Burn Nursing

Introduction

The bedside nurse caring for the severely burned patient is given more responsibility than in most types of serious illness. It is extremely important that the nurse be an integral part of the team of people caring for the burned patient. This is as important when modern burn care began as it is today. Care begins with the immediate resuscitation of the patient in the emergency department and continues until discharge, through rehabilitation and surgical reconstruction, until the patient is completely recovered and reintegrated into society. During the acute hospitalization, the nurse caring for the burned patient spends more time with the patient than any other member of the burn team. Because of this, especially during the acute hospitalization, the nurse is the best person to notice changes in patient condition and status and must continuously keep various team members updated on changes. Physical changes can include fluid balances, cardiovascular changes, neurological status changes, and tolerance of nutritional feedings. The nurse may also be the best person to act as patient advocate for psychosocial needs such as pain control, anxiety, and the like.

Emergency Needs: Resuscitation and Pulmonary Priorities

One of the first priorities in caring for the burn patient after assuring that the patient's airway is secure is to address cardiovascular needs. After a patient receives a severe burn injury, a leakage of fluids into the area of the burn injury causes swelling and may prevent circulation to that and distal areas. Circumferential burns especially need to be monitored to ensure there that is adequate circulation to the surrounding tissues and areas distal to the burn. Pulses must be checked hourly, and any diminished or absent pulses should be reported to the physician immediately. Another complication is circumferential third-degree burns around the chest and neck, which often cause restrictive defects. The increased amount of edema, combined with decreased chest excursion, may greatly decrease tidal volume. This condition may progress and can become life threatening, in which case chest escharotomy may be necessary to release the constricting eschar. The procedure may be done at the bedside or in the operating room. Equipment includes sterile drapes, scalpel, and electrosurgical unit (to control bleeding).

As fluids shift from the cardiovascular system to the interstitial regions of the burn, there may be a subsequent drop in blood pressure and organ perfusion and a decrease in urine output. It is the responsibility of the nurse, who is always with the patient, to monitor the patient's vital signs and urine output and notify the physician of changes to ensure an adequate fluid and cardiovascular status. An adult should maintain a urine output of 0.5 cc/kg per hour and a child should maintain a urine output of 1.0 cc/kg per hour. Lower urine volume rates may indicate hypovolemia, which can lead to cardiovascular collapse. Resuscitation fluids are to be started as soon as the patient first comes in contact with medical personnel. This is normally accomplished with IV fluids using resuscitation formulas designed for adults or children, or through oral ingestion of fluids. The goal is to provide adequate fluid resuscitation to maintain a normal cardiovascular status, perfusion of organs and tissues, and an adequate urine output.

Inhalation injury continues to be the most serious and life-threatening complication of burn injury. Early diagnosis and treatment greatly impact the outcome of care. Impaired gas exchange is a potential problem for patients who have face and neck burns and/or inhalation injury. Inhalation injury may include carbon monoxide poisoning, upper airway injury (heat injury above the glottis), lower airway injury (chemical injury to lung parenchyma), and restrictive defects (circumferential third-degree burn around the chest). Upper airway edema causes respiratory distress and is the primary concern during the initial 24- to 48-hour postburn phase. Tracheobronchitis, atelectasis, bronchorrhea, pneumonia, and adult respiratory distress syndrome (ARDS) may occur during the acute postburn stage either related or unrelated to inhalation injury.

Nursing care of a patient with inhalation injury begins with a detailed history of the accident. Inhalation injury is suspected when the accident occurred in a closed space. Close observation of the patient and frequent respiratory assessments are made throughout the initial and acute phase postburn. Initially the patient is observed for hoarseness and stridor, which indicate narrowed airways. Emergency equipment is placed at the bedside to facilitate intubation if necessary. Observing an increased frequency of cough, carbonaceous sputum, and increased inability to handle secretions may indicate possible inhalation injury and the potential for impaired gas exchange. Other important observations include respiratory rate, breath sounds, the use of accessory muscles to aid in respiratory effort, nasal flaring, sternal retractions, increased anxiety, and complaint of shortness of breath. Disorientation, obtundation, and coma may be due to significant exposure to smoke toxins such as carbon monoxide or cyanide. These conditions are managed emergently with 100% oxygen.

