procedure burn wound care - elsevier

1125

Unit VII Integumentary System

Section Twenty Burn Wound Management

PROCEDURE

126

Burn Wound Care Cameron Bell

PURPOSE: Burn wound care is performed to promote healing, maintain function, and prevent infection and burn wound sepsis. A major focus during burn wound care also incorporates strategies to effectively manage pain.

PREREQUISITE NURSING KNOWLEDGE • Burns destroy the structural integrity of the skin, disrupt-

ing its normal functions of regulating temperature, main-taining fl uid status, protecting against infection, covering nerve endings, and establishing identity. 11 The skin is composed of two layers, the epidermis and the dermis, and is supported by a subcutaneous layer that is rich in blood vessels ( Fig. 126-1 ). ❖ The epidermis is the outermost layer. It is capable of

rapid regeneration through division of cells closest to the dermis; older epidermal cells are pushed outward as the epidermis is regenerated. The epidermis pro-vides a barrier to the environment, containing melano-cytes (protection from the sun) and Langerhans cells (protection against foreign organisms).

❖ The dermis contains blood vessels, sensory fi bers (for pain, touch, pressure, and temperature), collagen, seba-ceous glands, and sweat glands. Epidermal cells line deep dermal structures (hair follicles and sweat glands); these epidermal elements provide the ability for the skin to regenerate (the more epidermal cells remaining in the wound bed, the faster the healing).

• The depth of burns has historically been classifi ed as fi rst degree (into epidermis), second degree (into dermis), or third degree (through skin into subcutaneous tissue; Table 126-1 ). 1,11

• First-degree, or superfi cial, burns extend only partially through the epidermis, thereby maintaining the barrier function of the skin. Burns involving only the epidermis are very painful, but do not form blisters. The epidermis is usually regenerated in 3 to 4 days. 11 These burns are not included when estimating the percentage of total body surface area burned (%TBSA) because they do not result in an open wound.

• Second-degree burns extend into the dermis and can be superfi cial (loss of the epidermis and part of the dermis) or deep (destruction of most of the dermis). They are also

referred to as partial-thickness burns because they extend partially through the skin ( Fig. 126-2 ). These wounds heal by epithelialization from epidermal cells remaining in the dermis. Shallow wounds are associated with rapid healing and less scarring. Deep wounds may result in slow healing (more than 21 days) and are fragile wounds prone to hypertrophic scarring. For that reason, surgical excision of partial-thickness wounds that affect functional and cosmetic areas and application of skin grafts may be preferable.

• A third-degree, or full-thickness, burn involves complete destruction of the dermis and extends into the subcutane-ous tissue. Because the skin is unable to regenerate, the dead tissue is removed and the wound is grafted with skin from another part of the patient ’ s own body (autograft). 11 The grafted wound loses epidermal appendages and is unable to sweat, maintain lubrication, or protect from sun exposure after healing ( Fig. 126-3 ).

• The depth of a burn wound is directly related to the tem-perature intensity and the duration of contact with the burning agent. The burning agent can be thermal (i.e., fl ame, contact, or scald), chemical, or electrical. An inha-lation injury should always be suspected if the patient was in an enclosed space with a fi re; mortality rate is signifi -cantly increased when burns are compounded by smoke inhalation. 6

• The burn injury produces three zones of injury: the zone of coagulation (cellular death), the zone of stasis (vascular impairment, potentially reversible tissue injury), and the zone of hyperemia (increased blood fl ow and infl amma-tory response). Decreased perfusion of the burn wound can cause the zone of stasis to deteriorate, deepening the initial wound. This progressive destruction can be mini-mized by providing adequate oxygenation and fl uid resus-citation, alleviating pressure on the injured tissue, maintaining local and systemic warmth, and decreasing edema by elevating the burned area. 1

• Assess for areas where full-thickness eschar is circumfer-ential. Because of the inelastic nature of eschar, it may act

1126 Unit VII Integumentary System

Figure 126-1 Depth of burn wound injury. (From Townsend CM, et al, editors: Sabiston textbook of surgery , ed 19. Philadelphia, 2012, Saunders.)

First degree

Superficialsecond degree

Deepsecond degree

Third degree

Fourth degree

Epidermis

Dermis

Muscle

Subcutaneous fat

Figure 126-2 Blisters of a partial-thickness burn wound on the arm.

Figure 126-3 A fresh burn that is a partial-thickness burn toward the patient ’ s left side and progresses to a full-thickness burn on the patient ’ s right side.

Type Physical Characteristics Healing

Superfi cial burn (fi rst degree): destruction of epidermis, usually caused by overexposure to sun or brief exposure to hot liquid. This type of injury is not included in calculations of burn size.

