care of patients with burns

8/2/2019 Care of Patients With Burns

http://slidepdf.com/reader/full/care-of-patients-with-burns 1/10

Care of Patients with Burns

Merianne Joy Galura

I. Categories

a. Thermal

Thermal burns are caused by exposure to or contact with flame, hot liquids,

semi-liquids, semi-solids, or hot objects. Specific examples of thermal burns

are those sustained in residential fires, explosive automobile accidents,

cooking accidents, or with ignition of poorly stored flammable liquids.

b. Chemical

Chemical burns are caused by contact with strong acids, alkalis, or organic

compounds. Chemical burns can result from contact with certain household

cleaning agents and various chemicals used in industry, agriculture, and the

military. Chemical injuries to the eyes and inhalation of chemical fumes can

be very serious.

c. Electrical

Electrical burn injuries are caused by heat that is generated by the electrical

energy as it passes through the body. Electrical injuries can result from

contact with exposed or faulty electrical wiring or high-voltage power lines.

People struck by lightning also sustain electrical injury.

d. Radiation

Radiation burns are the least common type of burn injury and are caused by

exposure to radioactive source. This types of injuries have been associated

with nuclear radiation accidents, the use of ionizing radiation in industry,and therapeutic irradiation. Sunburn is also considered to be a radiation

burn.

e. Smoke and inhalation

Exposure to asphyxiants and smoke commonly occurs with flame injuries,

particularly if the victim was trapped in an enclosed, smoke- filled space.

The pulmonary pathophysiologic changes that occir with inhalation injury

are multifactorial and relate to the severity and type of smoke or gasesinhaled.

II. Classification of burn injury

a. First-degree

First degree partial-thickness burns are superficial and painful and appear

red. They heal own their own by epidermal cell regeneration within about 3-

7 days. Sunburn is a good example.

b. Second-degree

Second-degree partial- thickness appears wet or blistered and are extremely

painful. They heal own their own as long as they are fairly small and they do

not become infected.

c. Third-degree

Third degree full-thickness burns are characterized by damage through the

entire epidermis and dermis. A full-thickness burn appears dry. And may be

mottled and colored black, brown, white, or red. The denatured skin is

called eschar. The burned tissue is most often painless as a result of damage

to the nerve endings however, the surrounding may be painful. Full-

thickness injuries heal by formation of granulation tissue to fill the wounddefect and contracture of the epithelium to close the wound.



d. Fourth-degree

Fourth-degree full-thickness burns involves skin, subcutaneous tissue,

muscle, and sometimes bones. The skin appears charred or maybe

completely burned away. Fourth-degree burns require extensive

debridement and skin grafting. Amputations are common in these extensive

injuries.

III. Body surface area injured

a. Rule of nines

The rule of nines is a quick way to estimate the extent of burns. The systems

assign percentages in multiples of nine to major body surfaces. The basis of

the rule is that the body is divided into anatomic sections, each of which

represents nine percent, or a multiple of nine percent, of the total body

surface area.

b. Lund and Browder Method

A more precise method of estimating the extent of a burn is the Lund and

Browder Method, which recognizes that the percentage of a surface area of

various anatomic parts changes with growth. By dividing the body into very

small areas and providing an estimate of the proportion of total body

surface area accounted for by each body part, one can obtain a reliable

estimate of total body surface area burned.

c. Palm Method

In patients with scattered burns, the palm method may used to estimate the

extent of the burns. The size of the patients palm is approximately onepercent of the total body surface area. The percent burned is derived by

visualizing the number of client hands it would take to cover the burn area.

This method is useful when the burned area or areas is small, less than five

percent.

IV. Phases of burn management

a.

Emergent phase

1. Pathophysiology and clinical manifestations

Fluid and electrolyte shifts. The greatest initial threat to a patient with a

major burn is hypovolemic shock. It is caused by a massive shift of fluids out

of the blood vessels as a result increased capillary permeability and can

begin as early as 20 minutes postburn. As the capillary walls become more

permeable, water, sodium, and later plasma proteins move into interstitial

spaces and other surrounding tissue. The colloidal osmotic pressure

decreases with progressive loss of protein from the vascular space. This

results in more fluid shifting out of the vascular space into the interstitial

space. Fluid also moves to areas that normally have minimal to no fluid.

