NURSING PROCESS: CARE OF THE PATIENT DURING THE ACUTE
PHASE
Continued
assessment of the burn patient during the early weeks after the burn injury
focuses on hemodynamic alter-ations, wound healing, pain and psychosocial
responses, and early detection of complications. Assessment of respiratory and
fluid status remains the highest priority for detection of poten-tial
complications.
The
nurse assesses vital signs frequently. Continued assess-ment of peripheral
pulses is essential for the first few postburn days while edema continues to
increase, potentially damaging pe-ripheral nerves and restricting blood flow.
Observation of the electrocardiogram may give clues to cardiac dysrhythmias
result-ing from potassium imbalance, preexisting cardiac disease, or the
effects of electrical injury or burn shock.
Assessment
of residual gastric volumes and pH in the patient with a nasogastric tube is
also important. Blood in the gastric fluid or the stools must also be noted and
reported.
Assessment
of the burn wound requires an experienced eye, hand, and sense of smell.
Important wound assessment features include size, color, odor, eschar, exudate,
abscess formation under the eschar, epithelial buds (small pearl-like clusters
of cells on the wound surface), bleeding, granulation tissue appearance, status
of grafts and donor sites, and quality of surrounding skin. Any significant
changes in the wound are reported to the physician, because they usually
indicate burn wound or systemic sepsis and require immediate intervention.
Other significant and ongoing assessments focus on
pain and psychosocial responses, daily body weights, caloric intake, gen-eral
hydration, and serum electrolyte, hemoglobin, and hemat-ocrit levels.
Assessment for excessive bleeding from blood vessels adjacent to areas of
surgical exploration and débridement is nec-essary as well. The Plan of Nursing
Care provides an outline of nursing activities in the acute phase of burn care.
Based
on the assessment data, priority nursing diagnoses in the acute phase of burn
care may include the following:
·
Excessive fluid volume related
to resumption of capillary in-tegrity and fluid shift from the interstitial to
intravascular compartment
·
Risk for infection related to
loss of skin barrier and impaired immune response
·
Imbalanced nutrition, less
than body requirements, related to hypermetabolism and wound healing needs
·
Impaired skin integrity
related to open burn wounds
·
Acute pain related to exposed
nerves, wound healing, and treatments
·
Impaired physical mobility
related to burn wound edema, pain, and joint contractures
·
Ineffective coping related to
fear and anxiety, grieving, and forced dependence on health care providers
·
Interrupted family processes
related to burn injury
·
Deficient knowledge about the
course of burn treatment
Based
on the assessment data, potential complications that may develop in the acute
phase of burn care may include:
·
Heart failure and pulmonary
edema
·
Sepsis
·
Acute respiratory failure
·
Acute respiratory distress
syndrome
·
Visceral damage (electrical
burns)
The
major goals for the patient may include restoration of nor-mal fluid balance,
absence of infection, attainment of anabolic state and normal weight, improved
skin integrity, reduction of pain and discomfort, optimal physical mobility,
adequate pa-tient and family coping, adequate patient and family knowledge of
burn treatment, and absence of complications. Achieving these goals requires a
collaborative, interdisciplinary approach to patient management.
To
reduce the risk of fluid overload and consequent congestive heart failure, the
nurse closely monitors IV and oral fluid intake, using IV infusion pumps to
minimize the risk of rapid fluid in-fusion. To monitor changes in fluid status,
careful intake and output and daily weights are obtained. Changes in pulmonary
artery, wedge, and central venous pressures, as well as in blood pressure and
pulse rate, are reported to the physician. Low-dose dopamine to increase renal
perfusion and diuretics may be pre-scribed to promote increased urine output.
The nurse’s role is to administer these medications as prescribed and to
monitor the patient’s response.
A
major part of the nurse’s role during the acute phase of burn care is detecting
and preventing infection. The nurse is responsi-ble for providing a clean and
safe environment and for closely scrutinizing the burn wound to detect early
signs of infection. Culture results and white blood cell counts are monitored.
