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1. Assessment
a) Activity / rest:
Signs: The reduction in force, prisoners, limited range of motion in the area of pain, disorders of muscle mass, tone changes.
b) Circulation:
Sign (with a burn injury of more than 20% APTT): hypotension (shock), decreased peripheral pulses distal extremity injuries, general peripheral vasoconstriction with loss of pulse, and cool white (electric shock), tachycardia (shock / anxiety / pain ), dysrhythmias (electric shock), the formation of tissue edema (all burns).
c) The integrity of the ego:
Symptoms: The problem of family, work, finances, disability.
Signs: anxiety, crying, dependence, denial, withdrawal, anger.
d) Elimination:
Signs: decreased urine output / no during the emergency phase, the color may be reddish black in case of myoglobin, indicating damage in the muscle, diuresis (after capillary leak and fluid mobilization into the circulation), decreased bowel sounds / does not exist, particularly in cutaneous burns greater than 20% as stress reduction in motility / gastric peristalsis.
e) Food / fluid:
Signs: general network edema, anorexia, nausea / vomiting.
f) Neurosensori:
Symptoms: area boundary, tingling.
Signs: changes in orientation, affect, behavior; decreased deep tendon reflexes (RTD) on extremity injuries, seizure activity (electric shock), corneal laceration, retinal damage, decreased visual acuity (electric shock), ruptured membranes timpanik (electric shock), paralysis (flow electricity in nerve injury).
g) Pain / comfort:
Symptoms: A variety of pain, examples of first-degree burns are eksteren sensitive to touch, pressure, air movement and temperature changes, the thickness burns are very painful second degree, while the response on the thickness of the second degree burns depends on the integrity of the nerve endings, the degree burns three no pain.
h) Respiratory:
Symptoms: trapped in an enclosed space; prolonged exposure (possible inhalation injury).
Symptoms: hoarseness, cough mengii, carbon particles in the sputum, inability to swallow oral secretions and cyanosis, indicative of inhalation injury.
Development of the piston may be limited to bust burns, airway or stridor / mengii (obstruction in connection with laringospasme, laryngeal edema), breath sounds: the gurgling (pulmonary edema), stridor (laryngeal edema), airway secretions in (ronkhi).
i) Security:
Signs:
General skin: tissue destruction may not be proven within 3-5 days with respect to the process of microvascular trobus on some cuts. Unburned areas of the skin may be cold / moist, pale, with slow capillary refill in a decrease in cardiac output with respect to fluid loss / shock status.
Injuries of fire: there is a mixture in the injured area with variase sehubunagn intensity burning heat generated clot. Singed nasal hairs; nasal mucosa and dry mouth; red; blisters on the posterior pharynx; edema girth or circumference of the mouth and nasal.
Chemical injury: wound varies according to the causative agent. The skin may be yellowish brown with smooth texture like leather; blisters; ulcers; necrosis, or scar tissue thickness. Injuries are generally deeper than it seems in percutaneous and tissue damage may continue until 72 hours after injury.
Electrical injury: external cutaneous injury is usually less under necrosis. Appearances can include wound injuries varies the flow of incoming / outgoing (explosive), burns of the flow in the proximal movement of the body covered and thermal burns in connection with clothes on fire.
A fracture / dislocation (falls, motorcycle accidents, tetanik muscle contraction with respect to electric shock).
j) Diagnostic tests:
LED: reviewing hemoconcentration.
serum electrolytes to detect an imbalance of fluids and biochemistry. This is especially important to check potassium there is an increase in the first 24 hours because of increased potassium can cause cardiac arrest.
arterial blood gases (GDA) and chest X-ray study of pulmonary function, particularly on smoke inhalation injury.
BUN and creatinine assess kidney function.
Urinalysis showed myoglobin and hemokromogen indicate muscle damage in extensive full thickness burns.
Bronchoscopy helps ensure smoke inhalation injury.
Coagulation check clotting factors that can decrease the massive burns.
increased serum levels of carbon monoxide in smoke inhalation injury.
