EMERGENCY ON Integumentary systemWOUNDS OF FUEL
A. Basic Concepts of Disease Burns1. Understanding Burn Injurya) the burn is an injury caused by heat, electricity, chemicals and lightning of the skin, mucosa and deeper tissues (Irna Dr.Soetomo Surgical Hospital, 2001).b) Burns (combustio / burn) is injured / injury as a result of direct contact or exposure to sources of heat (thermal), electricity (elektrick), chemicals (chemycal) or radiation (radiation).2. Etiology Burnsa) Thermal burns, exposure to or contact with flame or heat liquids other hot objects.b) Chemical burns, skin tissue contact with strong acids or basesc) electrically burns, heat from electrical energy is delivered through the bodyd) radiation burns, exposure to radioactive sources,3. Phase Burnsa) Acute phaseReferred to as the initial phase or phases of shock. In the initial phase the patient will experience disturbances airway (airway), brething (breathing mechanism), and circulation (circulation). Gnagguan airway not only can occur immediately or shortly after the fire, but can still occur due to obstruction of the respiratory tract inhalation injury within 48-72 hours post trauma. Inhalation injury is the leading cause of death in the phase akut.Pada penderiat acute phase of frequent disturbances of fluid and electrolyte balance due to the systemic effect of thermal injury.
b) Sub Acute PhaseTakes place after the shock phase is resolved. The problem that occurs is the result of tissue damage or loss of premises contact heat source. Injuries that occur cause:1) The process of inflammation and infection.2) Problempenuutpan wound with a focal point on the wound dressed or naked and extensive epithelial or on the structure or organ - a functional organ.3) The state of hypermetabolism.c) Advanced PhaseAdvanced phase will last until the wounds scar maturation and functional recovery of functional organs. Problems that arise in this phase is a complication of hypertrophic scar, kleoid, pigmentation disorders, deformities and contractures.4. Classification of burnsa. Depth of burns1) overall degree I (Superficial)Ø Only the epidermal layerØ mild erythema to redØ Skin blanch when pressedØ There is no blisterØ Skin warm / dryØ Pain / hiperetheticØ Pain is reduced by coolingØ Discomfort lasted some 48 hoursØ Can heal spontaneously in 3-7 days2) Grade II (Partial Tickhness)Ø Regarding the epidermis and dermisØ wound looks red to pinkØ Formed blisterØ EdemaØ PainØ Sensitive trehadap cold air3) Grade III (Full Tickhness)Ø Regarding all layers of the skin, subcutaneous Lemka, the surface of the muscle, neurological, vascularØ Color varies wound white, red brown and blackØ Without blisterØ wound surface dry / hardØ EdemaØ A little pain or without painØ Healing old woundsØ Need skingraftØ Can hypertrophic scars and contractures occur if not done preventiv4) Degree of IVRegarding all lapiasan skin, muscle, boneb. Broad Burns1) Rule Of NineØ Recognized since 1940,Ø The body is divided into anatomical partsØ Each section represents a 9% 1% except the genital area2) Lund and BrowderModification of the presentation of body parts by age3) Hand PalmØ Determine LB wide with palmsØ One hand represents 1% of the body surface burns yangamengalami.c. Severity of burnsAccording to the American College of Surgeon split in:1) severe burnsØ 20% in adultsØ 25% on aanak with age less than 10 yearsØ 20% in adults over 40 yearsØ wounds on the face, ears, eyes, arms, feet, and perineum resulting in functional or cosmetic disorders or cause disabiliti.Ø LB because of the high voltage powerØ All accompanied LB with inhalation injury or severe TRUMA.2) moderate burnsØ 15-25% of the adultØ 10-20% in children aged less than 10 yearsØ 10-20% in adults aged over 40 years3) Minor burnsThere is no risk of cosmetic and functional disorders / disabiliti5. Managementa Phase emergent (Resuscitation)Emergency phase begins at the time of injury and ends with the improvement in capillary permeability, which usually occurs at 48-72 hours after injury. The main objective during the recovery phase is to prevent hypovolemic shock and preserve the function of vital organs.1) treatment before hospitalization (Pre hospital care)Treatment before the client was taken to the hospital beginning on the scene when it burns and ends up in the emergency care facility. Pre-hospital care begins with moving / prevent client from the source or cause of LB and eliminate the source of heata) Keep away from sources of patient burnsØ Turn off your clothes catch fireØ Eliminate chemicals cause LBØ Flush with lots of water because the chemicals whenØ Turn off the power or remove the power source by using a dry object and does not conduct current (nonconductive).
