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MSK & BurnsRehabilitation Nursing

Glenrose Rehabilitation

Hospital

January 11, 2006

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Edmonton and Areawww.capitalhealth.ca

Learning ObjectivesMSK Rehabilitation Nursing

At the conclusion of the presentation the Rehabilitation Nurse will be able to explain:

The anatomy of the MSK system

The pathophysiology of MSK impairment

Clinical signs & symptoms related to MSK impairment

Lab results related to MSK impairment

Rehabilitation nursing interventions to provide care & education for clients with MSK impairment

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Anatomy and Physiology

Skeleton “dried-up body”: bones lying buried within muscles and other soft tissues, providing a rigid framework and support structure of the whole body

Axial: bones that form the longitudinal axis of the body

Appendicular: bones of the limbs and girdles

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Functions

Interdependent with other body systems

Provides protection for vital organs

Provides sturdy framework to support body structures

Stores calcium, phosphorus, magnesium, fluoride

Produces red and white blood cells (hematopoiesis)

Joints and muscles together allow body movement and assist in maintaining body temperature

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Structure and Function

206 bones in human body (350 in infants)

Two basic types of osseous (bone tissue):

• Compact bone (cortical)…dense, smooth and homogeneous

• Spongy bone (cancellous)…a branching network of trabeculae arranged to resist stresses and strains

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Classification

Regionally or according to shape

• Long

• Short

• Flat

• Irregular

• Sesamoid

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Classification

Long bone: • found in limbs (e.g. humerus, femur)• length is greater than width• tubular shaft (diaphysis) and usually a epiphysis at

each end• shaft has a central marrow cavity (yellow for adults;

red for infants)• outer part of shaft is composed of compact bone

covered by connective tissue sheath (periosteum)• ends are composed of spongy bone surrounded by

thin layer of compact bone (articular surfaces covered by hyaline cartilage)

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Classification

Short bone:

• found in hand and foot (e.g. scaphoid, calcaneous)

• cuboidal in shape

• composed of cancellous bone (spongy) surrounded by thin layer of compact bone

• covered with periosteum and articular surfaces covered by hyaline cartilage

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Classification

Flat bone:

• found in vault in skull (e.g. frontal and parietal bones)

• composed of thin inner and outer layers of compact bone

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Classification

Irregular bone:

• include the vertebrae and pelvic bones

• composed of thin shell of compact bone

• interior composed of cancellous bone

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Classification

Sesamoid bone:

• small nodules of bone found in certain tendons where they rub over bony surfaces

• greater [part of sesamoid bone is buried in the tendon and the free surface is covered with cartilage

• largest is the patella (located in the quadriceps femoris)

• function is to reduce friction on the tendon; may also alter the direction of a pull tendon

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Bone Anatomy

spongy bone: needle-like threads surround a network of spaces (trabeculae)

compact bone: no network of open spaces; instead have numerous structural units (osteon or haversian system)

bones are not lifeless; many living bone cells called osteocytes

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Bone Development

Developed by two methods:

• Membranous: bone developed directly from a connective tissue membrane

• Endocondral: a cartilaginous model is first laid down and later replaced by bone

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Bone Development

Osteoblasts: bone building cells; secrete collagen

Osteoclasts: cells that break bone down (bone resorption)

Osteoblasts and osteoclasts work side by side to shape bones

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Bone Healing

Hematoma and inflammation Angiogenesis and cartilage formation Cartilage calcification Cartilage removal Bone formation Remodeling• Serial x-ray films are used to monitor the progress

of bone healing• Type of bone fractured, adequacy of blood supply,

surface contact of fragments and general health of the person influence the rate of fracture healing.

