Random Sample of ER Burn Dressing Cases at Queensland - Research Paper Example

A random sample of ER burn dressing cases at Queensland in was done. It revealed deficiencies in the basic practices of nurses in their effort to attend to patients who complain about burns. The person served apparently wanted something to ease the pain. He wanted to feel relieved from the painful feeling of being choked, as shown by his actions and comments that tended to pressure ER Nurse-in-charge of accommodating the entry and provision of facilities for the burn patient. A sense of agitation causes the nurse to coordinate with the Doctor on duty to prescribe a pain reliever minutes after the patient has been officially admitted in the ER. This involves a Level 3 or 4 case based on the condition of the patient who can still interact with the nurse. However, that fact was not confirmed in any way. By April 7, 2011, Alison Sandy and Sophie Elsworth released government reports kept secret which stated patients die even before directly attended to by senior doctors. Documents said patients were not treated like there was an emergency. The patient was stable but choking and “symptoms included drooling, not speaking much, and dry wretching” (Sandy & Elsworth 2011). He arrived 8:09 pm. The doctor became available only after 1 hour + 11 minutes. He died 9:20 pm. The Nurse-in-charge responded to that patient by asking a resident doctor for a prescription to relieve pain. Further analysis revealed lack of proper standard operating procedures for nurses when patients complain about symptoms of burns. Nurses need to be aware of in-depth understanding of burns and how patients with the symptoms should be urgently treated within minutes of arrival at the ER. This paper provides that vital information to prevent further underestimations of burn dressing cases. Critical Analysis: Burn Dressing In the situation wherein a potential burn dressing patient was choking upon arrival at the Emergency Room (ER), there are quite a number of possible ways to properly serve the needs to relieve pain. The primary objectives include ensuring that the ability to breathe normally is not impaired, that pain can be provided relief as quickly as possible, and that wounded areas will not be infected. For conservatism purposes, although the patient appeared not in danger of death, the fact that he entered the ER means there must be an urgent reason why he was choking and feeling the pain and discomfort of choking. With some explanations for the patient, a nurse must act quickly by intubation and resuscitation. Vital signs of life must first be secured with intubation for the choking patient and also resuscitation with fluids. “Inhalation burns can cause rapid and serious airway compromise,” says Nancy Caroline (2010, p.20-8). Assessment of suspected burns-related inflammation within should be next. Other physical inspections should be included. For purposes of explaining why intubation and resuscitation should be immediately attempted, a nurse may clarify that sometimes, inflammation worsens due to chemical effect until it will be difficult to perform intubation. It would be better to secure definite access to oxygen through intubation while assessment of potential internal burns take place. A nurse will do more harm than good if no assessment is done prior to choosing the steps leading to a resolution of the burned areas. Wet dressings for burns should be limited to the 1st degree and 2nd degree types of burns while 3rd degree burns of full thickness, blackened, and insensitive burns should be given dry dressing. It is because the wet dressing on 3rd degree burns causes contamination and hypothermia, says Richard Beebe and Jeffrey Myers (2011, p.223). When the case involves chemical burns, first identify what chemical caused the burns. Applying water to administer wet dressing might “cause an exothermic reaction that worsens the burn”(p. 223). Chemicals like lithium, magnesium, potassium, and sodium react to water. Before washing out the chemical, paramedics or nurses should first cover the burned area with mineral oil instead. At the ER, the chemical should be washed and the burned area should be provided with an “oil-soaked gauze dressing over the wound” (p. 223). That choking patient needed to wash out a chemical that got inhaled and that caused eventual inflammation of the airways. If the chemical burn is due to Hydroflouric Acid, flushing should be done for about 5 minutes. Beebes and Myers recommended flushing even before the patient’s clothes are removed. The reason for quick flushing is to