b) Assess ABCØ Note the airway (airway)Ø Ensure breathing (breathibg) adekwatØ Assess circulationc) Assess other trauma.d) Maintain body heat.e) note the need for intravenous fluids.f) Immediately send to the hospital.2) Handling emergency sectionCare in the emergency is a continuation of the actions that have been given at the time of the incident. If the assessment and treatment performed or inadequate, then the pre-hospital care given in the emergency. Handling wound (debridement and dressing) is not preferred when there are other problems that threaten the life of the client, then this is a problem that should be prioritized.a) penaganan minor burnsCare clients with mild LB often given to outpatients. In making the decision whether or not the client is ready to go home with, among others Noting 1) the ability of the client to be able to run or to follow instructions, the instructions and the ability to perform self-care (self-care), 2) the home environment. If the client is able to follow instructions and self-care and home environment supports the recovery of the client can be discharged.Care in the emergency against minor burns include: menagemen pain, tetanus prophylaxis, early stages of wound care and health education.(1) Management of painPain management is often done with a light dose of morphine or meperidine emergency section. While oral analgesics are given to be used by outpatients.
(2) Prophylaxis of tetanusInstructions for tetanus prophylaxis was similar in patients with LB both light and other types of injury. On clients who had received tetanus immunization but not in the last 5 years may be given tetanus toxoid booster. For clients who are not immunized with human tetanus immune globulin and tetanus toxoid should therefore be given the first of a series of active immunization with tetanus toxoid.(3) Treatment of early woundLB treatment for minor injuries consisting of wound cleaning (cleansing) is debridement of dead tissue; dispose of substances that damage (chemicals, tar, etc.), and the provision / use of topical antimicrobial cream or ointment and a sterile bandage. In addition, nurses are responsible for providing education on wound care in home and clinical manifestations of infection so that the client can seek help. Another education is needed about the importance of exercise ROM (range of motion) actively to maintain joint function to remain normal and to reduce the possibility of the formation of edema and scar formation. And the need for follow-up evaluation or treatment must also be discussed with the client at the time.b) Handling of severe burnsFor clients with extensive injuries, the handling of the emergency will include a reevaluation of the ABC (airway, breathing conditions, circulation) and other trauma that may occur; resuscitation fluid (replacement of lost fluids); urinary catheter; installation of a nasogastric tube (NGT ); vital signs and laboratory examination; pain management; tetanus prophylaxis; collection of data, and wound care.(1) Reevaluation of the airway, respiratory conditions, circulatory and other trauma that may occur.Reassess the state of the airway, respiratory conditions, and ensures circulation of more fatherly presence or absence of gravity and to ensure early treatment. Besides assessing the presence or absence of other trauma that accompanies the burn injuries such as broken bones, bleeding and others need to be done in order to be recognized and dealt with immediately.(2) fluid resuscitationFor adult clients with burns over 15%, it is generally required intravenous fluid resuscitation. Peripheral intravenous administration can be administered through the skin that does not burn in the proximal part of the burned limb. As for the clients who suffered extensive burns enough or in which the client places for peripheral intravenous administration is limited, then the installation of a cannula (cannulation) in the central vein (such as the subclavian, internal or external jugular, or femoral) by a physician may be required.B. Nursing Burn1 Assessmenta. Activity and restSigns: Decrease in strength, resistance; limited range of motion in the affected area; disorders of