Nurse Practitioner CLINICAL PRACTICE GUIDELINE Burns
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. 1 Nurse Practitioner CLINICAL PRACTICE GUIDELINE 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. Healthscope Medical Centres acknowledges the Naturaliste Medical Group for the utilisation of this Clinical Practice Guideline. 2 Nurse Practitioner CLINICAL PRACTICE GUIDELINE 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. Healthscope Medical Centres acknowledges the Naturaliste Medical Group for the utilisation of this Clinical Practice Guideline. 3 Nurse Practitioner CLINICAL PRACTICE GUIDELINE 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 Ensure patient understands problem, treatment, follow up and is safe for discharge home Ensure patient understands problem, treatment, follow up and is safe for discharge home Ensure patient understands problem, treatment, follow up and is safe for discharge home Appropriate documentation completed Ensures continuity of care and referral to health care team Healthscope Medical Centres acknowledges the Naturaliste Medical Group for the utilisation of this Clinical Practice Guideline. 4 Nurse Practitioner CLINICAL PRACTICE GUIDELINE 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 Healthscope Medical Centres acknowledges the Naturaliste Medical Group for the utilisation of this Clinical Practice Guideline. 5 Nurse Practitioner CLINICAL PRACTICE GUIDELINE 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 Broadwater Medical Practice & Dunsborough Medical Practice Signature: _________________ Dr Mostyn Hamdorf -General Practitioner Broadwater Medical Practice & Dunsborough Medical Practice GP Down South: Chair Signature: _________________ Dr Scott McGregor - General Practitioner Broadwater Medical Practice & Dunsborough Medical Practice Signature: _________________ Jarred Smith - Pharmacist West Busselton Pharmacy Signature: _________________ Date written: June 2010 Review Date: June 2011 Healthscope Medical Centres acknowledges the Naturaliste Medical Group for the utilisation of this Clinical Practice Guideline. 6 Nurse Practitioner CLINICAL PRACTICE GUIDELINE 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 Healthscope Medical Centres acknowledges the Naturaliste Medical Group for the utilisation of this Clinical Practice Guideline. 7 Nurse Practitioner CLINICAL PRACTICE GUIDELINE Burns 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 Healthscope Medical Centres acknowledges the Naturaliste Medical Group for the utilisation of this Clinical Practice Guideline. 8 Nurse Practitioner CLINICAL PRACTICE GUIDELINE 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 Healthscope Medical Centres acknowledges the Naturaliste Medical Group for the utilisation of this Clinical Practice Guideline. 9 Nurse Practitioner CLINICAL PRACTICE GUIDELINE 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 Healthscope Medical Centres acknowledges the Naturaliste Medical Group for the utilisation of this Clinical Practice Guideline. 10 Nurse Practitioner CLINICAL PRACTICE GUIDELINE 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 Healthscope Medical Centres acknowledges the Naturaliste Medical Group for the utilisation of this Clinical Practice Guideline. 11 Nurse Practitioner CLINICAL PRACTICE GUIDELINE Burns Appendix 6. Rule of nines Healthscope Medical Centres acknowledges the Naturaliste Medical Group for the utilisation of this Clinical Practice Guideline. 12 Nurse Practitioner CLINICAL PRACTICE GUIDELINE Burns Appendix 7. PAIN SCALES Visual analogue scale (VAS) Numerical rating scale (NRS) Faces rating scale (FRS) Healthscope Medical Centres acknowledges the Naturaliste Medical Group for the utilisation of this Clinical Practice Guideline. 13 Nurse Practitioner CLINICAL PRACTICE GUIDELINE Burns 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. Healthscope Medical Centres acknowledges the Naturaliste Medical Group for the utilisation of this Clinical Practice Guideline. 14
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