TBSA medical Archives - Student Nurse Life

Burn Patient Rehabilitation

Burn patient rehabilitation is both a philosophy and an attitude which needs to start from the day in which the burn injury was inflicted.

Adequate nutrition is one of the most important aspects required for burn patient rehabilitation. Burn patients have increased caloric intake requirements. Lack of caloric intake leads the patient’s body to start metabolising protein, subsequently causing muscle wasting.

Retrieved from https://www.khanacademy.org/science/biology/macromolecules/proteins-and-amino-acids/a/orders-of-protein-structure on 24th January 2023

The Role of Nutrition in Burn Patient Rehabilitation

In patients with a burn injury, feeding should be established as early as possible, and ideally should be administered enterally. The patient’s weight should be monitored, especially since a 10% or more decrease in weight is considered to be a failure. However, it is important to note that while the catabolic state of large burn injuries result in a rapidly falling albumin level causing a decrease in dry weight, this decrease is masked due to the large fluid resuscitation volume administered in the first few days following the injury.

NOTE: patients requiring starvation for anaesthesia should be kept starved for the least time possible, starting from 6hrs pre-anaesthesia administration.

Basal Metabolic Rate – BMR

The Basal Metabolic Rate is the body’s resting rate of energy expenditure. The BMR doubles in cases where the patient has experienced more than 50% TBSA (Total Body Surface Area) burn. The larger the TBSA burned, the higher the hypercatabolism degree (excessive metabolic breakdown of complex substances including protein, within the body). The patient typically also experiences hyperglycaemia resulting as another endocrine response.

Typically, the patient’s BMR continues to increase and the core temperature resets to 1-2°C higher than normal, until the burn wound heals. During this healing process, the ambient temperature should be kept around 26-30°C to reduce the body’s energy demands.

NOTE: TBSA does not take into consideration superficial burns where only the epidermis is involved.

Nutritional Intake During Admission Stage

the patient is weighed so that dry weight measurement is established and recorded
a nasogastric tube is inserted, and feeding is started at low volume
feed volume is gradually increased if the nurse determines that the feed is actually being absorbed

Caloric requirements are calculated by a dietician based on the TBSA burned. In burn patients the Curreri formula is used to determine nutritional intake requirement:

The Curreri Formula

(25 x weight in kg) + (40 x TBSA percentage)

Enteral Feeding

studies show that patients receiving enteral feeding have a decreased mortality and morbidity rate
enteral feeding is relatively easy to establish early on, and this helps decrease caloric deficit
in patients with extensive burns obviously requiring a longer hospital stay, a PEG or nasojejunal tube is recommended, since this helps avoid repeated periods of starvation, and can also be passed at the bedside; since by using this way of feeding, nutritional intake bypasses the stomach and goes directly into the intestines, the patient would not require starvation pre-anaesthesia
PEG feeding is used less in burn patients, especially if the abdomen has suffered from a burn injury, or if the abdominal skin may be required as donor skin
Total Parenteral Nutrition TPN is only indicated if enteral feeding cannot be established, since studies have shown an increase in burn mortality with IV supplemental feeding in severely burned patients; additionally, due to an increase in burn patients’ core temperature, phlebo-fix used to hold in place a central line tends to keep coming off, thus, a central line is ideally avoided

Retrieved from https://healthcarenutrition.org/methods-of-nutrition/ on 24th January 2023

Retrieved from https://www.myupchar.com/en/surgery/percutaneous-endoscopic-gastrostomy-peg on 25th January 2023

Burn Patient Co-morbidities

A burn patient may have other primary diseases such as diabetes, high cholesterol, and obesity. Such diseases are referred to as co-morbidities. For this reason, every burn patient needs to be managed in a holistic way, where all pre-existing medical conditions, any related social circumstances, and obviously the patient’s age, are taken into consideration when drawing a burn patient rehabilitation plan.

