Pamantasan ng Lungsod ng Maynila (University of the City of Manila) Intramuros, Manila

COLLEGE OF NURSING

WRITTEN REPORT In INTENSIVE CARE NURSING

Submitted by: Emmanuelle Arana Jane April Castillo Ma. Franchesca Espiel

Submitted to: Prof. Kahlil Z. Arbo

BODYs RESPONSE TO BURN Local response The three zones of a burn were described by Jackson in 1947. Zone of coagulationThis occurs at the point of maximum damage. In this zone there is irreversible tissue loss due to coagulation of the constituent proteins. Zone of stasisThe surrounding zone of stasis is characterised by decreased tissue perfusion. The tissue in this zone is potentially salvageable. The main aim of burns resuscitation is to increase tissue perfusion here and prevent any damage becoming irreversible. Additional insultssuch as prolonged hypotension, infection, or oedema can convert this zone into an area of complete tissue loss. Zone of hyperaemiaIn this outermost zone tissue perfusion is increased. The tissue here will invariably recover unless there is severe sepsis or prolonged hypoperfusion. These three zones of a burn are three dimensional, and loss of tissue in the zone of stasis will lead to the wound deepening as well as widening.

Systemic response The release of cytokines and other inflammatory mediators at the site of injury has a systemic effect once the burn reaches 30% of total body surface area. Cardiovascular changesCapillary permeability is increased, leading to loss of intravascular proteins and fluids into the interstitial compartment. Peripheral and splanchnic vasoconstriction occurs. Myocardial contractility is decreased, possibly due to release of tumour necrosis factor . These changes, coupled with fluid loss from the burn wound, result in systemic hypotension and end organ hypoperfusion. Respiratory changesInflammatory mediators cause bronchoconstriction, and in severe burns adult respiratory distress syndrome can occur. Metabolic changesThe basal metabolic rate increases up to three times its original rate. This, coupled with splanchnic hypoperfusion, necessitates early and aggressive enteral feeding to decrease catabolism and maintain gut integrity. Immunological changesNon-specific down regulation of the immune response occurs, affecting both cell mediated and humoral pathways.

CLASSIFICATION OF BURNS According to Burn Depth: Superficial Burns Involves only the epidermis Redness, warmth, and slight edema Usually no blistering May be painful because sensory nerve endings are intact Most sunburns are classified as superficial Most can be treated in outpatient setting or through self care. Will heal within 3 to 6 days

Superficial Partial-Thickness Burns Damage to the outer epidermal layer Often moist and weeping, painful blistering Will blanch with pressure Painful and sensitive to temperature and air Healing occurs within 2 to 3 weeks Small burns (1-2% BSA) of this type can be treated through self care

Deep Partial Thickness Burns Damage to the dermis layer May appear as patchy white to red area Large blisters may be present May take up to 6 weeks to heal Patients should be examined in a hospital emergency room immediately Full Thickness Burns Dermis and epidermis destroyed

Skin appears dry, leathery that is painless, insensate Wound may initially appear red but will fade to white over 24 hours Healing occurs over months and hospitalization is normally required.

Classification of Burns Based on Depth Characteristics Classification Cause Ultraviolet light,very Superficial burn short (flame exposure) flash Dry and red; blanches with pressure Painful 3 to 6 days None Appearance Sensation Healing time Scarring

Blisters; Superficial partial thickness burn Scald or (spill moist,red and weeping; Painful air to Unusual; potential

splash),short blanches with flash pressure

and 7 to 20 days pigmentary changes

temperature

Blisters (easily unroofed); wet or waxy Deep partial Scald (spill), dry; flame, grease variable Perceptive More than 21 days Severe (hypertrophic) risk of contracture

thickness burn

oil, color (patchy of pressure to cheesy only

white to red); does blanch pressure not with

Scald

Waxy white to

(immersion), leathery gray flame, Full thickness steam, grease, chemical, to charred Deep pressure only

Never (if the burn affects

oil, and black; dry and inelastic;does blanch

more than 2 Very severe risk percent of the of total surface contrac ture area of the body)

high-voltage not electricity

with pressure

According to Causative Agent 1. Thermal ScaldsAbout 70% of burns in children are caused by scalds. They also often occur in elderly people. The common mechanisms are spilling hot drinks or liquids or being exposed to hot bathing water. Scalds tend to cause superficial to superficial dermal burns (see later for burn depth). FlameFlame burns comprise 50% of adult burns. They are often associated with inhalational injury and other concomitant trauma. Flame burns tend to be deep dermal or full thickness.

