Nursing care in burn patients

NURSING CARE IN BURN PATIENTS

Assistência de enfermagem em pacientes queimados

Adélia Dayane Guimarães Fonseca1

Sâmela Sindy Souza Reis1 Solange Maria Silva 1 Flávia Évanlen Lima Amaro1 Ana Izabel de Oliveira Neta1 Claudiana Donato Bauman2 Maria Fernanda Santos Figueiredo Brito2 Carla Silvana de Oliveira e Silva2

Abstract: the burns are one of the main external causes of deaths recorded in Brazil, so their victims

deserve special attention. The purpose of this review is to describe the nursing care to the victims of this

type of injury. This review allowed the creation of five categories related to nursing care of the burn subject,

namely: general care with the burn patient, responsibilities of the nurses, pain assistance to the burn patient,

patient monitoring, and systematization of the nursing support to these patients. The nursing support of

the burn victim is critical in the process of their healing and rehabilitation, requiring a consistent scientific

knowledge about the physiological changes in the organism that takes place after this sort of lesion in order

to identify and prevent changes that could unleash further complications. The care and nursing care have a

great contribution in the patient recovery, and if they are executed properly, they enable the accomplishment

of an effective result, free of damage and without complications to the victim.

Keywords: Nursing Care; Burns; Role of the professional nursing.

________________

Corresponding author: Adélia Dayane Guimarães Fonseca. E-mail: adeliadayane@yahoo.com.br

1 Faculdades Santo Agostinho de Montes Claros. 2 Universidade Estadual de Montes Claros.

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Resumo: as queimaduras constituem uma das principais causas externas de mortes registradas no Brasil,

assim, as vítimas de queimaduras merecem atenção especial. O objetivo dessa revisão é descrever os cuidados

de enfermagem aos pacientes, vítimas de queimaduras. A presente revisão possibilitou a criação de cinco

categorias relacionadas aos cuidados de enfermagem ao paciente queimado, a saber: cuidados gerais com o

paciente queimado, responsabilidades do enfermeiro, assistência à dor do paciente queimado, monitoramento

do paciente queimado, sistematização da assistência de enfermagem aos pacientes queimados. A assistência

de enfermagem ao paciente queimado é fundamental no processo de cura e reabilitação do paciente, e

exige que o enfermeiro tenha alto conhecimento científico sobre as alterações fisiológicas que ocorrem

no sistema orgânico após uma queimadura, para que assim possam identificar e prevenir alterações que

possam desencadear maiores complicações. Os cuidados e a assistência de enfermagem têm contribuição

na recuperação do paciente, e se forem executados de forma apropriada, permitem alcançar um resultado

eficaz, livre de danos e complicações ao paciente.

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INTRODUCTION

Burns are defined as injuries resulting from

thermal trauma from the exposure to cold, hot

liquids or surfaces, flames, chemicals, radiation

or to abrasion or friction. These results might

occur through the direct or indirect action of the

causative agent over the organism

_{. The burn}

classification is made according to their mode

of action, depth, extension of the compromised

area, region or part of the body affected, and its

extension

_.

In Brazil, there are a million cases of

burn each year, of which 200,000 are attended in

emergency services and 40,000 demand hospital

admission. Burnings are among the major external

causes of death recorded in Brazil, only after other

violent causes, such as car accidents and homicides.

A study conducted in the Federal District showed a

mortality rate of 6.2% among burn patients admitted

in an emergency hospital

_.

Burn victims deserve special attention, not

only because of their physical and psychological

weakness but also due to their great potential of

acquiring nosocomial infections, since in addition

to the lesion itself they present favorable conditions

for bacterial proliferation. Therefore, it is important

to provide good assistance, have appropriate

practices and technical skills related to burn

injuries

_{, a fact that remarks the importance of the}

nursing care delivered to the burn patient.

