Nurse Practitioner CLINICAL PRACTICE GUIDELINE Burns

Transcription

Nurse Practitioner
CLINICAL PRACTICE GUIDELINE
Burns
Nurse Practitioner
•
•
•
Scope
Minor burn injuries
Chemical burns
Major burns requiring resuscitative
interventions
• Burns complicated by inhalation injury
• Burns complicated by electrical injury
Initial Assessment and Interventions
Primary survey
• Airway
assessment
• Breathing
• Circulation
History
• Nature of burn i.e. thermal, chemical,
electrical
• MIST Mechanism, injuries sustained,
signs-vitals, treatment given pre
hospital management
• Ability to function/perform
ADL’s/occupation/social assessment
• Past medical history-medications
• Allergies-immunisations especially
tetanus
• Last food and fluids
• Compensable statusMVIT/WC/DVA/Private insurance
Focused clinical
• Assess the size, location and depth
assessment
using Wallace’s ‘rule of nines’ [1, 2]
-colour
-blistering
-sensation
-capillary return
-exudates
-inflammation
Pain assessment
• Pain scale numeric, depending on
nature and depth of burn, pain can be
mild to severe
Analgesia /
• Administration of analgesia
First Aid [2, 3]
• First Aid
• Rest
• Immobilisation
• Elevation
• Irrigation with room temperature water
for up to 30 minutes
• Remove jewellery and clothing
• Clean with sterile sodium chloride
General Practitioner
+/-Nurse Practitioner
Outcomes
Identify patients suitable for
NP CPG
Identify patients not suitable
for NP CPG and redirect to
GP +/- NP.
Outcomes
Abnormal primary survey
identified → exit CPG
Patient identified as not
suitable for NP CPG → exit
CPG
Wound assessment either
epidermal or superficial
dermal burn
Abnormal findings identified
for NP CPG → exit CPG
Determine need for and type
of analgesia
Reduction/relief of pain
Minimise/prevent possible
complications
Healthscope Medical Centres acknowledges the Naturaliste Medical Group for the utilisation of this
Clinical Practice Guideline.
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Nurse Practitioner
Burns
Imaging
Pathology
Working diagnosis and Investigations
• No imaging required if
- no concurrent injuries
•
Outcomes
Identify specific cause and
determine patient
management
Not applicable
Interpretation of results (diagnostic features) and management
decisions
Goals of Treatment
• Protect the wound during the healing
process
• Prevent infection
• Provide pain relief
Provisional Diagnosis
Epidermal Burn
• GP NP review with view for discharge
Sunburn or minor flash
• Dressing required as per amount of
injuries, minimal
exudates, pain, contamination and
exposure time.
location
Epidermal in depth, red,
• Expected to heal spontaneously within
PS minimal, heals within
7-14 days with minimal scarring
7-14 days, no cosmetic
• No dressing unless protection required
[3, 4]
defects
• Patient education/health promotion +/GP if required.
• Follow up appointment with GP NP +/GP if required.
Superficial Dermal
• GP/NP review with view for discharge
Burn
• Dressing required as per amount of
Epidermal and papillary
exudates, pain, contamination and
dermis involvement,
location
blisters present,
• Expected to have more exudates and
extremely painful with
more absorbent dressing more
exposed nerve endings,
appropriate.
heals in about 14 days,
• Dressing selection as per ‘Suggested
Dressings’ see Appendices
• Patient education/health promotion
• Follow up appointment with GP or
referral for surgical consult or follow up
with metropolitan hospital Burns Clinic
Mid Dermal Burn
• NP review in consultation with GP with
Larger zone of necrosis,
view for transfer to hospital emergency
Large zone of stasis,
department
Can be painful,
• Review and maintain adequate
Delayed capillary return,
analgesia
Blisters,
• Maintain hydration
Dark pink
• Document fluid balance
• Patient education and health promotion
Outcomes
Outcomes
Patient identified as suitable
for NP
CPG and discharged safely
Patient identified as suitable
for NP CPG and discharged
safely
Patient referred to specialty
units
Assessment by GP and
admission/transfer arranged.
