Burn Pain Management - Essay Example

Burn Pain Management Burn pain management presents several challenges to the nursing profession. This essay aims to understand all aspects of burn pain management and the role of nurses in this task. Types of burns A burn is an injury resulting from exposure to heat, chemicals, radiation, or electric current. The four types of burn injury are chemical, electrical, radiation and thermal. Thermal burns, the most common burns, are caused following exposure to dry or moist heat. Chemical burns are caused when the skin comes in direct contact with acid or alkaline agents. The type and duration of current and amount of voltage determine the extent of an electrical burn. Radiation burns are mostly associated with either sunburn or radiation for cancer treatment (LeMone & Burke, 2004). Pathophysiology of the burn wound Burn injuries may be conceived as producing three concentric volumes of tissue damage. The zone of coagulation, located at the center of the wound, is the volume that is injured most severely. Outside the zone of coagulation is the zone of stasis, beyond which lies the zone of hyperemia. In the case of a burn injury, the zone of coagulation is destroyed permanently; the zone of stasis is ischemic but potentially salvageable; and the zone of hyperemia features increased blood flow resulting from inflammation (Go´mez & Cancio, 2007). Depth of burn and burn size The extent of tissue damage following that occurs as a result of a burn is primarily determined based on the depth of the burn (layers of underlying tissue involved) and the extent of the burn (percentage of body surface area involved) (LeMone, & Burke, 2004). The depth of a burn injury is determined based on the temperature and heat capacity of the causative agent, the duration of exposure, and the thickness of the skin. A burn that remains confined to the epidermis is termed a first-degree burn (e.g., a nonblistering sunburn). Such burns are rarely of immediate medical consequence, heal rapidly, and are not included in burn size estimations for the purpose of determining fluid resuscitation requirements (Go´mez & Cancio, 2007). Pain levels are mild to moderate (Kowalske, 2002). A burn that extends into the dermis is termed as a second-degree or partial-thickness burn (e.g., Blistering scald burns). If only the superficial layer of the dermis is involved, it is termed a superficial partial-thickness burn. These burns heal in less than approximately 21 days and generally do not require skin grafting (Go´mez & Cancio, 2007). These are moderately painful (Kowalske, 2002). Deeper involvement of the dermis classifies the burn as a deep partial-thickness burn. These burns heal by re-epithelialization after more than 21 days and generally benefit from skin grafting (Go´mez & Cancio, 2007). Nerve endings are usually spared in these burns and pain is excruciating, especially when exposed to air (Kowalske, 2002). A burn involving the entire depth of the dermis and the epidermal appendages is termed a third-degree or full thickness burn. These burns heal only by contraction from the edges, if at all, over a prolonged period of time. Thus, skin grafting is required (Go´mez & Cancio, 2007). Although described as insensate, these wounds may vary in depth with partial sparing of nerve endings that cause pain. Additionally, the wound margins and surrounding skin become hypersensitive and produce pain (Kowalske, 2002). Patients with these burns may experience neuropathic or phantom-type pain. Several technologies have been developed to estimate burn depth; however, these methods have not been widely used in clinical settings. Estimation of the total body surface area burned (TBSA) as a percentage of the body surface area can be done using the rule of nines and this could refined with a Lund-Browder or Berkow chart that correlates the percentage of TBSA of different regions of the body as a function of developmental age (Go´mez & Cancio, 2007). In the rule of nines method, the body is divided into 5 surface areas (head, trunk, arms, legs, and perineum) and percentages that equal or total a sum of nines are assigned to each body area (LeMone & Burke, 2004). The rule of hands is another useful method wherein the patient’s hand (palm and fingers) comprises approximately 1 percent of his body surface area. This facilitates estimation of