muscle mass, tone changes.b. CirculationSign (with burn injury over 20% APTT): hypotension (shock); decreased peripheral pulse distal extremity injuries; common peripheral vasoconstriction with loss of pulse, and cool white (electric shock); tachycardia (shock / anxiety / pain ); dysrhythmias (electric shock); formation of tissue edema (all burns).c. Ego integritySymptoms: issues about family, work, finances, disability.Signs: anxiety, crying, dependence, deny, withdraw, rage.d. EliminationSigns: decreased urine output / not present during the emergency phase; dark reddish color may occur when myoglobin, indicating muscle damage in; diuresis (after capillary leak and fluid mobilization into circulation); decreased bowel sounds / no; particularly in cutaneous burns greater than 20% as the stress decreased motility / gastric peristalsis.e. Food / fluidSigns: edema public network; anorexia; nausea / vomiting.f. NeurosensoriSymptoms: border area; tingling.Signs: changes in orientation; affective, behavioral, reduction of deep tendon reflexes (RTD) on the injured limb; seizure activity (electric shock); corneal laceration; retinal damage; decrease in visual acuity (electric shock); timpanik membrane rupture (electric shock); paralysis (electrical injury to the nerve flow).g. Pain / comfortSymptoms: Various pain; example first-degree burns are eksteren sensitive to touch; pressed; air movement and temperature changes; thickness burns are very painful second degree; smentara response on the second-degree burns thickness depends on the integrity of the nerve endings; degree burns three no pain.h. BreathingSymptoms: locked in a confined space; prolonged exposure (inhalation injury possible).Symptoms: hoarseness; cough mengii; carbon particles in the sputum; inability to swallow oral secretions and cyanosis; indication of inhalation injury. Development of the piston may be limited to the chest circumference burns; airway or stridor / mengii (obstruction in connection with laringospasme, laryngeal edema); breath sounds: the rush (pulmonary edema), stridor (laryngeal edema); secretions in the airway (ronkhi).i. SecuritySymptoms: Common Skin: deep tissue destruction may not be evident for 3-5 days in connection with the process of microvascular trobus on some cuts. Unburned areas of the skin may be cool / moist, pale, with slow capillary refill in a decrease in cardiac output in relation to fluid loss / shock status. Injury fire: there are areas of injury in sehubunagn mixed with the intensity of the heat generated variase clot on fire. Singed nose hairs; nasal mucosa and dry mouth; red; blisters on the posterior pharynx; edema girth or circumference of the mouth and nasal. Chemical injuries: the wound appears varies according causative agent. Skin may fawn with subtle leather texture bleak; blisters; ulcers; necrosis, or scar jarinagn thick. Injuries are mum of ore in the percutaneous and seemingly tissue damage may continue for up to 72 hours after injury. Electrical injury: external cutaneous injury is usually less under necrosis. Appearance can vary injuries include cuts flow entry / exit (explosive), burns of movement flow in the proximal body covered and thermal burns in relation to burn clothing. Fracture / dislocation (fall, motorcycle accident, tetanik muscle contraction with respect to electric shock).2 Nursing DiagnosisMarilynn E. Doenges in Nursing care plans, guidelines for planning and documenting patient care suggests some nursing diagnoses as follows:a. High risk of ineffective airway clearance related to obtruksi trakeabronkial; mucosal edema and loss of cilia work. Burns neck area; compression of the airway.b. High risk of fluid volume deficits associated with loss of fluid through the abnormal. Increased needs: hypermetabolik status, insufficient income. Loss of bleeding.c. Risk of damage to gas exchange associated with smoke inhalation injury or thoracic compartment syndrome secondary to burns sirkumfisial of the chest or neck.d. High risk of infection related to inadequate primary defense; perlinduingan skin damage; traumatic tissue. Inadequate secondary defenses; decrease in Hb, suppression of inflammatory responses.