Clean
technique is used for wound care procedures. Aseptic technique is used for any
invasive procedures, such as insertion of IV lines and urinary catheters or
tracheal suctioning. Meticulous hand hygiene before and after each patient
contact is also an es-sential component of preventing infection, even though
gloves are worn to provide care.
The nurse protects the patient from sources of contamination, including other patients, staff members, visitors, and equipment. Invasive lines and tubing must be routinely changed according to recommendations of the Centers for Disease Control and Pre-vention. Tube feeding reservoirs, ventilator circuits, and drainage containers are replaced regularly. Fresh flowers, plants, or fresh fruit baskets are not permitted in the patient’s room because of the risk of microorganism growth. Visitors are screened to avoid exposing the immunocompromised burn patient to pathogens.
Patients
can inadvertently promote migration of microorgan-isms from one burned area to
another by touching their wounds or dressings. Bed linens also can spread
infection through either colonization with wound microorganisms or fecal
contamina-tion. Regularly bathing unburned areas and changing linens can help
prevent infection.
Oral
fluids should be initiated slowly when bowel sounds resume. The patient’s
tolerance is noted. If vomiting and distention do not occur, fluids may be
increased gradually and the patient may advance to a normal diet or to tube
feedings.
The
nurse collaborates with the dietitian or nutrition support team to plan a
protein- and calorie-rich diet that is acceptable to the patient. Family
members may be encouraged to bring nutri-tious and favorite foods to the
hospital. Milkshakes and sand-wiches made with meat, peanut butter, and cheese
may be offered as snacks between meals and late in the evening. Nutritional
sup-plements such as Ensure and Resource may be provided. Caloric intake must
be documented. Vitamin and mineral supplements may be prescribed.
If
caloric goals cannot be met by oral feeding, a feeding tube is inserted and
used for continuous or bolus feedings of specific formulas. The volume of
residual gastric secretions should be checked to ensure absorption. Parenteral
nutrition may also be required but should be used only if gastrointestinal
function is compromised.
Patients
should be weighed each day and their weights graphed. Patients can use this
information to set goals for their own nu-tritional intake and to monitor
weight loss and gain. Ideally, the patient will lose no more than 5% of preburn
weight if aggressive nutritional management is implemented.
The patient with anorexia requires encouragement
and sup-port from the nurse to increase food intake. The patient’s
sur-roundings should be as pleasant as possible at mealtime. Catering to food
preferences and offering high-protein, high-vitamin snacks are ways of
encouraging the patient to increase intake.
Wound care is usually the single most
time-consuming element of burn care after the emergent phase. The physician
will pre-scribe the desired topical antibacterial agents and specific
bio-logic, biosynthetic, or synthetic wound coverings and will plan for
surgical excision and grafting. The nurse needs to make astute assessments of
wound status, to use creative approaches to wound dressing, and to support the
patient during the emotionally dis-tressing and very painful experience of
wound care.
The
nurse serves as the coordinator of the complex aspects of wound care and
dressing changes for the patient. The nurse must be aware of the rationale and
nursing implications for the various wound management approaches. Nursing
functions include as-sessing and recording any changes or progress in wound
healing and keeping all members of the health care team informed of changes in
the wound or treatment. A diagram, updated daily by the nurse responsible for
the patient’s care, helps to inform all those concerned about the latest wound
care procedures in use for the patient.The nurse also assists the patient and
family by providing in-struction, support, and encouragement to take an active
part in dressing changes and wound care when appropriate. Discharge planning
needs for wound care are anticipated early in the course of burn management,
and the strengths of the patient and fam-ily are assessed and used in preparing
for eventual discharge and home care.
