Luka bakar bedah

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Luka bakar bedah

  1. 1. JUNI 10,FFJUNI 10,FF 11LUKA BAKARLUKA BAKAR(BURN)(BURN)
  2. 2. JUNI 10,FF 2Third – Degree BurnThird – Degree Burn
  3. 3. JUNI 10,FF 3Rule of NinesRule of Ninessurface ofsurface ofpatient’spatient’spalm = 1% BSApalm = 1% BSA
  4. 4. JUNI 10,FF 4Burn woundsBurn wounds occur when thereoccur when thereis contact between tissue andis contact between tissue andan energy source, such asan energy source, such asheat, chemicals, electricalheat, chemicals, electricalcurrent, or radiation.current, or radiation.Burns and PatientBurns and PatientManagementManagement
  5. 5. JUNI 10,FF 5The resulting effects ofThe resulting effects ofthe burn are influencedthe burn are influencedby the:by the: intensity of the energyintensity of the energy duration of exposureduration of exposure type of tissue injuredtype of tissue injured
  6. 6. JUNI 10,FF 6Burn StatisticsBurn Statistics At least 50% of all burn accidents canAt least 50% of all burn accidents canbe preventedbe prevented children playing with fire account forchildren playing with fire account formore than one-third of preschool deathsmore than one-third of preschool deathsby fireby fire In the US, approximately 2.4 millionIn the US, approximately 2.4 millionburn injuries are reported each year.burn injuries are reported each year. Burn injuries are second to motorBurn injuries are second to motorvehicle accidents as leading cause ofvehicle accidents as leading cause ofaccidental death in the USaccidental death in the US
  7. 7. JUNI 10,FF 7What 2 types of clientsWhat 2 types of clientsaccount for 2/3 of all burnaccount for 2/3 of all burnfatalities?fatalities? Older adultsOlder adults• Children (especiallyChildren (especiallypreschool aged children)preschool aged children)
  8. 8. JUNI 10,FF 8Where do most burnsWhere do most burnsoccur?occur? Children, newborn to 4 y.o, from kitchenChildren, newborn to 4 y.o, from kitchenand then the bathroomand then the bathroom ages 5-74, most burn injuries occurages 5-74, most burn injuries occuroutdoors with next area-kitchenoutdoors with next area-kitchen ages 75 and above, kitchen and thenages 75 and above, kitchen and thenoutdoorsoutdoors
  9. 9. JUNI 10,FF 9Major cause of fires in theMajor cause of fires in thehomehome Carelessness with cigarettes!!Carelessness with cigarettes!! Hot water from water heaters set at high levelsHot water from water heaters set at high levelsabove 140 degrees F (60 degrees C)above 140 degrees F (60 degrees C) cooking accidentscooking accidents space heatersspace heaters combustibles - gasoline, lighter fluids, etc.combustibles - gasoline, lighter fluids, etc. chemicalschemicals
  10. 10. JUNI 10,FF 10Types of Burn InjuryTypes of Burn Injury Thermal burnsThermal burns-can be caused by flame,-can be caused by flame,flash, scald, or contact with hot objectsflash, scald, or contact with hot objects Chemical burnsChemical burns-are the result of tissue-are the result of tissueinjury and destruction from necrotizinginjury and destruction from necrotizingsubstances.substances. Electrical burns-Electrical burns-results from coagulationresults from coagulationnecrosis that is caused by intense heatnecrosis that is caused by intense heatfrom an electrical currentfrom an electrical current Smoke & inhalation injury-Smoke & inhalation injury- inhaling hotinhaling hotair or noxious chemicalsair or noxious chemicals Cold thermal injury-Cold thermal injury- frostbite.frostbite.
  11. 11. JUNI 10,FF 11Referral CriteriaReferral Criteria 22ndndor 3or 3rdrdDegree Burns >10% BSADegree Burns >10% BSA Burns to Face, Hands , Feet, Genitailia,Burns to Face, Hands , Feet, Genitailia,Perineum, or major Joints. ESPECIALYPerineum, or major Joints. ESPECIALYCIRCUMFRENTIAL BURNSCIRCUMFRENTIAL BURNS Electrical BurnsElectrical Burns Chemical BurnsChemical Burns Inhalation InjuryInhalation Injury
  12. 12. JUNI 10,FF 12Referral CriteriaReferral Criteria Burns with pre-existing PMHX that couldBurns with pre-existing PMHX that couldcomplicate recoverycomplicate recovery Concomitant trauma (If Major Trauma,Concomitant trauma (If Major Trauma,The Trauma Center , Not the Burn CenterThe Trauma Center , Not the Burn Centershould be the initial stabilizing unit)should be the initial stabilizing unit) When in doubt , consult with a burn centerWhen in doubt , consult with a burn center
  13. 13. JUNI 10,FF 13Thermal BurnsThermal Burns most common typemost common type result from residential fires, automobileresult from residential fires, automobileaccidents, playing with matches,accidents, playing with matches,improperly stored gasoline, space heaters,improperly stored gasoline, space heaters,electrical malfunctions, or arsonelectrical malfunctions, or arson inhaling smoke, steam, dry heat (fire), wetinhaling smoke, steam, dry heat (fire), wetheat (steam), radiation, sun, etc...heat (steam), radiation, sun, etc...
  14. 14. JUNI 10,FF 14Chemical BurnChemical Burn2 types of chemical burns2 types of chemical burns acids-acids-can be neutralizedcan be neutralized alkalinealkaline- adheres to tissue, causing- adheres to tissue, causingprotein hydrolyses andprotein hydrolyses andliquefactionliquefaction examples: cleaning agents, drain cleaners,examples: cleaning agents, drain cleaners,and lyes, etc...and lyes, etc...
  15. 15. JUNI 10,FF 15Chemical BurnChemical Burn Different typesDifferent typesof burnsof burns1 Outer skin layer1 Outer skin layer2 Middle skin layer2 Middle skin layer3 Deep skin layer3 Deep skin layer4 First degree burn4 First degree burn5 Second degree5 Second degreeburnburn6 Third degree6 Third degree
  16. 16. JUNI 10,FF 16Remember….Remember…. With chemical burns, tissue destructionWith chemical burns, tissue destructionmay continue for up to 72 hoursmay continue for up to 72 hoursafterwards.afterwards. It is important to remove the person fromIt is important to remove the person fromthe burning agent or vice versa.the burning agent or vice versa. The latter is accomplished by lavaging theThe latter is accomplished by lavaging theaffected area with copious amounts ofaffected area with copious amounts ofwater.water.