These subjects might develop complications

in their clinical condition due to the extension and

depth of the burn lesions. The highest the exposure

to the aggressive agent the highest is the risk of

presenting secondary complications. Thus, the

importance of proper nursing care is essential to the

prevention of harm to burn victims, since the nurses

have a direct contact with them and are in charge of

their care and support

_.

The severity of the lesion is directly related

to its extension and depth, which might cause many

physical disturbances, such as, for example, loss of

liquids, metabolic changes, body deformities, and

risk of infection, besides the complications caused

directly by the burn, which might provoke major

complications in the health of the patient. As it

represents a trauma of great complexity requiring an

efficient, adequate, and prompt treatment, accidents

with burn victims have a high rate of morbidity and

mortality

_.

A high-quality nursing care demands a

24-hour assistance, in order to reduce the physical and

emotional pains, fears, and anxieties, taking part in

all the assistance and technical and administrative

procedures. For this purpose, the nursing personnel

should have a comprehensive knowledge of the

physiopathological process and therapeutics to

be given to the burn patient, aiming to provide a

proper primary nursing care, followed by the other

required care during the whole treatment.

In this context, it is essential that the nursing

professionals should recognize the importance

of granting a high-standard assistance and proper

technical practices for each type of burn, so they

can promote the rehabilitation and prevention of

grievances, identifying the risks presented by the

patients and performing the adequate interventions.

However, despite the importance of this

issue, the lack of current studies about the nursing

care delivered to burn victims is noteworthy. Based

on these considerations, this article aims to describe

the nursing care that should be given to patients that

are burn victims.

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LITERATURE REVIEW

Based on the results of the studies, the

data were categorized into the following thematic

categories: General care with the burn patient, Nurse

responsibilities, Pain assistance to the burn patient,

Monitoring of the burn patient, and Systematization

of the nursing support to the burn victims.

General care with the burn patient

The initial care of the burn patient is not

directed only to the lesions elicited by the causing

agent. The first aid involves the maintenance of

the permeability of the airways, fluid replacement,

and pain control. These measures aim to reduce the

complications caused by the thermal trauma. When

the burn subject is admitted to the emergency unit,

independent of the extension of its lesions, he should

be assisted by the health staff that will perform the

required procedures and exams in order to evaluate

the level of cutaneous and systemic involvement

_.

The nursing professional should choose the

priorities of action, planning an adequate assistance

according to the requirements of the affected areas

of the patients, as well as analyze and follow-up the

exams with regular periodicity. The professional

should also engage in an effective communication

with the patients and their relatives, as well as

with the health staff in charge of the case. The

mode of action and the treatment of the burn are

determined according to the severity of the lesions

that resulted from the exposure, type, and degree

of compromising, taking into account the real

need of the patient, with the purpose of stabilizing,

improving, and at last, shortening the admittance

time.

The burns, considered as great complexity

traumas, require a proper and immediate treatment,

due to the several damages and disturbances inflicted

to the patients, besides the complications that might

affect their health status. Caregiving should not

limit itself to the victim, but also be extended to his

family, which should also be included, possibly, as

one of the supports to the plans of intervention by

the nursing team in order to favor the rehabilitation

of the patient

_.

The general care is basically routine

procedures; more complicated cases demanding

more complex care with actions regarding hygiene,

feeding, hydration, bed positioning, and dressings

_.

The moment of cleansing the patient is the adequate

time to perform the required care of the burn patient,

since it favors the removal of the exudate and of

the necrotized tissue, preventing the proliferation

of the microorganisms, an important action in this

treatment. During the cleansing of the victim, since

the barrier of the skin is destroyed, measures should

be taken to prevent and control infections

_.

It should be considered that in all procedures

with burn people only sterile products should be

used and the correct techniques adopted as the major

practice in the prevention and control of infections

associated with the burn area, in order to avoid

cross-contamination. Thus, the wound should be

daily observed with detail. Any change in the lesion

should be reported, since, in many times, it indicates a

local or systemic infection demanding an immediate

intervention

_.