prevent delay in administration of antidote. Application of Calcium Gluconate Gel should be massaged onto the wounded area that got burned by Hydrofluoric Acid, which can be absorbed by the body and which can damage the bones if not eliminated quickly. Unbearable pain due to such an acid should be treated with injectable Calcium Gluconate 5% solution. Calcium Gluconate is different from Calcium Chloride. Hexafluorine. For burns due to chemicals, anesthesia to eliminate the pain will mislead administrators of the resolution into thinking the chemical has been successfully removed, when in fact, it was the anesthesia that took effect while the source of pain remains on the burned area. Another chemical that causes burns is Phenol. It is “poorly soluble in water and is therefore resistant to irrigation during decontamination.”This requires plenty of water to wash out the chemical. Cloth soaked in water will “expand the area of exposure and hasten absorption”. These information are all from Beebes and Myers (2011, p. 224). Importance of First Assessing Burns The first step is to perform a quick, initial assessment of burns by finding out what had happened and what caused the burns. This is not yet the full assessment. However, some knowledge of which type of burn must be treated would limit the alternatives to those that are appropriate to the given situation. For burns due to fire within a house, there would be probable inhalation of excessive smoke. And the heat can eventually lead to the inflammation of airways. Burn dressing will have to wait for until normal breathing is assured whether or not inflammation of the airways takes place hours later. This means attending to intubation as a priority, since doing it later will be difficult if the inflammation will block the passage of air supply. Without such a preparation, the patient can choke to death during the time when other steps like actual burn dressing are taking place. Another critical part of the preparation involves the need to resuscitate burn patients with an ongoing inflow of fluid, because failure to do so will result in shock. Within 6 to 8 hours from the time of the burning incident, burn shock as a result of lack of fluid can happen if upon arrival at the ER a patient is not yet in a state of shock. It might not appear like the patient needs it right after being burned. Given that the burned part is not yet swelling shortly after cleaning it and treating it with disinfectants, placing ice and wet dressing will help prevent or slow down the inflammation. How to dress a burn depends on the outcome of assessment of the injuries. And situations vary. Knowing the circumstances will definitely allow for the proper dressing of burns. A patient or witnesses should be asked what had happened, when such a problem actually occurred, and where or under what circumstances. Why Understanding Severity of Burns Is Necessary An understanding of the severity of burns will require familiarization with the pathological zones as described by Nancy Caroline (2010, p. 20-15 and 16), namely, (a) zone of coagulation, (b) zone of stasis, and (c) zone of hyperernia. That central part of the skin wherein burns did the apparent damage visible to the eye is called the zone of coagulation. It is described to have no blood or very little blood flow in the central part whereas in the surrounding or peripheral area called the zone of stasis, there is blood and inflammation. Within 24-48 hours shortly after a person gets burned, the zone of stasis will have dead cells. Within 7 to 10 days, the zone of hyperernia usually recovers during proper treatment. Key Factors for Assessment: Depth of Burns Once oxygen flow and breathing are maintained, followed by fluid supply, an assessment of burned parts of the body can be made more thorough. The questions to ask are: how extensive is the burn damage in terms of the coverage (percentage of that burned part of the body) and how severe are the burns. The usual categories of burns are called first degree, second degree, and third degree. More severe conditions can lead to 4th, 5th, and 6th degrees depending on the depth of damage to tissues, muscles, even bones. If inspections show reddish skin (like sunburn) with no apparent inflammation, it is classified as superficial burn or 1st degree. The usual healing period is “3 to 7 days” (Nancy Caroline 2010, p.20-16). If there is inflamed skin, like bubbles with fluid or blisters, the classification is known as partial thickness burn or 2nd degree. Depending on the depth of impact, 2nd degree burns may be superficial or deep, partial thickness burns. 