There are several diagnostic procedures that can be used to assess the extent of damage when treating a patient with a burn injury. Klein et al. (2009) explains that the first diagnostic information collected is the total body surface area or TBSA, which is calculated with the rule of nines. In the rule of nines the major anatomical areas of the body can be divided into percentages, in adults, nine percent for the head and neck, nine percent for each upper extremity, eighteen percent to each of the anterior and posterior portions of the trunk, eighteen percent to each lower extremity, and one percent to the perineum and genitalia. TBSA plays a vital role in care and fluid resuscitation.
Doenges et al. (2010) suggests that a complete blood count or CBC may show an initial increased hematocrit can be due to a fluid shift or loss. Later in treatment, hematocrit and red blood cells may decrease because of heat damage to the vascular endothelium. White blood cells may be elevated due to the inflammatory response of the burn. Doenges et al. (2010) also explains that arterial blood gases or ABGs describes the assessment of the arterial blood levels of oxygen or PaO2 and carbon dioxide or PaCO2. Baseline pH is important with a suspicion of an inhalation injury. A reduced PaO2 and an increased PaCO2 is indicative of carbon monoxide poisoning. Klein et al. (2009) states that carboxyhemoglobin or COHgb is a compound that is formed when inhaled carbon monoxide combines with hemoglobin, The COHgb binds with hemoglobin securely which makes the hemoglobin not able to carry oxygen. Klein et al. (2009) goes on to states that an elevation of more than ten percent indicates an inhalation injury. In a chem 10 panel the potassium level may be initially elevated because of injured tissues, red blood cell destruction, or decreased renal function. The sodium level may initially be decreased with body fluid losses, but hypernatremia can also occur later as renal conservation begins.
Doenges et al. (2010) suggests that a urinalysis is a screening test often used to evaluate the renal function. The presence of albumin, hemoglobin, and myoglobin can indicate deep tissue damage and protein loss, which is often seen with serious electrical burns. Reddish or black color urine can indicate the existence of myoglobin. Klein et al. (2009) says that photographs of burns can be useful to help document and provide a baseline to evaluate the healing process later. A laser doppler measures the micro vascular blood flow in the dermis layer. Laser doppler flow measurements performed early after a burn injury, is useful in assessing the depth of a burn and the potential for healing. Laser doppler flowmetry also helps select the patient for an early excision and grafting of wounds. Magnetic resonance imaging, or MRI scan, uses magnetic fields to create two or three dimensional images of organs inside the body. An MRI can detect tissue edema. Tissue edema is a manifestation of cellular membrane damage which begins to collect minutes after an electrical injury.
Doenges et al. (2010) explains that wound cultures are often performed by collecting drainage or other material from the burn area which is then grown in the laboratory to identify the presence of microorganisms such as bacteria or fungi. These cultures may be obtained for baseline data and repeated throughout care to evaluate the wound for infection or the effectiveness of antimicrobial therapies.
Doenges et al. (2010) states that chest x-rays can evaluate organs and structures within the chest for symptoms of disease. Chest x-rays may appear normal at first, even with inhalation injury, often progressing to whiteout on x-rays later on. Upper airway endoscopy and fiberoptic bronchoscopy is also known as direct or indirect laryngoscopy, is a direct visualization of the upper airways by a rigid or a flexible bronchoscope. It is very useful in diagnosing the degree of damage of an inhalation injury. Abnormal results of a laryngoscopy can include edema, hemorrhage, or ulceration of the airway. Electrocardiogram or ECG is a record of the electrical activity of the heart. An ECG may show signs of myocardial ischemia and dysrhythmias that may occur with electrical burns.
There are three collaborative parts to the care of a burn patient, Klein et al. (2009) describes them as resuscitative, acute, and rehabilitive. The resuscitative stage also called the emergency phase starts when the injury takes place and lasts until forty eight hours when the shift of fluids and proteins has subsided. Typically the first health care professionals to encounter the patient are emergency medical technicians, but occasionally the first care received may be at the emergency department. Klein et al. (2009) states that the first priority is to stop the burning process as quickly as possible. If the burn was caused by cement, tar, or scalding, clothing should be removed by using water. Ice should never be used as it can cause vasoconstriction and lead to further tissue damage.