ContactIn order to get a burn from direct contact, the object touched must either have been extremely hot or the contact was abnormally long. The latter is a more common reason, and these types of burns are commonly seen in people with epilepsy or those who misuse alcohol or drugs. They are also seen in elderly people after a loss of consciousness; such a presentation requires a full investigation as to the cause of the blackout. Burns from brief contact with very hot substances are usually due to industrial accidents. Contact burns tend to be deep dermal or full thickness. 2. Electrical Some 3-4% of burn unit admissions are caused by electrocution injuries. An electric current will travel through the body from one point to another, creating entry and exit points. The tissue between these two points can be damaged by the current. The amount of heat generated, and hence the level of tissue damage, is equal to 0.24(voltage)2resistance. The voltage is therefore the main determinant of the degree of tissue damage, and it is logical to divide electrocution injuries into those caused by

low voltage, domestic current and those due to high voltage currents. High voltage injuries can be further divided into true high tension injuries, caused by high voltage current passing through the body, and flash injuries, caused by tangential exposu re to a high voltage current arc where no current actually flows through the body. Domestic electricityLow voltages tend to cause small, deep contact burns at the exit and entry sites. The alternating nature of domestic current can interfere with the cardiac cycle, giving rise to arrhythmias. True high tension injuries occur when the voltage is 1000 V or greater. There is extensive tissue damage and often limb loss. There is usually a large amount of soft and bony tissue necrosis. Muscle damage gives rise to rhabdomyolysis, and renal failure may occur with these injuries. This injury pattern needs more aggressive resuscitation and debridement than other burns. Contact with voltage greater than 70 000 V is invariably fatal. Flash injury can occur when there has been an arc of current from a high tension voltage source. The heat from this arc can cause superficial flash burns to exposed body parts, typically the face and hands. However, clothing can also be set alight, giving rise to deeper burns. No current actually passes through the victim's body.

3. Chemical Chemical injuries are usually as a result of industrial accidents but may occur with household chemical products. These burns tend to be deep, as the corrosive agent continues to cause coagulative necrosis until completely removed. Alkalis tend to penetrate deeper and cause worse burns than acids. Cement is a common cause of alkali burns.

Chemical burn due to spillage of sulphuric acid

According to Burn Severity Minor burn injuries can be treated in the emergency departments with outpatient follow up every 48hrs, until the risk of infection is reduced and wound healing is underway. Moderate uncomplicated burn injuries may be treated in the average hospital, while patients with major burns should be cared for in a burn center.

American Burn Associations Grading System for Burn of Patients Type of burn Minor Moderate Major >20 burn in 10 to 20 percent TBSA >10 burn in adult 5 to 10 burn percent TBSA burn in young <10 TBSA percent burn in young or old 2 to 5 >5 percent or percent percent adult TBSA in old fullpercent TBSA

full-thickness thickness

adult <5 percent Criteria: TBSA burn in

burn High-voltage injury burn Suspected injury burn medical inhalation High-voltage burn

young or old <2 percent thickness burn full

Circumferential Known Concomitant injury

inhalation

problem Any significant burn

predisposing the patient to to infection sickle (e.g., face, eyes, ears,

diabetes, disease)

cell genitalia or joints

Significant associated injuries (e.g., fracture, other major trauma) Disposition: Outpatient management Hospital admission Referral center to burn

ASSESSMENT Physical Examination Total body surface area (TBSA) Total Body Surface Area is an assessment measure of burns of the skin. In adults, the "rule of nines" is used to determine the total percentage of area burned for each major section of the body. In some cases, the burns may cover more than

one body part, or may not fully cover such a part; in these cases, burns are measured by using the casualty's palm as a reference point for 1% of the body. For children and infants, the Lund-Browder chart is used to assess the burned body surface area. Different percentages are used because the ratio of the combined surface area of the head and neck to the surface area of the limbs is typically larger in children than that of an adult.

(A) Wallace Rule of "nines" (B) Lund-Browder diagram for estimating extent of burns However, Berkows method is more accurate, particularly for infants and children, because it accounts for proportionate growth. The extent of small scaterred burns can be estimated by compairing the size of the nurses hand to the patients hand. Allowing for differences, the comparison will indicate that the palmar surface of an adults hand equals approximately 1 % of an adults TSBA.

Burn Depth

Anatomical Location

Location of the burn is important to healing and general rehabilitation. Burns of face, head, neck, hands, feet, and genetalia create particular problems. These burns usually require hospitalization of the injured person and special care because they are important areas where rapid, uninfected healing with minimal scarring is desired. Facial burns involve edema and present airway management. Perineal burns edema can be a problem and the patient with these burns need to catheterized as soon as possible. External ear and hand burns these structures primarily composed of cartilage, lacks a good blood supply as a result, healing is quite difficult.