3rd degree burns are also called full thickness burns since the epidermis of outer skin down to the subcutaneous tissues are damaged, and the color of the skin is no longer red but brown or black. Capillaries are also damaged. To repair such burned parts, skin grafting has to be done. Appendix D contains the Key Factors for the Assessment of Burns. Burns, specially those that are severe, take weeks to heal. The trauma include not only physical pain but also “emotional, psychological, and financial” according to Nancy Caroline (2010, p.20-20). The scenario considered in this paper starts in the ER. It means the fire or source of burns has been stopped. Therefore, upon arrival at the ER, the probable major step to take would be to make sure the patient air passages will not deteriorate so as to eventually make breathing difficult and to provide adequate fluid for the resuscitation of burned portions. This could mean intubation and vascular or intravenous provision of fluid while burns are being treated. Failure to supply oxygen for ongoing normal breathing even after air passages begin to swell can lead to cardiac arrest or respiratory arrest. In the event that intubation is not possible, if the swelling has already blocked most airways, surgical means will be needed to open a passage for the oxygen supply. As much as possible for patients who are awake, nebulizers would be less inconvenient. That is because inserting a tube through the nose will be difficult for patients wake and not yet sedated. Also, there will be a need for fluid resuscitation by intravenous source. This will be the means of supplying the pain reliever along with the fluid. “An upper burned extremity” is preferred for the insertion of intravenous “large bore IV catheter”, says Nancy Caroline (2010, p.20-21). Her recommended fluid is a “lactated Ringer’s Solution or normal saline” administered in amounts following “the Parkland Formula which states that during the first 24 hours, the burned patient will need 4 ml. x body weight (in kg) x percentage of body surface burned” (p.20-21). Appendix B shows a chart of the amount of fluid to be given depending on the percentage of body burned and the weight of a patient. Using the formula, it will be important to give half of the computed amount within “the first 8 hours” as shown in the chart. Along with the fluid, and depending on the assessment of pain as well as any patient history of allergic response, the dosage of pain reliever and the right prescription should be included. Beware of exceeding the toxicity level when deciding what should be the dosage of pain reliever to be given. Treatment of burns depends on the assessment in terms of area and depth of affected parts of the body. If less than 5 % of surface area got burned and the prognosis is that it is only a superficial burn and definitely not more than a 2nd degree burn, a patient need not be admitted in a hospital. When more than 5% to 10% are burned and they appear to be at least 2nd degree burns or worse, the patient should be hospitalized. All burns related to electric shock, any 3rd degree burn, and burned ears, eyes, face, arms or merely hands, feet should be adequate reasons for hospitalization. In all these cases, the aim will be to treat inflamed areas, provide relief against pain, resuscitate with fluids and oxygen (if there is or will be difficulty breathing), prevent infection, and expedite the healing process. Appendix E can serve as basic guidelines about how to treat superficial burns, 2nd degree burns, and 3rd degree burns. The foregoing ER case may not have visible burns. It would have been easier for the nurse to respond with burn dressing. Albert Mulley (2009, p.1335) recommends that “Unruptured blisters should be left intact because they serve as biologic dressing.” Alton L. Thygerson (2006, p. 63) recommends placing “antibiotic ointment and a non-stick sterile or clean dressing” on raptured blisters but no “salve, ointment, grease, butter, cream, spray …or any other coating on a burn.” For him, cooling should not be done for more than 20 % of the body surface area for adults and 10% for children. This case, being a potential internal inflammation that causes airways to be blocked, will require oxygen through intubation. References Beebe, Richard and Myers, Jeffrey (2011). Paramedic Professional: EMS Operations. Delmar Cengage Learning, NY, USA. Borland, M.L., Bergesio, R., Pascoe, E.M. Turner, S. and Woodger, S. (2005). Intranasal Fentanyl Is An Equivalent Analgesic To Oral Morphine in Paediatric Burns Patients for Dressing Changes: A Randomised Double Blind Crossover Study. Burns. 