2. Nursing Diagnosis
Marilynn E. Doenges in Nursing care plans, guidelines for planning and documenting patient care to some of the nursing diagnosis as follows:
a) High risk of ineffective airway clearance related to obtruksi trakeabronkial, mucosal edema and loss of cilia work. The burn area of the neck, compression of the airway and chest or thoracic keterdatasan chest development.
b) High risk of lack of fluid volume associated with the loss of fluid through abnormal routes. Increased demand: hypermetabolik status, income is insufficient. Loss of bleeding.
c) Risk of damage to gas exchange associated with smoke inhalation injury or compartment syndrome secondary to thoracic burns sirkumfisial of the chest or neck.
d) High risk of infection associated with inadequate primary defense; perlinduingan damage to the skin; traumatic tissue. Inadequate secondary defenses: a reduction in Hb, suppression of inflammatory responses.
e) Pain associated with damage to the skin / tissue; the formation of edema. Manifulasi injured tissue sample wound debridement.
f) High risk of damage to tissue perfusion, changes / peripheral neurovascular dysfunction related to the reduction / interruption of blood flow of arterial / venous, burns examples around the extremities with edema.
g) Altered nutrition: Less than body requirements related to the hypermetabolic status (as much as 50% - 60% larger than normal proportion in serious injury) or protein catabolism.
h) Damage to physical mobility related to neuromuscular disorders, pain / discomfort, decreased strength and resistance.
i) Damage to skin integrity related to trauma: damage to the surface of the skin due to destruction of skin layers (partial / burn in).
j) Impaired body image (appearance roles) associated with a crisis situation; traumatic event depends on the client role, disability and pain.
k) Lack of knowledge about the condition, prognosis and treatment needs related to incorrect interpretation of information do not know the source of information.
3. Intervention Nursing Care Plans and Kepeperawatan combustio
a) Nursing Diagnosis: Risk of ineffective airway clearance related to obstruction trakheobronkhial; edema of the mucosa; compression of the airway.
Goals and Criteria Results: Airway clearance is still effective. Criteria Results: vesicular breath sounds, RR within normal limits, free of dyspnoea / cyanosis.
Intervention:
• Assess the reflex disturbance / swallowing; notice drainage of saliva, inability to swallow, hoarseness, wheezing cough.
Rational: Allegations of inhalation injury
• Keep an eye on the frequency, rhythm, depth of respiration; note the pale / cyanotic and sputum containing carbon or pink.
Rational: Tachypnea, aids muscle use, cyanosis and changes in sputum showed there respiratory distress / pulmonary edema and the need for medical intervention.
• Auscultation of lung, note stridor, wheezing / gurgling, decreased breath sounds, whooping cough.
Rationale: Airway obstruction / respiratory distress can occur very quickly or slowly the example up to 48 hours after the burn.
• Note the presence of pale or cherry red color on the injured skin.
Rationale: Suspected presence of hypoxemia or carbon monoxide.
• Elevate head of bed. Avoid using a pillow under the head, according to indications.
Rationale: Increasing the optimal lung expansion / respiratory function. If the head / neck burn, pillows may inhibit respiration, causing necrosis of the burned ear cartilage and increase konstriktur neck.
• Encourage coughing / deep breathing exercises and frequent position changes.
Rationale: Increased lung expansion, to mobilize secretions and drainage.
• suction (if necessary) at the extreme care, maintain sterile technique.
Rationale: Helps maintain the airway clear, but vigilance must be done because of mucosal edema and inflammation. Sterile technique decrease the risk of infection.
• Increase the voice breaks but examine the ability to speak and / or swallowing oral secretions periodically.
Rationale: Increased secretions / decreased ability to swallow showed an increase in tracheal edema and may indicate the need for intubation.
• Investigate changes in behavioral / mental example of anxiety, agitation, mental mess.
Rationale: Although often associated with pain, change in consciousness can indicate the occurrence / worsening hypoxia.
• Supervise 24 hours keseimbngan fluid, note variations / changes.
Rational: Transfer of excess fluid or fluid replacement increases the risk of pulmonary edema. Note: inhalation injury increases fluid requirements by 35% or more due to edema.
• Perform collaborative program include: Provide a moisturizer O2 through appropriate means, eg a face mask.
Rational: O2 improve hypoxemia / acidosis. Lower respiratory humidification and drying reduce the viscosity of sputum.
• Supervise / GDA picture series.
Rationale: The data base is important for further assessment of respiratory status and guidelines for treatment. PaO2 less than 50, PaCO2 greater than 50 and a lower pH indicates smoke inhalation and pneumonia / SDPD.
• Review of X-ray series.
