Nursing care after skin autotransplantation as a treatment method of second- and third-degree thermal burns – a case study based on the NANDA and ICNP ® classifications

INTRODUCTION

In Poland, burns affect approx. 400,000 people per year and are the fourth most common cause of injuries throughout the world [1]. According to data from the World Health Organization (WHO), they cause approx. 6.6 million injuries and 300,000 deaths each year, requiring a multidisciplinary approach and cooperation [2]. The most common is a thermal burn that “occurs through intensive heat contact to the body, which destroys and/or damages human skin” [3].
The degree of tissue damage depends on the temperature and duration of contact with the causative agent [4-6], and it requires hospitalization in accordance with the accepted criteria (Table 1) [7, 8].
Burn disease is diagnosed in the case of serious local and systemic disorders caused by burns covering more than 15-20% of the body surface in adults [9]. The course of the burn disease can be divided into 3 clinical periods (Table 2).
The basic treatment for the burn shock is fluid resuscitation supported by the supply of large doses of vitamin C [10], high-protein nutrition, early excision of dead tissue (up to 72 hours after the burn), the use of appropriate special-ist dressings, and targeted antibiotic therapy [7]. Prolonged catabolism (period II) requires protein/albumin supple-mentation and the use of non-selective β-blockers [11].
The non-surgical local treatment of a burn wound includes antibiotics, agents containing silver, and lubrication of the skin. Treatment should take place under aseptic conditions [1, 12].
Surgical treatment is recommended for second- and third-degree burns based on the early excision of necrotic tis-sues (necrectomy) and surgical closure of the burn wound by covering with skin grafts. In the case of deep burns of partial or full skin thickness, the standard for wound coverage is to use split-thickness skin grafts (STSG) [2]. It is rec-ommended that the 2 + 2 rule is followed, meaning surgery lasting no more than 2 hours with the transfusion limited to 2 blood units [13]. Autotransplantation up to 7-10 days after the burn accelerates the wound healing process (vs. 21 days or longer for spontaneous healing), significantly reducing the risk of infection and scarring, reducing pain, and enabling faster mobilization of the patient [2]. Other methods are the use of artificial skin, artificial epidermis, and al-logeneic or xenograft [12, 14].
The treatment of burn wounds can be supplemented with hyperbaric therapy (HBOT). However, while HBOT is used to treat a wide variety of conditions as either a standard treatment plan or as an auxiliary therapy, the use of HBOT as an adjuvant in the treatment of thermal burns remains controversial due to limited and conflicting evidence [15]. Pain control and treatment (continuous analgesia) are indispensable and critical when treating patients with severe burns. Burn pain is defined as burning, stinging, and scalding; it is resistant to treatment and has a major impact on the patient’s psyche [1].
According to the current recommendations, the early introduction of enteral nutrition reduces the body’s hyper-metabolic response [16]. In severe burns, proton pump inhibitors are used to prevent the formation of so-called Curl-ing ulcers in the fundus or duodenum associated with increased secretion of hydrochloric acid in reaction to burns and ischaemia of the gastrointestinal mucosa as a result of hypovolaemia [17].
The hypermetabolic state in a severely burned patient leads, among others, to rapid loss of muscle mass and re-quires bed rest. The treatment requires obligatory antithrombotic prophylaxis. Immobilization of the patient is the cause of peripheral polyneuropathy; therefore, after stabilizing the haemodynamic state, it is necessary to start rehabili-tation [11].
Burn disease alters the patient’s self-perception and quality of life, and is often associated with depression, post-traumatic stress disorder (PTSD), and anxiety disorders [6, 12, 18].
The study aimed to present selected nursing diagnoses in a patient after skin autotransplantation as a method of thermal burn treatment using the NANDA and ICNP^® classifications.

MATERIAL AND METHODS

A case study was used in this research. The research techniques used were observation, analysis of medical records (observation cards, fever cards, and medical orders), an interview, and the measurement of vital and anthropometric parameters. The research tools used were the proprietary observation and interview questionnaire, the American Burn Association (ABA) burn severity rating scale, and the NRS (numeric rating scale) pain scale. The patient’s consent was obtained for the examination and publication of the photos. Based on the collected data, nursing diagnoses were formu-lated according to NANDA and ICNP^® guidelines, nursing interventions were planned and implemented, and outcomes were evaluated.