Diabetes

diabetes affects the healing process of the burn injury due to poor circulation leading to less oxygen perfusion
burn wounds, like any other wound, is likely to become infected in a patient with diabetes, thus, patients with diabetes are frequently checked for microbe presence by wound swabbing
careful monitoring and control of blood glucose levels in patients with diabetes promote better clinical outcomes, therefore this should be monitored right from admission stage
antibiotic administration is likely to help improve graft take as well as healing period in patients with diabetes
upon admission of a diabetic patient with a burn injury, the diabetic liaison nurse should be informed

Obesity

obesity limits burn injury outcome in various ways
typically, the force of abdominal viscera on the diaphragm limits lung tidal volumes

Age

young burn injury patients are quite resilient especially since their skin is relatively thin but the ratio of their skin surface area to blood volume is relatively high
elderly patients have very thin skin, and so, burn injuries endured by patients over 65 years of age are typically classified as full thickness burns; superficial burns in the elderly tend to progress to full thickness burns due to lack of nutrition, lack of self care, and sluggish circulation

Burn Reconstructive Procedures

Reconstructive procedures are performed following burns as well as cancer tumour removal. Plastic surgery uses the Aucher classification to classify burn reconstructive procedures according to their urgency. Burn reconstruction involves scar release or excision. Closure is done either by using a normal flap or by recruiting local skin.

Primary Intention Burn Injury Healing – done through surgery; surgery however doesn’t restore sensory functioning
Secondary Intention Burn Injury Healing – done through normal wound healing, with dressing changes as required and antibiotics to avoid infection; normal wound care without plastic surgery tends to lead to contractures that limit the patient’s functionality

An injury in which part of the body is lost eg. dog bites, human bites, woodwork injuries, butchers etc, is ideally subjected to secondary intention healing, since unintentionally closing the wound with microbes inside may lead to infection and subsequent surgical reconstruction or possibly amputation.

burn patient rehabilitation — Skin Contractures – Retrieved from https://link.springer.com/chapter/10.1007/978-3-030-44766-3_13 on 25th January 2023

Skin Grafts

A skin graft is a surgical intervention in which tissue is moved from one area (donor site) to another (recipient area). The donor area can be either from the same body or from another.

FULL THICKNESS SKIN GRAFTS

include the epidermis and dermis
full thickness grafts can be harvested from only a few body sites
may be used to cover bone exposure
donor sites require direct closure or split thickness graft closure
uptake rate is higher than that by split thickness grafts since the dermal layer is involved
antibiotics are administered as prophylaxis to avoid infection of skin grafts

SPLIT THICKNESS GRAFTS

include the epidermis and less than the whole thickness of the dermis
is commonly done for acute burn wound closure
healing is done through secondary intention
uptake rate is less than full thickness skin grafts since only the epidermis is involved, and this is mashed, causing fenestrations in the graft area, and is also quite stretched

Care of Grafts

foam is usually sutured or stapled over the graft to increase pressure
foam is removed after 5 days so that the graft is reviewed
graft is covered with antibacterial dressings
alternate removal of staples from graft is carried out after 2 days

Care of Donor Site

following harvesting of the skin, the donor site is covered with an alginate dressing (kaltostat) to control bleeding and protect the wound from becoming infected through contamination
donor site is exposed after 15 days so as to minimise bleeding; DO NOT REMOVE, even if bleeding is noted – remove ONLY if the wound becomes very smelly, signalling infection

Flaps – Local and Distant

flaps refer to the transferring of tissue that contains its own blood supply since vascularity is moved along with the flap during surgery
local flaps have some continuity with the defect they cover
distant flaps are separated by distance through the use of micro-surgery
flaps need to be kept warm at all times

The difference between grafts and skin flaps is in the fact that grafts do not bring their own blood supply, however, skin flaps carry their own blood supply to the recipient area.

Care of Flaps

flaps are held in place by staples or sutures
removal of staples or sutures is done based on the surgeon’s advice

NOTE: NEVER apply pressure over the flap since this impedes circulation to the area, causing flap necrosis.

Burn Patient Rehabilitation Into Society

Burn injuries have comprehensive needs which are best treated with adequate resources. This is why a multidisciplinary team, commonly managed by a lead consultant, is involved in the burn patient rehabilitation process.