The nursing of a burn patient demands a

team that is aware and conscious that due to the

rupture of the integrity of the skin, these patients

are prone to infectious complications that might

compromise their clinical status, demanding a

greater accuracy during the procedures

_.

Finally, the general care delivered by the

nursing team to the burn patient demands the

adoption of safety precautions, such as the use of

devices for individual protection, one of the most

employed actions with an important contribution to

performing a clinical exam; pain control;

psychological support; nutritional support

associated with adequate techniques, executing

a teamwork that meets the specific needs of the

victim

_.

Thus, the nursing staff should be properly

prepared and qualified about the essential conducts

and precautions with burn patients, so they can

execute the demanded care in an efficient way,

contributing to a positive evolution of the treatment

_.

Pain assistance to the burn patient

During the practice of nursing support

to the burn victim, the essential assignment also

consists in relieving the pain in suffering. To do so,

the professional should forget previous deleterious

experiences, considering the patient in pain as an

integral being with exclusive characteristics

_.

The nursing team is considered essential

in the caregiving for patients in pain due to its

proximity to them, with evidence that the prognosis

of the pain status of burn patients depends, to a great

extent, to the way their pain is considered by these

professionals. This fact remarks the importance

of understanding the pain, since this can result in

restoring the sedation or, in contrast, becoming

psychologically traumatic, besides chronical

_.

There is a strong relationship between the

patients and nurses, whose direct efforts indeed

contribute to all the treatment process, including

the occasions where the pain is present, implying

in bigger responsibilities and technical skills to

manage and relieve the pain experienced by the

patient

_.

Pain related to burn has a significant impact

on the process of recovery of the patient, affecting

the basic human needs of the individual and also

bringing considerable negative consequences to

the prognosis of the patient. So, the nursing staff

plays an essential role in the pain relief, since it

the reduction of the risks of infection related to the

health assistance

_.

Nurse responsibilities

The nursing support is the action of taking

care of human beings, independent of the affection

for them. When providing this care, it is important

that the nurse, together with the multidisciplinary

team, present a high degree of scientific knowledge

about the physiological changes that take place in

the organism after a burning episode, putting their

skills and competencies into practice. An important

point in the safe rehabilitation is the practice of

health education in the ongoing care and after the

discharge of the patient, together with his family

_.

In the context of the burn victim, the nursing

assistance is critical in the process of healing and

rehabilitation, demanding a high level of scientific

knowledge about the physiological changes that

take place in the organism after a burn, in order

to identify and prevent alterations that might

trigger more complications as a result of tissue and

systemic lesions

_.

The nurse should have a critical thinking

capable of promoting the clinical decision that

helps to identify the needs of the patient and the

best measures to be taken in order to meet them.

Therefore, in order to acquire a better theoretical and

practical background of the nursing care, particular

updates of the contents directly linked to the burn

patients are required, such as skin physiology

and anatomy, the healing process of burns, and

especially to master the nursing process.

Burns are body lesions, both local and

systemic, that interfere in the treatment and

care provided to the patient. In this context, the

nursing and the health staff face many situations

that demand prompt intervention, such as, for

instance: monitoring the respiratory patterns;

fluid replacement; observing signs of infection;

Nursing care in burn patients FONSECA, A. D. G.; REIS , S. S. S.; SILVA, S. M.; AMARO, F. E. L.; OLIVEIRA

NETA, A. I..; BAUMAN, C. D.; BRITO, M. F. S. F.; SILVA, C. S. O. ISSN 2236-5257

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REVISTA UNIMONTES CIENTÍFICA

is responsible for the implementation of the drug

prescription. Therefore, this professional is in charge

of managing the pain felt by them in a proper way,

adopting the pharmacological measures according

to the needs of the patient

_.

Monitoring the burn patient

The initial stages of the physiopathological

changes that result from important burns are

systemic changes. The hemodynamic instability

is triggered by the loss of capillary integrity;

which promotes the movement of liquids from the

intravascular space to the interstitial space. The

monitoring of the hemodynamic conditions of

the patient is crucial to systematize the assistance

and optimize the treatment. Therefore, the clinical

conditions of the patient should be thoroughly

evaluated to, in this way, to determine the types of

monitoring to be used.