31 (7), November 2005 pp. 831-837. Bromley, Lesley and Brandner, Brigitta (2010). Acute Pain. Oxford University Press. NY, USA. Calvey, T. N. and Williams, Norton ( 2008). Principles and Practice of Pharmacology for Anaesthetists, 5th Edition. Blackwell Publishing Asia Pty Ltd., Australia. Caroline, Nancy L. (2010). Nancy Caroline’s Emergency Care in the Streets. American Academy of Orthopaedic Surgeons. Jones & Bartlett Learning Publishing International, USA, Canada, UK. Durrum, E.L. and DeArmond (1950). A Study of Silicone Dressings for Burns. Army Medical Research Lab. Fort Knox, KY, USA. Elliott, Doug, Aitken, Leanne, and Chaboyer, Wendy (2007). ACCCN’s Critical Care Nursing. Elsevier Australia. Glasper, Edward Alan, McEwing, Gill, and Richardson, Jim (2011). Emergencies in Children’s and Young People’s Nursing. Oxford University Press, USA. Goroll, Allan H. and Mulley, Albert G. (2009). Primary Care Medicine: Office Evaluation and Management of the Adult Patient. Wolters Kluwer / Williams and Wilkins, PA, USA. Pillitteri, Adele (2009). Maternal & Child Health Nursing: Care of the Childbearing & Childbearing Family. Wlters Kluwer Health. Ricci, Susan Scott and Kyle, Terri (2008). Maternity and Pediatric Nursing. Wolters Kluwer Health / Lippincott Williams & Wilkins, USA Rosdahl, Caroline Bunker and Kowalski, Mary T. (2008). Textbook of Basic Nursing. Wolters Kluwer Health / Lippincott Williams and Wilkins, USA. Sandy, Alison and Elsworth, Sophie (2011). Patients Dying in queensland Hospital Emergency Departments Waiting For Treatment. The Courier-Mail. April 7, 2011. Retrieved October 1, 2011 from http://www.couriermail.com.au/news/queensland/patients-dying-in-queensland-hospital-emergency-departments-waiting-for-treatment/story-e6freoof-1226034905519 . Thygerson, Alton L. (2006). First Aid, CPR, and AED Standard, 5th Edition. Jones and Bartletts Publishers International. Tintinalli, Judith E., Cameron, Peter, and Holliman, James (2010). EMS: A Practical Global Guidebook. People’s Medical Publishing House, USA Williams, Lippincott and Wilkins (2007). Best Practices: Evidence Based Nursing Procedures. Walters Kluwer Health, USA. Wolfson, Allan B., Hendey, Gregory W. and Ling, Louis J. (2009). Harwood-Nuss’Clinical Practice of Emergency Medicine. Wolters Kluwer Health / Lippincott Williams and Wilkins, USA. Wyatt, Jonathan P., Illingworth, Robin, and Graham, Collin (2006). Oxford handbook of Emergency Medicine. Oxford University Press. Appendix A.An Awareness of the Different Classification of Burns Thermal Burns, otherwise known as trauma due to fire, are obviously caused by fierce heat whether from flames or hot water or hot oil. It can also be caused by steam. A person whose clothes catch fire, or who was boiling water, or frying with oil can end up in the ER due to escald burns. Another type falling under thermal burns is known as the flash burns, which is due to explosion wherein the skin is momentarily exposed to great heat, e.g. like from a lightning strike. They can all result in burn shock. That is when the entire body feels not just the pain on the skin, but also chills, nausea, This requires fluid resuscitation because of an electrolyte imbalance within. Another classification would be Airway Burns resulting in problems in the lugs and oxygen passages and made manifest by cough, inflammation in the airway tissues, damage to the larynx. The right immediate remedy is to spray with a cool mist (called aerosol therapy) or to apply ice cold liquid or ice itself where there seems to be such a burn. Smoke inhalation, steam inhalation, and chemical inhalation can be causes of airway burns. In times of potential inhalation of these sources of burns, firemen wear gas mask to prevent damage to the lungs and air passages. Carbon Monoxide, when inhaled from within a burning house or from very polluted environment, can be another source of airway burns, starting from irritation, then inflammation. Still another type of burn takes place when a liquid or airborne particles irritates the skin. Muriatic acid, strong detergents, and other chemicals that get into contact with any part of the body can result in Chemical Burns. The logical first step to cut the impact of that chemical would have to be the removal of such chemical from direct contact with the skin. Acid can be washed out by water, If a chemical has attached itself onto the irritated part, and washing cannot eliminate its effect, quickly determine the needed formula that can disengage that chemical from the body. Then there are Electricity-related