Nursing Care of Severely Burned Patients

Author(s): Constance W. Milner

Source: The American Journal of Nursing, Vol. 54, No. 4 (Apr., 1954), pp. 456-459
Published by: Lippincott Williams & Wilkins
Stable URL: https://www.jstor.org/stable/3460954
Accessed: 07-01-2020 04:45 UTC

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before
beforegrafting
graftingprocedures
procedures are are
done.
done. In an
an unburned
unburned person,
person,the
thefat
fatun-
un- at the
the same
same time.
time.We
Wehave
havemany
manytimes
times
The
The burn
burnwound
wound becomes
becomesextremely
extremelyderlying freshly excised skin is the placed
placed fresh
fresh grafts
graftsimmediately
immediatelyad- ad-
painful;
painful;this
thispain
painpersists
persists
on motion
on motionbest possible recipient site for a graft jacent
jacent to
to undebrided
undebridedslough
sloughwith
withgood
good
or contact until wound closure has once complete hemostasis is secured. success.
success. When
When the
theslough
sloughcan
canbebere-
re-
been secured. Dressings must be In donethe burned patient, this ideal bed moved easily, that area is grafted,
under anesthesia. Pentothal serves is closely approximated by the fat and so on, until all areas have been
well. Dressings once every week are underlying the burned tissue if the covered. In general, debridement of
often enough; at the second or third subcutaneous fat is itself unburned, burned skin should not be carried out
dredsing, coverage may commence. if it is uninfected, and if thick red in areas where the burned tissue is
exuberant granulation tissue has not extremely adherent and cannot be re-
ThW' W1eek to Third Month-
formed. If all goes well, these three moved easily.
Close the Wound
conditions will co-exist sometime be- As wound coverage begins, the
During ',`is period, the physician tween the second and fifth week. If change in the patient's morale and
should I the golden moment," blood volume is also good, the "goldenappetite must be seen to be believed.
whi : i 4isbe first moment at which moment" has arrived. From that time on, he will cooperate
debrlcsMa nt of part or all of the This is the time to cover the burned in programs of physical therapy and
burned tissue can safely be done. areas to the maximum possible ex- ambulation, which must be pursued
The concept that a burned area must tent with split thickness grafts taken with dogged persistence. The care of
show "healthy" granulations before it from every available donor area. The the patient after the wounds are
is "ready" to graft has, we hope, dis- surgeon can expect truly phenomenal healed, leading to resumption of full
appeared forever. This change of con- success with the grafts under these activity with motion of all joints- and
dept is one of the greatest advances conditions. avoidance of contractures, is a major
of this decade in the treatment of In extensive burns, the "golden program in itself which we will not
burns. moment" may not arrive for all areas discuss here.

