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Margaret Care Plan Example

Margaret Care Plan Example

The Case study: –
Margaret (72 years old lady) is living with her husband (John). Margaret has presented to the emergency department following a burn injury. The burn happened when John tripped over the dog while holding two cups of tea that he just prepared using water boiled from the newly bought kettle. The tea poured on Margaret’s chest and the upper half of her abdomen. It was morning and Margaret was wearing summer sleepwear. John indicated that Margaret has type 2 diabetes. Develop a care plan care for this lady according to the marking guide considering Margaret’s age and clinical profile.
Points to consider
• Current burden of the condition (Burn) Australia and worldwide (differences between developing and developed countries)
• Different types of burns
• Burn assessment (size, area (location), depth, patient general condition)
• Pharmacological, non-pharmacological, complementary/alternative therapies, and rehabilitation
• Nursing care, inter-professional care, self-care and community care implications
• Individualised care plan for Margaret – consider discharge plans

Margaret Care Plan Example

Introduction

Margaret, a 72-year-old patient, has presented to the emergency department following a burn injury. The burn occurred when the husband tripped over their dog poured scalding hot tea on Margaret’s chest and the upper half of her abdomen. The paper presents a comprehensive and individualized care plan considering age, clinical profile, and discharge plans. The case study constitutes the burden of the burn condition in Australia and worldwide, classifications of burns by extent and depth, causes of burns, and underlying risk factors, anatomy, pathogenesis, clinical course, and implications for public health. The pharmacological, non-pharmacological, alternative therapies, and rehabilitation interventions were discussed in detail.

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Background Information

Definition of Burns

A burn is a type of injury to the skin or organic tissue mainly instigated by either heat, flames, radiation, electricity, friction, radioactivity, lightning, or chemical contact (WHO, 2018). Heat burns happen when all or some of the cells in the skin and other tissues have been destroyed by hot solids (contact burn), hot liquids (scald), or flames (flame burn). There are high levels of mortality and morbidity associated with severe cases of burn injuries (Toppi et al. 2019). Moreover, non-fatal burns are among the leading causes of morbidity, comprising prolonged hospitalization, disability, and disfigurement, with resultant rejection and stigma.

Epidemiological Data

The causes, patterns, gender, age groups, and incidences affected by burns differ significantly between the low-middle and high-income nations. According to WHO data, burns are a worldwide public health problem that accounts for about 180 000 deaths yearly. The majority of deaths happen in low- income and middle-income nations and nearly two thirds in South-East Asia and Africa. The burn death rates have been declining in most high-income nations. Also, the child death rate from burns is presently more than seven times greater in low- income and middle-income nations compared to high-income nations (World Health

Organization, 2018). In Australia, it is estimated that 1% of the population suffers burns that need medical attention annually, where 10% need hospitalization (Smith & Kaye, 2020). More than 2500 patients are managed in 17 pediatric and adult burn centers in Australia and New Zealand every year (Cleland et al., 2016).

Causes and Risk Factors of Burns

Burns occur mostly at home and working environment. There are several causes of burn injuries comprising hot fluids, highly flammable materials, fires, barbeques, physical contact with hot objects, explosions, electrical currents, and chemicals (WHO, 2018). The primary groups at risk are adult females and children as the female population has a somewhat higher rate of death from burn injuries than males. The higher risks for females occur at home in the bathroom and kitchen connected with the use of open fire cooking or unsafe cooking stoves that ignite loose clothing. Open flames for lighting and heating pose risks along with other self-directed and interpersonal violence factors. Among adult males, burn injuries are sustained at the workplace or recreational facilities. The children are susceptible to burns as they are ranked as the fifth most prevalent causes of non-fatal injuries. While the main risk is inadequate adult supervision, many burn injuries among children arise from maltreatment.

Pathogenesis and Clinical Course

The cellular injury by heat releases cellular enzymes and vasoactive substances, like histamine, leukotrienes, interleukin-1, kinins, prostaglandins, and serotonin as well as activates the occurrence of complement. Thus, vascular permeability is changed; and substantial immunological, hemodynamic, and metabolic effects happen systemically and locally (Dunphy et al. 2019). The scale of the response is proportional to the extent of the burn injury. In the capillary level, there is a shift of protein molecules, electrolytes, and fluids from an intravascular into extravascular space (Nielson, et al, 2017). Initially, the lymph flow rises but, consequently, declines or ceases as lymphatic vessels are blocked by serum proteins that leak through the impaired capillaries’ walls. In extensive burn injuries, the edema is formed in the burned and unburned regions due to generalized surge in hypoproteinemia and capillary permeability.

