash her wounds with antiseptic soap and fine mesh gauze (to remove debris) • Rinse the wound with sterile 0.9% sodium chloride or sterile water and pat the wound dry with sterile gauze. • apply a thin layer of silver sulfadiazine to gauze, Secure the gauze pads with roll gauze and place elastic netting • Carefully assess wounds for signs and symptoms of infection,including erythema, edema,increased heat, and discomfort .Obtain culture specimens if you suspect infection, although wound Monitor the patient ’s vital signs and temperature every 4 hours.

12. Making new skin • Skin grafting will help the wounds heal faster with less scarring and pain, and less risk of infection. • donor site heals in about2 weeks. Let patient know that after the donor site will be more painful than the burn wound. • In 2 days, the graft should have adhered • a splint to prevent the graft from shearing off . • Assess her peripheral pulses to make sure that edema, dressings, or splints are n’t impeding her circulation . • By the fifth postoperative day, the graft is healing and the wound can be left open to air. Patient also can begin exercising her hand to prevent contractures .

13. Supporting mind and body • Provide psychological and support services • After a burn injury, the body enters a hypermetabolic state • Provide a high-protein, highcalorie diet supplemented with additional minerals and vitamins. • Check her weight daily and consult with the nutritionist make sure nutritional needs are being met. • Because opioids and immobility can cause constipation,prevent constipation- high-fiber diet • As the wound heals,the skin changes colors andbecomes very dry and itchy. Show how pure emollients, such ascocoa butter or mineral oil

14. Supporting mind and body • Because healing skin is fragile,tell her to protect it from the sun for at least a year. Some burn survivors with deep wounds have trouble tolerating temperature extremes because sweat glands and nerves were lost. • A burn wound takes about 6months to heal, and scarring can become hypertrophic. Elastic pressu re garments can help smooth the skin and flatten the wound. • These custom-made garments are worn 23 hours a day for up to a year after healing.

15. Going home Once Patient can care for her wounds donor site care stretching exercises proper nutrition follow up care pain control the signs and symptoms of wound infection keep outpatient appointments so her health care provider can closely monitor her progress.

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