the size of irregularly shaped burns. Careful estimation of TBSA is essential in the early management of burn patients because fluid requirements and triage and transfer criteria are determined based on burn size (Go´mez & Cancio, 2007). Pain associated with burns The pain following severe burns is unpredictable and may persist for over a year or several years (Napoli, 2002) after the burn has healed. Burn pain is divided into three distinct types (excluding postoperative pain), depending on the clinical setting in which it occurs. “Background pain” is present continuously from the time of the injury until wound healing is complete, and can vary in severity. Wound cleaning, limb mobility exercises, therapeutic skin stretching, and other medical procedures result in “procedural pain,” which is of high intensity, but limited duration. When pain control interventions fail, patients experience “breakthrough pain” (Patterson, Hoffman, Weichman, Jensen, & Sharar, 2004). Pain may continue to affect daily activities and cause psychological problems. Hence, it is important to treat burn pain aggressively (Gallagher, Rae, & Kinsella, 2000). Nurses tend to underestimate the pain of burn patients. Emotional distancing-a strategy used by nurses to protect themselves from the tortuous amounts of pain they inflict on burn patients during wound care could be responsible (Anonymous, 2004). Pain assessment Assessment of pain is important in treatment planning programs & in establishing effectiveness of treatments. The only way to ensure that patients receive high quality pain relief is to use proven reliable indicators of pain, and depend on the patient’s self report whenever the patient can provide it. Pain scales are used to monitor pain. By using the 0-10 point scale, people have a means to communicate their pain intensity and clinicians have means to track it. Many scales for assessing pain have been designed, such as the Visual analogue scale (VAS), Descriptive pain scale, Numerical pain scale, Pain faces scale, Analogue chromatic scale, Palpation, Questioning etc. These are the more commonly used methods. Some other methods like the Mc Gill pain questionnaire & Pediatric Pain questionnaire are also used. The Brief Pain Inventory may be utilized for an overall assessment necessary for patients with acute pain (Jaywant & Pai, 2002). Picture scales may be more useful for those who do not speak or read English or in the case of young children. Descriptor differential scale of pain effect, VAS, and pain discomfort scale may be more useful for evaluating the affective component of pain. The Mc Gill pain questionnaire is used to differentiate the sensory and affective components of pain response in burn patients. Despite the availability of these tools, the correlation between pain assessment done by the healthcare provider and that reported by patients is very low (Kowalske, 2002). The scoring system that is used is less important than the consistent application of a score that is recorded at frequent intervals at rest for background pain and during procedures for procedural pain. This allows evaluation of the effectiveness of the analgesic regimen in use, and facilitates the early correction of inadequate pain relief and as such is central to the principle of effective burn pain management (Gallagher, Rae, & Kinsella, 2000). Pharmacologic interventions The following are some pharmacologic interventions used to manage burn pain. Opioids: The use of intravenous opioids is the most popular method of reducing burn pain. Morphine is widely used and it has a long duration of action, and has sedative and antitussive properties. Despite concerns, there is little evidence that patients with burns treated with opioids are at risk of developing opioid addiction. Other drugs such as benzodiazepines may be used in combination with opioids, particularly in the ventilated intensive care patient, to reduce the opioid requirement and to provide a greater degree of anxiolysis. Lorazepam when combined with morphine leads to better analgesia in patients with more severe pain. The use of patient controlled analgesia (PCA) with morphine for patients with burns is well established. For background pain, longer acting oral opioids such as methadone or “MSContin” (a sustained release morphine sulfate preparation) have been used. For procedural pain, opioids