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