PROTECTIVE FUNCTIONS

  1. Burns: wounds caused by exposure to excessive heat, chemicals, fire, steam, radiation, or electricity; most often related to carelessness or ignorance; 10,000-12,000 deaths annually; survival best at ages 15 - 30 yr and in burns covering less than 20% of total body surface
    1. Pathophysiology:
      1. Emergent phase (injury to 72 hr): shock due to pain, fright, or terror —> fatigue, failure of vasoconstrictor mechanisms —> hypotension. Capillary dilation, increased permeability —» plasma loss to blisters, edema —> hemoconcentration —» hypovolemia —> hypotension —» decreased renal perfusion —> potential shut-down.
      2. Acute phase (3-5 days): interstitial to plasma fluid shift —> hemodilution —> hypervolemia —» diuresis.
    2. Assessment:
      1. Subjective data: how the burn occurred
      2. Objective data:
        1. Extent of body surface involved: “rule of nines” - head and both upper extremities, 9% each; front and back of trunk, 18% each; lower extremities, 18% each; and perineum, 1%. Requires adjustment for variation in size of head and lower extremities according to age
        2. Location - facial, perineal, and hand and foot bums have potentially more complications because of poor vascularization.
        3. Depth of burn:
          1. First degree (superficial) - epidermal tissue only; not serious unless large areas involve
          2. Second degree (shallow or deep partial thickness) - epidermal and dermal tissue, hospitalization required if more than 10% of body surface involved (major burn).
          3. Third degree (full thickness) - destruction of all skin layers; requires immediate hospitalization; involvement of 10% of body surface considered major burn.
          4. Fourth degree (deep penetrating) - muscles (fascia), bone
        4. Indications of airway burns, singed nasal hair, progressive hoarseness, sooty expectoration; edema may occur in 1 hr; increased mortality rate
        5. Poorer prognosis - infants, due to immature immune system and effects of fluid loss; elderly, due to degenerative diseases and poor healing
        6. Medical history - presence of hypertension, diabetes, alcohol abuse, or chronic obstructive pulmonary disease increases complication rate
    3. Analysis/nursing diagnosis:
      1. Impaired skin integrity related to thermal injury.
      2. Pain (depending on type of burn) related to exposure of sensory receptors.
      3. Fluid volume excess or deficit related to hemodynamic changes.
      4. Risk for infection related to destruction of protective skin.
      5. Impaired gas exchange related to airway injury.
      6. Body image disturbance related to scarring, disfigurement.
      7. Ineffective individual or family coping related to traumatic experience
    4. Nursing care plan/implementation:
      1. Goal: alleviate pain, relieve shock, and maintain fluid and electrolyte balance
        1. Medications: give opioid analgesic and anxiolytics incrementally.
        2. Fluids: IV therapy; colloids, crystalloids, or 5% dextrose according to burn formula
        3. Monitor hydration status:
          1. Insert indwelling catheter.
          2. Note color, odor, and amount of urine hourly.
          3. Strict intake and output; hourly for 36 hr with large burns.
          4. Check hematocrit (normal: men >40%; women >37%). Increased Het with intravascular fluid depletion.
          5. Weigh daily
      2. Goal: prevent physical complications.
        1. Vital signs: hourly; central venous pressure (CVP) for signs of shock or fluid overload with at-risk patients.
        2. Assess respiratory function (particularly with head, neck burns); patent airway; breath sounds.
        3. Give medications as ordered - tetanus booster; antibiotics to treat documented infection; sedatives and analgesics; antipyretics - avoid aspirin; H 2 blockers.
        4. Isolation: protective; contact isolation (hand washing, protective clothing).
        5. Positioning: turn q2h; prevent contractures.
          1. Head and neck burns - use pillows under shoulders only for hyperextension of neck.
          2. Hand burns - splints.
          3. Arm and hand burns - keep arms at 90-degree angle from body and slightly above shoulders.
          4. Ankle and foot burns - splints; elevate to prevent edema
          5. Splints to maintain functional positions.
          6. ROM exercises according to therapy guidelines; usually several times per day; active exercises most beneficial.
        6. Diet: begin oral fluids at once; food as tolerated - high protein, high calorie for energy and tissue repair (promote positive nitrogen balance); enteral feedings if protein and calorie goals not met.
