Coordination of care: Burn nursing’s unique role

Burn nursing offers many challenges and rewards. To be burned is to sustain one of the worst injuries possible. The complex physical and psychosocial demands challenge patients for weeks to months. The one constant health care professional through all stages of recovery is the burn nurse. While the patient and family are the central focus of care around which all activities of the burn team revolve, it is the burn nurse who serves as the central coordinator of patient care (Table 13).

Nursing interventions: Emergent phase

During the emergent phase of care, the nurse is present for the admission procedure and is a participantobserver during the head-to-toe assessment and stabilization procedures. In collaboration with the burn physician, a wound care plan is decided upon and implemented by the nurse. The bedside nurse closely monitors the patient, which includes maintaining effective airway clearance and gas exchange, assessing the adequacy of fluid resuscitation, and monitoring adequate perfusion to vital organs and extremities. Supportive care to the patient and family are key features of the nursing role at this time.

Thorough assessments and prompt interventions are important as the patient’s clinical condition can change quite rapidly. Documenting and interpreting trends in objective patient data, along with keen subjective observations and guided clinical intuition alert the nurse to subtle changes in the patient’s condition that might require intervention. Interpreting the complex environment and required treatments to patients and families is very important. Preparing the family for their first glimpse of the patient since admission requires careful thought and sensitivity. If the patient’s face is burned, edema from the injury, compounded by the fluid resuscitation, may change the appearance dramatically. The eyes may swell shut and the head become enormously swollen. Reassuring the patient that the edema is only temporary and that his/her eyesight will return to normal is very important during the first 24 hours or so post-injury. If there is concern about the eyesight, the patient should be reassured that ophthalmology

will conduct a thorough examination as soon as the swelling subsides. Concerns about disfigurement are often high at this time, particularly with family members who can see the patient’s edematous, burned face. It is so very helpful if the nurse can instill in the family the importance of taking one day at a time and cautioning them that circumstances can change quickly and often in the first days post-burn.

Burn wounds are not uniform in depth and may need various wound care techniques. During the first few dressing changes, the nurse may notice changes in the wound appearance, indicating a deeper or lesser injury than initially diagnosed. Wounds should be assessed for their colour, size, odour, depth, drainage, bleeding, edema, eschar separation, possible infection, cellulitis, epithelial budding, and altered sensation. Clean technique can be utilized for dressing removal and wound cleansing, with sterile technique reserved for the inner, sterile cream/ointment/ dressing application [11]. Loose, necrotic and broken blister tissue can be removed with scissors and forceps as bacteria proliferate in burned tissue. Burn wounds can be cleansed using tap water, such as in a Home Care or Burn Clinic setting, or when using a cart shower system in a burn centre.

Normal saline can be used for dressing changes at the bedside on a nursing unit. Some burn centres utilize a mild soap solution to cleanse the wound of debris and reduce the microbial count. Consultation with the burn surgeon may result in an alteration in wound care or plan for surgery. Nursing’s role would include informing and explaining the change in care to the patient and family, and appropriate documentation in the nursing plan of care. Face care is conducted about every 6 hours with special attention paid to cartilagenous areas. Tie tapes used to secure endotracheal and/or nasogastric tubes should be inspected every hour to ensure they are not pressing into the burned skin or nose/ear cartilage, cutting off circulation and deepening the tissue damage. Eye drops or lubricating ointments are gently administered to protect the eye from further damage. Pulses to circumferentially-burned extremities need to be monitored closely, in the event the patient needs a releasing escharotomy or fasciotomy to restore circulation. Peripheral pulses should be palpated hourly in the emergent phase, when the onset of edema is profound. A hand-held audible, doppler may also be

Assess and monitor hourly and PRN for signs of airway obstruction: dyspnea, stridor, tachycardia, use of accessory muscles, respiratory effort, limited chest expansion

Assess for signs and symptoms of smoke inhalation injury: burns of the head, neck, face and chest, singed nasal hairs, eyebrows and eyelashes, darkened oral and nasal membranes, carbonaceous sputum, hoarseness, dyspnea, cough, headache, dizziness and irritability

Monitor arterial blood gases and carboxyhemoglobin results and report significant changes to physician

Elevate head of bed 30 degrees, if not contraindicated

Administer oxygen as ordered

If necessary, assist with chest escharotomies

Be prepared to intubate

If patient mechanically ventilated, monitor inspiratory pressures, tidal volume and minute volume hourly; report changes to respiratory therapist and physician

Suction patient down endotracheal or nasotracheal tube every hour and PRN

Establish 2 large-bore IV access lines for prompt IV fluid resuscitation

Insert indwelling urinary catheter

Assess and monitor urinary output every hour and PRN

Maintain accurate intake and output records from admission, including ambulance and emergency department volumes