Red; hypersensitive; no blisters. Injured layers peel away from totally healed skin at 5–7 days without residual scarring.

Superfi cial partial-thickness burn (superfi cial second degree): destruction of epidermis and upper dermis. Usually results from scalding or brief contact with hot objects.

Blistered; very moist; red or pink in color; exquisitely painful; capillary refi ll intact.

Reepithelializes from epidermal appendages in 7–14 days. Usually has minimal scarring but variable repigmentation.

Deep partial-thickness burn (deep second degree): destruction of epidermis through to lower dermis. May result from grease or longer contact with hot objects.

Mottled pink to white; drier than superfi cial burns; less sensitive to pinprick; does not blanch to pressure; hair follicles and sweat glands intact.

Slower regeneration from epidermal elements: 14–21 + days in absence of grafting. Prone to hypertrophic scars and contracture formation. May require grafting to reduce healing time and complications.

Full-thickness burn (third degree): destruction of epidermis and all of the dermis. Results from exposure to fl ames, chemicals that are not immediately washed, electrical injury, or prolonged contact with heat source.

Dry; leathery and fi rm to touch; pearly white, brown, or charred in appearance; no blanching to pressure; no pain; may see thrombosed vessels.

Incapable of self-regeneration. Preferred treatment is early excision and autografting.

TABLE 126-1 Depth Characteristics of Burn Wounds

like a tourniquet as edema develops, requiring surgical release (escharotomy) to prevent circulatory or respiratory compromise ( Fig. 126-4 ).

• Monitor pulses, capillary refi ll, and sensation distal to circumferential eschar. Signs and symptoms that indicate a need for escharotomy include cyanosis of distal unburned skin, unrelenting deep tissue pain, progressive paresthe-sias, and progressive decrease or absence of pulse. 1

• Circumferential eschar of the trunk can lead to decreased tidal volume and agitation ( Fig. 126-5 ) 1 ; therefore, ade-quacy of respiratory excursion must be assessed.

126 Burn Wound Care 1127

Figure 126-4 Escharotomy of the leg to improve circulation.

Figure 126-5 Full-thickness burn with chest escharotomy to improve chest expansion.

Figure 126-6 The Lund and Browder chart is used to assess and graphically document size and depth of the burn wound.

• Escharotomy is performed at the bedside by a physician, with a scalpel or electrocautery used to cut the eschar longitudinally. Bleeding should be minimal because only dead tissue is cut; any bleeding can be controlled with sutures, silver nitrate sticks, collagen packing, or electro-cautery. 1 Pain is usually managed with small intravenous doses of opiates and benzodiazepines.

• Burn size may be determined with several methods. 19 ❖ The rule of nines may be used to quickly calculate burn

size. In an adult, the head and neck and each upper extremity represent 9% of the patient ’ s body surface area. The anterior trunk, posterior trunk, and each leg represent 18% of the patient ’ s body surface area. This rule only applies to adults; infants and young children have much larger heads in proportion to body size. 1

❖ The Lund and Browder chart ( Fig. 126-6 ) breaks the body into smaller areas and takes into consideration the proportional differences of persons of different ages. 14

❖ The rule of the palm notes that the patient ’ s hand may be used as a template to represent roughly 1% of the TBSA. 1

• The infl ammatory response causes a massive fl uid shift to the interstitial space during the fi rst 24 hours, with mobi-lization of fl uid starting after 72 hours. Fluid resuscitation with a balanced salt solution is based on the patient ’ s weight and burn size (partial-thickness and full-thickness

wounds) . 10 Large wounds are prone to huge evaporative water losses that require close monitoring of volume status. 1,11

• Effective resuscitation results in adequate urinary output (0.5 mL/kg/hr) as a surrogate marker of end-organ perfusion. 1

• Burns of specifi c anatomical areas need special consider-ation. Assess eyes for injury and treat chemical exposure with copious normal saline solution irrigation; treat burned ears with a topical antimicrobial cream and protect from pressure by eliminating use of pillows or dressings about the head; elevate burned extremities; consider the need for an indwelling urinary catheter in the patient with perineal burns; and clip hair growing through the burn wounds.


colored urine, assessing for associated trauma, and establishing baseline neurological status are vital in the treatment of the electrical injury patient. 1,19

• Inhalation of smoke may cause localized airway infl am-mation and edema that can lead to airway obstruction. History, signs and symptoms that increase suspicion for inhalational injury include, but are not limited to, fi re in a closed compartment, prolonged entrapment, singed nares, cough, carbonaceous sputum, stridor and hoarse-ness. Naso-endoscopy on admission when these are present assists in the assessment for airway edema and mucosal injury. Signifi cant fi ndings may necessitate endotracheal intubation as a precautionary measure. Inhalational injury/burns are not included in the calculation for estimating the percentage of total body surface area burned. 21

• Criteria for transferring patients to a specialized burn-care facility have been adopted by the American Burn Associa-tion and the American College of Surgeons. These criteria are listed in Box 126-1 and are available at the American Burn Association website at www.ameriburn.org .