Physiotherapy

physiotherapy is focused on the anatomical and physiological factors related to patient rehabilitation, helping in preventing or treating impairments or disabilities
physiotherapy promotes exercises aimed at regaining strength, range of motion, and stretching of the scar area
physiotherapy may also include chest physio which helps during the healing process, especially in patients who were exposed to smoke inhalation

occupational therapy

occupational therapy focuses on the functional aspect of the patient’s ability to participate in the daily activities of life, providing functional training to promote improvement
occupational therapy helps prepare the patient for discharge in relation to required support and services, including necessary equipment and environmental adaptations, assessment and provision

Burn Patient Challenges Prevention

Burn patients may experience various challenges during their healing process, some of which may result in disabling and disfiguring contractures. Challenges may include:

pain
scarring
acute and/or chronic oedema
muscle wasting (caused by immobilisation and long periods of reduced functionality)
psychological pain caused by trauma and body image changes
physical, mental and social limitations when compared to pre-injury

There are things we can do or promote as nurses so as to decrease or ideally prevent such challenges. These include:

educating, motivating, and empowering the patient through promoting understanding of the healing process
positioning the patient in a way as to protect the joints, reduce pressure, immobilise, and decrease oedema
splinting to protect, immobilise, prevent contractures and regain range of movement
chest physiotherapy helps in secretion removal whilst increasing tidal lung volume
promoting passive, active, and active assisted exercises to prevent loss of range whilst strengthening the muscles
scar massage, silicone, and pressure garments

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Burn Injury ~ Types of Burns & Treatments in Critical Care Setting

A burn injury happens when the skin comes into contact with something hot, causing disruption within the skin’s cell structure, resulting in skin cell death.

NOTE: Throughout this blogpost, the various burns listed are classified into burn degrees, however, this method of classification does not indicate the injury depth, and so, focus should be on the type of burn eg. superficial burn, and the percentage of skin area affected using the Lund and Browder Chart (featured further down).

The Zone of Stasis

The Zone of Stasis is the surrounding area of the burn. It is characterised by decreased tissue perfusion. Nonetheless, the skin within this zone is potentially salvageable:

the burn injury dressing should be chosen with the aim of promoting wound moisture
burnt area should be elevated so as to minimise oedema
smoking should be avoided by the patient since it puts the patient at increased risk of poor outcomes and complications
systemic diseases eg. diabetes should be managed; blood sugar levels should be kept stable

Assessing Burn Injury Surface Area

Prior to assessing a burn injury and its depth, DO NOT apply any silver sulfadiazine or any other topical agents, since doing so gives an inaccurate indication of the wound’s depth.

Retrieved from https://www.theplasticsfella.com/total-body-surface-area-in-burns/ on 22nd January 2023

Superficial Burn Injury

A superficial burn, also called a 1st degree burn, is characterised by the following features:

painful
no blisters are present
only the epidermis layer is involved
erythema (redness) present due to vasodilation
complete healing typically takes up to 7 days due to re-epithelialisation

Care of Superficial Burn

superficial burns require no dressings
patient should be advised to apply emollient cream
patient should be advised to apply sunblock and to avoid the sun

Superficial Partial Thickness Burn Injury

A superficial partial thickness burn, also called a 2nd degree burn, is characterised by the following features:

very painful
pink or red
blisters present
wet and weepy
complete healing with relatively little scarring

Care of Superficial Partial thickness Burn

if available apply Aquacel (silver dressing) in the 1st 24 hours following injury
de-roof and debride the blisters UNLESS they are located on the palms or soles of the feet due to excessive pain as well as superficial nerves, to which debridement may cause irreparable problems
assess wound depth
apply silver sulfadiazine and cover with non-adherent dressing for the first 3 days following burn injury
advise patient that a lot of exudate is expected to come out from the wound
advise patient to take regular analgesia for pain management

Deep Partial Thickness Burn Injury

A deep partial thickness burn, also called a 3rd degree burn, is characterised by the following features:

usually lacks physical sensation
red with overlying eschar
scarring expected
delayed healing potential

Care of Deep Partial thickness Burn

de-roof and debride blisters (if any) UNLESS they are located on the palms or soles of the feet due to excessive pain as well as superficial nerves, to which debridement may cause irreparable problems
assess wound depth
apply silver sulfadiazine and cover with light dry dressing
inform patient that some exudate should be expected
advise patient to take regular analgesia for pain management

Full Thickness Burn Injury

A full thickness burn, also called a 3rd or 4th degree burn, is characterised by the following features:

lacks physical sensation
white, brown, tan, or black
dry and leathery
firm non-blanche
scarring expected
no healing potential