Nursing Care of Severely factors play

play in
she becomes
in the
becomes more
the care
care of
of the
the patient,
more conscientious
patient,
conscientious about
about
assuming her
her responsrliity
responsrliity for
for them.
them.
Burned Patients The Importance
Importance of
of Fluids
Fluids
The importance
importance of
of aa very
very accurate
accurate
intake and output
output record
record for
for severely
severely
These patients, who experience extreme physical burned patients
patients cannot
cannot be
be overesti-
overesti-
mated. Output can be determined
and mental trauma, require expert nursing care
more accurately if an indwelling
from the time of injury through the convalescent catheter is left in the patient's bladder
period. during the first phase of his care.
Hematuria then can be detected im-
mediately, and the rate of kidney
By Constance W. Milner output watched more closely. When
there is danger of anuria developing,
as there is following any severe burn,
T NTIL recent years, nurses and fected
fected tissues;
tissues;this
thiscauses
causesa loss
a loss
in it
inis imperative that nurses appreciate
0- physicians who took care of pa-circulating
circulatingfluid
fluidand,
and,in in
turn,
turn,
causes
causes
the importance of measuring the
tients with severe burns were mainlyhemoconcentration in the blood quantity of urine that the patient
concerned with treating the actual stream. The plasma and electrolyte secretes each hour: If anuria is noted
burned-areas. However, research andloss must be replaced to relieveearly, the much damage canfbe prevented.
-experience have proved that the sys-condition before serious kidney dam- It is not necessary to pour the urine
temic imbalance, which results whenage results. The quantity of replace- into a graduate to measure it every
the denuded body surface is extensive ment fluid that is administered is hour. The amount can be determined
and the wound is deep, must receivelargely determined by the patient's much more easily, and nearly as ac-
prompt,and thorough attention to saveurinary output and his weight. The curately, by using a large graduated
the patient's life; local treatment is of nurse should understand why fre-bottle as a receptale. Then, all that
ecw ary importance. Patients rarely quent blood tests are taken to detect is necessary is to markShe level of the
d& z'Wa direct result of burned tis- hemoconcentration, the importance of
urine and the time.;*Abe bottle with
sues; death is due much more often daily weights, and the necessity for
a wax pencil-every hour or at the
tO sho, loss of body fluids, and other accurate intake and output recordsintervals ordered.
s_emi causes. and parenteral therapy charts. WhenIf a graduated receptacle is not
i, becomes obvious, therefore, thatshe realizes the major part these available, it is a simple matter to
:le nurse who gives intelligent and convert any bottle into a graduate. To
'.i.nt care to patients with severe do this, place a strip of 1-inch ad-
.b.ns needs an understanding of the hesive lengthwise on a gallon bottle.
uytetsic injuries they have suffered Miss Milner
Milner (Warren
(Warren Academy
Academy Pour 50 cc. of water into the bottle
td the reasons for the treatment that School of
of Nursing,
Nursing, Woburn,
Woburn,
Mass.; B.S.
B.S. in
in N.Ed.,
N.Ed., Boston Uni- and mark c9 pc." at the appropriate
Boston Uni-
*t pfysician prescribes. Dr. Moore's versity School
School of
of Nursing, Boston, level on the desive; pour in another
Nursing, Boston,
i.'Ie which precedes this supplies Mass.) is
is supervisor
supervisor of
of clinical
clinical in-
in- 50 cc. and mark "100 cc." on the tape.
ji. iuotination. struction
struction atat the
the Peter
Peter Bent
Bent Brig-
Brig- Continue until the entire bottle has
dilation, which may fol- ham Hospital
Hospital School
School of
of Nursing
Nursing been graduated.
in Boston.
- u,,_- allows plasma to pass If the patient's hourly output of
lId strbeam into the af- urine is less than 50 cc., this method of

