Introduction to Burns

The skin has an important role to play in the fluid and temperature regulation of the body. if enough skin area is injured, the ability to maintain that control can be lost. the skin also acts as a protective barrier against the bacteria and viruses that inhabit the world outside the body. the anatomy of the skin is complex, and there are many structures within the layers of the skin. there are three layers: 1. epidermis, the outer layer of the skin 2. dermis, made up of collagen and elastic fibers and where nerves, blood vessels, sweat glands, and hair follicles reside. 3. hypodermis or subcutaneous tissue, where larger blood vessels and nerves are located. this is the layer of tissue that is most important in temperature regulation. the amount of damage that a burn can cause depends upon its location, its depth, and how much body surface area that it involves. how are burns classified? burns are classified based upon their depth. a first degree burn is superficial and causes local inflammation of the skin. sunburns often are categorized as first degree burns. the

inflammation is characterized by pain, redness, and a mild amount of swelling. the skin may be very tender to touch. second degree burns are deeper and in addition to the pain, redness and inflammation, there is also blistering of the skin. third degree burns are deeper still, involving all layers of the skin, in effect killing that area of skin. because the nerves and blood vessels are damaged, third degree burns appear white and leathery and tend to be relatively painless. burns are not static and may mature. over a few hours a first degree burn may involve deeper structures and become second degree. think of a sunburn that blisters the next day. similarly, second degree burns may evolve into third degree burns. regardless of the type of burn, inflammation and fluid accumulation in and around the wound occur. moreover, it should be noted that the skin is the body's first defense against infection by microorganisms. a burn is also a break in the skin, and the risk of infection exists both at the site of the injury and potentially throughout the body. only the epidermis has the ability to regenerate itself. burns that extend deeper may cause permanent injury and scarring and not allow the skin in that area to return to normal function.

Pathophysiology and types of burns Understanding the pathophysiology of a burn injury is important for effective management. In addition, different causes lead to different injury patterns, which require different management. It is therefore important to understand how a burn was caused and what kind of physiological response it will induce. The body's response to a burn Burn injuries result in both local and systemic responses.responses. Figure 1

Clinical image of burn zones. There is central necrosis, surrounded by the zones of stasis and of hyperaemia 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 oedemacan 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. widening. Figure 2

Jackson's burns zones and the effects of adequate and inadequate resuscitation 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. pathways. Figure 3

Systemic changes that occur after a burn injury

Mechanisms of injury Thermal injuries 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.thickness. Figure 4

Examples of a scald burn (left) and a contact burn from a hot iron (right) in young children 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. Electrical injuries 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, cause d by tangential exposure to a high voltage current arc where no current actually flows through the body.body. Figure 6

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Differences between true high tension burn and flash burn 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.body. Figure 7

Electrocardiogram after electrocution showing atrial fibrillation A particular concern after an electrical injury is the need for cardiac monitoring. There is good evidence that if the patient's electrocardiogram on admission is normal and there is no history of loss of consciousness, then cardiac monitoring is not required. If there are electrocardiographic abnormalities or a loss of consciousness, 24 hours of monitoring is advised. Chemical injuries

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.burns. Figure 8

Chemical burn due to spillage of sulphuric acid Certain industrial agents may require specific treatments in addition to standard first aid. Hydrofluoric acid, widely used for glass etching and in the manufacture of circuit boards, is one of the more common culprits. It causes a continuing, penetrating injury and must be neutralised with

calcium gluconate, either applied topically in a gel or injected into the affected tissues. The initial management of all chemical burns is the same irrespective of the agent. All contaminated clothing must be removed, and the area thoroughly irrigated. This is often best achieved by showering the patient. This has been shown to limit the depth of the burn. Litmus paper can be used to confirm removal of alkali or acid. Eye injuries should be irrigated copiously and referred to an ophthalmologist. ophthalmologist.

Specific chemical burns and treatments Non-accidental injury An estimated 3-10% of paediatric burns are due to non-accidental injury. Detecting these injuries is important as up to 30% of children who are repeatedly abused die. Usually young children (< 3 years old) are affected. As with other non-accidental injuries, the history and the pattern of injury may arouse suspicion. A social history is also important. Abuse is more common in poor households with single or young parents. Such abuse is not limited to children: elderly and other dependent adults are also at risk. A similar assessment can be made in these scenarios.scenarios.

