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The Burned Patient
J U L Y 1984, VOL 40, NO I
AORN JOURNAL
The Burned Patient PERIOPERATIVE NURSING CARE
Stewart A Engeman, RN The perioperative nurse contributes significantly to the care of the severely burned patient. Multisystem imbalances and acute metabolic and respiratory complications frequently result from thermal trauma. Being aware of the physiologic stress accompanying surgical intervention helps the perioperative nurse minimize these stressors for the burned patient.
epending on the severity and location of the bums and the patient's general physical condition, the initial surgery will usually be two to 14 days following the injury. At this time, the patient must be at optimal physical and emotional condition to ensure a safe and successful surgical experience. Fluids and electrolytes must be maintained in accordance with surgical requirements, and the wounds should be as clean and infection-free as possible. Most bums will become infected early. Those
rapidly treated with antibiotics and aggressive wound care will subside or remain localized; others will spread and become systemic. Currently septicemia and pneumonia account for many deaths of severely burned patients. Flawless aseptic technique will aid in reducing mortality and morbidity. A bum wound biopsy for culture is usually performed in the bum unit 48 hours preoperatively to provide information about bacterial colonization and the advisability of grafting (Fig 1). Even though grafting is considered a step toward recovery, most patients are anxious and apprehensive. At this time, most patients and families need encouragement, information, and support from the nurses. If possible when making the preoperative assessment, the perioperative nurse also educates the family. The preoperative assessment includes a careful evaluation of the patient's physical condition. Detailed study of the chart and discussions with the surgeon, the patient, and family yield valuable information for the preoperative care plan, inservice coordinator for the cipperuting rooms at Grunt Hospitril, Chicugo. H e received his crssoiiatta diyyi~ein nursing (it Muyjkir College. Chicago. As ( I member of the notioncil AORN Audiovisual Committee. Engemcin uuthored Perioperative Care of the Burned Patient, m i AORN slideltupe presentiitiorr premiered lit the I983 Congress cind shown ut World Congriw in Hritiolulu, 1983. Thc photos f o r this (irticle lire courtesy of Chorles Dritcck 111, MD. und Mitchell Grrrsseschi. MD. The Crtringer Burn Center, Evcinston Hospitiil. Evimston I
111. Stewari A Engeman, RN. is ( I stciff nurse and cicting 36
JULY 1984, VOL 40, NO 1
AORN JOURNAL
Types of Burns All types of bums, thermal, chemical, electrical, or those caused by radioactive agents may result in extensive injury to the skin and underlying tissues. Electrical and radiation bums may be more severe than initially suspected. Because the severity of a bum injury depends on the degree and extent of injury, and the duration and intensity of exposure, the patient may present any combination of first- to fourth-degree bums. Bum injuries are assessed by their extent and by their depth of penetration into the skin or degree of injury. The depth of the bum is generally described using classification by degree.
First-degree bums are limited to the outer layer of the epidermis and are characterized by reddening, tenderness. and pain without blister formation.
Third-degree bums involve destruction of both the epidermal and dermal layers with damage extending into the underlying subcutaneous fat.
Second-degree bums show damage extending through the epidermal layer and into the dermis. They are not deep enough to interfere with regeneration of the epidermis. Blistering usually occurs. The seconddegree bum injury is divided into superficial and deep dermal components depending on the depth of the injury.
Fourth-degree bums show damage to bone, muscle, and other deep tissues and are frequently seen in electrical bums. In addition,because of the passage of current through the body with an electrical bum, muscle, blood vessels, and nerves may be damaged under unburned skin.
31
AORN JOURNAL
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JULY 1984. VOL 40. NO I
Fig 1 . Bum wound biopsy for culture is taken before
surgery. Review the patient's medical history for preexisting conditions and document any history of alcohol or drug abuse, cardiac problems, or allergies. Also note pulmonary damage sustained at the time of injury as well as a history of smoking. Check any medications the patient is presently receiving to prevent adverse drug reactions during surgery, along with the laboratory data. particularly the latest chest x-ray, and potassium, hematocrit, hemoglobin, blood urea nitrogen (BUN) and creatinine levels. Because intraoperative blood loss is frequently substantial, the preoperative patient is often transfused with one or more units of packed red blood cells to raise the hematocrit (Fig 2). To ensure a minimal bacterial count and provide a clean surface for grafting, tub the patient and apply fresh dressings as near as possible to the time of departure for the operating room. Donor areas should be washed twice with soap and water according to routine. The preoperative medication ordered will vary, but usually includes a parasympathomimetic agent such as atropine and some combination of hypnotics, analgesics, or sedatives. Make sure the medication is given no less than one hour before transfer to the operating room because adequate sedation is a must to minimize pain from movement and decrease anxiety. Transporting the bumed patient from the bum unit to the operating mom requires close communication between the personnel of both areas (Fig 3). Operating mom personnel use the in38
Fig 2. Frequently, blood loss is substantial with operative debridement.