Inhalation Injury

The nurse must assess for findings that indicate in inhalation injury. Signed nasal hairs Burns of the oral or pharyngeal mucous membranes Burns in the perioral area or neck Coughing up of soot or change in voice Occurrence of burn in a confined area

History Patients Age People younger than 2 years and older than 60 years have a higher mortality than other age groups with burns of similar severity. A child younger than 2 years is more susceptible to infection because of the immature immune response. The older person may have degenerative processes that complicate recovery and that may aggravated by the stress of the burn. Children with burns of 10% or more and all adults whose injuries account for 12-15% or more of TSBA will require hospitalization.

Concomitant Injuries Usually burn patients are awake and alert, so any changes in neurological status usually indicate other injury, such as anoxia, head injury, drug use or intoxication, hypoglycemia or myocardial infarction. Because burns do not bleed, any external bleeding indicates lacerations of deeper structures. Extremities are assessed for fractures.

MANAGEMENT RESPIRATORY SUPPORT Inhalation is the leading cause of death in the first 24 hours following the burn injury and increases mortality by 20%-60% when combined with Pneumonia Goals in treating inhalation injury include improving oxygenation and decreasing interstitial edema and airway occlusion Bronchopneumonia may be superimposed on other respiratory problems at any time and may be hematogenous or airborne o Hematogenous bronchopneumonia- begins as a bacterial abscess secondary to another septic source, usually the burn wound o Airborne bronchopneumonia- is most common, with an onset occurring soon after injury. It is often associated with a lower airway injury or aspiration NURSES ROLE: Humidified oxygen is administered to prevent drying and sloughing of mucosa If injury is mild or moderately severe, administration of aerosolized racemic epinephrine along with high fowlers position may be sufficient to limit f urther edema formation Severe upper airway obstruction may require endotracheal intubation to protect the airway until the edema subsides

In patients with mild tracheobronchial injury, atelectasis may be prevented by coughing and deep breathing exercises, chest physiotherapy, repositioning, frequent tracheal suctioning, and incentive spirometry

More severe inhalation injury requires more frequent suctioning and possible bronchoscopic removal of debris. These patients usually require endotracheal intubation and mechanical ventilator support, whose objective is to provide adequate gas exchange at the lowest possible inspired oxygen concentration and airway pressure in an attempt to reduce the incidence of oxygen toxicity and pulmonary barotrauma

Patients with bronchospasm should be treated with aerosolized or intravenously administered bronchodilators Respiratory parameters should be monitored closely and extreme attention paid to breath sounds and vital signs so that fluid overload can be detected as early as possible

TISSUE PERFUSION Because of the injury, vessels are damaged and thrombosed. Adjacent intact vessels soon dilate, and platelets and leukocytes adhere to the vascular endothelium, resulting to eschar formation NURSES ROLE: Monitor tissue perfusion hourly by checking for capillary refill, numbness and tingling, loss of motor function and sensation, deep throbbing or aching pain, temperature and color of the skin, and presence of peripheral pulse. An ultrasonic flow meter is often useful in assessing peripheral pulses. Pulse oximetry may be used to monitor the vascular status of extremities to identify the need for escaharotomy Extremities should be elevated and put through passive range of motion exercises for at least 5 minutes each hour to prevent edema and mobilize what does accumulate

Escharotomy- is an incision through the entire thickness of the eschar that allows underlying viable edematous tissues to expand, thereby restoring adequate tissue perfusion must be performed after some circulatory compromise has occurred, but before tissue hypoxia exists; if performed too soon, massive blood loss will occur from normal vasculature. If performed too late, tissue death results made in the midlateral or midmedial line of the involved extremity this procedure is made at the bedside and does not require local anesthesia the escaharotomy site must be covered with a topical agent because viable tissue is exposed, and a light dressing may be applied

Fasciotomy- this procedure is necessary only in the setting of high-voltage electrical current of concominant crush injury would be undertaken in the operating room under general anesthesia

NUTRITION The formation of gastroduodenal ulcers, also known as Curlings ulcers used to be a major complication in burn patients NURSES ROLE: To prevent ulcer complications, administer H2 histamine receptor antagonists and antacids. H2 receptor antagonists (ex. Cimetidine) are given orally or intravenously every 4 hours. Antacids are administered every 2 hours to titrate gastric pH above 5. Because of the risk of adynamic ileus and gastric distension, the patient should receive no oral fluid or nutrition Nasogastric tube should be inserted if distension or nausea occurs