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Structure

Junction of two or more bones is called a joint (articulation)

3 types of joints:

Synarthrosis

Amphiarthrosis

Diarthrosis

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Joints

Synarthrosis: immovable (skull sutures)

Amphiarthrosis: limited motion (vertebral joints and symphysis); bones are joined by fibrous cartilage

Diarthrosis: freely movable

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Types of diarthrosis joints

Ball-and-socket: permit full freedom of movement (hip and shoulder)

Hinge: permit bending in one direction (elbow and knee)

Saddle: allow movement in two planes at right angles to each other (base of the thumb)

Pivot: characterized by the articulation between radius and ulna

Gliding: limited movement in all directions (wrist)

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Muscle Contractions

Isometric: muscle length remains constant but force generated by muscles is increased

Isotonic: muscle shortening with no increase in tension within the muscle

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Muscle Tone

Tone: relaxed muscles demonstrate a state of readiness to respond to contraction stimuli

• A muscle that is limp and without tone is flaccid

• A muscle with greater-than-normal tone is spastic

• In conditions characterized by lower motor neuron destruction, denervated muscle becomes atonic (soft and flabby) and atrophies

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Exercise, Disuse and Repair

Hypertrophy: when muscle repeatedly develops maximum tension over time, the cross-sectional area of muscle increases; persists only if the exercise continues

Atrophy: decrease in the size of the muscle because of disuse over a long period of time

Bedrest and immobility cause loss of muscle mass and strength.

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Gerontologic Considerations

Bone mass peaks at about 35 years of age Loss of height due to osteoporosis, kyphosis,

thinned intervertebral discs, and flexion of the knees and hips.

Osteoporosis due to metabolic changes (withdrawal of estrogen and decreased activity)

Bones change in shape and have reduced strength

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Gerontologic Considerations

Fractures are commonCollagen structures are less able to absorb

energy Ligaments become weakOsteoarthritis: joints enlarge and ROM is

diminished Increased inactivity, diminished neuron

stimulation, and nutritional deficiencies contribute to loss of muscle strength

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Fractures

A break in the continuity of the bone and is defined according to its type and extent

Bone is subjected to stress greater than it can absorb

Caused by direct blows, crushing forces, sudden twisting motions, and extreme muscle contractions

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Types of Fractures

Complete: across the entire cross-section of the bone and frequently displaced

Incomplete: through only part of the cross-section of the bone

Comminuted: produces several bone fragments

Closed (simple): does not cause break in skin

Open (compound): skin or mucous membrane wound extends to the fractured bone

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Fractures: Clinical Manifestations

Pain

Loss of function

Deformity

Shortening

Crepitus

Swelling and discoloration

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MSK Modalities

Pelvis: fused, stable, bony ring including sacrum, pubis, and ischium bones

• Stable

• Unstable

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MSK Modalities

Joint Replacement:

• Patients with severe joint pain and disability

• Conditions include osteoarthritis, rheumatoid arthritis, trauma, and congenital deformity

• Joints frequently replaced include hip, knee and finger joints

• “Simple” replacements not usually seen in rehab settings

• Complicated hips (Co-morbidities) and subsequent replacements seen

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Total Hip Replacement

Indications include: arthritis, femoral neck fractures, failure of previous reconstructive surgeries and problems with congenital hip disease

Usually 60 years or older, however, younger patients with severely damaged and painful hip joints are having surgery

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Total Hip Replacement

Nursing Implications:

• Awareness of potential complications including: dislocation of hip prosthesis, excessive wound drainage, thromboembolism, infection, heel pressure ulcer, heterotrophic ossification, avascular necrosis, and loosening of the prosthesis

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Total Hip Replacement: Patient Teaching

Daily exercise

Use of assistive devices (crutches, walker, cane)

Position legs in abduction and do not flex the hip more than 90 degrees

Avoid certain activities

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Knee Replacement

Indications: severe pain and functional disabilities related to joint surfaces destroyed by arthritis or bleeding into the joint (hemophilia)

• If a patient’s ligaments have weakened, a fully constrained (hinged) or semiconstrained prosthesis may be used to provide joint stability. A nonconstrained prosthesis depends on the patient’s ligaments for joint stability

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Knee Replacement

Efforts are directed at preventing complications (thromboembolism, peroneal palsy, infection, limited ROM)

Frequently, a CPM device is used

Knee is protected with a knee immobilizer (splint, cast or brace) and is elevated when sitting in a chair

Weight-bearing limits are prescribed

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Tibia and Fibula

Most common fracture below the knee resulting from a direct blow, falls with the foot in the flexed position, or a violent twisting motion

