Burns Case Study Essay Example

response can be broken down into three stages: coagulation, stasis, and hyperemia. At the site with maximum damage, coagulation takes place leading to irreversible tissue loss due to protein coagulation. Stasis is characterized by reduced tissue perfusion but remains viable unless prolonged hypotension, infection, or edema occur. Hyperemia occurs in the outermost area with increased tissue perfusion and tends to recover.

After sustaining a burn injury, the site experiences an elevation in capillary permeability due to the release of cytokines and other inflammatory mediators. As a result, intravascular proteins and fluids migrate into the interstitial space. According to Doenges et al. (2010), burns are classified into four degrees. The initial degree, referred to as superficial partial thickness burns, solely affects the epidermis. Typically, the skin feels warm and dry while wounds exhibit a bright pink to red appearance with minimal edema and small blisters. On the other hand, second-degree burns, known as moderate partial thickness burns, involve both the epidermis and dermis.

Second degree wounds display a reddish to pinkish hue, accompanied by moderate swelling and the presence of intact or draining blisters. These burns can also be categorized as deep partial thickness, reaching into the deep dermis and appearing drier than moderate partial thickness burns. The color of second degree burns ranges from pale pink to pale ivory, along with moderate swelling and the presence of blisters. On the other hand, third degree or full thickness burns encompass all layers of the skin and subcutaneous fat. In some instances, they may extend to muscle, nerves, and blood supply. These wounds exhibit a dry, leathery texture and their appearance varies from white to cherry red to brown

or black, with blistering being uncommon.

According to Doenges et al. (2010), electrical burns can cause a variety of signs and symptoms in patients, such as mixed areas of numbness, tingling, burning pain, changes in orientation, changes in vision, decreased visual acuity, decreased deep tendon reflexes, seizure activity, and paralysis. Fourth degree or full thickness subdermal burns affect all skin layers as well as muscle, organ tissue, and bone. While the center of the burn wound may lack pain, heightened sensation can be present at the edges.

The text explains that most burn patients will show signs of tachycardia, tissue edema formation, decreased urinary output, decreased or absent bowel sounds, nausea, vomiting, facial mask, changes in blood pressure, pulse, and increased respiratory rate. In the case of an inhalation injury, breath sounds may include crackles, stridor, or wheezing. According to Doenges et al. (2010), signs and symptoms such as hoarseness, wheezy cough, carbonaceous particles on face or in sputum, drooling or inability to swallow oral secretions, cherry colored face, and cyanosis, altered mental status can indicate carbon monoxide poisoning.

There are various diagnostic procedures to assess the severity of damage in burn injury treatment, as stated by Klein et al. (2009). The initial diagnostic information acquired is the total body surface area (TBSA), which is determined using the rule of nines. This rule divides different anatomical areas into specific percentages. In adults, nine percent each represents the head and neck, both upper extremities account for nine percent, both anterior and posterior portions of the trunk make up eighteen percent each, both lower extremities contribute to eighteen percent each, and one percent comprises the perineum and

genitalia.

Doenges et al. (2010) states that TBSA is crucial in patient care and fluid resuscitation management. A complete blood count (CBC) can indicate an initial increase in hematocrit due to fluid shift or loss. As treatment progresses, vascular endothelium heat damage may lead to decreased levels of hematocrit and red blood cells. The inflammatory response from the burn may cause elevated white blood cell levels. According to Doenges et al. (2010), arterial blood gases (ABGs) are used to assess oxygen (PaO2) and carbon dioxide (PaCO2) levels in the arterial blood. When there is suspicion of an inhalation injury, establishing a baseline pH is important.

The presence of carbon monoxide in the body can be identified by a decrease in PaO2 and an increase in PaCO2, as stated by Klein et al. (2009). When carbon monoxide is breathed in, it combines with hemoglobin to create carboxyhemoglobin or COHgb, which strongly binds to hemoglobin, blocking the transportation of oxygen. According to Klein et al. (2009), an elevation of more than ten percent of COHgb signifies inhalation injury. Furthermore, initial tissue damage, destruction of red blood cells, or impaired renal function can lead to an increase in potassium levels within a chem 10 panel.

At first, sodium levels may decrease due to fluid loss in the body, but later on, there is a possibility of developing hypernatremia as the kidneys begin to conserve sodium. According to Doenges et al. (2010), a urinalysis is commonly performed as a screening test to assess renal function. The presence of albumin, hemoglobin, and myoglobin in urine can indicate both deep tissue damage and protein loss, which are often observed in severe electrical burns. The

color of urine, whether red or black, might suggest the presence of myoglobin. As noted by Klein et al. (2009), photographs of burns can be valuable for documenting and establishing a baseline to evaluate the healing process at a later stage.

Both a laser doppler and an MRI scan are used to assess different aspects of the body's health.

A laser doppler is specifically used to measure micro vascular blood flow in the dermis layer. It can be helpful in determining the depth of a burn and predicting its potential for healing when performed soon after the injury. Additionally, laser doppler flowmetry can assist in identifying patients who may benefit from early excision and grafting of wounds.

