Introduction to Burns

Vivitha

Wound Care Nurse, Kauvery Hospital, Alwarpet, Chennai

Introduction

Burn injuries occur when energy from a heat source is transferred through conduction or

Electromagnetic radiation

Definition

A burn is an injury caused by thermal, chemical, electrical, or radiation energy. A scald is a burn caused by contact with a hot liquid or steam but the term ‘burn’ is often used to include scalds.

Nursing Assessment

  • Focus on the major priorities of any trauma patient
  • Assess circumstances surrounding the injury
  • Monitor vital signs frequently
  • Start cardiac monitoring if indicated
  • Check peripheral pulses
  • Monitor fluid intake (IV fluids) and output (urinary catheter) and measure hourly.
  • Assess neurologic status: consciousness, psychological status, pain and anxiety levels, and behaviour.
  • Assessment of wound and colour of soakage.

IV Fluids and Management

  • Placement of two large-bore intravenous (IV) lines (16G & 18G) in unburned skin
  • and if possible central venous access are indicated.
  • Rate of infusion according to the body weight.
  • Duration of infusion or the time over which the infusion is to be completed as per
  • doctors order for restoring normal fluid balance.
  • Proper cleaning and flashing of lines tubing’s with the use of Posi flush
  • (NS or sterile water).
  • Cover the IV line or central line tubing’s with sterile blue sheet.
  • Use hand rub and wear clean gloves each time of handling IV line. • Change of IV set every 3days and use separate IV set for IV ABX.. • Inspection of IV site each shift to avoid thrombophlebitis.

Pain Scale

According to the wong bakers scale assess the pain and administeredappropriate pain medication or sedation as per the Doctors order.

Providing diversional therapy.

Positioning and Patient Care

  • Providing comfortable adjusting mattress like nimbus or airbed.
  • Positioning every 2nd hourly to prevent further damage.
  • Back care and easy bath cleaning daily for early identification of pressure injury.
  • Make sure nimbus or airbed working condition each shift.
  • Providing additional pillow’s for comfort.

Ryles Tube Feeding and Care

  • After ryles tube insertion check position by taking x-ray and make sure that correct positioning of tube with doctors before starting the feeding.
  • Proper maintenance of intake and output is important in burns.
  • Make sure with the nutritionist if the patient is achieving adequate nutrition every day through ryles tube.
  • Proper flushing of tube for each feeding to prevent from infection and abdominal distention. Assess the position of ryles tube before each feeds with the help of stethoscope.
  • Change of ryles tube immediately if its blocked looks dirty or damaged.
  • As a protocol if it’s working good also we should change the ryles tube in 14 days. If it is freka tube change after 1month.

Monitoring

  • Assessment and monitoring of airway patency and breathing.
  • Administration of oxygen 2liter for 72 hours to improve the tissue oxygenation if the saturation is normal also.
  • Monitoring of temperature, pulse, respiration, blood pressure, saturation and cardiac rhythm changes hourly.
  • Monitoring of CBC and CRP according to the infectious doctors order and follow up of cultures.
  • Monitor the nutritional status (calories and protein).
  • Monitor peripheral pulses for few days if patient had burns in lower extremities.
  • Monitor fluid intake (IV fluids and oral or RT) and output (Urine output)to prevent dehydration.
  • Monitor neurological status daily.

Dressing and Wound Care Management

Wound dressing care

  • Burn dressing changes can produce feelings of anxiety and distress in both patients and their families. It is very important to inform the process and pain management to the patient and attenders.
  • Provide privacy and follow aseptic technique.
  • Before starting the dressing make sure adequate person are available inside the room and for cleaning arrange all needed dressing materials and things near the patient.
  • Changing of dressing every day or according to the soakage every alternate days
  • Checking of complete vitals before and after the dressing to maintain the haemodynamic stable.
  • During dressing assess colour of soakage and condition of wound and Document.

Burn bath

  • Burn bath will start after the patient becomes hemodynamically stable and wound becomes better.
  • Before starting the bath, make sure that adequate staff and physiotherapist will be there to mobilize the patient.
  • Arrange warm water, towel, microshield solution and dressing material inside the room.
  • Finish the bath and dressing within 30 min.

Infection Control and Barrier Nursing

Arranging the PPE kit and shoes outside the room. Physical isolation in a private room, use of mask, gloves, shoe covers and gowns during patient contact. Follow five moments of hand hygiene

Proper disinfection of instrument, cloths, bed sheets and other contaminated equipment’s. If patient is in ventilator routine maintenance of ventilator circuit and suction equipment. Proper cleaning of perineal and anal area if patient passed motion or urine to prevent UTI and further infection.

Catheters’ Care

Using of CAUTI bundle for catheterization. Insert catheter only when indicated. Insertion by trained person using aseptic technique with sterile instrument.

Daily cleaning and checking for any block or leakage. For CVC and long line, catheter also follow strict aseptic technique and proper handling technique is important.

Psychological Support and Rehabilitation

  • Encourage and motivate the patient.
  • Minimizing Pain and Anxiety.
  • Strengthening Coping Strategies.
  • Supporting Patient and Family Processes.
  • Teaching Self-care.
  • Improving Body Image and Self-Confident.
  • Promoting Activity Tolerance.
  • Encourage for active mobilization and physiotherapy.
  • Speech therapy for voice blocked patients.
  • Education about the home care management.

Evaluation (final assessment)

  • Absence of dyspnea.
  • Respiratory rate between 12 and 20 breaths/min.
  • Lungs clear on auscultation,
  • Arterial oxygen saturation greater than 96% by pulse oximetry.
  • ABG levels within normal limits.
  • Patent airway
  • Respiratory secretions are minimal, colorless, and thin.
  • Urine output between 0.5 and 1.0 mL/kg/h.
  • Blood pressure higher than 90/60 mmHg.
  • Heart rate less than 120 bpm.
  • Body temperature remains between 36.1ºC and 38.3ºC

Final Nursing Documentation of Burns

  • Breathe sounds and character of secretions.
  • Respiratory rate, pulse oximetry/O2 saturation, vital signs.
  • Plan of care and those involved in the planning.
  • Teaching plan.
  • Client’s response to interventions, teachings, and actions performed. • Use of respiratory devices or adjuncts.
  • Conditions that may interfere with oxygen supply.
  • I&O, fluid balance, changes in weight, urine specific gravity.
  • Attainment or progress toward desired outcomes.
  • Modifications to the plan of care.

Journals

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