Kamis, 30 Agustus 2012

NURSERY NURSING IN PATIENTS WITH BURNS (COMBUSTIO)

Good evening my friend today I will be sharing about nursing care in patients with burns.
Immediately ....



Burns can result in complex problems that can extend beyond the physical damage is visible on the network directly injured. This complex problem affects all body systems and some life threatening circumstances. Twenty years ago, a man with burns to 50% of the surface area of the body and suffered complications from the wound and treatment of functional disorders can occur, it does have a life expectancy of less than 50%. Now, an adult with extensive burns to 75% have a life expectancy of 50%. and is not a
the remarkable thing to memulangkanpasien with 95% Burns who was saved. Reduction in healing time, anticipation and handling in early to prevent complications, maintenance of body function in the treatment of injuries and rehabilitation techniques more effective overall can improve the average life expectancy in some clients with serious burns.
 
Some characteristics of the burns that occur require special measures. These characteristics include the extent, the causes (etiology) and Anatomy of burns. Burns involving large body surface or that extends to the deeper tissue, requires more intensive measures than smaller Burns and superficial. Burns caused by hot liquids (scald burn) had a difference in prognosis and complications of burns on the same caused by fire or exposure to radiation ionization. Burns due to chemicals requires different treatment than due to electric shock (electric) or persikan api. Burns that cause risk of genetalia nifeksi larger than in other places of the same size. Burns on feet or hands can affect the ability of the client and work function requires different treatment techniques of location on the body to another. General knowledge about Anatomy, Physiology, nursing, pathophysiology of skin burns is very necessary to know the difference and certain degrees of Burns and useful to anticipate the life expectancy as well as the occurrence of complications that accompany multi organ.
 
Clients who experience a Prognosis Burns is directly related to the location and size of the burn. Other factors such as age, previous health status and smoke inhalation can affect the severity of Burns and other influences that accompanied. Clients often suffered burns at the same time, adverse events such as injury or death of other family members, loss of home and more. Clients must be referred to Burns get better treatment facilities to deal with immediate and long-term problems that accompany on Burns.
 
Definition
Burns is a trauma caused by heat, electricity, chemicals and lightning on the skin, mucosa and deeper tissue (Surgical HOSPITAL Dr. Irna Soetomo, 2001).
 
Etiology
1. high-temperature Burns (Thermal Burn)
2. Gas, Liquid, solid Material (Solid)
3. Chemical Burns (hemical Burn)
4. Burns electric shock (Electrical Burn)
5. Burns of radiation (Radiation Injury)
 
The Burn Phase
A. Acute Phase.
Referred to as the initial phase or phases of the shock. In general this phase, on a sufferer would have been in a State of relative life thretening connotations. In the initial phase, sufferers will experience airway disorders threats (breath), brething (mechanisms of breathing), and circulation (circulation). Gnagguan airway not only can occur immediately or shortly after the burn, but can still occur due to respiratory tract obstruction inhalation injury in 48-72 hours after trauma. Inhalation injuries are the main cause of death in acute phase of penderiat.
In the acute phase, frequent disruption of the balance of fluids and electrolytes due to thermal injury impacting a systemic. Circulation problems that originated with the condition of shock (the imbalance between O2 and level needs paskan cellular respiration and tissue) that are hipodinamik can be continued with a State of hiperdinamik which is still ditingkahi with circulatory instability problems.

B. sub acute Phase.
Taking place after the shock phase is resolved. A problem that occurs is due to tissue damage or lose contact with the heat source. Injuries that occur cause:
1. the process of inflammation and infection.
2. Problempenuutpan wound with point attention to wound bare or not in shining and epithelial or on structures or organs – a functional organ.
3. a State of hipermetabolisme.

C. Advanced Phase.
Further phase will be continued until the onset of maturasi due to injuries and the recovery of grated functions of functional organs. The Problem that arose in this phase is either grate the penyulit hipertropik, kleoid, pigmentation disorders, deformities and kontraktur.
 