• Care of the burn wound and associated healing are deter-mined by the extent and depth of the injury and the overall condition of the patient.

• Most burn centers use clean technique for dressing removal and wound cleansing, with sterile technique for sterile dressing application only. 5

• Wound care should be done in a warm area. Many burn units have replaced traditional hydrotherapy tanks with shower tables for large wound care procedures to allow water runoff, thus decreasing leaching of electrolytes and minimizing wound exposure to perineal-contaminated water. Emergency equipment must always be immedi-ately available during hydrotherapy procedures. As

Two burned surfaces that contact each other need dress-ings between them to prevent fusing as they heal (e.g., between toes, skin folds).

• Emergency treatment of thermal injuries includes initially cooling the burned skin with tepid water (never with ice) and recognizing the importance of preventing hypother-mia. 1 In preparation for transfer, the airway should be assessed and 100% oxygen administered; large-bore intra-venous (IV) access should be established and fl uid resus-citation started; patients should be on nothing by mouth status; wounds should be wrapped with a clean, dry sheet and a warm blanket; pain medication should be given in small IV doses, with recognition that coexisting injuries or medical conditions exacerbate the effects of opiates; tetanus prophylaxis should be administered; and all initial treatment should be documented. 1,4,8

• Initial treatment of chemical burns includes removing saturated clothing, brushing off any powdered chemical, and continuously irrigating involved skin with copious amounts of water for 20 to 30 minutes. Neutralizing chemical burns with another chemical is contraindicated because the procedure generates heat. Burned eyes must be irrigated with large volumes of normal saline solution followed by an eye examination. 1 Some chemicals are absorbed systemically through burn wounds; contact the local poison control center to determine whether further treatment is indicated. 11 Ensure all physicians, advanced practice nurses, and other healthcare professionals wear appropriate personal protective equipment to prevent unintentional chemical exposure.

• Initial treatment of tar burn consists of cooling the tar with cold water until the product is completely cooled. ❖ After cooling, adherent tar should be covered with a

petrolatum-based ointment (such as white petrolatum jelly) and dressed to promote emulsifi cation of the tar. 1 Electrical injuries ( Fig. 126-7 ) result when the body becomes part of the pathway for the electrical current. Deep burns may occur from tissue resistance where the patient contacted the electrical source and where the patient was grounded. Initially of greater concern than the burns is the high incidence of cardiac dys-rhythmias, myoglobinuria resulting in acute tubular necrosis, and neurological sequelae. Monitoring elec-trocardiographic (ECG) results, increasing urine output to 1 to 1.5 mL/kg/hr in the presence of dark port-

Figure 126-7 Entry site of an electrical burn.

From Committee on Trauma, American College of Surgeons: Guidelines for the operation of burn centers resources for optimal care of the injured patient . Chicago, 2006, American College of Surgeons, pp. 79–86.

BOX 126-1 Criteria for Patient Transfer to a Specialized Burn-Care Facility

• Partial-thickness burns on more than 10% total body surface area

• Burns that involve the face, hands, feet, genitalia, perineum, or major joints

• Third-degree burns in any age group • Electrical burns, including lightning injury • Chemical burns • Inhalation injury • Burn injury in patients with preexisting medical disorders that

could complicate management, prolong recovery, or affect mortality

• Any patient with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk for morbidity or mortality

• Burned children in hospitals without qualifi ed personnel or equipment to care for children

• Burn injury in patients who will need special social, emotional, or long-term rehabilitative intervention


• An autograft (skin graft taken from the patient) is the only treatment that can heal a full-thickness burn wound. 11 A debrided full-thickness wound may be protected from infection and drying through the use of biologic or bio-synthetic dressings when donor sites are not available for autografting. Allograft, or homograft, refers to the use of “nonself” human skin grafts; such a graft becomes vascu-larized by the patient and risks rejection if it stays in place too long. A xenograft, or heterograft, is nonhuman skin obtained from commercial pigskin (porcine)–processing companies; it forms a collagen bond with the wound and protects it for a period of time until donor sites are avail-able for autografting. Porcine xenografts may be placed over clean partial-thickness wounds to protect the wound while it heals beneath the xenograft. 11,12

• Negative-pressure wound therapy may be used to main-tain fresh-graft placement, improve wound bed vascular-ization, and reduce microbial activity. 19

• The burn patient ’ s condition is hypermetabolic until burn wounds are closed and healing is complete, and up to 12 months after the injury. 20,24 Increased caloric and protein

wounds decrease in size and patients approach discharge, bathtubs and showers offer reasonable options for wound cleansing.