Rationale: The change shows atelectasis / pulmonary edema may not occur for 2-3 days after burn.
• Provide / assist chest physiotherapy / intensive spirometry.
Rational: Chest physiotherapy drain the dependent lung area, while intensive spirometry done to improve lung expansion, thus improving respiratory function and reduce atelectasis.
• Prepare / aids intubation or tracheostomy as indicated.
Rational: intubation / mechanical support is required if airway edema or burns affect lung function / oxygenation.
b) Nursing Diagnosis: High risk associated with lack of fluid volume loss of fluid through abnormal routes. Increased demand: hypermetabolik status, income is insufficient. Loss of bleeding.
Goals and Results Criteria: Patients may demonstrate improved fluid status and biochemistry. Evaluation criteria: no manifestations of dehydration, the resolution of edema, serum electrolytes within normal limits, urine output above 30 ml / hour.
Intervention:
• Monitor vital signs, CVP. Note the capillary and the strength of peripheral pulses.
Rationale: Provides guidelines for fluid replacement and assess cardiovascular response.
• Keep track of urine and its density. Observation of the color of urine and hemates as indicated.
Rational: The fluid replacement titrated to convince the average of urine-2 30-50 cc / hour in adults. Urine red on massive muscle damage and release of myoglobin because adanyadarah.
• Estimate the wound drainage and loss of sight.
Rationale: Increased capillary permeability, transfer proteins, inflammatory processes and fluid loss through evaporation and the influence circulating volume of urine.
• Weigh the weight every day.
Rational: Replacement of the liquid depends on the weight first and subsequent changes.
• Measure the circumference of the extremities are burned every day as indicated.
Rational: Estimating the extent of edema / fluid displacement which affects the circulation and volume of urine.
• Investigate the mental changes.
Rational: Irregularities at the level of consciousness may indicate a lack of circulating volume adequatnya / decrease in cerebral perfusion.
• Observation of abdominal distension, hematomesis, black stool.
Rationale: Stress (Curling) ulcer occurs in half of all patients with severe burns (may occur early in the first week).
• Hemates NG drainage and periodic stool.
Rational: strict observation of kidney function and prevent urinary stasis or reflex.
• Perform collaborative program include:
Install / maintain urinary catheter.
Rationale: Allows rapid fluid infusion.
Install / maintain IV catheter size.
Rational: Resuscitation fluids to replace lost fluid / electrolyte and helps prevent complications.
Give IV fluid replacement are counted, electrolytes, plasma, albumin.
Rationale: Identifying the blood loss / damage to human resources and needs replacement fluids and electrolytes.
Monitor the results of laboratory tests (Hb, electrolytes, sodium).
Rationale: Increase of urine and cleaning the tubules of the debris / prevent necrosis.
Give the drug as idikasi: Diuretics for example Mannitol (Osmitrol), Potassium, Antacids.
Rational: Replacement up for the loss of urine in large quantities, while the Lower acidity of gastric histamine inhibitors decrease the production of hydrochloric acid to lower the production of hydrochloric acid to reduce gastric irritation.
• Monitor: Vital signs every hour during the emergency period, every 2 hours during the acute period, and every 4 hours during the rehabilitation period. The color of urine. Input and output every hour during the emergency period, every 4 hours during the acute period, every 8 hours during the rehabilitation period. The results of the JDL and electrolyte report. Weight every day. CVP (central venous pressure) per hour Bial is required. General status every 8 hours.
Rationale: Identify deviations indication of progress or deviations from expected results. The emergency period (beginning 48 hours post-burn) is a critical period marked by the individual who sparked hypovolemia on renal perfusion and jarinagn not adequate. Adequate inspection of the burn.
• On receipt of the hospital, remove all clothing and jewelry from the burned site. Start IV therapy is determined by a large hole needle (18G), preferably through the skin that have been injured fuels. If the patient menaglami extensive burns and showed symptoms of hypovolemic shock, help physicians with the installation of central venous catheter for CVP monitoring.
Rational: rapid fluid replacement is important to prevent renal failure. Significant fluid loss occurs through the burning jarinagn with extensive burns. Central venous pressure measurements provide data on the status of intravascular fluid volume.
• Tell your doctor if: urine output <30 ml / hr, thirst, tachycardia, CVP <6 mmHg, serum bicarbonate below the normal range, restlessness, TD below the normal range, dark urine or watery dark.
