1 / 25

Nursing Care & Interventions in the Client with Burn Injury

Nursing Care & Interventions in the Client with Burn Injury. St. Cloud State University Dept. of Nursing Science Keith Rischer RN, MA, CEN. Today’s Objectives…. Compare and contrast the clinical manifestations of superficial, partial-thickness, and full-thickness burn injuries.

Sophia
Download Presentation

Nursing Care & Interventions in the Client with Burn Injury

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Nursing Care & Interventions in the Client with Burn Injury St. Cloud State University Dept. of Nursing Science Keith Rischer RN, MA, CEN

  2. Today’s Objectives… • Compare and contrast the clinical manifestations of superficial, partial-thickness, and full-thickness burn injuries. • Prioritize nursing care for the client during the emergent, acute, and rehabilitation phase of burn injury. • Analyze assessment data to determine nursing diagnoses and formulate a plan of care for clients with burn injuries. • Use laboratory data and clinical manifestations to determine the effectiveness of fluid resuscitation. • Describe nursing management wound care and nutritional needs for the burn client. • Evaluate assessment data to determine wound healing in the burn client. • Identify pain management strategies for burn clients. • Explain the positioning and range-of-motion interventions for the prevention of mobility problems in the client with burns. • Discuss the potential psychosocial problems associated with burn injury.

  3. Burn Injury: Patho • Skin • Epidermis • Dermis • Purposes • Skin destruction • Fluid/protein loss • Sepsis • Multi-system changes • Dependant on age • Health • Depth of injury • Body area involved

  4. Depth of Burn Injury • Superficial-thickness • Epidermis only • Partial-thickness • Epidermis + partial Dermis • Full-thickness • Epidermis + all dermis + underlying tissue/muscle/bone

  5. Assessment: Superficial-thickness • Pain • Redness • Heals in 3-5 days

  6. Assessment: Partial-thickness • Red-blanch • No blanch with deeper burn • Blister and broken epidermis • Painful • Heal in 10-21 days

  7. Assessment: Full-thickness • Pale, white to red, yellow • Charred eschar • Leathery skin, dry surface • Painless • Edema present • Signs of systemic shock may be present • Needs grafting

  8. Burns: Vascular Changes • Fluid shift • Capillary leakage • First 12 hours • Lasts 24-36 hours • Lyte & acid base imbalance • Hypovolemia • Hyperkalemia, hyponatremia • Fluid remobilization • Diuretic stage (48-72 hours) • Hyponatremia • hypokalemia

  9. Burns: Body System Assessment • Cardiac • HR increase • CO decreased initially • Respiratory • Airway edema • pulmonary cap. leakage • GI • Paralytic ileus • Metabolic • Increased due to catecholamines, cortisol and SNS • Caloric needs double or triple • Immune • Diminished response • Increased risk of infection

  10. Burns: Emergency Management • Primary Survey • Airway • Breathing • Circulation • C-Spine immobilization (when indicated) • Secondary Survey • Complete head to toe exam • % of TBSA • Depth of burn • Part(s) of body burned • Rule out other serious or life threatening injuries

  11. Inhalation Injury: Assessment Severe cough Hoarseness Shortness of breath Anxiety Wheezing Dyspnea Disorientation Obtunded Coma • Facial burns • Singed nasal hairs • Stridor • CO Poisoning • HA • Nausea • Alterered LOC • Confusion • Coma Signs Symptoms

  12. Burn Classification • Minor • <15% partial thickness • Moderate • 15-25% partial thickness • <10% full thickness • Severe • >25% partial thickness • >10% full thickness

  13. ABA Burn Referral Guidelines • 2° Burns > 10% TBSA • Burns involving the face, hands, feet, genitalia, perineum, & major joints • 3° Burns in any age group • Electrical Burns • lightning injuries • Chemical Burns

  14. Laboratory Findings: First 48 hours • Hgb/Hct • Glucose • Sodium • Potassium • BUN/creatinine • Albumin • ABG’s • pO2 • pCO2 • pH • CO

  15. Nursing Diagnostic Priorities: First 48 Hours • Decreased cardiac output r/t… • Deficient fluid volume r/t… • Ineffective tissue perfusion r/t… • Ineffective breathing pattern r/t… • Acute pain r/t…

  16. Fluid Resuscitation • Nursing interventions • Large bore IV/central IV access • Lactated ringers • Nursing Assessment • I&O • Urine output • Daily weight • Oxygenation needs • Fluid overload • VS • Labs • Creatinine • Albumin • lytes

  17. Nursing Diagnostic Priorities: First 48 Hours • Ineffective breathing pattern r/t… • Respiration pattern • Oxygenation • ABG’s • pH: 7.41….7.29 • p02: 73….55 • pCO2: 44….60 • Acute pain r/t… • Opiods IV • Fentanyl... Onset___ Peak___ Duration___ • Morphine… Onset___ Peak___ Duration___ • Dilaudid…Onset___ Peak___ Duration___

  18. Assessment Priorities: After 48 Hours • Cardiopulmonary • Pneumonia • Neuroendocrine • Increased metabolic demands • Immune (risk of infection) • Local • Systemic • VS • Altered LOC • u/o

  19. Nursing Diagnostic Priorities: After 48 Hours • Impaired skin integrity r/t… • Risk of infection r/t… • Imbalanced nutrition-less than body requirements r/t… • Impaired physical mobility r/t… • ROM • Early ambulation • Disturbed body image r/t…

  20. Impaired Skin Integrity-Wound Care • Debridement • Hydrotherapy • Wound dressings • Antibiotic ointment • Biologic • Synthetic • Skin grafts • Autograft • Artificial

  21. Dressings: Topical Antibiotics • Silver Sulfadiazine • Most frequently used topical • Gram negative/positive organisms • Penetrates eschar well • Applied with a gloved hand, tongue depressor or impregnated in gauze • Bacitracin • Acceptable for use with superficial burns • Least expensive antimicrobial agent

  22. Dressings • Decrease pain • Absorb drainage • Preserve joint mobility and allow ROM • Provide protection and isolation of wound from environment

  23. Nutrition • Metabolic changes • Hormone mediated • > Catecholamines • > Glucocorticoids and glucose to insulin ratios • Metabolic alterations • > Gluconeogenesis • > Proteolysis • > Ureagenesis • < Lipolysis & Ketone utilization • Net Results of Changes • > Nitrogen losses • > Energy Expenditures and nutrition metabolism • Results • Hypermetabolic - catabolic state

  24. Enteral Feedings • Preferred route • Safety • Better utilization of nutrients • Gut integrity • Lower cost • Parenteral (TPN) • Nonfunctional guts • High risk for sepsis • Objectives

  25. Psychological Issues & Follow Up • Inpatient • PTSD • Disfigurement • Sexual issues • CD • Outpatient • Ongoing therapy • Support groups • Burn Camp

More Related