Pain measures discussed earlier are continued
during the acute phase of burn recovery. Analgesic agents and anxiolytic
medica-tions are administered as prescribed. Frequent assessment of pain and
discomfort is essential. To increase its effectiveness, analgesic medication is
provided before the pain becomes severe. Nursing interventions such as teaching
the patient relaxation techniques, giving the patient some control over wound
care and analgesia, and providing frequent reassurance are helpful. Guided
imagery may be effective in altering the patient’s perceptions of and
re-sponses to pain. Other pain-relieving approaches include dis-traction
through video programs or video games, hypnosis, biofeedback, and behavioral
modification.
The
nurse works quickly to complete treatments and dressing changes to reduce pain
and discomfort. The patient is encouraged to take analgesic medications before
painful procedures. The patient’s response to the medication and other interventions
is assessed and documented.
Healing
burn wounds are typically described by patients as itchy and tight. Oral
antipruritic agents, a cool environment, frequent lubrication of the skin with
water or a silica-based lotion, exercise and splinting to prevent skin
contracture, and diversional activities all help to promote comfort in this
phase.
An
early priority is to prevent complications resulting from im-mobility. Deep
breathing, turning, and proper repositioning are essential nursing practices
that prevent atelectasis and pneumonia, control edema, and prevent pressure
ulcers and contractures. These interventions are modified to meet the patient’s
needs. Low-air-loss and rotation beds may be useful, and early sitting and
ambulation are encouraged. Whenever the lower extremities are burned, elastic
pressure bandages should be applied before the patient is placed in an upright
position. These bandages promote venous return and minimize swelling.
The burn wound is in a dynamic state for a year or
more after wound closure. During this time, aggressive efforts must be made to
prevent contracture and hypertrophic scarring. Both passive and active
range-of-motion exercises are initiated from the day of admission and are continued
after grafting, within prescribed limitations. Splints or functional devices
may be applied to ex-tremities for contracture control. The nurse monitors the
splinted areas for signs of vascular insufficiency and nerve compression.
In the acute phase of burn care, the patient is facing the reality of the burn trauma and is grieving over obvious losses. Depression, regression, and manipulative behavior are common responses of patients who have burn injuries.
Withdrawal from
participation in required treatments and regression must be viewed with an
under-standing that such behavior helps the patient cope with an enor-mously
stressful event. Much of the patient’s energy goes into maintaining vital physical
functions and wound healing in the early postburn weeks, leaving little
emotional energy for coping in a more effective manner. Nurses can assist
patients to develop effec-tive coping strategies by setting specific
expectations for behavior, promoting truthful communication to build trust,
helping patients practice appropriate strategies, and giving positive
reinforcement when appropriate. Most importantly, the nurse and all members of
the health care team must demonstrate acceptance of the patient.
The patient frequently vents feelings of anger. At
times the anger may be directed inward because of a sense of guilt, perhaps for
causing the fire or even for surviving when loved ones perished. The anger may
reach outward toward those who escaped un-harmed or to those who are now
providing care. One way to help the patient handle these emotions is to enlist
someone to whom the patient can vent feelings without fear of retaliation. A
nurse, social worker, psychiatric liaison nurse, or clergy member who is not
involved in direct care activities may fill this role successfully.
Burn patients are very dependent on health care
team members during the long period of acute illness. However, even when
phys-ically unable to contribute much to self-care, they can be included in
decisions regarding care and encouraged to assert their individ-uality in terms
of preferences and recognition of their unique iden-tities. As patients improve
in mobility and strength, the nurse works with them to set realistic
expectations for self-care, includ-ing self-feeding, assistance with wound care
procedures, exercise, and planning for the future. Many patients respond
positively to the use of contractual agreements and other strategies that
recog-nize their independence and their specific role as part of the health
care team moving toward the goal of self-care.
Family functioning is disrupted with burn injury.
One of the nurse’s responsibilities is to support the patient and family and to
address their spoken and unspoken concerns. Family members need to be
instructed about ways that they can support the patient as adapta-tion to burn
trauma occurs. The family also needs support by the health care team. The burn
injury has tremendous psychological, economic, and practical impact on the
patient and family. Referrals for social services or psychological counseling
should be made as appropriate. This support continues into the rehabilitation
phase.