Burns classified according to type—Type I, which is known as contact burn, Type II, which leads to electro thermal injury, and Type III., wherein a person’s clothes ignites as a result of electrocution. All these are considered critical burns due to probable internal troubles due to electrocution. As a result, burns due to electrocution will need the ER even if injured parts are not apparent. Such burns eventually become manifested in delayed spinal cord problems, cataracts, and amyotrophic lateral sclerosis that can take up to 2 years to be apparent after the electrocution. One other type would be the Radiation Burn. Radioactive materials are the sources of such burns. B..Parkland Formula Chart C. Breakdown of Parts of the Body that are subdivided into 9% Head (front, back, left, right) = 9% Left Arm (from shoulder down to fingers) = 9% Right Arm (from shoulder down to fingers) = 9% Left Leg (from waist down to toes) = 18% Right Leg (from waist down to toes) = 18% Front Body (from shoulders down to waist) = 18% Back Body (from shoulders down to waist) = 18% D. Key Factor for Assessment: Coverage or Proportion of Burns to Total Body Surface Area A common practice involves “the rule of palm” as cited by Nancy Caroline (2010, Chapter 20-16), wherein the ”palm excluding the fingers” represents 1% of the total body surface area (TBSA) that can be burned. This method of estimating appears to be simpler than other alternative ways and is recommended for instances when treatment and response time are of the essence. The “rule of nine” is a universal way of measuring the TBSA. Each of the major parts of the body, namely, back, front body, arms, and foot is divided into nine. The back is divided by 2 as it accounts for 18. This is done also for the front and each foot. But each arm is estimated to be 9% of total. See Appendix C for the breakdown. Estimating the surface area and depth of burns will be necessary in preparation for the fluid therapy. More damage means more fluid should be allowed to flow in the system to prevent burn shock. It is only after measuring the proportion of burns to the TBSA that a more complete head to foot detailed examination should b e done. And prior to selecting the medical remedies, there should be some knowledge about the medical history of the patient. Administering the wrong drug might result in allergic response, poor or no response. Circumstances ought to be established in order to determine whether or not a hospital has the facilities for the remedies. For example, if a patient has burns due to radiation from nuclear exposure and the hospital does not have a decontamination chamber or the facilities to remove the radiation particles, that patient must be transferred to the hospital that has such facilities as quickly as possible. Or other people will be contaminated by the radioactivity. Thus, the burns of such patients may only be treated with first aid or the means to eliminate or reduce pain in preparation for the transfer. E. Case-to-case Burn Dressing How-To’s How To Treat Superficial Burns Pain associated with reddish skin such as those experienced as a result of sunburn can be very uncomfortable. It can be swollen although there is no apparent edema. To reduce the skin irritation, simply provide the burned portion with cold water by immersing it (if possible) in cold temperature environment. Or apply cold compress. Wet a cloth that will absorb or hold ice water or ice and press it on the burned skin. The superficially burned area should be cooled for about 10-30 minutes with cold compress or wet cloth. The ice itself should not be placed directly onto the burns because it can damage skin tissues. It does not mean the patient should be made to feel cool, unless the entire body has superficial burns. People who get burned normally experience chill as though they will be having fever. To counter the feeling, a blanket is used to cover the body to keep it warm. Ideally, only the burned skin needs to be cooled while the patient should be kept warm to avoid “systemic heat loss” (Chapter 20-22). It is preferable not to apply cooling ointment on superficial burns due to the consequences of having to scrape off whatever is applied and feeling pain in the process of removing dead skin along with the used ointment. No dressing is needed. During the healing process, the skin may peel or lead to “post inflammatory hyper pigmentation” according to a description of Allan H. Goroll and Albert G. Mulley (2009, p. 1326). In common practice, patients want the pain to be relieved immediately. Thus, depending on the medical