3 Nursing Interventionsa. Risk of ineffective airway clearance related to obstruction trakheobronkhial; mucosal edema; compression of the airway.Purpose:Remain effective airway clearanceEvaluation Criteria:Vesicular breath sounds, RR within normal limits, free dispnoe / cyanosis.Intervention1) Assess the reflex disturbance / swallowing; notice drainage of saliva, inability to swallow, hoarseness, coughing, wheezingRational:InhalasiTakipnea alleged injury, use of accessory muscles, cyanosis and changes occur sputum showed respiratory distress / pulmonary edema and the need for medical intervention.2) Keep an eye on the frequency, rhythm, depth of breathing; noticed the pale / cyanotic and sputum containing carbon or pink.Rational:Obstruction of the airway / respiratory distress can occur very quickly or slow sample until 48 hours after the burn.3) Auscultation of the lungs, notice stridor, wheezing / gurgling, decreased breath sounds, whooping cough.Rational:Allegations of hypoxemia or carbon monoxide.b. High risk of fluid volume deficits associated with loss of fluid through the abnormal.Purpose:Patients may demonstrate improved fluid status and biochemistry.Evaluation Criteria:There was no manifestation of dehydration, edema resolution, serum electrolytes within normal limits, urine output above 30 ml / hour.Intervention:1) Keep an eye on vital signs, CVP. Note the strength of capillaries and peripheral arteries. Keep an eye on spending and urine specific gravity.Rational:Provide guidelines for fluid replacement and assess cardiovascular response.2) Observation and hemates urine color as indicated.Rational:Fluid replacement titrated to convince average 30-50 of urine 2 cc / hour in adults. Urine red on massive muscle damage due adanyadarah and release myoglobin.3) Estimate the wound drainage and loss are visible.Rational:Increased capillary permeability, displacement protein, inflammation and fluid loss through evaporation affects circulation and volume of urine.c. Risk of damage to gas exchange associated with smoke inhalation injury or thoracic compartment syndrome secondary to burns sirkumfisial of the chest or neck.Purpose:Patients can demonstrate adequate oxygenation.Evaluation Criteria:RR 12-24 x / min, normal skin color, GDA in renatng normal, breath sounds clean, no trouble breathing.Intervention:1) Monitor and report GDA serum levels of carbon monoxide.Rational:Progress and identify deviations from expected results. Smoke inhalation can damage the alveoli, affects gas exchange at the alveolar capillary membrane.2) Install or help with an endotracheal tube and temaptkan patients on mechanical ventilators to order in case of respiratory insufficiency (as evidenced by hypoxia, hypercapnia, rales, tachypnea and change sensorium).Rational:Supplemental oxygen increases the amount of oxygen available to the network. Required mechanical ventilation for respiratory support until pasie can be done independently.3) Encourage deep breathing with the use of incentive spirometry every 2 hours during bed rest.Rational:Breathing in developing alveoli, lowers the risk of atelectasis.d. High risk of infection related to inadequate primary defense; perlinduingan skin damage; traumatic tissue. Inadequate secondary defenses; decrease in Hb, suppression of inflammatory responses.Purpose:Patients were free of infectionEvaluation Criteria:There was no fever, good granulation tissue formation.Intervention:1) Monitor the appearance of burns (burn area, the status of the donor and a bandage over the skin tandur tandur bial done) every 8 hours.Rational:Identify indications of progress or penyimapngan expected results.2) Clean the area burns every day and remove necrotic jarinagn (debridement) to order.Rational:Following the principles of aseptic protect patients from infection.3) Give the bath tub to order, implement the prescribed treatment for the donor side, which can be covered with a bandage vaseline or op site.Rational:Bare skin be a good medium for the growth of culture baketri.