Gastric drainage may initially contain some blood. Therefore, observe the amount and type of drainage to ensure that the quantity of blood subsides

BODY ALIGNMENT AND PRESSURE RELIEF Pressure ulcers may develop quickly

NURSESS ROLE: Patient may be placed on a pressure relief mattress or in a special pressurerelief bed Endotracheal tubes and Nasogastric tubes should be secured midline the nares to prevent erosion of the nasal septum Range-of-motion exercises should be performed for 5 minutes every hour to prevent contractures and reduce edema PAIN CONTROL Burn injuries are one of the most painful forms of trauma a person can experience The degree of pain is influenced by the depth of injury, patients anxiety level, and number of invasive monitoring and wound care procedures required When protective layers of epidermis are damaged, nerve endings of pain fibers are exposed first to the atmosphere and air currents moving across the exposed nerve endings cause extreme discomfort As exudates accumulate in in the injured area, potassium, prostanoids, and substance P irritate exposed nerve endings, contributing even greater pain sensations NURSES ROLE: Covering wounds with a clean sheet during transfer thus will decrease pain Careful positioning and use of pressure-relieving beds or mattresses avoid pressure on injury and promote comfort

Administering intravenous Morphine Sulphate (3-5 mg for adults) or Meperidine (30-50 mg) helps control pain Intramuscular and subcutaneous injections should be avoided since they will have no therapeutic effect until the patient becomes hemodynamically stable Other techniques include: relaxation therapy, guided imagery techniques, biofeedback, hypnosis, patient-controlled analgesia, anxiolytic or

antidepressant drug therapy, anesthesia, and transcutaneous electronic nerve stimulation Because pain experience is unique to each individual, the nurse must be flexible in determining the best pain control approach for each patient. PATIENT AND FAMILY SUPPORT Patient Needs Burn patients are under severe, long term stress and nearly always manifest personality variants: Depression, Regression, Paranoia,

Schizophrenia Hallucinations, confusion, and combativeness are common in severely burned patients for physical and mental reasons Exhaustion, pain, and medications may distort reality and produce schizophrenic effects NURSES ROLE: For depressed and withdrawn patients who often asks to be left alone, the nurse should respond by making expectations clearexpecting the patient to feed himself, go to bathroom or do as much as his physical condition permits, communicating to the patient that his condition is not hopeless and recovery is expected To handle regression, the best way is to acknowledge it. The nurse must accept the fact that the patient may be unable to cope on an

adult level and that the patient may be unstable emotionally and physically The nurse must devise ways to help the patient cope on an appropriate level Interventions that usually help include: following a regular schedule so that the patient knows what is expected, rewarding the patient for adult behaviour, and permitting him as much as control and choice as possible Family Needs With high anxiety levels and lack of knowledge pertaining to burns, the family approaches the burn unit with fear, hesitancy, and sometimes hysteria NURSES ROLE: Preparing the family for initial visit by explaining what to expect and escorting them to the bedside is extremely important It may be helpful to suggest that the family members leave and return when they feel stronger Information about the patients condition and treatments should be shared with them using an honest and open approach

THE ACUTE PHASE: MANAGING THE BURN WOUND INFECTION CONTROL The most significant complication of the injury is sepsis Infection may arise from the burn wound itself or from pneumonia, UTI, invasive procedures and invasive monitoring devices The burn wound is the most frequent source of infection, caused by a variety of organisms

NURSESS ROLE: Watch out for the signs of septic shock: o Varying temperature o Pulse 140-170 bpm (Tachycardia) o Decreased blood pressure o Adynamic ileus o Petechiae o Frank bleeding from wounds o Disorientation The best method of limiting bacterial proliferation is the use of topical antimicrobial agents WOUND CARE All burned areas should be cleaned once or twice a day with an antimicrobial liquid detergent (ex. Chlorhexidine). After daily hydrotherapy, the burn wound is covered with a topical antimicrobial agent Hydrotherapy Some centers immerse patients in a Hubbard tank to loosen exudates, clean and assess the wound, and provide ROM exercises Bath solutions may vary, and may contain salt, povidone-iodine solutions, and bleaches Because baths are usually painful, patients should receive analgesics 20-30 minutes before The patient should also receive an explanation of what is to be done and it is necessary and by permitting the patient to participate in the care as much as possible This should be limited to 20 minutes to prevent extreme chilling which increases metabolic demand

Care must be taken to avoid cross-contamination of wounds. Some centers separates clean or healing wounds from contaminated ones when cleaning

