Nursing management of the burn-injured person

RReassurance

E Energy and effort

A Assertive

C Courage

H Humour

OOut

U Understanding

TTry again

(James Partridge, 1998)

Fig. 25. REACH OUT Communication Skills

Ongoing care

In addition to the care already discussed, there are a number of areas that require ongoing attention. They include infection prevention and control, rehabilitationmedicine,nutrition,pharmacologyandpsychosocial supports.

Infection prevention and control

Infection prevention and control is a major focus in burn care and multifactorial in nature. Since 70% of patients who die do so from sepsis, the onus lies with all members of the burn team to eliminate potential reservoirs and prevent transfer wherever possible. Broad strategies include suppression of infection transfer, elimination of reservoirs of infection, use of antimicrobials and support of immune mechanisms.

Suppression of infection transfer. In simple terms, all burn patients have organisms on their contaminated burn wounds. Some organisms are located in the gut and can migrate to other areas of the body, such as the lungs. If one considers that everything in a patient’s room becomes contaminated to him/her, then the focus can be on controlling that environment. Activities would include reducing items in that environment to those strictly essential, scrupulously cleaning those items that come in and out of the room, such as unused equipment, x-ray and ECG machines, wearing isolation gowns before entering a patient’s room and scrupulous hand washing technique by all those entering and leaving the room. These techniques can dramatically reduce the po-

“3–2–1 GO” Program

3 things to do when someone stares at you

2 things to say when someone asks what caused your scars/facial difference

1 thing to think if someone turns away from you

(James Partridge in Blakeney, 2008)

tential for spread of infection from one patient to another by a variety of vectors, the most frequent source being hands of caregivers. Common patient-care areas, such as hydrotherapy, dressing and operating rooms, need to be scrupulously cleaned after each patient use and swabbed every few months for the presence of organisms. Those patients, who have been identified as carriers of resistant or “difficult- to-treat” organisms, should be placed in strict isolation and not taken to the common areas. Particular concern centres around hydrotherapy rooms and the risk that water-borne resistant organisms could reside in the hose system or water supply.

Elimination of reservoirs of infection. Such practices include frequent dressing changes and surgical excision of eschar to reduce the bacterial load at the wound site. This also decreases the opportunity for invasive burn wound infections and systemic sepsis to develop. Another important practice is the physical handling and removal of soiled dressings and linen, and rapid, effective cleanup of body substance spills, such as urine and blood.

Use of antimicrobials. Most burn wounds are covered with a broad-spectrum antimicrobial in either a cream format (silver sulphadiazene or mafenide acetate) soaks (sodium hypochlorite – Dakin’s; mafenide acetate, acetic acid) or silver-impregnated dressings (Acticoat /Acticoat Flex/Aquacel Ag).

The bacterial load is, therefore, controlled until such time as the eschar is physically debrided through dressing changes or through surgical excision. As the bacterial load is reduced, the patient’s clinical condition is more likely to improve.

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Support of immune mechanisms. Burn patients are immunosuppressed until such time as their burn wounds have completely healed and sometimes longer. The immune system can be enhanced by maintaining the integrity of unburned skin, proper nutrition, including antioxidants, and administration of fresh frozen plasma albumin.

Rehabilitation medicine

Although the formal rehabilitative phase of burn care begins when the wounds have closed, rehabilitation begins shortly after the patient is admitted to hospital. The physiotherapist and occupational therapist are key members of the burn team and work hard to engage the patient’s participation in a long-term plan of care. The focus of this plan is aimed at regaining and maintaining function and independence. Interventions include edema management, positioning, splinting, passive/active-assisted/active range- of-motion (ROM) exercises, and ambulation. Attention is also directed towards functional activities, including activities of daily living (ADL’s), stretching, strengthening and endurance exercises, work hardening and conditioning activities, and burn scar management. Particular areas of the body pose greater rehabilitation challenges and require care in specialized burn treatment facilities. They include the face, neck, axillae, feet, hands and burns across joints.

