Advanced Paediatric Nursing. Burn Trauma. 26 April Wong Tze Wing NC (Burns), Burns Centre, Surgery, PWH

Transcription

1 Advanced Paediatric Nursing Burn Trauma 26 April 2016 Wong Tze Wing NC (Burns), Burns Centre, Surgery, PWH

2 Objective: Understand burn trauma in children Understand Important nursing interventions in burn management

3 Service Networking of Burn Service HAHO Operations Circular No. 9/2007 ( updating 2016) Burn units: Major burns PWH QMH Burn facilities: Moderate-sized or complex burns QEH TMH KWH General Surgical / O&T / A&E: Minor burns

4 Burn Unit Referral Criteria Major burn Adults 20% TBSA burn Children ( 12 yr. old) 10% TBSA burn Burn with inhalational injury need ICU care Burn with major functional and/or cosmetic implications Burn patients with significant pre-existing medical disorders Exclude- Pure inhalation injury without skin involvement

5 Burn facility referral criteria Burn > 5% BSA Burn involves: face, hands, feet, genitalia, perineum, major joints Full-thickness burn Electrical burn Chemical burn Burn with inhalational injury Circumferential burn Burn at extremes of age Burn patients with pre-existing medical disorders Exclude- Pure inhalation injury without skin involvement

6 Response plan for Admission of Multiple Major burn Admission of 4 patients with major burn

7 Advanced Burn Life support PRIMARY SURVEY - Airway with cervical spine control - Breathing & ventilation - Circulation- full-thickness burns & circumferential burn - Disability, Neurologic Deficit - Exposure, Environmental control STABILIZATION - Fluid resuscitation - Analgesics - Investigations - Insert urinary catheter & nasogastric tube SECONDARY SURVEY - History- mechanism of injury, time of accident, non-accidential injury - AMPLE - Head to Toe exam. - Immunization status- Tetanus - Extent of burn - Depth of burn

8 Types of burn injury Scald burn Flame burn Chemical burn Contact burn Electrical burn Radiation burn Cold burn + Associated injury

9 Lund and Browder Chart Chart for Estimating Severity of Burn Wound REGION % PTB HEAD NECK ANT. TRUNK POST. TRUNK RIGHT ARM LEFT ARM BUTTOCKS GENTALIA RIGHT LEG LEFT LEG TOTAL BURN % FTB Relative percentage of body surface area affected by growth AGE ADULT AREA A=½ OF HEAD 9½ 8½ 6½ 5½ 4½ 3½ B=½ OF ONE THIGH C=½ OF ONE LEG 2¾ 3¼ 4 4½ 4½ 4¾ 2½ 2½ 2¾ 3 3¼ 3½

10 Depth of Burn Epidermis Dermis - capillaries - nerves - collagen & elastin fibres Burn Wound Healing = re-epithelization Erythema Superficial Superficial partial thickness Sebaceous gland Hair follicle Sweat gland Subdermal fat Deep partial thickness Full Thickness

11 Erythema Involve epidermis No blisters Very painful Apply lubricant Sunburn

12 Superficial burn Involve epidermis & superficial Wound pale pink Extremely painful Fine blisters formation Dead epidermis slough off Replace by regenerating keratinocytes Heal within 3 4 days

13 Superficial partial thickness burn Involve epidermis & part of dermis Form larger blisters Wound - pink & wet Hypersensitive to touch Blanch with pressure Heal within 2 3 weeks

14 Deep partial thickness burn Involve deeper part of dermis Form blisters & rupture Wound mottled pink & white immediately follow injury Feel pressure on wound Capillary refill become slowly Less sensitive to pinprick Next day- white in color & dry Heal in 3 weeks or more Critical for healing

15 Full thickness burn Involve entire dermis & subcutaneous tissue, muscle & bone Wound- charred, leathery, firm & depressed No blister No capillary refill Common in Flame burn Hypertrophic scar formed

16 Burn Wound Management Superficial Superficial partial thickness Conservative treatment Deep partial thickness Full thickness Debridement & Skin graft

17 Case study 1 Ah Ying, F/12, Primary school student LPG gas stove caught fire and explosion in kitchen, fire extended to living room She was staying in living room and she caught fire She sustained 14% flame burn to her face, both forearms & both lower limbs She managed to get out of the house

18 What are the problems?

19 Problem 1: Impaired tissue perfusion Assess peripheral circulation hourly Elevate burn extremity to promote venous return Active & passive mobilization