formation gained during the preoperative assessment to plan for special requirements. Additional personnel or equipment may be required for ventilatory support. continuous oxygen, multiple intravenous lines, or the need to transport in a special bed or with the patient in skeletal traction. Because of the potential for hypothermia and respiratory distress, operating room personnel must prevent untimely delays once the patient has been transported from the bum unit. This requires assessing the patient's needs, planning with the surgeon and anesthesiologist. and implementing those plans. A well-organized, well-educated team can do much to maximize patient safety. The nurse ensures that adequate and appropriate supplies are available and func-
JULY 1984, VOL 40. NO I
AORN JOURNAL
Fig 3. Adequate personnel are required to move the burned patient. tioning properly. Extra personnel to help turn and position the patient may be necessary. Have special items for positioning, such as folded towels, blanket rolls, pillows, and table attachments near. Because the burned patient is often unstable, have a cardiac arrest cart close. throughout the procedure. The patient may be under exceptional metabolic stress from alteration of the thermoregulatory mechanism because. of widespread skin destruction. Heat loss is one of the greatest problems a burned patient faces in the OR. Place a warming mattress on the OR bed and warm it before the patient arrives. Monitor the patient’s temperature throughout the procedure with a rectal or esophageal temperature probe. The nurse should adjust room temperature to 80 OF to 85 OF and should warm all prep, irrigation, and dressing solutions to 98 OF to 104 OF. Also have intravenous fluid warmers available. Upon arrival in the holding area, the patient is likely to be frightened and apprehensive in spite of the preoperative teaching. Providing a quiet area with minimal noise and visual stimulation, encouraging him to verbalize, and answering any questions may decrease anxiety (Fig 4). Intrcropercitive
E
ven though the patient appears to be sleeping or resting quietly, he may be aware of comments and conversations in the room. Touching and speaking quietly and
Fig 4. Comfort and reassurance are given in the holding area.
comfortingly are appropriate. If possible, schedule the same team of physicians, nurses, and anesthesiologists that cared for the burned patient on previous procedures. The patient may be reassured by seeing familiar faces and knowing that those providing care are familiar with him. Careful positioning is necessary before draping (Fig 5 ) . Keep the patient covered with warm blankets until surgery begins. Keep all body areas not involved in the operative procedure covered at all times. The nurse plans for an adequate supply of warmed blankets for postoperative use. The anesthesiologist establishes a wellprotected airway and ensures adequate vascular access. Patients with bums of the head, neck, or chest may be difficult to intubate, and the circulating nurse assists. Cutdowns may be re39
JULY 1984, VOL 40. NO I
AORN J O U R N A L
Fig 5. Careful
positioning
is necessary during
intraoperative care. quired to administer fluids and blood. Invasive hemodynamic monitoring catheters may be inserted. The nurse accurately measuresand records the patient's intake and output, including intravenous fluids, urine, and blood loss. Sponges are weighed to estimate blood loss ( I gm = 1 cc), keeping a running total during the procedure.
Skirt GrnJiing
A
lthough skin grafting was performed by the ancient Hindus, it became popular for treatment of bum injuries in the late 19th and early 20th centuries. In the adult, a p proximately 55% of body surface is available for doner use. A one-year-old child, however, has only 45% of body surface available. Special dermatomes and slitting instruments have made grafting a relatively simple and effective way to cover burned areas. There are basically two types of dermatomes. The oscillating blade dermatome is probably the most popular. Excellent grafts may be taken from areas with adequate underlying support. Sterile mineral oil is used as a lubricant on the skin and also on the moving parts of the dermatome. The scrub nurse sets the depth gauge to zero before the procedure and after changing blades to avoid taking a full-thicknessgraft. Drum dermatomes provide excellent grafts of uniform size and thickness for use in reconstruc40
tive procedures. The donor area is cleaned with a skin degreasing agent after the area is prepped. Both dermatomesuse a special contact cement to achieve bonding between the donor site and the drum. Both use a free-swingingblade to cut the graft. Do not allow the blade to swing unconmlled across the drum because this could result in a flexor tendon laceration for the operator. Leave dermatomes on their carrying stands until ready for use and return them to the stand immediately after the graft is taken. All dermatomes are precision instruments, and as such, they should never be dropped or treated roughly. Hand washing and frequent lubrication of moving parts of dermatomes is recommended. Where little healthy skin is available, as in the case of extensive bum injuries, meshing will provide for much greater coverage with the available graft. A mechanical mesher will slit the graft according to a predetermined expansion ratio. Ratios of 1.5, 3, 6, and 9: 1 are available. Epithelial tissue will grow in between the slits to eventually provide full coverage. Grafting begins as soon as a suitable granulation bed is available or after tangential debridement of clean full-thicknesswounds. Grafts may be divided into two types, temporary and permanent. Several types of temporary graft materials are currently available. Hemografts or allografts are
JULY 1984, VOL 40. NO 1
AORN JOURNAL
Grafting begins when a suitable granulation bed is available or after tangential debridement of clean full-thickness wounds. composed of human cadaver skin; heterografts or xenografts are animal skin, most commonly pigskin. Pigskin, commercially available, aids in reducing fluid loss through evaporation and provides some protection for the wound. The use of synthetic skin substitutes and human amnion have also been successful. Although homografts, heterografts, and other skin substitutesare used often, they provide only temporary, short-term coverage. For permanent coverage and healing, the patient’s skin, or an autograft, must be used. Autografts are taken from unburned areas, preferably the trunk or extremities. The surgeon takes split- or partial-thickness grafts with a dermatome to a predetermined depth, generally between 0.009 and 0.014 inch. The donor areas will heal primarily when properly protected and cared for and may be reused within ten to 14 days. Jones and Feller reported a case in which one donor site was used 15 times in a patient with an 80% bum injury.’ Full-thickness grafts are cut thicker than 0.035 inch and are generally used in reconstruction procedures of the arms or legs. This donor site must be grafted or primarily closed-because it will not heal on its own.