  17. 17. JUNI 10,FF 17Smoke and InhalationSmoke and InhalationInjuryInjury Can damage the tissues of the respiratoryCan damage the tissues of the respiratorytracttract Although damage to the respiratoryAlthough damage to the respiratorymucosa can occur, it seldom happensmucosa can occur, it seldom happensbecause the vocal cords and glottis closesbecause the vocal cords and glottis closesas a protective mechanisms.as a protective mechanisms.
  18. 18. JUNI 10,FF 183 types of smoke and3 types of smoke andinhalation injuriesinhalation injuries 1.1. Carbon monoxide poisoningCarbon monoxide poisoning (CO(COpoisoning and asphyxiation count forpoisoning and asphyxiation count formajority of deaths)majority of deaths) Treatment- 100% humidified oxygen-drawTreatment- 100% humidified oxygen-drawcarboxyhemoglobin level- can occur withoutcarboxyhemoglobin level- can occur withoutany burn injury to the skinany burn injury to the skin
  19. 19. JUNI 10,FF 19 2.2. Inhalation injury above theInhalation injury above theglottisglottis (caused by inhaling hot air,(caused by inhaling hot air,steam, or smoke.)steam, or smoke.) Mechanical obstruction can occur quickly-Mechanical obstruction can occur quickly-True ER! Watch for facial burns, signedTrue ER! Watch for facial burns, signednasal hair, hoarseness, painful swallowing,nasal hair, hoarseness, painful swallowing,and darkened oral or nasal membranesand darkened oral or nasal membranes
  20. 20. JUNI 10,FF 20 33. Inhalation injury below glottis. Inhalation injury below glottis (above glottis-injury is thermally produced)(above glottis-injury is thermally produced) below glottis-it is usually chemicallybelow glottis-it is usually chemicallyproduced.produced. Amount of damage related to length ofAmount of damage related to length ofexposure to smoke or toxic fumesexposure to smoke or toxic fumes Can appear 12-24 hours after burnCan appear 12-24 hours after burn
  21. 21. JUNI 10,FF 21ELECTRICAL BURNSELECTRICAL BURNS Injury from electricalInjury from electricalburns results fromburns results fromcoagulation necrosiscoagulation necrosisthat is caused bythat is caused byintense heatintense heatgenerated from angenerated from anelectric current.electric current.
  22. 22. JUNI 10,FF 22Electrical BurnsElectrical Burns Can cause tissue anoxia and deathCan cause tissue anoxia and death The severity depends on amount ofThe severity depends on amount ofvoltage, tissue resistance, currentvoltage, tissue resistance, currentpathways, and surface area in contact withpathways, and surface area in contact withthe current and length of time the currentthe current and length of time the currentflow was sustained.flow was sustained.
  23. 23. JUNI 10,FF 23Electrical injury canElectrical injury cancause:cause: Fractures of long bones and vertebraFractures of long bones and vertebra Cardiac arrest or arrhythmias--can beCardiac arrest or arrhythmias--can bedelayed 24-48 hours after injurydelayed 24-48 hours after injury Severe metabolic acidosis--can develop inSevere metabolic acidosis--can develop inminutesminutes Myoglobinuria--acute renal tubularMyoglobinuria--acute renal tubularnecrosis- myoglobin released from musclenecrosis- myoglobin released from muscletissue whenever massive muscle damagetissue whenever massive muscle damageoccurs--goes to kidneys--and canoccurs--goes to kidneys--and canmechanically block the renal tubules duemechanically block the renal tubules dueto the large size!to the large size!
  24. 24. JUNI 10,FF 24Electrical injury canElectrical injury cancause:cause: Fractures of long bones and vertebraFractures of long bones and vertebra Cardiac arrest or arrhythmias--can beCardiac arrest or arrhythmias--can bedelayed 24-48 hours after injurydelayed 24-48 hours after injury Severe metabolic acidosis--can develop inSevere metabolic acidosis--can develop inminutesminutes Myoglobinuria--acute renal tubularMyoglobinuria--acute renal tubularnecrosis- myoglobin released from musclenecrosis- myoglobin released from muscletissue whenever massive muscle damagetissue whenever massive muscle damageoccurs--goes to kidneys--and canoccurs--goes to kidneys--and canmechanically block the renal tubules duemechanically block the renal tubules dueto the large size!to the large size!
  25. 25. JUNI 10,FF 25Electrical injury canElectrical injury cancause:cause: Fractures of long bones and vertebraFractures of long bones and vertebra Cardiac arrest or arrhythmias--can beCardiac arrest or arrhythmias--can bedelayed 24-48 hours after injurydelayed 24-48 hours after injury Severe metabolic acidosis--can develop inSevere metabolic acidosis--can develop inminutesminutes Myoglobinuria--acute renal tubularMyoglobinuria--acute renal tubularnecrosis- myoglobin released from musclenecrosis- myoglobin released from muscletissue whenever massive muscle damagetissue whenever massive muscle damageoccurs--goes to kidneys--and canoccurs--goes to kidneys--and canmechanically block the renal tubules duemechanically block the renal tubules dueto the large size!to the large size!
  26. 26. JUNI 10,FF 26Treatment of electricalTreatment of electricalburns…burns… Fluids--Ringers lactate or other fluids-Fluids--Ringers lactate or other fluids-flushes out kidneys--you want 75-100flushes out kidneys--you want 75-100cc/hr until urine sample clearcc/hr until urine sample clear an osmotic diuretic (Mannitol) may bean osmotic diuretic (Mannitol) may begiven to maintain urine outputgiven to maintain urine output
  27. 27. JUNI 10,FF 27Cold Thermal InjuryCold Thermal Injury(Frostbite)(Frostbite) Can be localized such as frostbiteCan be localized such as frostbite systemic (hypothermia)systemic (hypothermia)
  28. 28. JUNI 10,FF 28Classification of BurnClassification of BurnInjuryInjury Treatment of burns is directly related toTreatment of burns is directly related tothe severity of injury!the severity of injury! Severity is determined by:Severity is determined by: depth of burndepth of burn external of burn calculated in percent of totalexternal of burn calculated in percent of totalbody surface (TBSA)body surface (TBSA) location of burnlocation of burn patient risk factorspatient risk factors
  29. 29. JUNI 10,FF 29
  30. 30. JUNI 10,FF 30DEPTH OF BURNSDEPTH OF BURNS Burn injury involves the destruction ofBurn injury involves the destruction ofthe integumentary system.the integumentary system. What is the function of theWhat is the function of theintegumentary system?integumentary system? ProtectiveProtective holds in fluids and electrolyesholds in fluids and electrolyes regulates heatregulates heat keeps harmful agents from injuring orkeeps harmful agents from injuring orinvading the bodyinvading the body
  31. 31. JUNI 10,FF 31Burns are defined by...Burns are defined by... Were defined by degrees in the past! First,Were defined by degrees in the past! First,second, and third degreesecond, and third degree 2 common guidelines now used are the:2 common guidelines now used are the: Lund-Browder ChartLund-Browder Chart Rule of NinesRule of Nines
  32. 32. JUNI 10,FF 32Rule of NinesRule of Nines In the adult, mostIn the adult, mostareas of the bodyareas of the bodycan be dividedcan be dividedroughly into portionsroughly into portionsof 9%, or multiples ofof 9%, or multiples of9. This division,9. This division,called the rule ofcalled the rule ofnines, is useful innines, is useful inestimating theestimating thepercentage of bodypercentage of bodysurface damage ansurface damage anindividual hasindividual has In small children,In small children,relatively more arearelatively more areais taken up by theis taken up by thehead and less byhead and less bythe lowerthe lowerextremities.extremities.Accordingly, theAccordingly, therule of nines isrule of nines ismodified. In eachmodified. In eachcase, the rule givescase, the rule givesa usefula usefulapproximation ofapproximation ofbody surface.body surface.