• Initial wound cleansing requires thorough débridement of all devitalized tissue. Blisters are generally unroofed. 5,17 Use of a moistened washcloth is effective to gently remove burned tissue, with use of a slow and deliberate wiping motion. Wash the wounds with gentle pH-neutral liquid soap solution or wound cleanser and pat dry with clean towels.

• Topical antimicrobial agents limit bacterial proliferation and fungal colonization in burn wounds. There are numer-ous dressings used to limit bacterial burden in the wound, including antimicrobial ointments and creams and silver-based long-wear dressings. 23 Systemic antibiotics are not routinely administered to burn patients because of the high risk for development of antibiotic resistance 3 ( Table 126-2 ).

• The wound should be assessed daily for cellulitis and the wound care plan tailored to the needs of the patient. Moist healing may speed the time of burn wound healing.

Agent Activity Advantages Disadvantages

Silver sulfadiazine 1% cream (Silvadine).

Bactericidal effect on cell membrane and wall; excellent against Pseudomonas aeruginosa, Staphylococcus aureus, other burn fl ora, and yeast

Broad-spectrum antimicrobial coverage; low toxicity; no discomfort on application; easy to remove; rare hypersensitivity to sulfa component; may increase neovascularization

Poor eschar penetration; infrequent hypersensitivity; macerates surrounding tissues; contraindicated in pregnant women and newborns (risk for kernicterus); early transient neutropenia when applied to large burns

Mafenide acetate 10% cream (Sulfamylon)

Broad-spectrum against gram-positive and gram-negative organisms; not effective against yeast; diffuses through devascularized areas; is absorbed, metabolized, and excreted by kidneys

Highly soluble and penetrates eschar well; persistent activity against Pseudomonas

Pain on application of cream; systemically absorbed; may cause metabolic acidosis (through carbonic anhydrase inhibition); cutaneous hypersensitivity reactions occur; may see yeast overgrowth

Mafenide acetate (Sulfamylon) 5% solution

Broad-spectrum against gram-positive and gram-negative organisms; not effective against yeast

Moist dressings may be used over wounds, such as a new graft, when a liquid soak antibiotic is desired

Expensive; the wet dressings are often uncomfortable and may result in hypothermia

Silver nitrate, 0.5% in water (if dressing is allowed to dry, concentration of silver nitrate increases and becomes caustic at 2%)

Bacteriostatic against many organisms; does not penetrate drainage or debris

Painless application; few organisms are resistant to silver

Must be kept wet; poor penetration of eschar; stains unburned tissue and environment brown-black; hypotonicity of dressing may lead to hyponatremia and hypochloremia; requires thick dressings and resoaking every 4 hours to prevent drying

Silver nylon (a nonadherent nanocrystalline silver-coated dressing with sustained silver release for several days)

Lower minimal inhibitory concentration; a lower minimal bactericidal concentration; faster bacterial killing than other topicals

Decreases dressing changes by being left in place 3 days

Decreases ability to visualize wound

TABLE 126-2 Topical Antimicrobial Agents


• Sterile dressings as needed (e.g., gauze, Exu-dry [Smith & Nephew, St. Petersburgh, FL])

• Rolled dressing, gentle tape, or netting to secure dressings

• Pillows to elevate extremities • Pain and sedation medication (as prescribed) Additional equipment, to have available as needed, includes the following: • Emergent intubation and advance airway equipment • Nasolaryngoscope

PATIENT AND FAMILY EDUCATION

• Provide detailed wound care instructions electronically or in writing. Demonstrate wound care, and have patient and family return the demonstration before the planned dis-charge. Continue to involve patient and family in wound care for the remainder of the admission, and encourage them to ask questions. Provide positive feedback. Arrange for home care or clinic visits to follow up on wound care. Rationale: Education validates patient and family under-standing and ability to perform wound care, and allows time for them to develop a level of comfort. The oppor-tunity to reinforce important points is provided.

• Explore resources the patient will have for wound care at home (e.g., availability of running water, shower versus tub). Rationale: This measure ensures that the patient is knowledgeable about care based on what adjustments need to be made at home.