        7. Observe for: constriction (circumferential or chest wall burns); check peak inspiratory pressure in intubated patient - report increased pressure; check pulses in burned extremities every 1 - 2 hours for 24 hours - report loss of pulses.
      3. Goal: promote emotional adjustment and provide supportive therapy.
        1. Care by same personnel as much as possible, to develop rapport and trust.
        2. Involve patient in care plans.
        3. Answer questions clearly, accurately.
        4. Encourage family involvement and participation.
        5. Provide diversional activities and change furnishings or room adornments when possible, to prevent perceptual deprivation related to immobility.
        6. Point out signs of progress (decreased edema, healing) because patient and family tend to become discouraged and cannot see progress.
        7. Encourage self-care to highest level tolerate
        8. Anticipate psychological changes:
          1. Acute period - severe anxiety: medicate with anxiolytics as ordered; maintain eye contact; explain procedures.
          2. Intermediate period - reactions associated with pain, dependency, depression, anger; give medications to decrease pain; explain procedures; have open, nonjudgmental attitude; use consistent approaches to care; contract with patient regarding division of responsibilities; encourage self-care
          3. Recuperative period - grief process reactivate Anxiety, depression, anger, bargaining, as patient tries to cope with altered body image, leaving security of hospital, finances. Encourage verbalization; refer to support group to assist adaptation.
      4. Goal: promote wound healing - wound care:
        1. Open method - exposure of burns to air; useful in burns of face; thin layer (2-4 mm) topical antimicrobial ointment applied
        2. Closed method - dressings applied to burned areas, changed 1 - 3 times/day; give PO pain medication 30 min before change; IV pain medication during dressing change; tubbing facilitates removal.
        3. Multiple dressing change - common approach; dressings changed bid to q4h depending on wound condition.
        4. Topical antimicrobial therapies.
        5. Tubbing and debridement.
          1. Hydrotherapy - body  temperature bath water; loosens dressings so some float off; soak 20-30 min; encourage limb exercises; do not leave unattended; loss of body heat may occur, with chilling and poor perfusion resulting
          2. Removal of eschar (debridement) - done with forceps and curved scissors; medicate for pain before; use sterile technique; only loose eschar removed, to prevent bleeding; examine wound for infection, color change, decreased granulation - report changes immediately. Chemical debridement also done; agent digests necrotic tissue
        6. Wound coverage, to decrease chances of infection:
          1. Temporary and semipermanent wound coverings.
          2. Autograft - patient donates skin for wound coverage
            1. Types - free grafts (unattached to donor site) and pedicle grafts (attached to donor site).
            2. Procedure - general anesthesia; donor sites shaved and prepared; graft applied to granulation bed; face, hands, and arms grafted first.
            3. Post-skin-graft care:
              1. Sheet grafts: roll cottontipped applicator over graft to remove excess exudate; maintain dressings; aseptic technique; mesh grafts: irrigate as ordered.
              2. Third to fifth day - graft takes on pink appearance if it has taken.
              3. Padding, then splints applied to immobilize grafted extremities.
              4. Pressure garments worn up to 18 months to decrease hypertrophic scarring.
      5. Goal: health teaching.
        1. Mobility needs: exercise; physical therapy; splints, braces.
        2. Community resources: mental health practitioner or psychotherapist if needed for problems with self-image or sexual role; referrals as needed.
        3. Techniques to camouflage appearance: slacks, turtlenecks, long sleeves, wigs, makeup.
    5. Evaluation/outcome criteria:
      1. Return of vital signs to preburn levels.
      2. Minimal to no hypertrophic scarring.
      3. Free of infection; demonstrates wound care.
      4. Maintains functional mobility of limbs; no contractures.
      5. Adjusts to changes in body image; no depression.
      6. Regains independence; returns to work, social activities.