Organization of the study

The study was conducted in December 2021 during 3 selected days of hospitalization, meaning 14, 15, and 19 days after the injury (from the first to the fifth day after skin autotransplantation) in the plastic, reconstructive, and burn surgery department in a hospital in Małopolska.

Characteristics of the examined patient

A 35-year-old female patient suffered second-/third-degree thermal burns around the face, hands, torso, back, and lower limbs while adding fuel to a bio-fireplace. In the assessment of burn severity according to the ABA (Table 2), the burns were classified as major, covering approximately 40% of the body surface area. The patient was transferred to a plastic, reconstructive, and burn surgery ward.
The department included fluid treatment (Sterofundin 500 ml, 10% glucose 500 ml) with high doses of vitamin C (2 × 1 g), analgesic treatment (1% lidocaine 40 mg/h i.v. in continuous infusion; morphine 20 mg/20 ml i.v. in continuous infusion; Dexdor 200/50 ml i.v. continuous infusion; paracetamol PCA ad hoc 1 g) through a central vascular access inserted into the left internal jugular vein and anticoagulant treatment (Clexane 1 × 60 mg s.c.). The patient was con-scious, auto- and allopsychically oriented and in good verbal contact. In the ward, the patient was kept in protective isolation and was constantly monitored. Saturation ranged from 98% to 100%, the number of breaths was in the range of 14-15/min, blood pressure (BP) ranged from 120/60 mmHg to 130/85 mmHg, heart rate was regular, pulse with good tense ranging from 80 to 100 ud/min, temperature ranged from 36.5°C to 36.6°C, and body mass index (BMI) was 30.49 kg/m².
The patient received wholesome meals with an increased amount of protein, supported by a high-energy formula for special medical purposes (Nutridrink Protein 2 × 1 bottle) and an immunomodulating ingredient (Arginilan 1 × 1 p.o.). A proton pump inhibitor (IPP, 1 × 40 mg i.v.) was used in the prevention of Curling ulcers. The patient was sub-jected to passive oxygen therapy through a nasal cannula (5 l/min), and venous blood gas measurements were taken daily. The patient had a bladder Foley catheter in place, and the fluid balance was monitored.
The examined patient denied the presence of comorbidities and did not take any medications regularly. To prevent wound infection and to prepare for transplantation, the patient underwent the procedure of changing the dressings on burn wounds every day under aseptic conditions and general anaesthesia. The burned surfaces were cleaned of dead tissue, washed with an antiseptic (sterile 1% NaCl), and protected with special sterile dressings (Cuticerin). Lanolin, boric acid ointment, and betadine were also used on the fingers of the right hand. On the third day of hospitalization, a tangential necrectomy was performed on the area of third-degree burns (mainly the right shoulder), and on the tenth day, a tangential necrosis excision was done to the right arm and right torso. Wounds were covered with specialist Aq-uacel Ag dressings and reinforced with an elastic bandage. During the procedure, one unit of concentrated red blood cells (RBC) was transfused without complications. On day 12 after the injury, the patient was diagnosed with anaemia (RBC 3.01 × 10⁶/ql, Hb 7.9 g/dl, Hct 19%); therefore, 2 units of concentrated red blood cells were transfused, and no complications were observed. On the 14^th day of hospitalization, the right-side wounds were covered with a skin graft of intermediate thickness (Fig. 1), and on the 19^th day this was also done on the right arm area (Fig. 2). All grafts were collected using a dermatome from the healthy tissue area of the thigh and left shank.

THE PATIENT NURSING PROCESS USING THE NANDA AND ICNP^® CLASSIFICATIONS

In the nursing process, the NANDA classification was used, the interventions were developed according to the Nurs-ing Interventions Classification (NIC), and the results of care were rated according to the Nursing Outcomes Classifica-tion (NOC) [19]. The mapping of diagnoses and interventions using the 2017 version of the ICNP® dictionary was also used [20]. For the purposes of this publication, the terms derived from the following axes were used: subject (F – fo-cus), location (L), interventions (IC), and means (M).

Nursing diagnosis 1.