THE 4MERICAN IOURNAL OF NURSING

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measuring would be too inaccurate or seals the seeping surfaces, pre- applied carefully to avoid contamina-
to be of value. In this event, it is vents further loss of tissue fluids, andtion.
better to attach a 120 cc. urine reduces the danger of infection. A If the patient is not being cared
specimen bottle to the patient's con-
plasma film is the best temporary for on a frame, greater caution must
stant drainage tube and, at hourly substitute for healthy skin. This pro- be observed in turning him to prevent
intervals, to measure the urine and cedure is continued for several days scraping his wounds when the sheets
empty it into a larger collection until the plasma covering is tough are removed. These patients usually
bottle that is kept at the bedside. enough to remain intact when the prefer to turn themselves, if at all
The doctor may want the specific patient lies upon it for several hours.possible, for they seem to accomplish
gravity of the urine checked every When the exposed area on one sur- it with less pain although it may take
few hours. This can be accomplished face of the body becomes dry and a longer.
easily if a urinometer set and a plasma film has formed, the patient Occasionally, a patient is trans-
specific gravity chart are kept in the is turned and a new area is treated. ferred at intervals from a Stryker
patient's bedside unit. The urine usedThe Stryker frame and the Foster frame or Foster bed to a regular hos-
for this testing must not be discarded;bed are particularly useful in caring pital bed. The advisability of this pro-
the amount should either be recorded for patients with burns that involve cedure is determined for each indi-
on the output chart, or returned to boththe the anterior and posterior sur- vidual by the physician.
drainage bottle to be included in the faces of the body, or when burns on
total daily output. the extremities extend entirely Preventing Infection
When the nurse understands the around the leg or arm. A patient on Probably second in importance
physiological effects that resulteither from of these frames can be turned after treating shock is the prevention
burns, she can interpret better to easily for the change of position he of infection. Strict asepsis is used in
the patient the need for such careful needs every two hours. When he is caring for the burned areas which
attention to his urinary output, the turned on the frame, the possibility are treated like any open wound; only
importance of infusions and oral of rubbing off new cells that are form-sterile linen and equipment are used.
fluids, and the reasons for frequent ing on the burned areas is greatly re- The wounds are not cleansed unless
blood tests. When he understands the duced. they have been contaminated. For
reasons for treatments and pro- In turning him, a sterile sheet is example, if ointment has been applied
cedures, he is more willing to co- placed over him, the frame is strappedas emergency treatment it is removed
operate and he thus makes it easier in place, and he is turned without with Ringer's solution. Preferably,
for both himself and the nurse. any effort on his part. When he has cleansing is done only at the time of
been completely turned, the upper- operation for grafting.
Exposure Therapy for Burned most frame is removed and the lights, Antibiotic therapy is started im-
Areas
if used, are readjusted. The sheet that mediately. Everyone who comes in
Exposure therapy is used in treat- he was lying on before he was turned contact with the patient is required
ing severely burned patients at the is removed carefully, for as healing to wear a gown and mask. Persons
Peter Bent Brigham Hospital. The pa- takes place the injured areas become with upper respiratory conditions are
tient lies on sterile sheets, and the sensitive. The sterile sheets must be banned because of the patient's
burned areas are left exposed to the changed frequently to avoid satura- susceptibility to infections. The pa-
air. These sheets are 5 feet long and tion with the seeping fluid, which tient should be protected from drafts
3 feet wide and are made of double- would make them nonsterile and and chilling. This is sometimes a
thickness, white, cotton sheeting. might permit infectious organisms problemtosince exposure of the burned
Sometimes, lamps or electric heat- be drawn through them into the areas is necessary but, by keeping the
ers are directed from a safe distance wounds. Fresh sheets must also be doors closed and the air in the room
onto the moist denuded areas in an warm, he can be kept reasonably
effort to hasten the drying process. comfortable and free from respiratory
Gooseneck lamps are useful for this complications.
purpose because they can be adjusted In the summer, screen doors or
so easily to direct the light where it is Loops of adhesive attached to hand mosquito netting are used to keep
and arm bandages permit the patient
needed. Sixty-watt bulbs are used in to do things for himself that would flies and insects out.
otherwise be impossible. At the left, a Medications are administered when
the lamps. This drying process results nurse demonstrates how the loops can
in the formation of a plasma film over be used to hold a spoon and a drink- necessary to relieve pain, for pain
ing tube securely enough for the patient contributes to shock and restlessness.
the denuded areas, and thus covers to feed himself a light meal. At the
right, she shows how a rubber-covered
throat stick is held by a loop and used
for turning the pages of a magazine.