Once the burning process has stopped the patient may be transferred to a specialty burn center as the care for a severe burn is complex. Klein et al. (2009) states that once the resuscitative phase is complete the acute phase begins. The airway should be assessed first. If an inhalation injury is suspected intubation may be necessary to prevent airway closure from tracheal edema. If the patient is not intubated the nurse should constantly be monitoring for hoarseness, stridor, or wheezing, as these signs can indicate ineffective airway clearance. The patients’ breathing should also be assessed if carbon monoxide poisoning is established. Humidified one hundred percent oxygen therapy should be administered by endotracheal tube or face mask to decrease the work of breathing and help facilitate oxygen saturation until COHgb levels have returned to normal. When treating a burn patient fluid resuscitation plays a vital role in burn management and recovery. There are many methods in calculating burn resuscitation fluids, but in the end the overall goal is to maintain tissue perfusion and the organs function without fluid therapy deficit or overload. Klein et al. (2009) stated that the Parkland Formula is a common fluid resuscitative formula. The Parkland Formula determines the amount of Lactated Ringer’s solution to infuse the first twenty four hours at 4ml/kg/% TBSA. The first half of the calculated amount is given during the first eight hours, and the remaining amount given over the last sixteen hours. Klein et al. (2009) explains that the Consensus Formula is a revised formula of the Parkland Formula. The Consensus Formula suggests that adults should be given Lactated Ringer’s 2-4 ml/kg/%TBSA for the first twenty four hours. “The second twenty four hours the patient should be given dextrose in water plus potassium to maintain a normal electrolyte balance and a colloid containing formula at 20% to 60% of calculated plasma volume, which equals an infusion rate of approximately 0.35 to 0.5 ml/kg/%TBSA” says Klein et al. (2009)( p707).
Either method chosen to calculate fluid resuscitation the patient should have two large bore peripheral intravenous access established. According to Klein et al. (2009) lactated ringer’s solution is the most commonly used crystalloid, as it is composed of osmolality and electrolytes which is very similar to the body’s normal fluids. Lactated Ringer’s contain lactate which acts as a buffer for metabolic acidosis. Lactated Ringer’s do not provide intravascular protein so the colloid albumin is commonly used to increase the intravascular oncotic pressure. Albumin can reduce edema by pulling fluids from interstitial space back into the intravascular volume.
Doenges et al. (2010) explains that burn care and procedures can cause excruciating pain for the patient. Pain can vary depending on the degree and extent of burn. A first degree burn is extremely responsive to touch, pressure, passing air, and even temperature changes. Second degree moderate thickness burns are very painful, whereas pain response in second degree deep thickness burn is less painful because of the disconnected nerve endings. Pain control is vital in the care of a burn injury. Pain should be assessed often and should always be assessed before, during, and after any procedure. Opiates are the most commonly used medications to treat pain. Klein at al. (2009) explains that the medication should be administered through an IV and not intramuscular or subcutaneous. Klein et al. (2009) explained that a continuous Morphine IV infusion is used with severe burns, but a patient controlled analgesia can also be used to help the patient control their pain also.
Burn wounds are treated in a variety of ways, but all work towards the same goal of preventing infection and removing the nonviable tissue to promote re epithelialization and by skin graft as needed. Interventions to reach the goal can be achieved by cleansing, debridement, dressing therapy, or surgical closure. Wound care should be done a minimum of two times per day states Klein et al. (2009). When cleansing a wound, a mild soap or disinfectant should be used with warm water. In debridement wounds are scrubbed with sponges, washcloths, or brushes can be used to remove debris. Silver Nitrate is a topical antimicrobial agent used to treat a wide spectrum of a wide spectrum of surface pathogens. Silver Nitrate should be applied after wound care two to three times a day.
In full thickness burns often surgical or skin graft closure is necessary for closure. Doenges et al. (2010) explains that a biological dressing can be an allograft or homograft is a graft of skin from another human which can be living or a cadaver. Another type of biological dressing is a Xenograft. It is a graft of skin from another species, most commonly a pig. Both allograft and xenografts are biologic dressings only, and both eventually are rejected by the immune system, and are removed before skin grafting. Klein et al. (2009) explains there are two major types of biosynthetic dressings AlloDerm and TransCyte. TransCyte graft is a nylon mesh which is incubated with human fibroblasts that provide a partial dermis layer with an outer silicone layer, which serves as a temporary epidermis. It is often used in deep or full thickness wounds prior to autogenous skin graft placement. It must be removed prior to grafting full thickness injuries. AlloDerm is a skin graft which contains cryopreserved allogenic dermis. In this graft the epidermal, endothelial, and fibroblasts have all been removed.