with a more rapid onset and duration of action are more appropriate (intravenous alfentanil, transmucosal administration of fentanyl). Nalbuphine has been shown to be as effective as morphine for relief of burn debridement pain and has also been used successfully for prehospital analgesia (Gallagher, Rae, & Kinsella, 2000) Non-Opioid Analgesia: In some burn centers, opioids are not used and the pain relief is comparable to units using opioids. There is a reluctance to administer opioids to particular groups of patients, such as the elderly. Nonsteroidal anti-inflammatory drugs (NSAIDs) may be used successfully but care is required as their use in burn patients has been associated with deteriorating renal function. Experimental burn pain can be relieved using NMDA antagonists such as dextromorphan and ketamine. For short procedures, inhaled nitrous oxide is widely used (Gallagher, Rae, & Kinsella, 2000). Local Anesthesia: A number of reports of the use of epidural techniques, nerve blocks and topical and subcutaneous application of local anesthetic have been described. Several constraints may make local anesthesia inappropriate for a significant number of burn patients The use of intravenous lidocaine to provide analgesia, which has been shown to work in other types of pain, may also be extremely effective in burn patients. Concerns regarding adverse effects may be responsible for this effective technique not having gained more widespread acceptance (Gallagher, Rae, & Kinsella, 2000). .Inhalation Anesthetic Agents: The use of these agents at concentrations less than that required for anesthesia but sufficient to provide short lasting worthwhile analgesia has advantages such as ease of delivery, predictable elimination, and freedom from the need for prolonged fasting. Methoxyflurane and tri-chloroethylene have been shown to provide useful analgesia for burn dressings. Halothane, enflurane, and nitrous oxide were subsequently used as inhalational agents for burn dressings. Concerns regarding halothane hepatic toxicity, nitrous oxide–induced bone marrow suppression and enflurane use in patients at risk of convulsions have all tended to reduce the use of these agents. Currently the use of isoflurane, sevoflurane, and desflurane is being investigated because of the minimal metabolism and rapid recovery after these agents (Gallagher, Rae, & Kinsella, 2000). Anxiolytics: Anxiety results in a decrease in pain tolerance. Anxiolytics may help decrease anxiety and improve pain tolerance (Kowalske, 2002) Non-pharmacological approaches Alternative treatment approaches are very helpful in altering the affective component of procedure related burn pain. Commonly used techniques include behavioral modifications, desensitization, imagery, modeling, stress reduction, and hypnosis (Kowalske, 2002). Haythronthwaite, Lawrence, and Fauerbach, (2001) in their study showed that sensory focusing resulted in higher ratings of relief; however, distraction, including self selected music and training in music appreciation did not show any benefits. Hypnosis has been used for the treatment of burn pain and has been shown to reduce procedural pain. The use of auricular electrical stimulation, which is similar to acupuncture, can reduce procedural pain. Therapeutic touch techniques could reduce the pain scores in burn patients but not analgesic requirements. Massage therapy is associated with decreased pain and less depression. Mild pain can be reduced using a number of cognitive and behavioral techniques. Techniques include watching television or videos, talking about the pain or thinking about something else. These techniques are not effective for severe pain. Parental involvement may reduce pain and anxiety in children undergoing procedures (Gallagher, Rae, & Kinsella, 2000). Role of nurses in burn care Nursing in burn care is a very challenging task. Wound care in the burn unit has become an art of burn nursing practice and can be extremely challenging and complicated. The complexity exists because of the different types of wounds involved (Gordon, & Marvin, 2007). The rehabilitation nurse should not only be familiar with wound care but also be familiar with skin grafting procedures and donor site care (Regojo, & Wright 2000). In order to provide a safe and compassionate degree of care, nurses must possess both advanced technical skills and