Nursing Process: Care of the Patient During the Acute Phase

NURSING PROCESS: CARE OF THE PATIENT DURING THE ACUTE PHASE

Assessment

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.

Diagnosis

NURSING DIAGNOSES

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

COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS

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)

Planning and Goals

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.

Nursing Interventions

RESTORING NORMAL FLUID BALANCE

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.

PREVENTING INFECTION

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.

MAINTAINING ADEQUATE NUTRITION

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.

PROMOTING SKIN INTEGRITY

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.

RELIEVING PAIN AND DISCOMFORT

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.

PROMOTING PHYSICAL MOBILITY

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.

STRENGTHENING COPING STRATEGIES

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.

SUPPORTING PATIENT AND FAMILY PROCESSES

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.

MONITORING AND MANAGING POTENTIAL COMPLICATIONS

Heart Failure and Pulmonary Edema

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.

Sepsis

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.

Acute Respiratory Failureand Acute Respiratory Distress Syndrome

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.

Visceral Damage

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.

Evaluation

EXPECTED PATIENT OUTCOMES

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