Acute Care Nursing for Burns
Introduction
Acute care nursing is a type of nursing service that is administered to patient actively for a short period. It involves short term treatment of life-threatening injuries, routine health problems, illness, acute exacerbation of chronic diseases, and recovery from surgery. The main aim of acute care nursing is to improve and restore the health of the patient, and it is practiced in various areas including emergency care, trauma care, critical care, acute psychiatric care, acute care surgery, and rehabilitative care. The setting in which the care is provided is closely associated with the possibility of patient declining without warning. Therefore, the role of a nurse is to provide rapid intervention to injuries, and illnesses that are time-sensitive to prevent death or disability that may result and thus restore the health of the patient to the optimal, and better health status.
This paper will describe a case scenario of a patient who is admitted to the emergency care room and then identify two core acute care nursing concepts from it. It will describe the fluid loss and subsequent fluid replacement under ‘F,’ meaning fluid and management of wound under ‘E,’ representing exposure both in the A-G algorithm. The paper introduces the case scenario and describes the previous management of the workplace system.
In addition, the paper also describes the strength and weaknesses of the nursing interventions that are carried out by the nurses while comparing with the best practice guidelines in place with a critique of nursing care against the evidence-based practice.
Case scenario
A 45-year-old male client working in a chemical laboratory was brought to the health facility by an ambulance with a history of chemical spillage (Trifluoroacetic acid) while working. On assessment, the Total Body Surface Area (TBSA) was at 45% and a degree of burns between 2nd and 3rd degree. The regions of the body affected include; anterior upper both limbs, anterior trunk, and anterior both lower limb. The patient has a medical history of type-I diabetes mellitus, which has lasted for the past 30 years and well-controlled until three months ago. The client also has a history of hypertension and GABG surgery done six years ago.
On triage examination, there is a facial grimace, and the patient reports severe pain on the chest, abdomen, and anterior upper and lower limbs which he rates 10, in the scale of 0-10 with 0 being no pain and 10 being the worst pain he had ever experienced n his life. The patient also looked nervous during the process. The patient vital signs were taken and found to have a blood pressure 90/50mmHg, heart rate of 120 beats per minutes, the temperature of 39.6°C, respiratory rate of 25breaths/minute and oxygen saturation of 93%. The vitals, therefore, showed the presence of tachycardia, hypovolemia due to fluid loss, hyperthermia, tachypnea, and low oxygen saturation. The initial laboratory investigations, including baseline, HB, hematocrit, electrolytes, blood glucose, and urine analysis, were done.
During the examination, the A-G algorithm had also been checked according to the policies of the hospital, and therefore, oxygen 6ml was administered by a mask to improve on the oxygen saturation level. There were no signs of paralysis or weakness noted in the patient. All the patient clothes that were contaminated by chemical were removed and the area flooded with cold and running water for 20 minutes. The patient was also put on intravenous (IV) fluid (Ringer's lactate solution) to restore the fluid volume deficit based on the Modified Parklands resuscitation protocol for adults. The glucose levels for the patients were also checked and found to be 300mmol/l. The pain was effectively managed with Morphine IV 15ml and 50 mg IV ketamine.
In addition, after the initial management in the emergency department, the patient was attended by a surgeon to examine the wounds according to the policies of the hospital, and later the wound was closed with a biosynthetic dressing. The patient was then taken to the burns unit in the hospital after dressing care, insertion of a urinary catheter, and a central venous line for close monitoring.
The case scenario is complicated due to the multiple health conditions affecting the client and also the complex care needs that the client requires. The patient suffered from disease co-morbidities due to the loss of the fluids and presence of the burns, which thus had a significant impact on his health. Additionally, the patient also sufferers from diabetes mellitus, which have a high effect on the wound healing process, thus making the condition to be considered as complex. Presence of hypervolemia affects the levels of ketones in the body, predisposing the patient to diabetic ketoacidosis. The wounds will thus heal slowly and poorly and might also be infected.