Injury pattern of non-accidental burns

It is natural for non-accidental injury to trigger anger among healthcare workers. However, it is important that all members of the team remain non-confrontational and try to establish a relationship with the perpetrators. The time around the burn injury is an excellent opportunity to try to break the cycle of abuse. In addition, it is likely that the patient will eventually be discharged back into the care of the individuals who caused the injury. As well as treating the physical injury, the burn team must try to prevent further abuse by changing the relationship dynamics between victim and abuser(s).abuser(s).

History of non-accidental burns Any suspicion of non-accidental injury should lead to immediate admission of the child to hospital, irrespective of how trivial the burn is, and the notification of social services. The team should carry out the following:

Examine for other signs of abuse Photograph all injuries Obtain a team opinion about parent-child interaction Obtain other medical information (from general practitioner, health visitor, referring hospital) Interview family members separately about the incident (check for inconsistencies) and together (observe interaction).

It should be remembered that the injury does not have to be caused deliberately for social services to intervene; inadequate supervision of children mandates their involvement.involvement.

the significance of the amount of body area burned in addition to the depth of the burn, the total area of the burn is significant. burns are measured as a percentage of total body area affected. the "rule of nines" is often used, though this measurement is adjusted for infants and children. this calculation is based upon the fact that the surface area of the following parts of an adult body each correspond to approximately 9% of total (and the total body area of 100% is achieved):

head = 9% chest (front) = 9% abdomen (front) = 9% upper/mid/low back and buttocks = 18% each arm = 9% each palm = 1% groin = 1% each leg = 18% total (front = 9%, back = 9%)

as an example, if both legs (18% x 2 = 36%), the groin (1%) and the front chest and abdomen were burned, this would involve 55% of the body.

only second and third degree burn areas are added together to measure total body burn area. while first degree burns are painful, the skin integrity is intact and it is able to do its job with fluid and temperature maintenance. if more than15%-20% of the body is involved in a burn, significant fluid may be lost. shock may occur if inadequate fluid is not provided intravenously. the parkland formula (named for the trauma hospital in

dallas) estimates the amount of fluid required in the first few hours of care following a burn:

4cc/ kg of weight/% burn = initial fluid requirement in the first 24 hours, with half given in the first 8 hours.

as an example: a 175lb (or 80kg) patient with 25% burn will need 4cc x 80kg x 25%, or 8000cc of fluid in the first 24 hours, or more than 7 pounds of fluid.

as the percentage of burn surface area increases, the risk of death increases as well. patients with burns involving less than 20% of their body should do well, but those with burns involving greater than 50% have a significant mortality risk, depending upon a variety of factors, including underlying medical conditions and age. how important is the location of a burn? burn location is an important consideration. if the burn involves the face, nose, mouth or neck, there is a risk that there will be enough inflammation and swelling to obstruct the airway and cause breathing problems. if there are circumferential burns to the chest, as the burn progresses, the tissue involved may not allow enough motion of the chest wall to allow adequate breathing to occur. if circumferential burns occur to arms, legs, fingers, or toes, the same constriction may not allow blood flow and put the survival of the extremity at risk. burns to areas of the body with flexion creases, like the palm of the hand, the back of the knee, the face, and the groin may need specialized care. as the burn

matures, the skin may scar and shorten, preventing full range of motion of the body area. electrical burns electrical burns may cause serious injury that is not readily apparent. often the entry and exit points for the electrical shock may not be easily found. electricity flows more easily through tissues in the body that are designed to deal with electricity. nerves and muscles are "wired" for this task and often are damaged. if significant muscle damage occurs, muscle fibers and chemicals can be released into the bloodstream causing electrolyte disturbances and kidney failure. chemical burns burns can also occur when chemicals are spilled onto the body and generate a reaction that creates heat. chemical burns may be classified by their ph or acidity.

acids are those with ph less than 7 and include common household compounds like acetic acid, hydrochloric acid, or sulfuric acid.

bases or alkali compounds have a ph greater than 7. ammonia is a common alkali found in the home.

first aid for burns for major burns (second and third degree burns)