F
or a split-thicknessor full-thickness graft to heal or ”take,” several requirements must be met 0 meticulous aseptic technique graft must remain in contact with the recipient site 0 bleeding must be controlled the graft must be stabilized as fibrin is formed by the recipient site. Capillary buds spread through the fibrin, vascularizing the new graft and providing nourishment. Fresh grafts are held in place by sutures or skin
staples on larger grafts, and sterile adhesive strips on smaller areas. The surgeon may simply lay the graft on the recipient site and apply a stent dressing. Within two weeks the graft is firmly attached by connective tissue. The nurse applies occlusive dressings to prevent any movement of the graft on its recipient bed. The following dressing is especially useful in young children and uncooperative adults. A single layer of fine mesh gauze soaked in saline wrapped in a similarly soaked rolled gauze is sufficient. To prevent fluid accumulation under the graft, mild compression is achieved by incorporating a layer of gauze fluffs into the wrap. Preformed splints held in place by an outer wrap of dry rolled gauze will provide protection and maintain immobilization. Some surgeons prefer to leave the freshly grafted areas exposed to observe the site for hematoma, infection, and for early vascularization and “take” of the graft. For the donor site, a single layer of fine mesh gauze dressing impregnated with medication is sufficient. The dressing must protect against infection and trauma and at the same time be as comfortable as possible for the patient. An understanding of the needs of the severely burned patient in the operating room will allow the perioperative nurse to provide the high level of care that these patients demand. Many burn patients return to a normal life because of the perioperative nurse’s technical expertise and 0 compassion. Note I . Irving Feller, C A Jones, Nursing the Burned Pritienr (Ann Arbor, Mich: Institute for Bum Medicine) 973. Suggested reading Artz. C; Moncrief. J; Pruitt, B. Burns: A T w n Approrich. Philadelphia: W B Saunders Co. 1979. Hills, S; Birmingham, J. Burn Cure. Bethany, Conn: Fleschner Publishing Co, 1981. 41
J U L Y 1984. VOL 40, NO I
AORN J O U R N A L
Examination
. I
HOME STUDYPROGRAM
I . A red, tender burn extending into the epidermis is classified as a a) chemical injury b) first-degree bum c) second-degree bum d) radiation injury 2. When a burn involves underlying subcutaneous fat, it is classified as a a) deep dermal second-degree bum b) third-degree bum c) injury caused by electrical trauma d) fourth-degree bum 3. Damage to bone and muscle are frequently caused by a) second-degree bum b) chemical injury c) electrical burns d) third-degree bums 4. A severely burned patient is likely to develop which of the following conditions in the first 24 hours? I ) paralytic ileus 2) hypovolemic shock 3) bacterial endocarditis 4) hypervolemia a) I and 2 c) 2 only b) 3 and 4 d) 3 only 5 . One of the greatest problems the burned patient faces in the operating mom is a) extreme pain b) rapid loss of body heat c ) tracheal obstruction d) nutritional imbalances 6. Mortality for the severely burned patient is high. The cause of death is most often 48
attributed to a) septicemia b) renal damage c) hypothermia d) hypervolemia with massive edema 7. A biopsy of the bum wound is taken pteoperatively to ascertain the 1) advisability of grafting 2) degree of burn 3) bacterial count 4) tissue type c) 2 and 4 a) I , 3. and 4 d) 3 only b) I and 3 8. Anticipating intraoperative blood loss, the physician may order the patient to receive which of the following preoperatively a) whole blood b) packed red blood cells c) fresh frozen plasma d) vitamin K 9. To assure a safe transport of the burned patient to the operating morn the perioperative nurse must 1) make a preoperative assessment of patient’s needs 2) administer the patient’s preoperative sedation 3) arrange for extra personnel as needed 4) have the family leave the patient’s toom before transport begins c) 1 only a) 1 and 2 b) I and 3 d) all of the above 10. Nursing interventions aimed at preventing intraoperative hypothermia include I ) use of a hyperthermia blanket on OR bed
J U L Y 1984. VOL 40. NO 1
1I.
12.
13.
14.
15.
