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

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Nursing Care & Interventions in the Client with Burn Injury

Keith Rischer RN, MA, CEN

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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.

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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

Depth of Burn Injury

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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

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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

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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

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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

Facial burnsSinged nasal hairsStridor

CO Poisoning•HA•Nausea •Alterered LOC

• Confusion• Coma

Severe coughHoarsenessShortness of breathAnxietyWheezingDyspneaDisorientationObtundedComa

Symptoms

Signs

Burn Classification

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Minor• <15% partial thickness

Moderate• 15-25% partial

thickness• <10% full thickness

Severe• >25% partial thickness• >10% full thickness

ABA Burn Referral Guidelines

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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

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Laboratory Findings: First 48 hours

Hgb/Hct Glucose Sodium Potassium BUN/creatinine Albumin ABG’s

• pO2• pCO2• pH• CO

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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• I&O

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

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___

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Assessment Priorities: After 48 Hours

Cardiopulmonary• Pneumonia

Neuroendocrine• Increased metabolic demands

Immune (risk of infection)• Local• Systemic

VSAltered LOCu/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…

Impaired Skin Integrity-Wound Care

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Debridement• Hydrotherapy

Wound dressings• Antibiotic ointment• Biologic• Synthetic

Skin grafts • Autograft • Artificial

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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

Dressings

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Decrease pain Absorb drainage Preserve joint

mobility and allow ROM

Provide protection and isolation of wound from environment

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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

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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