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Nurse Practitioner
Burns
•
•
Medication as per formulary
Dressing selection as per ‘Suggested
Dressings’ see Appendices
Deep Dermal Burn
Some blistering,
Blotchy red base,
Does not blanch,
Reduced sensation to
pinprick,
Surgical correction
•
NP review in consultation with GP with
view for transfer to metropolitan hospital
burns unit
Review and maintain adequate
analgesia
Maintain hydration
Document fluid balance
Patient education and health promotion
Medication as per formulary
Dressings as advised
Full thickness
Both layers of skin
destroyed, May affect
deeper structures,
Dense, white, waxy or
charred appearance,
No sensation to pinprick,
Leathery appearance
•
Acute
Referral
•
•
•
•
•
•
NP review in consultation with view to
transfer to metropolitan hospital burns
unit
• Review and maintain adequate
analgesia
• Maintain hydration
• Document fluid balance
• Patient education and health promotion
• Medication as per formulary
• Dressings as advised
Criteria for specialised burns treatment
• Burns greater than 10% of TBSA
• Special areas – face, hands, feet,
genitalia, perineum and major joints
• Full thickness burns greater than 5% of
TBSA
• Electrical or chemical burns
• Burns with inhalation injury
• Circumferential burns of limbs or chest
• Very young and very old
• Those with pre-existing medical
disorders that could complicate
management, prolong recovery or
increase mortality
• Burns with associated trauma
Assessment by GP with view
for transfer
Identify patients not suitable
for NP CPG
Æ GP management +/- NP.
Assessment by Burns Unit
and admission/transfer
arranged.
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Nurse Practitioner
Burns
When to return
Patient Discharge Education
• Verbal instructions from NP
• NP/GP written patient information
Follow up
appointments
•
•
Verbal instructions from NP
Written instructions for NP/GP
Safety
•
•
Appropriate dressing fitted to burn
Correct fitting of aids ie. broad arm
sling, referral for crutches from
pharmacy
Patients greater than 60 yrs of age
-referral to physiotherapy
•
Specific care
•
•
Other
Referrals
•
Certificates
•
•
•
Letters
•
Verbal instructions from NP
Written information regarding dressing
changes and burn care
Referrals may be made for specific
patient problems or as required to;
- Silver Chain
- social work
- physiotherapy
- drug and alcohol
- counselor
- Aboriginal liaison officer
Absence from work certificates
WC certificate
Certificate of attendance
To local emergency department;
specialist; admitting hospital; allied
health
Outcomes
Ensure patient understands
problem, treatment, follow up
and is safe for discharge
home
home
home
home
Appropriate documentation
completed
Ensures continuity of care
and referral to health care
team
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Nurse Practitioner
Burns
Medications
See separate Analgesia Clinical Protocol
Analgesia
Vaccination/
Immunisation
Outcomes
Patients given analgesia
appropriate to allergies,
current medications and past
medical history
Analgesia requirements
determined by ongoing
assessment of pain and
adequate analgesia
provided
Patients with excessive pain
or pain unrelieved by
analgesia need review by GP
Tetanus Immunoglobulin intramuscular
Injection
Adsorbed diphtheria and tetanus toxoids
(ADT) 0.5mL intramuscular Injection
Refer to Australian Immunisation Handbook 9th
Edition - section on Immunisation for tetanus prone
wounds - for dosage regimen (dependent upon
previous immunisation status and type of exposure)
Topical agents
Intravenous fluids
Unexpected
representation
Missed problem
Superficial Burns: Algasite and fixamol.
Review within 3 days
Partial / full thickness burns: Acticoat® &
cover with Duoderm®. Review within 3 days
0.9% Sodium Chloride Intravenous fluid: 510ml flush of Intravenous cannulae 6/24 or
Infusion at 8-12hrly titrated to patients
requirements
Clinical audit evaluation strategies
Review Medical Director Progress Notes
Re-assessment of patient
Key to terms
NP- Nurse Practitioner
GP- General Practitioner
PS- Pain Score
S1-S4- Schedule of the drug administration act
CPG- Clinical Practice Guideline
WC- Work cover
MVIT – Motor Vehicle Insurance Trust
DVA- Department of Veteran Affairs
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Nurse Practitioner
Burns
1.
2.
3.
4.
5.
6.
7.