• Simplify wound care and assess the family ’ s ability to provide care at home. Rationale: Continued care of the wound may be necessary after discharge.

• Teach patient and family about signs and symptoms of infection and the importance of reporting these in a timely manner. Rationale: The patient and family can recognize problems early so that appropriate measures can be insti-tuted by the physician, advanced practice nurse, and other healthcare professionals.

• Teach patient and family about pain control; assess the patient ’ s personal acceptable level of pain. Rationale: Education and assessment decrease concerns about pain, facilitate an individualized pain-relief plan, and foster cooperation with care.

• Teach patient and family about pain management, including types of medications prescribed, timing of med-ications in relation to wound care, and nonpharmacologi-cal pain strategies. 5 Rationale: Comfort at home is supported.

• Provide instruction to the patient and family about the normal changes seen in the wound, including epithelial islands, healing margins, dryness on epithelialization, epidermal fragility on shearing, hypervascularization of the healed wound, and venous congestion in the depen-dent wound. Rationale: Anxiety about appearance is reduced.

• Teach the patient and family about care of healed burns, including medications to reduce itching, 3,14 use of nonper-fumed moisturizers, protection from shear, and protection from sun exposure for a minimum of a year. Rationale:

requirements for wound healing are usually met through nasogastric or nasojejunal tube feeding to maintain mucosal integrity in large burns. Dietician consultation is imperative and adjunctive supplemental therapies may be recommended to optimize wound healing. 9,15,20,22 Burn patients should be encouraged to consume a high-protein diet. Supplementation with high-calorie nutritional drinks facilitates meeting energy needs. Large quantities of free water should be discouraged because risk for hyponatre-mia is high after a large burn. 20

• An individualized plan for pain control should be in place for both background pain (pain that is continuously present), breakthrough pain (associated with activities of daily living), and procedural pain (intermittent pain related to procedures). 16,25 Unrelieved pain can lead to stress-related immunosuppression, an increased potential for infection, delayed wound healing, and depression. 13 Sub-cutaneous and intramuscular injections should be avoided because absorption is poor and unreliable as a result of edema. 1 As the wound heals, the patient has more discom-fort from itchiness and less discomfort from pain. 16 A moisturizing lotion prevents drying and reduces pruritus. Nonpharmacological techniques can be learned to assist with the management of pain and itch. 2,16

• Burn wounds contract during the healing phase. Self-care and range-of-motion exercises are encouraged. Stretching exercises and proper positioning are vital to prevent con-tractures and loss of function. 7 Static splinting is some-times added to maintain sustained stretch. 7 Hypertrophic scar formation is countered through the use of topical sili-cone gel sheeting and pressure garments worn 24 hours a day until the scars mature and soften (6–18 months). 18 Keloids, if they form, may require surgery, steroid injec-tions, and pressure treatment. 18

• Grafts and donor sites on the lower extremities require support during healing when the patient is out of bed. Application of elastic bandages to extremities may prevent pooling of venous blood, permanent discoloration, or skin breakdown.

• The burn wound should not be exposed to the sun for a year because new scars sunburn easily.

• Patients should be instructed to select clothing that blocks sun and to use sunscreen on exposed grafts, generally for life.

EQUIPMENT

• Personal protective equipment as needed (e.g., gown, mask, goggles)

• Nonsterile gloves • Sterile gloves • Warm water • Mild pH-neutral liquid cleansing agent • Normal saline solution • Washcloths • Towels • Scissors and forceps (clean and sterile) • Topical agents, as ordered • Tongue depressors


❖ Wound discoloration ❖ Increase in burn size or depth ❖ Blurring of wound edges

• Monitor for distal circulation (pulses, pain, color, sensa-tion, movement, and capillary refi ll) to areas with circum-ferential burns and increased edema. Rationale: Edema and circumferential burns impede distal circulation and cause worsening tissue perfusion and cell death.

• Determine patient ’ s understanding of pain-management strategies. Assess patient ’ s pain level on a standardized pain scale (such as the 0 to 10 scale) before, during, and after the procedure. Explore discrepancies between the patient ’ s level of pain and desired level of pain. Rationale: An individualized plan for pain control should be in place for background, breakthrough, and proce-dural pain. 16,23 In addition to the traditional use of pain and anxiety medications, alternative therapies should be included (e.g., relaxation techniques, distraction, massage therapy, music therapy). The patient ’ s needs change based on changes in the wound (e.g., healing, débridement, con-version to a deeper wound).