Classification Of Burns

A. It burns.

The Depth Of Color Appearance Causes Feelings
Superficial partial thickness
(level I) Sycophancy api, ultra violet rays (burned by the Sun). Dry no bubbles.
Oedem minimal or non-existent.
Pale when pressed with a fingertip, it contains a detachable pressure when back. Rose red. Pain
Deeper than the thickness of the partial
(level II)
-Superficial
-Materials in contact with water or solid materials.
Sycophancy to the fire clothes.
Sycophancy directly chemically.
Ultra violet rays.
Large and damp Blister size gets bigger.
Pale bial pressed with fingertips, when pressure is removed containing the return. A less obviously mottled, white, Brown, pink, red-brown. Very painful
Thickness of fully
(level III) Contact with liquid or solid material.
The flame.
Chemistry.
Contact with power lines. Dry flaking skin accompanied.
Blood vessels visible under the skin like charcoal that is flaking.
Bubble walls are very thin, sparse, not enlarged.
No pale when pressed.
White, dry, black, dark brown.
Black.
Red. It does not hurt, a little sick.
Easy hair off when pulled out.

B. Extensive Burns
Divide the body part Wallace's 9% or multiples of 9 are known as the rule of nine atua rule of wallace, namely:
1) head and neck: 9%
2) Arm respectively 9%: 18%
3) front Body, rear body + 18% 18%: 36%
4) maisng each Limb 18%: 36%
5) Genetalia/perineum: 1%
Total: 100%
C. Heavy ringannya Burns
To examine the severity of Burns will have to consider a number of factors, among others:
1) percentage of areas (Breadth) burns on the surface of the body.
2) depth of burns.
3) Anatomy location of burns.
4) age clients.
5) then treatment History.
6) Trauma that accompanies or concurrently.

American Burn Association divided in:
1) which include mild Burns (minor):
a level II) less than 15% of the Total Body Surface Area in adults or less than 10% Total Body Surface Area in children.
b) level III for less than 2% Total Body Surface Area that is not accompanied by complications.
2) which included Burns (moderate):
a) level II 15%-25% Total Body Surface Area in adults or less than 10%-20% Total Body Surface Area in children.
Level III b) is less than 10% Total Body Surface Area that is not accompanied by complications.

3) which includes critical Burns (major):
a) level II 32% Total Body Surface Area or more in adults or more than 20% Total Body Surface Area in children ...
b) level III 10% or more.
c) burns that involve the face, hands, eyes, ears, legs and perineum.
d) burns on the road or the presence of respiratory complications breathing.
e) burns electric shock (electrical engineering).
f) burns are accompanied by a problem that weakens the body's durability as our leading point network cuts, other trauma or fractur, health problems previously ...
American college of surgeon divided in:
A. Severe – critical:
a) level II: 30% or more.
b) level III: 10% or more.
c) level III on the hands, feet and face.
d the presence of penafasan complications), heart, soft tissue fractura, broad.
B. Are – moderate:
a) level II: 15 – 30%
b) level III: 1 – 10%

C. Light-minor:
a) level II: less 15%
b) level III: less than 1%
 
Pathophysiology (Hudak & Gallo; 1997)

Physiology effect on adverse burns can be mild, local or scarring severe burns in the form of death. On the burn a greater disability occurred. After the beginning of the burn and the skin can develop as a result of the trauma and damage various organs. The development of this complex and in some cases it happens inexplicable. An important change in the magnitude of the physiology that accompanied with the burns ranged in two incidents underlying namely:

1. direct damage to the skin and impaired function.
2. stimulation of massive defense reactions of compensation that includes activation of the stress response and keradangan nervous system response sympathetic dystrophy.

1. skin damage And loss of function.

The body has a few methods to compensate for variations in the temperature of the area externally. Blood circulation produces and delivers hot acting, pasas efficient transfers below normal. When heat is given on skin temperature increases then subdermal soon quickly. Soon the heat source was moved (appointed), the body will return to normal within a few seconds. If a heat source is not immediately removed or given an average or at a level that exceeds the capacity of the skin to pass it, then there was damage to the skin. Exposure to relatively low heat for a long or short exposure to higher temperature can cause skin damage that progressive on a deeper level. Most burns on the size which means causing damage to cells through all layers, although it is not the same in all areas.
The thickness of the skin is involved depends on the tissue damage caused by heat. Less heat in the time it takes for the damage to the body areas with thin skin is proportional to the area where the skin is thicker. The skin is thickest at the back and the thighs, and the thinnest around the medial part of the hand, face and nose bars. The skin is generally thinner in children and the elderly from the Middle at adulthood. Parents have a decreased subcutaneous layer, fiber loss and a reduction in all rubbery's ability to respond to the trauma.

