Unit 3: Burns: Intermediate Phase

Question 1

When does the Intermediate Phase Start?

Answer 1

• after resuscitation and stabilization has been achieved

- 48 to 72 hours after initial burn injury

Question 2

Management Priorities in the Intermediate Phase

Answer 2

• wound healing and closure
• pain management
• ensuring optimal nutrition
• continued prevention on infection
• continued assessment and management of respiratory and circulatory status

Question 3

Wound Care Practices

Answer 3

• Hydrotherapy
• Clean technique and infection Control
• Topical Medicines and Wound Dressings
• Mechanical and Enzymatic Debridement
• Surgical Debridement and Wound Closure

Question 4

Hydrotherapy

Answer 4

• favored cleansing method; allows for thorough wound cleansing
• uses water during dressing changes to assist in the removal of residual topical agents and necrotic tissue
• used to involve immersion into tank or tub of water; begun using portable shower trolleys covered w/ disposable plastic liners to help prevent spread of infection and cross-contamination

Question 5

Clean Technique

Answer 5

• burn wound care is a clean technique; not sterile
• involves using techniques to reduce the overall number of microorganisms, such as preparing a clean field and using clean gloves and instruments

Question 6

Wound Care: Clean Technique

Answer 6

• burn wound care is a clean procedure (not sterile)
• clean technique: using techniques to reduce the overall number of microorganisms, such as preparing a clean field and using clean gloves and instruments
• burn wound care is extensive, physically exhausting, with some dressing changes lasting up to 2 to 4 hours
• dressings changes occur in patients rooms that are set as high as 90 degrees to prevent risk of hypothermia

Question 7

Wound Care: Infection Control

Answer 7

• during every dressing change, it is essential that both the nurse and the physician assess the burn wound for progression of healing and evidence of infection
• dressing change is the ideal time for the physical and occupation therapists to assess the wound, as well as to observe the patient’s function and range of motion

Question 8

Wound Care: Topical Medicines and Wound Dressings

Answer 8

• numerous variations of topical medicines and wound dressings
• choice is dependent on wound depth, location of the injury, presence of infection, and provider preference
• special care is taken when wrapping fingers and toes b/c they must be dressed individually to prevent webbing (the growing together of the skin between the fingers and toes)

Question 9

Mechanical and Enzymatic Debridement

Answer 9

• the preferred method of wound cleansing involves the use of a mild soap or chlorhexidine and water along with gentle debridement of the burn wound
• 3 kinds of debridement: mechanical, enzymatic, and surgical
• while cleansing, removal of the loose tissue is important to allow for proper visualization of the burn wound and is accomplished through the use of tweezers and scissors and is often aided by the removal of gauze dressings and hydrotherapy
• if mechanical and enzymatic debridement are not effective, surgical debridement is necessary

Question 10

What does the preferred method of wound cleaning involve?

Answer 10

use of mild soap or chlorhexidine and water along with gentle debridement of the burn wound

Question 11

Enzymatic Debridement

Answer 11

• involves the application of a proteolytic ointment that hastens eschar separation and wound healing
• reserved for patients with deep-partial thickness wounds where signs of healing are evident; also used in full thickness burns where patient is not a candidate for surgery

Question 12

Burn Excision

Answer 12

• considered as soon as the patient is hemodynamically stable and able to tolerate the procedure
• not uncommon for the patient with a large full-thickness burn to be taken to the OR for excision and grafting within 24 to 48 hours of admission

Question 13

Autograft

Answer 13

• ideal replacement for lost skin
• patient’s own skin and will not be rejected by the body
• the epidermis and a partial layer of the dermis (split-thickness skin grafts) are harvested from an unburned area (donor site)
• common donor site: Thigh; any site may be utilized (scalp and scrotum if necessary)
• once healed, donor sites may be harvested numerous times
• these split-thickness skin grafts are then applied to the excised wound in the form of a sheet or meshed graft

Question 14

Sheet Grafts

Answer 14

-utilized on exposed areas of the body (face and hands) b/c they give a more seamless and cosmetic appearance due to the fact that the grafts are not meshed

Question 15

Meshed Graft

Answer 15

• have holes placed in them that allow for expansion

- skin grafts are meshed when unburned skin is in short supply in order to provide maximal wound coverage and closure

Question 16

Allograft

Answer 16

• cadaver skin
• a temporary covering
• eventually rejected by the body and is replaced by the patient’s own skin
• used in extensive burns where there is not enough unburned tissue to harvest
• with the placement of a allograft as a temporary covering, there is decreased evaporative loss of heat and better pain control for the patient, and it provides a barrier against bacterial growth

