Acute patients with burns

Pressure ulcer risk factors

In this blog we will look at the challenges for patients with burns.

As with any patient with a pressure ulcer risk factor we need to refer to our guidelines in care planning benchmarked to our policy and guidelines.

We will look at risk factors benchmarked to the aSSKINg principles which are as follows:

a = Assessment

S = Skin Inspection

S = Surface

K = Keep Moving

I = Incontinence

N = Nutrition

g = Giving Information

Firstly whats the definition of a burn:

A medical burn may be defined by damage to the skin or other body parts caused by extreme heat, flame, contact with heated objects, or chemicals. Burn depth is generally categorised as first, second, or third degree. (medicinenet.com)

Burns to the skin can vary in severity from mild to life threatening. Most burns will only affect the upper layers of the skin, but depending on how deep the burn is, it can affect underlying tissues too.

Traditionally burns are categorised by degree with the first degree being least severe and the third degree the most severe.

Another factor to assessing burn severity used by medical staff and paramedics is how much of a % the body is affected. For example front of chest 18% burn, each arm front and back 9%. To help gauge the surface area of the burn, the palm of the hand is approx 1% of the total surface area of the body. This is an indicator of how big the burn is and the increased risk of complications such as hypovolemic shock (decreased blood supply).

Small full thickness burns are sometimes treated at home, however, anything larger would require hospitalisation and expertise due to potential complications. (Fritsch et al 2001).

Risk factors for this patient group being treated in hospital for full thickness burns may be:

Reduced mobility or immobility

When large areas of the skin are burnt there may be sudden decreased blood supply. In the severe cases of decreased blood supply, this may result in hypovolemic shock which can be fatal. This type of shock can cause many organs to stop working. As a result the normal function of skin is greatly impaired and rapid failure a risk.

Pain 

Burns may not always be painful. With this type of burn, all layers of the skin — epidermis and dermis — are destroyed and the damage may even penetrate to the subcutaneous fat layer. These full-thickness burns may not always hurt when touched. This is because the nerve endings responsible for sensation are destroyed. The pain and itching may increase as the wound is in the healing stage and the nerve endings are repairing.

At this stage the patient may be taking NSAID and/or opioids which in turn may mask the pain signal to self-reposition when tissue hypoxia or the ‘birth of a pressure ulcer’ is occurring. 

Minimising risk using ASSKING

a – Assessment

Completing your risk assessments on admission as per your policy, in an acute setting, this is likely to be checked every day.

S – Skin Inspection

Identifying early stage pressure damage or a STDI under a burn site will not be possible in most cases. Care must be taken to ensure regular micro-movements are encouraged to actively continue the active reperfusion of the pressure risk areas.

S – Surface

For patients with burns that are unable to reposition, a very high risk or pumped mattress may be required to reduce the surface/bone interface pressures.

K – Keep Moving

The use of repositioning prompts/charts are used to offer regular turns and reperfusion of the body and surface interface to restore blood flow. For patients at very high risk that find it difficult to turn may require intermittent offloading between prompted manual repositioning. The use of lateral tilt mattresses are increasingly beneficial. If the patient is able to self reposition, prompting them to do so can be part of your repositioning care plan. Ensure they understand why you are asking them to do this, see ‘giving information below’.

I – Incontinence

Keeping the skin dry and clean in and around burn sites is vital to reduce the risk of infection. Reducing the risk of friction injury to fragile skin means cleansing these areas can be challenging. Referring to skin cleansers, when finding what’s best for your patient, ask the hospital what they have been using that suits the patient and reduced the risk of disturbing the healing process. For incontinent patients, the use of barrier cream or spray will still be required to maintain the PH balance of the skin and reduce incontinence associated dermatitis and further aggravation.

N – Nutrition

Your patient is likely to be nutritional and fluid compromised due to the body using all vital nutritions to heal burns. Seek advice from the GP/dietician along with hospital care plans. Where possible this should be encouraged through diet and food/fluid plans however, they may need increased protein or nutritional supplements.

g – Giving Information

Giving the patient information in terms of what they are able to do to help themselves, even a gentle tilt from side to side or explainations as to why they are on a specific mattress.

As with all patients with complex needs, ensuring care planning is done with a multi-disciplinary approach may give some innovative ideas on how to protect your patient from developing a pressure ulcer while recovering from burns.

I am certainly not a burns nurse expert so for anymore information for someone you are caring for, following discharge for burns injury, ask for skin care information and don’t forget to ask the champion group for any other tips.

References

https://www.medicinenet.com/script/main/art.asp?articlekey=31816 accessed 16th August 2019

Diane, Fritsch. Tammy, Coffee. Charles, Yowler (2001) ‘Characteristics of Burn Patients Developing Pressure Ulcers’. Journal of Burn Care & Rehabilitation 22(4): pp 293-299. Available online: Accessed on 16th August 2019: https://insights.ovid.com/pubmed?pmid=11482690