2. Activities Against Compensating Response Keradangan.

The network received some cuts the body homeostasis as a threat to a normal defense response is stimulated as the conditions and order of actual damage, it is always the same respun. The magnitude of the response depends on the intensity and duration of permulaam damage. One important thing to keep in mind dahwa response keradangan (inflamatory response) is a mechanism that helps the body compensated soon when the invasion or injury occurs. This action plan for local defense and in a relatively short. When this action is spreading quickly and settle down, then it will cause adverse physiological complications that also affect the defence of homeostasis.
Response to keradangan on the wound occurs in the primary level of vasculer. Tissue damage and makrofage in the network reduces the body's chemical glands (histamine, serotonin, bradikinin and vasoaktif-Amen for that matter) that cause dilatasi blood vessels (vaso) and increase capillary permiabilitas. When tissue damage, this broad substance of secreted in large amounts, distributed and systemic causes of vascular changes on all networks. vascular changes this is responsible terhadapmanifestasi the clinic early blood vessels (kardiovasculer) and the complications that accompany burns. This substance is also affecting the blood and blood vessels, chemical substance (chemotaksik) which was accompanied by the makrofage network-specific leukocytes in Friz wound location and change the bone marrow and the maturity of leukocytes. This change was soon thoroughly and further affect immune function.

3. activities of the nervous system Compensation Response sympathetic dystrophy.
Nervous system response triggered by separation of sympathetic dystrophy sympathetic dystrophy on autonomous nervous system on the relationship endokirn system as an internal reaction conditions that threaten disorder internal homeostasis. This reaction is sometimes a symptom of General adaptation (general Adaptive syndrom) or reaction to fight and flee (fight or flight) as they prepare the body for the activities that allow changes to its original state. The response to stress immediately cause changes in Physiology (adaptation) that stimulates or add functionality for the purposes of fight or flight (fight or flight) or add a function that does not immediately lead to fight or flight.
Change of physiological stimulation include improved average respiratory, increased depth and average heart rate, selective vasokunstriksi, increasing blood flow, brain, liver and myocardium, improving musculoskeletal metabolism and formation of high energy and decreased substance inventory glycogen and fat. The changes include a decrease in physiological blocked blood flow to the skin, kidney and digestive tract (intestinal traktus) as well as decreased movement of the digestive system (Gastrointestinal) and secretion. This response is helpful to the body for a short time and help sustain vital organs function in adverse conditions or aggravate the situation. However, when response sympathetic dystrophy continues for a long time without any influence from outside, the response body is becoming more depressed and cause pathological conditions leading to run out of resources which is adaptation.
 