20 Problem 2: Fluid & electrolyte imbalance Modified Parkland formula in first 24 hours: Crystalloids (Hartmann s sol.)- 4 ml x kg BW x % TBSA burn + daily maintenance (First 10 kg 100ml/kg kg 50ml/kg + 20 kg onwards 20ml/kg) Half volume administered in first 8 hours Remaining half volume administered in 16 hours Observe during infusion Monitor urine output hourly with urinary catheter: 1 ml / kgbw / hour

21 Fluid in 24 hours Hartmann s sol: 4ml x 45 x = 4520 ml First 8 hrs: 2260ml 8 = 282ml /hr 9 th -24 th hrs: 2260ml 16 = 141ml/hr Minimal urine output: 45 ml/hr

22 Problem 3: Pain Pain assessment & evaluation VAS Administer analgesics for procedure pain & background pain Provide emotional support

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25 Problem 4: Impaired Skin integrity Provide bathing daily Maintain aseptic technique during dressing Perform wound dressing use Porcine skin and Amniotic membrane Observe for signs of infection Evaluate wound progress Provide nutritional support

26 Problem 5: Impaired Physical mobility Assess factors: wound pain & limb edema Encourage active and passive range of exercise taught by Physiotherapist Administer analgesic before exercise Position the affected joints correctly Encourage support from relatives

27 Problem 6: Fear & anxiety Encourage expression of concern & needs Provide emotional support Explain reason for treatment & procedure Encourage relatives to help patient to cope with problems Consult Clinical psychologist

28 Discharge Ah Ying was discharged on with follow up Good wound progress Continue skin care with Aqueous cream Avoid sunlight - pigmentation

29 Case study 2 Ah Kin, M/ 7 m. baby His grandmother put a bucket of hot water in the living room, then went into kitchen Suddenly, she heard baby crying and found baby was lying on the floor in supine position The bucket was toppled over his side and hot water was spilled out onto his body He got 28% scald burn to left face, neck, left upper limb, left shoulder, upper back & left thigh

30 What are the problems?

31 Problem 1: Impaired tissue perfusion Assess peripheral circulation hourly Elevate burn extremity to promote venous return Beware of compartment syndrome Passive exercise

32 Problem 2: Fluid & electrolyte imbalance Modified Parkland formula in first 24 hours: Hartmann s sol. 4ml x 10 x 28 = 1120 ml Maintenance: ½ NSD5 sol. 1000ml First 8 hrs: Hartmann s sol. 560ml 8 = 70ml /hr ½ NSD5 sol. 41 ml/hr 9 th -24 th hrs: Hartmann s sol. 560ml 16 = 35ml /hr ½ NSD5 sol. 41 ml/hr Minimal urine output: 10 ml/hr Adjust the rate A/C to UO Administer 5% Albumin in PBD 2

33 Problem 3: Potential for infection Maintain Infection Control Policy Perform wound dressing with strict aseptic technique Obtain wound swabs for culture & sensitivity test Observe signs and symptoms of septicemia Administer antibiotics or topical antibacterial agents Provide adequate nutritional support Restrict visitors

34 Problem 4: Pain Assessment of pain Faces Pain Rating scale or FLACC Provide rest and comfort Elevate burned extremities Observe for psychophysiological response - heart rate, crying, irritability, abnormal sleep pattern Provide analgesics & evaluation Provide support to parents Consult Pain Team

35 Problem 5: Nutritional Insufficiency Provide high protein and high calories diet Strict Intake and Output chart Consult dietitian Provide Vitamins & minerals Monitor body weight Encourage home food Maintain oral hygiene

36 Problem 6: Deep & extensive burn wound Provide bath daily Maintain aseptic technique during dressing Perform wound dressing- AM to facial wound Perform skin grafting to left upper limb and neck wound (PBD 4) Protect skin graft and donor site Observe for signs of infection Provide nutritional support

37 Problem 7: Caregivers knowledge deficit in wound healing & treatments Involve family in daily care and rehabilitation Demonstration & return demonstration Reinforce continue of pressure garment Visit by Burn patient support group Teach on prevention of future burn accidents

38 Discharge Ah Kin was discharged on with follow up Refer to Physiotherapy for exercise Refer to Occupational therapy for scar management FU in Burns Nurse Clinic & Paed. Burns Clinic

39 Burn Nurses work in collaboration with multidisciplinary team of experts to support ongoing care of Burn patients

40 Reference: 1. Barret-Nerin & Herndon (2005) Principles & Practice of Burn Surgery. Marcel Dekker, New York. 2. Chiu T. & Burd A. (2005) Xenograft dressing in the treatment of burns. Clinics in Dermatology. p Herndon D.N. (2012) Total Burn Care (2 nd edition). W.B. Saunders Company. London. 4. Seyed N.H., Seyed N.M. & Mojtaba F. (2007) Xenoderm dressing in the treatment of Second Degree Burns. Burns (33) p