Often occur in association with each otherFractures are often open and involve severe

soft tissue damage because of little subcutaneous tissue in the area

Assess for complications

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Managing an External Fixator

Provide support for severe comminuted fractures while permitting active treatment of damaged soft tissue

Fracture is reduced, aligned, and immobilized by a series of pins inserted in the bone

Pin position is maintained through attachment to a portable frame

Provides patient comfort, early mobility, and active exercise of adjacent uninvolved joints

Complications related to disuse and immobility are minimized

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External Fixator: Nursing Implications

Prepare the patient psychologically Assess for complications Pin care Never adjust the clamps on the frame Teach and encourage isometric and active exercises Assist with weight bearing (as prescribed by the

physician) Fixator is removed after the soft tissue heals; may

require additional stabilization (cast or molded orthosis) while healing

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Ilizarov External Fixator

Device used to correct angulation and rotational defects, to treat non-union, and to lengthen limbs

Tension wires attached to fixator rings; joined by telescoping rods

Bone formation stimulated by prescribed daily adjustments of the telescoping rods

Generally encourage weight bearing

Correction achieved, no adjustments made, fix

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Casting

Indications: applied for purposes of immobilization

Plaster, synthetic fiberglass and synthetic non-fiberglass

Upper extremities, lower extremities, trunk, hip or shoulder areas (spica)

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Casting: Nursing Implications and Complications

Casting process can cause burning

Constrictive edema

Decubitus ulcer

Drop foot

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Traction

• The application of a pulling force to a part of the body

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Traction Guidelines

Purpose:

• To prevent or reduce muscle spasm

• To immobilize a joint or part of the body

• To reduce a fracture or dislocation

• To treat joint pathology(s)

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Traction Guidelines

The traction setup must:

• Align the distal fragment to the proximal fragment

• Remain constant

• Allow for adequate exercise and diversion

• Allow for optimum nursing care

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Traction Guidelines

Counter traction: the resistance of the body to move in a direction of the forces exerted by a traction device.

• Utilizes the patients body weight; may be increased by elevation of the foot of the bed

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Types of Traction

3 basic types:

Manual: hands are used to exert a pulling force on the bone which is to be realigned.

Skin: strips of tape, moleskin, or some type of commercial skin traction strips applied directly to the skin e.g. traction boots.

Skeletal: tractive force applied directly to the bone using pins, wires and screws.

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Skeletal Traction

Requires the use of Steinmann pins or Kirschner wires for long bone fractures.

Differences are in diameter (Steinmann are larger).

Both comes in a variety of lengths.

Choices based on physician preference, density of bone pin or wire to be inserted through, and the forces to be applied.

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Skeletal Traction

Can also be divided based on the direction of force:

• Straight-line traction e.g. Buck’s traction

• Block and tackle (suspensory)

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Application of Traction

Skin traction cannot be applied over an open wound

Check with patient for possible adhesive allergies

Do not reuse traction cord

Avoid pressure on bony prominences

Never add/remove weights without a written physicians order

Allow weights to hang freely

Never add anything to traction unless ordered by a physician

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Traction: Nursing Implications

Regular visual inspection and documentation includes:

• Weights are hanging freely

• Rope condition and placement

• Knots are free from pulley’s

• Bed linens etc. not interfering with traction

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Traction: Nursing Implications

Maintain proper positioning

Maintain continuous traction

Maintain correct line of pull

Neurovascular checks

Skin examination

Maintain patient independence

Traction systems can vary

NEVER IGNORE A PATIENT’S COMPLAINT

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Traction: Complications

Allergy to adhesive

Skin excoriation and pressure sore development

Peroneal palsy

Bone infection

Depressed scars

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Arthritis

One of the most prevalent chronic health conditions in Canada

A major cause of morbidity, disability, & HC utilization

2000 Affected 16% of population > 15 yrs Includes a large variety of diseases &

conditions

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Osteoarthritis

Affects both sexes, more women then men

Age – single most important factor

2x as common with obesity

Primary with unknown etiology

2nd due to joint injury & long term mechanical stressors

Often affects weight bearing joints first

Degenerative; caused by loss of cartilage

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Osteoarthritis

Pain is often localized

Unilateral joint involvement

Slow course of disease with flare-ups

Crepitus, audible grating, swelling, pain, decreased mobility

Treatment: PT, Stress Reduction, Pain management, Osteotomy, Joint Replacement

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Inflammatory DisordersRheumatoid Arthritis