Concepts
Fluid loss
Fluid balance is one of the critical aspects that need to be maintained to maintain the homeostasis of an organism, and it is controlled through behavioral and osmoregulation. Individuals with severe burns widely experience fluid volume deficit due to fluid loss, and thus, it is one of the most crucial factors to note during the admission of the burns patients. Presence of extensive burns results in fluid extravasation and hypovolemia, and thus, there is a need for fluid replacement within the first 1-2 days after the burns incident. Fluid resuscitation has been considered as one of the essential factors in the management of burns. This is because it restores the amount of fluid loss and aid in the prevention of dehydration.
However, controversies are present on the type of fluid to be used for fluid management within the first 24 hours following the burns injury. The amount of fluids to be administered to the patients of burns depends on the TBSA, which, according to the case scenario, the rule of nine was used in determining the surface area of the injuries. However, according to last et al. (2015), the most accurate method to use in calculating the total body burn is Schema for estimation of body surface area in adults because it is more specific and provides the exact amount of fluid that the client needs.
Furthermore, burns injuries which are less than 15% are not associated with a significant shift in body fluids and thus, the client can be resuscitated with oral fluids except burn injuries that occur in the face, the genitalia, children, the elderly and the hands. In the cases of burns with the surface area of more than 20%, the route of choice for rehydration is intravascular, and in the cases where the peripheral intravenous access cannot be found, central venous catheterization must be done and used to deliver the fluids.
The “Modified Parkland” formula is the most commonly applied formula in calculation of the number of fluids required in the resuscitation of the patient. The formula calculates the amount of fluid based on the percentage of the injury. In the case scenario of the patient described above, the amount of fluid was calculated based on the formula;
Total ml = 4ml* weight in kg* % TBSA
After the administration of the fluid calculated above for the first eight hours following the burn injury, the fluid is reduced to half the total calculated fluid needed for the best clinical practice based on the Agency for clinical Innovation 2014. The fluid administered to the client in the case scenario is Ringer's lactate. However, according to Bedi et al. (2019, it is not the best fluid to be used in maintenance due to its low levels of sodium and potassium, 130 mEq/L and 4 mEq/L respectively. This is due to the daily body electrolytes requirements. Ringers lactate also does not have any glucose content in it, which would have provided the body with calories. Therefore, normal daily saline needs to be added to the daily maintenance dose with ringers lactate to act as a replacement for the evaporative losses that result after burns. In the case above, it is clear that the intervention that was made had a weakness in restoring the level of the electrolyte of the client and also to aid in the provision of enough calories.
The use of opioid medication should be under close consideration, for example, in the case of morphine and ketamine drugs, because of the effect on the cardiovascular system. Opioids are associated with decreasing the blood pressure of an individual. The comparison emphasized that the fluid requirements in the patient should be correlated with the opioid dosage and therefore, the fluid creep was as a result of an increase in the usage of narcotics in the initial management of burns.
The shift in the fluid after burn injury is mainly considered to be rapid during the first 24-72 hours, and thus, determination of serum electrolytes, hematocrit, osmolality, glucose, calcium, and albumin are important in adding in determination of the suitable method for fluid restoration. The ratios for the fluid intake and output are taken hourly as a method of tracking the individual fluid requirements. Urine output is the most significant indicator, and it is done every hour.
Also, patients with significant burn injuries should be carefully and monitored with continuous electrocardiography, frequent vital signs recording and monitoring for positive patient outcome. In addition, acute renal failure has been found previously with severe burn injuries. Its first form is claimed to occur within the first few hours after the injury, and it has been related closely to low fluid volume with low cardiac output and systematic constriction of veins occurring during resuscitation. Fortunately, this form of acute renal failure has become less prevalent due to the presence of well controlled fluid resuscitation that is done during the initial phase of the management of burns.