The following parameters are considered

important to be evaluated: respiratory pattern;

hemoglobin saturation, with the help of oximetry;

the production of carbon dioxide by capnography;

blood pressure assessment by the regular device

with an arm cuff or by invasive monitoring;

hourly diuresis, with the insertion of a vesical

delay; body temperature using a thermometer or

invasive monitoring; monitoring of the central

venous pressure and of the lung pressure with

the aid of a Swan-Ganz; estimate of lactate by

arterial blood gas; cardiac output measurement;

follow-up with electrocardiogram with the use

of an electrocardiograph or cardioscope; and the

performing of serial exams such as blood count,

coagulation panel, renal function, blood glucose,

blood proteins, and electrolyte dosing

_.

It is important for the nursing personnel to

be aware of aggravating multiple factors that might

lead the patient to death. The holistic view, in this

case, might avoid grievances and/or discomfort

to the patient, since the care for his integrity is

assumed by the multidisciplinary team. However,

he should be observed by the nursing team, which

leads to an efficient approach in the diagnostics and

specific interventions by the nursing.

Depending on the extension of the burns, the

victims experience severe body lesions that might

affect them both physically and psychologically.

When providing care to the patient, the

professionals must be scientifically qualified about

the physiological changes in the organism caused

by the burn, so they can implement adequate

practices and techniques that favor the outcome

of the patient. The monitoring of these patients is

really important since it allows the early detection

of possible changes and complications, allowing

the team to employ fast and resolute conducts in

the treatment

_.

Systematization of the nursing support to the burn

patients

The foundation of the systematization of

the nursing support is the nursing process, which is

composed of stages with the function of identifying

the health problem of the patient, the determination

of the nursing diagnoses, the establishment of the

care plan, and implementation of actions and their

evaluation. However, to do so, it is important for the

nurse to have reliable parameters for the execution

of his actions, in order to develop a scientific and

qualified assistance

_.

The nurse should gather the necessary

information, through the anamnesis; to establish

the nursing support that answers the needs of the

burn patient and therefore continues the therapeutic

treatment started in the first moment

_.

The physical exam is paramount in the

evaluation of the burn patient, taking into account

the lesions he suffered, and should be performed

in a thorough way, paying attention frequently to

the vital signs, with an emphasis in the peripheral

pulses which might be unable to be checked due to

the presence of swelling. The evaluation of these

parameters gives the nurse a broad knowledge of

the outcome of the clinical condition of the patient

because, only in this way, it would be possible to

determine if the treatment is having an effective

response

_.

The Nursing Diagnose (ND) links the

nursing to the other health professions, being a

taxonomy that enables the communication of the

practices and perspectives of care, with the goal

of speeding, standardizing, and implementing

the practice of the systematization of the nursing

support, being essential in the assistance of burn

victims. It offers a clinical evaluation of the

responses of the individual, family, or community,

the difficulties and the current and potential

methodologies to support life

_.

In order to assist the burn patient, first,

it is necessary to implement the planning of the

nursing support that is part of a process to identify

and determine the required interventions for each

type of patient, aiming to accomplish the desired

results established by the nursing personnel,

according to the therapeutic treatment. To establish

interventions, both general and specific is to direct

the nursing care always toward the well-being and

improvement of the patient that has suffered any

type of burn, whether it is a small, medium or a

large burn

_.

The care plan should be established

according to the daily priorities, performing

changes in response to the needs of the patient and

to his clinical condition. To elaborate this plan it

is important to establish the nursing diagnoses,

since they match the bases and adequate nursing

objectives and interventions, aiming to obtain the

desired results in charge of the nurse

_.

The care plan should answer to the various

physical threats that might result, besides offering

psychological support to the patient and his family.

