A Registered Nurse is taking care of a patient who exhibits a deep partial thickness burn involving the left hand, left forearm, and left side of the chest. The wound is very painful, like most burn wounds. A wound of this nature extends deep into the second layer of skin and can quickly develop into a full thickness burn or third degree burn. The symptoms include skin that is red and white, not easily blanch able along with bloody blisters, which are often moist and painful. The Registered Nurse should assess and provide wound care including timely wound irrigation and dressing changes, along with monitoring for signs of infection. The primary goal is to promote healing, minimize further damage and prevent infection. If the patient’s wound is open, note its color. If the wound is red, that demonstrates healthy tissue regeneration. If the wound is yellow purulent drainage and slough (dead skin) are present. If the wound is black the presence of a thick, necrotic material called eschar is present which hinders healing and must be removed. If the wound is closed the skin edges should be well-approximated. Ultimately, the Registered Nurse is working towards a wound which is free of infection and, therefore, completely healed. When cleaning the wound area, the Registered Nurse should use asepsis/sterile technique so the wound is free of all microorganisms. When cleansing a wound, always start with the cleanest area; never return to an area you have previously cleaned. Be sure to discard cleansing swab after each horizontal or vertical stroke. The Registered nurse should moisten the wound bed prior to removal of the dressing. Patient mmedications used for pain control are; opioids, NSAIDS, anxiolytics, anesthetic agents and should be given 30-45 minutes prior to wound cleansing. That will assist in controlling the pain. It is also recommended for benzodiazepines are used along with opioids to achieve both pain free and anxiety free experience.A Registered Nurse should emphasize to the patient the use of Silvadene cream, which is prescribed by the ordering physician. However, “Honey dressings improve wound healing, make wound sterile in lesser duration, and have better outcomes in terms of incidence of hypertrophic scars and post burn contractures when compared to Silvadene (SSD) dressings (nih.gov)”. Honey had a positive effect in reducing the oxidative state in a burn victim that resulted in rapid wound healing. However, nonpharmacological pain management can also be achieved by; relaxation techniques, distraction, guided imagery, hypnosis, therapeutic touch, humor, music therapy and virtual reality techniques. The main priority is to manage the injury while minimizing the pain. To clean and cover the wounds; control pain; provide fluid for fluid loss from the burn wound; and check for other related injuries. It is priority to monitor patient progress, coordinate care and services for the patient, and educate the patient and family members of ongoing status and future plans for treatment and recovery. References
Gupta, S., Singh, O., Bhagel, P., Moses, S., Shukla, S., & Mathur, R. (2002, March 6). Abstract. National Center for Biotechnology Information. Retrieved January 22, 2014, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3263128/
Brunner, L. S., & Smeltzer, S. C. (2010). Brunner & Suddarth's textbook of medical-surgical nursing (12th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.