Physiological Changes In Burns

Changes in levels of hipovolemik
(s/d 48-72 hours) Levels of diuretics
(12 hours – 18/24 hours)
The impact of the mechanism of Impact Mechanism
Fluid shifts a distinguishing extracelluar matrix. The vascular insterstitial. Hemokonsentrasi oedem on the location of the burn. The Interstitial vascular. Hemodilusi.
Renal function. Renal blood flow is reduced because of the insistence of the blood down and reduced.
Oliguri. Increasing renal blood flow due to increased blood pressure. Diuresis.
Sodium/sodium levels. Na + direabsorbsi by the kidneys, but lost via Na + eksudat and is stuck in the liquid oedem. Sodium deficit. Loss of Na + through diuresis (back to normal after 2 weeks). Sodium deficit.
Potassium levels. K + detachable shoulder injury as a result of jarinagn of red blood cells, K + is reduced due to reduced renal excretion function.
Hiperkalemi K + moved back into their cells, K + wasted through diuresis (starting 4-5 days after Burns). Hipokalemi.
Protein levels. Protein loss into the network as a result of an increase in permeability.
Hipoproteinemia. Lost time goes on catabolism of proteins. Hipoproteinemia.
Nitrogen balance. Catabolism of protein loss in the network, the network, the more loss of input. Negative nitrogen balance. Protein catabolism of tissue, lost, immobilitas. Negative nitrogen balance.
Keseimbnagan acid bases. Anaerobic metabolism due to decreased perfusion of jarinagn acid end product enhancement, reduced renal function (resulting in the retention of the final product is stuck), loss of bikarbonas serum. Metabolic acidosis. Loss of sodium bicarbonas through diuresis, hipermetabolisme accompanied by an increase in metabolic end product. Metabolic acidosis.
The stress response. Occur due to trauma, increased production of cortison. Renal blood flow is reduced. Due to the nature of a longstanding shoulder injury and threatened personal psychology. Stress due to injuries.
Erythrocytes due to heat, breaks into fragil. Thermal burns. Does not occur in the first days. Hemokonsentrasi.
The Hull. Curling ulcer (the ulcer on gaster), gastric bleeding, pain. Stimulation of the hypothalamus and central in peingkatan number of cortison. Acute intestinal dilatasi and paralise. An increasing number of cortison.
Heart. MDF increases 2 x folding, is a glycoprotein produced by the toxic skin burn. Cardiac dysfunction. Improvement of MDF substances (infarction depresant factor) to 26 units, responsible for shock spetic. CO declines.

Indication Of Inpatient Burns
A. Burns grade II:
1) > Adult 20%
2) Child/parents > 15%
B. Burns grade III.
C. Burns with complications: heart, brain etc.
 
Implementation:
A. Resuscitate A, B, C.
1): Respiratory
a) hot air oedem damaged mucosa obstruction.
toxic Effect of b) smoke: HCN, NO2, HCL, gasoline à à Bronkhokontriksi à irritation obstruction à failed breath.
2) Circulation:
impaired capillary permeability: liquid from intra vascular moved into extra vascular shock relative à hipovolemi ATN kidney failure.

B. the catheter, Infusion, CVP, oxygen, laboratories, wound culture.
C. Fluid Resuscitation à Baxter.
Adult: Baxter.
RL 4 cc x W x% LB/24 hours.

Children: number of resuscitation + faal needs:
RL: Dextran = 17: 3
2 cc x W x% LB.

Faal needs:
< 1 year: BB x 100 cc
1 – 3 years: W x 75 cc
3 – 5 years: W x 50 cc
½ à given 8 hours first
½ à given 14 hours later.

The second day:
Adult: 500 – 2000 + Dextran D5%/albumin.
(3-x) x 80 x W gr/hr
100
(Albumin 25% = grams x 4 cc) à 1 cc/min.
Children: given a personalised faal.

D. Monitor urine and CVP.
E. Topical and close wound
-Wash the wound with savlon: NaCl 0.9% (1: 30) + waste network nekrotik.
-Tulle.
-Silver sulfa diazin thick.
-Close kassa thick.
-Evaluation of 5-7 days, except the wrap of dirty.
F. Medications – drugs:
o Antibiotics: not provided when patients come in 6 hours since the incident <.
o give antibiotic if necessary in accordance with the pattern and match results of culture the germs.
o Analgetik: strong (morphine, petidine)
o Antasida: if necessary
 
THE CONCEPT OF NURSING NURSERY

1. Assessment
a) Activities/break:
Mark: a decrease in strength, prisoner; limited range of motion in the area who are sick; disorders of muscle mass, change tonus.

b) Circulation:
Sign (with injury Burns over 20% of the APTT): hypotension (shock); decreased peripheral pulse distal extremities are injury; on vasokontriksi common with loss of peripheral pulse, skin white and cold (electric shock); takikardia (ansietas/shock/pain); disritmia (electric shock); oedema formation network (all Burns).

c) integrity of the ego:
Symptoms: problems of family, work, finances, disability.
Mark: ansietas, crying, reliance, denied, withdrawn, angry.

