Annals of the MBC - vol. 4 - n' 3 - September 1991

PRIORITIES IN NURSING CARE ON ADMISSION OF A SEVERELY BURNED PATIENT A STUDY OF TWO CASES

Palanque A.R.

Nursing Department, Severe Burns Unit, CHU Rangueil, 31054 Toulouse Cedex, France

SUMMARY. An account is given of the nursing of two burn patients, one the victim of an electrical bum, the other a would~be suicide with petrol burns. The various stages of nursing care are described in great detail. It is suggested that nurses involved in this kind of work should have the specific title of "specialized burns nurses.

We were told of the arrival of two severely burned patients, Mr P. and Mr T. For the medical and paramedical teams, this involves carrying out

• restoration of blood yolume and cardiopulmonary resuscitation
• temperature control
• treatment for the relief of pain and stress
• indirect care
• support of the family.

Here, I will consider only priority nursing care.
And as a nurse I will reflect on how this nursing care is carried out, and I shall also mention some of the compromises which have to be made.

Mr P., aged 28, was the victim of an industrial accident, an electrical flash bum. He had burns of 80% of total body surface, of which 65% were third-degree burns and 15% deep second-degree burns. The bum had gone as deep as the bone, ligaments and nerves. Only his head, left arm and the soles of his feet were untouched. The third-degree bums involved the thorax, right arm, both legs and the perineum. The back and buttocks had deep second-degree burns. haux's index was 108 and the burned surface units 275.
Mr T., aged 33, had tried to commit suicide by setting himself on fire with petrol. His burns covered 84% of total body surface, 72% being third-degree burns and 12% deep second-degree burns. The intact areas were the skull, the perineum and both feet. He had third-degree bums of the thorax, back, buttocks, posterior aspect of the right and left legs and both arms. The deep second-degree burns involved the face, the palms of both hands and the anterior aspect of the right leg. Baux's index was 117 and the burned surface units 300.

In this section, I shall describe the nursing care dealing with ventilatory support, which is carried out on the instructions of a physician.

1. The cases of Mr P. and Mr T.
   These two patients were brought in by the SAMU (the Emergency Medical Aid Service) and were already intubated. On their arrival in the Bums Unit, *fi 'al ventilation had to be continued. Mr P. was arti ic, put on the CPU respirator and Mr T. on the -C6sar" respirator, on assisted controlled ventilation. With these two types of respirators, all types and modes of ventilatory function can be carried out. A built-in monitor permanently indicates the parameters and their evolution. The nurse must monitor the respirator and its accessories: the tube and the pressure on the balloon. She must also watch the patient's clinical and biological condition.
2. Fiberoptie bronchoscopy
   Bronchoscopy was done in the first few hours following the arrival of Mr P. and Mr T. In Mr P.'s case, no anomaly was seen. However in the case of Mr T., there was oedema of the upper airways and of the junction of the oesophagus and the trachea, with a sooty deposit. Fiberoptic bronchoscopy is carried out:

• in burns of the neck and thorax
• in any circumstances suggesting burns of the airways
• and in any extensive burn greater than 40%.

The nurse prepares the necessary equipment for bronchoscopy and assists the physician in carrying out this investigation.

1. Tracheotomy
   For Mr P. and Mr T., tracheotomy was necessary in the hours following their arrival. This is carried out in the operating theatre in the Burns Unit. Tracheotomy is carried out very early, in general within 48 hours of admission, in order to reduce the later complications of intubation and tracheotomy. The nurse is responsible for the instruments, assists in the operation and/or takes part in resuscitation and monitoring of the patient during the procedure.

Here also I shall review the nursing care which is carried out on the instructions of a physician.

1. Data concerning Mr P. and Mr T.
   The emergency resuscitation carried out before arrival at the hospital is extremely important:

• fluid volume replacement
• monitoring of the clinical and biological condition of the patient.