Bronchoscopy may be done early to diagnose inhalation injury as well as to facilitate airway clearance. Humidified oxygen should be readily available and applied to patients who have evidence of impaired gas exchange (especially pediatric patients). Aggressive nasotracheal suction may be indicated if the patient has difficulty managing secretions either because of the increased amount of secretions and/or the decreased effectiveness of the cough. In addition, aggressive pulmonary toilet, including turning, coughing, deep breathing, and up and out-of-bed rocking in mother's arms may be done regularly and frequently. Elevation of the head of the bed, unless contraindicated, will also support and possibly improve ventilation. Trends and changes should be correlated with laboratory results and shared with the team.

Intubation and mechanical ventilation may be required to improve gas exchange. Tube placement should be checked and documented frequently and verified daily by X-ray. Securing the endotracheal tube requires a standard technique for stabilization and prevention of pressure necrosis. Adequate humidity is necessary to prevent secretions from drying and causing mucous plugging. Remember to provide pre-/postsuctioning hyperoxygenation. Sterile technique is used when suctioning to prevent infection. Attention to the details of oral hygiene will provide comfort for the patient and may reduce the occurrence of ventilator-associated pneumonia related to colonization in the oral pharynx.

Criteria for extubation depend on the reasons that the tube was inserted initially, but, overall, stable vital signs and hemodynamic parameters will support the plan for extubation. The patient should be awake and alert in order to protect the airway; therefore pain medications may be reduced before extubation. Ventilatory measurements and blood gas analysis should be within normal limits.

Immediately following extubation, the nurse must be alert for signs and symptoms of respiratory distress, administer suction as needed, monitor blood gas measurements, and provide optimal positioning for ventilation, as well as provide reassurance and support to decrease anxiety.

Age, burn size, and the presence of inhalation injury and pneumonia have been identified as major contributors to mortality. Thus vigilant nursing care (frequent nursing assessments, aggressive pulmonary toilet, etc.) combined with anticipating potential problems and being prepared to deal with those problems will add to the team effort and possibly improve patient outcome.

Acute Care of the Burn Wound

The primary goal for burn wound management is to close the wound as soon as possible. Prompt surgical excisions of the eschar and skin grafting have contributed to reduced morbidity and mortality in severely burned patients.

Wound care in the burn unit has become a specialized art of burn nursing practice. It can be extremely challenging and complicated, and, for a new nurse, it can be the most difficult and misunderstood part of burn nursing. The complexity exists because of the variety of wound types, each of which requires different interventions in relation to time postburn or time postoperative. Wound assessment and care is a learned skill that develops over time. These skills must be taught by experienced nurses to new burn nurses. Assessment of the burn wound takes place in the hydrotherapy area, the operating room, and at the bedside.

Wounds may consist of eschar, pseudo eschar, skin buds, autografts, donor sites, hypermature granulating tissue, blisters, and exposed bone and tendons. In addition to the many kinds of possible wounds, there are many topical antibacterial agents available for managing wounds. These choices raise many decisions for the team to address. Topical antimicrobial creams and ointments include mafenide acetate, silver nitrate, silver sulfadiazine, petroleum and mineral oil-based antibacterial products, and Mycostatin powder. Wounds may be treated in the open fashion (topicals without dressings) or closed fashion (topicals with dressings or soaks). There are several techniques for applying dressings to different areas of the body that need to be able to withstand exercise, ambulation, and moving around in bed. Biological dressings, such as homografts or heterografts, may be used as temporary wound coverage. Dressings may also be synthetic or biosynthetic or silver-impregnated. Selection is based on the present condition of the wound and the expected outcome.

Secondary goals of wound care are to promote healing and to maintain function of the affected body part. These goals are accomplished by preventing wound infection, treating wound infection, preventing graft loss and tissue necrosis, providing personal hygiene, and maintaining correct positioning and splinting throughout hospitalization. To prevent burn wound infection, the burn nurse must cleanse the wound with soap and water; débride the wound of loose necrotic tissue, crusts, dried blood, and exudate; apply topicals or dressings; and ensure that dressing changes are ordered and done. The nurse must inspect the wound for evidence of infection: cellulitis, odor, increased wound exudate, and/or changes in exudate; changes in wound appearance; and increased pain in the wound. The physician should be notified so that changes in wound care can be made. Cultures and biopsies may be ordered to identify the type and count of organisms, and infected wounds are treated with a specific systemic antibiotic, topical dressing, soak, or a combination of all treatments. The wound is often the source of bloodstream sepsis. The five cardinal signs of sepsis are hyperventilation, thrombocytopenia, hyperglycemia, disorientation, and hypothermia.