d) Elimination:
Signs: decreased urine haluaran/no during the emergency phase; the color may be black and reddish when there is mioglobin, indicating damage to the muscles; diuresis (after capillary leakage and mobilization into circulation of liquids); decrease intestinal noise/no; especially in Burns kutaneus greater than 20% as a stress reduction/gastrik inherent motility of peristalsis.

e) food/liquids:
Sign: Network General oedema; Anorexia; nausea/vomiting.

f) Neurosensori:
Symptoms: area boundaries; tingling.
Sign: change orientation; nor, behavior; a decrease in the tendon reflex (RTD) on the injured limb; seizure activity (electric shock); laserasi korneal; retinal damage; a decrease in acuity of vision (electric shock); timpanik membrane contained ruptures (electric shock); paralysis (electrical nerve injury in the flow).

g) Pain/comfort:
Symptoms: a variety of pain; examples of first degree burns are eksteren sensitive to the touch; pressed; air movement and temperature changes; thickness of 're-degree burns both very painful; smentara response on the thickness of the second degree burns depending on the integrity of the nerves; a three-degree burns are not painful.

h): Respiratory
Symptoms: confined in enclosed spaces; long-exposed (possibly inhalation injury).
Sign: hoarse; mengii cough; carbon particles in sputum; inability to swallow oral secretions and cyanosis; indication of inhalation injury.
Development of piston may be limited to the presence of Burns's chest circumference; Street breath or stridor/mengii (obstruction in connection with laringospasme, laringeal oedema); breath: the flowing sound (pulmonary oedema); stridor (oedema laringeal); secretions in the respiratory paths (ronkhi).
i) security:
Sign:
Skin destruction in General: jarinagn may not be proved for 3-5 days in connection with the process of trobus microvascular on some cuts.

No burned Area of skin is probably cold/damp, pale, with a capillary filling slow on the decrease with respect to the loss of bulk liquid heart/status of shock.

Fire injury: there are areas of injury to mix in sehubunagn with the variase the intensity of the heat generated by burning clot. Feather footed nose; dry mouth and nose mucosa; Red; blisters on the posterior pharynx; oedema or ring circumference mouth and nasal.

Chemical injury: wound looks vary according the agent causes.

The skin may be yellowish brown with skin smooth texture seprti samak; blisters; ulcer; necrosis; or thick scar jarinagn. Injuries are mum in ore of nucleoplasty and damage appeared to be in a network can be continued until 72 hours after the injury.

Electrical injuries: injury kutaneus external is usually less under necrosis. Injuries can include the appearance varies the inflow/Exit wounds (explosive), a burn of the proximal body movements flow in closed and thermal burns in connection with clothing on fire.

The presence of fractures/dislocations (fall, motorcycle accident, muscle contraction tetanik with respect to electrical shock).

a diagnostic Examination):
(1) LED: reviewing hemokonsentrasi.
(2) the serum Electrolyte fluid imbalances and biochemical detection rates. This is especially important to check potassium is increased in the first 24 hours due to the increased potassium can cause heart-stop.
(3) arterial blood gases (GDA) and chest x-ray study of the pulmonic valve function, especially in the smoke inhalation injuries.
(4) the BUN and creatinine is the study of kidney function.
(5) mioglobin and hemokromogen Urinalisis show indicates damage muscle in full thickness burns.
(6) Bronchoscopy helps ensure smoke inhalation injuries.
(7) a clotting factor check the clotting factors that can decrease the massive burns.
(8) increased serum levels of carbon monoxide in smoke inhalation injuries.
 