APRIL 1954 * VOL. 54, NO. 4 457

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 i[ i i' ~ iii.
dorants. Burns involving the geni-possible to brush his teeth. He often
talia require special attention. Thefeels that he is offensive to others,
Amenorrhea and Obesity and this adds to his discomfort. When
Foster bed is ideal for a patient who
has burns in this area, for it elimi-
he is able to eat and drink, the condi-
Obesity and amenorrhea have tion of his mouth will influence
previously been shown to be com- nates the necessity of lifting him onto
monly associated clinical symp- the bedpan. After elimination, thegreatly the appetite he has for the
toms. In nearly half of a series ofareas must be given special attentionfood he needs to promote the repair
32 obese women with amenor-
to prevent deposits of urea crystals and growth of new tissue cells.
rhea, weight reduction and re-
sumption of normal menses werefrom forming on the burns and to re- No special eye care is given to pa-
accomplished. The prompt onset duce the danger of colon bacilli in- tients with severe burns of the face
of menses, which in several cases fections. unless there is a possibility of cor-
occurred before a significant As healing progresses, the patient is neal injury. In this event, an oph-
amount of weight had been lost,
indicates that the decreased obes- encouraged to move about to prevent thalmologist is called in consultation
ity is not the only factor con- his joints from becoming stiff. At this and treatment is carried out as pre-
cerned in the restoration of the stage of convalescence, the physical scribed.
menstrual cycles but that a nega- therapist plays an important role in
tive energy balance may exert a his rehabilitation. The nurse should Nutritional Therapy
favorable influence. It is also pos-
sible that obesity and amenorrhea understand what the physical thera- Individual consideration is impor-
,are coincident symptoms of a pist is trying to accomplish, and thetant in planning meals for severely
basic emotional dfsorder that may limitations placed upon the patient, burned patients. The diet is primarily
respond to formal psychotherapy so that she may help him and en- the dietitian's responsibility, but the
or to friendly interest and simple nurse must realize that it is scientifi-
reassurance.- MITCHELL, GEORGE courage him in doing his exercises in
W. JR., and ROGERS, JOSEPH. The the absence of the therapist. cally calculated, and she must make
influence of weight reduction on no changes in it. For instance, she
amenorrhea in obese women. Face and Neck Burns
must not substitute water for a protein
New England J. Med., 249:835- If the burns involve the face and
837, Nov. 1953. drink just because the patient doesn't
neck, or if smoke or hot air was in- like it. The quantities and types of
m
haled, the patient should be watched fluid and food that he consumes are
constantly for signs of respiratory equally important.
Deep-breathing exercises should be complications. A complete tracheo- Half of the fluids given in a 24-
encouraged and supervised at fre- tomy set should be at the bedside at hour period are usually high in pro-
quent intervals. The nurse must al- all times. These burns are serious be- tein, such as milk or special protein
ways be alert for early signs of de- cause they involve the air passages. preparations. A liberal carbohydrate
veloping infection, such as restless- The mucous membrane of the respira- intake helps keep nitrogen loss at a
ness, pain, foul odor, elevated tem- tory tree reacts to the inflammation minimum. The patient's nutritive re-
perature and, later, suppuration from with edema which, if not controlled, quirements are greatly increased for
the burns. will result in death from asphyxia- a long time after he is burned. If
tion. If the early signs of "difficulty nutrition is not adequate, the patient
Cautmi *nd Comfort
develop-coughing, wheezing, and is predisposed to hypoproteinemia,
If dressings are used over circum- dyspnea-the doctor must be notified secondary anemia, and ?increased
ferential burns, the nurse should ob- immediately. This is a true emergency edema at the site of the burns, with
serve the distal part of the extremity which requires prompt action. resultant arrest of skin growth. Die-
fequently for coldness, pallor, cya-These patients often are burned titians and nurses must use all their
nois, or loss of pulse, all of which areabout the face so that their skin color ingenuity in trying to find ways of
in4d c ii fof circulatory interfer- cannot be observed for cyanosis. making food and fluids more attrac-
ee to b e may be employed Burns of the hands are often aso--- tive and appetizing. Emphasis should
"of function and ciated with burns of the face -be--t be placed on protein foods as well as
so e sedtoe d to prevent cause persons instincfively raise fluids because protein is needed for
'f hewounds eo. factures. When their hands in an attempt to piotect tissue repairs. The patient's prefer-
: :.g enad, athey should be their eyes. So the finger nails, also, ences are considered in so far as pos-
'iheele:W c o that they do not shift are of little value in indicating the sible but when his appetite is poor,
.ition., When the areas no longer patient's anoxia. It is necessary, very few foods appeal to him at all.
need to be exposed, bed cradles therefore, for the nurse to be most He usually has frequent small feed-
'should be used to keep the bedclothes observant in noting the character of ings between regular meals.
off the wounds. Maintenance of good the patient's breathing. Sometimes the patient cannot feed
ply alignment and adequate support Patients with burns of the respira- himself and the nurse or someone
or weakened muscles contribute to tory tract need excellent oral hygiene. else, who is skilled in creating a
*b comfort of the patient and helpThey usually are not able to retain pleasant atmosphere for eating and in
avid- preventable deformities. Posi- fluids for the first several days, and persuading the patient to eat, must
tiMns of comfort are important to rest, so their mouths become dry and foul. feed him. Relatives can help with this
for everely burned patients who are Burns around the mouth inhibit nor- and they usually are glad that there is
aible to walk must spend many mal moistening of the lips with thesomething they can do. It is important
teeks in bed. Frequent changes of result that they become dry, cracked,for them to realize, however, that they
oIntion and several properly placed and sore. Mouth breathing may be must tell the nurse or dietitian exactly
i-lows will make it easier for the necessary due to obstructed nasal what the patient has eaten so she can
ptitent to relax and rest. passages, and the buccal cavity be- record it on his caloric chart.
- uwral body cleanliness is essen- comes parched. If the patient must
~:, r'aid e!imination from the skin. breathe through his mouth, a moist- Something To Do
ed areas should be bathed fre- ened piece of gauze, placed lightly A patient with severe burns needs
The offensive odors from over it, will give some relief. He will recreational and diversional therapy.
,1isue and singed hair can appreciate frequent swabbing and He should do as mu4e fhp himself as
_fc '?eluminated by using deo- mouth washes, especially if it is im- his physical limita will allow.