• continue monitoring of the clinical condition
• participate in restoring normal haemodynamics
• and to note these data in the patient's record.

1. Laboratory tests
   Like all patients on admission to hospital, Mr P. and Mr T. underwent complete investigation. This included:

• general biological tests
• complete blood cell count and differential leukocyte count
• coagulation tests
• gasometry
• blood grouping
• blood culture
• blood alcohol level
• carbon monoxide level.

1. The venous line
   Mr P. arrived with one large-bore peripheral venous line in the bend of the left elbow. A single-line straight femoral catheter was inserted here. In Mr T.'s case, the emergency medical service had placed a single-line subclavian catheter. Because of his rather unstable haemodynamic state, a double-line left femoral catheter was inserted.
   It is the task of the nurse to:

• cheek the patency of the venous line
• insert any peripheral venous line
• prepare the equipment for the insertion of a central line and to assist the emergency physician in this task.

1. Infusion fluids
   In Mr P. and Mr T., as in any other patient, fluid and electrolyte losses were replaced by fluids given according to Evans' rule. This consists of-I ml crystal loid/kg/% burn + I ml colloid/kg/% burn (half this quantity is infused during the first eight hours and the other half is given over the next 16 hours) -plus 2,000 ml 5% glucose/24 h. The crystalloid used is Ringer's lactate and the colloid is albumin at 4% or 20%. This formula is adjusted according to the blood parameters and hourly urinary output. The crystalloids are particularly important during the first eight hours.
   The nurse:

• participates in setting up the infusion
• adapts the flow after assessing the clinical and biological condition of the patient with reference to the instructions and advice of the physician
• decides herself on the rhythm at which the solutes are to be given within a given time period
• fills in the fluid intake and losses sheet.

1. Clinical monitoring
   In the cases of Mr P. and Mr T., this consisted of assessing:

• blood pressure
• pulse rate
• hourly urinary output (this should be monitored extremely carefully)
• temperature.

This involves monitoring of core body temperature and external ambient temperature (25 to 3 7 'C).
The nurse must be particularly attentive to environment. temperature control in the case of severely burned patients, such as Mr P. and Mr T.

The emergency medical service deals with this double problem by sedating the patient and giving drugs for the relief of pain. In our unit, we use diaz-analgesia in patients receiving ventilatory support, such as Mr P. and Mr T. A benzodiazepine is used in association with a morphine derivative. This medication is given by means of a syringe driver at the following dose: Midazolam = Hypnovel : 48 ml = 240 mg
35 to 60 mg/hour R 1406 = Phenoperidine : 10 ml = 10 mg/40 ml isotonic sodium chloride 0.5 to 1.25 mg/hour
The nurse:

• prepares the syringe driver
• adjusts the flow rate after assessing the clinical condition of the patient, taking into account the instructions and advice of the physician.

The gravity of the burns is assessed when the vital functions are under control.

1. Shower
   After arrival, each burn patient must be showered, using polyvidone-iodine, and carefully shaved.
2. Incisions for decompression
   In the case of Mr P., these were performed in the right arm, the thorax and the legs. For Mr T., incisions were made in the arms, the legs and the thorax. This procedure is carried out in the operating theatre. The nurse prepares the instruments, assists in the procedure and watches attentively the effectiveness of this surgical intervention.
3. Aponevrotomy
   In the case of Mr T., this was carried out on both arms. The nurse assists the surgeon.

1. Methods of wound care

1. The semi-open method. Anti -inflammatory medications, antiseptics and agents to promote epithelialization are used with an ordinary dressing. (When the patient arrives, only the antiseptic Betatulle is used.) The burn is placed in an absorbent This method ensures ventilation and protection of the burn. It is analgesic and anti -infectious. It helps to control heat loss and loss of fluid and electrolytes better than the open method.
2. The open method. The bum is exposed to hot dry ambient air and the patient is placed on an air-fluidized bed. This method is anti-infectious and encourages the formation of an eschar which will gradually fall. But it is painful and causes loss of heat, fluid and electrolytes.
3. The case of Mr T. Because of his losses of heat, fluid and electrolytes, the semi-open method was chosen in preference to the open method.
4. The case of Mr P. The semi-open method was also used. However, his back and the posterior aspects of the legs were exposed to the ambient air on an air-fluidized bed, using a sheet of Metalline.
5. The role of the nurse She carries out the dressing changes, a task requiring dexterity, technical skill and a sense of cooperation.