1. remove the victim from the burning area, remembering not to put the rescuer in danger. 2. remove any burning material from the patient. 3. once the victim is in a safe place, keep them warm and still. try to wrap the injured areas in a clean sheet if available. do not use cold water on the victim; this may drop the body temperature and cause hypothermia. burns of the face, hands, and feet should always be considered a significant injury (although this may exclude sunburn. for minor burns (first degree burns or second degree burns involving a small area of the body)

gently clean the wound with lukewarm water. though butter has been used as a home remedy, it should not be used on any burn.

rings, bracelets, and other potentially constricting articles should be removed (edema, or swelling from inflammation may occur and the item may cut into the skin).

the burn may be dressed with a topical antibiotic ointment like bacitracin or neosporin.

if there is concern that the burn is deeper and may be second or third degree in nature, medical care should be accessed.

tetanus immunization should be updated if needed.

for electrical burns victims of electrical burns should always seek medical care.

for chemical burns 1. identify the chemical that was involved. t is well established that fluid management is fundamental when treating burn patients during the immediate post-trauma period. Through clinical experience, we know that adequate volumes of IV fluids are required to prevent burns shock in those with extensive burn injuries. The aim of resuscitation is to restore and maintain adequate oxygen delivery to all tissues of the body following the loss of sodium, water and proteins. Fluid loss starts immediately after the burn occurs, because heat damage increases the permeability of the capillaries, which means that plasma is able to leak out of the blood circulation. This increase disrupts the normal exchange of blood plasma into the extracellular space at the site of injury, which results in rapid fluid loss. The greatest loss of plasma occurs in the first 12 hours after burn injury. The plasma loss then slowly decreases during the second 12 hours of the post-burn phase, although extensive leakage can continue for up to three days (Ahrns, 2004). Optimal fluid replacement during this period is essential to ensure cardiac output and renal and tissue perfusion.

Usually, 36 hours post-burn, capillary permeability returns to normal and fluid is drawn back into the circulation. There is also visible fluid loss occurring from exudate, blisters and oedema, and evaporative loss at the burn surface. Tissue oedema develops quickly during the first 68 hours and continues gradually during the next 1824 hours post burn. The body is able to compensate by shutting down the blood supply to the skin, abdominal viscera and kidneys but continued loss overwhelms the system. Blood volume decreases, resulting in intravascular hypovolaemia sometimes referred to as burns shock which can be fatal if left untreated. During the initial resuscitation period, an escharotomy (a surgical incision into an eschar, a scab or slough formed on the skin) may be necessary as fluid can accumulate under the eschar and inhibit vascular perfusion, respiratory movement or both. Aim of fluid resuscitation The primary function of fluid resuscitation is to:

Prevent burn shock by giving adequate fluid without overloading the vascular system or causing excessive oedema; Maintain circulatory volume in the face of losses due to the burn this is essential for cardiac output, renal perfusion and tissue perfusion; Provide metabolic water;

Maintain tissue perfusion to the zone of stasis and prevent the burn from deepening.

The main function is not to correct depleted intravascular volume. Criteria for fluid resuscitation Burns of more than 15% of surface body area in adults and of over 10% in children warrant formal resuscitation. There is no ideal resuscitation regimen. Many different types are used and have been adapted over the years, such as those recommended by: Brooke (1953); Evans et al (1952); Muir and Barclay (1962); and Parkland (1968). All these formulas can be found in Bosworth (2003). For many years, there was no consensus on the ideal fluid for preventing burn shock except that the essential ingredients should include water and salt. The formula to be followed is 0.5mmol sodium per kilogram of body weight per percentage of total burn surface area (TBSA). A variety of fluids have been recommended for use, such as plasma, human albumin solution (HAS), dextran and Hartmanns solution. However, it would appear that controversy still remains about which fluids should be used (the crystalloid versus colloid debate). Hypertonic saline achieves much the same results but with less volume than isotonic saline and oedema is less. Colloids may be extravasated to tissues because of the increased vascular permeability but withholding protein replacement may further decrease plasma oncotic pressure.

