BURN

GENERAL DIRECTORATE OF NURSING
BURN CARE
Functions Duties Policies and Procedures
Nursing Standards Organizing Committee for Hospital Services
2005
Ministry of Health, General Nursing Administration
Functions & Duties Policies & Procedures
___________________________________________________
SPECIALIZED NURSING: BURNS
TITLE: INDEX NUMBER

RESPONSIBILITIES OF STAFF NURSE IN BURNS UNIT SNR-BC-002
EFFECTIVE DATE APPLIES TO APPROVED BY PAGE NUMBER

NURSING 1 of 3
POLICY:
1. A graduate of Bachelor of Science in Nursing from accredited school, with one-

year experience in Burns Unit.
2. Registered with current license and CPR license.
3. Staff nurse without experience in Burn Unit shall be trained and supervised by
senior nurses until she is proficient.
4. Assistant nurse without experience in Burn Unit shall be trained and supervised
by senior nurses until she is sufficient.
PURPOSE:
1. Provide professional care for burn’s patient and comply with established nursing
standards.
2. To clearly define duties and responsibilities.
3. To guide nursing actions.
DUTIES AND RESPONSIBILITIES:
1. Admit and orient new patients and family.
2. Instruct that watchers are not allowed to stay; only pediatric patients can have
watchers aged 1 to 12 years old.
3. Check patient chart, information must be clear and consistent.
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INDEX NUMBER PAGE NUMBER
RESPONSIBILITIES OF STAFF NURSE IN SNR-BC-002 2 of 3
BURNS UNIT
4. Take patient medical past, present history and must be properly documented.
5. Assemble patient chart, should be neat and properly arranged.
6. Carryout doctor’s order properly and correctly.
7. Plan nursing care according to patient problem priorities.
8. Update kardex.
9. Maintain required unit records.
10. Plan patient’s diet and arrange with dietician.
11. Plan for patient discharge or transfer.
12. Maintain controlled drug records.
13. Check supplies, crash cart content must be complete.
14. Answer telephone politely and deliver message accurately.
15. Observe proper technique (asepsis) in all performance of duties.
16. Make rounds with doctor. Prepare and assist physician during treatment and
examination.
17. Administer prescribed medications by following the seven rights.
18. Clean wounds, change dressing aseptically. Bath patient as needed.
19. Make nursing rounds, assess patient condition, answer questions give
instructions to obtain nurse-patient interaction, check vital signs (TPR, B/P, and
HR).
20. Check functioning medical equipment attached with the patient.
21. Administer fluid therapy. Accurately.
22. Observe and record progress of patient appetite, attitude, activity of daily living or any
symptoms.
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RESPONSIBILITIES OF STAFF NURSE IN SNR-BC-002 3 of 3
BURNS UNIT
23. Notify in-charge doctor of any significant changes in patient response to

treatment and care.
24. Recognize emergencies and respond with proper protocol e.g. incubation.
25. Record all legal matters about patient and document legibly.
26. Know how to keep confidence in case patient shares her/his private life.
27. Communicate with the head nurse for any request. It should be done through
proper channel of communication.
28. To receive and endorse patients pre and postoperatively according to hospital
routine.
4
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TITLE: INDEX NUMBER

ORIENTATION OF NEW STAFF IN BURNS UNIT SNR-BC-003

NURSING 1 of 3
POLICY:
1. Standard Burns Unit orientation shall be provided to the new staff.
2. Orientation program shall take at least three months.
3. New staff shall have the opportunity to experience all aspect of burn unit.
4. Allow new staff to give opportunity to repeat new learning experiences for
purposes of review with a later date.
5. Orientation will be able to complete burn unit checklist for the orientation periods,
which will serve as a reference between orientee and mentor.
PURPOSE:
To familiarize new staff with the burns unit environment, equipment, policy, and
procedures.
PROCEDURES:
First Week – Burns Unit Introduction
1. Identify the staff and colleagues.
2. Can locate the duty schedule and follow hours of duty
3. Identify the doctors.
4. Locate the office of Department of Nursing.
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ORIENTATION OF NEW STAFF IN BURNS UNIT SNR-BC-003 2 of 3
Other Wards and Departments:
Location of Emergency Room

Main ICU, Operating Room
Delivery Room, Maternity I and II.
Male surgery, Female Surgery, Orthopedics Surgery
Female Medical, Male Medical Ward
Pediatric Ward.
PICU
NICU
NICU Isolation
SCBU
X-ray, CT Scan Department, and MRI Department
OPD I and II
Laboratory
Second Week
1. Location of equipment and supplies.
2. Care of equipment and linen.
3. Use of oxygen cylinders, oxygen flow meter on the wall.
4. Care of drugs and narcotics.
5. Use of narcotics and controlled drug forms.
6. Explain and demonstrate crash cart function.
Other Wards and Departments:
Send samples to laboratory

Pharmacy request
Laundry
General Store
Bio-medical Department
Medical secretary office
Adinistration office
Library
Auditorium
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ORIENTATION OF NEW STAFF IN BURNS UNIT SNR-BC-003 3 of 3
Third Week
1. Recall the Burns Unit policy and procedures.
2. Setting with and check the cardiac monitors.
3. Carry out assignments and responsibilities.
4. Care of laboratory specimens.
5. Completion of burns unit records.
6. Disposition of contaminated linen.
7. Clean patient’s bed, bedside table after discharge.
8. Use of telephone and pager, beeper.
Fourth Week
Respond to every hospital procedures:
CPR
Code Blue
Fire Procedures
Safety Awareness
Disaster Plan
Second month orientee shall be able to repeat the same with minimum guidance.
End third month she/he should be able to perform independently.
7
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TITLE: INDEX NUMBER

BURNS UNIT ATTIRE SUIT SNR-BC-004

NURSING 1 of 3
DEFINITION:
An approved uniform used in Burns Unit
OBJECTIVE:
1. To provide effective barriers that prevents the dissemination of microorganisms to

patient or environment.
2. To protect personnel or patients against exposure to communicable disease and

hazardous materials.
POLICY:
1. The approved burns unit attire suit consists of head covers, shirt, trousers, and
shoe cover.
2. The sterile scrub suite for sterile personnel consists of sterile gown, sterile
gloves, and facemask, added to the basic operating room attire.
3. All personnel or visitors are required to change into operating room attire from
outside clothes at all times upon entering burns unit. Clean burns attire is donned
upon reentrance into OR.
4. All burns unit personnel must wear freshly laundered clean burns unit attire at all
times. Burns unit attire should be discarded for laundry and not hang in the
locker/cupboard with outside cloths.
5. It is required to change into new burns unit attire if wet/blood stained.
6. Burns unit attire must be worn correctly at all times.
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BURNS UNIT ATTIRE SUIT SNR-BC-004 2 of 3
7. Burns unit attire should no be worn outside burns unit complex.
8. Facemask should be worn in restricted area of burns unit.
8.1 Facemask must be worn over both nose and mouth and conform to facial
contour.
8.2 Mask string must be tied tightly and never cross overhead as it can distort
contour of mask along cheeks.
8.3 No hanging of mask around neck.
8.4 Must should be kept clean and must be changed whenever necessary.
8.5 Talking should be kept to a minimum.
9. Jewelry should be removed, pierced – ear studs must be confined within head
cover.
10. Fingernails should kept short, without nail polish and artificial nails.
11. Outside clothes are only allowed in unrestricted area.
12. Shoe inside burns unit should not be worn outside the unit.
12.1 Shoe cover should be removed when outside the burns unit.
12.2 Change shoe cover between dressings and whenever it become wet or
torn.
13. All nursing staff to do initial hand wash for 5 minutes between patient bath and
sterile dressing.
14. Comfortable supportive shoes should be worn to relieve fatigue.
15. Staff with acute infection, such as cold or sore throat, or skin lesion such as
furuncle or any contagious condition, should not be permitted to do the sterile
dressing.
16. Only head cover that is provided by the hospital are allowed, white colored-Tarha
is allowed as long as it is not worn outside the unit.
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BURNS UNIT ATTIRE SUIT SNR-BC-004 3 of 3
PROCEDURES:
1. Wash hands
2. Remove outside clothes and shoes.
3. Put on head cover first.
3.1 Confine all hairs in the head cover.
3.2 Confine earrings or ears studs in the head cover
4. Wear approved scrub suit or attire.
5. Wear approved shoes.
6. Wash hands upon entering burns unit.
7. Wear mask whenever required.
7.1 Hold mask by the strings
7.2 Cover both mouth and nose with mask completely.
7.3 Tie upper strings at back of head first, followed by lower strings behind the
neck. Secure the nurse while uncomfortably.
7.4 Press the exterior pliable strip or noseband to contour mask over the bridge
of the nose.
7.5 Check mask cover nose and mouth at all times. Check mask is not hanged
around the neck or tucked into pocket for further use.
7.6 Remove mask by:
7.6.1 Untie upper string
7.6.2 Untie lower string
7.6.3 Discard mask in a proper receptacle.
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____________________________________________________
SPECIALIZED NURSING BURNS
TITLE: INDEX NUMBER

ISOLATION NURSING, MASK, GOWNS, AND GLOVES SNR-BC-005

NURSING 1 of 2
DEFINITION:
The patient is taken care of in a separated room for reverse isolation.
OBJECTIVE:
1. To prevent transmission of infection.
2. To provide the physical barriers.
3. To prevent soiling of clothing during patient care.
4. To maintain aseptic environment.
5. To reduce the possibility that personnel will become contaminated with any blood
or body fluids spills.
6. To reduce the possibility that personnel will become transiently colonized with
microorganisms that can be transmitted to other patients.
POLICY:
1. All personnel entering the patient’s room under isolation should use
precautions as indicated by the CDC card category of isolation.
2. Sterile gown, gloves, and mask should be used for any sterile procedure.
3. Gowns are never to be used more than once and should be changed if
soiled or moist.
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ISOLATION NURSING, MASK, GOWNS, AND INDEX NUMBER PAGE NUMBER
GLOVES SNR-BC-005 2 of 2
4. Dispose of the contaminated gown within the patient’s room in the

appropriate hamper trolley.
5. Hands must be washed before and after wearing gloves.
6. Mask should be worn only once and replace if it will become moist or
damp.
7. Gloves should not be used as a substitute for meticulous hand washing.
8. Mask must be discarded inside the patient’s room before leaving and
never hang around the neck.
MATERIALS & EQUIPMENTS:
1. Clean mask.
2. Sterile gown (to perform sterile procedures only).
3. Sterile and non-sterile gloves.
PROCEDURE RATIONALE
1. Assess the patient’s condition.
2. Explain the patient the need of using 2. To reduce anxiety.

mask, gown, and gloves.
3. Wear mask fitted to cover nose and

3. To prevent particles aerosols
mouth and fit tightly against the skin
transmitted by close contact.
without gaping at the sides.
4. Wear gown and fasten it securely at 4. To maintain sterility.