  33. 33. JUNI 10,FF 33Rules of NinesRules of Nines
  34. 34. JUNI 10,FF 34Location of BurnsLocation of Burns Has a direct relationship to the severity ofHas a direct relationship to the severity ofthe burn.the burn. Face, neck & chest burns may inhibitFace, neck & chest burns may inhibitrespiratory illness RT mechanicalrespiratory illness RT mechanicalobstruction secondary to edema or escharobstruction secondary to edema or escharformationformation
  35. 35. JUNI 10,FF 35Complicating or Co-MorbidComplicating or Co-MorbidFactorsFactors Associated TraumaAssociated Trauma Inhalation InjuriesInhalation Injuries Circumferential BurnsCircumferential Burns ElectricityElectricity Age (Young or Old)Age (Young or Old) Pre-Existing DiseasePre-Existing Disease AbuseAbuse
  36. 36. JUNI 10,FF 363 Phases of Burn3 Phases of BurnManagementManagementemergent (resuscitative)emergent (resuscitative)acuteacuterehabilitativerehabilitative
  37. 37. JUNI 10,FF 37Pre-hospital CarePre-hospital Care Remove from area! Stop the burn!Remove from area! Stop the burn! If thermal burn is large--If thermal burn is large--FOCUS onFOCUS onthe ABC’sthe ABC’s A=airway-A=airway-check for patency, soot aroundcheck for patency, soot aroundnares, or signed nasal hairnares, or signed nasal hair B=breathingB=breathing- check for adequacy of- check for adequacy ofventilationventilation C=circulation-C=circulation- check for presence andcheck for presence andregularity of pulsesregularity of pulses
  38. 38. JUNI 10,FF 38Other precautions...Other precautions... Burn too large--don’t immerse in waterBurn too large--don’t immerse in waterdue to extensive heat lossdue to extensive heat loss Never pack in iceNever pack in ice Pt. should be wrapped in dry cleanPt. should be wrapped in dry cleanmaterial to decrease contamination ofmaterial to decrease contamination ofwound and increase warmthwound and increase warmth
  39. 39. JUNI 10,FF 39Emergent PhaseEmergent Phase(Resuscitative Phase)(Resuscitative Phase) Lasts from onset to 5 or more days butLasts from onset to 5 or more days butusually lasts 24-48 hoursusually lasts 24-48 hours begins with fluid loss and edema formationbegins with fluid loss and edema formationand continues until fluid motorization andand continues until fluid motorization anddiuresis beginsdiuresis begins Greatest initial threat isGreatest initial threat ishypovolemic shock to a major burnhypovolemic shock to a major burnpatient!patient!
  40. 40. JUNI 10,FF 40Complications duringComplications duringemergent phase of burnemergent phase of burninjury are 3 major organinjury are 3 major organsystems...systems...CardiovascularCardiovascularRespiratoryRespiratoryRenal systemsRenal systems
  41. 41. JUNI 10,FF 41Cardiovascular SystemsCardiovascular Systems Arrhythmias, hypovolemic shock which mayArrhythmias, hypovolemic shock which maylead to irreversible shocklead to irreversible shock circulation to limbs can be impaired bycirculation to limbs can be impaired bycircumferential burns and then the edemacircumferential burns and then the edemaformationformation Causes: occluded blood supply thus causingCauses: occluded blood supply thus causingischemia, necrosis, and eventually gangrene.ischemia, necrosis, and eventually gangrene. Escharotomies (incisions through eschar) doneEscharotomies (incisions through eschar) doneto restore circulation to compromisedto restore circulation to compromisedextremities.extremities.
  42. 42. JUNI 10,FF 42Respiratory SystemRespiratory System Vulnerable to 2 types of injuryVulnerable to 2 types of injury 1.1. Upper airway burnsUpper airway burns that cause edemathat cause edemaformation & obstruction of the airwayformation & obstruction of the airway 2. Inhalation injury2. Inhalation injury can show up 24 hrs later-can show up 24 hrs later-watch for resp. distress such as increasedwatch for resp. distress such as increasedagitation or change in rate or character of resp.agitation or change in rate or character of resp. preexisting problem (ex. COPD) more prone to getpreexisting problem (ex. COPD) more prone to getresp. infectionresp. infection Pneumonia is common complication of major burnsPneumonia is common complication of major burns Is possible to overload with fluids--leading to pulmonaryIs possible to overload with fluids--leading to pulmonaryedemaedema
  43. 43. JUNI 10,FF 43Renal SystemRenal System Most common renal complication of burnsMost common renal complication of burnsin the emergent phase isin the emergent phase is ATN.ATN. BecauseBecauseof hypovolemic state, blood flowof hypovolemic state, blood flowdecreases, causing renal ischemia. If itdecreases, causing renal ischemia. If itcontinues, acute renal failure maycontinues, acute renal failure maydevelop.develop.