Question 17

Xenograft

Answer 17

(pig skin); or bovine (cow) skin

• used when allograft is not available
• temporary
• used as a temporary covering once eschar is removed to help close and protect the wound
• will eventually reject and have to be replaced by permanent grafting

Question 18

Cultural Epithelial Autograft (CEA)

Answer 18

• permanent
• considered only in the most severely burned patients where there is no other alternative b/c the patient remains very vulnerable to infection, and the CEA skin is extremely fragile
• involves a biopsy taken from an area of unburned skin and then sent to a laboratory where, over a 2-week period, epithelial cells are grown in the lab and attached to petroleum impregnated gauze
• excision of the burn wound is not delayed while waiting for the CEA, and ideally, the wound is excised, and an allograft is placed as a temporary covering
• CEA is extremely delicate b/c it involves the growth of only the epidermal layer
• after placement on CEA, patient is often placed in traction, which allows elevation of extremities and pressure relief
• patients then require extensive one-on-one nursing care that focuses on time-consuming wound healing and infection control

Question 19

Pain Management

Answer 19

• for background, procedural, and breakthrough pain
• plan of care is individualized
• pharmacological/non-pharmacological
• IV narcotics (morphine sulfate [morphine], fentanyl [Sublimaze], ketamine, and/or hydromorphone [Dilaudid])
• IV narcotics considered while pain is severe and unrelenting
• all efforts are made to transition to oral pain medicine as soon as tolerated
• given on a scheduled basis instead of PRN b/c this helps to better manage pain over time and hopefully prevents it from being intolerable

Question 20

Safety Alert: When giving large doses of IV Pain Medication

Answer 20

when giving large doses of IV pain medication, especially during dressing changes, ensure that proper ventilatory support and emergency equipment are immediately available

Question 21

Nutritional Support

Answer 21

• large burn injuries place the patient in a prolonged hypermetabolic and catabolic state, resulting in an increased caloric need to assist in wound healing
• early enteral nutrition is associated w/ a reduction in ileus and stress ulcers b/c it reduces the inflammatory mediators released by the body
• once a person has sustained a burn of approximately 20% or greater, it is difficult to consume the amount of calories an protein needed for wound healing, and nutritional supplementation is often required b/c of the fact that his/her metabolic rate is greatly increased as a result of the burn injury
• in large burn injuries, longer nutritional support is required
• supplemental vitamins and minerals
• placement of NG tube

Question 22

How is Nutritional Supplementation Achieved?

Answer 22

• placement of a Nasogastric Tube (NG Tube); feedings can be given continuously or intermittently in the form of a bolus
• in large burn injuries, longer nutritional support is required; placement of a duodenal feeding tube is recommended to help prevent aspiration and allow for feedings up to and during procedures
• supplemental vitamins and minerals often administered to promote wound healing
• TPN not utilized

Question 23

Prevention of Infection

Answer 23

• most common cause of death after the emergent phase is infection resulting in sepsis and multisystem organ failure b/c these patients have lost the largest protective barrier, the skin
• prohpylatic antibiotics NOT recommended; treatment is based on positive culture results
• isolation guidelines
• proper hand-washing
• some burn centers use contact precautions

Question 24

Connection Check: The nurse anticipates supplementary feedings via a nasogastric tube in a patient for which reasons? (select all that apply)
A. Hypermetabolic state
B. Multiple open wounds
C. Increased heat loss
D. Increased caloric needs
E. Burn greater than 20% TBSA

Answer 24

A. Hypermetabolic state
B. Multiple open wounds
D. Increased caloric needs
E. Burn greater than 20% TBSA

Question 25

Nursing Management: Assessment and Analysis

Answer 25

-as the patient progresses into the intermediate phase after successful resuscitation, the priorities expand to wound management and infection control
-requires close observation of respiratory status and hemodynamic stability
>Nurse monitors for:
-wound color and consistency
-wound drainage
-eschar
-responses to therapeutic interventions
-graft sites
-pain
-weight
-serum total protein and albumin
-infection

Question 26

Nursing Diagnoses

Answer 26

• Risk for infection r/t impaired immune response and loss of skin integrity
• Altered nutrition less than body requirements r/t hypermetabolism and burn injury
• Acute pain r/t exposure of nerve endings in wound bed and wound-care procedures
• Anxiety r/t painful wound-care procedures
• Self-care deficit r/t impaired mobility due to the burn injury
• Powerlessness r/t hospitalization and inability to care for self