Burn patients are commonly sent to burn centers far
from home. Because burn injuries are not anticipated, family roles are
disrupted. Therefore, both the patient and the family need thorough
infor-mation about the patient’s burn care and expected course of treat-ment.
Patient and family education begins at the initiation of burn management.
Barriers to learning are assessed and considered in teaching. The preferred
learning styles of both the patient and fam-ily are assessed. This information
is used to tailor teaching activi-ties. The nurse assesses the ability of the
patient and family to grasp and cope with the information. Verbal information
is supple-mented by videos, models, or printed materials if available. Patient
and family education is a priority in the rehabilitation phase.
The
patient is assessed for fluid overload, which may occur as fluid is mobilized
from the interstitial compartment back into the intravascular compartment. If
the cardiac and renal systems cannot compensate for the excess vascular volume,
congestive heart failure and pulmonary edema may result. The patient is
assessed for signs of heart failure, including decreased cardiac output,
olig-uria, jugular vein distention, edema, and the onset of an S3 or
S4 heart sound. Increasing
central venous, pulmonary artery, and wedge pressures indicate increased fluid
volume.
Crackles in the lungs and increased difficulty with
respiration may indicate a fluid buildup in the lungs, which is reported
promptly to the physician. In the meantime, the patient is posi-tioned
comfortably, with the head of the bed raised (if not con-traindicated because
of other treatments or injuries) to promote lung expansion and gas exchange.
Management of this compli-cation includes providing supplemental oxygen,
administering IV diuretic agents, carefully assessing the patient’s response,
and providing vasoactive medications, if indicated.
The signs of early systemic sepsis are subtle and
require a high index of suspicion and very close monitoring of changes in the
patient’s status. Early signs of sepsis may include increased temperature,
in-creased pulse rate, widened pulse pressure, and flushed dry skin in unburned
areas. As with many observations of the burn patient, one needs to look for
patterns or trends in the data.
Wound and blood cultures are performed as
prescribed, and re-sults are reported to the physician immediately. The nurse
also ob-serves for and reports early signs of sepsis and promptly intervenes,
administering prescribed IV fluids and antibiotics to prevent sep-tic shock, a
complication with a high mortality rate. Antibiotics must be given as scheduled
to maintain proper blood concentra-tions. Serum antibiotic levels are monitored
for evidence of maxi-mal effectiveness, and the patient is monitored for toxic
side effects.
The patient’s respiratory status is monitored
closely for increased difficulty breathing, change in respiratory pattern, and
onset of adventitious (abnormal) sounds. Typically at this stage, signs and
symptoms of injury to the respiratory tract become apparent. Respiratory
failure may follow. As described previously, signs of hypoxia (decreased O2 to
the tissues), decreased breath sounds, wheezing, tachypnea, stridor, and sputum
tinged with soot (or in some cases containing sloughed tracheal tissue) are
among the many possible findings. Patients receiving mechanical ventilation
must be assessed for a decrease in tidal volume and lung compli-ance. The key
sign of the onset of ARDS is hypoxemia while re-ceiving 100% oxygen, decreased
lung compliance, and significant shunting. The physician should be notified
immediately of dete-riorating respiratory status.
Medical
management of the patient with acute respiratory fail-ure requires intubation
and mechanical ventilation (if not already in use). If ARDS has developed,
higher oxygen levels, positive end-expiratory pressure, and pressure support
are used with mechanical ventilation to promote gas exchange across the
alveolar–capillary membrane.
The nurse must be alert to signs of necrosis of
visceral organs due to electrical injury. Tissues affected are usually between
the en-trance and exit wounds of the electrical burn. All patients with
electrical burns should undergo electrocardiographic monitoring, with
dysrhythmias being reported to the physician. Careful at-tention must also be
paid to signs or reports of pain related to deep muscle ischemia. To minimize
the severity of complica-tions, visceral ischemia must be detected as early as
possible. The physician can perform fasciotomies to relieve the swelling and ischemia
in the muscles and fascia and to promote oxygenation of the injured tissues.