Chronic, systemic, inflammatory disease affecting the synovia of the joints

Affects all racial/ethnic groups Affects women 2-3 x as often as men Onset at any age (commonly 20 – 40 yrs) Etiology unknown - Theories:

- Autoimmune process- Genetic predisposition- Immune response to unknown antigen- Environmental Factors

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Inflammatory Disorders Rheumatoid Arthritis

Hands affected early; then wrists, ankles, knees

Advanced: hips, shoulders, all joints

May affect all connective tissue

Remissions & exacerbations

Lab results: ↑ erythrocyte sed rates; + rheumatoid factor

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Treatment goals:– Preservation of function

– Reduction of pain & inflammation

– Prevention of deformities (or correction)

Treatment begins conservatively: rest, salisylates & PT

Patient education program – link to resources (Arthritis Society)

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Medications: salicylates, NSAIDs, indoles,, antimalarials, penicillinase, with Enbrel, Corticosteroids

Treatments: Immobilization of joints in acute flare-ups; applications of hot & cold, splints to maintain function

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Inflammatory Disorders Juvenile Arthritis

5th most common chronic illness

Cause: Environmental Theories (Microbial, etc.)

S&S of sepsis (fever) ; arthralgias

Serology results

Growth & developmental delay as a result of

↓ physiological function

Progressive systemic sclerosis or scleroderma

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Inflammatory DisordersSystemic Lupus Erythematosus (SLE)

Multisystem, autoimmune, inflammatory disorder

Unknown etiology

Initial manifestation of transient arthritis

Multisystem: Remissions & Exacerbations

Manifestations: Facial butterfly rash, skin rashes, fever, weakness/fatigue, anemia, mouth ulcers, photosensitivity, alopecia, kidney disease,

peri/myocarditis, pleurisy, depression

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Systemic Lupus Erythematosus (SLE)

Management:

Prevention of exacerbations

Nutrition – weight loss or gain

Caution with OTC meds, immunizations

Medications: NSAIDS

Antimalarials- highly effective but slow acting in controlling lupus arthritis, rashes, fatigue

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Systemic Lupus Erythematosus (SLE)

Meds cont’d:

Corticosteroids –reduce inflammation; many side effects

Azathioprine- transplant medication,

immunosuppressant

Cyclophosphamide- for severe infections Used when many organs have been affected

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Inflammatory DisordersSpondylarthropathies

“Spinal arthritis”: group of inflammatory arthropathies with unknown etiology

Common S&S: Inflammatory arthritis of the back (tendon- ligament

insertion points)

Skin lesions may also occur

↑ specific HLA

Absent Rheumatoid Factor

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Inflammatory DisordersAnkylosing Spondylitis

Onset of mild pain in adolescence

Progression: increasing pain & restricted movement d/t development of postural abnormalities

Diagnosis based on S&S

Lab tests

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Metabolic Disorders

Gout – uric acid crystalizes & is deposited in the synovial fluid, joints or articular cartilage

Majority are men > 30

S&S – severe pain, swelling

Diagnosis – History, Lab, Physical Exam

Treatment: Diet, NSAIDS, prednisone colchicine

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Osteoporosis “The Silent Thief”

Bone loss results when bone resorption exceeds bone formation-resulting in decreased bone density increased fragility & risk of fractures (hip, wrist & spine)

Types of osteoporosis include:

- Postmenopausal ( 55 – 70 )

- Senile (over age 70)

- Disease/disuse

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Osteoporosis

Prevalence 1.4 million Canadians (5:1 women to men)

Risk Factors: Genetic, Nutritional, Lifestyle, Ethnic, Endocrine, Medications

Management:- Medications: Oral calcium 800 – 1200 mg/day

- Vitamin D, Estrogen replacement therapy,

- Calcitonin injections (SC or IM)

- Other: Exposure to sunlight, weight bearing exercises

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Osteoporosis

Lab results usually normal

Xray: >30% bone loss

Bone mineral density test

Prevention – strategies to develop peak bone mass & reduce risk factors begin with the young