the neck and waist. Cover the overlap To protect gross-clothing
completely at the back. contamination.
5. Wear gloves by covering the wrist and

cups of gown, if worn.
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___________________________________________________
TITLE: INDEX NUMBER

ADMISSION OF BURNS PATIENTS SNR-BC-006

NURSING 1 of 3
DEFINITION:
Any patients admitted to Burns Unit who is in contact with profound trauma of the
skin.
OBJECTIVES:
1. To properly assess and provide immediate management for further treatment.
2. To administer proper sedation to alleviate suffering.
3. To provide comfort and psychological support.
4. To give proper nursing care for burns patients.
5. To facilitate and increase the effectiveness of emergent burn-phase procedures.
POLICY:
1. Admits patients without delay.
2. There must be written order from physician.
3. Must have referral form if patient is referred from other hospital.
4. Patient must have police clearance for medico legal case.
5. Patients with the following categories of burn injuries should be admitted:
5.1 Children
Partial Thickness - more than 7 %
Full Thickness - more than 2 %
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ADMISSION OF BURNS PATIENTS SNR-BC-006 2 of 3
5.2 Adult
Partial Thickness - more than 10 %
Full Thickness - more than 2 %
6. Burns complicated by respiratory tract injury, major soft tissue injury, and
fracture.
7. Burns complicated by other medical or surgical conditions, which needs close

observation.
8. Electrical burns.
9. Strictly no watchers allowed staying with the patient except with pediatrics. No
patient shall allow to be loitering outside the hospital.
10. Visitors are entertained only in the visiting area. In case patient is serious, allow
relatives to see the patient inside the ward but give them proper scrub suits and
two persons at a time only in a limited time.
EQUIPMENTS AND MATERIALS:
1. Lund and Browde's Charts
2. Pencil
3. Dressing trolley
4. Sterile gamgee, lap sponge, $ X $ gauze
5. Flammazine and Flamagel
6. Basin
7. Normal Saline
8. Betadine Solution
9. Culture Swab sticks
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ADMISSION OF BURNS PATIENT SNR-BC-006 3 of 3
PROCEDURE
1. Render admission bath, if patient is sedated; give full bath with normal saline at
the bedside.
2. Call admitting doctor to check and estimate depth and BSA (body surface area)
of burns.
3. Do dressing quickly as possible but aseptically.
4. Insert IV lines; collect blood samples for laboratory investigation in case not
done in emergency room.
5. Insert Foley catheter if needed.
6. Check patient weight.
7. Initial vital signs and monitor intake and output hourly.
8. Allow doctor to complete patient’s file, medication notes, BSA form, and
doctor’s order form.
9. Provide clean and comfortable quite room for the patient.

10. Document patient condition and response to treatment.
15
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TITLE: INDEX NUMBER

PHYSICAL ASSESSMENT O THE BURNS PATIENT SNR-BC-007

NURSING 1 of 2
DEFINITION:
The initial assessment of burned patient upon admission.
OBJECTIVES:
1. To assess severity of the burns.
2. To give appropriate treatment.
3. To render good nursing care
POLICY:
1. Doctor and qualified nurses working in burns unit must perform the physical
assessment of newly admitted patients.
2. Thorough physical and mental examination must be done immediately after

admission.
3. To decide whether patient require hospital treatment of out patient treatment only.
PROCEDURE:
1. Stay with the patient side and assist the doctor during examination.
2. Check vital signs, temperature, pulse rate, rhythm and character.

PHYSICAL ASSESSMENT OF THE SNR-BC-007 2 of 2
16
BURNS PATIENT
PROCEDURE RATIONALE
3. Evaluate mental status for: 3. To assess patient neurological

3.1 Presence of confusion status.
3.2 Delirium
3.3 Stupor
3.4 Semi-coma
3.5 Coma
4. Check for status of hydration, assess 4. To determine earlier as

by checking: possible for the hydration
4.1 Skin temperature therapy.
4.2 Skin turgor
4.3 Inspect the tongue for dryness
4.4 Jugular venous pulse
5. Check cardiovascular system including 5. To assess cardiovascular

apart from pulse. system status.
5.1 Blood Pressure
5.2 Character of heart sound
5.3 Character of peripheral
circulation by nail beds
blanching.
6. Assess respiratory system adequacy 6. To evaluate patient airway

of: entry and differentiate for
6.1 Air entry patient having possible
6.2 Character of breathe sounds inhalation injury.
6.3 Presence of crepitating and
rhonchi
6.4 Oral cavity and nose for presence
of soot particles, erythema or
ulcers.
7. Examine abdomen for: 7. To assess abdominal

7.1 Distention for bowel and bladder peristalsis.
7.2 Presence of bowel sounds
8. Assess muscoloskeletal system for

associated fractures.
9. Document all observation noted.

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TITLE: INDEX NUMBER

CLASSIFICATION OF BURNS ACCORDING SNR-BC-008
TO DEPTH AND BODY SURFACE AREA
NURSING 1 of 2
DEFINITION:
The assessment and evaluation method on the severity of burn injury by application
of Lund and Browder charts.
OBJECTIVES:
1. To assess severity of the burn injury.
2. To give appropriate treatment needed.
3. To render optimal nursing care services.
4. To provide IV fluid therapy according to the percentage of burns.
5. To classify according to the cause (thermal, electrical, chemical, or irradiation),

the extent of the body surface, burned and the depth of tissue damaged or
destroyed.
POLICY:
1. The physician must categorized depths of burns according to:
1.1 Superficial Burns
1.2 Superficial Partial Burns
1.3 Deep Partial Thickness Burns
1.4 Full Thickness Burns
CLASSIFICATION OF BURNS ACCORDING

TO DEPTH AND BODY SURFACE AREA
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SNR-BC-008 2 of 2
2. Lund and Browder Charts are to be used to determine the extent of burns in the
Physical Assessment of burn patient.
MATERIALS AND EQUIPMENTS:
Lund and Browder chart.
PROCEDURE RATIONALE
1. Unstable vital signs and

1. Assess the patient’s vital signs.
hypothermia will lead to more
deterioration.
2. Explain the procedure. 2. To reduce anxiety and to take

consent.
3. Take the patient to the tank room upon

3. To estimate depths and BSA
admission. Exposed patient body for
involved properly.
the doctor.
4. Provide the doctor chart for grading

patient BSA depths.
5. Start initial record in ICU monitoring

sheet.
6. Obtain at least two IV cannula for

severe cases. If no peripheral access
6. To avoid hypovolemic shock and
notify the doctor the need to insert
organ failure.
central line and follow IVF therapy.
19
TITLE: INDEX NUMBER

FLUID RESUSCITATION IN BURNS SNR-BC-009

NURSING 1 of 3
DEFINITION:
The Immediate intervention to replace the fluid volume deficit related to increase
capillary permeability and evaporative losses from the burn wound.
OBJECTIVE:
1. To replace fluid loss.
2. To maintain adequate tissue perfusion and circulating fluid volume.
3. To avoid ischemic damage to injured tissues and also to reduce tissue edema.
4. To prevent shock and damage to the vital organ.
POLICY:
1. Doctors and nurses working in Burns Unit must have the knowledge of
calculation for fluid resuscitation. of burns victim.
2. All burns patient must be prevented from going into hypovolemic shock.
3. Fluid resuscitation should be given to adult patient of more than 15 %

burn and pediatric patients of more than 10 % burn.
4. The basic of resuscitation will depend upon the extent and severity of
burns.
5. Nurses must assure a reliable intravenous route or central line for prompt
adequate fluid replacement.
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FLUID RESUSCITATION IN BURNS INDEX NUMBER PAGE NUMBER
SNR-BC-009 2 of 3
6. Parkland formula must be applied for fluid resuscitation after calculating

the size of burns and patients body weight
1st 24 hours
Adult: Parkland Formula: 4 X wt. of patient X % of burns
To give ½ of the total amount in 1 st 8 hours then remaining ½ in next 16

hours as Ringer Lactate only.
Pediatric: Parkland Formula: % of burns X wt. of patient X 3 + maintenance.
½ of the total amount should be given in 1 st 8 hours. 2nd ½ of the total

amount should be given in next 16 hours.
2nd 24 hours : Crystalloid + Colloid
For Adult and Pedia
Evaporated fluids + Maintenance
1 X % of Burns X Weight = Evaporated + Maintenance

= Total amount/24 hours.
¼ of the total amount is given as PPF, ¾ of the total amount is given as

D5NS or D5 ½ NS depends upon patient’s electrolytes results.
(N.B)
This formula is only a guideline to fluid resuscitation and it should be adjusted

according to hourly urine output and clinical evaluation.
To calculate the maintenance fluid, the following steps are to be

considered:
100 mL/kg for each kg 1 – 10 kg

50 mL/kg for each kg 11 – 20 kg,
Then, the remaining weight 20 mL/kg
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FLUID RESUSCITATION IN BURNS INDEX NUMBER PAGE NUMBER
SNR-BC-009 3 of 3
1. Intravenous cannulas
2. I.V stand
3. Type of IV Fluid to be given
4. Infusion pump and IV sets
PROCEDURE RATIONALE
1. Administer fluid therapy according to

doctor’s order.
2. Hypovolemia and
2. Give accurate amount of fluid by the use
hypervolemia will lead to
of infusion pump.
many complications.
3. Measure intake and output hourly. 3. It provides information about

renal perfusion, adequacy of
fluid replacement and fluid
requirements.
4. Observe the IV line frequently.
5. Monitor vital signs closely.
22
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TITLE: INDEX NUMBER

BASE LINE INVESTIGATION FOR BURNS PATIENT SNR-BC- 010

NURSING 1 of 2
DEFINITION:
A specific investigation for Burn patient on admission done to evaluate patient’s

clinical data to identify imminent problems that may arise.
OBJECTIVE:
1. To provide a base line data for comparisons
2. To assist in monitoring patient’s laboratory results.
3. To identify imminent problems that may arise
4. To give appropriate management and treatment.
POLICY:
1. There must be written Physician’s order.
2. Each laboratory request must be stamp by the requesting doctors.
3. Burns unit staff nurse shall sent patient’s specimen CBC, Sickle anemia, BUSE,
RBS, LFT, CK, LDH, Total protein, Albumin to the laboratory and a chest X ray is
carried out on admission.
4. The Chemistry profiles must be taken once or twice daily during the
patient’s critical phase while fluid resuscitation is in progress.
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BASE LINE INVESTIGATION FOR BURNS INDEX NUMBER PAGE NUMBER
PATIENT SNR-BC-010 2 of 2
5. The wound swab for culture and sensitivity must be taken on every parts
from different region of the affected burn parts on admission and twice
weekly.
6. All investigations results must be noted to doctor immediately.
7. Patients who are intubations, inhalation injuries require periodic CXR

studies.
8. The patient’s nutritional status is monitored through albumin levels and

urea nitrogen.
MATERIALS AND EQUIPMENTS
1. Blood Investigations Forms and Blood samples container
2. Spirit swabs, Tourniquet and Gloves
3. Swabs for culture and sensitivity
PROCEDURE RATIONALE
1. To allay fear and gain