The nursing care action goes well beyond technical

actions such, for instance, cleansing in bed/

aspersion, debridement, dressings, pre- and

post-surgical moments, among others

_.

In burn patients, the nursing actions

according to the Theory of Basic Human Needs

from Wanda de Aguiar Horta (NHB) related to

the Context of Education and Assistance are the

following: psychobiological, psychosocial, and

psychospiritual needs: oxygenation, hydration,

nutrition, evacuation, sleep, rest, body and oral

hygiene, physical and cutaneous-mucosa integrity,

mobility/locomotion, regulation, pain perception,

therapeutic, communication and learning,

gregarious, religious, and ethical

_.

The systematization of the nursing support

is an important tool for the nurse to obtain

high-quality assistance since it allows the professional to

prioritize the needs of each patient and still develop

actions based on technical-scientific knowledge.

These proposed nursing actions are important

because they establish the priorities of the required

care to attend the burn patient, determining the

required interventions to each type of burn victim,

independent of the size and weight

_.

FINAL REMARKS

The present review was elaborated based

on studies that have addressed the major nursing

care provided to burn patients, each one with a

different contribution, proposing interventions that

optimize the assistance delivered to these subjects.

This investigation offers an important contribution

to the knowledge of the nursing professionals, since

Nursing care in burn patients FONSECA, A. D. G.; REIS , S. S. S.; SILVA, S. M.; AMARO, F. E. L.; OLIVEIRA

NETA, A. I..; BAUMAN, C. D.; BRITO, M. F. S. F.; SILVA, C. S. O. ISSN 2236-5257

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they frequently nurse burn patients, and therefore

should be able to provide a qualified assistance. All

the appointed measures embrace the reduction of

the risks of complications, management of pain,

and standardization and systematization of the

assistance.

It is critical that the nursing professionals

have a vast scientific knowledge about the

physiopathological changes caused by burns

in order to be careful about the intrinsic risks

associated with this type of lesion, setting proper

adequate and proper plans according to the needs

and damage caused by these lesions.

CONFLICT OF INTEREST

The authors declare the absence of any

conflict of interest.

REFERENCES

1. OLIVEIRA, T. S.; MOREIRA K. F. A.;

GONÇALVES T. A. Assistência de enfermagem

com pacientes queimados. Rev Bras Queimaduras,

Florianópolis, v. 11, n. 1, p. 31-37, 2012.

Available in:

http://www.rbqueimaduras.com.br/

details/97/pt-BR

Accessed in: 2 August, 2017.

2. MOSER, H.; PEREIMA, R. R.; PEREIMA,

M. J. L. Evolução dos curativos de prata

no tratamento de queimaduras de espessura

parcial. Rev Bras Queimaduras, Florianópolis,

v. 12, n. 2, p. 60-67, abr./jun, 2013. Available

in:

http://www.rbqueimaduras.com.br/

details/147/pt-BR

Accessed in: 1 August, 2017.

3. VALE, E. C. S. Primeiro atendimento em

queimaduras: a abordagem do dermatologista.

An Bras Dermatol., Rio de Janeiro, v. 80, n.

1, p. 9-19, jan./fev. 2005. Available in:

http://

www.scielo.br/scielo.php?script=sci_ar

t t e x t & p i d = S 0 3 6 5 - 0 5 9 6 2 0 0 5 0 0 0 1 0 0 0 0 3

Accessed in: 2 August, 2017.

4. PEREIRA, M. S.; SILVA E SOUZA, A.

C.; TIPPLE, A. F. V.; DAMACENO, A. P.;

CASTRO, K. Assistência hospitalar ao paciente

portador de queimaduras na perspectiva do

controle de infecção: um estudo de caso. Rev

Eletr Enferm, Goiânia, v. 4, n. 1, p. 40-50, 2002.

Available in:

https://revistas.ufg.br/fen/article/

view/743/804

Accessed in: 2 August, 2017.