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Fibromyalgia Syndrome FMS

Associated with RA, SLE

Unknown etiology: theory of normal aging, genetics or environmental factors

High incidence rate in females (85%)

Chronic pain, tenderness, stiffness, fatigue & sleep disturbances

Symmetrical pressure points painful to touch

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Osteogenesis imperfecta

Genetic disorder characterized by bones that break easily with little or no cause

Genetic

Characteristic features vary greatly

Skin biopsy – determine amount of collagen

Surgery – rods placed in long bones to stabilize

Nursing care involves caution with all care

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Traditional Nonpharmacological Interventions

Application of heat & cold

Cold decreases pain & swelling

Heat relaxes the joint & increases ROM

FES (Functional Electrical Stimulation)

Biofeedback techniques – reduce stress

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Alternative Management

Acupuncture

Magnetic therapy

Glucosamine

Herbal preparations

T’ai Chi

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Exercise

OA – daily exercise, progression, general fitness

RA – based on disease progression, patient fatigue level, etc.

Fibromyalgia – slowly increasing exercise relieves S&S

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Complications

Anticoagulation – heparin, warfarin

DVT - common post hip/knee replacement

PE – common complication of DVT, orthopedic surgery

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Complications

HITT - Heparin Induced Thrombocytopenia

Hemophilia - a hereditary coagulation disorder

Anemia – 2nd to blood loss (acute or chronic) nutritional, chronic disease

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MSK Complications

Infections – acute, chronic require prevention! Osteomyelitis, tetanus, gas gangrene

Neuropathic Pain – injury/ aberrant stimulation of the efferent nervous system

Compartment syndrome – high pressure within a closed fascial space reduces the capillary perfusion required

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Nursing

Comprehensive history

Physical examination

Pain assessment

Limitations in performing ADLs

Psychological assessment (changes in body image)

Role change, job retraining

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Mobility

Maintain mobility with therapeutic exercise

Safety considerations

ROM exercises

Therapeutic positioning & positioning aids

Ambulation & gait training

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Mobility

Assessment of movement– Physical: ROM, Muscle strength, balance/coordination,

Weight bearing status (full, partial, non)

– Cognitive

– Psychological

– Environmental

– ROM

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Immobility

Prevent impairment from immobilityMSK – weakness, muscle atrophy,↓ ROM, contractures, osteopenia, HOCV – deconditioning, thromboembolism, postural responsesIntegument - breakdownRespiratory - PneumoniaGU – UTIsGI – constipationCNS – depression, irritability, confusion, social isolation

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Mobility with Aids

Ambulation Aids:• Canes: correct length; Various types. Hold on

• unaffected side, advance cane then affected leg

• Walkers: Various types. Advance walker, affected leg, unaffected leg

• Crutches: correct length. 2, 3, 4 point gait

• Wheelchairs: individualized

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Client Wheelchair Education

Education should include:• Transfers to and from the chair

• Position changes and weight shifts required

• Basic wheelchair maintenance. Modifications increase maintenance & costs

• Operating the wheelchair safely indoors & out

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Orthotics, Splints & Braces

AFOs – prevents ankle pronation; used with the shoe

Corrective shoes routinely used with orthotics

KAFOs – stability at knee, ankle & foot

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Self-CarePersonal Hygiene

Many devices available• Hair – built up handle, universal cuff, loops strapped to

handle

• Oral Hygiene

• Grooming: fixed containers

• Dressing: modification in design & assistive devices • Stretchable clothes, adaptations with velcro, large buttons, loops

on zippers

• Shoes with velcro or elastic closures

• Reachers, long handled shoehorsn, sock pull-ups

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Home Assessment

Home Assessment • Stairs – indoors & out

• Location of all rooms, accessibility

• Thresholds, floor obstructions & coverings

• Furniture arrangement & ability to use

• Telephone location, ability to use

• Bathroom size, safety equipment, toilet height,

• Bedroom height of bed

• Other safety considerations: Ability to control water temperature, access to phone, TV while in bed

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Self-CareBathing & Toileting