Physical therapy: The main goals are to: a) regain and maintain normal range of motion to all the joints. Range can be achieved through passive, active or active-assisted means; b) prevent/reduce contractures. Wounds heal by the process of contraction and vigourous efforts must be made to position and/or splint patients into positions of function as opposed to comfort (anti-function). Joints and limbs must be moved and stretched numerous times a day to overcome the powerful forces attempting to reduce full range; c) increase muscle strength. Patients need to continue to use muscles unaffected by the burn to avoid muscle wasting. In addition, a program to learn to reuse and regain strength and endurance of those muscles affected by the burn needs to be set up for each patient; and finally, d) restore/maintain cardiorespiratory function. Chest physiotherapy, suctioning, deep breathing and coughing, and early ambulation are essential to the plan of care. Physiotherapy

can take place in the patient’s room, during hydrotherapy, in the operating room while the patient is under anaesthesia, and in a burn centre rehabilitation room. The patient then receives the benefits of a varied and intensive program. Progress can be evaluated and activities altered to meet the patient’s changing needs.

Occupational therapy: The primary goals of occupational therapy are to assist the patient in returning to as functional an ability level as possible, to maximize his/her independence and to assist with burn scar management. In order to enhance personal motivation and to encourage active participation, the occupational therapist helps the patient to record and celebrate progress through wall charts and personal diaries. Encouraging participation in activities that are meaningful to the patient and journaling as a means of personal reflection are two strategies to engage a patient in long-term and often painful therapy. Early active involvement in activities of daily living is very important both from a physical and psychological perspective. Making a conscious effort to maximize independence is one of the major keys to successful rehabilitation. Use of adaptive devices, such as padded handles for cutlery and button hooks, should be restricted to such time as the patient can perform the activities unassisted.

The occupational therapist also fabricates cus- tom-fitted splints to maintain appropriate positioning for burned hands, feet, neck and axillae. These splints are essential during the early post-burn period (for antideformity/anticontracture positioning), immediately post-op (to preserve function) and during rehabilitation/post-burn reconstructive surgery periods (to maintain or increase elongation of scar tissue). Splints need to be reassessed and remolded frequently as the patient’s edema increases or decreases, the contours of the wound change or range of motion improves. A very important part of the occupational therapist’s role is the application of pressure devices to flatten burn scars. Conventional goals for the treatment of burn scars include minimizing hypertrophy, increasing pliability, preventing or minimizing contracture, maximizing the formation of scar to normal anatomic contours, and optimizing cosmetic outcomes. Application of pressure during the early to mid-phases of wound healing is useful in treating edema. Products include elastic bandages,

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self-adherent wraps, such as Coban (and tubular, cotton elasticized bandages like Tubigrip ). Later, when the skin is less fragile, patients are measured for custom-fitted pressure garments to be worn 23½ hours a day for anywhere from 1–1½ years. It is essential to provide patients with much support and encouragement during this difficult period of adapting to these garments. It is exceptionally difficult for patients to adjust to facial masks, whether they be fabric or rigid, transparent plastic in nature. In order to provide extra support to contoured areas on the central face, in finger/toe web spaces, on the palm of the hand or interscapular area, inserts made from a variety of foam, rubberized materials or thermoplastic splinting materials can be used. Silicone gel sheets have recently been used to treat smaller areas of the body where adequate pressure cannot be achieved, such as the face, arm or hand.

Other physical agents commonly used as part of occupational therapy include hydrotherapy, paraffin, ultrasound, electrical stimulation and continuous passive motion machines.

Nutrition

During the early hypovolemic shock phase, there is decreased perfusion to the gastrointestinal system, resulting in temporary paralytic ileus. Patients are generally kept NPO until their bowel sounds return. In recent years, there has been some movement towards feeding patients enterally soon after admission in order to preserve gut function and prevent stress ulcers. A nasogastric tube is inserted and connected to low intermittent suction to decompress the area. Intravenous fluid replacement is begun and the patient assessed for nutritional/metabolic needs by the burn centre dietitian. When bowel sounds return in about 48–72 hours post-burn, the patient can be fed using the most appropriate route, based on stage of recovery and size of burn. Nutrition plays an important role in burn recovery. Patients require a diet high in calories and protein to counteract the hypermetabolic response noted post-burn and to support the growth of healthy tissue. A burn patient’s metabolic rate increases in proportion to the size of the injury. Burns are considered the most extreme example of hypermetabolic stress. Inadequate nutrition can negatively impact upon an individual’s im-

mune response, wound healing, metabolic function and survival. Metabolic expenditures can be calculated using a metabolic cart. Most caloric requirements now are based on a formula of 1.4 × basal energy expenditure (BEE).