2) adjusting room temperature to 98 O F 3) warming all solutions to 80 O F to 85 O F 4 ) having blood and IV fluid warmers available c ) 2 and 3 a ) 1. 2, and 4 b) 1 and 4 d) all of the above Renal impairment is a common complication of extensive bum injuries. Intraoperative responsibilities of the circulating nurse in monitoring renal function include I ) weighing sponges 2) maintaining intake and output record 3) assisting with hemodynamic monitoring 4 ) preparing for fluid replacement c) 3 a) 1 b) 1 and 2 d) all of the above Which of the following hemodynamic values indicates the patient may be in hypovolemic shock? 1 ) cardiac output 2.5 L/min 2) mean arterial pressure 60 mm Hg 3) cardiac index 5 L/min/m2 4 ) heart rate 120 bpm c ) 1 and 4 a) I , 2, and 3 d) all of the above b) 2, 3. and 4 Which of the following values best indicates the amount of oxygen available to the body’s tissues? a ) arterial blood gas b) mixed venous oxygen tension c ) arterial oxygen tension d ) hematocrit The best equation for measuring blood volume in sponges is a ) 1 gm = I cc b) I Kg = 70 cc c) 1 mg = I cc d ) 1 gm = 70 cc The burned patient is prone to intraoperative cardiac arrhythmias from I ) hypoxemia 2) unstable potassium levels 3) exposure of highly vascular tissue to ambient air 4) suppression of endogenous catecholamines c ) 4 only a) 1 and 2 d ) all of the above b) I . 2, and 3
A O R N JOURNAL
16. Used as an induction agent, sodium thiopental (Pentothal) causes a 1) dose-dependent depression of myocardial metabolism 2) decreased concentration of the drug in brain tissue shortly after administration 3) release of intracellular histamine 4) decreased catecholamine metabolism c) l a n d 4 a) I and 2 b) 2 a n d 3 d) all of the above 17. Which of the following is not true of Ketamine? a) it prevents re-uptake of catecholamines b) it is known to cause frightening dreams c) it supports respiratory reflexes d) less than 1% is metabolized 18. Muscle relaxants are important adjuncts in anesthesia management of the burned patient. Nondepolarizing muscle relaxants exert their effect by a) inhibiting transmission of impulses at the neuromuscular junction b) antagonizing the breakdown of acetylcholine c) releasing massive quantities of intracellular potassium d) enhancing neuromuscular transmission 19. Succinylcholine should be avoided in burned patients between 7 to 60 days postbum, because it may cause a) hypovolemia leading to hypotension b) hyperkalemia leading to arrhythmias c) emergency psychosis d) release of toxins and cellular debris leading to permanent renal damage 20. To prevent postoperative aspiration pneumonia, the patient should have 1) a nasogastric tube to suction 2) application of the Sellick’s maneuver 3) an inflated cuff around the endotracheal tube 4) an antacid preoperatively a) 1 and 2 c) 1, 3, and 4 b) 3 and 4 d) all of the above 2 I . The preparation of the donor site for a splitthickness graft includes use of a) a depilatory b) sterile mineral oil 49
AORN J O U R N A L
c) sterile water d) an oil-based soap 22. The burned patient is a candidate for grafting when a) human amnion becomes available b) fibrin is seen in the bum wound c) hypovolemia is corrected d) a suitable donor is found 23. Skin substitutes are used for a) areas on face and neck b) partial thickness grafts c) temporary coverage d) permanent protection for the wound 24. The scrub nurse prepares the dermatome for use by setting the depth gauge at a) 0.009inch b) 0.035 inch c) 0.029 cm d) 0 inch 25. Danger associated with the free-swinging blade dermatome is (are) I ) laceration to the operator 2) inconsistent graft thickness 3) decreased healing process 4) increased postoperative pain a) alloftheabove c) 2 only d) 3 and 4 b) I only 26. A skin mesher is used a) to maximize use of donor skin b) to improve wound granulation c) as a homograft d ) as a short term wound cover 27. The term used for a skin graft taken from the patient's body for use on another part is a) homograft b) heterograft c) autograft d) xenograph 28. Xenographs provide I ) epithelial tissue 2) pain control 3) debridenient 4) decreased fluid loss a) 1 and 4 c) 3 and 4 b) 2 only d) 4only 20. Success of a graft depends on I ) hemostasis of the graft site 2) graft depth 50
JULY 1984. VOL 40. NO I
3) capillary nourishment of the recipient site 4) the stabilizingeffect of the postoperative dressing a) I and 2 c) 3 and 4 d) I . 3, and 4 b) I , 2, and 3 30. Immediate postoperative needs of the burned patient include I ) reverse isolation to prevent infection 2) liberal use of analgesics 3) muscle relaxants to prevent graft movement 4) pulmonary artery pressure monitoring c) 2 only a) 1 and 2 b) I , 2, and 3 d) all of the above Eilitor's note: Professional nurses are invited to
submit manuscripts for review for a home study program. Manuscripts or queries should be sent to the Editor, AORN Jourtinl, 10170 E Mississippi Ave. Denver, CO 80231. As with all manuscripts sent to the Joitrriul. papers submitted for home study programs should not have been previously published or submitted simultaneously to any other publication.
JCAH Approves Guidelines for Freestanding Clinics The Joint Commission on Accreditation of Hospitals (JCAH) has approved a new standard outlining guidelines for accrediting freestanding emergency facilities. The standard, published in June in the JCA H 's A~iibirlrrtor?.Hutrlrh Coru Sicttid(rrds Mrrriiucl. will take effect Jan I . 1985. For information on obtaining the new guidelines, contact Elizabeth Flanagan. director of the accreditation program for ambulatory health care. JCAH. 875 N Michigan Ave. Chicago, IL 6061 I .
AORN JOURNAL
JULY 1984. VOL 40, NO 1
Answer Sheet
P
lease fill out application and answer form below. Tear out page fromJournal or make photocopies. You may make as many photocopies as necessary. Deadline for this program is January 31, 1985.