• Evaluate patient ’ s general level of function, particularly in burned areas. Rationale: An individualized plan for range-of-motion exercises, positioning, and splinting should be made to optimize the patient ’ s level of function. Burns contract during the healing phase, and immobility enhances loss of function.

Patient Preparation • Ensure the patient understands procedural teaching.

Answer questions as they arise and reinforce information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.

• Verify that the patient is the correct patient using two identifi ers. Rationale: Before performing a procedure, the nurse should ensure the correct identifi cation of the patient for the intended intervention.

• Notify other appropriate healthcare providers who need to assess the burn wound (e.g., the physician) or perform a task (e.g., quantitative wound biopsies, range-of-motion exercises by physical therapist) at the time of dressing changes. Rationale: Organization of care allows impor-tant assessment and intervention to take place without causing extra pain and stress to the patient.

• After checking previous requirements for patient comfort during the dressing change, premedicate the patient with pain medication and any sedative as prescribed, allowing an appropriate amount of time before starting wound care. Rationale: Premedication allows time for medication to take effect and promotes optimal comfort for the patient.

• Consider synergistic effects of opioids, sedatives, and drugs that affect the central nervous system. Closely monitor the patient for 30 to 60 minutes after the wound care procedure is completed or until there is a return to baseline. Rationale: Stimulatory effects that counteract central nervous system depression are reduced after wounds are covered; decreased noxious stimuli and respi-ratory depression may occur.

Education reduces complications and promotes patient satisfaction.

• Explain the rationale to the patient and family for the wearing and care of pressure garments. Rationale: Pres-sure garments need to fi t properly to reduce scar forma-tion, and they can be diffi cult to apply. 19

• Discuss the importance of mobility and proper positioning (e.g., splinting) on function. Self-care (activities of daily living) and range-of-motion exercises should be encour-aged during the healing phase. Rationale: Contractures associated with healing skin, improper positioning, and immobility are prevented.

• Identify caloric needs for healing and suggest appropriate nutritional supplements. Rationale: Metabolic needs are increased for months after discharge, and a balanced diet facilitates gain of muscle mass versus adipose tissue.

• Inform patient and family that nightmares, alterations in body image, and psychological disturbances are experi-enced by many burned patients. 19 Provide resources, including someone to follow up with, if desired. Ratio-nale: Information increases awareness of these problems and reassures patient and family that these experiences, although unpleasant, are not abnormal.

• Provide patient and family with follow-up appointments and someone to call with any problems. Rationale: Nec-essary information for further care and follow-up is provided.

PATIENT ASSESSMENT AND PREPARATION Patient Assessment • Assess vital signs, including temperature. Rationale:

Baseline vital signs allow for comparison during and after the procedure to evaluate patient tolerance, normothermia, and adequacy of pain medication.

• Evaluate for signs of healing, including the following. Rationale: Healing should occur within a predictable time frame determined by the depth of burns, unless complica-tions occur. ❖ Decreased pain ❖ Reepithelialization from epithelial islands within the

wound ❖ Decreasing wound size ❖ Decreased edema ❖ Compare the patient ’ s level of healing with the expected

level of healing for the number of days after burn. • Evaluate for the following signs and symptoms of infec-

tion. 19 Rationale: Infection can result in delayed wound healing, prolonged hospitalization, and death. ❖ Foul odor ❖ Purulent drainage ❖ Increased pain ❖ Increasing edema ❖ Cellulitis ❖ Fever ❖ Development of eschar or early eschar separation


Steps Rationale Special Considerations

1. Prepare all necessary equipment and supplies. The treatment area should be warmed.

Preparation facilitates effi cient wound care and prevents needless delays. Warming the room decreases the risk for hypothermia.

Other physicians, advanced practice nurses, and other healthcare professionals who need to observe the wound should be notifi ed ahead of time so that they can be present while the wound is uncovered.

2. HH 3. PE For larger dressing changes, all

physicians, advanced practice nurses, and other healthcare professionals participating in the wound care should apply caps, masks, and gowns. Smaller graft changes may require less personal protective equipment.

4. Remove old dressings and discard them in infectious waste containers. Place towel or pad under exposed extremity.

Old dressings can contain large amounts of body secretions and blood. A clean fi eld under the extremity allows the patient a place to rest the extremity during care.

Remove dressings only from areas that can be redressed within 20–30 minutes at one time. Finish wound care to these areas before moving to new areas (decreases heat loss and pain related to nerve endings being exposed to air).

5. Remove and discard gloves and HH, and apply a pair of clean gloves.

Used gloves are contaminated by handling of the burn dressing. Aseptic techniques are necessary for wound care.