The net result of the fluid shift is intravascular volume deletion. Decreased

blood pressure, increased pulse rate, and other manifestations of

hypovolemic shock are clinically detectable signs. If not corrected,

irreversible shock and death may result. Another source of fluid loss is

insensible loss by evaporation from large, denuded body surfaces.

The circulatory status is also impaired because of the hemolysis of RBCs. The

RBCs are hemolyzed by a circulating factor released at the time of the burn

as well as by the direct insult of the burn injury. Thrombosis in the

capillaries of the burned tissue causes an additional loss of circulating RBCs.

An elevated hematocrit is commonly caused by hemoconcentration

resulting from fluid loss.

Sodium and potassium are involved in electrolyte shifts. Sodium rapidly

shifts to the interstitial spaces and remains there until edema formationceases. A potassium shift develops initially because injured cells and

hemolyzed RBCs release potassium into the circulation.



Toward the end of the emergent phase, capillary membrane permeability

will be restored if fluid replacement is adequate. Fluid loss and edema

formation cease. Interstitial fluid gradually return to the vascular space.

Inflammation and healing. Burn injury causes coagulation necrosis,

whereby tissues and vessels are damaged or destroyed. Neutrophils and

monocytes accumulate at the site of injury. Fibroblasts and newly formed

collagen fibrils appear and begin wound repair within the first six to twelve

hours after injury.

Immunologic changes. Burn injury causes widespread impairment of the

immune system. The skin barrier to invading organisms is destroyed,

resulting in bone marrow depression and decreased circulating levels of

immunoglobulins. Defects occur in the function of WBCs. The inflammatory

cytokine cascade triggered by tissue damage impairs the function of

lymphocytes, monocytes, and neutrophils, which puts the patient at greater

risk for infection.

2. Complications

Cardiovascular. Cardiovascular system complications include dysrhythmias

and hypovolemic shock, which may progress to irreversible shock.

Circulation to the extremities can be severely impaired by circumferential

burns and subsequent edema formation. These processes occlude the blood

supply, causing ischemia, paresthesias, necrosis, and eventually gangrene.

An escharotomy (a scalpel incision through the full-thickness eschar) is

frequently performed following transfer to a burn unit to restore circulation

to compromised extremities.

Initially, there is an increase in blood viscosity with burn injuries because of

fluid loss that occurs in the emergent period. Microcirculation is impaired

because of the damage to the skin structures that contain small capillary

systems. These two events result in a phenomenon termed sludging.Sludging can be corrected by adequate fluid replacement.

Respiratory. The respiratory system is especially vulnerable to two types of

injury: (1) upper airway burns that cause edema formation and obstruction

of the airway and (2) inhalation injury. Upper airway distress may occur with

or without smoke inhalation, and airway injury at either level may occur in

the absence of burn injury to the skin.

Upper Respiratory Tract Injury. Upper respiratory tract injury results from

direct heat injury edema formation and can lead to mechanical airway

obstruction and asphyxia. The edema associated with an upper respiratory

tract burn injury can be massive and onset insidious and it occurs in all

patients with major thermal burn injuries. Mechanical obstruction of the

airway is not limited to the patient with flame burns to the upper airway.

Swelling that accompanies scald burns to the face and neck can be lethal, as

can pressure from the accumulated edema compressing the airway

externally. Flame burns to the neck and chest may contribute to respiratory

difficulty because the inelastic eschar becomes tight and constricting due to

the underlying edema.

Inhalation Injury. Inhalation injury refers to a direct result at the alveolar

level secondary to the inhalation of chemical fumes or smoke. The result is

interstitial edema that prevents the diffusion of oxygen from alveoli into the

circulatory system. The patient with smoke inhalation may not exhibit

physical manifestations of injury during the first 24 hours after sustaining a

major burn. Fiberoptic bronchoscopy can be used as an early diagnostic tool

for suspected inhalation injury. Another diagnostic indicator may be a

history of prolonged exposure to smoke or fumes. Therefore the nurse must

especially sensitive to signs of respiratory distress such as increased

agitation or change in the rate or character of respirations. Sputum that

contains carbon may be present. Generally, there is no correlation between

the extent of TBSA burn and severity of inhalation injury because inhalation

is a factor of time exposure plus the type and density of the material

inhaled. The initial chest x-ray may appear normal on admission, withchanges noted over the next 24-28 hours. ANG values may also be within

the normal range on admission and then change during hospitalization.