A study by Bunn et al (2004) concluded that hypertonic crystalloid is no better than isotonic and near-isotonic crystalloid for the resuscitation of patients with burns. Therefore it could be concluded that the optimal composition of fluid to be used remains unknown. There is no robust scientific evidence to support the adoption of one particular protocol over any others. To date, no single formula recommendation has been established as the most successful approach to adopt on fluid resuscitation of burn patients who are critically ill. Each burns unit/centre will have its own preference and experienced staff can exercise some discretion regarding their fluid composition of choice. Lund and Browder (1944) charts are used to calculate the percentage of burn surface area to assess the burn before fluid resuscitation is started. Even though this chart is more than 60 years old, it is still considered the most accurate way to calculate the burn injury. Erythema should not be counted in the final TBSA as, most of the time, it does not require treatment and does not affect fluid loss. Parkland formula Historically, fluid management has been as much an art as a science a fine line must be negotiated between an adequate resuscitation and one of fluid overload. Predominantly, fluid resuscitation is carried out intravenously and the most commonly used resuscitation formula is the pure crystalloid Parkland formula.

This advocates the guideline for total volume of the first 24 hours of resuscitation at approximately 4ml per kilogram of body weight per percentage burn of TBSA. Half the volume is given in the first eight hours post burn, with the remaining volume delivered over 16 hours. The Parkland formula has the advantage of being easy to use. It leads to fewer respiratory problems later on, although there may be pronounced general oedema in the first stages of its use as large volumes of fluid are required. The formula The Parkland formula for the total fluid requirement in 24 hours is as follows:

4ml x TBSA (%) x body weight (kg); 50% given in first eight hours; 50% given in next 16 hours.

Children receive maintenance fluid in addition, at an hourly rate of:

4ml/kg for the first 10kg of body weight plus; 2ml/kg for the second 10kg of body weight plus; 1ml/kg for >20kg of body weight.

End point

Urine adults: 0.51.0 ml/kg/hour; Urine children: 1.01.5ml/kg/hour.

Note: in order to ensure accurate calculations subtract any fluid that has already been received from the amount that is required for the first eight hours. Muir And Barclay formula The other commonly used formula was developed by Muir and Barclay (1962). This uses a colloid resuscitation with plasma and runs over 36 hours. As the fluid lost from the circulation is plasma, it seems logical to replace it with plasma. With colloid resuscitation, less volume is required and the blood pressure is better supported. However, both colloid and plasma are expensive. They may also leak out of the circulation and may result in oedema of the lungs. The 36 hours are divided into six periods of varying length, and an equal volume of plasma is administered in each period. The volume to be transfused in each period is calculated via the formula. This volume is given in each successive period of four, four, four, six, six and 12 hours. At the end of a period, if the assessment shows that the patients clinical condition is stable, the transfusion is continued according to the formula. If there is any clinical evidence of under- or overtransfusion then the plasma rations for the next and following periods are altered accordingly. The formula The Muir and Barclay formula is as follows: % x kg = volume needed.

Total % of burn surface area x body weight in kilograms = volume in millilitres of fluid to be given in each period.

The volume needs to be recalculated at each change in time period:

Every four hours for the first 12 hours; Every six hours between 12 and 24 hours; After 36 hours.

Note: areas of erythema should be excluded from TBSA. When using this formula, maintenance fluid is also required. Individual care It is worth noting that the time-dependent variable for all formulas begins from the moment of injury, not from the time that a patient is seen in A&E. The formulas are a starting point. It is important to be aware that the actual amount of fluid infused varies according to each patients clinical condition and must be titrated according to their requirements and clinical condition, regardless of the choice of formula.

The pivotal role of nursing personnel in burn care The nurses play an important role in the overall management of a burn patient. They must be well versed with the various protocols available that can be used to rationally manage a given situation. The management not only involves medical care but also a psychological assessment of the victim and the family. The process uses a scientific method to combine systems theory with the art of nursing, entailing both problem solving techniques and a decision making process. It involves assessment of the patient to arrive at a diagnosis and then determining the patient goals.An action plan is implemented and is evaluated in the context of patient response. The article discusses many such scenarios in burn patients and outlines the nursing care plans. Keywords: Role of nurses, holistic approach, evidence based medicine, critical pathways Optimal care of the burn patient requires a distinctive multidisciplinary approach. Positive patient outcomes are dependent on the composition of the burn care team and close collaboration among its members. At the centre of this team is the burn nurse, the coordinator of all patient care activities. The complexity and multisystem involvement of the burn patient demand that the burn nurse possess a broad-based knowledge of multisystem organ failure, critical care techniques, diagnostic studies and rehabilitative and psychosocial skills. The nurse oversees the total care of the patient, coordinating activities with other disciplines such as occupational and physical therapy, social services, nutritional services and pharmacy. At the same time, the burn nurse is also a specialist in wound care. As a burn wound heals, either spontaneously or through

