BURN

Ns. Winda Ayu Fazraningtyas

Definition
Burn is a tissue injury, its caused by dry hot (fire), muggy (steam and
hot water), chemical (e.g. Corrosive substance), the electric
object (lamp or electricity), friktion, or electromagnetic energy,
and radian (Dorland).
Wien's document
Clasification of Burn
According light in weight from American Burn Association in
Whaley Wong (1999), the burn consist of:
Minor burn the burn less than 10% from the wide of body.
Moderate burn the burn 10-20 from the wide of body.
Mayor burn the burn more than 20% from the wide of body.
Wien's document
According the defect of burn, the burn consist of:
Superficial partial-thickness burn damage in epidermis or injury
in partly of dermis.
Deep partial-thickness burn destruction in epidermis, upper
layer dermis, and injury in deeper of dermis.
Full-thickness burn completely destruction in epidermis and
dermis.
Wien's document
Burn Pathophisiology
Tissue destruction caused by coagulation, denaturation of protein,
or ionization of cell substance.


The depth of burn depend in agens temperature engender burn
and period of contact with that agens.
Wien's document
Wien's document
Cardiovascular Respons
Pulmoner Respons
Systemic Respons
The Other Systemic
Respons
Depth of Burn
Usually the depth of burn not same. Every area in burning have 3
zone injury. This zone are:
Coagulation zone the death of cellular.
stasis zone blood-supply unbalanced, inflamation, and tissue
injury.
Hiperemia zone the outmost zone.
Wien's document
Wide of Burn
Rule of Nine: the fastest manner for calculation the wide burn. Its
use persentage at ninth the distance about the wide body.
Lund and Browder method: the burn percentage in variety of
anatomic part, specially for head and leg. This part on the turn to
follow growth.
Palm method: the wide of palm can use for appraise the wide of
burn.
Wien's document

Wien's document
Rule of Nine
1
st
Purpose at Burn Care
Prevention.
Implementation for save client with severe burn.
Prenvention for dyslexia and spoilage by early, spesialistic, and
personal care.
Client restoration or rehabilitation by reconstruction surgery and
rehabilitation programe.
Wien's document
Burn Healing
Burn healing is planned according the wide and the depth of burn,
this is done with 3 phase:

Emergency/resusitation phase.
Acute phase.
Rehabilitation phase.
Wien's document

Wien's document
Priority:
1. The first rescue.
2. Shock prevention.
3. Respiration distrub prevention.
4. Injury care detection.
5. Burn assessment and preface care.
Wien's document
Shock Phase
Observation:
1. Comprehensive dehidration.
2. Deficiency blood volume.
3. Deficiency output urine.
4. Over kalium (K
+
) amount.
5. Reduce natrium (Na
+
) amount.
6. Methabolic acid.
7. Hemoconcentration.
Wien's document
The Replacement of Liquid
The requirement of liquid is calculation according the wide of burn.

Rule of Konsensus. NIH Consensus Development Conference on
Supportive Therapy in Burn Care determine that a mineral salt
and water is a esensial requirement for burn client.
Wien's document
1. Pasien berbobot 70 kg dengan luas luka bakar 50%.

Dengan menggunakan Rumus Konsensus, cairan yang diberikan pada
24 jam pertama adalah berkisar 2-4 mL/kg/%.
Sehingga diketahui kebutuhan cairan kx adalah
2 mL/kg/% x 70 kg x 50% = 7000 mL/24 jam.
Rencana pemberian cairan melalui infus: 8 jam pertama = 3500 mL;
berikutnya 16 jam = 3500 mL
Wien's document
Contd ..
Nursing Care Plan
Assessment
1. Kaji tanda vital.
2. Kaji status respirasi.
3. Kaji intake dan output cairan.
4. Kaji luas luka bakar.
5. Kaji status kesadaran kx, status fisiologik, tingkat nyeri, serta
kecemasan.
6. Kaji tingkat pemahaman kx dan keluarga mengenai luka
bakar.
Wien's document
Contd ..
Nursing Diagnoses
1. Kerusakan pertukaran gas b.d ventilasi-perfusi.
2. Inefektif bersihan jalan napas b.d inhalasi asap.
3. Defisit volume cairan b.d kehilangan cairan secara aktif.
4. Hipotermia b.d illness.
5. Nyeri akut b.d agen injury (kimia,fisik).
6. Ansietas b.d ancaman terhadap status kesehatan dan konsep diri.
Wien's document
Nursing Intervention
1. Meningkatkan pertukaran gas dan bersihan jalan napas.
2. Memulihkan keseimbangan cairan dan elektrolit.
3. Mempertahankan suhu tubuh normal.
4. Mengurangi nyeri dan ansietas.

Wien's document
Contd ..

Wien's document
Prioritas:
1. Perawatan dan penutupan luka.
2. Pencegahan atau penanganan komplikasi, termasuk infeksi.
3. Dukungan nutrisi.
Wien's document
Nursing Care Plan
Assessment
1. Kaji perubahan hemodinamika.
2. Kaji proses kesembuhan luka.
3. Kaji nyeri.
4. Kaji respons psikososial.
5. Deteksi komplikasi.
Wien's document
Nursing Diagnoses
1. Risiko infeksi dengan faktor risiko inadekuat pertahanan primer.
2. Ketidakseimbangan nutrisi: kurang dari kebutuhan tubuh b.d faktor
biologis.
3. Kerusakan integritas jaringan b.d faktor mekanik (luka bakar).
4. Kerusakan integritas kulit b.d faktor mekanik.
5. Nyeri akut b.d agen injury (kimia,fisik).
6. Kerusakan mobilitas fisik b.d ansietas, nyeri.
7. Koping tidak efektif b.d inadekuat tingkat kepercayaan pada
kemampuan untuk mengatasi masalah.
8. Kurang pengetahuan b.d keterbatasan kognitif.
Wien's document
Contd ..
Nursing Intervention
1. Memulihkan keseimbangan cairan.
2. Mempertahankan nutrisi yang adekuat.
3. Memperbaiki integritas kulit dengan perawatan luka.
4. Mengurangi nyeri dan ketidaknyamanan.
5. Meningkatkan mobilitas fisik.
6. Memperkuat strategi koping.
7. Pendidikan pasien dan pertimbangan perawatan di rumah.
Wien's document
Contd ..

Wien's document
Prioritas:
1. Pencegahan Parut dan kontraktur.
2. Rehabilitasi fisik, okupasional, dan vokasional.
3. Rekonstruksi fungsional dan kosmetik.
4. Konseling psikososial.
Wien's document
Nursing Care Plan
Assessment
1. Kaji tingkat pengetahuan kx.
2. Kaji tingkat penyembuhan luka bakar kx.

Wien's document
Nursing diagnoses
1. Intoleransi aktivitas b.d immobilisasi, bed rest.
2. Gangguan body image b.d illness.
3. Kurang pengetahuan b.d keterbatasan kognitif.
Wien's document
Contd ..
Nursing Intervention
1. Meningkatkan toleransi terhadap aktivitas.
2. Memperbaiki citra tubuh dan konsep diri.
3. Pendidikan pasien dan pertimbangan perawatan di rumah.
Wien's document
Contd ..
Wien's document