University:
Texas Lutheran University
Course:
NURS 432 | Complex Nursing Concepts & Practice II
Academic year:

2023
Views:

25

Pages:

8
Author:

SapphireSol

Burn wound Care Def: the use of warm, running water to help the healing process and reduce the infection, relieve the Pain. Purpose: Remove the old dressing Clean the wound Assess the wound provide range of motion exercise Promote The healing process. The Step: If The patient is ambulatory, Clean by shower If non ambulatory Cleanby Two → Shower carts → mobile stretcher that have -side able to remove drainage hole -position capabilities -unstable Patient, Clean at bedside The total immersion hydrotherapy is performed rare because can be risk of infection and sepsis use of Plastic liners, Filtered water To Clean The wound, equipment to prevent cross of infection The Temprature → water 37,8°CT the duration is according to Patient Tolerance During the bath the patient is encourage To be active unburned area should be washed resulary The skin Sinspected too For any infection Hair should be Cut or shoved blister shouldn't be break down mechanical debridement (remove dead Tissue) should be perform Wound Debridement → Purpose/Goal remove The tissue contaminated with bacteria or Foreign body remove of dead Tissue, or burn to prepare for grafting Type: 1- Nature spontaneously without any interference From any body, by the effect of enzyme under death Tissue and the activity of normal healthy Tissue make liquification of scar Tissue and then separation spontaneously. → Take long Time, use for small burn 2- mechanical use instrument to remove The Tissue by artery Forceps to hold it and Cut is done during hydrotherapy 3. Chemical Debridement Chemical substance or cream to remove dead tissue. 4. Surgical Debridement Patient taking anesthesia and going under surgical procedure using surgical instruments. 5. Maggot Therapy Type of insect using special species of maggot introduced to ulcer burn, these it only the dead skin. Purpose of wound dressing: Protect the wound from the physical damage Be comfortable Be nontoxic, non irritant, non adherent Allow gas exchange Allow high humidity Allow maximum activity of wound healing Method of wound dressing → Open dressing is a popular form of treatment for burn wound, application of topical agent without use dressing • Advantage: Continue observation & assess burns Reduce hyperthermia Facilitate physical therapy Treat burn of face, neck, ear… • Disadvantage: Hypothermia Require frequent ointment Can’t be use in children. → Closed method the application of dressing over the burn • Use in area with new skin graft to protect the graft and promote condition to adhere Donor site → Take a layer of skin Recipient → Put the graft Occlusive dressing - thin gauze that impregnated with Topical antimicrobial agent for 3 to 5 days Precautions with occlusive: Fingers or toes The area under the breasts Or between genital folds, [prevent two body surfaces from touching] Nurses Alert! If the dressing is too tightly it impeded the circulation تعيق الدورة الدموية Peripheral Pulse must be checked Burn extremities elevated on 2 pillows Extremities wrapped from distal to proximal Equipment: Gloves Liquid antibacterial Water Sterile Container Sterile Field Gauze Non-adhering dressing Step Explain procedure Give analgesics as ordered 20-30 min before procedure Prepare environment Prepare nurse (wear PPE) Prepare equipment - check supplies Ambulate patient to room Clean the wound before hydrotherapy Remove old dressing Physical therapy exercise is performed at end of hydrotherapy Clean the wound with gauze with circular motion and wash Unburned area too 10. Cover wound with several layers of dressing 11. Light dressing to allow for motion from distal to proximal 12. If the burn is in face use ointment 13. Careful attention given to ensure that topical agent doesn't interfere with face

Burn Wound Care

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