THE AMERICAN JOURNAL OF NURSING

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When he is able to do even the rubber
rubber glove,
glove,andandififthe
thethroat
throatstick gery that will be done when the
stick
siiplest things, he gains self-confi- is placed
placed in
in the
theloop
loopononthe
theunder
under physician decides he is ready for it.
sur-
sur-
dence and has a feeling of accom- face
face of
of the
the hand
handbandage,
bandage,the
the patientThe social worker and occupational
patient
plishment. can
can easily
easily turn
turnthe thepages
pagesofofa con-
a con-therapist may help a patient a great
If his hands are bandaged, there veniently
veniently placed
placedbook magazine. deal in preparing for the future.
bookorormagazine.
are ingenious ways to help him The ingenious nurse will devise Members of the clergy often instill
help himself. If an adhesive loop is other simple activities which give the courage and confidence. If adjust-
attached to the upper surface of the patient self-confidence, help to keepment is particularly difficult, psy-
bandage on his hand, a long cigarette him busy, and have the additional chiatric consultation may be indicated.
holder can be inserted, and a ciga- benefit of providing exercise for el- The patient's family may also need
rette can be placed in the holder and bow and shoulder muscles, which is help in adjusting to his physical
lighted. He will enjoy a cigarette important in the restoration of mus- change, understanding his emotional
that he smokes in this way far morecle tone. needs, and accepting the stares and
than one he must smoke hastily be- inquiries of the curious. We can only
cause he doesn't want to detain the Facing the Future hope that society will be kind to both
busy nurse or aide who is holding A itseverely burned patient needs the patient and his family.
for him. Likewise, a loop can be considerable help with the emotional BIBLIOGRAPHY
placed on the under surface of the problems that invariably accompany ELIASON, ELDRIDGE L., FERGUSON, L. K. AND
bandage to hold a spoon and permit scarring, and possibly incapacitating, SHOLTIS, LILLIAN A. Surgical Nursing. 9th
ed. rev. Philadelphia, J. B. Lippincott Co.,
the patient to feed himself, at least injuries. If those who care for him 1950.
partially. A similar loop may be ap-are kind, thoughtful, and encouraging, Hazel E. DORIS.
JOHNSON, Modern Dietetics. Edited by
Munsell. New York, G. P. Put-
plied to the bandage on the other handthey can help him accept the changes nam's Sons, 1951.
MOORE, FRANCIS D. Burns, an annotated out-
and a drinking tube inserted to per-in his appearance and physical abili- line for practical treatment. Med. Clin. N.
mit the patient to help himself to ties which have resulted from his America 36:1201-1214, Sept. 1952-
NATHAN, CYNTHIA R. Social service to plastic
fluids. Between-meals beverages accident. surgery cases. The Family 26:9-15, March
1945.
should be left with a drinking tube The badly scarred patient can be PROUDFIT, FAIRFAX T. AND ROBINSON, CORINNE
in place where the patient can use it
told that modern plastic surgery H. Nutrition and Diet Therapy. 10th ed.
New York, Macmillan Co., 1950.
conveniently without assistance. If erases or minimizes many disfigure- WEST, JOHN P., KELLER, MANELVA W. AND HAR-
the end of a throat stick is covered ments and that he, too, can hope and MON, ELIZABETH. Nursing Care of the Surgi-
cal Patient. 5th ed. New York, Macmillan
with a finger cot or a finger from a
expect excellent results from the sur- Co., 1950.