Access

Safety bars on the tub & toilet

Benches or tub seats

Hand held shower hoses

Non-slip bath mats & other surfaces

Transfer board

Raised toilet seat

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Altered Body Image

Altered gait, use of assistive devices, deformities, rheumatoid nodules, bruising

Directly related to functional ability

Requires ongoing assessment of the client based on developmental stage

Timing of interventions is essential

Peer support groups are often helpful

Individual counseling may be preferable

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Rehab Nursing Interventions

Prevent complications

Promote quality of life

Promote positive self concept

Advocate through client education & health promotion

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References

Carlos, A. (2005). A Practical Illustrated Guide to Modern Orthopaedics. Mediscript Communications Inc.; Canada.

Homan, S. (2002). Rehabilitation Nursing: Process, Application & Outcomes. 3rd Ed., Mosby; St. Louis.

Schoen, D. (2000). Adult Orthopedic Nursing

Lippincott, Williams & Wilkens; Philadelphia.

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References

Smeltzer, S., Bare, B. (2004). Brunner & Suddarth’s Textbook of Medical – Surgical Nursing. 10th Ed., Lippincott Williams & Wilkens; Philadelphia.

Phipps, W., Monahan, F., Sands, J., Marek, J ., Neighbors, M. (2003). Medical-Surgical Nursing: Health & Perspectives. 7th Ed., Mosby; St. Louis.

www.capitalhealth.ca

Nursing the Rehabilitation Client with Burns

January 11, 2006

Glenrose Rehabilitation Hospital

Edmonton, Alberta

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Objectives

1. Review of the anatomy of skin in relation to burns

2. Discussion of the pathophysiology of burns

3. Examination of the potential complications of burns

4. Rehabilitation nursing interventions for the patient with burns

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Survivability

• The chances of surviving a severe burn has increased dramatically in the past 20 years - a person with 70% burns now has a 50% chance of surviving.

Factors associated with survivability include:1. Age - the very old or very young have increased

mortality2. Total body surface area burned (TBSA) Time +

Intensity = Damage3. Inhalation injury - increases mortality by 30% and

lengthens stay4. Pneumonia and sepsis leading cause of death

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Pathophysiology of Burns/Anatomy of the Skin

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Burn Assessment

• Mechanism of injury/causative agent

• Depth

• Extent

• Patient age

• Location of injury

• Comorbid factors

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Types of Burns

• Thermal

• Electrical

• Chemical

• Inhalation

• Radiation

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Thermal Burns

– Most common type, includes exposure to steam, flash, scald, contact and flame

– Caused by exposure or contact with flame, hot liquids, steam, tar or hot objects

– Use cool water initially to decrease skin temperature

– S/S: pain, redness, swelling and drainage of pus

– dressings: AgNO3, polysporin

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Electrical or Lightning Burns

– Severity of damage is determined by: Type and voltage of the circuit, the pathway through the body, the duration & the resistance of the body

– Least resistance - Nerve tissue; vascular, muscle, skin, fat, bone most resistance

– Entry wound – localized, deep, depressed, dry, charred

– Exit wound – may have multiple exit sites, injury resulting from an explosion

– Visible trauma contradicts underlying trauma

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Chemical Burns

• Caused by acids and alkalis

• The concentration of the chemical agent and the length of exposure to it are the key factors that determine the extent and depth of damage

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Inhalation Burns

• Composed of three distinct problems

1. Carbon monoxide intoxication

2. Upper airway obstruction

3. A chemical injury to the lower airway

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Radiation

• Least common type of burn injury

• Caused by exposure to radioactive source

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Depth of InjuryFirst Degree – Superficial

• Skin depth – epidermis

• Mechanism of injury – sunburn (UV light), flash flame

• Color/Pain – erythematous, pink, dry & tender no blisters, painful

• Healing time – 5-10 days with no residual scarring

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Second Degree or Partial Thickness(Superficial & Deep)

• Skin depth – complete epidermis & partial dermis

• Mechanism of injury – hot liquids or solids, direct flame, chemicals, clothing flame, UV light

• Color – moist & blister to white & dry• Pain - very painful• Healing time – 5-21 days with no grafting,

longer if grafting required

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Superficial Partial Thickness