1. Explain the procedure to the patient
cooperation
2. Take blood sample needed enough to

distribute each required investigations.
3. Call and communicate with radiology

departments for portable X ray
4. Take wound swabs for different regions of 4. To track the bacterial

the body for culture and sensitivity.. colonization of the wounds
5. Document all investigation done in nursing
kardex and nurse’s notes.
6. Inform doctor immediately when result is

back
24
25
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TITLE: INDEX NUMBER

ORAL NUTRITIONAL SUPPORT IN BURNS SNR-BC-011

NURSING 1 of 3
DEFINITION:
The provision of nutrition in solid or liquid form by mouth.
OBJECTIVE:
1. To achieve a daily proper nutrition.
2. To prevent malnutrition and weight loss.
3. To promote healing and fight infection.
4. To meet the physiological and psychological needs of burned patients.
5. To supply energy repair tissues aid in growth and development.
POLICY:
1. All patients admitted to burns unit must be started on diet as soon as possible.
Begin a clear liquid diet progressing to full diet as tolerated.
2. Patients be examined for the presence of diabetes, hyperlipidemias, liver

pancreatic or bowel diseases, and alcohol abuse and lactose intolerance.
3. Encourage patients but not forced to ingest increasing amounts of food.
4. Patients on narcotics should be observed for nausea and anorexia.
5. The nutritional requirements should includes carbohydrate, fat, protein, vitamins,

minerals, and trace elements.
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ORAL NUTRITIONAL SUPPORT IN BURNS SNR-BC-011 2 of 2
6. The diet should be adequate, palatable, and varied including all the
nutritional requirements and should be served at regular intervals more
frequently than regular meals.
7. Instruct the patient and family of the need for adequate nutritional and
encourage their cooperation.
8. Nurses should offer between meal nourishments such as juice, ice

cream, custard, sandwiches, and beverages.
1. Intake and output charts.
2. Prescribed food.
PROCEDURE RATIONALE
1. Assess the patient on the ability of 1. To make sure the patient can eat
feeding independently and feed the by himself or need assistance.
patient as required.
2. Explain to patient the importance of 2. To gain cooperation.

good caloric intake and aid him/her To honor any dietary requests the
menu selection. patient may have.
3. Allow the patient to rest before

each mealtime.
4. Elevate the head of the bed 4. To avoid aspiration or chocking

and promote comfort
5. Start with sips of water 5 To observe on the ability of

swallowing.
6. Place the tray in a secure position.
7. Prepare the food, open box, pour 7. To encourage the patient to

liquids, cut meat, chicken, fish, and consume all the food and
bread in small pieces. avoid choking.
27
ORAL NUTRITIONAL SUPPORT IN
BURNS SNR-BC-011 3 of 3
PROCEDURE RATIONALE
8. If patient can eat by himself place

a call bell nearby.
9. Encourage a leisurely pace of 9. To aid digestion.

eating.
10. Remove the tray immediately 10. To maintain clean

when finished. environment.
11. Provide mouth wash after meal 11. To provide comfort
12. Record calorie and liquid intake

in Intake and Output chart.
13. Keep the patient comfortable.
14. Document in nurses notes on

patient respond to meal and
amount taken.
28
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TITLE: INDEX NUMBER

DIETARY SUPPORT TABLE SNR-BC-012

NURSING 1 of 4
DEFINITION:
Formula exist for estimating the daily metabolic expenditure and caloric
requirements of patient with injuries.
OBJECTIVE:
1. To optimize the daily requirement of protein, carbohydrates, fat, and minerals,

etc.
2. To determine the nutrition needs.
3. To prevent malnutrition.
POLICY:
1. All patient admitted to Burns must have dietary chart.
2. The dietician must visit the patient at least twice a week.
3. All patients admitted to Burns follow the dietary formula below.
3.1 Calories
Adults:
[25 kcal x wt (kg)] + [40 % x % burn]
For burns over 50 % BSA use a constant of 50 % for the percent burn to prevent
over feeding
29
DIETARY SUPPORT TABLE SNR-BC-012 2 of 4
Pediatrics:
Age (Years) Kilocalories
0 – 0.5 kg x 115
0.5 – 1.0 kg x 105
1–3 kg x 100
4 – 10 kg x 85
11 – 14 kg x 60 (male)
11 – 14 kg x 48 (female)
1. Protein
Adults:
For burns greater than 10 % BSA:
kilocalories requirements x 20 % = Protein (gm)

4
= 20 x kcal
100 4
For burns 1 – 10 % BSA:
kilocalories requirements x 15 % = Protein (gm)

4
= 15 x kcal
100 4
Pediatrics:
over age 1 year – use adult formula
under age 1 year – 2 grams protein/kg weight
30
2. Carbohydrates
Enterally - 40 % - 50 % total kilocalories
Parenterally - 50 % - 70 % of non-protein kilocalories
3. Fat:
Enterally - 30 % - 40 % total kilocalories
Parenterally - maximum 2.5 grams/kg/day
4. Vitamins:
Water Soluble Vitamins
(B vitamins, folate, biotin):
Adults 2 x RDA*
Pediatrics over 9 months 2 x RDA*
Vitamin C:
Adults 1 – 2 grams/day
Pediatrics 500 mg/day
Infants 0 – 9 months 250 mg/day
Fat Soluble Vitamins (A, D, E):
Adults RDA
Pediatrics RDA
4. Minerals
Zinc:
Adults 2 x RDA
31
Pediatrics 2 x RDA
Infants RDA
Trace Elements:
Adults 2 x RDA
Pediatrics 2 x RDA
Infants RDA
1. Calculated diet list
2. Patient’s food
3. Measuring container
4. Meal table
5. Spoon, fork, and knife
PROCEDURE RATIONALE
1. Assess the patients condition and cooperation.
explain the need for proper nutrition
2. To ensure all required food
2. Help patient to eat assist him if
are consumed.
necessary
3. Record the food consumed in intake and 3. To monitor intake and output.
output chart
4. Encourage patient to sit or walk after 4. To help digest food

taking meals.
32
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TITLE: INDEX NUMBER

HYDROTHERAPY SNR-BC-013

NURSING 1 of 3
DEFINITION:
Hydrotherapy (tubing or tanking) is the bathing of the burn patient in tub or tank
water.
OBJECTIVES:
1. To assess the burned area and calculate the percentage of burns.
2. To facilitate the removal of adherent dressing and topical medications.
3. To loosen debris, sloughing eschar and exudates.
4. To provide an opportunity for the patient to practice range of motions exercises.
POLICY:
1. Burn wounds must be cleansed initially and daily with a need antibacterial
cleansing agent and saline solution.
2. Have the hydrotherapy room cleaned thoroughly before taking the patient to the
tank.
3. Patients with the following assessment should not be taken for hydrotherapy:
3.1 Newly grafted patients until 10 days after grafting.
3.2 Patients with core temperature below 36.5 degrees Celsius, and
3.3 All those special cases designed by the physician.
33
HYDROTHERAPY SNR-BC-013 2 of 3
4. Informed the physiotherapist before taking the patient to the tank room.
5. Two or three nurses should attend the patient for hydrotherapy.
6. Never leave the patient unattended in the water tank.
7. Give the prescribed analgesic before taking the patient to the tank room.
8. Respect the patients feeling and expressions of stress, pain, cold, and fatigue.
9. Fill tub with water of acceptable temperature to the ½ of the tank.
1. Hubbard tank or any other tank.
2. Hoist
3. End bars
4. Sterile blanket and bed sheet
5. Povideine-iodine scrub solution
6. Sterile 4 X 4 gauze sponges
7. Cups, mask, gowns, and sterile gloves
8. Bath lifter
PROCEDURE RATIONALE
1. Assess the patient and explain the 1. To allay fear and gain
procedure cooperation
2. If the patient has an indwelling catheter,

drain and plug it, or maintain a close 2. To avoid contamination.
system.
34
HYDROTHERAPY SNR-BC-013 3 of 3
PROCEDURE RATIONALE
3. Limit therapy to no more than 30 3. To avoid hypothermia and

minutes. fatigue.
4. Don cap, mask, gown, and sterile gloves.
5. Provide as much privacy as possible.
6. Performed wound cleaning and

debridement after opening the dressing
7. Allow physiotherapist to perform

exercises.
8. Wash the patient’s hair with shampoo.
9. Clean the wound with iodine scrub

9. To avoid irritation.
solution, then with normal saline.
10. Remove the patient from tub and shift to

sterile field.
11. Dry the patient with towel and gamgee

11. To avoid shivering and
on the wound. Apply the warmer if
hypothermia
required.
12. Apply the dressing as general dressing

policy with the prescribed topical cream.
35
TITLE: INDEX NUMBER

PHYSIOTHERAPY OF BURNED PATIENTS SNR-BC-014

NURSING 1 of 2
DEFINITION:
A vital service for the burn patient from the day of admission through the entire
course of rehabilitation.
OBJECTIVE:
1. To maintain or increase the pre-burn level of strength, range of motion,

endurance, and coordination.
2. To attain a pre-burn gait pattern.
3. To assist the patient in reaching the highest possible level of function and
maximum rehabilitation.
4. To promote good and normal posture.
5. To avoid contractures and deformities.
6. To promote self-care, mobility, positive body image, skin integrity and comfort.
7. To facilitate individual/family coping and learning process.
POLICY:
1. There must be a consultation form request per doctor’s order.
2. The exercises must be done by a physiotherapist, mandatory assigned in burns

unit.
3. Passive and active exercises of all limbs and joints are required daily.
36
PHYSIOTHERAPY OF BURNED PATIENTS SNR-BC-014 2 of 2
4. Cough and deep breathing exercises are encouraged soon after resuscitation
whenever possible.
5. Splints/backslabs should be judiciously used as indicated.
6. Prevention of post burn deformities begins along with the early management of
burn injuries.
7. Dressing must be removed before starting physiotherapy to any part of the body.
8. If not contraindicated physiotherapy should always be given in the tank room.
1. 4 X 4 gauze
2. Soft paraffin
3. Splints
4. Walker frame
PROCEDURE RATIONALE
1. Assess patient vital signs and wound

site.
2. Explain the procedure and stay with the 2. To reduce anxiety and gain
patient during physiotherapy. cooperation.
3. Give the order pain reliever then 3. To reduce pain and get the
remove the bandages. desired joint movement.
37
___________________________________________________
TITLE: INDEX NUMBER