Other Respiratory Problems. The patient with preexisting respiratory

problems (e.g., chronic obstructive pulmonary disease) is more likely to

develop a respiratory infection. Pneumonia is a common complication of

major burns (especially in the older adult) because of debilitation, abundant

microbial flora, and relative immobility of the patient. If fluid replacement is

vigorous, the older adult patient can develop pulmonary edema.

Urinary. The most common complication of the urinary system in the

emergent phase is acute tubular necrosis (ATN). If patient is allowed to

become hypovolemic, blood flow to the kidneys may be decreased, causing

renal ischemia. If this continues, acute renal failure may develop.

With full-thickness and electrical burns, myoglobin (from muscle cell

breakdown) and hemoglobin (from RBC breakdown) are released into to

blood stream and occlude renal tubules. Adequate fluid replacement and

diuretics can counteract myoglobin and hemoglobin obstruction of tubules.

3. Nursing and collaborative management

Airway management. Airway management frequently involves early

endotracheal (preferably orotracheal) intubation. Early intubation

eliminates the necessity for emergency tracheostomy after respiratory

problems have become apparent. In general, the patient with major injuries

involving burns to the face and neck requires intubation within 1 to 2 hours

after burn injury. After intubation, the patient may be placed on ventilator

assistance, and the delivered oxygen concentration is determined by

assessing ABG values. Extubation may be indicated when the edema

resolves usually 3 to 6 days after burn injury, unless severe inhalation injury

is involved. Escharotomies of the chest wall may be needed to relieve

respiratory distress secondary to circumferential, full-thickness burns of the

neck and trunk.

Within 6 to 12 hours after injury in which smoke inhalation is suspected, afiberoptic bronchoscopy should be performed to assess the lower

respiratory tract. Significant findings include the appearance of

carbonaceous material, mucosal edema, vesicles, erythema, hemorrhage,

and ulceration.

When intubation is not performed, treatment of inhalation injury includes

administration of humidified air and supplemental oxygen as required. The

patient should be placed in a high-Fowlers position unless contraindicated

by a possible spinal injury, in which case reverse Trendelenburg may be the

position of choice. The patient should also be encouraged to cough and

deep breath every hour, be repositioned every 1 to 2 hours, given chest

physiotherapy, and suctioned as necessary. If respiratory failure is

impending, intubation should be performed and the patient should be

supported with mechanical ventilation. Positive end-expiratory pressure

(PEEP) may be used to prevent collapse of the alveoli and progressive

respiratory failure. Bronchodilators may be administered to treat severe

bronchospasm. CO poisoning is treated by administering 100% O2 until

carboxyhemoglobins return to normal. The use of hyperbaric oxygen

therapy remains controversial.

Fluid therapy. As soon as the patient (usually with a >15% TBSA burn)

arrives at the health care facility, at least one (and usually two) large-bore

intravenous (IV) access routes must be obtained. It is critical to establish IV

access that can accommodate large volumes of fluid. For burns >30% TBSA,

central lines and arterial lines for fluid/medication/blood access should be

considered.

The extent of an adult’s burn should be assessed using the Rule of Nines or

Lund-Browder charts. These universal standards will allow for the accurate

estimation of the fluid resuscitation requirements.

IV fluid therapy is usually instituted in the adult patient with burns >15%

TBSA. The type of fluid replacement is determined by the size and depth of

burn, age of the patient, and individual considerations, such as dehydration

in the preburn state or preexisting chronic illness. Each burn unit has a

preference for a replacement regimen. Fluid replacement is accomplished

with crystalloid solutions (usually lactated Ringer’s), colloids (albumin), or acombination of the two, paramedics generally give IV saline until the

patient’s arrival at the hospital.



Wound care. Wound care should be delayed until a patent airway,

adequate circulation, and adequate fluid replacement have been

established. Full-thickness wounds will be dry and waxy white to dark

brown/black and will have only minor, localized sensation because nerve

endings have been destroyed. Partial-thickness wounds are pink to cherry

red and wet and shiny with serous exudates. These wounds may or may not

have intact blisters and are painful when touched or exposed to air.

Cleansing and gentle debridement, using scissors and forceps, can occur in a

hydrotherapy tub, cart shower, shower, or patient bed/stretcher. Extensive,

surgical debridement should be performed in the operating room (OR).

During debridement , necrotic skin is removed. Releasing escharotomies and

fasciotomies can be carried out in the emergent phase, usually in burn units

by burn physicians. Care should be taken to accomplish these procedures as

quickly and effectively as possible.