empathy (Wikehult, Hedlund, Marsenic, Nyman, & Willebrand, 2008). The nurse must also provide the patient’s family with information and explanations about treatment procedures. Nurses must prepare a nursing program for the care of the patients taking into account the instructions of the physicians and incorporating their knowledge of the patients’ special needs (Aacovou, 2005). Nurses should be educated about acute stress disorder, post traumatic stress disorder, the normal grieving process and depression. This will make them more sensitive to the psychological issues faced by burn patients and help them deal with these issues in a more effective manner (Klein, 2009) It is very important for nurses to work with the families of burn patients to promote strategies for improving patient care after hospital discharge. Relatives of caregivers may also need support which could include just hearing them out in some cases and allowing them to express their fears related to the patient’s reactions when returning to the social world (Goyatá, & Rossi, 2009). Conclusion Thus, the nursing of burns patients cannot be limited to just general nursing, physiotherapy, and social work. The role of nurses in such cases is much wider, for they contribute to the success of the patients’ coping as regards not only their acceptance of their new body image but also their integration into society (Aacovou, 2005). References Anonymous. (2004). Burns pain misjudged by nurses. Australian Nursing Journal. 11(11), 35. Aacovou, I. (2005). The role of the nurse in the rehabilitation of patients with radical changes in body image due to burn injuries. Annals of Burns and Fire Disasters, XVIII, 2. Haythronthwaite, J. A., Lawrence, J. W., Fauerbach, J, A. (2001). Brief cognitive interventions for burn pain. Annals of Behavioral Medicine. 23(1), 42-49. Gallagher, G., Rae, C. P., & Kinsella J. (2000). Treatment of pain in severe burns. American Journal of Clinical Dermatology, 1 (6), 329-335. Go´mez, R., & Cancio, L. C. (2007) Management of burn wounds in the emergency department. Emergency Medicine Clinics of North America. 25, 135-146. Gordon, M., & Marvin, J. (2007). Burn Nursing. In D. N. Herndon (Ed.), Total burn care. Retrieved March 19, 2009, from http://books.google.com/books?id=m_QnStA_JPsC&pg=PA478&lpg=PA478&dq=Burn+care+%2B+nursing&source=bl&ots=Eoe9zB3N4D&sig=NbIx5cD00Nig0nc9dUVOThwBMvA&hl=en&ei=0wrDSZueLpegkQXhgPXDDA&sa=X&oi=book_result&resnum=6&ct=result#PPA478,M1 Goyatá, S. L. T., & Rossi, L. A. (2009). Nursing diagnoses of burned patients and relatives' perceptions of patients' needs. International Journal of Nursing Terminologies and Classifications. 20(1), 16-24. Jaywant, S. S., & Pai, A. V. (2002) A comparative study of pain measurement scales in acute burn patients. The Indian Journal of Occupational Therapy, XXXV, 3. Klein, J. M. (2009). The psychiatric nurse in the burn unit. Perspectives in Psychiatric Care, 45, 71-74. Kowalske, K. J. (2002) Burn pain-evaluation and management. In T. N. Monga and M. Grabois (Eds.), Pain management in rehabilitation. Retrieved March 19, 2009, from http://books.google.com/books?id=_Ile9itT7sAC&pg=PA273&lpg=PA273&dq=Burn+pain+assessment&source=bl&ots=m8GMRGeoIX&sig=SOCKQXKDithMKANHkHOB_1aIjq0&hl=en&ei=gom-ScXEG5SM6gPqk-TbBA&sa=X&oi=book_result&resnum=4&ct=result LeMone, P., & Burke, K. M. (2004) Medical-Surgical Nursing: Critical Thinking in Client Care (3rd Edition). New Jersey: Pearson Education Inc. Napoli, M. (2002). Phantom burn pain often goes unrecognized. HealthFacts, 27 (3), 5. Patterson, D. R., Hoffman, H. G., Weichman, S. A., Jensen, M. P., Sharar, S. R. (2004). Optimizing control of pain from severe burns: a literature review. American Journal of Clinical Hypnosis. 47(1), 43-54. Regojo, P. S., & Wright C. (2000). A holistic approach to burn rehabilitation. In J. B. Derstine and S. D. Hargrove (Eds.), Comprehensive rehabilitation nursing. Retrieved March 19, 2009, from http://books.google.com/books?id=gnjFCYMeaBUC&pg=PA529&lpg=PA529&dq=pain+assessment+%2B+burns&source=bl&ots=Lldv9PrW2-&sig=MabYVtbP143TUnKHWTHQyXkSEfY&hl=en&ei=Aoy-SZPgEJz47AOloZTuBA&sa=X&oi=book_result&resnum=10&ct=result#PPR7,M1 Wikehult, B., Hedlund, M., Marsenic, M., Nyman, S., & Willebrand, M. (2008) Evaluation of negative emotional care experiences in burn care. Journal of Clinical Nursing. 17, 1923-1929.   Read More