• Epidermis and upper 1/3 dermis involved

• Dark pink/red, blistered, wet

• Severe pain (exposed nerves)

• Takes longer to heal: 7-14 days

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Deep Partial Thickness

• Involves injury to deeper skin layers

• Burns are dry and white with red areas that don’t blanch, skin may appear spotted

• Sensation is decreased

• Infection is a concern

• Healing takes longer than 2 weeks, with scarring and possible need for debriding and grafting

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Third Degree – Full Thickness

• Skin depth – epidermis & dermis

• Mechanism of injury – hot liquid or solids, flame, chemicals, electrical injury

• Color – eschar, charred vessels and dry

• Pain - limited/no pain

• Healing time – grafting required

• Usually have permanent impairments

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Fourth Degree – Full Thickness Plus

• Skin depth – epidermis & dermis – complete - affects fat, bone fascia, muscle

• Mechanism of injury – hot liquids/solids, flame, chemicals, electrical injury

• Color– eschar, charred vessels and dry

- also affects fat, bone, fascia and muscle

• Pain - limited/no pain

• Healing time – reconstructive surgery usually indicated; severe disfigurement

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Determining Extent of Injury

• Rule of nines – total body surface areas

• Pediatric assessment

• Estimation of burn size using palm

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Adult Burns – The Rule of Nines

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Pediatric Burns Lund & Browder Method

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Triage Criteria for Burn Patients

• Minor burn injury: can be treated on outpatient basis

• Moderate uncomplicated burn injury: usually requires hospitalization in a institute with experience in burn care or specialized burn treatment facility

• Major burn injury: requires hospitalization in a specialized burn treatment facility

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Age/Location/Comorbidities

• Children ages 2-4 and young adults ages 15 – 25 years old are the age groups with the greatest numbers of injuries from burns

• Elderly people experience high mortality and morbidity from burns

• Locations of highest risk are the face, neck, hands, feet and perineum

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Systemic Response

1. Hypovolemia

2. Edema to non burned areas

3. Burn shock

4. Cardiovascular

5. Pulmonary

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Systemic Response cont’d

6. Gastrointestinal

7. Renal

8. Cellular

9. Metabolic

10. Immunologic

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3 Phases of Burn Care

1. Emergent/resuscitative phase

2. Acute phase

3. Rehabilitative phase

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Priorities of Burn Management

• Wound care and closure• Pain management• Prevention or treatment of complications,

including infection• Nutritional support• Maintenance of respiratory and circulatory

status• Fluid and electrolyte balance• GI function

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Goals of Wound Care

1. Prevent infection

2. Provide comfort

3. Debridement

4. Reduce scarring/contractures

Goal: To promote physical and psychological healing to the fullest extent possible

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Burn Wound Healing

Burn wound healing occurs in primarily two forms:

- epithelialization

- contraction

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Factors affecting wound healing

1. Age

2. Infection

3. Nutrition

4. Vitamins

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Factors affecting wound healing cont’d

5. Trace elements

6. Oxygen

7. Diseases that impair healing

8. Medications

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Topical Antibacterial Therapy

• Decrease the colonization of bacteria so control of the body’s host defense mechanisms can be maintained

• Promotes healing and closure of a clean wound bed

• Most common agents are polysporin, silver nitrate, ActicoatTM, and SulfamylonTM

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Wound Dressing Product

• Adaptic

• Telfa

• Sofratulle

• Xeroform

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Cleansing Solutions

• Clorhexidine (4%)

• Sterile normal saline

• Tap water

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Special Care Areas

• Eyes– cleanse with NS– lacrilube ungt or tear drops

• Ears– prone to chondritis– sulfamylon ungt BID– avoid pressure

• Face– shave daily– polysporin ungt BID (wash between applications)– NS soaks continuous, change Q4H, rewet prn

• Fingers & toes– wrap separately to prevent webbing

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Grafts(in order of preference)

• Homograft– allograft

• cadaver

• skin bank

• Xenograft– heterograft

• pig

• cow

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Graft Care

• Apply appropriate dressing– AgNO3 to clean up graft

– PolysporinTM/AdapticTM to small open areas

• Once healed (red and itchy)– Apply lotion

• Donor Sites– Xeroform placed on in the OR

– Leave xeroform until it falls off (trimming the edges as it dries)