  44. 44. JUNI 10,FF 44Nursing management in theNursing management in theemergent phase is...emergent phase is... Airway managementAirway management-early nasotracheal or-early nasotracheal orendotracheal intubation before airway isendotracheal intubation before airway isactually compromised (usually 1-2 hours afteractually compromised (usually 1-2 hours afterburn)burn) ventilator? ABGs? Escharotomies?ventilator? ABGs? Escharotomies? 6-12 hours later-Bronchoscopy to assess lower6-12 hours later-Bronchoscopy to assess lowerresp. tactresp. tact high fowler’s position-cough & deep breathehigh fowler’s position-cough & deep breatheevery hour, turn q 1-2 hrs, chest physiotherapy,every hour, turn q 1-2 hrs, chest physiotherapy,suction prnsuction prn
  45. 45. JUNI 10,FF 45Fluid ShiftsFluid Shifts Massive fluid shifts out of blood vesselsMassive fluid shifts out of blood vesselsas a result of increased capillaryas a result of increased capillarypermeability. When capillary wallspermeability. When capillary wallsbecome more permeable, water,become more permeable, water,sodium, and later plasma protein (esp.sodium, and later plasma protein (esp.albumin) moves into interstitial spacesalbumin) moves into interstitial spaces& other tissues. The colloidal osmotic& other tissues. The colloidal osmoticpressure decreases with loss of proteinpressure decreases with loss of proteinfrom the vascular space. This calledfrom the vascular space. This calledsecond spacing.second spacing.
  46. 46. JUNI 10,FF 46Third SpacingThird Spacing Fluids goes into areas with no fluids andFluids goes into areas with no fluids andthis is called third spacing. Examples ofthis is called third spacing. Examples ofthird spacing are exudate and blisterthird spacing are exudate and blisterformation.formation. Net result is decreased volume, depletionNet result is decreased volume, depletiondue to fluid shifts = edema, decreaseddue to fluid shifts = edema, decreasedblood pressure, and increased pulseblood pressure, and increased pulse
  47. 47. JUNI 10,FF 47Hypovolemic ShockHypovolemic Shock Occurs when there is a loss ofOccurs when there is a loss ofintravascular fluid volume. The volume isintravascular fluid volume. The volume isinadequate to fill vascular space and isinadequate to fill vascular space and isunavailable for circulation.unavailable for circulation. Also, burns have a direct loss of fluid dueAlso, burns have a direct loss of fluid dueto evaporation.to evaporation.
  48. 48. JUNI 10,FF 48Inflammation & HealingInflammation & Healing Burn injuries casue coagulation necrosisBurn injuries casue coagulation necrosiswhereby tissues and vessels arewhereby tissues and vessels aredamaged or destroyeddamaged or destroyed Wound repair begins within the first 6-12Wound repair begins within the first 6-12hours after injury.hours after injury.
  49. 49. JUNI 10,FF 49Immunologic ChangesImmunologic Changes Are caused by burns.Are caused by burns. Skin barrier destroyed and all changesSkin barrier destroyed and all changesmake the burn patient more susceptible tomake the burn patient more susceptible toinfectioninfection Pt may be in shock from pain andPt may be in shock from pain andhypovolemia.hypovolemia.
  50. 50. JUNI 10,FF 50Other factors to consider...Other factors to consider... Full-thickness burns and deep partialFull-thickness burns and deep partialthickness burns are initially anestheticthickness burns are initially anestheticbecause nerve endings are destroyed.because nerve endings are destroyed. Superficial to moderate partial thicknessSuperficial to moderate partial thicknessburns are very painful.burns are very painful. Why?Why?
  51. 51. JUNI 10,FF 51Still more factors toStill more factors toconsider...consider... Severe dehydration is possible even thoughSevere dehydration is possible even thoughthe patient maybe edematous--the patient maybe edematous--Why?Why? May have an dynamic ileus RT body’sMay have an dynamic ileus RT body’sresponse to massive trauma and potassiumresponse to massive trauma and potassiumshiftsshifts--Why?--Why? Shivering due to chilling caused by heat loss,Shivering due to chilling caused by heat loss,anxiety, and painanxiety, and pain unable to recall events RT hypoxia associatedunable to recall events RT hypoxia associatedwith smoke inhalation, or head trauma orwith smoke inhalation, or head trauma oroverdose of sedatives or pain medsoverdose of sedatives or pain meds
  52. 52. JUNI 10,FF 52Fluid TherapyFluid Therapy 1 or 2 large bore IV replacement lines (may1 or 2 large bore IV replacement lines (mayneed jugular or subclavian)need jugular or subclavian) Cutdown rare RT increased risk of infection &Cutdown rare RT increased risk of infection &sepsissepsis Fluid replacement based on: size/depth of burn,Fluid replacement based on: size/depth of burn,age of pt., & individualized considerations--ex.age of pt., & individualized considerations--ex.Dehydration in preburn state, chronic illnessDehydration in preburn state, chronic illness options- RL, D5NS, dextam, albumin, etc.options- RL, D5NS, dextam, albumin, etc. there are formula’s for replacement: Parklandthere are formula’s for replacement: Parklandformula and Brooke formulaformula and Brooke formula
  53. 53. JUNI 10,FF 53Assessment of adequacyAssessment of adequacyof fluid replacementof fluid replacement Urinary output is most commonly usedUrinary output is most commonly usedparameterparameter urine OP-30-50 cc/hr in an adulturine OP-30-50 cc/hr in an adult cardiopulmonary factors- BP (systolic 90-100cardiopulmonary factors- BP (systolic 90-100mmHg, pulse less than 100, resp 16-20 breathsmmHg, pulse less than 100, resp 16-20 breathsper min. (BP more accurate with arterial line)per min. (BP more accurate with arterial line) sensoruim-alert, oriented to time, place, &sensoruim-alert, oriented to time, place, &personperson
  54. 54. JUNI 10,FF 54Wound Care for BurnsWound Care for Burns Can wait until patent airway, adequateCan wait until patent airway, adequatecirculation, fluid replacement is in place!circulation, fluid replacement is in place!