Mail to: AORN Accounting Department 10170 E Mississippi Ave Denver, Colorado 80231
1
Application Form 1 . Record your identification number in the appropriate section. 2. Completely darken the space that indicates your answer to the examination starting with question one. 3. A score of 70% correct is required for contact hour certificate. 4. Enclose fee: Members: $7; Nonmembers:$14 Please print: Name Address City State
Zip
Offering No 4704. Activity No 847D Program offered July 1984 AORN (ID) number
RN license and state If nonmember, please provide Social Security number Fee enclosed
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Please complete this evaluation form. Mark your ratings of the home study unit starting with question one. Use a scale of 1 to 5 with 1 = low and 5 = high. To what extent: Did the program increase your knowledge of the subject matter? Were the objectives of this program met? Was the content clear and organized? Did this article facilitate your learning? Were your individual objectives met? 51
AORN JOURNAL
The Burned Patient PERIOPERATIVE NURSING CARE
Stewart A Engeman, RN The perioperative nurse contributes significantly to the care of the severely burned patient. Multisystem imbalances and acute metabolic and respiratory complications frequently result from thermal trauma. Being aware of the physiologic stress accompanying surgical intervention helps the perioperative nurse minimize these stressors for the burned patient.
epending on the severity and location of the bums and the patient's general physical condition, the initial surgery will usually be two to 14 days following the injury. At this time, the patient must be at optimal physical and emotional condition to ensure a safe and successful surgical experience. Fluids and electrolytes must be maintained in accordance with surgical requirements, and the wounds should be as clean and infection-free as possible. Most bums will become infected early. Those
rapidly treated with antibiotics and aggressive wound care will subside or remain localized; others will spread and become systemic. Currently septicemia and pneumonia account for many deaths of severely burned patients. Flawless aseptic technique will aid in reducing mortality and morbidity. A bum wound biopsy for culture is usually performed in the bum unit 48 hours preoperatively to provide information about bacterial colonization and the advisability of grafting (Fig 1). Even though grafting is considered a step toward recovery, most patients are anxious and apprehensive. At this time, most patients and families need encouragement, information, and support from the nurses. If possible when making the preoperative assessment, the perioperative nurse also educates the family. The preoperative assessment includes a careful evaluation of the patient's physical condition. Detailed study of the chart and discussions with the surgeon, the patient, and family yield valuable information for the preoperative care plan, inservice coordinator for the cipperuting rooms at Grunt Hospitril, Chicugo. H e received his crssoiiatta diyyi~ein nursing (it Muyjkir College. Chicago. As ( I member of the notioncil AORN Audiovisual Committee. Engemcin uuthored Perioperative Care of the Burned Patient, m i AORN slideltupe presentiitiorr premiered lit the I983 Congress cind shown ut World Congriw in Hritiolulu, 1983. Thc photos f o r this (irticle lire courtesy of Chorles Dritcck 111, MD. und Mitchell Grrrsseschi. MD. The Crtringer Burn Center, Evcinston Hospitiil. Evimston I
111. Stewari A Engeman, RN. is ( I stciff nurse and cicting 36
JULY 1984, VOL 40, NO 1
AORN JOURNAL
Types of Burns All types of bums, thermal, chemical, electrical, or those caused by radioactive agents may result in extensive injury to the skin and underlying tissues. Electrical and radiation bums may be more severe than initially suspected. Because the severity of a bum injury depends on the degree and extent of injury, and the duration and intensity of exposure, the patient may present any combination of first- to fourth-degree bums. Bum injuries are assessed by their extent and by their depth of penetration into the skin or degree of injury. The depth of the bum is generally described using classification by degree.
First-degree bums are limited to the outer layer of the epidermis and are characterized by reddening, tenderness. and pain without blister formation.
Third-degree bums involve destruction of both the epidermal and dermal layers with damage extending into the underlying subcutaneous fat.
Second-degree bums show damage extending through the epidermal layer and into the dermis. They are not deep enough to interfere with regeneration of the epidermis. Blistering usually occurs. The seconddegree bum injury is divided into superficial and deep dermal components depending on the depth of the injury.
Fourth-degree bums show damage to bone, muscle, and other deep tissues and are frequently seen in electrical bums. In addition,because of the passage of current through the body with an electrical bum, muscle, blood vessels, and nerves may be damaged under unburned skin.
31
AORN JOURNAL
-~~
JULY 1984. VOL 40. NO I
Fig 1 . Bum wound biopsy for culture is taken before
surgery. Review the patient's medical history for preexisting conditions and document any history of alcohol or drug abuse, cardiac problems, or allergies. Also note pulmonary damage sustained at the time of injury as well as a history of smoking. Check any medications the patient is presently receiving to prevent adverse drug reactions during surgery, along with the laboratory data. particularly the latest chest x-ray, and potassium, hematocrit, hemoglobin, blood urea nitrogen (BUN) and creatinine levels. Because intraoperative blood loss is frequently substantial, the preoperative patient is often transfused with one or more units of packed red blood cells to raise the hematocrit (Fig 2). To ensure a minimal bacterial count and provide a clean surface for grafting, tub the patient and apply fresh dressings as near as possible to the time of departure for the operating room. Donor areas should be washed twice with soap and water according to routine. The preoperative medication ordered will vary, but usually includes a parasympathomimetic agent such as atropine and some combination of hypnotics, analgesics, or sedatives. Make sure the medication is given no less than one hour before transfer to the operating room because adequate sedation is a must to minimize pain from movement and decrease anxiety. Transporting the bumed patient from the bum unit to the operating mom requires close communication between the personnel of both areas (Fig 3). Operating mom personnel use the in38
Fig 2. Frequently, blood loss is substantial with operative debridement.