Patients find the initial wound care to be both physically and psychologically

demanding. Immersion in a tank for longer than 20-30 minutes can cause

electrolyte loss from open burned areas. Prolonged immersion can lead to

chilling after the bath and cross-contamination of wounds from one area of

the body to another. Because of these factors, many institutions no longer

submerge or “tub” their burn patients. Instead they are showered using a

cart shower or, if the patient is well enough and the TBSA burn is small, a

regular shower can be used. The water does not need to be sterile; tap

water, not exceeding 1040F (40

0C), is acceptable. Because pathogenic

organisms are present on the burn wound, a surgical detergent,

disinfectant, or cleansing agent may be used.

Infection is most serious threat to further tissue injury and possible sepsis.

Survival is directly related to prevention of wound contamination. The

source or infection in burn wounds is the patient’s own flora, predominantly

from the skin, respiratory tract, and gastrointestinal (GI) tract. The

prevention of cross-contamination from one patient to another is a priority

for nursing care. Two types of wound treatment used to control infectionare the open method and the use of multiple dressing change method, the

patient’s burn is covered with a topical antimicrobial and has no dressing

over the wound. In the multiple dressing change method, sterile gauze

dressings are impregnated with or laid over a topical antimicrobial. These

dressings are changed anywhere from every 12-24 hours to once every 3

days, depending upon the topical agent and dressing used. Most burn units

support the concept of moist wound healing and use dressings to cover the

burned areas, with the exception of the burned face.

When the patient’s open burned wounds are exposed, staff must wear

disposable hats, masks, gowns, and gloves. When removing contaminated

dressings and washing the dirty wound, the nurse may use nonsterile,

disposable gloves. Sterile gloves are used when applying ointments and

inner, sterile dressing.

Coverage is the primary goal for burn wounds. Because there is rarely

enough unburned skin in the major (>50%) burn patient for immediate skin

grafting, other temporary wound closure methods are sometimes used.

Allograft or homograft (usually from cadavers) is used. Along with newer

biosynthetic options, with varying frequency among burn units.

Drug therapy

Analgesics and Sedatives. Analgesics are ordered to promote patient

comfort. Early in the postburn period, IV medications should be given

because (1) GI function is slowed or impaired due to shock or paralytic ileus

and (2) intramuscular (IM) injections will not be absorbed adequately in

burned or edematous areas, causing pooling of medications in the tissues.

When fluid mobilization begins, the patient could be inadvertently

overdosed from the interstitial accumulation of previous IM medications.

The need for analgesia must be reevaluated frequently as patient’s needs

may change and tolerance to medications may develop overtime. The drug

of choice for pain control is morphine, but hydromorphone and methadone

may also be used. When given appropriately, these drugs should provide

adequate pain control. Sedative agents should also be given along with

analgesics to control the anxiety that patients experience. Analgesic

requirements can vary tremendously from one patient to another. Theextent and depth of burn may not correlate with pain intensity. Hospital



pharmacists, psychiatrists, and multidisciplinary pain services are valuable

resources for the more complex situations.

Tetanus Immunization. Tetanus toxoid is given routinely to all burn patients

because of the likelihood of anaerobic burn wound contamination. If the

patient has not received an active immunization within 10 years before the

burn injury, tetanus immunoglobulins should be considered.

Antimicrobial Agents. After the wound is cleansed, topical agents are

applied and covered with a light dressing. Systemic antibiotics are not

usually used in controlling burn wound flora because there is little delivery

of antibiotics to the wound. Some topical agents penetrate the eschar,

thereby inhibiting bacterial invasion of the wound. Silver sulfadiazine

(Silvadene, Flamazine) and mafenide acetate (Sulfamylon) are commonly

used. Silver-impregnated dressings (acticoat, Silverlon, Aquacel Ag) that can

be left on for up to 3 days and in some cases longer are used in some burn

units. They are effective against many organisms. Systemic sepsis remains

the leading cause of death in patient with major burns, which may lead to

multiple organ dysfunction syndrome. Systemic antibiotics therapy is

initiated when the clinical diagnosis of invasive burn wound sepsis is made,

or when some other sources of sepsis i s identified (e.g. pneumonia).

Frequently, fungal infections develop in the patient’s mucous membranes

(mouth and genitalia) as a result of antibiotic therapy and low resistance in

the host.