NANDA: Severe burning pain in the chest, abdomen, and extremities related to tissue trauma caused by thermal burn and pain at the site of skin transplant [21].
ICNP®: Pain [10013950 + 8] + abdomen [10000023] + right [10017234] + left [10011267] + arm [10002504] + leg [10011298] + burn [10003763] + thermal injury [10019637] + transplantation [10020053].

INTERVENTION

NANDA
• Assessment of pain (duration, nature, pain aggravating and alleviating factors), intensity based on the NRS pain scale.
• Patient education on the causes of pain.
• Assisting in adopting a pain-relieving position.
• The use of amenities: anti-bedsore mattress, pillows, rollers.
• Providing the patient with conditions for rest.
• Combined and gently performed skin care treatments.
• Pharmacotherapy according to a doctor’s orders (1% lidocaine 40 mg/h i.v. in the pump, Morphine 20 mg/20 ml i.v. in the pump, Dexdor 200/50 ml i.v. in the pump [the first day of observation], paracetamol PCA ad hoc 1 g [the third day of observation]).
• Observing the patient in terms of her increased need for painkillers.
• Participating in patient rehabilitation according to the plan agreed upon with the doctor and physiotherapist.
• Motivating the patient to use relaxation methods, such as listening to her favourite music and conscious breathing.
ICNP^®
• Monitoring pain [10038929].
• Assessing pain [10026119].
• Assessing knowledge about pain [10039104].
• Assessing control of pain [10002710].
• Assessing knowledge of pain management [10039041].
• Identifying attitude toward pain [10009654].
• Teaching about pain [10039115].
• Managing pain [10011660].
• Assessing psychological response to pain [10038964].
• Managing exercise regime [10023890].
• Collaborating on pain management plan [10039831].
• Administering pain medication [10023084].
• Monitoring response to treatment [10032109].
• Distraction [10039232].
• Assessing medication side effect [10039087].
• Teaching about medication side effects [10044614].
• Teaching about managing pain [10019489].
• Teaching breathing technique [10039213].
• Teaching relaxation technique [10038699].
• Collaborating with physician [10023565].

NURSING OUTCOMES

NANDA: Pain intensity decreased from 6 to 4 on the NRS scale in the right hand. Pain remained at level 3 for the rest of the body.
ICNP^®: Reduced pain [10027917].

NURSING DIAGNOSIS 2.

NANDA: Risk of decreased cardiac output related to hypovolaemia and anaemia associated with burn disease [22].
ICNP^®: Impaired cardiovascular system [10022949], metabolism [10012005].

INTERVENTIONS

NANDA
• Monitoring heart rate, blood pressure, respiratory rate.
• Monitoring oxygen saturation and pulse with a pulse oximeter.
• Monitoring body temperature 2 /day or as indicated.
• Performing a 12-lead ECG in case of the patient’s worsening well-being.
• Blood sampling for venous blood gas analysis, biochemistry t^{o determine electrolytes (K+, Na+, Cl–, Ca++}, Mg⁺⁺), glu-cose, and protein/albumin levels.
• Pharmacotherapy as prescribed by a doctor [Metoprolol 1 × 50 mg p.o., 10% glucose 500 ml + 10 mmol Glycophos i.v. (on the first day of observation), MgSO4 1 × 2 g i.v. (regarding the first, second, and third days of observation), Ex-acyl 1 g (regarding the second day of observation).
ICNP^®
• Monitoring vital signs [10032113].
• Monitoring cardiac status [10034285].
• Assessing cardiac status [10036738].
• Monitoring blood pressure [10032052].
• Monitoring respiratory status [10012196].
• Assessing respiratory status [10036786].
• Blood glucose monitoring [10032034].
• Monitoring body temperature [10012165].
• Managing symptom [10031965].
• Promoting self-management of symptom [10038469].
• Diagnostic testing [10031140].
• Monitoring laboratory result [10032099].
• Administering medication and solution [10001804].
• Monitoring response to treatment [10032109].
• Collaborating with physician [10023565].