formation gained during the preoperative assessment to plan for special requirements. Additional personnel or equipment may be required for ventilatory support. continuous oxygen, multiple intravenous lines, or the need to transport in a special bed or with the patient in skeletal traction. Because of the potential for hypothermia and respiratory distress, operating room personnel must prevent untimely delays once the patient has been transported from the bum unit. This requires assessing the patient's needs, planning with the surgeon and anesthesiologist. and implementing those plans. A well-organized, well-educated team can do much to maximize patient safety. The nurse ensures that adequate and appropriate supplies are available and func-
JULY 1984, VOL 40. NO I
AORN JOURNAL
Fig 3. Adequate personnel are required to move the burned patient. tioning properly. Extra personnel to help turn and position the patient may be necessary. Have special items for positioning, such as folded towels, blanket rolls, pillows, and table attachments near. Because the burned patient is often unstable, have a cardiac arrest cart close. throughout the procedure. The patient may be under exceptional metabolic stress from alteration of the thermoregulatory mechanism because. of widespread skin destruction. Heat loss is one of the greatest problems a burned patient faces in the OR. Place a warming mattress on the OR bed and warm it before the patient arrives. Monitor the patient’s temperature throughout the procedure with a rectal or esophageal temperature probe. The nurse should adjust room temperature to 80 OF to 85 OF and should warm all prep, irrigation, and dressing solutions to 98 OF to 104 OF. Also have intravenous fluid warmers available. Upon arrival in the holding area, the patient is likely to be frightened and apprehensive in spite of the preoperative teaching. Providing a quiet area with minimal noise and visual stimulation, encouraging him to verbalize, and answering any questions may decrease anxiety (Fig 4). Intrcropercitive
E
ven though the patient appears to be sleeping or resting quietly, he may be aware of comments and conversations in the room. Touching and speaking quietly and
Fig 4. Comfort and reassurance are given in the holding area.
comfortingly are appropriate. If possible, schedule the same team of physicians, nurses, and anesthesiologists that cared for the burned patient on previous procedures. The patient may be reassured by seeing familiar faces and knowing that those providing care are familiar with him. Careful positioning is necessary before draping (Fig 5 ) . Keep the patient covered with warm blankets until surgery begins. Keep all body areas not involved in the operative procedure covered at all times. The nurse plans for an adequate supply of warmed blankets for postoperative use. The anesthesiologist establishes a wellprotected airway and ensures adequate vascular access. Patients with bums of the head, neck, or chest may be difficult to intubate, and the circulating nurse assists. Cutdowns may be re39
JULY 1984, VOL 40. NO I
AORN J O U R N A L
Fig 5. Careful
positioning
is necessary during
intraoperative care. quired to administer fluids and blood. Invasive hemodynamic monitoring catheters may be inserted. The nurse accurately measuresand records the patient's intake and output, including intravenous fluids, urine, and blood loss. Sponges are weighed to estimate blood loss ( I gm = 1 cc), keeping a running total during the procedure.
Skirt GrnJiing
A
lthough skin grafting was performed by the ancient Hindus, it became popular for treatment of bum injuries in the late 19th and early 20th centuries. In the adult, a p proximately 55% of body surface is available for doner use. A one-year-old child, however, has only 45% of body surface available. Special dermatomes and slitting instruments have made grafting a relatively simple and effective way to cover burned areas. There are basically two types of dermatomes. The oscillating blade dermatome is probably the most popular. Excellent grafts may be taken from areas with adequate underlying support. Sterile mineral oil is used as a lubricant on the skin and also on the moving parts of the dermatome. The scrub nurse sets the depth gauge to zero before the procedure and after changing blades to avoid taking a full-thicknessgraft. Drum dermatomes provide excellent grafts of uniform size and thickness for use in reconstruc40
tive procedures. The donor area is cleaned with a skin degreasing agent after the area is prepped. Both dermatomesuse a special contact cement to achieve bonding between the donor site and the drum. Both use a free-swingingblade to cut the graft. Do not allow the blade to swing unconmlled across the drum because this could result in a flexor tendon laceration for the operator. Leave dermatomes on their carrying stands until ready for use and return them to the stand immediately after the graft is taken. All dermatomes are precision instruments, and as such, they should never be dropped or treated roughly. Hand washing and frequent lubrication of moving parts of dermatomes is recommended. Where little healthy skin is available, as in the case of extensive bum injuries, meshing will provide for much greater coverage with the available graft. A mechanical mesher will slit the graft according to a predetermined expansion ratio. Ratios of 1.5, 3, 6, and 9: 1 are available. Epithelial tissue will grow in between the slits to eventually provide full coverage. Grafting begins as soon as a suitable granulation bed is available or after tangential debridement of clean full-thicknesswounds. Grafts may be divided into two types, temporary and permanent. Several types of temporary graft materials are currently available. Hemografts or allografts are
JULY 1984, VOL 40. NO 1
AORN JOURNAL
Grafting begins when a suitable granulation bed is available or after tangential debridement of clean full-thickness wounds. composed of human cadaver skin; heterografts or xenografts are animal skin, most commonly pigskin. Pigskin, commercially available, aids in reducing fluid loss through evaporation and provides some protection for the wound. The use of synthetic skin substitutes and human amnion have also been successful. Although homografts, heterografts, and other skin substitutesare used often, they provide only temporary, short-term coverage. For permanent coverage and healing, the patient’s skin, or an autograft, must be used. Autografts are taken from unburned areas, preferably the trunk or extremities. The surgeon takes split- or partial-thickness grafts with a dermatome to a predetermined depth, generally between 0.009 and 0.014 inch. The donor areas will heal primarily when properly protected and cared for and may be reused within ten to 14 days. Jones and Feller reported a case in which one donor site was used 15 times in a patient with an 80% bum injury.’ Full-thickness grafts are cut thicker than 0.035 inch and are generally used in reconstruction procedures of the arms or legs. This donor site must be grafted or primarily closed-because it will not heal on its own.