Nutritional therapy. Fluid replacement takes priority over nutritional needs

in the initial emergent phase. However, early and aggressive nutritional

support within several hours of the burn injury can decrease mortality and

complications, optimize healing of the burn wound, and minimize negative

effects of the hypermetabolism and catabolism. Nonintubated patients with

a <20% TBSA burn will generally be able to eat enough to meet their

nutritional requirements. Intubated patients and/or those with larger burns

require additional support. Enteral feedings preserves GI function, increases

intestinal blood flow, and promotes optimal conditions for wound healing.The patient with large (>20% TBSA) burns frequently develops paralytic ileus

within a few hours as a result of the body’s major response to major

trauma. If a large nasogastric tube is inserted on admission, gastric residuals

should be checked frequently to rule out paralytic ileus and delayed gastric

emptying. In general, feedings can be commended slowly at 20 to 40 ml/hr

and can be increased to the goal rate within 24-48 hours.

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 lead to malnutrition and delayed healing. Calorie-

containing nutritional supplements and milkshakes are often given because

of the great need for calories. Protein powder can also be added to food

and liquids. Supplemental vitamins may be given as early as the emergent

phase, with iron supplements often started in the acute phase.

b. Acute Phase

1. Pathophysiology and clinical manifestations

Burn injury involves pathophysiologic changes in many body systems.

Diuresis from fluid mobilization occurs, and the patient is less edematous.

Areas that are full- or partial-thickness burns are more evident than in the

emergent phase. Bowel sounds return. The patient may now become

aware of the enormity of the situation. Some healing begins as WBCs

surround the burn wound and phagocytosis occurs. Necrotic tissue begins

to slough. Fibrolasts lay down matrices of the collagen precursors that

eventually form granulation tissue. Kept free from infection and

dessication, a partial-thickness burn wound will heal from the edges and

from the dermal bed below. However, full-thickness burn wounds, unless

extremely small, must be covered by skin grafts. Often, healing time and

length of hospitalization are decreased by early excision and grafting.Partial-thickness wounds form eschar, which begins separating fairly soon

after injury. Once the eschar is removed, re-epithelialization begins at



the wound margins and appears as red or pink scar tissue. Epithelial

buds from the derma bed eventually close in the wound, which then

heals spontaneously without surgical intervention, usually within 10 to

14 days.

Margins of full thickness eschar take longer to separate than partial-

thickness eschar. As a result, full-thickness wounds require surgical

debridement and skin grafting for healing.

2. Complications

Infection. The body’s first line of defense, the skin, has been destroyed by

burn injury. Pathogens often proliferate before phagocytosis has

adequately begun. The burn wound is now colonized with organisms. If

the bacterial density at the junction of the eschar with underlying viable

tissue rises to greater than 105/g of tissue, the patient has a burn wound

infection. In the presence of an infection, localized inflammation,

induration, and sometimes suppuration can be seen at the burn wound

margins. Partial-thickness burns can convert to full-thickness wounds

when these organisms invade viable, adjacent, unburned tissue.

Invasive wound infections may be treated with systemic antibioticsbased on culture results.

Cardiovascular and Respiratory Systems. The same cardiovascular and

respiratory system complications present in the emergent phase may

continue into the acute phase of care. In addition, new problems might

arise, requiring timely intervention.

Neurologic System. Neurologically, the patient usually has no physical

symptoms, unless severe hypoxia from respiratory injuries or

complications from electrical injuries occur. However, some patients

may demonstrate certain behaviors that are not completely

understood. The patient can become extremely disoriented, maywithdraw or become combative, and may have hallucinations and

frequent nightmare-like episodes. Delirium is more acute at night and

occurs more often in the older patient. This is a transient state, lasting

from a day or two to several weeks. Various causes have been

considered, including electrolyte imbalance, stress, cerebral edema,

sepsis, intensive care unit psychosis syndrome, and the use of analgesics

and antianxiety drugs.

Musculoskeletal System. The musculoskeletal system is particularly prone

to complications during the acute phase. As the burns begin to heal and

scar tissue forms, the skin is les supple and pliant. ROM may be limited,

and contractures can occur. Because of pain, the patient will prefer to

assume a flexed position for comfort. Splinting can be beneficial to

prevent or reduce contracture formation.