BURNS DRESSING, LOCAL DEBRIDEMENT SNR-BC-015

NURSING 1 of 3
DEFINITION:
The covering of the wound after the removal of foreign substances and injured
tissue.
OBJECTIVE:
1. To reduce risk and promote good healing process.
2. To clean the burn wound and prevent infection.
3. To protect the burn wound, absorb exudates and keep patient comfortable.
4. To hold topical agents against the wound.
5. To help preserve position of limb.
6. To conserve patient’s body heat.
7. To minimize scarring.
8. To prevent mechanical trauma.
9. To reduce pain and allow debridement of burn.
10. To avoid muscle stiffness and contractures.
POLICY:
1. Patient to be redressed as required or as ordered.
2. Shall be an aseptic technique.
38
BURNS DRESSING, LOCAL DEBRIDEMENT SNR-BC-015 2 of 3
3. Masks, sterile gowns, sterile gloves, hair coverings shall be worn.
4. Dressing is to be performed by two burns trained nurses.
5. Procedure to be performed in treatment room or patient’s room in a closed

environment.
6. Procedure to be performed in the minimum amount of time.
7. Narcotic analgesia will be given prior to dressing as ordered by physician.
8. Physiotherapist is performed for physiotherapy after removing the dressing.
1. Sterile gown and gloves, mask and hat.
2. Trolley and cleaning agent.
3. Basic or burns dressing set which includes mosquito forceps, dissecting forceps,
and scissor.
4. Gauze swabs, 4 X 4 gauze, lap sponges, and gamgee.
5. Normal saline.
6. Topical agent as ordered, flamazine or flamagel.
7. Bactigras or supratule as ordered.
8. Bandages setonet (size according to patient and area of burn).
9. Ring remover if needed.
10. Tape.
11. Sterile towels.
12. Wound swabs.
39
BURNS DRESSING, LOCAL DEBRIDEMENT SNR-BC-015 3 of 3
PROCEDURE
1. Render admission bath, if patient is sedated; give full bath with normal saline at
the bedside.
2. Take swab for all old burns cases upon admission before bathing.
3. Call admitting doctor to check and estimate depth and BSA (body surface area)
of burns.
4. Do dressing quickly as possible but aseptically.
5. Insert IV lines; collect blood samples for laboratory investigation in case not
done in emergency room.
6. Insert Foley catheter if needed.
7. Check patient weight.
8. Put patient on bed comfortably and start normal fluid therapy according to
doctor’s order.
9. Start medication per doctor’s order.
10. Initial vital signs and monitor intake and output hourly.
11. Allow doctor to complete patient’s file medication notes, BSA form, and doctor’s
order form.
12. Provide clean and comfortable quite room for the patient.
13. Document patient condition and response to treatment.
40
___________________________________________________
INDEX NUMBER
TITLE:
SNR-BC-016
ASSISTING FASCIOTOMY OF CIRCUMFERENTIAL BURNS

NURSING 1 of 3
DEFINITION:
The eschar is surgically cut into squares to alleviate stricture and to allow exudates
to drain, and permit adequate circulation to underline tissues.
OBJECTIVE:
1. To release the pressure on the circumferential burn site.
2. To prevent damage of the organ.
3. To promote blood supply to the peripherals.
4. To allow passive movement of the joints.
POLICY:
1. The peripheral pulses should be taken every hourly and if possible with the
Doppler Ultrasound Device.
2. The procedure is done under aseptic technique.
3. All constricting jewelries and clothing should be removed.
4. The Inspect dressing is required to be inspected regularly, if mild bleeding occurs

to reinforce dressing.
5. The nail beds are required to be inspected for any cyanosis and tips of
extremities for cold temperature.
41
ASSISTING FASCIOTOMY OF INDEX NUMBER PAGE NUMBER
CIRCUMFERENTIAL BURNS SNR-BC-016 2 of 3
1. Big dressing trolley
2. Basic procedure set
3. Diathermy machine
4. Betadine scrub and solution
5. Sterile gauze 4 X 4, lap sponge
6. Bactigras
7. Creep Bandage
8. Sterile Linen
9. 3 Sterile Gown (1 for the doctor, 1 for the scrub nurse, 1 for circulating nurse).
10. Surgical gloves, surgical blade (size 11 and 20)
11. Silk suture (different sizes).
PROCEDURE RATIONALE
1. Assess the patients condition and explain 1. To allay fear and gain
the procedure cooperation.
2. Place the patient in supine position or as

required by the doctor according to the
site
3. Bring prepared the trolley on the bed side
4. Wash hands, wear gown, gloves and mask
42
ASSISTING FASCIOTOMY OF INDEX NUMBER PAGE NUMBER
CIRCUMFERENTIAL BURNS SNR-BC-016 2 of 3
PROCEDURE RATIONALE
5. Expose only the part of patient’s body for

fasciotomy and wash with normal saline
by Circulating Nurse.
6. Scrub Nurse to assist the doctor.

7. Once fasciotomy completed, dress with
bactigras and gauze soaked with
7. To absorb bleeding.
batadine,
apply flammazine and thick dressing.
8. To reduce edema and
8. Elevate the post operative site promote
blood circulation.
43
_______________________________________________
TITLE: INDEX NUMBER

THERAPEUTIC POSITIONING & PREVENTION OF SNR-BC-017
DEFORMITY AND CONTRACTURES
NURSING 1 of 3
POLICY:
1. Prevention of post burn deformities can be carried out more effectively if one
understands the facts that the position of comfort is the position of contracture,
and burn wound will continue to shorten until it has met and equal and opposite
force.
2. Prevention of post burn deformities begins along with the early management of
burn injuries.
3. Strict program of proper joint positioning, splinting , pressure dressing and

physical exercise must be instituted as soon as possible and should be carried
on till full maturation of the burn scar, so as to avoid the crippling post burn
deformities due to scar contractures.
4. Patient should be examined, and the sites of burn injury at risk for development
of complications are indentified and evaluated.
5. Principles of proper positioning and splintage should be continued even when

skin grafting is done. The graft are retained with occlusive dressing and splints
applied over the dressing are retained with elastic bandages.
44
THERAPEUTIC POSITIONING & PREVENTION INDEX NUMBER PAGE NUMBER
SNR-BC-017 2 of 3
OF DEFORMITY AND CONTRACTURES
TABLE TO FOLLOW
Region of Position of Position of Technique of prevention during

Body Possible Prevention wound stage
Contracture
Neck Flexion Extension Custom made isoprene conforming
splint-purchase on mandibular rami
above and on clavicles. Inferiorly
retained by two crostraps.
Axilla Abduction 90° abduction Splints avoided tohelp in daily

15° forward dressing.
flexion
Hips Abduction 15° abduction Splints avoided to facilitate

flexion dressings carefully supervised
positioning yields good result.
Elbow and Flexion Extension Splints are essential padding

knees continuous application 24 hrs.
except for interval of dressings.
Ankles Depending upon 90° Splint are not contraindicated but

the area of dorsiflexion early ambulation even in the
maximum presence of lower extremity wounds
involvement gives good results.
Hands Flexion at wrist 20° extension Splints are absolutely necessary to
extension of meta at wrist; 15 to keep thumb abducted and flexed
carpophalangeal 20°metacarpo- well away from the hand continuous
joint flexion at phalangeal application except for interval of
interphalangeal extension, dressing.
joint interphalangeal
extension
45
THERAPEUTIC POSITIONING & PREVENTION INDEX NUMBER PAGE NUMBER
SNR-BC-017 3 of 3
OF DEFORMITY AND CONTRACTURES
PURPOSE:
1. To give good nursing care.
2. Toa void contractures and deformities.
3. To promote good and normal posture.
4. Prevent for another complicated surgery.
PROCEDURE:
1. Upon admission make it a rule for the patient to exercise affected joints form time
to time, to avoid contracture as early as possible.
2. Send physiotherapy request per doctor’s order.
3. Stay with the patient during the procedure to lessen anxiety.
4. Encourage positive outcome for the patient.
5. Assist early ambulation.
6. Participate with the patient actively every morning to start the routine.
7. Practice patient early selfcare to achieve optimal goal.
8. Document patient programs to treatment and interventions.
46
_____________________________________________________
TITLE: INDEX NUMBER

CARE OF PATIENT WITH INHALATION INJURY SNR-BC-018

NURSING 1 of 1
DEFINITION:
The specific nursing care of patient who has inhaled smokes resulting from any kind
of burns.
OBJECTIVES:
1. To maintain a patent airway, adequate oxygenation and ventilation
2. To identify carbon monoxide poisoning promptly.
POLICY:
1. All patients who are burned on the face and neck or those who inhaled flame,
steam, or smoke should be observed closely for sign of laryngeal edema and
airway obstruction.
2. All patients in closed spaces fires should be assess for the signs and symptoms
of carbon monoxide poisoning.
3. The physician should be informed immediately if any sounds of hoarseness and

crackles are identified.
4. The arterial blood gas should be checked daily and carboxyhemoglobin level on
admission and when condition requires.
5. The chest X-ray must be done on admission as baseline data and when ever
needs arises as ordered by doctor.
47
CARE OF PATIENT WITH INHALATION INJURY SNR-BC-018 2 of 2
6. Oxygen administration should be humidified at all times to patient with inhalation

injury.
1. Stethoscope
2. Arterial blood gas results
3. Oxygen with humidifier
PROCEDURE
1. Assess the patient for :
1.1 Respiratory Status
1.2 Carbon Monoxide poisoning
1.3 Areas of burns involved
1.4 Signs and symptoms of inhalation injury:

laryngeal edema and stridor
1.5 Observe for burns of lips, vocal mucosa, or pharynx, droll gray or black
sputum.
2. Administer humidified oxygen as ordered by doctor
3. Obtain arterial blood gases and ensure chest X- ray is done.
4. Observe patient’s respiratory status every hourly
5. Observe signs of stridor or apnea during sleeping
6. Instruct patient to do deep breathing excises every 4 hourly.
7. Document in the nurses notes on the specific care given, any signs of
inhalation injury and the patient’s condition
48
TITLE: INDEX NUMBER

CARE OF BURNED LIPS AND MOUTH SNR-BC-019
NURSING 1 of 2
DEFINITION:
The specific care of burned wound at lips and mouth and establishment of routine
care that involves debridment.
OBJECTIVE:
1. To prevent infection in oral cavity.
2. To enable patient to eat.
3. To prevent contractures around lips and mouth.
POLICY:
1. Mouth care should be given frequently especially before and after meals and as
often as necessary. The mouth care cleansing must be thoroughly done and pay
attention to the lips.
MATERIALS AND EQUIPMENT:
1. Dressing Sets
2. Tongue spatula
3. Sterile gown and gloves
4. Sterile towel
5. Normal saline
6. Sodium Bicarbonate
7. Gauze
49
CARE OF BURNED LIPS AND MOUTH SNR-BC-019 2 of 2
PROCEDURE RATIONALE
1. Explain the procedure to patient 1. To allay fears and ensures

cooperation.
2. To be organized in doing
2. Assemble complete equipment to bedside
procedure
3. To create sterile field and