Preventing graft loss is another wound care challenge for nursing. Usually the patient returns from the operating room in a position that is maintained for 3 or 4 days. Any interaction with the patient during this time of graft immobilization requires creativity and care in order to prevent shearing of the graft. Postoperative dressings on the thighs and back are protected with Polysporin/polymyxin and a fine-mesh gauze to prevent soiling by feces and to minimize cleanup. The dressings are continuously monitored for increased drainage and odor, which would indicate possible wound infection. If infection is suspected, then the postoperative dressings may be removed early for a closer inspection of the wound.

Donor sites will also require additional care to prevent infection. Of course, the postoperative care depends on the coverage of the donor site. If the donor site is covered with fine-mesh gauze, initial care is to ensure homeostasis and adherence of the gauze to the wound. Therefore the postop pressure dressing remains intact for 6–12 hours and is then removed. The focus of managing the donor site is to keep the wound dry. If grafts/donor sites are on the back or backs of the legs, the patient is placed in a Clinitron bed for 4–5 days to promote drying. If the donor site remains wet, additional drying techniques (hair dryers, external heaters) may be used periodically during the day.

If the donor site is covered with a synthetic or biological dressing, the same principles apply. Basically, a pressure dressing is applied to ensure adherence to the wound for a short period of time postoperatively and then the wound is exposed to the air to support drying. A bed cradle is used to keep bed linen from contacting wounds. The location of the graft, donor site, and eschar may all be on the same extremity, which again requires creativity to accomplish all three interventions of care.

Nurses must always be vigilant when it comes to skin assessment; early detection and prevention is the key ingredient in preventing pressure ulcers in major burn patients. Pressure ulcers are no longer treated as a burn wound. There is evidence to support nursing practices in the prevention of pressure ulcers in burn patients. Burn patients have many risk factors that predispose them to developing pressure ulcers. Initially hypovolemic shock with blood flow shunted away from the skin to preserve vital organ function is a factor. Additional injuries may increase the risk for pressure ulcers, such as inhalation injury, which may require intubation and use of paralytic agents to manage the airway. Fluid resuscitation may contribute to massive edema in both burned and unburned areas. The edema is maximized at about 2–3 days postburn, which also decreases the blood flow to the skin and adds weight to all parts of the body.

Maintaining systemic hydration can continue to be a problem long after the patient has received adequate resuscitation for burn shock. Continued fluid therapy to replace fluid loss through the burn wound is essential. If systemic hydration is not maintained, even normal skin may be at risk. To complicate this situation, the quantity of fluid lost through the burn wound may increase the moisture on normal skin adjacent to the burn wound. This moisture may cause the normal skin to break down and predisposes the skin to further compromise.

All patients, except those with skin grafts postoperatively, will benefit from a bath or shower. Large acute burns are placed on a shower cart and the wounds are gently showered with warm water. The overhead heater is turned on, and the room temperature is maintained at 85°F (29°C) or higher. Large acute burns are not immersed in a tub of water to prevent autocontamination and electrolyte imbalance. Hydrotherapy can be used for careful assessment of wounds, as well as for personal hygiene such as shampooing, mouth care, face care, and perineal care.

Hydrotherapy is an excellent opportunity for the nurse to teach the patient and family about wound care and dressing application. As the patient gets closer to discharge, families are required to do more of the care. The trend for earlier release from the hospital poses additional challenges for nursing since it reduces the time available to prepare the patient for discharge. The better the patient and family are educated, the better the outcome. Early involvement with patient and family helps identify potential obstacles at discharge and facilitates care coordination in the discharge process.