history that would show which drugs have been tried and proven effective for specific patients, the corresponding pain reliever is administered. Extreme sunburn is treated with “a topical corticosteroid lotion” (p. 1327) for pain relief although it cannot reduce edema and such corticosteroids are not recommended. Like Nancy Caroline (2010), Allan Goroll and Albert Mulley (2009, p.1335) also recommend that “Unruptured blisters should be left intact because they serve as biologic dressing.” Alton L. Thygerson (2006, p. 63) recommends placing “antibiotic ointment and a non-stick sterile or clean dressing” on raptured blisters but no “salve, ointment, grease, butter, cream, spray …or any other coating on a burn.” For him, cooling should not be done for more than 20 % of the body surface area for adults and 10% for children. How To Treat 2nd Degree Burns Otherwise Known As Partial Thickness Burns An immediate remedy to ease the pain of having partial thickness burns is by placing a wet, cool dressing on the parts that got burned, without removing the burned skin or blisters. Edema serves the purpose of cooling the burned spot. However, others fear that edema can be the starting point of infections. The skin epidermis and dermis are damaged and feeling the pain. When intravenous catheter is connected to resuscitate a patient’s burned portions, pain reliever can be added to allow for elimination of the feeling of pain. Eventually, complications can be avoided with the facilitation of IV resuscitation. In order to prevent infection, wounded areas are gently washed “with water and a mild antiseptic soap, such as one containing chlorhexidine… followed by gentle irrigation with sterile isotonic solution and the application of sterile occlusive dressing.” (p.1327). If a chemical burned the area, washing has to be done “for at least 15 to 30 minutes before cleansing or debridement” (p. 1327). Anti-tetanus injection will be necessary. Those particles that adhere and cannot be easily removed can be hardened or softened. If ice compress fails to harden it, use a topical antibiotic (Polysporin or Inupirocin) to soften adherent parts with an ointment. Recovery is estimated between 2 weeks to 3 weeks. Scars are often left on the part that got burned. After cleaning and disinfecting the 2nd degree burn, dressing can be done using one of the alternatives that have the ability to hold moisture, namely, “hydrocolloid, hydrofiber, silicon, alginate, and polyurethane dressings” (p. 1327). Another way of dressing is with the use of a “non-adherent, fine mesh gauze soaked in sterile saline solution” which should be covered by one of the dressings that hold moisture. Inspection should be done in 2 days to assess pain, fever, and any sign of infection. There may be need for replacement of dressing with a new dressing unless the symptoms are not present so that the dressing may stay intact for another “5 to 7 days” (p.1327). Once a wounded area is healing, application of Vaseline grease or a moisturizing lotion will help prevent dry skin or cracked skin. How To Treat 3rd Degree Burns Otherwise Known As Full Thickness Burns Immediate dressing (wet if there is pain on the part burned; dry if there is numbness on that part) should be followed by administering a pain reliever, preferably via IV. For ICU cases, burn dressing primarily aims to mitigate infection and to minimize the risk of contamination, according to Doug Elliot, Leanne Aitken, and Wendy Chaboyer (2007, p. 527). Debridement, which involves removing dead tissues and dirt to clean the wounded area, will require forceps and scissors. Blisters have to be left intact. That part which undergoes escharotomy or the incision to the side of the trunk or a limb should be dressed after cleaning so that it will not be infected. The common burn dressing used is “dry sterile dressings… (that) can be dampened with sterile water.”(Tintinalli, Cameron, and Holliman 2010, p. 281), and the Burn Gel which may be used to relieve pain during the emergency transport to the ER, although it should be avoided as much as possible. In practice, burn dressing is thought of as the mere application of a sanitized covering. The definition of an ideal burn dressing written by Wyatt, J., Illingworth, R. and Graham, Collin (2006, p. 394) is one wherein the material used is clean and sterilized, non-adherent, and capable of faster healing of the wounded area. Burn dressings may be done after pain relievers have been applied intravenously or intra-muscularly for adults and children, says Bromley, Lesley and Brandner, Brigitta (2010, p.84). Read More