Question 27

Nursing Assessments during the Intermediate Phase of burns

Answer 27

• Vital Signs
• Daily Weight
• Daily caloric intake
• Total protein and albumin levels
• WBC count
• Wounds for signs of healing and clinical manifestations of infection
• Pain and Anxiety
• Participation in plan of care and ADLs

Question 28

Assessments: Vital Signs

Answer 28

• elevated heart rate may be secondary to sustained hypovolemia, as well as pain and anxiety
• respiratory rate and blood pressure may also be elevated secondary to pain and anxiety
• temperature may be elevated d/t infection
• patient needs to be assessed for hypothermia, particularly with large burns that can lead to increased loss of heat through the open wounds

Question 29

Assessment: Daily weight

Answer 29

increased metabolic rate may result in weight loss

Question 30

Assessment: Daily caloric intake

Answer 30

increased metabolic rate results in an increased caloric need to assist in wound healing

Question 31

Assessment: Total Protein and Albumin levels

Answer 31

• assessment of nutritional status includes monitoring total protein and albumin levels
• Normal serum total protein: 6 to 8 g/dL
• Serum albumin: 3.4 to 5.1 g/dL

Question 32

Assessment: WBC count

Answer 32

loss of the protective mechanisms d/t burn injuries increases the risk of infection, and an elevated WBC count may indicate infection

Question 33

Assessment: Wounds for signs of healing and clinical manifestations of infection

Answer 33

• if the burn wound is not showing any evidence of healing, surgery may be indicated, or a change in wound-care regimen may be warranted
• with the loss of the skin as a protective barrier, the patient remains at constant risk for infection resulting from the invasion of microorganisms

Question 34

Assessments: Pain and Anxiety

Answer 34

pain associated with daily dressing changes places the patient at risk for tachycardia and hypertension

Question 35

Assessments: Participation in plan of care and ADLs

Answer 35

important for the patient to be actively involved in the plan of care and to understand the rationales for all interventions

Question 36

Nursing Actions in the Intermediate phase of Burns

Answer 36

• Time medication administration so that the patient receives the full benefit during wound-care procedures
• Give pain medication on a scheduled basis instead of on as as-needed (prn) basis
• Explore the effectiveness of nonpharmacological pain relief of techniques, such as music therapy and guided imagery
• Calorie counts and encouragement of oral intake
• Wound care
• Assist w/ ADLs and compliance with rehabilitation exercises

Question 37

Actions: Time medication administration so that the patient receives the full benefit during wound-care procedures

Answer 37

procedural pain is often the most intense pain associated with a burn injury, and medication must be timed to allow for maximum absorption, as well as to time the most painful procedures during the peak effectiveness times of medications

Question 38

Actions: Give pain medications on a scheduled basis

Answer 38

• assists in effectively managing pain and allows a steady state to develop within the body
• provides the patient with more consistent pain relief

Question 39

Actions: Explore the effectiveness of nonpharmacological pain relief techniques, such as music therapy and guided imagery

Answer 39

-nonpharmacological techniques have been shown to assist in the reduction of procedural burn pain and anxiety

Question 40

Actions: Calorie counts and encouragement of oral intake

Answer 40

maintenance of caloric needs is essential in determining whether adequate nutrition is provided for wound healing

Question 41

Nursing Teachings

Answer 41

• Instruct the patient to request additional pain medication when needed and not to delay until the pain is intense
• Provide information to the patient and family about the natural progression of burn wounds, grafts, and/or donor sites
• Provision of a rehabilitation plan and discussion of the importance of doing ADLs and rehabilitation therapy
• Education on the importance of nutrition and provision of a diet plan

Question 42

Evaluating Care Outcomes

Answer 42

• during intermediate phase, there are additional priorities for the nurse to focus on: adequate nutrition, pain management, wound healing, and infection control
• stable body weight, and normal albumin and total protein levels = improving nutritional status
• effective pain management is supported by stable vital signs, as well as the patients report of adequate comfort
• patient comfortable enough to participate in ADLs and understands the importance of asking for pain medications prior to pain becoming intolerable
• effectiveness of wound management is determined by evidence of the healing of burn injuries as well as no signs of infection
• stable vital signs (normal HR and BP) are consistent with adequate fluid volume status and pain management
• normal temperature and normal WBC support a lack of infection

Question 43

Background Pain

Answer 43

underlying pain from the primary injury that is continuous and ongoing

Question 44

Breakthrough Pain

Answer 44

pain related to specific episodes associated with activities of daily living (ADLs), such as walking

Question 45

Procedural Pain

Answer 45

pain associated with therapeutic activities such as wound care and physical therapy