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or a split-thicknessor full-thickness graft to heal or ”take,” several requirements must be met 0 meticulous aseptic technique graft must remain in contact with the recipient site 0 bleeding must be controlled the graft must be stabilized as fibrin is formed by the recipient site. Capillary buds spread through the fibrin, vascularizing the new graft and providing nourishment. Fresh grafts are held in place by sutures or skin
staples on larger grafts, and sterile adhesive strips on smaller areas. The surgeon may simply lay the graft on the recipient site and apply a stent dressing. Within two weeks the graft is firmly attached by connective tissue. The nurse applies occlusive dressings to prevent any movement of the graft on its recipient bed. The following dressing is especially useful in young children and uncooperative adults. A single layer of fine mesh gauze soaked in saline wrapped in a similarly soaked rolled gauze is sufficient. To prevent fluid accumulation under the graft, mild compression is achieved by incorporating a layer of gauze fluffs into the wrap. Preformed splints held in place by an outer wrap of dry rolled gauze will provide protection and maintain immobilization. Some surgeons prefer to leave the freshly grafted areas exposed to observe the site for hematoma, infection, and for early vascularization and “take” of the graft. For the donor site, a single layer of fine mesh gauze dressing impregnated with medication is sufficient. The dressing must protect against infection and trauma and at the same time be as comfortable as possible for the patient. An understanding of the needs of the severely burned patient in the operating room will allow the perioperative nurse to provide the high level of care that these patients demand. Many burn patients return to a normal life because of the perioperative nurse’s technical expertise and 0 compassion. Note I . Irving Feller, C A Jones, Nursing the Burned Pritienr (Ann Arbor, Mich: Institute for Bum Medicine) 973. Suggested reading Artz. C; Moncrief. J; Pruitt, B. Burns: A T w n Approrich. Philadelphia: W B Saunders Co. 1979. Hills, S; Birmingham, J. Burn Cure. Bethany, Conn: Fleschner Publishing Co, 1981. 41
J U L Y 1984. VOL 40, NO I
AORN J O U R N A L
Examination
. I
HOME STUDYPROGRAM
I . A red, tender burn extending into the epidermis is classified as a a) chemical injury b) first-degree bum c) second-degree bum d) radiation injury 2. When a burn involves underlying subcutaneous fat, it is classified as a a) deep dermal second-degree bum b) third-degree bum c) injury caused by electrical trauma d) fourth-degree bum 3. Damage to bone and muscle are frequently caused by a) second-degree bum b) chemical injury c) electrical burns d) third-degree bums 4. A severely burned patient is likely to develop which of the following conditions in the first 24 hours? I ) paralytic ileus 2) hypovolemic shock 3) bacterial endocarditis 4) hypervolemia a) I and 2 c) 2 only b) 3 and 4 d) 3 only 5 . One of the greatest problems the burned patient faces in the operating mom is a) extreme pain b) rapid loss of body heat c ) tracheal obstruction d) nutritional imbalances 6. Mortality for the severely burned patient is high. The cause of death is most often 48
attributed to a) septicemia b) renal damage c) hypothermia d) hypervolemia with massive edema 7. A biopsy of the bum wound is taken pteoperatively to ascertain the 1) advisability of grafting 2) degree of burn 3) bacterial count 4) tissue type c) 2 and 4 a) I , 3. and 4 d) 3 only b) I and 3 8. Anticipating intraoperative blood loss, the physician may order the patient to receive which of the following preoperatively a) whole blood b) packed red blood cells c) fresh frozen plasma d) vitamin K 9. To assure a safe transport of the burned patient to the operating morn the perioperative nurse must 1) make a preoperative assessment of patient’s needs 2) administer the patient’s preoperative sedation 3) arrange for extra personnel as needed 4) have the family leave the patient’s toom before transport begins c) 1 only a) 1 and 2 b) I and 3 d) all of the above 10. Nursing interventions aimed at preventing intraoperative hypothermia include I ) use of a hyperthermia blanket on OR bed
J U L Y 1984. VOL 40. NO 1
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2) adjusting room temperature to 98 O F 3) warming all solutions to 80 O F to 85 O F 4 ) having blood and IV fluid warmers available c ) 2 and 3 a ) 1. 2, and 4 b) 1 and 4 d) all of the above Renal impairment is a common complication of extensive bum injuries. Intraoperative responsibilities of the circulating nurse in monitoring renal function include I ) weighing sponges 2) maintaining intake and output record 3) assisting with hemodynamic monitoring 4 ) preparing for fluid replacement c) 3 a) 1 b) 1 and 2 d) all of the above Which of the following hemodynamic values indicates the patient may be in hypovolemic shock? 1 ) cardiac output 2.5 L/min 2) mean arterial pressure 60 mm Hg 3) cardiac index 5 L/min/m2 4 ) heart rate 120 bpm c ) 1 and 4 a) I , 2, and 3 d) all of the above b) 2, 3. and 4 Which of the following values best indicates the amount of oxygen available to the body’s tissues? a ) arterial blood gas b) mixed venous oxygen tension c ) arterial oxygen tension d ) hematocrit The best equation for measuring blood volume in sponges is a ) 1 gm = I cc b) I Kg = 70 cc c) 1 mg = I cc d ) 1 gm = 70 cc The burned patient is prone to intraoperative cardiac arrhythmias from I ) hypoxemia 2) unstable potassium levels 3) exposure of highly vascular tissue to ambient air 4) suppression of endogenous catecholamines c ) 4 only a) 1 and 2 d ) all of the above b) I . 2, and 3