Topical Antimicrobial Agents The choice depends on wound depth, location, condition, and presence of specific organisms Commonly used agents include 0.% Silver nitrate, Mafenide Acetate

(Sulfamylon), Nitrofurazone, Povidone-Iodine, Silver sulfadiazine, Gentamycin, and Nystatin No single agent is totally effective against all burn wound infections Silver sulfadiazine- is the primary topical agent of choice on admission the most common adverse reaction is leukopenia, therefore, serial complete blood count must be monitored. If WBC count falls below 3,000, the physician probably will change it to another agent Mafenide acetate- an effective broad-spectrum bacteriostatic agent diffuses within 3 hours after application

The best topical agents are water-soluble because they will not hold in heat and macerate the wound

Debridement of the Burn Wound Mechanical Debridement- may be accomplished by using forceps and scissors to lift gently and trim necrotic tissue another form is by using wet-to-dry dressings and wet-to-wet dressings Enzymatic Debridement- involves the application of a proteolytic substance to burn wounds to shorten the time of eschar separation Travase and Elase are the most commonly used agents The wound is first cleaned and debrided of any loose necrotic material and the agent is applied directly to the wound bed and covered with a layer of fine mesh gauze. A topical antimicrobial

agent is then applied, and the entire area is covered with salinesoaked gauze. The dressing is changed 2-4 times a day Hypovolemia may occur as a result of excessive fluid loss through the wound Cellulitis and maceration of normal skin may occur, and patients may complain of burning sensation lasting 30-60 minutes after application Surgical Excision the wound is excised in viable bleeding points while minimizing the loss of viable tissue Should be done as soon as the patient is hemodynamically stable, usually within 72 hours After removal of necrotic tissue, the exposed underlying structures must be dressed with a temporary or permanent dressing to provide protection and prevent infection Grafting Sheet grafts- sheets of patients epidermis and a partial layer of the dermis are harvested from unburned locations using a dermatome the graft must be inspected frequently for collection of fluid under. Fluid accumulation is prevented by rolling with a cotton-tip applicator Mesh grafts- the harvested skin is slit to allow it to expand and then placed on the burn site allows for greater coverage and drainage and is draped more easily over uneven surfaces NURSES ROLE: Dressings are used postoperatively to immobilize the grafted area and prevent shearing and dislodging of the graft

Pulse checks distant to the dressing should be checked every 4 hours The donor site is covered intraoperatively with a single layer of fine mesh gauze. A heat lamp may be used to hasten the drying of donor site Positioning to prevent pressure on site is important Daily inspection is important to detect early signs of infection or cellulitis

Biological Dressings Includes homograft (allograft) and Heterograft (xenograft) Homograft skin is obtained from living or deceased human donors It is possible to transmit disease through homograft skin; thus, it is important to test donor skin for HIV, Hepatitis V, and syphilis before use Heterografts are used when demand for homograft skin exceeds supply. Porcine skin is the most commonly used substance Synthetic Dressings are developed in an attempt to overcome the pitfalls of biologic dressings: disease transmission, storage problems, and limted supply Biobrane is a collagen-based substance that adheres to wound surface within 48 hours after application. It forms an occlusive barrier to protect against bacterial infection and fluid losses while permitting drainage of exudate and penetration on topical antimicrobial agents THERMOREGULATION Hypothermia is a potential problem for burned patients, especially during hydrotherapy and immediately after surgery Heat is lost through the open burn wounds by means of radiation and evaporation Body temperature can be maintained at 99 to 101F by maintaining environmental temperature at 82 to 91 F with heat lamps or shields, foil blankets, and temperature-controlled air beds

NUTRITION The precise energy requirement to achieve weight and nitrogen balance and energy equilibrium depend on burn size, patient age, and other coexisting medical conditions The requirement has been found to be approximately 25 kcal/kg + 40 kcal % TBSA burn/24 hours Multivitamins and increased amounts of vitamin C, potassium, zinc, and magnesium are also required

THE REHABILITATIVE PHASE PHYSICAL REHABILITATION Nutrition The diet should remain high in protein until all wounds have healed

Prevention of scarring and Contractures Positioning the body with extremities extended is extremely important The ROM exercises should be carried out with each dressing change or more often if indicated PSYCHOLOGICAL REHABILITATION Stabilize staff as much as possible so that they become familiar with patients needs so that a sense of identification between patient and nurse is established Incorporate family members into the overall plan of care Instruct family members in selected procedures Encourage diversional therapy (reading, watching tv, listening to music) as soon as possible in recovery period Begin occupational therapy as soon as the patient is able to particiapate