excision and grafting, the nurse is responsible for wound care and for noting subtle changes that require immediate attention, prevention of infection and pain management. The nurses role is continuously expanding. Nurses are conducting nursing research and contributing to evidence-based practice of burn care. Practice guidelines, critical pathways and nursing care plans are all tools that help define and refine the nurses role in burn care. EVIDENCE-BASED PRACTICE Recent advances in health care technology, public disclosure and published information as well as a realization that we are obligated to reduce prohibitive health care costs are some of the several factors that have promoted the interest in and development of evidence-based practice or a more objective, scientific approach to health care. Previous standards of care, based largely on experience, are now being used as a control in randomized clinical trials. Both are evaluated using specific endpoints such as cost, benefit and risk.[1] Barnsteiner and Provost[2] suggest that there are both research and nonresearch elements in evidence-based practice. Clinical judgment and critical thinking are equally vital to the process. PRACTICE GUIDELINES Practice guidelines have evolved from the evidence-based practice revolution. They are intended to provide recommendations based on critical reading and interpretation of the current literature for managing specific problems. They attempt to define not only the best but also the most cost-effective treatment. When correctly written, practice guidelines can help minimize practice variances that lead to poor patient outcomes

and high health care costs. Because burn centres are few in number and are geographically scattered, there are few burn-focused multicentre trials. Many burn research studies involve only one centre, animal models and small sample sizes. Their limited strength of any demonstrated findings and study conclusions is obvious. There are currently a minimal number of randomized controlled clinical trials that have validated burn clinical care practices. Of the few that do exist, many have been extrapolated from research performed in other critical care patient populations. Recent efforts by the American Burn Association to initiate and support collaboration between burn centres to conduct multicentre trials are on-going. The resulting research studies should generate evidence-based practice and greatly impact future burn care. Additionally, the American Burn Association Committee on Organization and Delivery of Burn Care has published updated Practice Guidelines that were originally published in 2000 as a supplement to the Journal of Burn Care and Rehabilitation. The revised and updated recommendations represent the work of the 2004 to 2006 Committee on the Organization and Delivery of Burn Care.[3] CRITICAL PATHWAYS Critical pathways that were developed in the late 1990s as another measure to guide medical and nursing practice are more detailed disease and institution-specific protocols that are usually based on practice guidelines. They define the sequence of standardized, multidisciplinary processes or critical events that must occur in order for a particular patient to move toward desired outcomes within a defined period of time. The goal is to use an interdisciplinary perspective to identify expectations of patient care, improve quality care as demonstrated by improving

patient outcomes, decreasing length of stay, decreasing readmissions, decreasing costs and increasing patient satisfaction.[4] They define anticipated length of stay, delineate desired outcomes and goals, provide directions for care, identify the best practice model for a specific group of patients, promote collaboration between disciplines and provide an opportunity for continuous improvement in care delivery. Critical pathways represent the standard of care in average cases and were developed in response to economic incentives and pressures as they encourage the proper use of resources, which in turn reduces waste of time, energy and material. They promote well-coordinated, wellcommunicated continuity of care through collaborative practice and facilitate adherence to regulations imposed by regulatory bodies, reduce length of stay and resource utilization and reduce practice variances and adverse outcomes. Purposes of critical pathways Implementation of critical pathways is challenged by many pros and cons. While they provide a useful guideline in assessment, intervention and evaluation, they must be constantly monitored and updated based on the patients response to therapy. Further, they must be individualized for each patients needsThey should not to be construed as a cookbook mentality. They are not laws that must be rigidly followed. Contrary to popular belief, they do not annihilate individuality. It is important to remember that they are guidelines that outline the current standards of care. They also provide a useful educational tool for all members of the burn care team as they reflect each team members responsibilities. The nurse spends the most time with a patient and is in