NURSING OUTCOMES

NANDA: The patient’s vital signs were as follows: saturation 98-99%, breathing 14-15/min, BP 120/60 mmHg, heart rate equal to the pulse, regular, with good tense, 80-100 bpm. Body temperature 36.6°C. Laboratory test results on the first day of care were as follows: Ht 19-26.3%, Hb 7.8-8.5 g/dl, Na⁺ 134-138 mmol/l, K⁺ 3.9-4.8 mmol/l, Ca⁺⁺ 1.17-1.2 mmol/l, Cl^– 103-107 mmol/l, Mg⁺⁺ 0.79 mmol/l, glucose 5.5-6.4 mmol/l.
ICNP^®: Effective cardiovascular status [10033692].

NURSING DIAGNOSIS 3.

NANDA: Fluid volume deficit related to the damage of microcirculation vessels manifested by hyponatraemia and weight loss [23]. ICNP^®: Impaired fluid volume [10042008], hypovolaemia [10042020], electrolyte imbalance [10033541], hypo-natraemia [10031500], dehydration [10041882], hypovolaemic shock [10009599].

INTERVENTIONS

NANDA
• Continuous monitoring and assessment of vital signs (BP, pulse, oxygen saturation, respiratory rate).
• Body weight measurement 1×/day.
• Measurement of the central venous pressure (CVP) 1-2×/day.
• Insertion of a Foley catheter into the bladder.
• Hourly and daily diuresis control.
• Keeping fluid balance.
• Venous blood sampling for blood gas testing.
• Venous blood sampling for biochemical testing (Na⁺, Cl^–, K⁺, Ca⁺⁺, Mg⁺⁺).
• Collecting urine for general examination (osmolality).
• Assessment of the state of consciousness using the Glasgow scale.
• Observing the patient for signs of shock, i.e. weakness, dizziness, lower pulse rate, decreased diuresis, and pale skin.
• Assessment of oedema (lower and upper limbs, abdominal circumference).
• Supplementing fluid deficiency and electrolytes intravenously on doctor’s orders [10% glucose 500 ml + 10 mmol Glycophos i.v. (the first day of observation), Sterofundin 500 ml (the first and second days of observation), MgSO4 1 2 g i.v. (the first, second, third days of observation)].
• Pharmacotherapy according to doctor’s orders to reduce the inflammatory response (Biseptol 2 × 960 mg i.v., Ampi-cillin 4 × 2 g i.v.).
ICNP^®
• Monitoring vital signs [10032113].
• Symptom control [10025812].
• Monitoring fluid balance [10040852].
• Diagnostic testing [10031140].
• Monitoring laboratory result [10032099].
• Assessing urine [10050164].
• Assessing risk for dehydration [10040932].
• Monitoring blood pressure [10032052].
• Monitoring cardiac status [10034285].
• Monitoring respiratory status [10012196].
• Monitoring blood glucose [10032034].
• Monitoring body temperature [10012165].
• Monitoring fluid output [10035319].
• Administering medication and solution [10001804].
• Electrolyte therapy [10039324].
• Fluid therapy [10039330] + intravenous therapy [10010808].
• Monitoring response to treatment [10032109].

NURSING OUTCOMES

NANDA: Fluid balance was negative and amounted to –1550 ml on day 1, –1120 ml on day 2, and –2160 ml on day 3. The patient’s body weight decreased by 4 kg during the evaluated days. CVP result +7 cm H2O on day 1, +3 cm H2O on day 2, and +2 cm H2O on day 3. Laboratory test results on the first day of care: Na⁺ 134-138 mmol/l, K⁺ 3.9-4.8 mmol/l, Ca⁺⁺ 1.17-1.2 mmol/l, Cl^– 103-107 mmol/l, Mg⁺⁺ 0.79 mmol/l, glucose 5.5-6.4–mmol/l, phosphorus 1.26 mmol/l, creatinine 36 qmol/l, eGFR 189.11 ml/min/1.73 m², urea 4.73 mmol/l, total protein 49 g/l, albumin 24 g/l. There was no sign of shock, and the patient was weak and tired.
ICNP^®: Impaired fluid volume [10042008], hyponatraemia [10031500], hypomagnesia [1003149], weakness [10024897].

NURSING DIAGNOSIS 4.

NANDA: The risk of skin integrity impairment (e.g. infection, haematoma, necrosis) related to the burn and partial skin autograft [24].
ICNP^®: Impaired skin integrity [10001290 + 3] + risk of infection [10015133] + haematoma [10008931] + necrosis [10012482], transplantation [10020053] + skin [10018239].