3. Drape sterile towel around patient’s neck
protect patient’s.
4. Swab mucosa and tongue with dissolved

Sodium Bicarbonate 4. To remove mucous.
5. Remove debris from between patient’s teeth

with a tongue depressor on a wrap-around
gauze.
6. Assist patient to clean teeth with toothbrush and

toothpaste to prevent caries
7. Provide antiseptic solution to gargle mouth.
8. Document in nursing notes the condition of

wound and mouth care procedure that has been
given
50
___________________________________________________
TITLE:
INDEX NUMBER
CARE OF BURNED EYELIDS SNR-BC-020

NURSING 1 of 2
DEFINITION:
The specific dressing required for wound of burned ear.
OBJECTIVE:
1. To preserve function.
2. To prevent infection.
3. To promote patient’s comfort.
4. To render proper eye and eyelid care.
POLICY:
1. Burn wounds to eyelids to be cleansed every two to three hours or as required.
2. Staff nurse experienced in burns care must carryout the procedure.
1. Dressing set
3. Sterile towel
4. Normal Saline
5. Prescribed medications
51
CARE OF BURNED EYE LIDS SNR-BC-020 2 of 2
PROCEDURE RATIONALE

cooperation
2. Assemble complete equipment to bedside 2. To be organized in

procedure
3. Instruct patient to close eye and remove as

much loose debris as possible by cleaning
eye lashes thoroughly using soaked saline
gauze
4. Wipe eye with normal saline swab from inner 4. To prevent spread of
infection
cantus and move away from nose.
5. Repeat the procedure until eyelid is clean
6. Apply antibiotic cream to the conjunctiva sac 5. Antibiotic act as a

as ordered by the physician. prophylactic
52
___________________________________________________
TITLE: INDEX NUMBER

CARE OF BURNED EARS SNR-BC-021

NURSING 1 of 2
DEFINITION:
The specific dressing required for wound of burned ear.
OBJECTIVE:
1. To prevent deformities and infection.
2. To prevent chondritis and deterioration or loss of cartilage due to infection
3. To promote good healing
4. To initiate ear care.
POLICY:
1. Care must be taken to prevent patient from lying on the affected ear to
prevent any pressure on injured portion of cuticle.
2. Frequent change of dressing or change dressing every 6 hourly is

important to keep the wound dry.
1. Dressing Sets
2. Cotton tip applicator.
4. Sterile towel
53
CARE OF BURNED EARS SNR-BC-021 2 of 2
5. Normal Saline
PROCEDURE RATIONALE

cooperation.
2. To be organized in doing
2. Assemble complete equipment to bedside
procedure
3. Place sterile green towel on top of the
3. To provide barrier between the
pillow or mattress.
pillow and the ear.
4. Clean pinea and folds using cotton tip
applicator
5. Clean wound at ear aseptic technique
6. Apply prescribed ointment or saline packs

as ordered by the physician
7. Place wet normal saline gauze in between 7. To prevent pinea sticking to the
the pinea and the head and close the side of head.
dressing the burn ears.
8 Document dressing and observation of

wound,
54
_______________________________________________________
TITLE: INDEX NUMBER

CARE OF BURNED FACE SNR-BC-022

NURSING 1 of 2
DEFINITION:
The specific dressings required for burned wound of face establish a routine of face
care by keeping moist dressing.
OBJECTIVE:
1. To remove all exudates.
3. To prevent deep scarring.
4. To give patient a sense of well-being.
5. To protect and examine patients eyes.
POLICY:
1. Facial burned wounds are to be cleared every 2 to 4 hours in the acute phase,
less frequently as the area heals. Faces are usually left exposed. Men’s faces
must be showed daily.
2. Procedure to be performed in a warm environment (not less than 26 degrees

Centigrade). i.e. treatment room or patient’s own room with door closed.
3. The accumulation of crust and exudates must be removed during dressing.
55
CARE OF BURNED FACE SNR-BC-022 2 of 2
1. Dressing Sets
3. Sterile towel
PROCEDURE RATIONALE
1. Explain the procedure to patient 1. To allay fear and gain

cooperation.
2. Assemble complete equipment to 2. To be organized in

bedside. procedure
3. Drape sterile towel around patient’s

3. To create a sterile field.
neck.
4. Clean the whole face with saline.

5. Shave hair off around face, forehead, 5. To prevent infection
ears, and neckline.
6. Check scalp for burn areas and shave
affected areas.
7. Carefully remove exudates to stop from

drying out cracking.
8. Pay particular attention to nose, ears,

eyes, and lips.
9. Apply saline packs or ointment as

ordered to the face.
10. Repeat dressing until wound clean

11. Document in nurses notes of
procedures and condition of wound
observed.
56
___________________________________________________
TITLE: INDEX NUMBER

CARE OF BURNED NECK AND CHEST SNR-BC-023

NURSING 1 of 2
DEFINITION:
The specific nursing care of patient with burned neck and chest in maintaining the
respiratory status and prevention of neck contractures.
OBJECTIVE:
1. To take the necessary precautions to maintain airway patency and eliminate

respiratory difficulty.
2. To preserve a cosmetic appearance.
3. To reduce scarring and contractures.
4. To evaluate the need of escherotomy
5. To promote good healing
POLICY:
1. The patient’s neck shall be kept in a hyperextend position all the time to prevent
neck from contracting.
2. Patient should not use any pillows when lying down on bed.
3. Customize cervical collar should be applied if ordered.
4. The physician must be informed immediately if any restriction of chest movement

during breathing.
5. The patient‘s head should not be supported when in sitting position.
57
CARE OF BURNED NECK AND CHEST INDEX NUMBER PAGE NUMBER
SNR-BC-023 2 of 2
1. Rolled sterile bath towel
2. Shaving set
3. Wash basin with water
4. Customized Cervical collar
PROCEDURE RATIONALE

cooperation.
2. Assemble complete equipment to 2. To be organized in doing

bedside procedure
3. Shave the neck, remove loosens debris. 3 To keep wound clean and
prevent potential infection.
4. Clean the wound in neck and chest

aseptic technique in dressing procedure
5. Apply splint or neck collar as ordered.
6. Place rolled towel under shoulders when 8. To prevent contractures.

patient lies supine extend the neck.
7. Observe patient’s respiratory rate, 7. To assess patient

rhythm and chest expansion every half respiratory status
an hour until patient’s stable.
8. Instruct patient to do deep breathing 8. To facilitate a good

exercise every 4 hourly. expansion of chest
9. Document in nurses notes the wound

condition, respiratory status and
patient’s
respond to exercise.
58
TITLE: INDEX NUMBER

CARE OF BURNED HANDS IN POLYTHENE BAGS SNR-BC-024

NURSING 1 of 3
DEFINITION:
A specific care and dressing of wound at burned hands.
OBJECTIVES:
3. To decrease and prevent edema.
4. To prevent the deepening of partial thickness burns to full thickness.
5. To enable patient to mobilize his/her hands.
6. To enable patient to self care especially feeding.
POLICY:
1. The wound care should be carried out as required or at least 12 hourly.
2. Staff nurse experienced in burns care must perform the procedure.
1. 1 large sterile bowl/basin
2. 1 pair sterile gloves
59
CARE OF BURNED HANDS IN POLYTHENE INDEX NUMBER PAGE NUMBER
BAGS SNR-BC-024 2 of 3
3. 2 small clean plastic bag
4. 2 small bandage
5. Sterile gauze 4 X 4
6. Tape
MATERIALS AND EQUIPMENT
1. Flamazine or Flamagel
2. Betadine and water
3. 2 sterile towels
4. Sterile forceps and scissors
PROCEDURE RATIONALE
1. Explain the procedure to patient 1. To allay fear and gain cooperation.
2. Assemble complete equipment to bedside. 2. To be organized in procedure
3. Add betadine in water
4. Don gloves, wash patient hands and

gently exercise the patient’s hands.
Perform debridement on loose skins and
blister.
5. Apply flammazine sparingly to both side of 5. To provide antiseptic and promote

hands healing
6 Apply polythene bag and make sure 6. To encourage mobilization

patients can move his hands
7 Apply 4 X 4 gauze to wrists loosely 7. To absorb exudates and not allow

bag to slip.
60
CARE OF BURNED HANDS IN POLYTHENE INDEX NUMBER PAGE NUMBER
BAGS SNR-BC-024 3 of 3
PROCEDURE RATIONALE
8. Bandage the bags securely at the wrist. 8. To keep bag in position
9. Keep hands elevated at all times 9. To reduce edema and

encourage venous return
10. Teach patient's to perform fingers and 10 To reduce the risk of fingers
hands exercise. Inform patient to perform and hands contractures.
every hourly.
11. Document in nurses notes on condition of

wound and care given.
61
_______________________________________________
TITLE: INDEX NUMBER

CARE OF BURNED HANDS IN CLOSED DRESSING SNR-BC-025

NURSING 1 of 2
DEFINITION:
The specific dressing requiresfor hands and the fingers and individually dress to
prevent contractures.
OBJECTIVE:
3. To promote healing.
POLICY:
1. Closed dressing can be used lightly when minimal dressing is required.
2. Procedure is to be performed using aseptic technique in treatment room on

patients own room with door closed.
1. Dressing Sets
3. Sterile towel
4. Narrow stocking or gauze.
5. Fine scissors
62
CARE OF BURNED HANDS IN CLOSED SNR-BC-025 2 of 2
DRESSING
PROCEDURE RATIONALE
1. Explain the procedure to patient 1. To allay fear and gain

cooperation
2. Assemble complete equipment to bedside. 2. To be organized in

procedure
3. Clean wounds on the hands and dry
completely
4. Perform debridement of loose skin using

fine scissors and forceps.
5. Cover wound with paraffin gauze and

betadine soaked with gauze.
6 Apply light gauze and wear stockinet to each 6. To prevent contractures and
finger individually. allow movement.
7. Elevate the hand 7. To prevent edema
63
_________________________________________________
TITLE: INDEX NUMBER

CARE OF BURNED FEET AND LEGS SNR-BC-026

NURSING 1 of 2
DEFINITION:
The optimum care given to patient with burned feet and legs by keeping the leg
elevated and prevention of trauma to the feet.
OBJECTIVE:
1. To promote good healing of wound..
2. To prevent contractures and abnormality.
POLICY:
1. The dressing is done in aseptic technique.
2. The dressing is changed every 4 to 6 hourly or when ever necessary.
3. The dressing to the burns to toes should be done individually and separate them
with rolls of gauze before application of bandage.
4. Passive exercises of leg are carried out during the dressing.
1. Dressing Sets and Sterile towels
3. Normal Saline
5. Pillows to elevate legs
6. Splints
64
CARE OF BURNED FEET AND LEGS SNR-BC-026 2 of 2
PROCEDURE RATIONALE