Skin which is taken from a healthy part of the patient’s body and placed over a burn injury is called an autogenous graft or autograft. Doenges et al (2010) states that skin grafts can be classified as either a split thickness or full thickness graft. This classification is dependent on the amount of dermis used. Full thickness skin grafts are best used on visible areas of the face because they undergo less contraction. Full thickness grafts often simulate normal skin, including color, texture, and thickness. Full thickness grafts are used more in children because they can grow with the patient. In adults the use of full thickness skin graft is limited to relatively small and clean wounds. Donor sites must be closed surgically. Split thickness skin grafts can be used to resurface large wounds or line cavities. Split thickness skin graft donor sites typically heal spontaneously. Doenges et al. (2010) explains that a cultured epidermal autograft or CEA is a skin graft is obtained from an uninjured area on the patient’s body and prepared in a laboratory. CEA may be full thickness or partial thickness. This entire process can take up to twenty to thirty days.
The last phase of care is the rehabilitative phase. Sheridan (2011) states that therapy should begin early and typically starts with ranging. Ranging is the passive movement of all joints through the ranges of motion. It should be performed twice a day and is done to prevent contractures. Hypertrophic scarring is a major complication of deep dermal burns. Therapies such as scar massage, compression devices, and topical silicone have been developed to help minimize the scar.
When treating a burn patient there are dozens of nursing diagnosis which can be implemented in patient care. Risk for ineffective airway clearance and impaired gas exchange related to tracheal edema is a top priority in patients. Nursing interventions for this diagnosis would be to monitor the respiratory rate, rhythm, and depth. The nurse should note any presence of pallor or cyanosis and pink colored sputum. The rationale is that tachypnea, use of accessory muscles, presence of cyanosis, and changes in sputum suggest developing respiratory distress or pulmonary edema and may need medical intervention. The nurse should also auscultate lungs, noting stridor, wheezing, crackles, and diminished breath sounds. The rationale is that airway obstruction and respiratory distress can occur very quickly or may be delayed, for example, up to three days after burn. The nurse can suction, if necessary, with extreme care, while maintaining sterile technique. This helps maintain clear airway, but should be done cautiously because of mucosal edema and inflammation.
Risk for infection related to burn trauma. Implement appropriate isolation techniques, as
ordered. To achieve an infection free patient isolation precautions should be in place, dependent on type and extent of wounds. Isolation precautions reduce the risk of cross contamination and exposure to bacteria from other patients. The nurse should also emphasize and implement good hand washing technique for all individuals coming in contact with the patient. This prevents cross contamination and reduces the risk of acquired infections. The nurse should also monitor vital signs for fever and increased respiratory rate and depth, presence of diarrhea, decreased platelet count, and increased white blood cell count. As these are all indicators of sepsis, often occurring with full thickness burns which require prompt evaluation and intervention.
Acute pain related to burn trauma. Nursing interventions include covering the wounds as soon as possible unless open air exposure burn care method required. This reduces temperature changes and air movement that can cause great pain to exposed nerve endings. The nurse should also administer analgesics opioid and non opioids as ordered. The patient may require around the clock medication and dose titration. IV method is often used initially to maximize drug effect. If the doctor orders patient controlled analgesia may be used, and the nurse should provide and instruct in use of a PCA. A PCA provides for timely drug administration, preventing fluctuations in intensity of pain, often at lower total dosage while allowing the patient to have control over the situation.
The care of a burn patient is both complex and meticulous. There are many facilities across the nation, which offer burn centers, housed with specialized nurses and doctors to treat patients with burns. The treatment plan varies from each facility to another, so it is important for the nurse to understand their facilities policies regarding the care of a burn patient.
References
Chistenson, B. L., & Kockrow, E. O. (2011). Foundations and Adult Health Nursing. St. Louis,
MO: Mosby Elsevier. 1330-1339
Doenges, M. E., & Moorhouse, M.F., & Murr, A.C. (2010). Nursing Care Plans. Philadelphia,
PA: F.A. Davis Company. 596-598.
Klein. D. G., Moseley. M.J., Sole. M. L. (2009) Critical Care Nursing. St. Louis, MO: Mosby
Elsevier. 683-726.
Sheridan. R. L. (2011). Initial Evaluation and Management of the Burn Patient. Medscape. 13
Dec 2011. http://emedicine.medscape.com/article/435402-overview#showall.
