Pulmonary priorities

Inhalation injury continues to be the most serious and life-threatening complication of burn injury today. Early diagnosis and treatment greatly impact the outcome of care. Impaired gas exchange is a potential problem for patients who have face and neck burns and/or inhalation injury. Inhalation injury may include carbon monoxide poisoning, upper airway injury (heat injury above the glottis), lower airway injury (chemical injury to lung parenchyma), and restrictive defects (circumferential third-degree burn around the chest). Upper airway edema causes respiratory distress and is the primary concern during the initial 24–48 h post-burn phase. Tracheobronchitis, atelectasis, bronchorrhea, pneumonia, and adult respiratory distress syndrome (ARDS) may occur during the acute, post-burn stage either related or unrelated to inhalation injury.

Nursing care of a patient with inhalation injury begins with a detailed history of the accident. Inhalation injury is suspected when the accident occurred in a closed space. Close observation of the patient and frequent respiratory assessments are made throughout the initial and acute phase post-burn. Initially, the patient is observed for hoarseness and stridor, which indicate narrowed airways. Emergency equipment is placed at the bedside to facilitate intubation if necessary. Observing the frequency of cough, carbonaceous sputum, and increased inability to handle secretions may indicate possible inhalation injury and the potential for impaired gas exchange. Other important observations include respiratory rate, breath sounds, and the use of accessory muscles to aid in respiratory effort, nasal flaring, sternal retractions, increased anxiety, and complaint of shortness of breath. Disorientation, obtundation, and coma may be due to significant exposure to smoke toxins such as carbon monoxide or cyanide. These conditions are managed emergently with 100% oxygen.

Bronchoscopy may be done early to diagnose inhalation injury as well as facilitate airway clearance. Humidified oxygen should be readily available and applied to patients who have evidence of impaired gas exchange (especially pediatric patients). Aggressive nasotracheal suction may be indicated if the patient has difficulty with managing secretions either because of the increased amount of secretions and/or the decreased effectiveness of the cough. In addition, aggressive pulmonary toilet, including turning, coughing, and deep breathing, up and out-of-bed rocking in mother’s arms may be done regularly and frequently. Elevation of the head of the bed, unless contraindicated, will also support and possibly improve ventilation. Trends and changes should be correlated with laboratory results and shared with the team.

Another complication is circumferential third-degree burns around the chest and neck, which often cause restrictive defects. The increased amount of edema combined with decreased chest excursion may greatly decrease tidal volume. This condition may progress and can become life-threatening, in which case chest escharotomy may be necessary to release the constricting eschar. The procedure may be done at the bedside or in the operating room. Equipment includes sterile drapes, scalpel, and electrosurgical unit (to control bleeding).

Intubation and mechanical ventilation may be required to improve gas exchange. Tube placement should be checked and documented frequently and verified daily by X-ray. Securing the endotracheal tube requires a standard technique for stabilization and prevention of pressure necrosis. Adequate humidity is necessary to prevent secretions from drying and causing mucous plugging. Remember to provide pre/post-suctioning hyperoxygenation. Sterile technique is used when suctioning to prevent infection. Attention to the details of oral hygiene will provide comfort for the patient and may reduce the occurrence of ventilator-associated pneumonia related to colonization in the oral pharynx.¹

Criteria for extubation depend on why the tube was inserted initially, but, overall, stable vital signs and hemodynamic parameters will support the plan for extubation. The patient should be awake and alert in order to protect the airway; therefore, pain medications may be reduced before extubation. Ventilatory measurements and blood gas analysis should be within normal limits.

Immediately following extubation, the nurse must be alert for signs and symptoms of respiratory distress, administer suction as needed, monitor blood gas measurements, provide optimal positioning for ventilation, as well as provide reassurance and support to decrease anxiety.

Age, burn size, and the presence of inhalation injury and pneumonia have been identified as major contributors to mortality.² Thus, vigilant nursing care (frequent nursing assessments, aggressive pulmonary toilet, etc.) combined with anticipating potential problems and being prepared to deal with the problems will add to the team effort and possibly improve the patient outcome.

Burn wound care

The primary goal for burn wound management is to close the wound as soon as possible. Prompt surgical excisions of the eschar and skin grafting have contributed to reduced morbidity and mortality in severely burned patients.^3–5

Wound care in the burn unit has become an art of burn nursing practice. It can be extremely challenging and complicated and, for a new nurse, it can be the most difficult and misunderstood part of burn nursing. The complexity exists because of the variety of wound types that require different interventions in relation to time post-burn or time postoperative. Wound assessment and care is a learned skill that develops over time. These skills must be taught by experienced nurses to new burn nurses. Assessment of burn wound takes place in the hydrotherapy area, operating room, and at the bedside.

Wounds may consist of eschar, pseudoeschar, skin buds, autograft, donor sites, hypermature granulating tissue, blisters, and exposed bone and tendons. Besides the many kinds of possible wounds, there are many topical antibacterial agents available for managing wounds. These choices raise many decisions for the team to address. Topical antimicrobial creams and ointments include mafenide acetate, silver nitrate, silver sulfadiazine, petroleum and mineral oil-based antibacterial products, and Mycostatin powder. Wounds may be treated in the open fashion (topicals without dressings) or closed fashion (topicals with dressings or soaks). There are several techniques for applying dressings to different areas of the body, that need to be able to withstand exercise, ambulation, and moving around in bed. Biological dressings such as homograft or heterograft may be used as temporary wound coverage. Dressings may also be synthetic or biosynthetic or silver impregnated. Selection is based on the present condition of the wound and the expected outcome.