1. Explain the procedure to patient
cooperation.
2. To be organized in
2. Assemble complete equipment to bedside.
procedure
3. Clean the wound with normal saline

4. To provide even
4. Bandage toe to groin. pressure for venous
return.
5. Elevate the limbs as high as possible to
patient comfort.
6. To prevent foot drop and
6. Apply splint as ordered.
knee contractures
7. To provide good muscle

7 Provide regular passive exercise to patient
tone and prevent deep
venous thrombosis.
8. Document in nurses notes on the wound
condition and the respond to passive
exercise.
65
___________________________________________________
TITLE: INDEX NUMBER

CARE OF BURNED GENITALIA SNR-BC-027

NURSING 1 of 2
DEFINITION:
To promote hygiene and comfort.
OBJECTIVES:
1. To reduce the risk of infection.
2. To keep patient comfortable.
3. To enable patient to mobilize comfortably.
4. To promote good healing.
POLICY:
1. Dressings are changed four hourly in the acute phase, they must always be
changed after defecation.
2. Use aseptic technique.
3. The procedure is to be carried out by a burns trained nurse.
1. As per general dressing procedure.
2. Setonet stockinette to make net pants X 2.
66
CARE OF BURNED GENITALIA SNR-BC-027 2 of 2
3. Wool gauze pad and tape
PROCEDURE RATIONALE
1. Prepare equipment as per general dressing To decrease patient

policy. exposure time.
2. Explain procedure to patient To allay fears.
3. Cleanse with saline and apply flammazine to

burned areas.
4. Apply dressing making sure patient can pass

urine, if patient is catheterized apply pad to
perineum area.
67
TITLE: INDEX NUMBER

CARE OF THE PATIENTS WITH FLAME BURNS SNR-BC-028

NURSING 1 of 3
DEFINITION:
To provide nursing care, pain management for the flame burns.
POLICY:
1. Result from conflagrations when patient has direct contact from burning object,
or from industrial accidents involving flammable liquids.
2. A burn of different distributions occurs when a patient tries to beat out the flames
of burning clothing with his/her hands.
3. Most of the serious injuries of flames are due to clothing burns, due to ignition of
clothing.
4. Following at severe flame burns patient may pass into a state of shock, and it is
the recognition and management of this condition, which is the surgeon’s most
urgent duty during the first few days after such an injury.
5. Usually involves large areas of the body and may involve the lungs as a result of
smoke inhalation.
6. Estimating body surface area burn is done by the use of Rule of 9 and the Lund-
Browders chart.
7. Depths of the burns are classified as:
7.1 rficial Burns
7.2 rficial to Facial-Thickness Burns
7.3 Full-Thickness Burns
68
CARE OF PATIENTS WITH FLAME BURNS SNR-BC-028 2 of 3
8. Qualified nurse working in Burns Unit must be manageable to initiate immediate

measures of burns.
PURPOSE:
1. To give good nursing care.
3. To promote healing.
4. To prevent contractures.
5. To prevent further damage of skin.
1. Pencil
2. Lund and Browders Chart
3. Dressing trolley
4. Basin
5. Betadine Solution
6. 4 X 4 gauze
7. Lap sponge
8. Gamgee
9. Sterile gown, gloves, and mask
10. Flammazine and flamigel cream
69
CARE OF PATIENTS WITH FLAME BURNS SNR-BC-028 3 of 3
PROCEDURE:
1. Admit patient, listen endorsement from endorsing nurse.
2. Give full bath as required, ensure the sedation is given as ordrer.
3. Expose affected parts and assist doctor during examination.
4. Prepare fasciotomy setting if needed.
5. Dress with flammazine cream only; apply thick gauze, close with crepe bandage
6. Insert IV cannula; collect blood samples in case not done in emergency room.
7. Insert Foleys catheter for intake and output.
8. Put patient on bed and start IV fluids therapy.
9. Elevate burned extremities to promote venous return.
10. Monitor vital signs hourly.
11. Inspect dressing hourly and reinforce if mild bleeding occur.
12. Inform doctor for profuse bleeding.
13. Gather patient for past and present history if patient is stable and can be able to
recall the incident.
14. For children, involve parents for interview.
15. Administer medication per doctor’s orders.
16. Give routine analgesic per doctor’s prescription.
17. Check patient weight daily and record.
18. Assist patient for ambulation.
19. Encourage positive outcomes for every treatment and procedures.
20. Document patient progress to treatment and care.
70
___________________________________________________
TITLE: INDEX NUMBER

CARE OF PATIENTS WITH THERMAL BURNS SNR-BC-029

NURSING 1 of 2
POLICY:
1. The patient’s consultant plastic surgeon or designee shall be notified upon

admission.
2. Based on the size of the body surface area of burn is done by the use of rule of
nines and the Lund-Browdies chart. Obtain an accurate estimation of the extent
and depth of the wound.
3. Usually those who have large burns and are extremely young or old that will
require volumes in excess of predictions.
4. The most common and occur as a result of the transfer of energy from a heat
source to the body: e.g. flames contact and scald burns.
5. Treated in the same may as burns of skin structures.
6. Caused by flame or fine results in a dry burn that can be much deeper than is
visually apparent.
7. Treatment of thermal burns depends on the severity of the injury.
8. Depths of burns classified as first degree, second degree, and third degree.
9. Qualified nurse working in burns unit must be knowledgeable to initiate
emergency measures of burns.
10. Information given to the relatives concerning visiting times, regulations, dress
codes within the unit. Cardiovascular and respiratory status should be assessed
immediately; any signs of inhalation burns injury must be repeated to the
physician without delay.
PURPOSE:
1. To provide good quality nursing care.

3. To promote healing process.
4. To prevent impending contractures.
5. To prevent further damage of the skin.
71
CARE OF PATIENTS WITH THERMAL BURNS SNR-BC-029 2 of 2
6. To provide relatives with information concerning patient’s treatment and hospital/

unit regulation.
EQUIPMENTS / MATERIALS NEEDED:
1. Lund – Browder’sChart
2. Blood drawing Equipment
3. Dressing Trolley
4. Burns Dressings
5. IV Set-Ups for both peripheral and central lines
PROCEDURE:
1. Prepare all equipment needed in the bed available upon receiving information
about the admission.
2. Set up necessary dressings materials in the dressing room according to the
percentage and severity of the burn.
3. Receive patient from endorsing staff listen attentively. Don’t hesitate to ask for
further history if the notify patients.
4. Bring patient in the dressing room soon assess patients burn by using the rule of
nines and the Lund –Browder’s chart.
5. Pasture laboratory studies, Chart obtary.
6. Give full bath or bedside bath to patients based according to situation.
7. Do dressing aseptically and as possible use appropriate wound dressing cream
and to allow loose closed dressing with gauge and crepe bandage.
8. Put patient in a comfortable position and start monitoring and neurological status
and vital signs.
9. Give IV fluid therapy by using the Pasbland formula and start medication
according to the practice order.
72
___________________________________________________
TITLE: INDEX NUMBER

CARE OF PATIENTS WITH ELECTRICAL BURNS SNR-BC-030

NURSING 1 of 4
DEFINITION:
The specific care rendered to patient with electrical burns. The damage is due to
passage of electricity through the tissues, and the amount of destruction depends on
the strength of the current and the time during which contact is maintained.
Electrical burns occur most commonly on the hands. The horny layer of skin is
raised and loose.
The majority of electrical burns are due to contact with the domestic electrical supply
(220-240 volts AC); burns caused by contact with the high voltage grid system
(11000 – 66000 volts AC), are occasionally seen.
Firm contact with wet skin will allow more current to pass than light contact with dry
skin.
The skin component of an electrical burn is clearly demarcated, and corresponds

with the area of contact. Deep to the skin, the damage decreases with increasing
depth. Because of their fluid content blood vessels form, good conductors and
thrombosis of digital or other vessels may occur with serious consequences.
When this loose skin is removed, the area of skin destruction is seen as a dead
white area with a narrow surrounding rim of bright red.
In domestic supply accidents, although the burn may be deep, the area of deep
damage corresponds approximately with the area of superficial damage and
extension under intact skin is limited.
In high-tension injuries, the current gains entrance through the skin and passes up
the center of the limb, as it would up the core of conducting cable, causing extensive
necrosis of vessels, muscles and nerves.
73
CARE OF PATIENTS WITH ELECTRICAL BURNS SNR-BC-030 2 of 4
OBJECTIVE:
1. To provide effective nursing care.
2. To prevent infection and promote healing.
3. To prevent damage of the organ.
4. Early detection and avoidance of nerve paralysis.
POLICY:
1. A thorough Physical Assessment should be carried out on admission and identify

the entry and exit wound on the body and any signs of bone fracture.
2. The patient’s ECG is closely monitored to identify any presence of cardiac

arrhythmias.
3. The patient’s oxygen saturation should be assess continuously using Pulse

oximetry
4. The wound care rendered will depends on the severity of the skin damage
caused by the electrical burn.
5. The patient should be kept warm using thermal blanket and overhead warmer to
prevent hypothermia.
6. The specific investigation such as 12 lead ECG; ABG and Chest X-ray should be
carried out on admission as base line data.
7. The surgeon should not embark on the excision of an electrical burn unless he is
able and prepared to perform a flap repair on the spot.
74
CARE OF PATIENTS WITH ELECTRICAL BURNS SNR-BC-031 3 of 4
1. Dressing Sets
4. Sterile towel
5. Normal Saline
6. Cardiac Monitors, Pulse oxymetry
PROCEDURE RATIONALE
1. Assemble all equipment needed in the

patient’s room
2. Assess patient thoroughly by history

taking and assist doctor in physical
assessment
3. Dress the wound with bactigras only and

allow loose closed dressing with gauze
and crepe bandage
4. Monitor patient closely every 30 minutes

on vital signs and any signs of
hypothermia.
4.1 Observe for any bluish discoloration 4. To identify signs of shock

of the nail beds. or hypothermia early.
4.2 Check radial pulse and brachial

pulse every 30 minutes and report
to the doctor if absent.
4.3 Observe patient mental status.
75
CARE OF PATIENTS WITH ELECTRICAL INDEX NUMBER PAGE NUMBER
BURNS SNR-BC-031 4 of 4
PROCEDURE RATIONALE
5. Encourage patient to move his/her finger

from time to time.
6. Elevate patient affected hand with
pillows.
7. Administer intravenous fluid therapy and

medication as ordered by physician
8. Perform dressing of the wound

accordingly.
9. Document in nurses notes patient’s
condition and type of wound dressing
76
_______________________________________________
TITLE: INDEX NUMBER