the best position to monitor progress, report changes and coordinate activities of other team members. Critical pathways are most commonly depicted along two axes, one representing time and one representing aspects of care, including laboratory studies, consult services, nutrition, pharmaceutical support, patient education, etc. Another useful element of critical pathways is their ability to identify variances, or unexpected events, both positive and negative. The analysis of these variances provides an excellent framework for a quality improvement program and can help focus improvement efforts in any of the four major areas: caregiver or provider, hospital or system, patient or family and/or community variance. NURSING DIAGNOSES AND CARE PLANS During all phases of injury, assessment by the nurse must focus on early detection or prevention of complications associated with moderate to severe burn injury. Frequent monitoring is required to assess indices of essential organ function. Nursing diagnoses The nurses goal is to deliver patient-focused care using a holistic approach. In order to accomplish this, the nursing process was introduced in the 1950s and has served as the framework for nursing care delivery ever since. The process uses a scientific method to combine systems theory with the art of nursing. It entails both problem-solving techniques and a decision-making process The nursing process consists of five steps, which together facilitate the delivery of high-quality, individualized patient care. The five steps are as follows:

Assessment is the first step of the process and is a systemic approach to collecting information about the patient. It includes not only symptoms and physiologic factors but also social, cultural, psychological and spiritual aspects of the patients life. Diagnosis, the second step, is the nurses analysis of the assessment. It is sometimes also referred to as needs identification. Outcomes/planning uses the two previous steps to determine patient goals, both long- and short term, desired outcomes and appropriate nursing interventions. These outcomes and interventions are written as the nursing care plan and serve as a written guide for all health care professionals. Implementation is the action portion of the nursing process and care plan. Evaluation of both the patients response to interventions and progress toward achieving outcome goals is critical. Both need to be documented and the plan of care modified accordingly. The nursing process is both dynamic and interactive. It is a continuous cycle of logical progression from one step to the next. Because each step relies of the accuracy of the previous step, data must be validated. Clearly, the plan that is developed from the nursing process must be adjusted based on the interactions with other disciplines in order to meet the continuously changing needs of the patient. In creating the care plan, the nurse uses theory, nursing judgment and clinical expertise. In many ways, the nursing process and written plan of care help define the nurses role. By using the nursing process, the nurse is able to establish

autonomy and a common ground within the practice of nursing through nursing diagnoses. The continuous review of the care plan facilitates evaluation and documentation of outcomes and helps provide the basis for establishing standards of care. Go to: NURSING DIAGNOSIS 1 Ineffective airway clearance and impaired gas exchange related to tracheal oedema or interstitial oedema secondary to inhalation injury and/or circumferential torso burn manifested by hypoxemia and hypercapnia Patient outcomes

Adequate airway clearance and gas exchange. Partial pressure of oxygen >90 mmHg; partial pressure of arterial carbon dioxide <45 mmHg; oxygen saturation >95%. Respiration rate 1620 breaths/min and unlaboured; breath sounds present and clear in all lobes; chest wall excursion symmetrical and adequate. Mentation clear; patient mobilises secretions, which are clear to white.

Nursing interventions

Monitor oxygen saturation every hour, arterial blood gases as needed; Chest X-ray as ordered Assess respiratory rate, character and depth and level of consciousness every hour; breath sounds every 4 h;

If not intubated, assess for stridor, hoarseness and wheezing every hour

Administer humidified oxygen as ordered Assist patient in coughing and deep breathing every hour while awake; Suction every 12 h or as needed Monitor sputum characteristics and amount

Turn every 2 h to mobilize secretions Elevate head of bed Schedule activities to avoid fatigue

Rationales

Assess oxygenation and ventilation Evaluate respiratory status and Response to treatment Expedite elimination of carbon monoxide and prevent/treat hypoxemia Promote lung expansion, ventilation, clearing of secretions and clear airway Facilitate lung expansion Decrease ventillatory effort and dyspnea

Go to: NURSING DIAGNOSIS 2 Adequate fluid volume

Deficient fluid volume secondary to fluid shifts into the interstitium and evaporative loss of fluids from the injured skin Patient outcomes

Heart rate 80120 beats/min; blood pressure adequate in relation to pulse and urine output; optimal tissue perfusion; nonburn skin warm and pink Hourly urine output 3050 ml/h; 75100 ml/h in electrical injury; 1 ml/kg/h in children <30 kg body weight Weight gain based on volume of fluids given in the first 48 h, followed by diuresis over the next 35 days Laboratory values within normal limits; urine negative for glucose and ketones

Nursing interventions

Monitor: vital signs and urine output q1h until stable; mental status every hour for at least 48 h. Titrate fluid requirements to maintain urinary output and haemodynamic stability Record daily weight and hourly intake/output measurements; evaluate trends

Rationales

Assess perfusion and oxygenation status Restore intravascular volume. Evaluate fluid loss and replacement.