Wound management
Burns injuries are common in Australia and New Zealand, and it affects at least one person in 100 people. The injuries from heat, electricity, chemicals, radiation, and also from cold result to the development of wounds. Burns are usually classified by depth into partial thickness, superficial, and full-thickness burns (all of the dermis is destroyed, it may also extend to include the subcutaneous, neuromuscular, muscular or skeletal structures).
According to the agency for clinical innovation, the burn area is flooded with cool running water and not cold unless there are contraindications such as significantly extensive burns, hypothermia, and presence of multiple traumas. This is the hospital policy concerning the best clinical practice for the management of burns wound. Cold water is associated with increased tissues damage and increasing the severity of hypothermia. However, it contributes to the reduction of pain and also edema of the wound
The ideal wound dressing will provide the perfect microenvironment to facilitate the healing process of the injuries. Wound healing process occurs well in an environment that maintains the temperature of the wound its moisture level, allows for respiration, permits epithelial migration, and prevents the entry of bacteria into the wound. The rate of healing of the wounds depends on the layers of the skin that were damaged from the injury; superficial burns heal faster than those involving the deeper layers of the skin.
In addition, biosynthetic dressing in comparison with silver sulfadiazine cream may be more effective in speeding the healing process of the partial-thickness burns. The frequency for changing the burn wound dressings have to be regular for most of the dressings done. In addition to dressing, the deep wounds are cleansed, and debridement is done as standard care before it is then covered. After that, the wound dressing is done daily together with pain management to prevent unnecessary discomfort that that can be felt by the client during the routine care delivery, this is usually done for patients who have 1st and 2nd-degree burns.
The type of dressing that was used for the patient in the case scenario is biosynthetic and contained the biosynthetic contents, Eiratex®, which contains biosynthetic cellulose (BC) having same structure like the collagen. Studies concerning its use for drug delivery, biomedical purposes, wound healing, and tissue engineering, and it is not the ideal one due to the fact that exudate and other fluids draining from the wound can be trapped in the interspace that lies between the burn wound and the membrane. The materials stuck in the interspace might cause infection of the wounds and thus slow the process of healing, especially for the patient because of the diabetes mellitus. Wound examination was done every day by nurses on duty and every two days by attending doctor until the wounds were healed entirely. Proper wound dressing type is vital and depends on the nature of the injury such as the size, depth, frequency of dressing, and status of the wound bed.
According to Jull et al. (2015), there is evidence suggesting that honey dressing contributes to the healing of the partial thickness burns faster than the conventional dressing. It is good to note that burn wound undergo various changes especially in the first 48 hours and for this reason, there is a need for the caregivers in the health care team to performs wound assessment before making the necessary decision on the type of dressing method to choose or the need for surgery.
Conclusion
In conclusion, injuries resulting from burns are usually severe, and therefore, there is a need for more effective interventions to improve the healing process and prevention complication that results from poor management. Burns have been closely associated with a fluid volume deficit, and this means that the amount of fluid in the body is significantly reduced and therefore, there will also be a reduction in the cardiac output which might then result to hypotension and more complications. Thus there is a need for close monitoring to prevent developments of complications. Individuals who have significant burns injuries with delays in fluid resuscitation should also be investigated for the possibility of acute renal failure.
In addition, fluid resuscitation is essential. However, the amount of fluid infusion should be calculated using the most accurate formula depending on the policies of the hospital frequently; this means that before a patient is infused with any intravenous fluid, it should be calculated to avoid the issues of fluid overload through an infusion. It will also help in monitoring the functionality of the kidneys.
Furthermore, the wound resulting from burns injury needs to be adequately managed to enhance the healing process. The practice of ideal dressing depending on the nature of the burns wound is necessary because it means, the wound will achieve the essential environment that promotes the healing process such as the absence of environmental bacteria, maintained wound temperature and moisture. There is also a need to access the wound frequently because this will aid in making decisions on the intervention that can be made to hasten the healing process.
However, there is a need for more research to be done on the existing methods and also to come up with better ways to improve the current interventions in order to improve the quality of care delivered to the clients, for example, ways to reduce wound infection resulting from dressing methods.