On the other hand, an MRI scan utilizes magnetic fields to create two or three dimensional images of organs within the body. This type of scan is able to detect tissue edema, which occurs as a result of cellular membrane damage following an electrical injury. Tissue edema begins accumulating minutes after such an injury.

The text discusses the process of wound cultures, which involve collecting drainage or other material from the burn area and growing it in the laboratory to identify microorganisms like bacteria or fungi. These cultures can be obtained initially for baseline data and repeated during care to assess for infection or the effectiveness of antimicrobial therapies. Additionally, according to Doenges et al. (2010), chest x-rays can be used to evaluate organs and structures in the chest for signs of disease. Initially, chest x-rays may appear normal, even in cases of inhalation injury, but they may later progress to whiteout on x-rays.

The upper airways can be visually examined

using upper airway endoscopy and fiberoptic bronchoscopy, also known as direct or indirect laryngoscopy. These procedures utilize either a rigid or flexible bronchoscope to assess the extent of damage caused by inhalation injuries. Abnormal findings during laryngoscopy may include airway edema, hemorrhage, or ulceration. In addition, an electrocardiogram (ECG) is capable of recording the heart's electrical activity and detecting signs of myocardial ischemia and dysrhythmias that may arise from electrical burns.

According to Klein et al. (2009), caring for a burn patient involves three collaborative stages: resuscitative, acute, and rehabilitive. The resuscitative stage, also referred to as the emergency phase, begins at the time of injury and lasts until forty-eight hours after fluid and protein shifts have subsided. In most cases, initial contact with the patient is made by either emergency medical technicians or in the emergency department. Stopping the burning process promptly is identified by Klein et al. (2009) as the primary priority. If the burn was caused by cement, tar, or scalding, it is recommended to remove clothing using water.

It is not recommended to use ice as it can cause vasoconstriction and further damage to the tissue. After stopping the burning process, it is important to transfer the patient to a specialized burn center due to the complex care required for severe burns. According to Klein et al. (2009), once the resuscitative phase is complete, the acute phase begins which involves assessing the airway. In cases where inhalation injury is suspected, intubation may be necessary to prevent closure of the airway caused by tracheal edema. If intubation is not performed, nurses should continually monitor for hoarseness, stridor, or wheezing as these symptoms may indicate

ineffective clearance of the airway.

When diagnosing carbon monoxide poisoning, it is important to assess the patients' breathing. To reduce the effort needed for breathing and improve oxygen saturation until COHgb levels normalize, it is recommended to administer 100% oxygen therapy through an endotracheal tube or a face mask. Fluid resuscitation is crucial in treating and aiding the recovery of burn patients. Multiple methods are available to determine the correct amount of fluid needed for burn resuscitation; however, the main goal remains maintaining tissue perfusion and organ function without causing deficits or fluid overload.

Klein et al. (2009) assert that the Parkland Formula is commonly utilized for fluid resuscitation. This formula determines the necessary quantity of Lactated Ringer's solution to be administered within a 24-hour period at a rate of 4ml/kg/% TBSA. Half of this calculated amount should be provided in the first 8 hours, while the remaining portion should be given over the following 16 hours. Klein et al. (2009) also clarify that the Consensus Formula is an updated version of the Parkland Formula, recommending adults receive Lactated Ringer's solution at a rate ranging from 2-4 ml/kg/% TBSA during the initial 24 hours.

According to Klein et al. (2009)(p707), it is recommended to administer dextrose in water plus potassium and a colloid-containing formula to the patient during the second twenty-four hours in order to maintain electrolyte balance and plasma volume. Regardless of the fluid resuscitation calculation method used, establishing two large bore peripheral intravenous access is advised. The most commonly utilized crystalloid, as stated by Klein et al. (2009), is lactated Ringer's solution due to its similar composition in terms of osmolality and electrolytes compared to normal

body fluids.

Lactated Ringer's is a solution that includes lactate, which acts as a buffer for metabolic acidosis. However, it does not contain intravascular protein. To increase intravascular oncotic pressure and alleviate edema, colloidal albumin is often used. Albumin can pull fluids from the interstitial space back into the intravascular volume. According to Doenges et al. (2010), burn care and procedures can cause excruciating pain for patients, and the intensity of pain depends on the degree and extent of the burn. First degree burns are particularly sensitive to touch, pressure, air passage, and temperature changes.

Moderate thickness burns of the second degree cause significant pain, while deep thickness burns of the second degree are less painful due to the absence of nerve endings. Pain management is crucial for burn treatment. Regular assessment of pain is necessary, both before and after any procedure. Opiates are typically prescribed for pain relief. According to Klein et al. (2009), opiate medication should be administered intravenously rather than through intramuscular or subcutaneous routes.

Both Morphine IV infusion and patient controlled analgesia can be utilized to assist patients with severe burns in managing their pain. The objective of treating burn wounds is to prevent infection, facilitate re-epithelialization, and eliminate nonviable tissue through techniques like cleansing, debridement, dressing therapy, or surgical closure. As per Klein et al. (2009), wound care must be conducted a minimum of two times daily.