6. Wash the wound with mild pH-balanced soap solution or wound cleanser, rinse with warm tap water, and pat dry.

Cleanses wound of debris with mechanical débridement and reduces microorganisms.

Cleanse beyond wound to reduce microbial count on surrounding tissue. Patient tolerance may improve if allowed to cleanse one ’ s own wounds.

7. Use scissors and forceps to remove loose necrotic tissue and any broken blister tissue.

Bacteria proliferate in necrotic tissue. Typically, physicians perform this function in hospitals that do not specialize in burn wound care.

8. Assess the burn wound for color, size, odor, depth, drainage, bleeding, edema, cellulitis, epithelial budding, eschar separation, sensation, movement, peripheral pulses, and any signs of pressure areas from splints. For wet dressings, proceed to Step 9.

Validates the healing process and identifi es complications.

9. Creams: use sterile tongue depressor to remove the required amount of topical agent from the container. Ointments: apply a thin layer to the wound as prescribed; apply dressing as needed.

Use of a sterile tongue depressor and removal of only what is needed from the container prevent contamination of the topical agent. Dry dressings protect the topical agent from premature removal.

If the area to be covered has folds and crevices, or if the wound consists of scattered areas, topical agents should be placed directly on the wound, rather than on the burn dressing (ensures good coverage without applying unnecessary amounts of an absorbable topical agent to uninjured areas).

10. Soaks: pour the prescribed solution onto sterile gauze pads. Squeeze out excess fl uid and apply to the wound.

Ideal moisture is when the dressing is similar to a damp sponge. Excess fl uid may macerate tissue.

Procedure for Care of Burn Wounds


Steps Rationale Special Considerations

11. Loosely wrap extremities with gauze rolls. Secure dressings with elastic net.

Holds dressings in place. Wrap extremities from distal to proximal. Check pulses and capillary refi ll after wrapping to ensure circulation is not compromised.

12. Assess need for additional pain medication before continuing.

Patients have a right to good pain control. The success or failure of pain control for the current dressing change affects the way the patient responds to future dressing changes.

13. Repeat steps, starting at Step 4, until all burn wounds have been cared for.

Isolating areas for dressing changes prevents unnecessary temperature loss, pain from increased nerve ending exposure to air movement, and cross contamination of wounds.

The size of the team doing the dressing and the amount of débridement time required determine how much of the wound should reasonably be exposed at any given time.

14. Apply splints as needed and elevate burned extremities with pillows or elastic net sling or both; elevate the head of the bed.

Maintains position of function, prevents contractures and pressure ulcers, and reduces edema. Elevation of donor sites and exposure to air facilitates healing. 8,19

Do not bend knees if popliteal space is burned. Do not put pillows under the patient ’ s head if neck or ears are burned. Do not inhibit movement with splints if the patient is awake and able to use the involved extremity.

15. Remove gloves and discard used supplies.

16. HH

Procedure for Care of Burn Wounds—Continued

Expected Outcomes • Wounds heal as expected without infectious

complications • Patient maintains a self-identifi ed acceptable level of

pain relief • Patient attains comfort from measures taken for

anxiety and itching • Patient and family verbalize knowledge of patient

condition and plan of care • An optimal level of function is maintained or attained • Patient and family response and interactions

demonstrate adaptation to injury • Patient and family collaborate in management of care • At the time of discharge, patient and family verbalize

and demonstrate an understanding of posthospital care

Unexpected Outcomes • Wound converts to deeper injury • Loss of allograft • Wound infection or systemic sepsis occurs • Wound heals with unnecessary loss of function

Procedure continues on following page


Patient Monitoring and Care Steps Rationale Reportable Conditions

These conditions should be reported if they persist despite nursing interventions.

1. Follow institutional standards for assessing pain. Administer analgesia as prescribed. Evaluate and treat the patient for pain. Ask the patient to rate the pain on a scale of 0–10; check the orders for pain and sedation for dressing changes; check patient ’ s medication requirements with previous dressing changes and have that amount of medication available in the room before starting the procedure; assess the need for more medication throughout the dressing change. Incorporate alternative pain relief techniques (e.g., relaxation techniques, massage therapy, distraction, music, visual imaging).

Identifi es need for pain interventions. The burn patient has baseline pain that requires analgesia and increased pain-medication requirements, and possibly sedation requirements for the pain involved in dressing changes. Attention to the patient ’ s pain fosters the patient ’ s trust in healthcare personnel to control pain and promotes cooperation with future burn wound care. The goal of pain management is an alert patient who is able to cooperate, follow commands, and respond to verbal stimuli.