  55. 55. JUNI 10,FF 55Full-thickness burns areFull-thickness burns are Will be dry and waxy white to dark brownWill be dry and waxy white to dark brown will have little to no sensation becausewill have little to no sensation becausenerve endings have been destroyednerve endings have been destroyed
  56. 56. JUNI 10,FF 56Partial thickness burnsPartial thickness burns Are pink to cherry red, wet, shiny withAre pink to cherry red, wet, shiny withserous exudateserous exudate May or may not have intact blisters andMay or may not have intact blisters andare very painful when touched or exposedare very painful when touched or exposedto airto air
  57. 57. JUNI 10,FF 57Cleansing andCleansing andDebridementDebridement Can be done in tank, shower, or bedCan be done in tank, shower, or bed Debridement may be done in surgery.Debridement may be done in surgery.(Loose necrotic skin is removed)(Loose necrotic skin is removed) bath given with with surgical detergent,bath given with with surgical detergent,disinfectant, or cleansing agent to reducedisinfectant, or cleansing agent to reducepathogenic organismspathogenic organisms
  58. 58. JUNI 10,FF 58Infection is the mostInfection is the mostserious threat to furtherserious threat to furthertissue injury and possibletissue injury and possiblesepsis.sepsis. SURVIVAL is related to prevention ofSURVIVAL is related to prevention ofwound contamination.wound contamination. Source of infection is pt’s own flora,Source of infection is pt’s own flora,predominantly from the skin, resp. tract, andpredominantly from the skin, resp. tract, andGI tract.GI tract. Prevention of cross contamination from otherPrevention of cross contamination from otherpatients is the priority for nurses!patients is the priority for nurses!
  59. 59. JUNI 10,FF 592 methods used to control2 methods used to controlinfections in burninfections in burnwounds...wounds... Open methodOpen method- pt’s burn is covered wit- pt’s burn is covered witha topical antibiotic and has no dressingha topical antibiotic and has no dressing Closed method-Closed method-uses sterile gauzeuses sterile gauzeimpregnated with or laid over a topicalimpregnated with or laid over a topicalantibiotic. Dressings changed 2-3 times qantibiotic. Dressings changed 2-3 times q24 hrs.24 hrs.
  60. 60. JUNI 10,FF 60Wound Care continued...Wound Care continued... Staff should wear disposable hats, gowns,Staff should wear disposable hats, gowns,gloves, masks when wounds are exposedgloves, masks when wounds are exposed appropriate use of sterile vs. nonsterileappropriate use of sterile vs. nonsteriletechniquestechniques keep room warmkeep room warm careful handwashingcareful handwashing any bathing areas disinfected before andany bathing areas disinfected before andafter bathingafter bathing
  61. 61. JUNI 10,FF 61 Coverage is the primary goal for burnCoverage is the primary goal for burnwounds. Since usually not enoughwounds. Since usually not enoughunburned skin for immediate skinunburned skin for immediate skingrafting, other temporary wound closuregrafting, other temporary wound closuremethods are usedmethods are used Allograph or homograft (same speciesAllograph or homograft (same specieswhich is usually from cadavers) is used forwhich is usually from cadavers) is used forwound closure-- temporary--3 days to 2wound closure-- temporary--3 days to 2wkswks Porcine skin-heterograft or xenograftPorcine skin-heterograft or xenograft(different species)--temporary--3 days to 2(different species)--temporary--3 days to 2wkswks autograft or cultured epithelial autograft-autograft or cultured epithelial autograft-
  62. 62. JUNI 10,FF 62Surgeons use a dermatome (left) toSurgeons use a dermatome (left) toremove donor skin and a mesherremove donor skin and a mesher(right) to put holes in it.(right) to put holes in it.
  63. 63. JUNI 10,FF 63 Surgeons agree that no single product orSurgeons agree that no single product ortechnique is right for every burn situation.technique is right for every burn situation.And so far, theres no true replacement forAnd so far, theres no true replacement forhealthy, intact skin, which is the bodyshealthy, intact skin, which is the bodyslargest organ, and one of the most complex.largest organ, and one of the most complex.Its the first line of defense againstIts the first line of defense againstinfection and dehydration, but itsinfection and dehydration, but itsmore than just a physical barrier. Skinmore than just a physical barrier. Skinalso helps control temperature,also helps control temperature,through adjustments of blood flow andthrough adjustments of blood flow andevaporation of sweat. Its anevaporation of sweat. Its animportant sensory organ, too.important sensory organ, too.
  64. 64. JUNI 10,FF 64Other care measuresOther care measuresincludeinclude Face is vascular and subject to increasedFace is vascular and subject to increasededema- use open method if possible toedema- use open method if possible todecrease confusion and disorientationdecrease confusion and disorientation eye care-use saline rinses, artificial tearseye care-use saline rinses, artificial tears hands &arms-extended and elevated onhands &arms-extended and elevated onpillows or in slings to minimize edema,pillows or in slings to minimize edema,may need splints to keep them inmay need splints to keep them infunctional positionsfunctional positions
  65. 65. JUNI 10,FF 65 Ears- keep free of pressure. Ear burns-Ears- keep free of pressure. Ear burns-no pillows! Neck burns should not useno pillows! Neck burns should not usepillows in order to decrease woundpillows in order to decrease woundcontraction.contraction. Perineum-must be kept clean & dry.Perineum-must be kept clean & dry.Indwelling foley will help in this & also toIndwelling foley will help in this & also toprovide hourly outputs.provide hourly outputs. Lab tests prn to monitor electrolyteLab tests prn to monitor electrolyteimbalance and ABGsimbalance and ABGs Physical therapy stared immediatelyPhysical therapy stared immediately
  66. 66. JUNI 10,FF 66Drug TherapyDrug Therapy Analgesics and SedativesAnalgesics and Sedatives given for pt comfortgiven for pt comfort IV pain meds initialy due to:IV pain meds initialy due to: GI function is slowed or impaired because ofGI function is slowed or impaired because ofshock or paralytic ileusshock or paralytic ileus IM injections will not be absorbed wellIM injections will not be absorbed well
  67. 67. JUNI 10,FF 67Drug TherapyDrug Therapy Tetanus immunization-Tetanus immunization- given routinelygiven routinelyto all burn patients because of theto all burn patients because of thelikelihood of anaerobic burn-woundlikelihood of anaerobic burn-woundcontaminationcontamination Antimicrobial agents-Antimicrobial agents-usually topicalusually topicaldue to little or no blood supply to the burndue to little or no blood supply to the burneschar so little delivery of the antibiotic toeschar so little delivery of the antibiotic towoundwound Drug of choice is:Drug of choice is: Silver sulfadiazineSilver sulfadiazine
  68. 68. JUNI 10,FF 68Nutritional TherapyNutritional Therapy Fluid replacement takes priority overFluid replacement takes priority overnutritional needs in the initial emergentnutritional needs in the initial emergentphase.phase. Why?Why? NG tube is inserted and connected toNG tube is inserted and connected tolow intermittent suction forlow intermittent suction fordecompression. When bowel soundsdecompression. When bowel soundsreturn (48-72 hrs) after injury, start withreturn (48-72 hrs) after injury, start withclear liquids and progress up to a dietclear liquids and progress up to a diethigh in proteins and calorieshigh in proteins and calories
  69. 69. JUNI 10,FF 69 Burn patients need more calories & failureBurn patients need more calories & failureto provide will lead to delayed woundto provide will lead to delayed woundhealing and malnutrition.healing and malnutrition. Give calorie containing liquids instead ofGive calorie containing liquids instead ofwater due to need for calories andwater due to need for calories andpotential for water intoxicationpotential for water intoxication Enteral feedings into the duodenumEnteral feedings into the duodenum(recommended) can: reduce n&v, more(recommended) can: reduce n&v, morecontinuous feedings, and increase wdcontinuous feedings, and increase wdhealing!healing!