Gastrointestinal System. The GI system may also exhibit complications

during this phase. Paralytic ileus results from sepsis. Diarrhea may be

caused by the use of supplemental feedings or antibiotics. Constipation

can occur as a side effect of opioid analgesics decreased mobility, and a

low-fiber diet. Curling’s ulcer is caused by a generalized stress response

resulting in decreased production of mucus and increase gastric acid

secretion. This condition is due to the decreased blood flow to the GItract during the hypovolemic shock phase. Many patients with major

burns also have occult blood in their stools during the acute phase.

Endocrine System. An increase in blood glucose levels may be seen

transiently because of stress-mediated cortisol and catecholamine

release, resulting in the increased mobilization of glycogen stores,

gluconeogenesis, and the subsequent production of glucose. There is

also an increase in insulin production and release. However, insulin’s

effectiveness is decreased because of relative insulin insensitivity,

leading to an elevated blood glucose level. Later, hyperglycemia can be

caused by the increased calorie intake necessary to meet some patient’s

metabolic requirements. When this occurs, the treatment issupplemental IV insulin, not decrease feeding. Serum glucose levels are

checked frequently, and an appropriate amount of insulin is given if



hyperglycemia is present. As the patient’s metabolic demands are met

and les stress is placed on the entire system, this stress-induced

condition is reversed.

3. Nursing and Collaborative Management

Wound Care. The goals of wound care are to (1) cleanse and debride the

area of necrotic tissue and debris that would promote bacterial growth

and (2) promote wound re-epithelialization and/or successful skin

grafting.

Wound care consists of daily observation, assessment, cleansing,

debridement, and dressing reapplication. Nonsurgical debridement,

dressing changes, topical antibiotic therapy, graft care, and donor site

care may be performed from 2 times daily to once every few days.

When partial-thickness burn wounds have been debrided, a protective,

coarse or fine-meshed, greasy gauze dressing is applied to protect the

re-epithlializing cells as they resurface and close the open wound bed. If

grafting is necessary, the meshed, split-thickness skin graft may be

protected with the same greasy gauze dressings next to the graft,

followed by middle and outer dressings.

Excision and Grafting

During the procedure of excision and grafting, eschar is removed down to

the subcutaneous tissue or fascia, depending on the degree of injury. A

graft is then placed on clean, viable tissue to achieve good adherence.

Hemostasis is achieved by pressure and the application of topical

thrombin or epinephrine, after which the wound is covered with

autograft skin. With early excision, function is restored and scar tissue

formation is minimized. Because the dead tissue is planed off until

viable tissue is reached, extensive bleeding is expected to occur, which

may pose a problem when grafting is performed. Frequent observation

and appropriate nursing interventions can help identify and manageexcessive postoperative bleeding and enhance graft survival.

Pain management. Burn patients experience two kinds of pain: (1)

continuous, background pain that exists throughout the day and night

and (2) treatment induced pain associated with dressing changes,

ambulation, and rehabilitation activities. The first line of treatment is

pharmacologic. With background pain, if the patient has a continuous IV

infusion of morphine, this will allow for a steady, slow-release twice-a-

day opioid medication. For treatment-induce pain, premedication with

an analgesic and an anxiolytic is required via the IV or oral route. During

treatment or activity, small doses should be given to keep the patient as

comfortable as possible.

Pain can also be managed using nonpharmacologic strategies, such as

relaxation tapes, visualization, hypnosis, guided imagery, biofeedback,

and meditation. These techniques are considered adjuncts to traditional

pharmacologic treatments of pain. They are not meant to be used

exclusively to control pain in the burn patient. An important point to

remember about pain management is that the more control the patient

has in managing the pain, the more successful the chosen strategies.

Physical and Occupational Therapy. Rigorous physical therapy throughout

burn recovery is imperative to maintain optimal joint function. A goodtime for exercise is during and after wound cleansing when the skin is

softer and bulky dressings are removes. Passive and active ROM should

be performed on all joints. The patient with neck burns must sleep

without pillows or with head hanging slightly over the top of the

mattress to encourage hyperextension. Custom-fitted splints are

designed to keep the joints in functional position and must be re-

examined frequently to ensure an optimal fit.

Nutritional Therapy. The goal of nutrition therapy during the acute burn

phase is to provide adequate calories and protein to promote healing.