CARE OF PATIENTS WITH CHEMICAL BURNS SNR-BC-031

NURSING 1 of 2
DEFINITION:
The specific care rendered to patient with chemical burns of gaseous, liquid or solid
that has come direct contact with skin and epithelial surfaces.
Chemicals capable of causing burn injuries are usually strong acids such as
hydrochloric acid, chromic acid or sulfuric acid or strong bases, such as sodium
hydroxide.
.
OBJECTIVE:
1. To provide good nursing care.
2. To prevent infection and promote healing.
3. To prevent further damage of skin.
POLICY:
1. Neutralization of one chemical substance with another should be undertaken

only by physician who are familiar with specific chemical involved.
2. Injuries caused by Chemical agents containing sodium or potassium may

continue to burn in the presence of water, so the wound should be
covered with mineral oil before transfer the patient to a Burn Unit
77
CARE OF PATIENTS WITH CHEMICAL BURNS SNR-BC-031 2 of 2
1. Normal Saline
2. Calcium Salts
3. Mineral oil
4. Dressing Set
PROCEDURE RATIONALE
1. Assess the type of chemical involve on

admission
2. Place patient in comfortable position for

dressing.
3. Assemble all complete materials needed 3. To be organized in procedure

for dressing.
4. Exposed the affected part.
5. Chemical burns Clorox, dye,
5.1 Flush with copious amounts of water or

5.1 To mechanically remove surface
normal saline.
chemicals and cool skin.
6. Hydrochloric burns, 6.2 To buffer the acid and limit injury.
6.1 Administer topical calcium salts.
INDEX PAGE NUMBER

CARE OF PATIENTS WITH CHEMICAL BURNS NUMBER SNR- 3 of 3
BC-031
78
PROCEDURE RATIONALE
7. Sodium or potassium
7.1 To inhibit further destruction of
7.1 Coat affected area with mineral oil. causative agent action.
8. Observe the wound closely for further

occurrence of any destruction to tissues
resulting from the delayed effect of chemical
burn.
9. To identify any deviation of vital
9. Monitor vital signs of patient closely. signs immediately
10. Commence intravenous therapy according to

physician’s order.
11. Administer medication or specific application of
medication as per physician’s order.

12. Document in nurses notes on patient’s
condition and on the wound condition.
79
_______________________________________________
TITLE: INDEX NUMBER

CARE OF PATIENTS WITH RADIATION BURNS SNR-BC-032

NURSING 1 of 2
DEFINITION:
The specific care rendered to patient with burns due to the emanation of energy in
the form of electromagnetic waves.
Acute phase, within one or two days of the irradiation the affected area becomes red
and swollen and may blister. In most instances the burn is of partial thickness depths
and heals slowly over the course of a few months.
Chronic phase- the healed post irradiated skin is always abnormal to a greater or
lesser degree. In a typical case, it is atrophic, hairless, indurate and white with red
spidery.
Atrophic skin may later breakdowns, forming a simple ulcer, or undergoes malignant
changes and become a squamous cells carcinima
OBJECTIVES:
1. To provide good nursing care.
3. To lessen skin irritation.
4. To avoid further damage of the skin.
POLICY:
1. The radiation burn wound requires irrigation under running water.
2. They may be due to excessive doses of radiation during radiotherapy, or radio diagnosis,
or to accidents involving nuclear energy.
80
CARE OF PATIENTS WITH RADIATION BURNS SNR-BC-032 2 of 2
1. Basin
2. Water
PROCEDURE RATIONALE
1. Provide quite room 1. To promote rest
2. Apply soothing applications 2. To allay irritation.
3. Monitor vital signs at least every hour and

report any abnormality to the doctor.
4. Explain to patient to avoid another contact

with radiation.
5. Document nurse note legibly and correctly.
81
TITLE: INDEX NUMBER

CARE OF PATIENTS WITH ESCHARECTOMY SNR-BC-033

NURSING 1 of 2
DEFINITION:
The surgical debridement of slough which forms after the destruction of tissue
resulting from burns injuries.
OBJECTIVES:
1. To enhance natural healing.
2. To promote regeneration and repair of the tissues.
4. To promote epithelialization of the skin layers.
POLICY:
1. All patients with escharectomy must undergo hydrotherapy daily
2. The doctor must be informed if bleeding occurs or any notice of gangreneous

tissue.
3. When the remaining eschar starts to loosen, separation of it should be done by

daily debridement.
82
CARE OF PATIENTS WITH ESCHARECTOMY SNR-BC-033 2 of 2
1. Sterile dressing trolley
2. Basic procedure set.
3. Sterile gown, gloves, and mask
4. Surgical blades different sizes
5. Sterile gauze 4 X 4 lap sponge
6. Normal Saline
7. Flammazine or any other topical cream or ointment as ordered.
PROCEDURE RATIONALE

cooperation.
2. Assemble complete equipment to bedside 2. To be organized in doing

procedure
3. Perform desloughing , debridement and 3. Slough, debris and loose skin can
remove loose skin be a source for bacteria growth.
4. Clean the wound aseptically with normal

saline.
5. Apply flammazine or any other topical

cream or ointment as ordered.
6 Document in nurses notes the condition of

the wound and the specific medication
applied to the wound.

83
___________________________________________________
TITLE INDEX NUMBER

PREPARATION OF GRAFT SITE SNR-BC-034

NURSING 1 of 3
DEFINITION:
To prepare the operation site before applying the skin graft.
OBJECTIVE:
To ensure that recipient area is ready for the application of skin.
POLICY:
1. To prepare a burn wound prior to operative procedure for skin grafting.
2. Dressing shall be performed in order to keep area clean prior to grafting.
3. Procedure to be carried out by a trained nurse.
1. Swabs for culture and sensitivity.
2. As per general dressing equipment.

PREPARATION OF GRAFT SITE SNR-BC-034 2 of 2
84
PROCEDURE RATIONALE
1. Take swabs from each area. 1. To exclude the presence of

hemolytic streptococcus group D
and M.R.S.A
2. Assemble equipment on a sterile surface.
2. To reduce patient’s exposure
time.
3. Explain procedure to patient. 3. To allay fears.
4. Clean recipient bed with saline + betadine 4. To ensure a bacteriologically

and gauze swabs. clean bed for grafts.
5. Dry gently. 5. To prevent infection.
6. Apply saline gauze, dry gauze, and

bandage loosely.
7. Document in nurses notes on the

preparation of graft
85
___________________________________________________
TITLE: INDEX NUMBER

PREPARATION OF DONOR SITE SNR-BC-035

NURSING 1 of 3
DEFINITION:
To prepare the donor site for healthy skin graft.
OBJECTIVE:
1. To reduce risk of infection.
POLICY:
1. To ensure clean donor bed prior to operative procedure for skin grafting.
2. To be performed in hydrotherapy pool or room by qualified burns nurse prior to

operation.
3. Area may be any part of body.
1. 3.1 disposable razor.
2. Soap, water, and hibiscrub.
86
PREPARATION OF DONOR SITE SNR-BC-035 2 of 2
PROCEDURE RATIONALE
1. To soften skin easier to

1. Soap donor area
shave.
2. To avoid damage to skin

2. Gently shave hairy areas. surface, thus preventing
infection.
3. Clean and rinse donor area well. 3. To allay fears.
4. Dry donor area
5. Cover prepared area with a sterile

towel.
87
_______________________________________________
TITLE: INDEX NUMBER

TRANSPORT OF PATIENT TO OPERATING ROOM SNR-BC- 036

NURSING 1 of 2
POLICY:
1. There shall be written order from treating doctor.
2. Anesthetist must see and examine patient prior to the date of operation.
3. Patient file must be complete.
3.1 Operative Checklist

3.2 Consent
3.3 Anesthesia Form
3.4 Recovery Form
3.5 Progress Note
4. Insert IV cannula and must be done 9-8.
5. Patient must wear or gown with OR cap and wrist tag.
6. Pre-medication must be done by 2 nurses one to give and one as witness.
7. Patient must be transported per stretcher with side rails up.
8. Qualified nurse working in burns unit only must transport the patient in OR with
the messenger.
9. Provide privacy during transport.
PURPOSE:
1. To provide safety of the patient during transport.
2. To ensure continuity of care by verbal communication between ward and operating room.
88
TRANSPORT OF PATIENT TO SNR-BC-036 2 of 2
OPERATING ROOM
3. To ensure quality patient care by efficient patient movement between areas.
PROCEDURE:
1. Receive call from operating room to dispatch the patient.
2. Assist patient from bed to trolley.
3. Give pre-medication per anesthetist order.
4. Assess and secure IV lines and drainage bag.
5. Burns unit staff shall dispatch patient through stretcher to operating room.
6. Operating room staff shall receive the patient and transfer to OR stretcher.
7. Burns unit staff shall give complete report of patient to receiving nurse before
returning to bed.
89
TITLE: INDEX NUMBER

CARE OF POSTOPERATIVE DONOR SITE SNR-BC-037

NURSING 1 of 2
DEFINITION:
To protect and promote healing of donor site
OBJECTIVE:
1. To prevent need for subsequent grafting of donor site.
POLICY:
1. As per general dressing policy.
2. Check dressing daily (but do not open).
1. Normal Saline
2. Betadine solution
3. Bactigras
4. Sterile 4 X $ gauze
5. Gamgee
90
CARE OF POSTOPERATIVE DONOR SITE SNR-BC-037 2 of 2
PROCEDURE RATIONALE
1. Explain procedure to patient 1. To allay fears.
2. Dressing left intact until 8th to 11th day

depending on the doctor’s order. Apply extra
padding over dressing if there is excess
exudate.
3. While dressing do not remove the bactiges

which is adherent to the wound, as it will pull
the thin epithelium layer cause bleeding, the
loose bactiges should be trimmed. The
following dressing is done every 3 – 4 days as
per doctor’s order.
4. On the 8th to 11th day the dressing are

removed to the layer of paraffin gauze as per
doctor’s order. 4. If bandage is stuck soak the
dressing with normal saline
Wash with betadine and saline. Pat dry and for 1 – 2 hours then
paint with betadine. If the area is left exposed remove.
use a bed cradle. Wash daily and trim loose
dressing.
5. To prevent slipping and

friction damage.
5. Firmly bandage.
To prevent excess pain.
6. When donor site is healed, massage often 6. To avoid excess trauma to

with non-scented moisturizer. donor site.
7. To prevent dryness and

7. Rinse with saline scaling so that the site may
be used again in case of
severe burns.
91
___________________________________________________
TITLE: INDEX NUMBER