It is recommended to use a mild soap or disinfectant mixed with warm water when cleaning a wound. Wounds should be scrubbed using sponges, washcloths, or brushes to remove any debris during the process of debridement. Silver Nitrate is applied as a topical antimicrobial agent to treat

various surface pathogens. The application of Silver Nitrate should be done two to three times a day following proper wound care. In cases of full thickness burns, surgical intervention or skin graft closure is often necessary for proper wound closure. According to Doenges et al. (2010), an allograft or homograft in the form of a biological dressing can be used, which involves using skin from another human - either living or obtained from a cadaver.

Another type of biological dressing is a Xenograft, which is a graft of skin from another species, typically a pig. Both allografts and xenografts are biologic dressings and are eventually rejected by the immune system, requiring removal before skin grafting. According to Klein et al. (2009), there are two main types of biosynthetic dressings: AlloDerm and TransCyte. TransCyte is a nylon mesh that is incubated with human fibroblasts to provide a partial dermis layer and an outer silicone layer, acting as a temporary epidermis.

It is often used in deep or full thickness wounds prior to placing autogenous skin grafts. It must be removed before grafting full thickness injuries. AlloDerm is a skin graft containing cryopreserved allogenic dermis, with the removal of epidermal, endothelial, and fibroblasts. Skin taken from a healthy part of the patient's body and placed over a burn injury is referred to as an autogenous graft or autograft. According to Doenges et al (2010), skin grafts can be categorized as split thickness or full thickness grafts.

The classification of skin grafts is based on the amount of dermis used. Full thickness skin grafts, which utilize the entire dermis, are optimal for visible areas of the face as they have minimal

contraction. These grafts exhibit similarities to normal skin in terms of color, texture, and thickness. In children, they are frequently employed to accommodate growth; however, in adults, they are only appropriate for small and clean wounds. Donor sites necessitate surgical closure.

Split thickness skin grafts can be utilized to cover extensive wounds or fill cavities.

Split thickness skin graft donor sites usually heal naturally. According to Doenges et al. (2010), a cultured epidermal autograft or CEA is a skin graft obtained from an unaffected part of the patient's body and prepared in a lab. CEA can be either full or partial thickness. The entire process may take around twenty to thirty days. The final stage of care is the rehabilitative phase. As mentioned by Sheridan (2011), early therapy should begin, typically starting with ranging. Ranging involves passively moving all joints through their full range of motion.

Performing it twice a day is necessary to prevent contractures and avoid the major complication of deep dermal burns, which is hypertrophic scarring. Various therapies like scar massage, compression devices, and topical silicone have been created to reduce the appearance of scars. When dealing with burn patients, numerous nursing diagnoses can be implemented to provide appropriate care. A top priority in patient care is addressing the risk for ineffective airway clearance and impaired gas exchange due to tracheal edema. To manage this diagnosis, nursing interventions should include monitoring the respiratory rate, rhythm, and depth.

The nurse should observe for pallor or cyanosis and pink colored sputum as signs of developing respiratory distress or pulmonary edema, which may require medical intervention. The nurse should also listen to the lungs for stridor, wheezing, crackles,

and diminished breath sounds to assess for any airway obstruction or respiratory distress. It is important to note that these symptoms can occur rapidly or have a delayed onset, even up to three days after a burn.

The nurse should use extreme care and sterile technique when suctioning, if needed, to maintain a clear airway. However, caution should be exercised due to mucosal edema and inflammation. Infection risk is a concern in burn trauma cases. Follow orders to implement suitable isolation techniques. The extent and type of wounds determine the necessary isolation precautions for achieving a patient free of infection. These precautions help reduce the risk of cross contamination and exposure to bacteria from other patients.

The nurse should prioritize and enforce proper handwashing technique for anyone in contact with the patient in order to prevent cross contamination and lower the chances of acquiring infections. Additionally, observing the patient's vital signs is crucial for identifying signs such as fever, increased respiratory rate and depth, diarrhea, decreased platelet count, and increased white blood cell count. These indicators are all associated with sepsis, which commonly occurs with severe burns and necessitates immediate assessment and treatment. It is also important to manage acute pain resulting from burn injuries in this situation.

In order to minimize pain caused by exposed nerve endings, nursing interventions typically involve promptly covering wounds, unless an open air exposure burn care method is necessary. The nurse should administer analgesics as prescribed, including opioid and non-opioid medications. The patient may require medication throughout the day and dosage adjustment. Initially, intravenous (IV) administration is commonly used to maximize effectiveness. If ordered by the doctor, patient-controlled analgesia (PCA) may

be employed, and the nurse must provide proper instruction on its usage.

A PCA allows for timely drug administration, preventing pain intensity fluctuations, often with lower total dosage, while giving the patient control. Burn patient care is intricate and meticulous, with specialized nurses and doctors in burn centers across the nation. Each facility has different treatment plans, so it's important for nurses to understand their facilities' burn patient care policies.