Impact on Public Health

 Burns are one of the most devastating injuries that constitute a widespread public health problem globally. Burn injury is one of the leading public health issues, with about 11 million cases globally annually resultant in over 300,000 deaths, 90 percent of occurring in low-income and middle-income nations (Barrett et al., 2019). Significant burn injury is one of the distinct and critical components of the overall burden of injury that scope from the most common and minor wounds, which are dealt with in the local communities to acute and devastating burn injuries. The major burns can have a permanent impact on the quality of lives, with persistent problems linked to scars, contractures, thermoregulation, weakness, pain, sleep patterns, body image as well as psychosocial wellbeing. (Moi et al. 2016). The injuries can lead to hospital admissions and deaths. Along with the direct impacts of the burn, the intensive care treatment causes affective, behavioral, and cognitive challenges. Furthermore, burns need extended hospital stays and are the leading cause of disability, which exerts enormous social and economic burden on the affected families (Biswas et al. 2018). Treatment costs are high as burns necessitate devoted treatment settings with specialist physicians and equipment.

Classification of Burns

Burns are classified by the causes and extent (the affected percentage body surface area). It is imperative to assess the burn injury accurately since the extent is used to determine the prognosis and treatment either in the form of resuscitation, transfer and surgical management.

Assessment of Burn Extent

One of the essential classifications for a burn injury is the total body surface area that has been affected. The Lund and Browder chart is presently the most accurate and extensively used chart for calculating the TBSA affected by burn injuries (Murari & Singh, 2019). In adults, the rule of nines is applied, where each arm and head is 9% TBSA, while each leg, front, and back of the torso is 18% each, as shown below (Smith & Kaye, 2020). ANZBA proposes referrals to the specialist burns unit based on specific criteria including burns more than 10% of TBSA, select areas including face, perineum, hands, genitalia, feet, and major joints, full thickness burns exceeding 5% of TBSA, chemical burns, inhalation injury, electrical burns, circumferential burns chest and limbs, and trauma (ANZBA, 2017).

Assessments of Burns Based on Rules of Nines Estimation of Burn Extent in Adults

Assessment of Burn Depth

A burn could be reasonably minor or lead to life-threatening complications dependent on its severity. Majority of burns affect the uppermost skin layers only, but dependent on the depth, underlying tissues can be affected too. Conventionally, burns are classified by degree, with first degree being least severe and third degree being most severe. The classification system of the depth or thickness of the burn wound is commonly used. First, the superficial burns damage the epidermis only. Secondly, the superficial dermal (partial thickness) extends to the papillary dermis. A serous blister is characteristic of the red, blistering, swelling, peeling, with clear and yellowish fluid that leaks from the skin (D’Arcy & Marmo, 2013). Next, deep partial thickness burn damages the reticular region of the dermis that contains connective tissue, hair follicles, cutaneous sensory receptors, blood vessels, sebaceous and sweat glands (Shiber & Weingart, 2020). Finally, the full thickness burns extend to the hypodermis, where all skin layers are affected. There is no perseveration of dermal structures, and hypodermic fat can be implicated.

Clinical Manifestations

The patient has presented to the emergency unit with a burn injury after her husband poured scalding hot tea on her chest and the upper half of the abdomen. Scalding is caused by wet heat like hot liquids, boiling water, steam, and other hot gases. The patient has deep partial-thickness burns that destruct the epidermis layer with most of the dermis. The serious burn occurred on a large section of the patient’s body with a seeping wound and irregular pattern. The symptoms include fever, intense pain on deep pressure, and wound does not banch when pressed (Lobo & Bali, 2015). The sweat glands and epidermal cells that line the hair follicles remain intact. The symptoms are pale red color, early blisters, with sluggish circulation (Angelini et al. 2017). The burn is mottled, pearly white, dry, often decreased sensation, and hard to differentiate from the full-thickness burns.