After the burn injury occurs, catecholamines are released and there is an increase in the patient’s metabolic rate. In fact, there is a direct relationship between the size of the burn, the increase in metabolic rate and urinary catecholamine excretion. The metabolic rate returns to normal, but it may be several years after the burn wounds have completely healed. In addition to hypermetabolism, the patient experiences a state of hypercatabolism in which lean body mass is broken down to provide amino acids for gluconeogenesis. Nitrogen loss through urine and wounds is a concern, as are the heightened requirements for protein necessary for anabolism, wound repair and improved immune response. Burn patients require fat in the form of lipids, vitamins and trace minerals.

In order to determine each patient’s caloric needs, the dietitian assesses his/her energy requirements using indirect calorimetry. A decision in then made as to what product should be given at what rate and by which route of enteral access. For burns less than 20%, many patients are well enough to consume sufficient calories and protein by mouth in the form of diet trays and oral supplements. If the oral intake doesn’t meet metabolic demands, supplementation is required. The enteral route is preferred in order to maintain the functional integrity of the gut. If patients don’t receive food early enough in their post-burn recovery period, it can result in intolerance to later feeding, diarrhea, greater likelihood bacteria will translocate from the gut to another part of the body, and increased risk of infectious complications. Patients can be fed enterally by both noninvasive and invasive procedures. The least complex method is nasogastric feeding, which can be administered continuously or by bolus feeds. Critically ill patients may have a gastric ileus and can’t be fed by the gastric route. A small-bore, feeding tube, with a weighted end to facilitate passage, can then be passed beyond the pylorus into the small intestine. This approach is also safer for patients with altered levels of consciousness, artificial airways, ineffective cough reflexes and altered swallowing ability.

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Duodenal feeding tubes can be placed, endoscopically or via fluoroscopy, if the specialized equipment and staff are available. This allows for quicker absorption of nutrients and a decrease in the nausea and vomiting that may occur with large volume tube feedings into the stomach. If long-term placement is required, percutaneous endoscopic gastrostomy (PEG) or percutaneous endoscopic jejunostomy (PEJ) tubes are available. The position of any feeding tube must be checked at frequent intervals and attempts made to secure it safely into position. The measurement of gastric residuals to monitor gastric motility and the addition of blue dye to enteral feeds to monitor gastric and pulmonary secretions for these feeds are two safety precautions that should be followed. Some disadvantages associated with these tubes include displacement and blockage. The feeds may also give patients diarrhea, although that may have more to do with medications, particularly antibiotics. Less common nutri- tion-related complications include abdominal distention and delayed gastric emptying, both of which can be assessed by a general surgery or internal medicine consultant. Patients also require monitoring for hyperglycemia and electrolyte imbalances associated with enteral feeding. As the patient’s wounds heal, the metabolic demands are decreased and a reassessment is performed at least weekly by the dietitian to determine the optimal nutritional plan of care. Tube feedings are generally reduced, then tapered, as oral intake increases. Adaptive devices to feeding utensils, such as padded handles, can assist patients with burned hands to feed themselves. Families are also encouraged to bring in favourite foods from home to stimulate their loved one’s appetite. Before discharge, the burn patient is advised on dietary requirements at home by the dietitian to avoid unnecessary weight gain once the burn injury has completely healed.

Pharmacology

Throughout burn recovery, patients require a number of medications. Some are admitted with a past medical history that includes drugs for pre-existing conditions. A number of patients have a drug and/or alcohol abuse history. The role of the pharmacist in burn care is an important one in order to ensure pa-

tients receive the most appropriate medications in the correct amounts for the most appropriate period of time.

