Burns 2

Hypertonic (salt solution)

(D5NS) -Require a osmotic pull of fluid from the interstitial space back into the depleted vascular space -Helps decrease the amount of fluid needed for resuscitation -Decreases chances of edema, pulmonary edema, and heart failure

Causes of neurological complications

-Electrolyte imbalances -Stress -Cerebral edema -Sepsis -Sleep disorders -use of analgesics

Sepsis in burns

-Gram negative bacteria -If suspected, cultures are immediately obtained from all possible sources including the wound, blood, urine, sputum, larynopharyx, perineal pharynx, and IV site -Treatment immediately begins with antibotics -Frequent assessment is appropriate to manage changes

Complications of Endocrine System

-Observe for transient increases in the patient's blood glucose levels as a result of stress-mediated cortisol and catecholamine release. -There is an increased mobilization of glycogen stores and gluconeogenesis. Subsequently, glucose is produced, along with an increase in insulin production. -However, insulin's effectiveness is decreased because of relative insulin insensitivity. This results in an elevated blood glucose level. -Hyperglycemia may also be caused by the increased caloric intake necessary to meet some patients' metabolic requirements. -***When this occurs, the treatment is supplemental IV insulin, not decreased feeding. Check blood glucose levels frequently and give insulin as ordered. -Point-of-care testing of glucose can be done, but serum glucose testing is more accurate. As the patient's metabolic demands are met and less stress is placed on the entire system, this stress-induced condition is reversed.

More complication Acute Phase*

-Paralytic Ileus if pt becomes septic -Pt can become agitated, withdrawn, or combative -As scar tissue forms, there may be a limited ROM with contractures

fiberoptic bronchoscopy

Assess lower airway (6-12 hours after burn, smoke inhalation suspected)

Two types of grafts

Mesh & Sheets

The goals of donor site care

The goals of donor site care are to promote rapid, moist wound healing; decrease pain at the site; and prevent infection.

Signs of adequate fluid resusitation

Urine output 1ml/kg/hr, weight, systolic >100, HR <100

Mesh

Used everywhere else

-Assessment

includes how did the burn occur, when?, how long, and type of agent used, previous medical problems, size & depth of wound, age, body part involved, and mechanism of injury

Emergent phase

•This is the period of time required to resolve immediate, life-threatening problems. It usually lasts 48 to 72 hours from the time of the burn. -Emergent phase ends when fluid mobilization and diuresis begins •The greatest threat is hypovolemic shock and edema formation. Toward the end of the phase, if fluid replacement is adequate, the capillary membrane permeability is restored. Fluid loss and edema formation cease. The interstitial fluid gradually returns to the vascular space. Diuresis is characterized by urine output with low specific gravities. -Pt will most likeley be in hypovolemic shock, need to frequently •Areas of full-thickness and deep partial-thickness burns are initially painless because the nerve endings are destroyed. Superficial to moderate partial-thickness burns are extremely painful. -Shivering may be a result of chilling, caused by heat loss, anxiety or pain •Most patients are alert (use calm reassurance) Unconsciousness or altered mental status is usually a result of hypoxia associated with smoke inhalation, head trauma, or excessive sedation or pain medication. •If inhalation injury has occurred, the upper airway is vulnerable to edema formation and obstruction of the airway.****** •If the patient is hypovolemic, kidney blood flow may decrease, causing renal ischemia. If it continues, acute kidney injury may develop. With full-thickness and electrical burns, myoglobin and hemoglobin are released into the bloodstream and can occlude the renal tubules.

Colloids

(e.g., 5% albumin) -Given after the first 24 hours replace intravascular volume once capillary permeability significantly decreases

Emergent Phase Goals

*Immediate problem is fluid loss, edema, reduced blood flow (fluid & electrolyte shifts) 1. Secure airway 2. Support circulation by fluid replacement 3. Keep the client comfortable with analgesics 4. Prevent infection through wound care 5. Maintain body temp 6. Provide emotional support

Sheets

-Are used for the face -Produce a better cosmetic appearance than mesh grafts

Indications for Fluid resuscitation

-Burns >20% of TBSA with adults -Burns >10% of TBSA with children -Age >65 or <2 -PARKLAND FORMULA