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Diagnostic Process

The doctor can diagnose the severity of the patient’s burn by looking at the patient’s skin, asking questions about the causes of the burn, and other conditions. The diagnosis is based on the extent and depth of the burn. However, the severity is also influenced by the extent of damage to the affected area in the patient’s body. The rule of nines classifications will be used as a rough diagnosis by determining the percentage of the body covered by the burn (Hamm, 2019). Lund Browder’s diagram is an accurate diagram available for measuring the burned surface area in adults (Yasti, 2015). These tools will assess the burn percentage to guide treatment decisions like fluid resuscitation and guidelines to ascertain transfer to burn units. Since the patient developed a fever after sustaining the burn, she could have an infection. The laboratory studies include CBC, electrolytes, blood urea nitrogen, glucose, and creatinine (Dunphy et al., 2019). The rationale for is evaluation of the risks of infection and other serious health complications. Besides, arterial blood gas and pulse oximetry determinations should be conducted, comprising the COHb levels to ascertain the proportion of hemoglobin bound to the carbon monoxide.

Treatment

The goal of treatment is relieving pain, reducing swelling, preventing infection, promoting healing, preventing dehydration, removing dead tissue, and covering the wounds with skin.

Individualized Care Plan

Margaret’s care plan will involve three distinct stages of burn injury, whereby each requires various levels of Margaret’s care. The stages are emergent, intermediate, and rehabilitative phases. First, the emergent phase will start with the onset of her injury and lasts till the completion of resuscitation of fluids in the first 24 hours (Ackley, et al., 2020). The main priority of care will involve interventions for the promotion of airway clearance and gas exchange, and restoration of fluids and electrolyte balance. Other interventions include maintenance of normal body temperature, minimization of anxiety and pain, as well as observation and management of potential complications like acute respiratory failure, and distributive shock.

Secondly, the intermediate stage of Margaret’s burn care commences about 48 to 72 hours following the burn injury. The core priorities are hemodynamic alterations, burn wound healing, psychosocial and pain responses, and detecting complications (Brown, et al., 2020).  The interventions will focus on the restoration normal fluid balance, prevention of infection, observation of culture results and WBC counts, maintenance of adequate nutrition, promotion of skin integrity and physical mobility, relief of pain and discomfort using analgesic medications. Other interventions include implementation and coping strategies, patient and family education processes to support patient.

The final stage in caring for Margaret is the rehabilitative stage that begins with closure of the burn wound and ends after she has reached her optimal functioning level. The focus is to help Margaret return to her injury-free life and adjust to changes in the burn injury. The prescribed medication for infections is tetanus prophylaxis and either oxacillin, gentamicin, or mezlocillin (Rowan et al. 2015). The dressing changes is recommended until five to seven days after the burn injury. Finally, the patient should be reassessed in 24 hours to reexamine the extent and depth of the burn. Her discharge guidelines will be directed toward outpatient care and home care. First, the patient and her husband are trained to wash the open wounds daily using water and mild soap and apply the prescribed topical agents and dressing (Doenges, et al., 2019).  Secondly, the nurse provides careful verbal and written instructions about the management of pain, proper nutrition, prevention of any complications, mild exercises, and use of splints and pressure garments. The follow-up care will involve returning to the burn clinic intermittently for evaluation, amendment of burn wound care instructions, and plans for reconstructive surgery to improve self-concept and body image. Lastly, Margaret could be offered referrals for home care if she cannot manage her burn care due to her old age and inadequate support system.

Conclusion

The patient presented to the emergency department following a burn injury on the chest and the upper half of the abdomen. The clinical presentation constituted deep partial-thickness burns on a large section of the body with seeping wounds and irregular patterns. The diagnosis of the burn injury was determined by the causes, depth, and extent. The burn size was assessed as a percentage of the TBSA using the Lund and Browder chart to measure the affected percentage body surface area. The accurate assessment of the burn injury determined the prognosis and treatment in the form of initial stabilization, resuscitation, wound dressing, wound management, pain medication, and tetanus immunization. Finally, the treatment’s main goals were preventing hypothermic shock, relieving discomfort, and reducing the risks of infection.

 References

Ackley, B. J., Ladwig, G. B., Makic, F. M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care. Elsevier

Angelini, D. J., In LaFontaine, D., In Cronin, E., & In Howard, E. D. (2017). Obstetric triage and emergency care protocols. Springer Publishing Company.