Secondary goals of wound care are to promote healing and to maintain function of the affected body part. These goals are accomplished by preventing wound infection, treating wound infection, preventing graft loss and tissue necrosis, providing personal hygiene, and maintaining correct positioning and splinting throughout hospitalization. To prevent burn wound infection, the burn nurse must: cleanse the wound with soap and water; debride the wound of loose necrotic tissue, crusts, dried blood, and exudate; apply topicals or dressings and ensure dressing changes are done/ordered. The nurse must inspect the wound for evidence of infection: cellulitis, odor, increased wound exudate, and/or changes in exudate; changes in wound appearance; and increased pain in the wound. The physician should be notified so that changes in wound care can be made. Cultures and biopsies may be ordered to identify the type and count of organisms and treat with a specific systemic antibiotic, topical dressing, soak, or a combination of all three treatments. The wound is often the source of bloodstream sepsis. The five cardinal signs of sepsis are: hyperventilation, thrombocytopenia, hyperglycemia, disorientation, and hypothermia.⁶

Preventing graft loss is another wound care challenge for nursing. Usually the patient returns from the operating room in a position that is maintained for 3 or 4 days. Any interaction with the patient during this time of graft immobilization requires creativity and care in order to prevent shearing of the graft. Postoperative dressings on the thighs and back are protected with polymycin, fine-mesh gauze to prevent soiling by feces and to minimize cleanup. The dressings are continuously monitored for increased drainage and odor, which would indicate possible wound infection. If infection is suspected, then the postoperative dressings may be removed early for a closer inspection of the wound.

Donor sites will also require additional care to prevent infection. Of course, the care postoperatively depends on the coverage of the donor site. If the donor site is covered with fine-mesh gauze, the initial care is to ensure homeostasis and adherence of the gauze to the wound. Therefore the post-op pressure dressing remains intact for 6–12 h and is then removed. The focus of managing the donor site is to keep the wound dry. If grafts/donor sites are on the back or backs of the legs, the patient is placed in a Clinitron bed for 4–5 days to promote drying. If the donor site remains wet, additional drying techniques (hair dryers, external heaters) may be used periodically during the day.⁷

If the donor site is covered with a synthetic or biological dressing, the same principles apply. Basically, apply a pressure dressing to ensure adherence to the wound for a short period of time postoperative and then expose to the air to support drying of the wound. A bed cradle is used to keep bed linen from contacting the wounds. The location of the graft, donor site, and eschar may all be on the same extremity, which again requires creativity to accomplish all three interventions of care.

Nurses must always be vigilant when it comes to skin assessment; early detection and prevention is the key ingredient in preventing pressure ulcers in major burn patients. Pressure ulcers are no longer treated as a burn wound. There is evidence to support nursing practices in the prevention of pressure ulcers in burn patients. Burn patients have many risk factors that predispose them to develop pressure ulcers. Initially, hypovolemic shock with blood flow shunted away from the skin to preserve vital organ function is a factor. Additional injuries may increase the risk for pressure ulcers, such as: inhalation injury, which may require intubation and use of paralytic agents to manage the airway. Fluid resuscitation may contribute to massive edema in both burned and unburned areas. The edema is maximized at about 2–3 days post-burn, which also decreases the blood flow to the skin and adds weight to all parts of the body.

Maintaining systemic hydration can continue to be a problem long after the patient has received adequate resuscitation for burn shock. Continued fluid therapy to replace fluid loss through the burn wound is essential. If systemic hydration is not maintained, even normal skin may be at risk. To complicate this situation, the quantity of fluid lost through the burn wound may increase the moisture on normal skin adjacent to the burn wound. This moisture may cause the normal skin to break down and predispose the skin to further compromise.

Surgical care

The perioperative setting combines a number of professionals with different levels of experience and expertise, all directed towards patient care. Each team member has a specialized role: the surgeon provides surgical intervention; the surgical technician supports the surgeon; the anesthesiologist or CRNA provides life support functions, and the circulating nurse’s role is to provide safe patient care by ensuring that all team members adhere to professional standards and guidelines. The perioperative nurse is a professional registered nurse who provides nursing care to patients in the preoperative, intraoperative and postoperative phases of surgery. Perioperative burn nursing care can be described as hot, intense and demanding. Burn nursing in fact, represents one of the profession’s most challenging specialties.

Once surgery is completed, perioperative nurses provide postoperative care and assessment. This phase of nursing care can also be challenging for the nurse caring for the patient during the immediate postoperative period. Nursing care and plan for care depends on many factors: amount of blood loss, surgical time and the site and extent of excision and grafting. The post-anesthesia nurse caring for the burn patient must be knowledgeable as to the medications and procedures used during surgery, to provide appropriate safe nursing care.

Related posts:

Pathophysiology of burn shock and burn edema Respiratory care Psychiatric disorders associated with burn injury Mitigation of burn-induced hypermetabolic and catabolic response during convalescence Musculoskeletal changes secondary to thermal burns The burn problem: A pathologist’s perspective

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