  70. 70. JUNI 10,FF 70Acute PhaseAcute Phase Begins with mobilization of extracellularBegins with mobilization of extracellularfluid and subsequent diuresis.fluid and subsequent diuresis. Is concluded when the burned area isIs concluded when the burned area iscompletely covered or when woundscompletely covered or when woundsare healed. May take weeks or months.are healed. May take weeks or months. Pt is no longer grossly edematous duePt is no longer grossly edematous dueto fluid mobilization, full & partialto fluid mobilization, full & partialthickness burns more evident, bowelthickness burns more evident, bowelsounds return, pt more aware of painsounds return, pt more aware of painand condition.and condition.
  71. 71. JUNI 10,FF 71 Healing begins when WBCs haveHealing begins when WBCs havesurrounded the burn and phagocytosissurrounded the burn and phagocytosisbegins, necrotic tissue begins to slough,begins, necrotic tissue begins to slough,fibroblasts lay down matrices offibroblasts lay down matrices ofcollagen precursors to form granulationcollagen precursors to form granulationtissue.tissue. Partial-thickness burns (if kept free fromPartial-thickness burns (if kept free frominfections) will heal from edges andinfections) will heal from edges andfrom below. (10-14 days)from below. (10-14 days) Full-thickness burns must be coveredFull-thickness burns must be coveredby skin grafts.by skin grafts.
  72. 72. JUNI 10,FF 72Laboratory ValuesLaboratory Values Sodium-Sodium- Hyponatremia can occur due to:Hyponatremia can occur due to:silver nitrate topical oints as a result of sodiumsilver nitrate topical oints as a result of sodiumloss through eshcar, hydrotherapy, excessiveloss through eshcar, hydrotherapy, excessiveGI drainage, diarrhea, excessive water intakeGI drainage, diarrhea, excessive water intake S/S of hyponatremia: weakness, dizziness,S/S of hyponatremia: weakness, dizziness,muscle cramps, fatigue, HA, tachycardia, &muscle cramps, fatigue, HA, tachycardia, &confusionconfusion Hypernatremia can occur: too muchHypernatremia can occur: too muchhypertonic fluids, improper tube feedings,hypertonic fluids, improper tube feedings,inappropriate fluid administrationinappropriate fluid administration S/S of hypernatremia: thirst; dried furry tongue;S/S of hypernatremia: thirst; dried furry tongue;lethargy; confusion; and possible seizureslethargy; confusion; and possible seizures
  73. 73. JUNI 10,FF 73 Potassium-Potassium- hyperkalemia is note if pt is inhyperkalemia is note if pt is inrenal failure, adrenocortical insufficiency, orrenal failure, adrenocortical insufficiency, ormassive deep muscle injury with lg. amts.massive deep muscle injury with lg. amts.of potassium released from damaged cells.of potassium released from damaged cells.Cardiac arrhythmias and ventricular failureCardiac arrhythmias and ventricular failurecan occur if K+ level greater >7mEq/L.can occur if K+ level greater >7mEq/L.muscle weakness & EKG changes aremuscle weakness & EKG changes arenoted.noted. Hypokalemia is noted with silver nitrate therapyHypokalemia is noted with silver nitrate therapyand long hydrotherapy. Other causes:and long hydrotherapy. Other causes:vomiting, diarrhea, prolonged GI suction,vomiting, diarrhea, prolonged GI suction,prolonged IV therapy without K+prolonged IV therapy without K+supplementation. Constant K+ losses occursupplementation. Constant K+ losses occur
  74. 74. JUNI 10,FF 74Complications of AcuteComplications of AcutePhasePhase Infection-Infection- due to destruction of body’s 1stdue to destruction of body’s 1stline of defense. Partial thickness wds canline of defense. Partial thickness wds canconvert to full-thickness wds with infectionconvert to full-thickness wds with infectionpresent. Pt may get sepsis from woundpresent. Pt may get sepsis from woundinfections. Signs of sepsis are: high temp.,infections. Signs of sepsis are: high temp.,increased pulse & resp., decreased BP, andincreased pulse & resp., decreased BP, anddecreased urinary output, mild confusion,decreased urinary output, mild confusion,chills, malaise, and loss of appetite. WBC bet.chills, malaise, and loss of appetite. WBC bet.10,000 and 20,000. Infections usually gram10,000 and 20,000. Infections usually gramneg. bacteria (pseudomonas, proteus)neg. bacteria (pseudomonas, proteus) Obtain cultures from all possible sources: IV,Obtain cultures from all possible sources: IV,foley, wound, oropharynx, and sputumfoley, wound, oropharynx, and sputum
  75. 75. JUNI 10,FF 75 Cardiovascular-Cardiovascular- same as in emergentsame as in emergentphasephase Neurologic-Neurologic-possible from electrical injuriespossible from electrical injuries Musculoskeletal-Musculoskeletal- has the most potentialhas the most potentialfor complications during acute phase due tofor complications during acute phase due tohealing and scar formation making skin lesshealing and scar formation making skin lesssupple and pliant. ROM limited, contracturessupple and pliant. ROM limited, contracturescan occurcan occur Gastrointestinal-Gastrointestinal-adynamic ileus resultsadynamic ileus resultsfrom sepsis, diarrhea or constipation (RTfrom sepsis, diarrhea or constipation (RTnarcotics & decreased mobility), gastricnarcotics & decreased mobility), gastriculcers RT stress, occult blood in stoolsulcers RT stress, occult blood in stools
  76. 76. JUNI 10,FF 76Nursing management-acuteNursing management-acutephasephase Predominant therapeuticPredominant therapeuticinterventions are:interventions are: fluid replacement, physical therapy, wd care,fluid replacement, physical therapy, wd care,early excision and grafting, and painearly excision and grafting, and painmanagementmanagement Fluid replacementFluid replacement continues fromcontinues fromemergent phase to acute phases--emergent phase to acute phases--givengivenfor:for: fluid losses, administer medications,fluid losses, administer medications,& for transfusions.& for transfusions. Physical therapy-Physical therapy- to maintain optimalto maintain optimaljoint functionjoint function Pain management-Pain management- most criticalmost critical
  77. 77. JUNI 10,FF 77 Wound Care-Wound Care- the goals are cleanse andthe goals are cleanse anddebride the area of necrotic tissue &debris,debride the area of necrotic tissue &debris,minimize further damage to viable skin,minimize further damage to viable skin,promote patient comfort, & reepithelializationpromote patient comfort, & reepithelializationor success with skin grafting.or success with skin grafting. Care for donor site and other graftsCare for donor site and other graftsnecessarynecessary Excision and grafting-Excision and grafting- eschar removed toeschar removed tosubcutaneous tissue or fascia, graft appliedsubcutaneous tissue or fascia, graft appliedto tissueto tissue Cultured epithelial autograft (CEA)uses patient’sCultured epithelial autograft (CEA)uses patient’sown cells to grow skin-permanentown cells to grow skin-permanent artificial skin is the latest trend. Examples:artificial skin is the latest trend. Examples:
  78. 78. JUNI 10,FF 78Rehabilitation PhaseRehabilitation Phase Defined as beginning when the patient’s burnDefined as beginning when the patient’s burnwound is covered with skin or healed andwound is covered with skin or healed andpatient is capable of assuming some self-patient is capable of assuming some self-care activity.care activity. Can occur as early as 2 weeks to as long asCan occur as early as 2 weeks to as long as2-3 months after the burn injury2-3 months after the burn injury Goals for this time is to assist patient inGoals for this time is to assist patient inresuming functional role in society &resuming functional role in society &accomplish functional and cosmeticaccomplish functional and cosmeticreconstruction.reconstruction.