Nursing Interventions in Emergent Phase

-Collaborative effort in managing burns -Priority is going to AIRWAY, watch for larynogeal edema -Give 100% FiO2 mask -Early Intubation for inhalation injury is most often required (do not wait for swelling) -ALWAYS ASSESS AIRWAY, if at risk- early intubation -Maintain circulation, fluid resuscitation- crystalloids (isotonic, hypertonic) and colliods

Physical Therapy

-Continuous physical therapy, throughout burn recovery, is imperative if the patient is to regain and maintain muscle strength and optimal joint function. -A good time for exercise is during and after wound cleansing, when the skin is softer and bulky dressings are removed. -Passive and active ROM should be performed on all joints. *Ensure that the patient with neck burns continues to sleep without pillows or with the head hanging slightly over the top of the mattress to encourage hyperextension. -Maintain the occupational therapy schedule for wearing custom-fitted splints, which are designed to keep joints in functional position. -Examine the splints frequently to ensure an optimal fit, with no undue pressure that might lead to skin breakdown or nerve damage.

When patient is not intubated

-Delivery of 100% humidified O2 -Place pt in high fowlers, unless contraindicated in spinal injury -Encourage coughing and deep breathing -Turn pt every 1 to 2 hours to promote chest physiotherapy and suction

Nutritional Therapy

-Early and aggressive nutritional support within several hours of the burn injury can decrease mortality risks and complications, optimize healing of the burn wound, and minimize the negative effects of hypermetabolism and catabolism. -A hypermetabolic state proportional to the size of the wound occurs after a major burn injury. -Resting metabolic expenditure may be increased by 50% to 100% above normal in patients with major burns. -Core temperature is elevated. Catecholamines, which stimulate catabolism and heat production, are increased. Massive catabolism can occur and is characterized by protein breakdown and increased gluconeogenesis. -Failure to supply adequate calories and protein leads to malnutrition and delayed healing. -Calorie-containing nutritional supplements and milkshakes are often given to meet the caloric needs. -Protein powder can also be added to food and liquids. -Supplemental vitamins may be started in the emergent phase, with iron supplements often given in the acute phase

Fluids

-Establish IV access for fluid resuscitation and drug administration (2 large bore, for burns more than 15%) -Burns greater than 30% TBSA, use central line for fluid -Arterial LINE! -Crystalloids solution (LR), Colloids (Albumin) -EMS usually give NS -PARKLAND FORMULA (still must be titrated based on pt's response) -Colliod solution (albumin) is recommended given after the first 12-24 hours after capillary permability return to near normal. After this time, the plasma remains in the vascular space and expands the circulating volume. -Replacement amount is caculated based on pt's weight and TBSA burn

Wound Care

-Once a patent airway, effective circulation, and adequate fluid replacement have been established, priority is given to care of the burn wound. -Partial-thickness burn wounds appear pink to cherry-red and are wet and shiny with serous exudate. These wounds may or may not have intact blisters; are painful when touched; and have only minor, localized sensation because nerve endings have been destroyed in the burned dermis.

Complication of GI

-Paralytic ileus can be caused by sepsis. -Diarrhea may result from the use of enteral feedings or antibiotics. -Constipation can occur as a side effect of opioid analgesics, decreased mobility, and a low-fiber diet. -Patients with major burns may also have occult blood in their stools during the acute phase and require close monitoring for bleeding.

Nutrition

-The goal of nutritional therapy during the acute burn phase is to provide adequate calories and protein to promote healing. When the wounds are still open, the burn patient is in a hypermetabolic and highly catabolic state. -The patient may benefit from an antioxidant protocol, which includes selenium, acetylcysteine, ascorbic acid, vitamin E, zinc, and a multivitamin. -If the patient is on a mechanical ventilator or unable to consume adequate calories by mouth, a small-bore feeding tube is placed and enteral feedings are initiated. -When the patient is extubated, contact the speech pathologist to perform a swallowing assessment before an oral diet is started. -Encourage the patient to eat high-protein, high-carbohydrate foods to meet caloric needs. -Ask caregivers to bring in favorite foods from home. -Appetite is usually diminished, and you will need to reinforce whatever steps are necessary to achieve adequate intake. Ideally, weight loss should not be more than 10% of preburn weight. - If the patient is on a mechanical ventilator or unable to consume adequate calories by mouth, a small-bore feeding tube is placed and enteral feedings are initiated. When the patient is extubated, contact the speech pathologist to perform a swallowing assessment before an oral diet is started.29 Encourage the patient to eat high-protein, high-carbohydrate foods to meet caloric needs. Ask caregivers to bring in favorite foods from home. Appetite is usually diminished, and you will need to reinforce whatever steps are necessary to achieve adequate intake. Ideally, weight loss should not be more than 10% of preburn weight.