Monitor serum electrolytes, osmolality and hematocrit

Titrate IV fluids as necessary to maintain urinary output between 30–50 mL/hr and a CVP between 1–6 mm Hg

Monitor blood pressure and pulse hourly and PRN

Assess and monitor for signs and symptoms of hypovolemic shock : BP, HR, urinary output, cardiac output, CVP

Monitor peripheral pulses on all burned extremities hourly and PRN, obseving for capillary refill and skin temperature

Assist physician with escharotomies and/or fasciotomies to extremities and/or chest if indicated

Monitor acid/base balance

Regulate IV resuscitation to maintain adequate BP, pulse, urinary output and level of sensorium

Provide frequent and repeated explanations and information about care, procedures and new surroundings/personnel

Reunite patient and family as soon as possible following admission

Offer repeated explanations, information and support to family

Familiarize them with burn centre facilities and hospital layout

Describe burn care routines and visiting policies

Establish contract between family and social worker PRN

Assess and monitor mental status to determine level of anxiety

Assess how anxiety may interfere with sleep or activity

Demonstrate willingness to listen and talk to patient and family at frequent intervals in order to encourage ventilation of feelings

Identify previous methods of coping with stressful situations

Encourage and reinforce individual/family participation in care

Evaluation

The patient, without inhalation injury, will maintain optimal pulmonary/airway status.

The patient, with inhalation injury, will regain optimal pulmonary/airway status.

The patient will regain an appropriate fluid and electrolyte balance and recover completely from the burn-induced hypovolemia.

The patient will maintain optimal cardiac and circulatory status.

The patient will freely discuss ongoing fears, concerns and anxieties related to being burned.

The patient will begin to verbalize a reduction in fears, concerns and anxieties.

The patient will communicate that anxiety does not interfere with sleep or activity.

Assessment

Subjective

Ask the patient whether his grafted donor site areas are causing him any discomfort. Inquire as to the overall assessment of pain.

Discuss the patient’s assessment of his ability to participate in self-care activities

Objective

Assess mesh graft donor site areas post-op for intact dressings and absence of bleeding

Assess sheet grafts open to air for any accumulated secretions or blood clots

Assess need for specialty low-air loss or air fluidized bed to reduce pressure, friction or shear to grafted sites

Assess need for bed cradles to keep linen off grafted sites

Assess patient’s level of pain at the graft site(s), donor site(s) and in general

Assess physician’s post-operative orders and intraoperative notes to determine what burn wounds were debrided and grafted, what type of grafts were used, location of donor site(s)

and dressing orders for wounds, grafted sites and donor sites

Perform post-op blood work i.e. CBC and electrolytes

Assess and document patient’s level of pain every 4 hours and PRN using a visual analog scale

Assess and document effectiveness of administered pain medications one hour post-administration

Assess patient’s range of motion and level of strength in all areas not involved in the burn injury

Assess patient’s range of motion and level of strength in areas affected by the burn injury

Gather data from physiotherapist and occupational therapist regarding patient’s level of functioning and their plan of care

Assess patient’s ability to ambulate

Nursing Diagnosis

Altered skin integrity related to skin graft donor sites secondary to full-thickness burn injury

Alteration in comfort: acute pain related to burn injury and associated treatments and interventions

Impaired physical mobility related to pain, dressings and joint contractures

Expected Outcomes

The patient will have a graft take of >90% as manifested by:

– intact, adherent, vascularized graft

– progressive re-epithelialization of interstices of meshed grafts

– no signs of infection

– no signs of graft breakdown due to pressure, shear or friction

The patient will verbalize satisfaction with level of pain

control and demonstrate a tolerable level of pain as evidenced by:

–verbal reports of an acceptable level of comfort based on a measurable scale after pain intervention

–asking for pain intervention in the presence of pain

–improved mobility and ability to participate in self-care

–relaxed facial expression and body posture

–absence of crying, moaning or stoic behaviour during dressing changes, positioning, rehabilitation exercises or treatments

–non-communicative patients exhibiting signs of comfort during rest periods and after comfort interventions i.e. vital signs within acceptable range, absence of facial grimacing, resistance, withdrawal, triggering ventilator alarm, biting down on endotracheal tube

–verbal reports that pain does not interfere with physical activity, self-care or sleep

–successful use of non-pharmacological techniques, such as

relaxation, distraction, self-hypnosis, and assistive devices, such as patient-controlled analgesia or therapeutic touch, to manage discomfort

The patient will maintain or attain an optimal level of function as manifested by:

–normal range of motion in all areas not involved in the burn injury

–range of motion in areas affected by the burn injury show progressive signs of improvement

–muscle strength in unburned areas remains same as on admission

–muscle strength in burn-involved muscle groups shows progressive improvement

–demonstration of functional ambulation

–demonstration of physiotherapy routines and occupational therapy program with and without assistance

–demonstration of appropriate application, care and use of splints

–participation in activities of daily living

The patient will be as free from complications associated with immobility as possible.