INTERVENTIONS

NANDA
• Educating the patient about the increased risk of infection and prevention methods.
• Monitoring the patient’s general condition, vital signs (temperature, breathing, heart rate, BP), and complaints re-ported by the patient on symptoms of infection.
• Compliance with the rules of asepsis and antisepsis when performing medical procedures.
• Educating the patient on the symptoms of infection (e.g. low-grade fever/fever, weakness, pain).
• Assisting the patient in keeping her skin clean.
• Change of underwear and bed linen.
• Administration of pharmacotherapy as prescribed by the doctor (Biseptol 2 × 960 mg i.v., ampicillin 4 × 2 g i.v.).
ICNP^®
• Prevention infection [10036916].
• Assessing susceptibility to infection [10002821].
• Assessing signs and symptoms of infection [10044182].
• Monitoring signs and symptoms of infection [10012203].
• Environmental safety management [10042507].
• Use aseptic technique [10041784].
• Teaching about health seeking behaviour [10032956].
• Promoting health-seeking behaviour [10032465].
• Teaching about wound care [10034961].
• Teaching about self-care [10045014].
• Skin assessment [10041126].
• Evaluating risk for infection after operation [10034048].
• Evaluating signs and symptoms of
• Infection after operation [10034069].
• Assessing skin integrity [10033922].
• Assessing wound [10030799].
• Assessing susceptibility to infection [10002821].
• Assisting the surgeon during operation [10002866].
• Dressing patient [10031164].
• Wound care [10033347 + 2] + ointment [10013670] + wound dressing [10021227]
• Surgical wound care [10032863].

NURSING OUTCOMES

NANDA: No general symptoms of infection. The patient did not report any symptoms of infection. Laboratory test results were as follows: CRP 122.25 mg/l, leukocytes 6.78 × 10³/ql [of 13.12]. Vital signs were as follows: temperature 36.6°C, heart rate 80-100 bpm, respiration 14-15/min, BP 120/60 mmHg.
ICNP^®: No infection [10028945].

NURSING DIAGNOSIS 5.

NANDA: Low mood related to immobilization and anxiety related to a deficit of knowledge about burn wound man-agement and skin transplantation, changed appearance, and impairment in further functioning at home and in the so-cial environment manifested as insomnia [25].
ICNP^®: Depressed mood [10022402 + 3] + impaired mobility [10001219], + lack of knowledge [1000083] + body image [10003405]. Anxiety [10000477]. Impaired psychological status [10038411].

INTERVENTIONS

NANDA
• Establishing a support plan for the patient with a psychologist.
• Explaining the purpose of the actions undertaken in the care and therapy plan.
• Motivating the patient to undertake self-care and physical activity according to the established care plan.
• Informing the patient about the undertaken nursing activities.
• Encouraging telephone contact with relatives.
• Providing silence and conditions for rest.
• A therapeutic conversation with the patient based on communication techniques (active listening, empathy, respect, exploration).
• Pharmacotherapy as prescribed by a doctor [pregabalin 2 × 75 mg orally, Seronil 1 × 20 mg orally, hydroxyzine 2 × 25 mg orally (all for the first, second, and third days of observation), Dexdor 200/50 ml i.v. pump (on the first day of observation)].
ICNP^®
• Assessing depressed mood [10026055].
• Assessing attitude toward disease [10024192].
• Assessing coping [10002723].
• Providing emotional support [10027051].
• Motivating [10012242].
• Talking [10019436].
• Teaching about diversional therapy [10043536].
• Care planning [10035915].
• Promoting self-esteem [10024455].
• Assessing psychological status [10030734].
• Promoting positive psychological status [10032505].
• Supporting psychological status [10019161].

NURSING OUTCOMES

NANDA: The patient did not want to contact a psychologist. Initially, the sleep continuity problems persisted, but af-ter a while the anxiety decreased and the quality and quantity of sleep improved.
ICNP^®: Decreased depressive mood [10027901]. Effective response to therapy [10036423], able to adjust [10021828].