 
2. Nursing Diagnosis
The client portion of the burns can happen the primary Diagnosis and Diagnosis for Additional suffering burns (common and additional). Diagnosis commonly occur on clients who were treated at hospital menderila Burns over 25% Total Body Surface Area

1. a decrease in Cardiac Output correlated with increased capillary permiabilitas.
2. Fluid Volume Deficit related to electrolyte loss and inefficient provision and the volume of plasma from blood vessels.
3. changes to Network-related decrease in Perfusion Cardiac Output and edema.
4. the ineffectiveness of Breath Patterns relate to difficulties in breathing (Respiratory Distress) of trauma, inhalation of the blockage (Obstruction) of breath and pneumoni roads.
5. the changes Pleasant Taste: Pain associated with exposure to the ends of the nerve to the skin that was damaged.
6. Skin Integrity Impaired related to Burns.
7. Potential Infection is associated with impaired skin integrity.
8. changes to Nutrition: less than Body Needs Nutrients associated with increased average metabolism.
9. Physical Mobility Disorders associated with burns, scar and kontraktur.
10. Body Image Disturbance (Body Image) associated with a change in physical appearance

Marilynn e. Doenges in Nursing care plans, Guidelines for planning and documenting Rapa patient care posited some nursing Diagnosis as follows:

1 High Risk roads ineffective breath impurity associated with obtruksi mucous edema and trakeabronkial; loss of Cilia work. Cervical area Burns; compression way breath thorak and chest or pectoral development keterdatasan.
2 high volume liquid shortage Risk associated with the loss of fluids through the abnormal route. Needs improvement: the status of hypermetabolik, the historical argumentation infusion. Loss of bleeding.
3 the risk of damage to gas exchange related to smoke inhalation injuries or compartment syndrome secondary to the torakal Burns sirkumfisial of the chest or neck.
4 high risk of infection associated with primary Defense is not adekuat; perlinduingan damage to the skin; traumatic stress network. Secondary defense is not adekuat; a decrease in inflammatory response of the emphases of Hb.
5 Pain associated with skin/tissue Damage; the formation of edema. Manifulasi network debridemen example cuts. injury

6 high risk damage to tissue perfusion, peripheral changes/dysfunction is related to a decrease in neurovaskuler/interruption of blood flow arterial/venous, for example Burns around the extremities with edema.
7 changes in nutrition: less than body requirements related to the status hipermetabolik (as much as 50%-60% greater than normal proportions on injuries) or protein catabolism.
8 damage to physical mobility related to neuromuscular disorders, pain/discomfort, decrease power no and prisoners.
9 Damage the integrity of the skin associated with Trauma: damage due to the skin surface skin layers of destruction (partial/burn in).
10 body image Disturbance (appearance roles) associated with the crisis situation; traumatic events depending on the client's role, disability and pain.
11 Less knowledge about the condition, prognosis and treatment needs related to Wrong interpretation of information does not know the source of information.
 
Marilynn e. Doenges in Nursing care plans, Guidelines for planning and documenting Rapa patient care posited some nursing Diagnosis as follows:

1 High Risk roads ineffective breath impurity associated with obtruksi mucous edema and trakeabronkial; loss of Cilia work. Cervical area Burns; compression way breath thorak and chest or pectoral development keterdatasan.
2 high volume liquid shortage Risk associated with the loss of fluids through the abnormal route. Needs improvement: the status of hypermetabolik, the historical argumentation infusion. Loss of bleeding.
3 the risk of damage to gas exchange related to smoke inhalation injuries or compartment syndrome secondary to the torakal Burns sirkumfisial of the chest or neck.
4 high risk of infection associated with primary Defense is not adekuat; perlinduingan damage to the skin; traumatic stress network. Secondary defense is not adekuat; a decrease in inflammatory response of the emphases of Hb.
5 Pain associated with skin/tissue Damage; the formation of edema. Manifulasi network debridemen example cuts. injury

6 high risk damage to tissue perfusion, peripheral changes/dysfunction is related to a decrease in neurovaskuler/interruption of blood flow arterial/venous, for example Burns around the extremities with edema.
7 changes in nutrition: less than body requirements related to the status hipermetabolik (as much as 50%-60% greater than normal proportions on injuries) or protein catabolism.
8 damage to physical mobility related to neuromuscular disorders, pain/discomfort, decrease power no and prisoners.
9 Damage the integrity of the skin associated with Trauma: damage due to the skin surface skin layers of destruction (partial/burn in).
10 body image Disturbance (appearance roles) associated with the crisis situation; traumatic events depending on the client's role, disability and pain.
11 Less knowledge about the condition, prognosis and treatment needs related to Wrong interpretation of information does not know the source of information.
 
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