Phases of Burn Injury

Phases of Burn Injury: Patient Care Time Period: Goals: Nursing Dx: Resuscitation Onset of injury and continues for about 24-48 hours Maintain patent airway and have adequate oxygenation Blood pressure and tissue oxygenation restored to normal Pain level expected to be alleviated or reduced Maintain normal ling compliance; not experience ARDS Pain related to tissue injury as evidenced by damaged skin, debridement, and dressing changes. Impaired skin integrity related to burns as evidenced by damaged skin. Risk for deficient fluid volume related to massive fluid shift and circulating volume loss. Acute 36-48 hours after injury No wound extension and have wounds healed Remain free from infection Maintain adequate nutrition intake Expected to have a positive perception of his or her own appearance, body functions, and self-worth Pain related to burn injury as evidenced by verbal report of pain. Risk for infection related to open burns. Impaired mobility related to pain as evidenced by grimacing. Rehab Begins with wound closure and ends when the patient achieves highest level of functioning Maintain adequate gas exchange and perfusion to all vital organs; patent airway; cardiac output restored to normal; pain reduced; remain free from infection; maintain adequate nutrition; have positive perception of own appearance and body functions Disturbed body image related to burn injury as evidenced by verbal report. Risk for ineffective coping related to situational crisis. Knowledge deficit related to self-care post burn injury as evidenced Assessment: Head to toe assessment; respiratory assessment; detailed medical history. Assess type of burn sustained. Start cardiac monitoring and monitor kidney function. Assess GI function. Use rule of nines to assess the body surface affected and use the Parkland formula to assess the fluid replacement needed to administer in the next 24 hours. Interventions : PRIORITY- secure airway, support circulation and organ perfusion by fluid replacement, keep patient comfortable with analgesics, prevent infection through careful wound care, maintain bod temp, and provide Assess cardiovascular and respiratory systems. Assess for signs of fluid overload and dyspnea. Weigh the patient daily and compare with pre-burn weight. Continually assess for signs and symptoms of local and systemic infections including changes in wound appearance, changes in neurologic and GI function, and subtle changes in vital signs. Assess the wound using sterile technique. Monitor for signs and symptoms of gram positive, gram negative, and fungal infections. Assess active and passive ROM for all joints including the neck. PRIORITY- assess cardiovascular and respiratory systems and wound care. Use principles of infection control and provide a safe environment by verbal reports. Assess psychosocial problems by obtaining info from the patient and family. Explore feelings about the injury. Assess for history of psychosocial problems. Assess and document type of coping mechanisms patient has used successfully. Assess patients feeling at each stage of grief. Assess family and home care situation. Discharge planning begins at admission All people who will be involved in the patient’s home care participate in discharge planning emotional support. Maintain patent airway and observe closely for pulmonary edema If so, elevate head of bed, apply oxygen, notify rapid response team Observe for ease of respiratory movements and loosen tight dressings as needed Tracheostomy may be needed for long term intubation Obtain and monitor lab tests – fluid & electrolytes, ABGs, carboxyhemoglobin Monitor ECG Bronchoscopy to examine vocal cords, chest x-rays Oxygen therapy with humidified oxygen. Keep emergency airway equipment near bedside. Turn patient every 2 hours and assist out of Remove exudates and necrotic tissue, clean area, stimulate granulation and revascularization, apply dressings as needed Debride and clean wounds one or two times each day during hydrotherapy Change dressings every 12 to 24 hours after thoroughly cleaning area Monitor for signs of infection- foulsmelling discharge, fever, blood culture and/or wound site colonization, and WBC count elevation Perform routinely quantitative biopsies of eschar and granulation tissue Use topical antimicrobial drugs for infection prevention- apply once or twice daily. & teaching sessions Continue to provide psychosocial support throughout hospitalization and rehabilitative phase Psychosocial assistance is best provided by a professional counselor Visits from friends and short public appearances before discharge may help patient adjust Refer to community reintegration programs Teach patient and family members to perform such care tasks as dressing changes Explain signs and bed to a chair as much as possible (if appropriate) Teach patient deep breathing and coughing exercises Teach patient to use incentive spirometer every hour while awake Administer IV fluids for fluid resuscitation using the Parkland formula; assess IV site and monitor vital signs hourly and assess urine output hourly; assess for fluid overload Drug therapy can be used to aid in respiratory issues and infection prevention Pain medications IV Provide a quiet environment Some can be left up to 7 days If signs of infection are presentadminister systemic antibiotics and monitor blood levels Isolation therapy to reduce crosscontamination Calculate the patient’s calorie needs and provide adequate daily source of calories & nutrients that they can digest Collaborate with dietitian and consider the patient’s preferences Position the client every 2 hours and perform ROM exercises at least TID Teach the patient to perform active ROM for the hand, thumb, and fingers every hour while awake If appropriate, symptoms of infection, drug regimens, proper use of prosthetic and positioning devices, correct application and care of pressure garments, comfort measures, and dates to follow-up appointments Case managers and visiting nurses can assist families if problems arise at home If rehabilitation is prolonged, patient may be discharged to rehabilitation facility ambulate patient two or three times a day and progress in length each time Use pressure garments at least 23 hours a day, every day, until scar tissue is mature. Reinforce that its beneficial in saving mobility & reducing scarring