Implementation

Protect grafted areas from excess pressure, friction and shear by using low-air loss or air fluidized specialty beds

Protect open sheet grafts from bedding through use of overbed cradles

If protective bolster dressings or plaster casts are utilized, inspect every shift for intactness or excessive pressure

Reduce incidence of infection by washing hands well before and after patient contact, changing gloves after removing soiled dressings and before applying clean dressings, and following aseptic technique during dressing changes

If grafted donor areas are in the perineal region, keep area clean and dry following bladder and bowel movements

Culture graft donor sites if purulent drainage is noted, and commence topical or IV antibiotic therapy, if indicated, to minimize graft loss

Gently aspirate or roll accumulated hematomas and drainage from centre of sheet graft to slit made in “bleb” using saline-moistened cotton-tipped applicators

Notify physician for management of excessive accumulations or signs of infection

Apply topical treatments and dressings as ordered to grafted areas to prevent infection and enhance graft “take”

When grafted donor sites areas are healed and stable, gently apply water-based moisturizers to prevent dry skin and reduce itchiness

Observe grafts donor sites for signs of hypertrophic scarring and need for pressure therapies i.e. silicone sheeting, pressure garments

Resume therapy program under guidance of physiotherapist and/or occupational therapist to preserve functional status and prevent/reduce contractures

Assess the patient’s level of pain by using a verbal, subjective response. If non-communicative, observe vital signs, facial grimacing, withdrawal or biting down on the endotracheal tube and triggering the ventilator alarm

Administer IV analgesia at a level that keeps the pain tolerable, such as continuous infusions for background pain and bolus doses for treatment-specific pain

Consider a range of IV and po medications, and opioid and non-opioid drugs

Ensure increasing fluids and fibre in diet to prevent constipation due to immobility and use of codeine-containing medications

Document patient ratings of pain intensity and effectiveness of medications

Consult with a pain service for suggestions if usual practices are not optimal

Explore use of non-pharmacologic pain management strategies, such as relaxation, distraction, music therapy, therapeutic touch

Ask patient what he/she has found helpful in the past to manage previous painful experiences

Evaluate patient’s response to pain medications every 4 hours or PRN and notify physician if strategies are ineffective in managing the patient’s suffering

Administer analgesics about 30 minutes before painful treatments, such as dressing changes or exercises

Provide procedural and sensory information prior to and during painful interventions

Elevate burned arms on pillows to reduce swelling and decrease pain

Provide emotional support to patient and ensure he knows you believe he has pain and you will do whatever you can to alleviate the discomfort

Provide age and condition-appropriate diversional activities, such as television, radio, music, reading, videos

Provide knowledge to patient/family regarding pharmacologic and non-pharmacologic strategies and the overall plan of care to manage the pain during the difficult wound healing phase, in particular

Provide adequate opportunities for the patient to rest between dressing changes and therapy sessions. Consider hydrotherapy once a day and any second dressing changes to be performed at the bedside. Consider negotiating for “time outs” during dressing changes to make them more tolerable. Limit debridement to 20 minutes/session.

Discuss rehabilitation plan with physiotherapist and occupational therapist

Assessment

Subjective

Obtain the patient’s perspective on how the burn has impacted upon his body image, self-esteem and ability to return home and/or to work/school. Explore what the patient expects will occur during the next few weeks and months of rehabilitation.

Objective

Assess patient’s feelings about his altered appearance

Determine if the patient has seen his burn wound, particularly if the face in involved

Explore with the patient the importance of his appearance to his self-esteem and self-concept pre-burn

Identify patient’s current support systems

Assess patient’s previous coping strategies

Identify patient’s needs for rehabilitation and whether he/she requires inpatient or outpatient management

Assess patient’s desire/readiness to return home

Assess patient’s desire/readiness to return to work/school

Determine if patient requires vocational education for job retraining

Nursing Diagnosis

Potential disturbance in self-concept related to potential or actual change in body image, and potential or actual change in role responsibilities

Knowledge deficit related to rehabilitation process including home care and long-term rehabilitation program

Expected Outcomes

The patient will grieve over the loss of the pre-burn self in an adaptive and therapeutic manner.

The patient will be able to discuss the meaning of the loss and specific feelings over the altered appearance and interruption in roles and responsibilities.

The patient will develop effective coping strategies to handle the alteration in appearance and lifestyle, and the lengthy rehabilitation process.

The patient will resume activities of daily living and be able to socialize with others in the community aside from family and close friends.

The patient will incorporate his altered appearance into a positive sense of self-esteem.

The patient will acknowledge that his appearance will continue to change for the next year to two years post-burn, and that improvements are slow and somewhat unpredictable.

The patient will display hope and verbalize goals regarding home/school/work, which are realistic.