• Continued pain despite pain interventions

• Nonverbal indications of pain (restlessness, grimacing, teeth clenching)

• Increased respiratory rate • Verbalization of pain • Inability to cooperate with

dressing change • Increased heart rate • Increased or decreased blood

pressure • Oversedation, depression of

respiratory rate, not being arousable

2. Obtain baseline vital signs before the procedure, monitor throughout the procedure, and check for 30 minutes after the procedure is complete.

Changes in vital signs can be an indication that the patient is experiencing pain or anxiety. Decreasing blood pressure, heart rate, and respiratory rate can be complications of pain medication (especially after the dressing change is complete and stimulation has stopped).

• Increased or decreased heart rate • Increased or decreased blood

pressure • Increased or decreased respiratory

rate; increased need for higher oxygen supplementation

• High peak pressures on ventilator

3. Check patient ’ s temperature before dressing changes. Ensure the patient ’ s environment is warm; cover the portions of the patient ’ s body that are not involved in dressing changes. Check the patient ’ s temperature at the end of dressing changes.

Heat is lost through burn wounds. Hypermetabolism and shivering increase caloric demand.

• Hypothermia • Shivering

4. Monitor peripheral pulses and circulation in the burned extremity during the dressing change, within 1 hour after applying the dressing, and every 2 hours thereafter. Keep extremities elevated and assess for increased edema.

Circumferential burns can decrease or prevent blood fl ow to the involved extremity. The dressing can be too tight, especially if edema increases.

• Increased peripheral edema • Pain or numbness in the extremity • Prolonged or absent capillary

refi ll in the extremity • Decreased or absent pulses • Conversion to deeper burn wound

5. Assess the burn wound for color, size, odor, depth, drainage, bleeding, pain, early eschar separation, healing, and cellulitis in the surrounding tissue. Obtain a wound biopsy as needed for suspected infection.

Observes for usual progression of wound healing versus complications of infection, progression of burn to deeper wound, and bleeding. Wound colonization is common. Histological determination of the level of organism invasion in the presence of systemic symptoms is diagnostic for burn wound infection.

• Foul odor • Purulent or increased amounts of

drainage • Elevated body temperatures • Cellulitis • Healthy granulation tissue

developing eschar • Increasing necrosis, loss of graft • Blurring of burn wound edges • Discoloration of the wound or the

presence of fungal elements • Early eschar separation • Bleeding


Patient Monitoring and Care Steps Rationale Reportable Conditions

6. Encourage exercise and activities of daily living; perform range-of-motion exercises during dressing changes; place patient in a position of optimal function, with splints used as needed, to maintain maximal function. 8,19 Use pain medication as needed to facilitate mobility. 14 (Level C * )

Burns and grafts contract during the healing phase if not correctly splinted and exercised; loss of function is a complication of immobility. Pain inhibits patients from moving.

• Contractures • Loss of function

7. Monitor the patient ’ s tolerance of tube feedings or ingestion of a high-calorie and high-protein diet with supplements; encourage a nutritious diet and discourage empty calories. 13,21 Limit free water intake. (Level D * )

Nutrition is necessary for wound healing; burn patients are hypermetabolic. Protein-rich fl uids promote healing; free water decreases intake of nutritional supplements and can lead to hyponatremia.

• Refusal to eat or inability to ingest adequate amounts of nutrition

• Poor wound healing

* Level C: Qualitative studies, descriptive or correlational studies, integrative reviews, systematic reviews, or randomized controlled trials with inconsistent results. * Level D: Peer-reviewed professional and organizational standards with the support of clinical study recommendations.

—Continued

Documentation Documentation should include the following: • Patient and family education • Date, time, and duration of wound care • Areas of burn, other wounds, and pressure ulcers;

weekly diagrams (or digital photographs) of unhealed wounds to monitor healing and wound changes

• Appearance of the wound (color, size, odor, depth, drainage, bleeding)

• Assessment of wound areas for level of pain (appropriate for depth and level of healing)

• Progression toward healing (e.g., presence of epithelial budding)

• Evidence of cellulitis around the wound (red, warm, tender)

• Assessment of peripheral pulses; color, movement, sensation, and capillary refi ll distal to a circumferential wound or an extremity wrapped in dressings

• Pain assessment, interventions, and effectiveness • Medications given for pain, anxiety, and sedation • Other comfort measures used • Dressings and topical agents applied • Patient ’ s tolerance of the procedure • Unexpected outcomes • Nursing interventions

References and Additional Readings For a complete list of references and additional readings for this procedure, scan this QR code with any freely available smartphone code reader app, or visit http://booksite.elsevier.com/9780323376624 .

procedure burn wound care - elsevier

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