Surgical Care

The perioperative setting combines a number of professionals with different levels of experience and expertise, all directed toward patient care. Each team member has a specialized role: the surgeon provides surgical intervention, the surgical technician supports the surgeon, the anesthesiologist or certified registered nurse anesthetist (CRNA) provides life support functions, and the circulating nurse's role is to provide safe patient care by ensuring that all team members adhere to professional standards and guidelines. The perioperative nurse is a professional registered nurse who provides nursing care to patients in the preoperative, intraoperative, and postoperative phases of surgery. Perioperative burn nursing care can be described as hot, intense, and demanding. Burn nursing, in fact, represents one of the profession's most challenging specialties.

Once surgery is completed, perioperative nurses provide postoperative care and assessment. This phase of nursing care can also be challenging for the nurse caring for the patient during the immediate postoperative period. Nursing care and plan for care depend on many factors: amount of blood loss, surgical time, and the site(s) and extent of excision and grafting. The postanesthesia nurse caring for the burn patient must be knowledgeable about the medications and procedures used during surgery to provide appropriate safe nursing care.

Many burn-injured patients will make repeated trips to the operating room for surgical excision of the burn wound and grafting, with grafts taken from unburned areas. These procedures may require the patient to be anesthetized for long periods of time. Patients are at risk for pressure ulcers in the operating room; thus proper positioning and the use of pressure-reducing devices is essential to reduce the risk of pressure ulcer formation. During these operative procedures the patient may lose large quantities of blood, resulting in decreased tissue perfusion, and the patient may develop shock. Vasopressors and fluid resuscitation are the usual treatments for shock. Low-flow states and the use of vasopressors may also result in decreased tissue perfusion and increased risk of pressure ulcer formation.

Postsurgery, the patient or surgical area is often immobilized with large bulky dressings and splints to protect the grafts. These dressings need to be applied with enough pressure to stop bleeding from the grafted wound and the donor site. But if the dressings are applied too tightly, or if edema develops after dressing application, this may cause increased pressure on the skin.

To prevent wound bed desiccation, antimicrobial ointments or soaks are used to maintain moisture in the grafted wound and to aid in decreasing wound colonization with bacteria. This moisture, when in contact with adjacent normal skin, may increase the risk of tissue breakdown.

Inadequate nutrition prior to or after the burn injury is potentially a significant problem. The hypermetabolic response in the burn-injured patient leads to protein malnutrition if caloric intake is compromised. To reduce the risks of systemic infection and to promote wound healing, enteral hyperalimentation is most frequently used and the patient is fed by nasogastric or nasojejunal tubes.

In summary, burn patients are among the high-risk populations for pressure ulcer development. The physiology of the burn injury combined with many of the therapies and treatments used during hospitalization impacts the burn patient's risk for pressure ulcers.

Nutrition and Metabolic Changes

Hypermetabolism, or metabolic stress, is the direct response to a burn injury. The amount of stress increases proportionally to the extent of the injury and strongly influences a patient's nutritional requirements. This response can magnify the normal metabolic rate by 200%. Malnutrition, starvation, and delayed wound healing will result if calories are not provided consistently to meet nutritional requirements. Children require more calorie and protein replacement than do adults because they have additional nutritional demands to support growth and development.

Managing nutritional intake and monitoring output are among nursing's primary responsibilities. An accurate record of intake and output is critical to patient care because potential problems can be detected early and alternate options of care can be individualized to help the patient achieve his or her goals. Accurate weights, daily or as ordered, are also important. Remember to record whether dressings, splints, or linens are included in the weight. Obviously, including additional elements does not reflect an accurate weight, but trends in weight either up or down may be identified and may be helpful in the overall management of the patient.

Typically when patients cannot consume enough calories by mouth, then enteral feedings are begun. Sometimes enteral feedings are started before the patient is given the option of eating because the amount of calories is so great and/or the condition of the patient is unstable. Parenteral nutrition is used when enteral nutrition fails to deliver adequate nutrition. The goal is to provide adequate nutrients, calories, and protein. A nasogastric tube is inserted initially and used to decompress the stomach until bowel sounds return. Then tube feedings are started at a very low volume per hour to act as a buffer against ulcer formation. The nasogastric tube allows for checking hourly gastric residuals, gastric pH, and guaiac. If the gastric pH falls below 5, or if the guaiac is positive, Maalox and Amphojel are given every 2 hours, alternately every hour.