The patient will be able to identify and utilize available support systems and resources, and be open to suggestions of additional resources as the need arises.

The patient will be able to identify and utilize strategies to handle problems as they might arise with respect to altered self-concept and role responsibilities.

The patient will return to work/school/job retraining when medically fit to do so.

The patient will demonstrate an understanding of post-hos-

pital care and the rehabilitation process as manifested by:

–knowledge regarding wound care performed at home by home care nurses

–knowledge regarding wound care performed by patient/ family

–ability to perform a return demonstration of self-care activities - appropriate care of healed skin, signs and symptoms of wound infection

–knowledge about scar formation and the role of pressure therapies

–knowledge about exercise routines and participation in activities of daily living - ability to apply and care for pressure therapy products

–realistic understanding of the time required for complete rehabilitation post-burn

–understanding the importance of follow-up care in the Burn Clinic

–having the number of the burn centre if questions or problems arise

Implementation

Encourage patient to discuss meaning of loss to him as they pertain to an altered appearance and disruption of roles and responsibilities at home/school/work

Provide patient/family with information on scar maturation process

Reassure patient that the burn wound appearance will continue to improve slowly over the next one to two years

Encourage sharing of patient’s feelings with family to foster understanding and ongoing support

Encourage family to be supportive to patient and assist them with expression of their feelings and concerns

Provide family with concrete examples of how to be helpful and supportive to the patient

Discuss impact of body image and roles/responsibilities changes on patient and on family system

Provide support to patient and family as they adjust to these various changes

Provide patient with a nonjudgemental atmosphere in which to share fears/concerns/grief

Encourage a feeling of hope for a meaningful future for the patient

For patient with a facial burn re-entering society, role play possible communication and socialization techniques to assist with community reintegration

Help patient to identify helpful coping strategies that might be effective in working through adjustments to appearance, roles and responsibilities

Assist patient in setting realistic expectations during rehabilitation process

Reinforce individual nature of grieving and adjustment process and the importance of adopting a hopeful, one-day-at-a-time philosophy

In conjunction with physician, physiotherapist and occupational therapist, identify long-term rehabilitation needs and options for achieving long-term goals

If long-term rehabilitation involves transfer to an inpatient facility, familiarize patient and family with new facility, personnel and services to assist in the transition from the familiar surroundings of the burn centre to a new environment

Communicate with rehabilitation facility about patient’s current status to foster a seamless continuum of care

Set up home care referral if indicated

Explain role of home care personnel prior to discharge

Distribute discharge planning literature to patient and family, if available

Discuss importance of follow-up burn clinic appointments and schedule one following discharge

Provide patient/family with burn centre telephone number if questions arise at home

Consider formal referral to a burn survivors’ support group, if the patient/family are interested

Consider informal introductions of one patient to another during burn clinic and following discharge through the mutual exchange of telephone numbers for mutual support and information-sharing, if appropriate

When/if appropriate, discuss supportive self-esteem enhancement strategies, such as paramedical cosmetic camouflage, communication techniques, wardrobe and colour analysis

Encourage questions and discussion of anxieties regarding discharge

Review care activities/procedures required at home with patient/family

Have patient/family perform a return demonstration of skills required at home

Prepare patient/family for adjustments that will take place upon the return home

Discuss the return home and any problems/concerns that arose when patient/family return to burn clinic

Evaluation

The patient will continue to experience positive self-esteem and be able to incorporate his altered appearance into his self-concept.

The patient will continue to participate in meaningful activities in society related to home, family, friends and work/school.

The patient will verbalize satisfaction with his life post-burn.

The patient will express satisfaction with his recovery during return-to-clinic appointments and begin to discuss future reconstructive surgeries, if applicable.

© Copyright Judy Knighton, Reg.N., M.Sc.N. November 2010

needed, if palpation is ineffective. Signs of impaired circulation include progressive decrease or absence of pulses, progressive paresthesias, pallor and deep tissue pain. Burned arms and hands should be elevated, above the heart, on pillows or wedges to minimize edema. Patients with neck burns should not have pillows in order to prevent contractures. Burned ears must also be protected from external pressure as the blood supply to the cartilage is poor and infection can occur quite quickly. Patients should be positioned appropriately i. e. anti-contracture positioning, and assessed regularly for comfort and warmth. Moist dressings and prolonged dressing changes can

increase the incidence of hypothermia. Care must be taken to continually monitor the patient’s temperature and hypothermia avoided or minimized by increasing the ambient temperature of the room, using overbed heat lamps and covering the patient with a hypothermia blanket. Intravenous fluids can also be warmed using a specially designed infusion device. In concert with the rehabilitation staff, the patient’s range of motion should be assessed at least twice a day. Rehabilitative or orthopedic devices should be inspected for appropriate application and specific instructions written in the patient’s plan of care or posted in the patient’s room for easy visibility and