A O R N JOURNAL
16. Used as an induction agent, sodium thiopental (Pentothal) causes a 1) dose-dependent depression of myocardial metabolism 2) decreased concentration of the drug in brain tissue shortly after administration 3) release of intracellular histamine 4) decreased catecholamine metabolism c) l a n d 4 a) I and 2 b) 2 a n d 3 d) all of the above 17. Which of the following is not true of Ketamine? a) it prevents re-uptake of catecholamines b) it is known to cause frightening dreams c) it supports respiratory reflexes d) less than 1% is metabolized 18. Muscle relaxants are important adjuncts in anesthesia management of the burned patient. Nondepolarizing muscle relaxants exert their effect by a) inhibiting transmission of impulses at the neuromuscular junction b) antagonizing the breakdown of acetylcholine c) releasing massive quantities of intracellular potassium d) enhancing neuromuscular transmission 19. Succinylcholine should be avoided in burned patients between 7 to 60 days postbum, because it may cause a) hypovolemia leading to hypotension b) hyperkalemia leading to arrhythmias c) emergency psychosis d) release of toxins and cellular debris leading to permanent renal damage 20. To prevent postoperative aspiration pneumonia, the patient should have 1) a nasogastric tube to suction 2) application of the Sellick’s maneuver 3) an inflated cuff around the endotracheal tube 4) an antacid preoperatively a) 1 and 2 c) 1, 3, and 4 b) 3 and 4 d) all of the above 2 I . The preparation of the donor site for a splitthickness graft includes use of a) a depilatory b) sterile mineral oil 49
AORN J O U R N A L
c) sterile water d) an oil-based soap 22. The burned patient is a candidate for grafting when a) human amnion becomes available b) fibrin is seen in the bum wound c) hypovolemia is corrected d) a suitable donor is found 23. Skin substitutes are used for a) areas on face and neck b) partial thickness grafts c) temporary coverage d) permanent protection for the wound 24. The scrub nurse prepares the dermatome for use by setting the depth gauge at a) 0.009inch b) 0.035 inch c) 0.029 cm d) 0 inch 25. Danger associated with the free-swinging blade dermatome is (are) I ) laceration to the operator 2) inconsistent graft thickness 3) decreased healing process 4) increased postoperative pain a) alloftheabove c) 2 only d) 3 and 4 b) I only 26. A skin mesher is used a) to maximize use of donor skin b) to improve wound granulation c) as a homograft d ) as a short term wound cover 27. The term used for a skin graft taken from the patient's body for use on another part is a) homograft b) heterograft c) autograft d) xenograph 28. Xenographs provide I ) epithelial tissue 2) pain control 3) debridenient 4) decreased fluid loss a) 1 and 4 c) 3 and 4 b) 2 only d) 4only 20. Success of a graft depends on I ) hemostasis of the graft site 2) graft depth 50
JULY 1984. VOL 40. NO I
3) capillary nourishment of the recipient site 4) the stabilizingeffect of the postoperative dressing a) I and 2 c) 3 and 4 d) I . 3, and 4 b) I , 2, and 3 30. Immediate postoperative needs of the burned patient include I ) reverse isolation to prevent infection 2) liberal use of analgesics 3) muscle relaxants to prevent graft movement 4) pulmonary artery pressure monitoring c) 2 only a) 1 and 2 b) I , 2, and 3 d) all of the above Eilitor's note: Professional nurses are invited to
submit manuscripts for review for a home study program. Manuscripts or queries should be sent to the Editor, AORN Jourtinl, 10170 E Mississippi Ave. Denver, CO 80231. As with all manuscripts sent to the Joitrriul. papers submitted for home study programs should not have been previously published or submitted simultaneously to any other publication.
JCAH Approves Guidelines for Freestanding Clinics The Joint Commission on Accreditation of Hospitals (JCAH) has approved a new standard outlining guidelines for accrediting freestanding emergency facilities. The standard, published in June in the JCA H 's A~iibirlrrtor?.Hutrlrh Coru Sicttid(rrds Mrrriiucl. will take effect Jan I . 1985. For information on obtaining the new guidelines, contact Elizabeth Flanagan. director of the accreditation program for ambulatory health care. JCAH. 875 N Michigan Ave. Chicago, IL 6061 I .
AORN JOURNAL
JULY 1984. VOL 40, NO 1
Answer Sheet
P
lease fill out application and answer form below. Tear out page fromJournal or make photocopies. You may make as many photocopies as necessary. Deadline for this program is January 31, 1985.
Mail to: AORN Accounting Department 10170 E Mississippi Ave Denver, Colorado 80231
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Application Form 1 . Record your identification number in the appropriate section. 2. Completely darken the space that indicates your answer to the examination starting with question one. 3. A score of 70% correct is required for contact hour certificate. 4. Enclose fee: Members: $7; Nonmembers:$14 Please print: Name Address City State
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Offering No 4704. Activity No 847D Program offered July 1984 AORN (ID) number
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Please complete this evaluation form. Mark your ratings of the home study unit starting with question one. Use a scale of 1 to 5 with 1 = low and 5 = high. To what extent: Did the program increase your knowledge of the subject matter? Were the objectives of this program met? Was the content clear and organized? Did this article facilitate your learning? Were your individual objectives met? 51