Full Thickness Burn Injury 3rd Degree Burn (Left) and 4th Degree Burn – Retrieved from https://www.capersonalinjurycaselawnotes.com/2009/06/burn-injuries/partial-thickness-and-full-thickness-burns/ on 22nd January 2023

Care of Full Thickness Burn

following diagnosis of burn wound stage, refer patient to the Burns Unit
apply aquacel
elaborate surgical debridement, reconstruction, or amputation, may be indicated, depending on the case

Thermal Burns

The WHO estimates that thermal burns account for around 6.6 million injuries and 300,000 deaths yearly, worldwide. A thermal burn can be experienced through the following:

scalding (commonly caused by hot drinks in children)
direct contact with hot materials
flash and flame burns
can be a 1st, 2nd, 3rd or 4th degree burn (most full thickness burns are classified under thermal burns)

1st, 2nd and 3rd Degree Thermal Burn – Retrieved from https://burncenters.com/burns/burn-services/thermal-burns/ on 22nd January 2023

Chemical Burns

Chemical burns can be caused by direct contact with, or fumes of a chemical, usually an alkali or a strong acidic substance. Such burns can happen within various settings, including homes, work, or during an assault.

One such commonly used chemical is hydrofluoric acid – a colourless highly corrosive solution containing hydrogen fluoride in water. It is stored in a plastic container and is commonly used in industrial chemistry, glass finishing, and cleaning. Liquid hydrofluoric acid has the potential to interfere with calcium metabolism. It can cause deep skin burns, which though initially painless, may lead to a cardiac arrest and subsequent death, whilst in gas form, it can cause immediate and permanent lung damage, as well as damage to the eyes’ corneas.

care of a chemical burn

A chemical burn requires special care and attention so as to stop the substance from spreading within the skin. When caring for a chemical burn:

obtain information as to what caused the chemical burn
obtain information on how long the area was exposed to the chemical
remove any contaminated clothing that the patient may still be wearing
wash area to dilute or remove the substance
keep the wound under running water for 20 minutes

Smoke Inhalation

Smoke inhalation, which includes inhalation of heat, chemicals, and soot, can lead to a burn injury to the airway. To confirm smoke inhalation, it is important to assess for:

burns in mouth area
sooty sputum
voice change
difficult cough

If in doubt one should still provide oxygen therapy following intubation whilst protecting the cervical spine.

TREATMENT

Based on the inhalation severity:

patient may be intubated for minimal upper airway swelling
if soot is present in large amounts, patient’s airway may need suctioning
if the respiratory tract requires support, an aggressive approach should be taken…
chest physiotherapy
bacteriological surveillance – prophylactic antibiotic is administered
administration of The Galvenstone Protocol: inhaled H1 blockers, inhaled heparin, and nebulised acetyl cysteine

Electrical Burns

Electrical burns are caused by exposure to an electric source. They typically have both an entry and an exit site. The extent of such an injury ranges from minimal injury to severe multi-organ involvement.

An electrical burn needs to be evaluated by a medical professional despite the patient’s condition, be it stable or not.

Radiological Burns

Radiological burns are caused by the exposure to radiation. Whilst the most common cause of a radiation burn is through UV radiation as sunburn, patients undergoing radiation may present with radiation ulcers following radiotherapy, which unfortunately increases cancer risk and causes cell death.

Burn Injury Nursing Care

A patient with burns is ideally kept in a positive-pressure room when hospitalised. Positive-pressure rooms have higher air pressure than the adjoining areas, preventing airborne pathogens from entering the room to avoid the air inside becoming contaminated. This reduces the risk of burn patients acquiring infection and causing further complications in their healing process.

Shock and Fluid management

In patients with critical burns, shock causes progressive failure of the circulation, leading to a decrease in oxygen perfusion within the vital organs. Fluid resuscitation aims to:

maintain vital organ function especially when it comes to renal function
replace fluid lost within the first 8 hours following burn infliction

Fluid Resuscitation Formula – Hartmann’s

4ml x weight x affected Total Body Surface Area (TBSA)

to be administered over the first 24 hrs

(Half of the prescribed volume should be administered over the first 8 hours from burn infliction, with the rest over the following 16 hours)

CRYSTALLOIDS VS COLLOIDS

The most commonly used resuscitation fluid for initial resuscitation is the Ringer’s Lactate (Hartmann’s) or other crystalloids. Crystalloids make up a balanced solution which helps balance electrolytes in large fluid replacements.