Aspiration of stomach contents is a potential complication and always a concern. Gastric residuals are checked before suctioning to prevent the patient from vomiting and possibly causing aspiration. Another precaution is to keep the head of the bed elevated. A Dobbhoff tube is also inserted initially, and feedings are begun as soon as 6 hours postburn. The rate starts slowly and is advanced as tolerated to meet the calculated amount of nutritional replacement. Tube feedings continue until the patient can take the required amount of calories by mouth.

Another potential problem with both tubes is dislocation; therefore it is important to check placement periodically throughout the day. When gastric residuals start climbing, it may be because the Dobbhoff tube has slipped into the stomach or the patient is septic. Tube feedings may become contaminated and become a source of infection for the patient, leading to significant morbidity. Routine procedures should be established to prevent this occurrence, and care should include sterilization of the blender and limiting to 4 hours the amount of time that tube feedings can be hung at the bedside. The tubing and container should be changed every 4 hours.

Sometimes when patients are encouraged to begin taking food by mouth, tube feedings may be discontinued during the day and be used only at night. Not scheduling painful activities around meal times and providing frequent mouth care will also contribute to improved oral intake.

Regular bowel patterns are expected in the postburn period. Patients are given many medications during hospitalization that may contribute to either diarrhea or constipation. Patients are expected to have at least one bowel movement per day. If not, then a bowel evacuation regimen should be considered. If diarrhea is the problem and the volume exceeds 1500 mL/day, then bulking agents and/or antidiarrhea medication may be useful to promote routine bowel elimination.

The importance of monitoring and documenting the many parameters of intake and output cannot be overemphasized. Established clinical protocols and guidelines facilitate the implementation and evaluation of the nutritional program.

Other strategies to support the hypermetabolic phenomenon of the burn patient are to keep the room temperature higher than 85°F (29°C) and to keep the room door closed to prevent drafts. Also frequent rest periods must be provided during the day. Nursing generally makes the schedule of activities for the day, so including frequent rest periods is just as important as anything else that needs to be done during the day. Adequate sleep during the night is also very important: often this makes the difference between a good day and a bad day. A quiet comfortable environment without sensory overload (lights and noise) is essential for the patient to sleep.

Nurses are the grand communicators of progress and/or problems. Nurses work closely with dietitians, physicians, patients, and families to ensure that optimal metabolic and nutritional support is achieved during the postburn period.

Pain and Anxiety Assessment and Management

Throughout the acute phase of care the burn patient is predisposed to pain and anxiety. Pain in the burn wound and fear of pain cause patients to try not to move. Careful titration of anxiolytics and narcotics can result in an alert patient who is relatively pain-free, but this requires intense attention to detail from the nursing staff. The expected outcome for pain and anxiety management is for the patient to achieve a balance between successful participation in activities of daily living and therapies and being comfortable enough to rest and sleep as needed. The ultimate goal is for the patient to be satisfied with the pain management plan as it is implemented. Assessment of pain and anxiety provides a baseline for evaluation of pain and anxiety relief measures. Pain and anxiety scales are essential to quantify painful episodes and to evaluate effectiveness of medication. Knowing when and how much to intervene is guided by knowing the baseline pain and anxiety rating for the individual. Patients and families should be given information upon admission on how to use the assessment scales and to identify an acceptable level of pain and anxiety.

Intravenous administration of opioids and anxiolytic agents is essential to manage pain and anxiety during the initial stage of injury due to the altered absorption and circulation volume following a major burn injury. A patient-controlled analgesia (PCA) pump is useful for children older than 5 years and adults. It is important to manage background pain as well as procedural pain, for which medication should be given 15–30 minutes prior to a painful procedure. Nursing-driven protocols for sedation and analgesia have been developed for the burn ICU and were reported to be effective in controlling pain. Nurses positively supported the introduction of the protocol but junior nurses seemed to be more uncomfortable with its use than more senior nurses.

Constipation is frequently a complication of pain management; thus a bowel management program should be instituted at the same time.

Relaxation, guided imagery, music therapy, hypnosis, and therapeutic touch are adjunct techniques to complement analgesia and reduce anxiety. Virtual reality is a relatively new technique used for pain control and has been quite successful. It involves a computer software program with which the patient actively interacts, thereby transferring the patient's attention away from the painful event. Emotional support and patient and family education decrease fear and anxiety, thereby enhancing the pain management plan.