Appendices
Suggested Dressings for the Management of Minor Wounds
Guidelines for the Management of a Minor Burn using Retention Dressings
Care for the Minor Facial Burn
Care for your Burn Wound using Retention Dressing
Care for your Healed Burn
Rule of Nines
Pain Scales
References and existing CPG’s
Naturaliste Medical Group Nurse Practitioner Clinical Practice Guideline: Burns
Authorship and Endorsement
This guideline was written by:
Lisa Scholes - Nurse Practitioner
Broadwater Medical Practice & Dunsborough Medical Practice
Signature: _________________
Reviewed and authorised by:
Dr Andrew Lill - General Practitioner
Signature: _________________
Dr Mostyn Hamdorf -General Practitioner
GP Down South: Chair
Signature: _________________
Dr Scott McGregor - General Practitioner
Signature: _________________
Jarred Smith - Pharmacist
West Busselton Pharmacy
Signature: _________________
Date written: June 2010
Review Date: June 2011
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Nurse Practitioner
Burns
Appendix 1.
SURGICAL DIVISION – ROYAL PERTH HOSPITAL
Suggested dressing for Management of the Minor Burn
OBJECTIVES OF TREATMENT:
• To create a moist, warm, constant environment for wound healing
• Promote autolysis
• Increase patient comfort and reduce pain
• Encourage tissue growth
• Reduce infection rates
• Minimize interference to the patient’s lifestyle
GENERIC
GROUPS
Hydrocolloid
TRADE NAMES
INDICATIONS
ADVANTAGES
DISADVANTAGE
DRESSING CHANGES
DuoDERM,
Comfeel, Cutinova
Hydro (hydrocellular
product)
¾ Small areas of partial to full
thickness skin loss
¾ Presence of slough
¾ Light to moderate exudate
¾ Non-infected wounds
Calcium
alginate
Kaltostat, Algoderm,
Algisite M
Curasorb
¾ Partial thickness skin loss
¾ Minor bleeding wounds
¾ Moderate to heavy exudate
¾ Occlusive
¾ Assists autolytic
debridement
¾ Self adhesive
¾ Promote granulation
¾ Reduce pain
¾ Reduce pain
¾ Absorbs exudate
¾ Haemostatic
properties
¾ Assists autolytic
debridement
¾ Not transparent
¾ Offensive odour with
heavy, clouded
exudate
¾ May macerate
surrounding skin
¾ Ineffective on dry
eschar
¾ Inactive on dry
wounds
¾ Requires a secondary
dressing
Retention
Dressing
Fixomull stretch,
hyperfix
¾ Superficial to partial
thickness skin loss
¾ Minor skin lacerations
¾ Minimal to moderate
exudate
¾ Prior to leaking from
beneath the dressing
¾ 2-5 days
¾ If used for scar
management 10-14
days
¾ Prior to exudate
leaking from beneath
dressing
¾ Donor site dressing
can be left sealed for
up to 14 days if clean
and dry
¾ 3-14 days according
to wound assessment
¾ Can be left for up to
14 days if clean and
dry
Silver
Dressings
Silver Sulphadiazine
(SSD), Acticoat,
Avance, Contreet,
Aquacel silver,
acticoat absorbant
¾ Facilitates joint
mobility
¾ Allows for normal
hygiene
¾ Reduce friction at the
wound surface
¾ Deep partial to full thickness ¾ Reduces incidence of
skin loss
burn sepsis
¾ Antimicrobial
SSD is a preferred dressing for
patient transfer from rural areas
to major referral centres
¾ Not transparent
¾ Specific technique
required for easy
removal
¾ May cause stinging
on superficial burns
¾ Can reduce mobility
over small joints
¾ Some temporary
silver staining may
occur
¾ Cost effectiveness
¾ SSD – DAILY
CHANGE
ESSENTIAL
¾ Product specific
information should be
sought before use
If in doubt contact ROYAL PERTH HOSPITAL (08)9224 2244 Plastic Registrar (on page) of the Clinical Nurse Specialist for the Plastic Surgery and Burns (on page) or
Plastic Dressings Clinic on Ext: 42200 direct fax: (08) 9224 7059
Compiled in 1996 by: B Sperring CN, (Plastic Dressing Clinics) Royal Perth Hospital
Revised: 2006
Authorised by: F Wood Director of Burns Unit
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Nurse Practitioner
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Appendix 2.
Consider referral to a specialised Burns Centre if the burn falls into one of the
following categories: Body Surface Area: > 10% adult patient; > 5% child / less 18 months
of age / hands / face / feet / perineum / major joint involvement / circumferential burns / full
thickness burns / electrical burns / chemical burns / any infected burns
GUIDELINES FOR THE MANAGEMENT OF MINOR BURN INJURY USING RETENTION
DRESSINGS (ie ‘Fixomull Stretch’ or ‘Hypafix’)
APPLICATION OF DRESSING:
1. Analgesic requirements:
a. consider requirements for initial treatment (may require intravenous / intramuscular
narcotic).
b. once dressing is intact oral analgesia should be adequate, if not reassess.
