VII. Nursing Management
Teach about or provide emergency care at the scene of burn, when appropriate.
Eliminate the source of the burn, depending on cause.
• Flame – if clothes are smoldering, wet them using any available water, or smother flames using a blanket, rug or coat.
• Scald – pour liquid over the area and remove clothing
• Chemicals – remove clothing form involved areas, and dilute the chemical by flushing the area with copious amounts of water; if eyes are involved, flush each eye with at least 1 L of lactated Ringer’s or other solution.
• Tar, asphalt, or melted plastic – cool area by flushing with water. Do not attempt to remove material unless the airway is compromised. (solvents may be used after initial assessment to soften product and facilitate removal).
• Electric current – do not touch a person still in contact with an electrical source. If safe, move the person away from the electrical source without touching the source.
Cool the burn for several minutes. Do not use ice.
Remove the restrictive objects.
Cover the wound with sterile dressing or a clean, dry cloth.
Apply the ABCs of trauma: airway, breathing, circulation
Prevent shock by initiating IV fluid therapy immediately
Ensure that the client avoids oral intake and is placed in upright position to prevent aspiration of vomitus, because nausea and vomiting typically occur as a result of paralytic ileus, which results from the stress of the injury.
Transport the client to the nearest emergency medical center. Note the time of the burn (needed for resuscitation)
Assess for and treat smoke-inhalation injury.
• Support pulmonary function through early intubation and volume ventilator-assisted respiration with optimal positive end-expiratory pressure, large tidal volume, and the lowest possible inspired oxygen concentration.
Assess for and treat carbon monoxide inhalation.
• Administer 100% oxygen, as prescribed, until the arterial blood gas determination demonstrates adequate oxygenation and perform frequent neurologic assessment until hypoxia resolves.
Provide pain relief.
• Assess the client’s pain, rule out complication, medicate or intervene as appropriate.
• Institute safety measures (e.g. side rails up , call light within reach) and evaluate the effectiveness of pain medication.
• Premedicate the client prior to any whirlpool or debriding.
Monitor acid-base balance and electrolyte levels. Intervene as necessary to correct imbalances.
Take special precautions for electrical burns.
• Apply a cervical collar, and place the client on a spinal board as soon as possible. (Severe contractions produced by electrical current passing through the body may injure the spinal cord).
• Monitor for cardiac arrest or arrhythmias for at least 24 hour after the injury.
• Assess for and treat myoglobinura resulting from massive soft-tissue destruction accompanying a major electrical injury.
• Administer IV infusion of lactated Ringer’s solution at a rate to maintain urine output (100 ml/hour for adults or 2ml/kg/hour for children) until urine clears.
• Prepare the client for early surgical exploration and wound debridement after cardiovascular stabilization. Debridement is performed every 48 to 72 hours until wound closure is complete.
• Prepare the client for amputation, if indicated. Amputation is necessary in more than 90% of electrical injuries because of the extensive damage caused by the electrical current.
• Discuss potential late complications of electrical injury (e.g. corneal cataracts, ataxic gait abnormalities, associated neurologic problems).
Monitor and treat potential complications, which include acute respiratory failure, distributive shock, acute renal failure, compartment syndrome, paralytic ileus and a Curling ulcer.
Monitor for and treat burn shock, which occurs in all clients with a major burn injury. The sequence begins within minutes of injury and leads to death from hypovolemic shock unless treated appropriately.
Estimate burn size using the Rule of Nines chart of the Lund and Bowder chart.
Provide appropriate fluid resuscitation based on the Parkland formula (4 ml of lactated Ringer’s solution x % of total body surface area burned x kg body weight = total fluid requirement for 24 hours postburn).
• Provide one half of the total administered in the first 8 hours after the burn, one fourth of the total administered in the second 8 hours after the burn, and the last one fourth administered in the third 8 hours after the burn.
Estimate the adequacy of fluid resuscitation, based on urine output of 30ml/hour. Increase or decrease fluid to maintain hourly urine output.
Provide infection prevention measures. Clean and debride the wound, apply topical antimicrobial burns require skin grafting with the client’s own skin (i.e. autograft) because all dermal elements have been destroyed and cannot regenerate.
Promote optimum recovery.
• Ensure optimum nutrition. Total parenteral nutrition (TPN) is often administered.
• Provide meticulous wound management to prevent infection and achieve early wound coverage.
• Initiate physical therapy to regain and maintain optimal range of motion and prevent contractures.
• Provide psychosocial support to promote mental health.
• Carefully monitor the client to detect problems early. Provide appropriate interventions to minimize complications.
• Provide family-centered care to promote integrity of the family until as it meets the demands of the rehabilitating burn client over several years.
• Encourage post discharge follow-up for several years of reconstructive therapy s needed.