Goals of Wound Care

-The goals of wound care are to (1) prevent infection by cleansing and debriding the area of necrotic tissue that would promote bacterial growth and (2) promote wound re-epithelialization and/or successful skin grafting. -Wound care consists of ongoing observation, assessment, cleansing, debridement, and dressing reapplication. -Nonsurgical debridement, dressing changes, topical antimicrobial therapy, graft care, and donor site care are performed as often as necessary, depending on the topical cream or dressing ordered. -*Enzymatic debriders made of natural ingredients, such as collagen, may be used for enzymatic debridement of burn wounds, which speeds up the removal of dead tissue from the healthy wound bed. -Cleanse wounds with soap and water or normal saline-moistened gauze to gently remove the old antimicrobial agent and any loose necrotic tissue, scabs, or dried blood. -During the debridement phase, cover the wound with topical antimicrobial creams (e.g., silver sulfadiazine) or silver-impregnated dressings. CHECK FOR SULFA ALLERGY -When the partial-thickness burn wounds have been fully debrided, a protective, coarse or fine-meshed, greasy-based (paraffin or petroleum) gauze dressing is applied to protect the re-epithelializing keratinocytes as they resurface and close the open wound bed. -If grafting is necessary, protect the skin graft (discussed below) with the same greasy gauze dressings next to the graft, followed by saline-moistened middle, and dry gauze outer dressings. -With facial grafts the unmeshed sheet graft is left open, so it is possible for blebs (serosanguineous exudate) to form between the graft and the recipient bed. -Blebs prevent the graft from permanently attaching to the wound bed. -The evacuation of blebs is best performed by aspiration with a tuberculin syringe and only by those who have received instruction in this specialized skill.

Collaborative Care cont.

-The type of fluid replacement is determined by size and depth of burn, age of the patient, and individual considerations. Standardized formulas may be used. Adequacy of fluid resuscitation is made using clinical parameters. o The primary goals of wound care are coverage and prevention of infection. o Regardless of the type of wound, patients often find the initial wound care to be both physically and psychologically demanding. o Early in the post-burn period, administration of IV pain medication with opioids is common. • Early and aggressive nutritional support decreases mortality and complications, optimizes healing of the burn, and minimizes negative effects of hypermetabolism and catabolism. • Venous thromboembolism prophylaxis should be initiated if not contraindicated.

Fluid resuscitation parameter

-Urine output, the most commonly used parameter, and cardiac parameters are defined as follows. •Urine output: 0.5 to 1 mL/kg/hr; 75 to 100 mL/hr for electrical burn patient with evidence of hemoglobinuria or myoglobinuria. •Cardiac parameters: Mean arterial pressure (MAP) greater than 65 mm Hg, -systolic BP greater than 90 mm Hg, -heart rate less than 120 beats/minute. -MAP and BP are best measured by an arterial line. Manual BP measurement is often invalid because of edema and vasoconstriction.

Debridement

-You and appropriate personnel can perform cleansing and gentle debridement, using scissors and forceps, on a cart shower, regular shower, or patient bed or stretcher. -Extensive, surgical debridement is performed in the operating room (OR) . During debridement, necrotic skin is removed. Releasing escharotomies and fasciotomies are carried -Patients find the initial wound care to be both physically and psychologically demanding. Provide emotional support and begin to build trust during this activity.

Two kinds of Pain

-continuous, background pain that might be present throughout the day and night; and -treatment-induced pain associated with dressing changes - The first line of treatment is drugs. With background pain, a continuous IV infusion of an opioid (e.g., hydromorphone [Dilaudid]) allows for a steady, therapeutic level of medication. If an IV infusion is not present, slow-release, twice-a-day opioid medications (e.g., morphine [MS Contin]) are indicated. Around-the-clock oral analgesics can also be used. -Breakthrough doses of pain medication need to be available regardless of the regimen selected. Anxiolytics, which can potentiate analgesics, are also indicated and include lorazepam (Ativan) and midazolam (Versed). -For treatment-induced pain, premedicate with an analgesic and an anxiolytic via the IV or oral route. For patients with an IV infusion, a potent, short-acting analgesic, such as fentanyl (Sublimaze), is often effective. -During treatment and activity, small doses should be given to keep the patient as comfortable as possible. -Elimination of all the pain is difficult, and most patients indicate acceptance of "tolerable" levels of discomfort.