Because of the deep incisions involved with fasciotomies, the patient must be
monitored carefully for signs of excessive blood loss and hypovolemia.
Expected
patient outcomes may include:
1) Achieves
optimal fluid balance
a) Maintains
intake and output and body weight that correlate with expected pattern
b) Exhibits
vital signs and central venous, pulmonary artery, and pulmonary artery wedge
pressures within designated limits
c) Demonstrates
increased urine output in response to diuretic and vasoactive medications
d) Has
heart rate less than 110 beats/min in normal sinus rhythm
2) Has
no localized or systemic infection
a) Has
wound culture results showing minimal bacteria
b) Has
normal urine and sputum culture results
3) Demonstrates
anabolic nutritional status
a) Gains
weight daily after initial loss secondary to fluid diuresis and no oral intake
of food or fluid
b) Shows
no signs of protein, vitamin, or mineral defi-ciencies
c) Meets
required nutritional needs entirely by oral intake
d) Participates
in selecting diet containing prescribed nutrients
e) Exhibits
normal serum protein levels
4) Demonstrates
improved skin integrity
a) Sustains
generally intact skin that remains free of in-fection, pressure, and injury
b) Demonstrates
remaining open wound areas that are pink, re-epithelializing, and free of
infection
c) Demonstrates
donor graft sites that are clean and healing
d) Has
healed wounds that are soft and smooth
e) Demonstrates
skin that is lubricated and elastic
5) Has
minimal pain
a) Requests
analgesic agents for specific wound care pro-cedures or physical therapy
activities
b) Reports
minimal pain
c) Gives
no physiologic, verbal, or nonverbal cues that pain is moderate or severe
d) Uses
pain control measures such as nitrous oxide, re-laxation, imagery, and
distraction techniques to cope with and alleviate pain and discomfort
e) Can
sleep without being disturbed by pain
f) Reports
skin is comfortable, with no itching or tightness
6) Demonstrates
optimal physical mobility
a) Improves
range of motion of joints daily
b) Demonstrates
preinjury range of motion of all joints
c) Has
no signs of calcification around the joints
d) Participates
in activities of daily living
7) Uses
appropriate coping strategies to deal with postburn problems
a) Verbalizes
reactions to burns, therapeutic procedures, losses
b) Identifies
coping strategies used effectively in previous stressful situations
c) Accepts
dependency on health care providers during acute phase
d) Verbalizes
realistic view of problems resulting from burn injury and plans for future
e) Cooperates
with health care providers in required therapy
f) Participates
in decision making regarding care
g) Resolves
grief over losses resulting from burn injury and circumstances surrounding
injury (eg, death of others, damage to home or other property)
h) States
realistic objectives for plastic surgery, further medical intervention, and
results
i) Verbalizes
realistic abilities and goals
j) Displays
hopeful attitude toward future
8) Relates
appropriately in patient/family processes
a) Patient
and family verbalize feelings regarding change in family interactions
b) Family
emotionally supports the patient during the hospitalization
c) Family
states that own needs are met
9) Patient
and family verbalize understanding of the treat-ment course
a) States
rationale for different aspects of treatment
b) States
realistic time period for recovery
10) Absence
of complications
a) Lungs
clear on auscultation
b) Exhibits
no dyspnea or orthopnea and can breathe easily when standing, sitting, and
lying down
c) Exhibits
no S3 or S4
heart sounds or jugular venous distention
d) Exhibits
urine output; central venous, pulmonary artery, and pulmonary artery wedge
pressures; and cardiac out-put within normal or acceptable limits
e) Exhibits
normal blood, sputum, and urine culture results
f) Maintains
arterial blood gas values within normal or acceptable limits
g) Has
normal lung compliance
h) Has
no visceral organ damage
i) Has
stable cardiac rhythm
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