Concept of Burns

BURNS TREATMENT Practicum 5 Case Studies: A 40 year old woman was hospitalized for 2 days because she suffered burns from an oil lamp at home on her right upper arm exposed to hot water. The patient said, "My arm hurts a lot, especially when I move it. The examination revealed burns on the right hand, front of the chest and lower right leg, the reddish color of the wound appeared to be blistered. Vital sign results: BP: 100/80 mmHg, pulse: 70 x/minute, temperature 37°C Questions: 1. Explain what causes burns! 2. Name and explain the classification of burns! 3. What is the area of the patient's burns? 4. State and describe how to calculate the area of a burn wound! 5. Mention the nursing problems that arise in this patient? CONCEPT OF BURNS Understanding Burns are a form of tissue damage or loss caused by contact with heat sources such as fire, hot water, chemicals, electricity and radiation. Classification of burns based on depth 1. Grade I burns a. Also called superficial burns b.Affects the outer layer of the epidermis, but does not affect the dermis area. Often referred to as epidermal burns c. The skin looks reddish, slightly edematous, and feels painful. d. On the fourth day, epithelial desquamation (peeling) will occur. 2. Grade II burns a. Superficial partial thickness: 1) Burns cover the epidermis and the upper layer of the dermis 2) The skin appears reddish, edematous and the pain is more severe than a grade I burn 3) Characterized by bullae that appear several hours after the wound b. Deep partial thickness 1) Burns cover the epidermis and deep layers of the dermis accompanied by bullae 2) the wound surface has pink and white spots due to variations in blood vessel vascularization (the white part has few blood vessels and the pink part has some blood flow) 3. Grade III burns a. Burns cover the skin, subcutaneous fat and even muscles and bones b. Causes permanent tissue damage c. Sometimes the pain is not felt much because the nerve endings and blood vessels have died. BURNS TREATMENT PROCEDURE Patient preparation: 1. Greet and greet the patient by name 2. Explain the purpose and procedure of action to the family/client 3. Ask the client's readiness before the activity is carried out. 4. Giving the patient a position to create a comfortable atmosphere tools preparation 1. Instrument tank containing: a) Anatomical tweezers b) Chirurgis tweezers c) Debridemand scissors d) Sterile gauze e) Comm: 3 pieces f) Other equipment consists of: g) 5 cc or 10 cc syringe h) Gloves 2. Cut out the plaster 11. Plaster or adhesive 12. NaCl 0.9% 13. Bend 2 pieces, 1 piece contains disinfectant solution 14. Verbands 15. Wound medicine as needed IMPLEMENTATION PROCEDURE A. Pre-Interaction Stage 1. Verify the client's treatment program 2. Wash your hands 3. Place the device near the patient correctly B. Orientation Stage 1. Giving greetings as a therapeutic approach 2. Explain the objectives and procedures of action to the client/family 3. Ask the client's readiness before the activity is carried out C. Work Phase 1. Bathing stage a. Maintain privacy b. Before bathing the patient is given an analgesic suppository c. Clean the patient's body first with a soaking bath. d. Prepare sterile and antiseptic water. e. Splash with water while removing dead skin tissue (eschar) which is easily removed using tweezers and scissors (don't force it if it hasn't come off yet) f. Dry with a soft cloth by pressing gently (do not rub). 2. Wound care stage a. Position the patient so that the wound can be seen clearly b. Open the equipment and bring the tool closer c. Install the pad and bring the bend closer to the patient d. Wear sterile gloves e. If the wound is still closed: remove the dressing carefully, if difficult, moisten with 0.9% NaCl f. Observe the condition of the wound (color, area, depth) g. Clean the wound using 0.9% NaCl h. Carry out debridemand if there is necrotic tissue. (If there are bullae, aspirate using a sterile syringe after the bullae are maximal) i. Clean the wound again with 0.9% NaCl j. Dry the wound using sterile gauze k. Give topical medication according to the condition of the wound (Silver Sulfa Diasil ointment / SSD/ Burnazin cream can be given) with a thickness of approximately 0.5 cm over the entire surface of the burn wound. l. Cover the wound with sterile gauze, then apply gauze (roll) and plaster it m. Tidying up the patient D. Termination Stage 1. Evaluate the results of actions 2. Clean up and return the tools 3. Wash your hands 4. Documentation