Rationale: These findings mennadakan hypovolemia and the need to increase fluids. At LKA extensive burns, the displacement of fluid from the intravascular space into interstitial space menimbukan hypovolemia.
• Consultation doketr when manifestations of fluid overload occurs.
Rationale: Patients susceptible to intravascular volume overload during the recovery period when the movement of fluid from the interstitial compartment to the intravascular compartment.
• Test guaiak vomit or stool color was black coffee. Report positive findings.
Rational: The findings of positive guaiak ennandakan of GI bleeding. Adaiah indicates GI bleeding stress ulcers (Curling's).
• Give prescription antacids or histamine receptor antagonists such as cimetidine.
Rationale: Prevent GI bleeding. Sparked extensive burns patients on stress ulcer caused increased secretion of adrenal hormones and HCl by the stomach acid.
c) Nursing Diagnosis: Risk of damage to gas exchange associated with smoke inhalation injury or compartment syndrome secondary to thoracic burns sirkumfisial of the chest or neck.
Goals and Results Criteria: Patients can demonstrate adequate oxygenation. Kriteroia evaluation: RR 12-24 times / min, normal skin color, GDA in renatng normal breath sounds clean, no trouble breathing.
Intervention:
• Monitor and GDA report serum levels of carbon monoxide.
Rationale: Identify progress and deviations from expected results. Inhalation of fumes can damage the alveoli, affects gas exchange in the alveoli capillary membrane.
• Beriakan supplemental oxygen at the specified level. Replace or help with an endotracheal tube and place the patient on a mechanical ventilator to order in case of respiratory insufficiency (as evidenced by hypoxia, hypercapnia, rales, tachypnea, and changes in sensorium).
Rational: Supplements oxygen increases the amount of oxygen available to the network. Required mechanical ventilation for respiratory support until pasie can be done independently.
• 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.
• Maintain semi-Fowler position, if there is no hypotension.
Rationale: Allows ventilation with lower abdominal pressure against the diaphragm.
• For burns around the thoracic, tell your doctor if there is dyspnea accompanied by tachypnea. Prepare patients for surgery escharotomy to order.
Rational: some thoracic burns can limit the expansion of Adda. Peeling of skin (escharotomy) allow chest expansion.
d) Nursing Diagnosis: High risk of infection associated with inadequate primary defense; perlinduingan damage to the skin; traumatic tissue. Inadequate secondary defenses: a reduction in Hb, suppression of inflammatory responses.
Goals and Results Criteria: Patients are free from infection. Evaluation criteria: no fever, good granulation tissue formation.
Intervention:
• Monitor: Appearance of burn (the burn area, the donor side and the status of a bandage over the skin tandur tandur Bial done) every 8 hours. Temperature every 4 hours. The amount of food consumed at each meal.
Rationale: Identify indications of progress or penyimapngan from expected results.
• Clean the area burns each day and remove the necrotic tissue (debridement) to order. Give bathing pond to order, implement a prescribed treatment for the donor side, which can be covered with a bandage or Vaseline op site.
Rational: Cleanup and removal of necrotic tissue increases the formation of granulation.
• Remove the old cream of injury before granting a new cream. Use sterile gloves and beriakan topical prescription antibiotic cream on the burn area with a fingertip. Give the cream over the wound thoroughly.
Rational: Topical Antimicrobial helps prevent infection. Following the principles of aseptic protect patients from infection. Bare skin be a good medium for bacterial growth culture.
• Tell your doctor if fever, purulent drainage or foul odor from the burned site, the donor side or side dressing tandur. Get wound culture and give antibiotics IV according to the provisions.
Rationale: These findings mennadakan infection. Culture helps identify the pathogen causes so that appropriate antibiotic therapy can be prescribed. Since wrapping siis tandur only replaced every 5-10 days, this side memberiakn culture media for bacterial growth.
• Place the patient in a special room and precautions for extensive burns on large areas of the body. Use a sterile bed linen, towels and skort for patients. Use a sterile skort, gloves and headgear with a face mask when providing care to patients. Place the radio or televisis on the patient's room to relieve boredom.
Rational: The skin is the body's first layer of defense against infection. Sterile techniques and patient care measures lainmelindungi protection against infection. Lack of various excitatory ekstrenal and freedom of movement sparked the patient to boredom.