) } } } } \ \ ANA Makes Six New Grants for Research K K K K <K K

At its January
January meeting,
meeting, the
theBoard
BoardofTo the Alabama State Nurses Associa-
of A Study of Nursing Functions in
Directors of the American Nurses' Asso- tion, $1683 for the purpose of completing Twelve Hospitals in the State of New
and publishing the report of a study
ciation approved six additional grants for the approved by the New York State
York,
research, as recommended by the ANA"Role Relationships Among Nurses and Nurses Association and conducted by the
Technical Committee on Studies of Nurs- Between Nurses and Non-nursing Per- Department of Nurse Education of New
ing Functions. sonnel in Hospitals." This study was made York University.
by the University of Alabama in three Charles T. Miller Hospital Study, St.
New Grants hospitals, of different sizes, and located Paul, Minnesota, a study of activities of
The grants, totaling a little over $80,- in different communities. all nursing personnel employed in the
000, were made to the following: hospital, sponsored by the Minnesota
To the University of Arkansas, $22,005 Studies Now in Progress State Nurses Association.
for a study of the functions of the gen- Studies that are in progress under A Study of Nursing Functions, spon-
eral duty nurses in 10 hospitals in Ark- grants from the ANA are: sored by Washington State Nurses
ansas. This is an extension of the pilot A study of nursing services in surgical Association.
study for which ANA granted $2350 in and medical wards of Charity Hospital, Institutional Nursing Activities Per-
1953. New Orleans, being conducted by the formed by Faculty of the School of Nurs-
To Boston Psychopathic Hospital, Urban Life Institute of Tulane Univer- ing of Vanderbilt University, sponsored
sity and sponsored by the Louisiana
$11, 81 fsr a test with chronically ill men- by Tennessee State Nurses Association
tal patints of those techniques and meth- State Nurses Association. (unpublished).
ods which have been found successful in A study of the work of the general The Functions of the General Duty
improving the condition of acutely ill duty nurse in non-metropolitan general Nurse in the General Hospital, a pre-
patients. The experiment will be carriedhospitals in central Missouri, and the liminary study by Donald D. Stewart,
on at Metropolitan State Hospital, a meaning of this work as seen through Ph. D., and Hazel E. Owen, R. N., of the
large state mental hospital. University of Arkansas, made for the
the eyes of the nurse herself. The study
To the Georgia State Nurses Associa- is being conducted by the University of Arkansas State Nurses Association.
tion, $1220 for the first study of the Missouri and is sponsored by the Mis- Activities of Registered Nurses in
professional, organizational, and human souri State Nurses Association. Small Kansas Hospitals, Governmental
relations functions of private duty nurses A study of the social-psychological Research Center of the University of
practicing in hospitals in seven Georgia characteristics of the student and grad- Kansas, made for the Kansas State
communities. The study will be conduct-uate nurse which correlate with durable Nurses Association.
ed by a private research firm. membership in the profession, and fac- Role Relationships Among Nurses and
To the Minnesota State Nurses Asso- tors which make for high or low morale. Between Nurses and Non-nursing Per-
ciation, $14,929 to study the on-the-job This study is being conducted by the sonnel in Hospitals, made by the Com-
duties and responsibilities of practical University of Pennsylvania for the Penn- mittee on Human Relations of the Uni-
nurses in relation to their preparation andsylvania State Nurses Association. versity of Alabama, for the Alabama
to the duties and responsibilities of pro- State Nurses Association. Thomas Ford,
fessional nurses and auxiliary personnel. Reports of Studies Completed Ph. D., and Mrs. Diane Stephenson, R. N.,
The study will be carried on under the The following reports of completed are the co-authors.
supeivis i' of the Bureau of Institu- studies may be obtained from the re- Studies of the functions of personnel
tional . rch of the University spective of state nurses associations: caring for mentally ill patients at Bos-
Nursing Practice in California Hos- ton Psychopathic Hospital; mimeograph-
'To fe Society of the New York Hos- pitals, Volume I, a study sponsored by ed reports and reprints of various studies
pita, $18,525 for a study of the work the of California State Nurses Association, are available from the hospital. These
grswuate nurses in the obstetric service based on a representative sample of studies were sponsored by the Mass-
of the New York Hospital. nurses in 40 California hospitals. achusetts State Nurses Association.

APIL 1954 * VOL. 54, NO. 4 459

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