DISCUSSION

Normal peripheral perfusion was maintained in the patient by using fluid resuscitation supported by providing large doses of vitamin C, which, as research has shown, reduces vascular permeability and the need for fluids [11, 28]. The research results show that burn pain is very strong, is resistant to treatment, and can accompany the patient for many months after the injury. Pain treatment is indispensable and a critical component of therapy, and the early period is particularly painful [12, 18]. The examined patient required a continuous infusion of opioid drugs, but the pain was not eliminated and decreased by one point in a subjective assessment by the patient.
Large burned areas of the body over time resemble a state of severe malnutrition and require high-energy and high-protein nutrition supported by supplying immunomodulating ingredients (e.g. arginine, glutamine). Doing so improves the functioning of the immune system, reducing the number of infections and shortening the hospitalization time [29]. The patient was treated with a high-protein diet supported by preparations for special medical purposes and arginine.
After the patient was relieved from the shock phase, measures were continued to prevent the development of gen-eralized infection associated with impaired skin integrity, immune disorders, and the use of invasive treatments. The patient was treated with antibiotics, and skin autotransplantation was performed twice. The autograft method signifi-cantly reduces the risk of infection, reducing pain and enabling the patient to become mobile sooner [2]. In the studied patient, the grafts healed (Figs. 3-5), and no infection of the post-transplant sites or other burn sites was found.
The period of catabolism in the patient manifested by a borderline heart rate (100 bpm) required the use of non-selective β-blockers, which reduce the myocardial oxygen demand and protect against cardiomyopathy. Such a procedure is the basic treatment for long-term metabolic consequences of severe burns indicated by some authors [11]. During this period, the patient’s anaemia required the transfusion of 2 units of concentrated red blood cells with-out early and late transfusion complications. To counteract the development of Curling ulcers, intravenous prophylaxis with proton pump inhibitors were administered. In the treatment of patients with severe burns, immobilization is used [13], while applying therapeutic management of antithrombotic therapy, which was also used in the examined patient.
Pain, lack of knowledge, external injuries, and the necessity to return to fulfilling social roles were the reasons for a low mood in the examined patient, accompanied by anxiety and insomnia. A psychologist’s care and the use of a neuroleptic were recommended. The examined patient denied the need for psychological consultation. Research indi-cates that a burn is a highly traumatizing situation that may lead to anxiety, depression, and post-traumatic stress disor-der [12, 18]. The occurring problems result mainly from physical changes (deformations), limiting and sometimes pre-venting a person from fulfilling roles, and causing depression due to someone not acceptance their appearance. An im-portant role here is played by early psychological intervention aimed at providing psychological support, psychoeduca-tion, and training in coping with everyday life [30].
The patient showed a stable mood on the 37^th day of hospitalization and was discharged home in good general con-dition, with the burn wounds healed and visible scars, knowing how to deal with burned skin after transplantation, and being ready to undertake self-care with the recommendation of using Tardyferon-Fol orally 1 × 1, Metocard 50 mg oral-ly 1 × 1, and Seronil 10 mg 1 × 1 for 7 days then every 2 days, and Fenistil in drops.
treatment in the case of thermal burns is long-lasting and multidisciplinary; therefore, the goal in nursing care should be to assess the patient’s ability to self-care, to motivate him/her to undertake it, and to provide the patient with emotional and informational support.
In this case report 2 approaches were used in nursing care to formulate nursing diagnoses and plan interventions – the NANDA and ICNP classifications. The 2 classifications complemented each other – NANDA described in detail the process of arriving at a diagnosis and the analysis of the causes of the problems, while ICNP^® allowed for a synthesised presentation of the patient’s problems and offered brief, practical guidelines for nursing interventions.

CONCLUSIONS

Severe burns resulted mainly in the occurrence of burn wound pain in the examined patient despite the use of opi-oid therapy, and she was also at risk of developing other disorders of a clinical and psychological nature. Therefore, the patient required comprehensive treatment and nursing care. Surgery on dead tissues, skin transplantation, and its proper care allowed for complete healing of burned places, with no complications and tolerance of the grafts.
The use of the NANDA and ICNP^® classifications of nursing diagnoses and interventions allowed us to analyse the patient’s problems in detail and to plan nursing interventions according to evidence-based practice principles. The shown case report helps demonstrate the usefulness of both complementary classifications of nursing diagnoses.

Disclosure

The authors declare no conflict of interest.

References