Australian and New Zealand Burn Association. (2017). Burn survivor rehabilitation: Principles and guidelines for the Allied Health Professional. Australian and New Zealand Burn Association.

Barrett, L. W., Fear, V. S., Waithman, J. C., Wood, F. M., & Fear, M. W. (January 01, 2019). Understanding acute burn injury as a chronic disease. Burns & Trauma, 7.

Biswas, A., Abdullah, A. S. M., Rahman, F., Mashreky, S. R., Dalal, K., Deave, T., Rahman, F., Mashreky, S. R. (June 18, 2018). Exploring perceptions of common practices immediately following burn injuries in rural communities of Bangladesh. Bmc Health Services Research, 18, 1.

Brown, D., In Edwards, H., In Buckley, T., & In Aitken, R. L. (2020). Lewis’s medical-surgical nursing: Assessment and management of clinical problems. Elsevier.

Cleland, H., Greenwood, J. E., Wood, F. M., Read, D. J., Wong, S. R., Maitz, P., Castley, A., Gabbe, B. J. (January 01, 2016). The Burns Registry of Australia and New Zealand: progressing the evidence base for burn care. The Medical Journal of Australia, 204, 5.

D’Arcy, Y., & Marmo, L. (2013). Compact Clinical Guide to Critical Care, Trauma, and Emergency Pain Management: An Evidence-Based Approach for Nurses. Springer Publishing Company.

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, prioritized interventions, and rationales.  F.A. Davis Company.

Dries, D. J., & Marini, J. J. (January 01, 2017). Management of Critical Burn Injuries: Recent Developments. Korean Journal of Critical Care Medicine, 32, 1, 9-21.

Dunphy, L. M. H., In Winland-Brown, J. E., In Porter, B. O., & In Thomas, D. J. (2019). Primary care: The art and science of advanced practice nursing – an interprofessional approach. Davis Company.

Hamm, R. (2019). Text and atlas of wound diagnosis and treatment. McGraw-Hill Education / Medical.

Jeschke, M. G., Kamolz, L.-P., Sjöberg, F., & Wolf, S. E. (2020). Handbook of burns: Volume 1. Springer.

Lobo, M. & Bali, B. (2015). Burns, Scalds and Thermal Injuries. VFPMS Seminar

The Royal Children’s Hospital Melbourne. Retrieved from https://www.rch.org.au/uploadedFiles/Main/Content/vfpms/2_Burns%202015_ni.pdf

Moi, A. L., Haugsmyr, E., & Heisterkamp, H. (January 01, 2016). Long-Term Study of Health And Quality Of Life After Burn Injury. Annals of Burns and Fire Disasters, 29, 4, 295-299.

Murari, A., & Singh, K. N. (January 01, 2019). Lund and Browder chart-modified versus original: a comparative study. Acute and Critical Care, 34, 4, 276-281.

Nielson, C. B., Duethman, N. C., Howard, J. M., Moncure, M., & Wood, J. G. (January 01, 2017). Burns: Pathophysiology of Systemic Complications and Current Management. Journal of Burn Care & Research, 38, 1.

Rowan, Matthew, Cancio, Leopoldo, Elster, Eric, Burmeister, David, Rose, Lloyd, Natesan, Shanmugasundaram, Chan, Rodney, … Chung, Kevin. (2015). Burn wound healing and treatment: review and advancements. BioMed Central Ltd.

Shiber, J. R., & Weingart, S. (2020). Emergency department critical care. Springer.

Smith, J. A., & Kaye, A. H. (2020). Textbook of surgery. Wiley-Blackwell.

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Toppi, J., Cleland, H., & Gabbe, B. (September 01, 2019). Severe burns in Australian and New Zealand adults: Epidemiology and burn centre care. Burns, 45, 6, 1456-1461.

World Health Organization (2018, March 6). Facts About Injuries: Burns. Geneva, Switzerland World Health Organization. Retrieved from https://www.who.int/news-room/fact-sheets/detail/burns

Yasti, A. C. (January 01, 2015). Guideline and Treatment Algorithm for Burn Injuries. Turkish Journal of Trauma and Emergency Surgery.21, 2, 79-89

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