Complications of Acute Phase

-include wound infection progressing to sepsis as a result of manipulation (e.g., after showering and debridement) and prolonged presence of eschar. -The same cardiovascular and respiratory system complications seen in the emergent phase may continue. -Infection -Mild confusion -Malaise -Chills -Loss of appetite -WBC will usually be between 10,000 and 20,000

Curling's Ulcer

-is a type of gastroduodenal ulcer characterized by diffuse superficial lesions (including mucosal erosion). -It is caused by a generalized stress response to decreased blood flow to the GI tract. -The patient has increased gastric acid secretion. -Aim to prevent Curling's ulcer by feeding the patient as soon as possible after the burn injury. -Antacids, H2-histamine blockers (e.g., ranitidine [Zantac]), and proton pump inhibitors (e.g., esomeprazole [Nexium]) are used prophylactically to neutralize stomach acids and inhibit histamine and the secretion of hydrochloric acid

Musculoskeletal Complications

-is particularly prone to complications during the acute phase, and the involvement of both the physical and occupational therapist is vitally important. -As the burns begin to heal and scar tissue forms, the skin is less supple and pliant. ROM may be limited, and contractures can occur. -Because of pain, the patient likely prefers a flexed position for comfort. Encourage the patient to stretch and move the burned body parts as much as possible. -Consult with the occupational therapist about proper positioning and splinting to prevent or reduce contracture formation.

PPE

Clean gloves to clean dirty wounds Sterile gloves to apply ointment Prevent shivering

Nursing Diagnosis: Emergent Phase

Ineffective airway clearance (are they coughing?) Impaired gas exchange (gas exhange improved) Ineffective fluid volume deficit (want fluid to move to vascular space) Fluid volume excess Hypothermia Infection Acute pain (partial-thickness) Skin integrity, impaired Anxiety Knowledge deficit

Grafting

Management of full-thickness burn wounds involves early removal (surgical excision) of the necrotic tissue followed by application of split-thickness autograft skin

Isotonic

NS & LR Do not cause fluid shifts Large amounts of fluid are required

Delirium

is more acute at night and occurs more often in the older patient. Use a screening tool to diagnose delirium and initiate appropriate nursing interventions to prevent delirium, whenever possible. -Focus on nursing strategies to orient and reassure your patient if he or she is confused or agitated. -This state is usually transient, lasting from a day or two to several weeks, but complications and sequelae can last for years and be quite serious.

Severe respiratory distress devleop

mechanical ventilation is initiated

Burn Management

•Burn management is organized chronologically into three phases: emergent (resuscitative), acute (wound healing), and rehabilitative (restorative). Overlaps in care exist from one phase to another. •At the scene of the injury, priority is given to removing the person from the source of the burn and stopping the burning process. According to the type of burn, the ABCs (airway, breathing, and circulation) are supported and wound care is initiated.

NURSING AND COLLABORATIVE MANAGEMENT: EMERGENT PHASE

•Initial management of a major burn includes a rapid and thorough assessment of the patient's ABCs. Interventions include airway management, fluid therapy, and wound care. Analgesics are ordered to manage pain. -Usually early intubated with ETT to prevent getting trach -Pt with burn to face and neck requires intubation within 1-2 hours of injury (EDEMA OF UPPER AIRWAY) -Pt will be extubated when edema resolves (3-6 days after burn) -Escharotomy of chest wall may be needed to relieve respiratory distress syndrome

Nursing Management: Acute Phase

•The acute phase begins with the mobilization of extracellular fluid and subsequent diuresis and concludes when burned area is completely covered by skin grafts or when wounds are healed. This may take weeks or many months. -The depth of the wound may be more apparent as they declare themselves as partial or full thickness -Pt will benefit from psychosocial support and information •Partial-thickness wounds form eschar, which begins separating fairly soon after injury. Nectrotic tissue begins to slough and granulation tissue forms. Once the eschar is removed, re-epithelialization appears as red or pink scar tissue. •Margins of full-thickness eschar take longer to separate. As a result, they require surgical debridement and skin grafting for healing. •Because the body is trying to reestablish fluid and electrolyte homeostasis, it is important for you to follow the patient's serum electrolyte levels closely, particularly for changes in sodium and potassium levels.