  79. 79. JUNI 10,FF 79Clinical ManifestationsClinical Manifestations Burn wd either heals by primary intentionBurn wd either heals by primary intentionor by grafting.or by grafting. Scars may form & contractures.Scars may form & contractures. Mature healing is reached in 6 months toMature healing is reached in 6 months to2 years2 years Avoid direct sunlight for 1 year on burnAvoid direct sunlight for 1 year on burn new skin sensitive to traumanew skin sensitive to trauma
  80. 80. JUNI 10,FF 80ComplicationsComplications Most common complications of burn injuryMost common complications of burn injuryare skin and joint contractures andare skin and joint contractures andhypertrophic scarringhypertrophic scarring Because of pain, pts will assume flexedBecause of pain, pts will assume flexedposition. It predisposes wds to contractureposition. It predisposes wds to contractureformationformation Use of physical therapy, pressureUse of physical therapy, pressuregarments, splints, etc. are usedgarments, splints, etc. are used
  81. 81. JUNI 10,FF 81Nursing managementNursing managementduring rehabilitation phaseduring rehabilitation phase Must be directed to returning patient toMust be directed to returning patient tosociety, address emotional concerns,society, address emotional concerns,spiritual and cultural needs, self-esteem,spiritual and cultural needs, self-esteem,teaching of wound care management,teaching of wound care management,nutrition, role of exercises and physicalnutrition, role of exercises and physicaltherapy explained. A common emotionaltherapy explained. A common emotionalresponse seen isresponse seen is regression.regression.
  82. 82. JUNI 10,FF 82Special needs of the nursingSpecial needs of the nursingstaffstaff The staff of burn units are prone to higherThe staff of burn units are prone to higherrates of burn-out. The care of a burnrates of burn-out. The care of a burnpatient is a long journey that the patient,patient is a long journey that the patient,nurse, and significant others must travel.nurse, and significant others must travel.The road to recovery is full of potentialThe road to recovery is full of potentialthreats to the patient. Support services arethreats to the patient. Support services arenecessary for the medical team of anynecessary for the medical team of anylong-term burn patients.long-term burn patients.
  83. 83. JUNI 10,FF 83Care ofCare of BB UU RR NN SSB -B - breathingbreathingbody imagebody imageUU - urine output- urine outputRR - rule of nines- rule of ninesresuscitation of fluidresuscitation of fluidN -N - nutritionnutritionSS - shock- shocksilvadenesilvadene
  84. 84. JUNI 10,FF 84B- Breathing-B- Breathing- keep airwaykeep airwayopen. Facial burns, singedopen. Facial burns, singednasal hair, hoarseness, sootynasal hair, hoarseness, sootysputum, bloody sputum andsputum, bloody sputum andlabored respiration indicatelabored respiration indicateTROUBLETROUBLE!!Body Image-Body Image- assist Bernie inassist Bernie incoping by encouragingcoping by encouragingexpression of thoughts andexpression of thoughts andfeelings.feelings.
  85. 85. JUNI 10,FF 85U- URINE OUTPUT-U- URINE OUTPUT- in anin anadult, urine output should beadult, urine output should be30-70 cc per hour, in the child30-70 cc per hour, in the child20-50 cc per hour, and in the20-50 cc per hour, and in theinfant, 10-20 cc per hour.infant, 10-20 cc per hour.Watch the K+ to keep itWatch the K+ to keep itbetween 3.5-5.0 mEq/L. Keepbetween 3.5-5.0 mEq/L. Keepthe CVP around 12 cm waterthe CVP around 12 cm waterpressure!pressure!
  86. 86. JUNI 10,FF 86R- RESUSCITATION OF FLUID-R- RESUSCITATION OF FLUID-Salt & electrolyte solutions are essentialSalt & electrolyte solutions are essentialover the 1over the 1stst24 hours. Maintain B/P at24 hours. Maintain B/P at90-100 systolic. ½ of the fluid for the90-100 systolic. ½ of the fluid for thefirst 24 hrs should be administered overfirst 24 hrs should be administered overthe first 8 hour period, then thethe first 8 hour period, then theremainder is administered over the nextremainder is administered over the next16 hours. First 24 hour calculation starts16 hours. First 24 hour calculation startsat the time of injury.at the time of injury.RULE OF NINE’S-RULE OF NINE’S- used for adults toused for adults todetermine burn surface area!determine burn surface area!
  87. 87. JUNI 10,FF 87N-NUTRITION-N-NUTRITION- protein &protein &calories are components ofcalories are components ofthe diet! Supplemental gastricthe diet! Supplemental gastrictube feedings ortube feedings orhyperalimentation may behyperalimentation may beused in pts with large burnedused in pts with large burnedareas. Daily weights will assistareas. Daily weights will assistin evaluating the nutritionalin evaluating the nutritionalneeds!needs!