5. CONCEIÇÃO, M.; OLIVEIRA, A.;

RODRIGUES, F. Trauma pediátrico:

assistência de enfermagem a crianças vítimas

de queimaduras. Rev Esc Enferm USP, v. 82,

n. 4, p. 52-56, 2007. Available in:

http://www.

prac.ufpb.br/anais/xenex_xienid/xi_enid/

monitoriapet/ANAIS/Area6/6CCSDEMCAMT10.

pdf

Accessed in: 2 August, 2017.

6. MENDES, K. D. S.; SILVEIRA, R. C. de. C.

P.; GALVÃO, C. M. Revisão integrativa: método

de pesquisa para a incorporação de evidências na

saúde e na enfermagem. Texto Contexto Enferm,

Florianópolis, v. 17, n. 4, p.758-764, out./dez, 2008.

Available in:

http://www.producao.usp.br/bitstream/

handle/BDPI/3509/art_MENDES_Revisao_

integrativa_metodo_de_pesquisa_para_a_2008.

pdf?sequence=1

Accessed in: 2 August, 2017.

7. CHAVES, S. C. S. Ações da enfermagem

para reduzir os riscos de infecção em grande

queimado no CTI. Rev Bras Queimaduras,

Rio de Janeiro, v. 12, n. 3, p. 140-144, 2013.

Available in:

http://rbqueimaduras.org.br/

details/159/pt-BR/acoes-da-enfermagem-para-

reduzir-os-riscos-de-infeccao-em-grande-queimado-no-cti

Accessed in: 02 August, 2017.

8. PINTO, E.; DELLA-FLÓRA, A. M.; SILVA,

L. D.; RORATO, T. J.; REQUIA, J.; MARTINS,

E. S. R. et al. O sentimento e a assistência de

enfermagem perante um grande queimado.

Rev Bras Queimaduras, v. 13, n. 3, p.

127-129, 2014. Available in:

http://rbqueimaduras.

org.br/details/210/pt-BR/o-sentimento-e-

a-assistencia-de-enfermagem-perante-um-grande-queimado

Accessed in: 2 August, 2017.

9. CANELA, A. F.; SÓRIA, D. A. C.; BARROS,

F. E.; MELOS, R. O. L.; CASTRO, R. C.

Monitorização do paciente grande queimado e

as implicações na assistência de enfermagem:

relato de experiência. Rev Bras Queimaduras,

v. 10, n. 4, p. 133-137, 2011. Available in:

http://

www.rbqueimaduras.com.br/details/84/pt-BR/

monitorizacao-do-paciente-grande-queimado-e-

as-implicacoes-na-assistencia-de-enfermagem--relato-de-experiencia

Accessed in: 2 August, 2017.

10. SILVA, B. A.; RIBEIRO, F. A. Participação

da equipe de enfermagem na assistência à

dor do paciente queimado. Rev Sociedade

Brasileira para o Estudo da Dor, São

Paulo, v. 12, n. 4, p. 342-348, out-dez, 2011.

11. ALMEIDA, J. W. F.; SANTOS, J. N.

Assistência de enfermagem em grupos de

riscos a queimadura. Rev Bras Queimaduras,

Curitiba, v. 12, n. 2, p. 71-76, 2013. Available

in:

http://rbqueimaduras.org.br/details/149/pt-

BR/assistencia-de-enfermagem-em-grupos-de-riscos-a-queimadura

Accessed in: 2 August, 2017.

12. PINHO, F. M.; AMANTE, L. N.; SALUM, N.

C.; SILVA, R.; MARTINS, T. Guideline das ações no

cuidado de enfermagem ao paciente adulto queimado.

Rev Bras Queimaduras, Florianópolis, v. 15, n. 1,

p. 13-23, 2016. Available in:

http://rbqueimaduras.

org.br/details/288/pt-BR/guideline-das-acoes-

no-cuidado-de-enfermagem-ao-paciente-adulto-queimado

Accessed in: 2 August, 2017.