6. Nasogastric intubation

Mr T. arrived with the nasogastric tube in place. In the case of Mr P., the tube was inserted soon after his arrival. The aim of the nasogastric tube is:

• to empty the stomach contents
• to ensure early enteral nutrition.

The nurse:

• inserts the nasogastric tube
• and monitors the above two objectives.

Reflection on the accomplishment of priority nursing care

The French decree of 6 October 1989 makes the following statement: "The function of the nurse includes analysis, organization and assessment of nursing care and its implementation, either on the order of a physician or as part of his or her specific role". Confronted by the tasks listed above, the nurse assesses and collaborates in the application of treatment programmes and the orders and advice of the physician.

2. The carers

For these surgical procedures, the patient must be transferred to the operating theatre. This requires handling of the patient and reorganization on the part of the nursing team. We have already mentioned twice the professional qualities required of the nurse working in the operating theatre.

The "care load" varies according to the method of dressing chosen. The open method, as I have defined it, reduces the care load.
The semi-open method, which I have also presented, means a heavier care load (local care, and the technique in itself). The occlusive method, which uses anti inflammatory and pro-inflammatory medications, a compress and a bandage, and is not employed for a severely burned patient on arrival, would considerably increase the nursing requirements.

In general, all the facilities (hospitalization, logistic and technical) are lacking in space. For example, the area of a room is 10.5 sq. m, the entry 7.7 sq. in, the admission room 20 sq. m and the operating theatre 35 sq. m. We have to admit that the small area and the way these premises are fitted out hinder effective nursing care, especially in the case of a severely burned patient. Maintenance of the equipment is important as it must always be in working order: as part of the nursing team, are we always as attentive to this as we ought to be?
The number of staff present is reduced in the afternoon (two nurses, two nursing auxiliaries) and at night (two nurses, one nursing auxiliary),

2. Nursing care: incisions for decompression tracheotomy

The team working in the operating theatre (one nurse, two nursing auxiliaries) is off duty in the evening and at night. The various members of the team have various levels of professional experience. The most difficult moment is the recruitment of a new member of the team! Each member is responsible for organizing his or her own work, and this is very important for the efficiency of nursing care, in particular in an emergency situation.

3. The severely burned patient

The arrival of the patient can cause anxiety and stress in the team, and of course it creates an increase in the work load. The occupancy of the beds is Variable (the maximum is seven patients). It is evident that the admission of a severely burned patient, when the number of staff is reduced and with a maximum of three beds occupied by patients under artificial ventilation, obliges all staff to reorganize their work.

Priorities in nursing care are three in number. They are carried out on the instructions of a physician:

• control of haematosis
• restoration of circulatory volume
• relief of internal compression.

The other acts of nursing care which are carried out on arrival of the burns patient are:

• installation of the patient in his or her room
• completing the patient's record
• support of the family.

These are part of the specific tasks of the nurse. Admission of a severely burned patient results in a workload of about three hours. Surely the nurse deserves the title of "specialized burns nurse" in recognition of her specific role?

RÉSUMÉ. L'Auteur décrit les soins infirmiers donnés á deux brúles, dont l'un était victirne d'une brúlure électrique et Pautre avait tenté de se suicider avee de l'essenee. Les phases successives des soins infirmiers sont décrites dans les moindres détails. On propose que les infirmiéres qui se vouent aux soins des brúles mériteraient Pappellation Xinfírmiéres "brúlologues".