Burn Injury management and nursing care paln. pptx

Burn Injury management and nursing care paln. pptx

1. FIRST AID AND EMERGENCY MANAGEMENT OF BURNS Mutiara Syagitta , S. Kep ., Ners ., MSN

2. Learning Objective Students understand the Definition, and classification of burn injury Students understand burn injury management referrals Students understand management of burn injury Students understand the nursing care plan of burn injury

3. Table of content Management of burn injury The Nursing care plan of burn injury

4. Definition and degree of burn injury Damage/injury to an epithelial surface or other tissues caused by flames, heat, chemicals, radiation orelectricity 4 Morbidity and mortality depends on the total body surface area (TBSA) involved, depth of the injury and age of patient CALHN 2023

5. Localize to the epidermis No blisters, but reddish Heals in 1 week with no scar Include hot water scalds Skin tanning Superficial partial: epidermis+part dermis, red painful ruptured and un-ruptured blister, heals in 2-3 weeks witn min scaring Deep partial thickness burns: involved epidermis, upper dermis and part of the lower dermis, mottled, pain (+/-), takes weeks to heal w/significant scaring <10% / derajat luas <2% 5-10% Superficial (1 st degree) burns 5 Classification of Burn Injury Partial thickness (2 nd degree) burns CALHN, 2023

6. Both epidermis, whole dermis and subcutaneous Skin appendages also burned No blister, no pain Takes long to heal Contractures formation Full thickness, extend to muscle or bone Commonly seen with electric injury or severe thermal burns Surgical amputation of the affected extremity may be required >10% 5-10% Full thickness (3 rd degree) burns 6 Classification of Burn Injury Fourth degree burns CALHN, 2023

7. Burn Injury Management Referrals Rule of nine Lund browder chart Rule of the palm Head and neck 9% Each upper extremity (Arms) = 9% Each lower extremity (legs) = 18% Anterior trunk = 18% Posterior trunk = 18% Genetalia (perineum) = 1% 7 Determining size and extent of burn injury (TBSA) Rule of Nine ( adult )

8. Lorem ipsum dolor sit amet , consectetur adipiscing elit . Morbi et rutrum felis , eget tristique tortor . Maecenas lobortis mattis turpis ut hendrerit . Fusce placerat ipsum at dictum lobortis . Lorem ipsum dolor sit amet , consectetur adipiscing elit . Morbi et rutrum felis , eget tristique tortor . Maecenas lobortis mattis turpis ut hendrerit . Fusce placerat ipsum at dictum lobortis . Lorem ipsum dolor sit amet , consectetur adipiscing elit . Morbi et rutrum felis , eget tristique tortor . Maecenas lobortis mattis turpis ut hendrerit . Fusce placerat ipsum at dictum lobortis . 25% 38% Lorem ipsum Lorem ipsum Lorem ipsum 8 Burn Injury Management Referrals: Lund Browder Chart

9. Applicable small burns Use the palm of the patients hand (with fingers extended) Both adults and children This equates to approximately 1% of the body surface area) 9 Burn Injury Management Referrals: Rule of Palm

10. Management of burn injury Remove from hazard Primary survey Patency of airway, C-spine protection, O2, IV fluids, phsycal / neurogical disability Cover w/dry blanket (hypothermia) Cover wound Remove all jewelry, belts Protective clothing Secondary survey: SAMPLE (Sign and symptoms, Allergy, Medications, Past medical history, Last meal Event leading Pain management Labs Vaccine Surgery/skin grafting Psychological support/counselling Cosmetic reconstruction Prevention of contractures Emergent/Resuscitative 10 Rehabilitation phase Acute-Intermediate phase

11. Lorem ipsum dolor sit amet , consectetur adipiscing elit . Morbi et rutrum felis , eget tristique tortor . Maecenas lobortis mattis turpis ut hendrerit . Fusce placerat ipsum at dictum lobortis . Baxter Protocol for adults with >20% Total Burn Surface Area 11 Management of burn injury

12. Nyeri Akut Risiko infeksi Hypothermia Gangguan Keseimbangan nutrisi Bersihan Jalan nafas tidak efektif Gangguan pertukaran gas Gangguan integritas kulit / jaringan (D.0129) Gangguan perfusi jaringan Risiko ketidakseimbangan cairan (D. 0036) Syok Hypovolemia 12 Nursing Care Plan of burn injury PPNI (2017) Standar Diagosis Keperawatan Indonesi (SDKI)

13. FIRST AID TEMPLATE Lorem ipsum dolor sit amet , consectetur adipiscing elit . Morbi et rutrum felis , eget tristique tortor . Maecenas lobortis mattis turpis ut hendrerit . Fusce placerat ipsum at dictum lobortis . Etiam porta nunc sit amet pellentesque feugiat . Lorem ipsum dolor sit amet , consectetur adipiscing elit . Morbi et rutrum felis , eget tristique tortor . Lorem ipsum dolor sit amet , consectetur adipiscing elit . Morbi et rutrum felis , eget tristique tortor . Lorem ipsum dolor sit amet , consectetur adipiscing elit . Morbi et rutrum felis , eget tristique tortor . 01 02 03 13

14. THANK YOU