The burn patient is in a hypermetabolic and highly catabolic state ad a

result of burn injury. Infection also increases metabolic rate.Meeting daily caloric requirements is crucial and should begin within the

first 1 to 2 days postburn. If the patient is on a mechanical ventilator or



unable to consume adequate calories by mouth, a feeding tube can be

placed and a complete liquid diet administered. If caloric requirements

cannot be met by enteral feeding alone, parenteral nutrition may be

given temporarily while continuing to deliver enteral feedings. The alert

patient should be encouraged to eat high-protein, high-carbohydrate

foods to meet increased caloric needs. If family members wish to bring

in favorite foods from home, this should be encouraged. Appetite is

usually diminished, and constant encouragement may be necessary to

achieve adequate intake.

Psychosocial Care. The patient and the family have many needs for

psychosocial support during the often lengthy, unpredictable, and

complex course of care. The nursing staff has important support and

counseling roles to play. Pastoral care may also be helpful for some

patients and their families.

c. Rehabilitation Phase

1. Pathophysiological changes and clinical manifestations

Burn wounds heal either by primary intention or by grafting. Layers of

epithelialization begin rebuilding the tissue structure destroyed by the

burn injury. Collagen fibers, present in the new scar tissue, assist with

healing and add strength to weakened areas. The new skin appears flat

and pink. In approximately 4 to 6 weeks, the area becomes raised and

hyperemic. If adequate ROM is not instituted, the new tissue will

shorten, causing a contracture. Mature healing is achieved in 6 months

to 2 years when suppleness has returned, and the pink or red color has

faded to a slightly lighter hue that the surrounding unburned tissue.

Often, skin never completely regains its original color.

The patient typically experiences discomfort from itching where healing is

occurring. As “old” epithelium is replaced by new cells, flaking willoccur. The newly formed skin is extremely sensitive to trauma. Blisters

and skin tears are likely to develop from slight pressure or friction.

Additionally, these newly healed areas can be hypersensitive or

hyposensitive to cold, heat, and touch. Grafted areas are more likely to

be hypersensitive until peripheral nerve regeneration occurs. Healed

burn areas must be protected from direct sunlight for 6 to 9 months to

prevent hyperpigmentation and sunburn injury.

2. Complications

The most common complications during the rehabilitation phase are skin

and joint contractures and hypertrophic scarring. A contracture

develops as a result of the shortening of scar tissue in the flexor tissues

of a joint. Areas that are most susceptible to contracture formation

include the anterior and lateral neck areas, axillae, antecubital fossae,

fingers, groin areas, popliteal fossae, knees, and ankles. These areas

encompass major joints. Not only does the skin over these areas

develop contractures, but the underlying tissues also have a tendency

to shorten during the healing process.

Because of pain, the patient will prefer to assume a flexed position for

comfort. This position predisposes wounds to contracture formation.

Positioning, splinting, and exercise should be instituted to minimize thiscomplication. These procedures should be continued until the skin

matures. Therapy is aimed at extension of body parts because the

flexors are stronger than the extensors burned legs may be wrapped

with elastic bandages to assist with circulation to leg graft and donor

sited before ambulation. This additional pressure prevents blister

formation, promotes venous return, and decrease pain and itchiness.

Once the skin is completely healed and less fragile, custom-fitted

pressure garments replace the elastic bandages.

3. Nursing and Collaborative Management

During the rehabilitation phase, both the patient and the family are activelyencouraged to participate in care. Since the patient may go home with

small, unhealed wounds, education and “hands-on” instruction will be



needed in dressing changes and wound care. Constant encouragement

and reassurance are necessary to maintain a patient’s morale,

particularly once the patient realizes that recovery can be slow and

rehabilitation may need to be a primary focus for at least the next 6 to

12 months.

Because of the tremendous psychologic impact of a burn injury, health care

providers should be particularly sensitive and attuned to the patient’s

emotions and concerns. It is essential that patients be encouraged to

discuss their fears regarding loss of their life as once they knew it, loss

of function, temporary/permanent deformity and disfigurement, return

to work and home life, and financial burdens resulting from a long and

costly hospitalization. Care should also be taken to address individual

spiritual and cultural needs, as both these facets of a patient’s life play a

role in recovery.

Encouraging appropriate independence, an eventual return to preborn

activities, and interactions with other burn survivors will involve the

patient in familiar activities that may bring comfort and help to restore

self-esteem. Counseling should be made available after the patient goes

home. Patients need reassurance that their feelings during this period

of adjustment are normal, and tat their frustration is to be expected asthey attempt to resume a normal lifestyle.

care of patients with burns

Documents