Monitor serum electrolytes, glucose, creatinine, haematocrit, blood urea nitrogen as required by patient status Evaluate need for fluid and electrolyte replacement resulting from large fluid and protein shifts.

Go to: NURSING DIAGNOSIS 3 Ineffective tissue perfusion related to compression and impaired vascular circulation in the extremities with circumferential burns, as demonstrated by decreased or absent peripheral pulses. Patient outcomes

Adequate tissue perfusion, as manifested by strong peripheral pulses. No tissue injury in the extremities secondary to inadequate perfusion from oedema or eschar.

Nursing interventions

Assess peripheral pulses every hour for 72 h. Notify the physician of changes in pulses, capillary refill or pain capillary refill or pain Elevate upper and lower extremities Be prepared to assist with escharotomy or fasciotomy

Rationales

Assess peripheral perfusion and the need for escharotomy Decrease oedema formation Allows oedema expansion and restore peripheral perfusion

Go to: NURSING DIAGNOSIS 4 Acute pain related to burn trauma. Patient outcomes

Relief of pain. Identifies factors that contribute to pain. Verbalizes improved comfort level. Physiological parameters within normal limits and remain stable after administration of narcotic analgesia.

Nursing interventions

Monitor physiological responses to pain, such as increased blood pressure increased heart rate, restlessness and nonverbal cues. Use validated tools in each patient to assess pain and anxiety Assess response to analgesics or other interventions Evaluate effectiveness of interventions Administer analgesic and/or anxiolytic medication as ordered; administer IV during critical care phases Medicate patient before bathing, dressing changes and major procedures as needed Use nonpharmacological pain-reducing methods as appropriate

Rationales

Pain responses are variable and unique to each patient

Facilitate pain relief. Intramuscular/ intravenous, during critical care phases, medications not consistently absorbed Assist patient to perform at higher level as needed of the function Reduce need for narcotics

Go to: NURSING DIAGNOSIS 5 Risk for infection related to loss of skin, impaired immune response and invasive therapies. Patient outcomes

Absence of infection. No inflamed burn wound margins. No evidence of burn wound, donor site or invasive catheter site infection. Autograft or allograft skin is adherent to granulation tissue. Body temperature and white blood cell count within normal limits. Sputum, blood and urine cultures negative. Glycosuria, vomiting, ileus,and/or change in mentation absent.

Nursing interventions

Assess temperature and vital signs and characteristics of urine and sputum every 14 hours Monitor white blood cells, burn wound healing status and invasive catheter sites Ensure appropriate protective isolation; provide meticulous wound care; educate visitors in burn unit guidelines

Rationales

Facilitate early detection of developing infections Prevent infection by decreasing exposure, to pathogens

Go to: NURSING DIAGNOSIS 6 Risk for injury Gastrointestinal bleeding related to stress response. Imbalanced nutrition Less than body requirements related to paralytic ileus and increased metabolic demands secondary to physiological stress and wound healing. Patient outcomes

Absence of injury and adequate nutrition. Decreased gastric motility and ileus resolved. No evidence of gastrointestinal haemorrhaging. Enteral feedings absorbed and tolerated. Daily requirement of nutrients consumed. Positive nitrogen balance. Progressive wound healing. 90% of preburn weight maintained.

Nursing interventions

Place nasogastric tube for gastric decompression in >20% TBSA burns Assess abdomen and bowel sounds every 8 hours Assess NG aspirate (color, quantity, pH, and hemocult blood); monitor stool for hemocult blood Administer stress ulcer prophylaxis Initiate enteral feeding, and evaluate tolerance. Provide high-calorie/protein supplements Record all oral intake and count calories

Schedule interventions and activities to avoid interrupting feeding times Monitor weight daily or biweekly

Rationales

Prevent nausea, emesis, and aspiration from ileus Evaluate resolution of decreased gastric motility Facilitate early detection of development of gastrointestinal ulcer Prevent stress ulcer development Caloric/protein intake must be adequate to maintain positive nitrogen balance and promote healing Pain, fatigue, or sedation interferes with desire to eat Assess tolerance and response to feeding interventions

