Transcript body lewis
Case study on acute burn injury from an explosion by Ancy Biju & Bindu Alukkal Poulose BURN . Introduction Mr X is a 21 years old female patient admitted to Emergency Department with approximately 40%of Body Surface Area (BSA) burns on 10th July at 0450hrs. Patient assessed by doctors and interventions started for burn and pain. To measure the severity of burn, some mandatory tests checked out. On Assessment of Mr X Following details found on examination of Mr X in ED Partial thickness burns of upper thigh(15%) & abdomen and anterior chest (18%) Circumferential burn to left arm (8%) Deep burns on lower left arm Singed face-nasal hairs and eyebrows She was experiencing too much pain Vital signs Initial Vital signs of Mr X was BP - 100/50 mm of H SPO2 - 93% on room air Pulse – 120/minute Respiration- 28/minute Weight - 62 kg What is Burn - Burn is injury to tissues caused by the contact with heat, flame, chemicals, electricity, or radiation. First degree burns show redness; second degree burns show vesication; third degree burns show necrosis through the entire skin. Burns of the first and second degree are partialthickness burns, those of the third degree are full-thickness burns. Defferent types of Burn Different Types of Burn - First –Degree Burn A burn that affects the epidermis only and causing erythema without blistering. Second- Degree Burn A burn that affects the epidermis and the dermis, (extending into the reticular dermis). Also Called partial thickness burn. Third-Degree Burn A burn that destroys both the epidermis and the dermis, often also involving the subcutaneous tissue. Also called full-thickness burn. Pathophysiology The effect of burn depends on two factors The extend of body surface involved The depth of cutaneous injury. The immediate physiological effect of a major burn injury is hypovolemic shock that occurs in conjunction with cellular and immunologic disruption within a few hours of injury. Burn shock is a condition consisting of both hypovolemic cardiovascular component and cellular component Management of burn Mr X need a comprehensive nursing management for Meticulous wound healing Adequate fluid volume replacement therapy Pain Adequate nutritional support Prevention of infections and associated complication. Modulation of hyper metabolic state Early surgical excision and grafting Psychosocial support Different methods of wound management Burn treated with silver cream A soft gauze over primary dressing for protecting wound burn covered by synthetic material Silver covering used for infection control Medical procedures of Mr X Cardiac monitoring – for monitoring vital signs continuously including SPO2- because extensive tissue destruction and cell rupture delayed cardiac arrithymia or arrest may occur. ABG-to assess acid base balance and lung capacity.(PH,Pco2,Po2,Hco3and BE levels). Chest X-ray-checking the internal organs damage and Oedema and lung capacity. Check ECG -12lead ECG helps to find out cardiac arrithymia Blood tests-FBE-helps to find out hypo or hyperglycemia and the status of infection which is essential for wound healing. Blood for grouping and cross matching- blood transfusion in case of emergency. Urine analysis- monitor urine for the development of myoglobinuria, renal perfusion and urinary infection. IV canula insertion –administer medication and fluid therapy. Catheterization- to get accurate intake and output . Physical assessment of Mr X General examination according to Rule of 9 Check vital signs every half hourly. Assess airway, breathing and circulation.. Assess daily weight and fluid intake and output- for checking fluid resuscitation requirement Assess severity of pain Keep nil orally-preparing for intubation in case of emergency. Medications for Mr X Inj. Pethidine-an Opioid Analgesic (pain killer). Inj. Cephazolin-anti bacterial agent(for preventing infections) Inj. ADT 0.5 ml IM-ADT booster(for tetanus prevention) Silver Sulfadiazine- wide spectrum anti bacterial agent indicated for gram positive and gram negative organisms. Solugel - Inj.Pethidine: It is an Opioid analgesic- Ordered for Mr X to reduce the severe pain. Contraindication: Respiratory depression, severe hepatic dysfunction, brain tumour, arrhythmia Side effects: Nausea, vomiting, Respiratory depression, drowsiness, disorientation, tremor, hallucination, seizures,irritation,hypotension. Nursing responsibility: Before administering the medicine nurse monitor the vital signs especially blood pressure, respiratory rate, and pulse rate, watch for any side effects and follow the six rights of the medications .Ampoules should be protected from light before use. Inj.Cephazolin: It is a Broad spectrum anti bacterial agent- for stopping the growth of bacteria that are causing the infection. Contra indication: hypersensitivity, renal impairment. Side effects: GI upset, thrombophlebitis, nausea, vomiting, dizziness, anaphylaxis, hypotension, rash, purities. Nursing responsibility: careful routine history taken to exclude any form of allergy to avoid anaphylaxis . inspect I/V site for signs of phlebitis . Inj. ADT 0.5 ml IM – It is a Diphtheria- Tetanus Vaccine (ADT Booster). Because to prevent an aerobic wound contamination.. Side effects: Redness, Pain, swelling on the injection site. Contraindication: hypersensitivity. Silver Sulfadiazine: It is a topical anti-bacterial agent against Gram negative organisms to prevent and treat wound infection. Contraindication: hypersensitivity Side effect : local reactions ( pain, burning,& rash), and skin discolorations. Nursing Diagnosis Alteration in body structure related to burn Alteration in comfort, severe pain related to burn injury. Risk for imbalanced nutrition and high risk for infection related to skin wounds. Potential for fluid volume deficit. Patient needs psychological support Fear and anxiety related to hospitalisation and altered body image. Altered tissue perfusion related to burn injury. Nursing Management. For managing pain pethidine 50 mg IV started and after 4 dose patients feels more comfortable. After controlling pain starts Normal Saline 1000mls 2/24 for fluid level management, the antibacterial agent- Cephazolin2g IV and tetanus booster ADT 0.5 ml IM Patients blood is taken for examination. Chest X-ray done and it is clear. ABG done and waiting for result. Patients vital signs are recorded continuously and coming to normal rates, check LOC-drowsy but rousable Care plan contains 10 litres Hartman's over 24/24 to correct fluid balance. Keep nil per orally. Urinary catheter insert- to get correct input and output. Wound dressing with Silver Sulphadiazine For neck and face –solugel is applied Checked weight Discharge Planning It includes medication review Controlling infection –aseptic techniques. Pain management Diet- a nutritious diet with plenty of fluid is important in the healing process. Activity – is important to increasing circulation ,preventing loss of muscle strength and improves general well being. Wound care – teach to keep the wound clean and dry. Family education – regarding wound care Proper follow up These are the areas need to be trained by the nurses to the patient and the family. Summery Mr X admitted with acute burn, but, with proper medical management his conditions become acceptable . After few days of hospitalisation, he can be discharged with improved health status . But, still some follow-up measures take to enhance a complete cure from burn injury. A proper nursing intervention including psychological support will helps Mr X to achieve a total cure quickly. References AdrianaTiziani (2006 ) Havard’s Nursing guide to Drugs ( 7th edition ). Di Brown, Helen Edwards and Sharon L Lewis ( 2004 ) Lewis's Medical-Surgical Nursing (2nd edition). THANK YOU ALL