2. Wash the burn wound under running water.
3. Debride blisters, except palm and sole, which need to be slit (create an ellipse) to allow for
adequate decompression and to prevent the blister re-occurring.
4. Ensure the surrounding skin is dry - the dressing will not adhere to moist skin.
5. Apply the retention dressing to the surface of the wound - no interface gauze/cream is
required. Allow an overlap of 2cm of retention dressing on to intact skin.
6. If covering a joint surface, apply with the line of the stretch of the non-woven fabric
following the line of flexion of the joint. DO NOT STRETCH WITH APPLICATION.
7. When joining two pieces of retention dressing over the wound surface allow no more than
2cm overlap of the dressing. Overlap can reduce the effectiveness of the dressing by
preventing moisture vapour permeability.
8. Discharge patient with information sheet on care of and removal of the dressing.
9. Review in 2 - 5 days.
10.If ‘blisters’ form beneath the retention dressing they can be treated without removing all of
the dressing. Simply cut away the retention dressing covering the blistered area. The
blistered skin will come away with the dressing releasing the exudate. The raw area
remaining is then treated as the burn area was initially ie clean, dry and apply a patch of
retention dressing with an overlap of no greater than 2cm
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Nurse Practitioner
Burns
Appendix 3.
CARE OF THE MINOR FACIAL BURN
1. Wash your face carefully twice each day with a simple non-perfumed soap and water, when
showering or bathing.
2. Men should shave each day to reduce the risk of infection.
3. Remove any loose tissue and crusting while showering.
4. Gently pat with a clean towel. Apply a thin smear of emollient-based ointment to all burn
areas except for the eyelids.
5. Take special care of the eyes, applying eye ointment, as directed by your doctor, to the eye
lids.
6. After eating or drinking, apply an oily cream such as ‘lanoline’ to the lips to prevent them
from becoming dry and cracked. This helps to reduce infection.
7. It is necessary to take special care of burns to the ears, by gently cleaning the ears while
showering and applying a thin smear of an emollient based ointment to prevent drying.
Pressure on the ears while they are healing may reduce the blood supply causing further
damage to the skin and increasing the risk of infection.
8. The burn may cause the face to swell. Sitting up on two or more pillows at night will help to
reduce facial swelling.
9. If your wound increases in pain or you are concerned about the swelling, contact the clinic
for review by the nurse.
10. Retention dressings such as ’Fixomull Stretch’ and ‘Hyperfix’ are not recommended
for use on facial burns
Appendix 4: Patient Information Sheet
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Nurse Practitioner
Burns
CARE FOR YOUR BURN WOUND USING RETENTION DRESSING
WHILE HEALING
1. Wash twice daily over the dressing with simple soap and water. Remove
any crusting or yellow/green fluid that may collect
2. Dry thoroughly using a towel to pat dry
3. If soaked in water for over 5 minutes the dressing and wound bill become
soggy and increase the risk of infection
4. Avoid activities that may cause injury to the wound and lead to bleeding or
infection, eg digging in sand, swimming, gardening, mechanical repairs
5. If your wound becomes red and hot with an increase in pain or swelling
beneath the dressing, or if it blisters then return for review of the wound
6. DO NOT REMOVE THE DRESSING. It will not come off easily with water.
Attempts to remove it will cause pain and damage the healing tissue.
REMOVING THE RETENTION DRESSING
Please remove the dressing on: __________________________________
Carefully follow these instructions:
1. Coat the dressing in oil (olive, peanut, baby, vegetable) making sure the
dressing is well soaked.
2. Wrap the dressing in plastic food wrap and bandage if necessary to prevent
oil from staining your clothing or bed linen or cover with an old clean T-shirt
or sock.
3. Leave plastic food wrap in place for a minimum of 4 hours. This can be
overnight.
4. Wash carefully in shower/bath to remove the dressing
5. Simply cover again in fresh plastic food wrap to prevent raw areas from
drying and hold in place with bandages or clothes
6. Your wound can now be easily assessed when you arrive
Multidisciplinary Burn Management Royal Perth Hospital Jan 2004
Appendix 5: Patient Information Sheet
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Nurse Practitioner
Burns
CARING FOR YOUR HEALED BURN
Once the skin has healed it will be fragile and need care and protection
1.