Patient and Family Education

In order for nurses to be competent teachers, they must be competent practitioners with solid theoretical foundations. Continuing education to maintain competency is key for clinical staff because of their role as educators of patients and families. Reinforcement of the educational process (assess, plan, implement, evaluate, and document), characteristics of patient populations, updates on educational strategies, age-appropriate interventions, and ways to evaluate learning are topics that will sharpen educator competency.

Discharge planning and education begins upon admission. It begins with a thorough assessment of the patient's life prior to the injury. Identifying knowledge deficits and barriers to education, prioritizing strategies for education, and providing supplemental educational handouts and/or classes, as well as developing a plan for evaluating the effectiveness of the teaching opportunity are integral parts of the educational process.

Assessment provides essential information for planning an educational program to meet the specific individual needs of each patient and family. It is also done periodically during different stages of the educational process to determine if the plan remains valid or changes need to be made.

The assessment findings become part of the educational plan in that the plan is tailored to meet the needs and concerns of the patient and family. The plan includes the learning objectives, strategies for education, and learning materials. All of these parts of the educational goal are agreed upon by the patient, family, and educator.

Implementation of the plan is the next step, followed by a thorough evaluation of the effectiveness of learning and/or determination of whether the educational goal is being accomplished. Alterations in the original plan may be needed at any time during the educational process depending on unforeseen situations or unanticipated changes in conditions.

The benefits are many. This process ensures communication of educational topics among the team members, provides a historical account of education, and documents progress and/or changes in the plan. It benefits the patient and family by making them competent in their role as care provider when discharged from the hospital. Knowledge allays anxiety about the unknown and aids in compliance with recommended care after discharge, thus improving the long-term outcomes. Patients and families can be empowered to become active participants in the burn care team early in the postburn course through a well-structured educational plan.

Rehabilitation of the Burn Patient

A major burn is one of the most devastating injuries, both physically and emotionally, known to man. After weeks of being an invalid, undergoing repeated surgeries, fighting infection, having the body ravaged by the metabolic consequences of injury, and enduring pain and anxiety, the patient now faces months of continued physical therapy to regain the level of function that he or she had known before the injury. Most patients who have sustained a major burn will continue to have a higher than normal metabolic rate for more than a year and thus find that they do not have the stamina to easily regain their lifestyle. In addition to the catabolic effects of burn injury, being hospitalized and in bed with minimal activity for many weeks or months causes loss of muscle and bone weakening. Children are more prone to fractures. During the rehabilitation phase these patients must continue to exercise to prevent contractures, but they may not have the physical strength or endurance necessary to actively participate in such programs. In addition, these patients frequently become depressed as they face an altered self-image and a forced physical dependence on others. They fear that they will never look normal and that they will not be able to return to a normal life. For adults, the concerns of whether they will be able to return to work or have to change occupation is also a factor. What is the role of the nurse at this phase of treatment? Although nurses have been very involved in the care of the patient in the early phases of care, the role of the nurse changes at this stage. The transition from the hospital to home care is often difficult for both the patient and family. It is important prior to discharge that the patient and family be educated in the care of open wounds, healed skin, itching, pain, and anxiety before they leave the hospital. They also need information about the normal depression that occurs posthospitalization and resources in their home community to which they have access. This is where the nurse case manager becomes an integral part of the patient care team. Hospital-based nurse case managers can begin to work with the patient and family soon after admission to assess the patient's future needs and coordinate these with outside agencies to ensure that the transition goes smoothly. Often case managers from workmen's compensation carriers or health maintenance organizations (HMOs) are involved during the early phase as well. Coordination of activities between case managers is important to provide seamless care. With children, it is important for the nurse case manager to begin working with the school nurse or community health nurses to provide for this seamless transition in care.

Although the rehabilitation therapist plays an important role in providing referrals to community therapists and psychologists, and social workers frequently make referrals to community mental health providers, the nurse case manager should be involved in the overall coordination of these and other services to foster a unified approach. The free flow of communication among all providers is necessary for optimal rehabilitation of the patient.