CARE OF POST OPERATIVE GRAFT SITES SNR-BC-038

NURSING 1 of 2
DEFINITION:
Limited access to site to promote good healing and prevent infection.
OBJECTIVE:
To ensure healthy and infection free skin graft.
POLICY:
1. Staff nurse experience in burns care must carryout the procedure.
2. The first dressing should be performed after 4 days post operative skin graft
upon physician orders.
3. Elevate the site of the graft.
1. Dressing set
2. Betadine solution
3. 4 X 4 sterile gauze
4. Sterile cotton pledged
5. Sterile gloves and gown
92
CARE OF POSTOPERATIVE GRAFT SITES SNR-BC-038 2 of 2
PROCEDURE RATIONALE
1. First preoperative dressing is done at the

bedside, outer dressing are removed with
gloves and scissors.
2. Using set up and equipment for general 2. To prevent displacement of

dressing: P & P remove all dressing carefully, graft.
without pulling on grafted areas.
3. The patient is showered or bathed according to 3. To loosen inner dressings.

physician instructions.
4. Remove paraffin gauze from grafted area with 4. To prevent displacement of

sterile cotton buds. Gently roll gauze diagonally graft.
from corner to corner.
5. Sutures can usually be removed. At first 5. To prevent further scarring.

dressing change, as per doctor’s order.
6. Trim dead tissue from around the graft edges if 6. To prevent infection.
necessary.
7. Any fluid collection should be pricked with

sterile needle and squeeze the fluids.
8. Cleanse the graft site with normal saline and

betadine.
9. Redress if necessary with paraffin gauze, gauze

swabs, soaked betadine, and the required
gauze bandages.
10. Position the patient to elevate the graft site if 9 To aid venous return.
possible.
11. Repeat dressing changes to graft site daily if

graft infected. If graft is left exposed, rest limb
on sterile towel and cover with bed cradle. Use
overhead heater to dry out exudates. Perform
graft care as often as necessary to keep graft
free from exudates.
93
___________________________________________________
TITLE: INDEX NUMBER

CARE OF INFECTED DONOR SITE SNR-BC-039
NURSING 1 of 2
DEFINITION:
Prevention of further infection and promote healing
OBJECTIVE:
1. To clear wound exudates.
2. To promote a clean flat granulation bed.
POLICY:
1. Staff nurse experienced in burns care must carryout the procedure.
2. Dressing is to be changed every alternate day.
3. To keep the donor site dry and free from any profuse oozing.
1. Dressing set
2. Sterile 4 X 4 gauze
3. Iodine solution
4. Normal Saline
5. Basin
6. Prescribed ointment
94
CARE OF INFECTED DONOR SITE SNR-BC-039 2 of 2
PROCEDURE RATIONALE
1. Explain procedure to patient 1. To allay fears.
2. Patient to be washed in burns tank.
3. To reduce patient
3. Assemble equipment.
exposure time.
4. Gently remove outer dressing.
5. Apply dressing making sure patient can

pass urine, if patient is catheterized apply
pad to perineum area.
6. Use half strength hydrogen peroxide to

6. To avoid excess trauma to
loosen inner dressing (tube bathing is
donor site.
preferable).
7. To prevent further irritant

action of hydrogen
7. Rinse with saline
peroxide.
8. Apply paraffin gauze and a topical agent (if 8. To prevent slipping, cross
prescribed) cover with dry gauze and then infection, and
bandage. unnecessary pain.
9. Dress daily.
95
_______________________________________________

TITLE: INDEX NUMBER
ELIMINATION CARE OF BOWEL SNR-BC 040

NURSING 1 of 2
POLICY:
1. The genitalia and perineum needs special nursing care.
2. It is imperative that nurses know about individual habits and use knowledge
implement and individualized nursing plan.
3. Staff nurses must recognize bowel potential problems that may or may not
recognized by the patient and must be discussed with the patients.
4. Check for fecal impaction on any patient who has not had a stool for 24 hours.
5. Maintain adequate fluid intake.
6. Offer balance diet.
OBJECTIVES:
1. All personnel entering the patient’s room under isolation should use precautions
as indicated by the CDC card category of isolation.
2. Sterile gown, gloves, and mask should be used for any sterile procedure.
3. Gowns are never to be used more than once and should be changed if soiled or
moist.
4. Dispose of the contaminated gown within the patient’s room in the appropriate
hamper trolley.
96
ELIMINATION CARE OF BOWEL
SNR-BC 040 2 of 2
5. Hands must be washed before and after wearing gloves.
6. Mask should be worn only once and replace if it will become moist or damp.
7. Gloves should not be used as a substitute for meticulous hand washing.
8. Mask must be discarded inside the patient’s room before leaving and never hang
around the neck.
1. Clean mask.
2. Sterile gown (to perform sterile procedures only).
3. Sterile and non-sterile gloves.
PROCEDURE RATIONALE
1. Assess the patient’s condition.
2. Explain the patient the need of using 2. To reduce anxiety.

mask, gown, and gloves. To eliminate the patient’s
feeling of being sick.
3. Wear mask fitted to cover nose and mouth 3. To protect from inhaling.
and fit tightly against the skin without To prevent particles aerosols
gaping at the sides. transmitted by close contact.
4. Wear gown and fasten it securely at the 4. To maintain sterility.

neck and waist. Cover the overlap To protect gross-clothing
completely at the back. contamination.
5. Wear gloves by covering the wrist and

cups of gown, if worn.

97
_______________________________________________
TITLE: INDEX NUMBER

SOCIAL WORKER AND REHABILITATION SERVICES SNR-BC-041

NURSING 1 of 2
POLICY:
1. The social worker is to assist the burn patient and the family in resolving
personal, interpersonal and practical problems related to the injury.
2. The social worker must visit the burns unit daily.
3. The social worker must work to gain specific knowledge about the clinical
management of burn patients.
4. To have an understanding of the characteristic responses and their social

implications.
5. Mask should be worn only once and replace if it will become moist or damp.
PURPOSE:
1. To keep the burn team better understand the patient in relation to a specific
social and emotional background.
2. To facilitate communications among team members.
3. To assist the patient and family with problems precipitated by the burn injury.
4. To relieve social and emotional difficulties that stand in the way of optimal use of
medical care.
5. To identify community resources and encourage the use of these resources.

SOCIAL WORKER AND REHABILITATION SNR-BC-041 2 of 2
SERVICES
98
EQUIPMENT:
1. Social worker male/female according to the patient.
2. Family members.
PROCEDURE:
1. Assess patient condition.
2. The social worker must introduce himself to the patient.
3. Explain to the patient through Islamic and Scientific knowledge.
99
___________________________________________________
TITLE: INDEX NUMBER

DISCHARGE INSTRUCTIONS FOR THE SNR-BC-042
PATIENTS WITH A BURN
NURSING 1 of 2
POLICY:
1. There must be written doctor’s order.
2. Patient must be fit for discharge.
3. Written discharge summary must be done by the doctor and must be sent for
typing.
4. For medico-legal case, inform admission office before sending patient home.
5. For non-Saudi patient, inform sponsor (kopil) about patient discharge.
PURPOSE:
1. To prepare the patient and family physically and psychologically before

discharge.
2. To promote the highest possible level of independence patient and his/her family
by encouraging self-care activities.
3. To provide continuity of care between the hospital and the community by

facilitating effective communication.
4. To encourage a safe, ordered transfer home.
PROCEDURES:
1. Discuss the patient discharge plan with others involved in his/her care. This
includes the patient, family or significant others.
100
DISCHARGE INSTRUCTIONS FOR A SNR-BC-042 2 of 2
PATIENTS WITH A BURNS
2. Take OPD appointment and inform patient appointment date, time and send
summary for typing and translation.
3. Inform patient family about the time of discharge if patient is child.
4. Give instructions about home medications.
5. Instruct patient the importance of continuous exercise at home, as well as next

visit in physiotherapy.
6. Do dressing before sending patient home.
7. Write patient discharge in admission and discharge note, statistic form.
8. Document properly in nurses note patient discharge.
9. For LMC cases call admission office about the discharge.
10. Send patient file in medical records after doctor completed admission and
discharge form.
101

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GENERAL DIRECTORATE OF NURSING

Functions Duties Policies and Procedures

Nursing Standards Organizing Committee for Hospital Services

SPECIALIZED NURSING: BURNS

TITLE: INDEX NUMBER

EFFECTIVE DATE APPLIES TO APPROVED BY PAGE NUMBER

1. A graduate of Bachelor of Science in Nursing from accredited school, with one-

2. Registered with current license and CPR license.

2. To clearly define duties and responsibilities.

3. To guide nursing actions.

DUTIES AND RESPONSIBILITIES:

1. Admit and orient new patients and family.

3. Check patient chart, information must be clear and consistent.

5. Assemble patient chart, should be neat and properly arranged.

6. Carryout doctor’s order properly and correctly.

7. Plan nursing care according to patient problem priorities.

9. Maintain required unit records.

10. Plan patient’s diet and arrange with dietician.

11. Plan for patient discharge or transfer.

12. Maintain controlled drug records.

13. Check supplies, crash cart content must be complete.

14. Answer telephone politely and deliver message accurately.

15. Observe proper technique (asepsis) in all performance of duties.

17. Administer prescribed medications by following the seven rights.

18. Clean wounds, change dressing aseptically. Bath patient as needed.

20. Check functioning medical equipment attached with the patient.

21. Administer fluid therapy. Accurately.

23. Notify in-charge doctor of any significant changes in patient response to

SPECIALIZED NURSING: BURNS

TITLE: INDEX NUMBER

EFFECTIVE DATE APPLIES TO APPROVED BY PAGE NUMBER

1. Standard Burns Unit orientation shall be provided to the new staff.

2. Orientation program shall take at least three months.

First Week – Burns Unit Introduction

1. Identify the staff and colleagues.

2. Can locate the duty schedule and follow hours of duty

3. Identify the doctors.

4. Locate the office of Department of Nursing.

Other Wards and Departments:

Location of Emergency Room

1. Location of equipment and supplies.

2. Care of equipment and linen.

3. Use of oxygen cylinders, oxygen flow meter on the wall.

4. Care of drugs and narcotics.

5. Use of narcotics and controlled drug forms.

6. Explain and demonstrate crash cart function.

Other Wards and Departments:

Send samples to laboratory

1. Recall the Burns Unit policy and procedures.

2. Setting with and check the cardiac monitors.

3. Carry out assignments and responsibilities.

4. Care of laboratory specimens.

5. Completion of burns unit records.

6. Disposition of contaminated linen.

7. Clean patient’s bed, bedside table after discharge.

8. Use of telephone and pager, beeper.

Respond to every hospital procedures:

End third month she/he should be able to perform independently.

SPECIALIZED NURSING: BURNS

TITLE: INDEX NUMBER

EFFECTIVE DATE APPLIES TO APPROVED BY PAGE NUMBER

An approved uniform used in Burns Unit

1. To provide effective barriers that prevents the dissemination of microorganisms to