Retention dressing may be used to protect the surface for a period after
healing. The retention dressing can be left in place until it comes off by
itself. If it gets dirty, you may wish to change it before it comes off
naturally. It is usually stays on for about 5-7 days. If at 2 weeks post
healing the scar is a concern to you please make a follow-up
appointment.
2.
Protect yourself from the sun by using sun block (SPF 30+). Hats and
protective clothing are a must.
The pigment cells need time – one to two years - to recover
3.
The glands in the skin take time to recover. Moisturising creams need to
be applied regularly (at least twice daily) and continued for several
weeks. Massage the moisturizing cream into the skin. It prevents drying
and cracking. It can also help to reduce itching and increase comfort.
Avoid highly perfumed creams or creams that have alcohol base.
Appropriate creams are available from the supermarket or local chemist
at competitive prices. Ed Sorbolene, Lanoline or Aqueous Cream.
4.
In some scars pressure therapy is helpful. Pressure garments may be
considered. The need for further scar treatment will be assessed by your
GP.
Multidisciplinary Burn Management Royal Perth Hospital Jan 2004
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Appendix 6. Rule of nines
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Nurse Practitioner
Burns
Appendix 7.
PAIN SCALES
Visual analogue scale (VAS)
Numerical rating scale (NRS)
Faces rating scale (FRS)
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Behavioural rating scale: For patients unable to provide a self-report of pain
0
1
2
Face
Face muscles
relaxed
Restlessness
Muscle tone*
0
Quiet,
relaxed
appearance, normal
movement
0
Normal muscle tone
Vocalisation**
0
No abnormal sounds
Consolability
0
Content, relaxed
Facial muscle
tension, frown,
grimace
1
Occasional restless
movement, shifting
position
1
Increased tone,
flexion of fingers and
toes
1
Occasional moans,
cries, whimpers and
grunts
1
Reassured by touch,
distractible
Score:
Frequent to constant
frown, clenched jaw
2
Frequent restless
movement may include
extremities or head
2
Rigid tone
Score:
2
Frequent or continuous
moans, cries,
whimpers or grunts
2
Difficult to comfort by
touch or talk
Score:
Behavioural pain assessment scale total (0–10)
Score:
Functional activity score#
(Cough/movement)
A – No limitation
B – Mild limitation
C – Severe limitation
#
Relative to baseline
Score:
/10
* Assess muscle tone in patients with spinal cord lesion or injury at a level above the lesion injury. Assess
patients with hemiplegia on the unaffected side.
** This item cannot be measured in patients with artificial airways.
Pain rating scales instructions
Subjective pain score
•
All patients are to have a functional activity score recorded in addition to the chosen subjective score.
Visual analogue scale (VAS)
•
Instruct the patient to point to the position on the line between the faces to indicate how much pain they are
currently feeling. The far left end indicates ‘No pain’ and the far right end indicates ‘Worst pain ever’.
Numerical rating scale (NRS)
•
Instruct the patient to choose a number from 0 to 10 that best describes their current pain. 0 would mean ‘No
pain’ and 10 would mean ‘Worst possible pain’.
Faces rating scale (FRS)
•
Adults who have difficulty using the numbers on the visual/numerical rating scales can be assisted with the use
of the six facial expressions suggesting various pain intensities. Ask the patient to choose the face that best
describes how they feel. The far left face indicates ‘No hurt’ and the far right face indicates ‘Hurts worst’.
Document number below the face chosen.
Behavioural rating scale
The behavioural pain assessment scale is designed for use with non-verbal patients unable to provide self-reports of
pain.
•
Rate each of the five measurement categories (0,1 or 2).
•
Add these together.
•
Document the total pain score out of 10.
Functional activity score
•
This is an activity-related score. Ask your patient to perform an activity related to their painful area (for
example, deep breathe and cough for thoracic injury or move affected leg for lower limb pain).
Observe your patient during the chosen activity and score A, B or C.
A – No limitation meaning the patient’s activity is unrestricted by pain
B – Mild limitation means the patient’s activity is mild to moderately restricted by pain
C - Severe limitation means the patient ability to perform the activity is severely limited by pain
*Relative to baseline refers to any restriction above any pre–existing condition the patient may already have.
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Nurse Practitioner CLINICAL PRACTICE GUIDELINE Burns

Transcription

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