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Common Problems/Complications

• Altered sensation

• Heterotropic ossification (HO)

• Scarring

• Pain

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Altered Sensation

• Sensory nerves or sensory receptors in the injured skin may be affected, causing decreased sensation

• Includes – Itchiness

– Skin alterations –Blisters

– Thermoregulation

– Edema

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Heterotrophic Ossification (HO)

• Accumulation of excess bone across joints

• Occurs in 13-23 % of clients with burns

• Most common in patients with greater than 20% full thickness burns

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Types of Scars

• There are a number of different scars that can occur in the burn patient and that play an important role in the rehabilitation and treatment of the burned patient.– Normal scars

– Contractures

– Hypertropic scars

– Keloids

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Factors Affecting Scar Formation

1. Race

2. Age

3. Location

4. Depth

5. Tension

6. Other

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Pain Management

• Pain is more severe in partial thickness burns due to exposed nerve endings

• Full thickness burns – nerve endings are destroyed

• Pain in full thickness burns is associated with deep pain/pain in the surrounding areas

• Fear & anxiety can increase perception of pain

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Two Types of Pain Commonto the Burn Client

1. Background pain• Associated with AADL and at rest

• Pain that never goes away

2. Associated pain• Associated with wound care, therapy and

treatments

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Important nursing actions when caring for a patient with excessive burns

1. Monitor VS

2. Monitor intake and output

3. Assess for pain and administer pain medication as ordered, especially before dressing changes

4. Assess for distal neurovascular changes and monitor for development of limited movements and numbness of affected areas

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Important nursing actions when caring for a patient with excessive burns

5. Provide dressing changes using sterile technique at least daily and more frequently for excessive drainage

6. Avoid chilling the patient

7. Monitor for development of complications, such as hydration, hypovolemia, infection, and renal failure

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Nursing Interventions related to Impaired Skin Integrity

• Dryness

• Photosensitivity

• Pruritius

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Nursing Interventions related to Impaired Physical Mobility

• Positioning

• Splinting

• Exercise

• Compression

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Nursing Interventions related to Altered Health Maintenance

• Lifestyle

• Self care

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Emotional Support

• The psychological implications for a client with burns

• Clients may exhibit a variety of responses depending on their phase of recovery

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Expected Outcomes of Rehab

• Optimal function

• Endurance

• Self direction of care

• Comfort

• Psychosocial adjustment

• Social support

• Family coping, family functioning

• Coping, body image acceptance

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Discharge Education

• Blister care – NEVER BREAK OPEN

• Exposure to temperature extremes

• Skin care

• Face care

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Discharge education cont’d

• Pressure garments

• Itching

• Nutrition

• Exercise

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Health Promotion/Prevention

• Education:– 80% of fires are due to carelessness

– 35% involve children playing with matches

– Smoke detectors are present in 13/14 homes (require regular battery checks/changes)

– Seasonal causes for burns

– Focus on high risk groups

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Discharge

• Support services are necessary throughout Rehabilitation

• Education begins with onset of treatment• Earlier discharge means that education continues

post discharge• All team members provide to client/family at every

level of treatment• Community support groups assist with

resocialization & coping for years post-discharge• Complications can include PTSD/psychological

problems at any time

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References

• Bickston, T.H. (2004). Medical-Surgical Nursing Recall. Lippincott Williams & Wilkins:Philadelphia

• Firefighter’s Burn Treatment Unit – University of Alberta, 2005

• Hoeman, S.P. (2002). Rehabilitation Nursing; Process, Application, & Outcomes, 3rd edition. Mosby:Toronto

• http://www.med.ualberta.ca/acicr/pages/ protocols/burns.htm

• Thelan, L., Davie, J., Urden, L., and Lough, M. (1994). Critical Care Nursing:Diagnosis and Management. Mosby:Toronto

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Musculoskeletal Disorders in Rehabilitation Nursing

Presented by:

Chris Wright RN, BScN, CRRN

([email protected])

Evelyn Myles RN, BScN

([email protected])

Glenrose Rehabilitation Hospital

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