  88. 88. JUNI 10,FF 88S-SHOCK-S-SHOCK- Watch the B/P, CVP,Watch the B/P, CVP,and renal function.and renal function.Silvadene-Silvadene-for infection.for infection.REMEMBER THESE PEOPLEREMEMBER THESE PEOPLEARE AFRAID AND NEEDARE AFRAID AND NEEDSUPPORT!!!!!SUPPORT!!!!!
  89. 89. JUNI 10,FF 89 Burn Wound InfectionBurn Wound Infection An ability to make the diagnosis of burn wound infection is important. A clinicallyAn ability to make the diagnosis of burn wound infection is important. A clinicallyfocused set of burn wound infection definitions has recently been published and isfocused set of burn wound infection definitions has recently been published and issummarized as follows:summarized as follows: Burn impetigoBurn impetigo Diagnostic points - Loss of epithelium from previously epithelialized surface; not related toDiagnostic points - Loss of epithelium from previously epithelialized surface; not related tolocal traumalocal trauma Treatment strategies - Regular cleaning of debris and exudate; topical antistaphylococcalTreatment strategies - Regular cleaning of debris and exudate; topical antistaphylococcalantibiotics; grafting of chronically unstable areas of epitheliumantibiotics; grafting of chronically unstable areas of epithelium Burn-related surgical wound infectionBurn-related surgical wound infection Diagnostic points - Infection in surgically created would that has not yet epithelialized;Diagnostic points - Infection in surgically created would that has not yet epithelialized;includes loss of any overlying graft or membraneincludes loss of any overlying graft or membrane Treatment strategies - Regular cleaning of debris and exudate; systemic and topicalTreatment strategies - Regular cleaning of debris and exudate; systemic and topicalantistaphylococcal antibiotics; grafting of chronically unstable areas of epitheliumantistaphylococcal antibiotics; grafting of chronically unstable areas of epithelium Burn wound cellulitisBurn wound cellulitis Diagnostic points - Infection occurs in uninjured skin surrounding a wound; signs of localDiagnostic points - Infection occurs in uninjured skin surrounding a wound; signs of localinfection progress beyond what is expected from burn-related inflammationinfection progress beyond what is expected from burn-related inflammation Treatment strategies - Systemic antibiotics directed againstTreatment strategies - Systemic antibiotics directed against Streptococcus pyogenes;Streptococcus pyogenes; properpropertreatment of primary woundtreatment of primary wound Invasive burn wound infectionInvasive burn wound infection Diagnostic points - Infection occurs in unexcised burn and invades viable underlying tissue;Diagnostic points - Infection occurs in unexcised burn and invades viable underlying tissue;diagnosis may be supported by results from histologic examination or quantitative culturediagnosis may be supported by results from histologic examination or quantitative culture Treatment strategies - Systemic antibiotics directed against presumed pathogen; woundTreatment strategies - Systemic antibiotics directed against presumed pathogen; woundexcision, with biologic closure when possibleexcision, with biologic closure when possible
  90. 90. JUNI 10,FF 90 Outpatient wound care strategiesOutpatient wound care strategies Components of outpatient burn care include theComponents of outpatient burn care include thefollowing:following: Patient and family educationPatient and family education Wound cleansingWound cleansing Choice of topical or membrane dressingChoice of topical or membrane dressing Pain controlPain control Early return instructionsEarly return instructions Follow-up clinic visitsFollow-up clinic visits Long-term follow-up careLong-term follow-up care
  91. 91. JUNI 10,FF 91 s:s: First-degree burns are usually red, dry, and painful. Burns initiallyFirst-degree burns are usually red, dry, and painful. Burns initiallytermed first-degree are often actually superficial second-degreetermed first-degree are often actually superficial second-degreeburns, with sloughing occurring the next day.burns, with sloughing occurring the next day. Second-degree burns are often red, wet, and very painful. TheirSecond-degree burns are often red, wet, and very painful. Theirdepth, ability to heal, and propensity to form hypertrophic scars (seedepth, ability to heal, and propensity to form hypertrophic scars (seeMedia file 2Media file 2) vary enormously.) vary enormously. Third-degree burns are generally leathery in consistency, dry,Third-degree burns are generally leathery in consistency, dry,insensate, and waxy. These wounds will not heal, except byinsensate, and waxy. These wounds will not heal, except bycontraction and limited epithelial migration, with resultingcontraction and limited epithelial migration, with resultinghypertrophic and unstable cover (seehypertrophic and unstable cover (see Media file 3Media file 3). Burn blisters (see). Burn blisters (seeMedia file 4Media file 4) can overlie both second- and third-degree burns. The) can overlie both second- and third-degree burns. Themanagement of burn blisters remains controversial, yet intact blistersmanagement of burn blisters remains controversial, yet intact blistershelp greatly with pain control. Debride blisters if infection occurs.help greatly with pain control. Debride blisters if infection occurs. Fourth-degree burns involve underlying subcutaneous tissue,Fourth-degree burns involve underlying subcutaneous tissue,tendon, or bone. Usually, even an experienced examiner hastendon, or bone. Usually, even an experienced examiner hasdifficulty accurately determining burn depth during early examination.difficulty accurately determining burn depth during early examination.As a general rule, burn depth is underestimated upon initialAs a general rule, burn depth is underestimated upon initialexamination.examination.
  92. 92. JUNI 10,FF 92 Wound dressing, whether one is usingWound dressing, whether one is usingtopical medication or a wound membrane,topical medication or a wound membrane,should provide 4 benefits, includingshould provide 4 benefits, including(1) prevention of wound(1) prevention of wounddesiccation, (2) control of pain,desiccation, (2) control of pain,(3) reduction of(3) reduction ofwound colonization and infection, andwound colonization and infection, and(4) prevention of(4) prevention ofadded trauma to the woundadded trauma to the wound
  93. 93. JUNI 10,FF 93 Elaborate specific conditions mayElaborate specific conditions maymandate an early return to the hospital.mandate an early return to the hospital.Particularly important areParticularly important are(1) pain and anxiety(1) pain and anxietyassociated with wound care to the degreeassociated with wound care to the degreethat wound care is compromised,that wound care is compromised,(2) signs of(2) signs ofinfection, or (3) ainfection, or (3) awound that appears deeper thanwound that appears deeper thanappreciated during the initial examination.appreciated during the initial examination.Review wound care instructions withReview wound care instructions withcaregivers.caregivers.
  94. 94. JUNI 10,FF 94

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