When compared to colloids, crystalloids have a less prominent affect of volume expansion, however colloids tend to exacerbate third space losses. In burn patients, colloids (commonly used being albumin) are added to decrease the total volume of resuscitation fluid needed, since these reduce capillary leakage. Albumin is however commonly used as a rescue approach since it increases mortality in critically ill patients. Albumin:

reduces fluid creep (fluid overload)
tends to cause haemodynamic instability – hypotension, oliguria, and increasing haematocrit

If Albumin is indicated as an adjunct to the fluid resuscitation protocol, it should replace HALF of the crystalloid amount.

URINE OUTPUT

Urine output is vital for indicating successful fluid resuscitation. A urine catheter should be inserted whenever fluid resuscitation is being performed, since in burn patients, the nurse needs to monitor:

urine output
heart rate
blood pressure
ABGs
pH (patient may experience lactic acidosis)

Expected Urine Output in Patients Undergoing Fluid Resuscitation:

Adults: 0.5ml/kg/hr

Children: 1.0ml/kg/hr

NOTE: fluid resuscitation increases oedema. Fluid formulae should only be used as guidelines, and fluid calculations need to be calculated from the time at which the burn was inflicted. Ideal fluid resuscitation should include the LEAST amount of fluid necessary to maintain tissue perfusion, maintain vital physiological functions, and return physiology to normal as soon as possible.

Retrieved from https://slideplayer.com/slide/13463859/ on 23rd January 2023

THE GASTROINTESTINAL SYSTEM OF A PATIENT WITH BURNS

In burn patients, the liver’s function forms part of the systemic response to the burn injury, excreting glucagon and inflammatory markers.

Secondary Abdominal Compartment Syndrome (SACS) is a common crystalloid resuscitation complication caused by increased intra-abdominal pressure which may cause a secondary organ infarction if ignored. Typically, a patient with SACS has reduced urinary output which may also be bloody.

To avoid SACS, the patient’s intra-abdominal pressure should be measured, either via the patient’s bladder, or by measuring the intra-vesical pressure.

cleaning the burn Injury

a new burn is considered to be sterile, thus, it is important to attempt to keep it that way
clean thoroughly with an antibacterial wash eg. betadine surgical scrub
antibiotics should not be prescribed as prophylaxis, but only if infection is noted (a temperature of up to 38.5°C is considered to be normal in patients with burn injuries)
de-roof and debride large blisters UNLESS they are located on the palms or soles of the feet due to excessive pain as well as superficial nerves, to which debridement may cause irreparable problems
debride any dead skin to promote healing

Change of Dressings

in the initial stage, dressings should be changed daily, especially since at this stage these are usually found soaked
once healing starts to progress, change of dressing should be performed every 3-5 days, however, if the wound becomes painful, smelly, or soaked at any time, it should be immediately changed

Further care

encourage daily moisturiser application eg. aqueous cream
encourage sunblock use over healed areas for 6-12 months
advise patient that pruritus is a common problem following burn injury, and that advise should be sought if this becomes problematic
provide patient with support and reassurance, without any false hopes

NOTE: unhealed burns lasting 3 weeks should be referred to the Burns Unit.

Renal Failure

Renal failure in a patient with burns is usually a late septic complication, especially since within the acute stage the patient would be receiving aggressive fluid resuscitation. To avoid such complication, haemofiltration is commonly considered in large burn injuries. Renal failure signs include:

oliguria of <4o0ml per day
a decline in the GFR
a rise in Urea and Creatinine

A patient needing kidney relief may be put on the PrismaFlex System.

Patient Education on Burns First Aid Care

always aim to stop the burning process by removing the heat source and any affected clothing
if clothes catch on fire, “STOP, DROP & ROLL”
put burn wound under running water for 20 minutes following a burn injury
protect the burn by covering it with a sterile non-adhesive bandage
manage pain through analgesia eg. paracetamol
DO NOT use ice water since this causes vasoconstriction, leading to burn progression
DO NOT apply any creams or ointments to burn injuries since these may cause further complications

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