Go to: NURSING DIAGNOSIS 7

Risk for hypothermia related to loss of skin and/or external cooling. Patient outcome Normothermia. Rectal/core temperature 37C (98.6F)38.3C (101F). Nursing interventions

Monitor and document rectal/core temperature every 1 to 2 hours; assess for shivering Minimize skin exposure; maintain environmental temperatures For temperature <37 C (98.6 F), institute rewarming measures

Rationales

Evaluate body temperature status Prevent evaporative and conductive losses Prevent complications

Go to: NURSING DIAGNOSIS 8 Impaired physical mobility and self-care deficit related to burn injury, therapeutic splinting and immobilization requirements after skin graft and/or contractures. Patient outcomes

Physical mobility. Demonstrates ability to care for burn wounds.

No evidence of permanent decreased joint function. Verbalises understanding of plan of care. Vocation resumed without functional limitations or adjustment to new vocation.

Nursing interventions

Perform active and passive range of motion exercises to extremities every 2 hours while awake. Increase activity as tolerated. Reinforce importance of maintaining proper joint movement/function, alignment with splints Elevate extremities Provide pain relief measures before self-care activities and occupational and physical therapy Explain procedures, interventions, and tests in clear, simple, ageappropriate language Promote use of adaptive devices as needed to assist in self-care and mobility

Rationales

Prevent contractures and loss of Decrease edema and promote range of motion and mobility Facilitate mobility; assist performance at a higher level of function Patient more likely to participate and adhere if understands purpose Decrease dependency

Go to:

NURSING DIAGNOSIS 9 Risk for ineffective individual coping and disabled family coping related to acute stress of critical injury and potential life-threatening crisis. Patient outcomes

Effective coping. Verbalises goals of treatment regimen. Demonstrates knowledge of support systems. Able to express concerns and fears. Patients and familys coping is functional and realistic for the phase of hospitalisation.

Nursing interventions

Orient patient and family to unit guidelines and support services; provide written information and reinforce frequently; involve in plan of care. Support adaptive and functional coping mechanisms Use interventions to reduce fatigue and pain Use social worker for assistance in discharge planning Consult psychiatric services for inadequate coping skills or substance abuse treatment Promote use of group support sessions

Rationales

Decrease fear and anxiety Adequate pain control and rest facilitate patient coping Provide expert consultation and intervention.

Assist patient and family in understanding experiences, reactions, and methods of coping

Go to: SUMMARY The importance of a multidisciplinary approach to patient care cannot be overstated. At the centre of this team is the nurse. The burn nurses assessments, observations and evaluations of the patients response to interventions are crucial to preventing complications and make the critical difference in patient outcomes. REFERENCES 1. American Burn Association, Evidence-Based Guidelines Group. Practice guidelines for burn care. J Burn Care Res. 2001;22:169. 2. Barnsteiner J, Prevost S. How to implement evidence based practice. Reflections on nursing leadership. 2002;28:1821. [PubMed] 3. Gibran NS. Practice Guidelines for Burn Care. J Burn Care Res. 2006;27:4378. [PubMed] 4. Gordon M, Greenfield E, Marvin J. The Truth About Critical Pathways in Burn Care. J Burn Care Res. 1996;17:1336. 5. Greenfield E. Critical pathways: What They Are and What They Are Not. J Burn Care Res. 1995;16:1967. 6. Greenfield E. Burns. In: Bucher L, Melander S, editors. Critical Care Nursing. 1st ed. Philadephia: W.B. Saunders; 1999. pp. 103669.

7. Doenges M, Moorhouse M, Murr A. In: Nursing Diagnosis Manual: Planning, Individualizing and Documenting Client Care. 3rd ed. St. Louis: F A Davis Co; 2010. The Nursing Process: The foundation of quality client care; pp. 18. 8. Molter N, Greenfield E. Burns. In: Hartshorn J, Sole M, Lamborn M, editors. Introduction to Critical Care Nursing. 2nd ed. Philadephia: W.B. Saunders; 1997. pp. 52355. 9. Ahrns-Klas K. Burns. In: Sole M, Klein D, Moseley M, editors. Introduction to Critical Care Nursing. 5th ed. Philadephia: W.B. Saunders; 2009. pp. 682728.

Articles from Indian Journal of Plastic Surgery : Official Publication of the Association of Plastic Surgeons of India are provided here courtesy of Medknow Publications Formats:

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