• If no adequate history of immunization, human tetanus immune globulin given (hyper-tet) to order.
Rational: Protects against tetanus.
• From referral to the dietitian, beriakn high protein, high calorie diet. Provide nutritional supplements like Ensure or sustacal with or between meals when food intake is less than 50%. Instruct the NPT or enteral feeding Bial patient can not eat by mouth.
Rational: Dieticians are nutrition specialists who can evaluate the best patient's nutritional status and diet plan to meet the nutritional needs of patients. Adequate nutrition helps wound healing and energy needs.
e) Nursing Diagnosis: Pain associated with damage to the skin / tissue, edema formation. Manipulation of tissue injury wound debridement example.
Goals and Results Criteria: Patients may demonstrate loss of discomfort.
Evaluation criteria: deny pain, reported feeling comfortable, facial expression and relaxed posture.
Intervention:
• Provide anlgesik prescription narcotics and provided with at least 30 minutes prior to wound care procedures. Evaluation of effectiveness. Encourage IV analgesics when extensive burns.
Rational: narcotic analgesics are needed to block the pathway of pain with severe pain. Poor IM drug absorption in patients with extensive burns caused by interstitial displacement with respect to increased capillary permeability.
• Keep the door closed, increase the temperature of the room and give it an extra blanket to provide warmth.
Rational: Heat and water is lost through the burn tissue, causing hypothermia. These external actions to help conserve heat loss.
• Provide swing over the bed when needed.
Rational: Menururnkan pain to maintain body weight away from the bed linen to the wound and reduce the exposure of nerve endings in the air flow.
• Help with changing position every 2 hours when needed. Get extra help as needed, especially if the patient could not help turning around itself.
Rationale: Eliminates pressure on bony dependent. Adequate support to the burn during the movement to help minimize discomfort.
f) Nursing Diagnosis: High risk of damage to tissue perfusion, changes / peripheral neurovascular dysfunction related to the reduction / interruption of blood flow of arterial / venous, burns examples around the extremities with edema.
Goals and Criteria Results: Patients showed circulation remains adequate. Evaluation criteria: normal skin color, denied numbness and tingling, peripheral pulse can be palpated.
Intervention:
• For burns around ekstermitas or electrical burns, monitor the neurovascular status of ekstermitas every 2 hours.
Rationale: Identify indications of progress or deviations from expected results.
• Maintain ekstermitas elevated swelling.
Rationale: Increased venous return and decrease swelling.
• Tell your doctor immediately if there is diminished pulse, poor capillary refill, or decreased sensation. Prepare for surgery escharotomy to order.
Rationale: These findings indicate damage to the distal sirkualsi. The doctor can assess the pressure the network to determine the need for surgical intervention. Escharotomy (scrape on eskar) or fasiotomi may be required to improve the circulation is adequate.
g) Nursing Diagnosis: Damage to the integrity of the skin b / d of secondary damage to the skin surface skin layer destruction.
Goals and Results Criteria: Memumjukkan tissue regeneration. Expected outcomes: Achieve timely healing in burn areas.
Intervention:
• Assess / record size, color, depth of wound, necrotic tissue and look at the conditions around the wound.
Rationale: Provides basic information about the investment needs of the skin and possible clues about the circulation in the aera graft.
• Perform proper burn care and infection control measures.
Rational: Setting up a network for the planting and reduce the risk of infection / skin failure.
• Keep the wound closure as indicated.
Rational: Woven nylon / silicone membrane of porcine collagen-containing peptides are attached to the surface of the wound until the release, or peeling skin repitelisasi spontaneously.
• Elevate the area of the graft when possible / appropriate. Maintain a desired position and immobilization of the area when indicated.
Rational: Reduce swelling / limit the risk of graft separation. Movement of tissue under the graft can change that affects the position of optimal healing.
• Keep the bandage over the area of the new graft and / or the donor side as indicated.
Rationale: The area may be covered by a translucent material with a surface not reactive.
• Wash your hand with a mild soap, wash, and oiled with cream, several times a day, after the bandage is removed and healing is complete. Rational: The skin graft donor side of the new and healed require special care to maintain flexibility.
• Perform collaborative program: Prepare / aids surgical procedures / biological dressings.
Rational: skin graft taken from the skin of one's own / someone else for the temporary closure of the burn area until the skin is ready to be planted.
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