When burn patients are first admitted, they are assessed for tetanus toxoid, because of the risk of anaerobic burn wound contamination. Tetanus immunoglobulin is given to those patients who have not been actively immunized within the previous 10 years. They are also given pain medication, which should always be administered intravenously during the hypovolemic shock phase as gastrointestinal function is impaired and intramuscular (IM) medications would not be absorbed adequately. There is a risk that the IM medications would pool in the edematous tissue and the patient would be overdosed when fluid mobilization begins. The medication of choice for moderate to severe pain management is an opioid, such as morphine or hydromorphone, as they are generally quite effective for most patients, can be given intravenously and orally, and are available in fast-acting and slow-release forms. There are a number of other analgesics that have been identified as very effective with the burn patient population (Table 8). It is essential that burn patients’ pain be acknowledged and treated from the time of admission until that point in their rehabilitation when the physical discomforts have lessened to the extent they don’t require medication. A combination of analgesics for background pain (resting) and acute episodes (dressing changes, therapy) is most effective and gives team members flexibility to use the medication that is best for a variety of painful situations. As the burn wounds close and the patient’s pain level decreases, reductions in analgesic therapy should occur by careful taper, rather than abrupt discontinuation, of opioids. If tapering does not occur, acute opioid withdrawal syndrome can occur. Burn patients, understandably, may be highly anxious and agitated. Sedative agents, along with analgesics, are necessary and can be very effective (Table 14). Non-pharmacologic approaches to pain management (hypnosis, relaxation, imagery) can serve as useful adjuncts to opioid-based approaches.

Topical antimicrobial therapy is an important part of burn wound care (Table 7). Most centres have one agent of choice and add others if a resistance pattern emerges. The most widely used, broad-spec-

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Table 14. Anxiolytics commonly used in burn care

Generalized Anxiety	Situational Anxiety (dressing changes,	Delirium
	major procedures)
Lorazepam (Ativan®) I.V	Midazolam (Versed®) I.V.	Haloperidol (Haldol®) I.V.
works nicely in combination with	works nicely in combination with	works nicely for patients who appear
analgesics for routine dressing changes	analgesics when very painful and	agitated or disoriented
and care	prolonged procedures are performed

trum antimicrobial agent is silver sulphadiazene. Its role is to reduce the bacterial load on the burn wound until the eschar can be removed. Local application on the burn wound is necessary, as systemic antibiotics would not be able to reach the avascular burn wound. Mafenide acetate is indicated for burned ears and noses as it has a greater ability to penetrate through cartilage. It is, however, more painful upon application than silver sulphadiazene and its use to restricted to small areas of the body. Systemic antibiotics are indicated when a burn wound infection has been clinically diagnosed or other indicators of sepsis are present, such as pneumonia or uncontrolled fever.

Additional medications are generally prescribed to manage gastrointestinal complications, treat antiobiotic-induced superinfections and boost the patient’s metabolic and nutritional status (Table 15). Because they receive pain medications that are constipating, patients should be placed on a bowel routine upon admission. Attention must also be paid to reviewing and ordering those medications the patient was on before the burn injury, and possibly arranging follow-up with a family physician upon discharge.

Table 15. Medications commonly used in burn care

Psychosocial supports

Psychosocial support to burn survivors and their family members is an essential part of their ongoing care. Concern for family provides them with necessary comfort so they, in turn, can be the patient’s single most important social support. Family frequently keep vigil by their loved one’s bedside throughout a potentially lengthy recovery period and become primary caregivers once the patient returns home. The social worker in a burn centre can provide ongoing counselling and emotional support to patients and family members. Assistance in coping with difficult or stressful matters, such as financial concerns, finding accommodation, questions about hospital insurance coverage or ongoing problems at work or home, is also available. Chaplains offer spiritual support during times of crisis and at various points along the road to recovery. For some, the burn injury is a tremendous test of spiritual faith and brings forward troubling questions for which there are no easy answers, such as “Why did this happen to me? to my husband? to my daughter?” Coming to terms with this traumatic event does much to free up a patient’s energies to move forward

Types and Names	Rationale
Gastrointestinal Care
Ranitidine (Zantac )	Decreases incidence of stress (Curling’s) ulcers
Nystatin (Mycostatin )	Prevents overgrowth of Candida albicans in oral mucosa
Milk of Magnesia, Lactulose, Docusate sodium,	Prevents/corrects opioid-induced constipation
Sennosides, Glycerin or Bisacodyl suppository
Nutritional Care
Vitamins A,C,E and multivitamins	Promotes wound healing, immune function,
Minerals: selenium, zinc sulfate, iron (ferrous	hemoglobin formation and cellular integrity
gluconate and sulfate), folic acid, thiamine

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