Asuhan Keperawatan Luka Bakar-November 2022

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Asuhan Keperawatan: Luka Bakar

Departemen Keperawatan Medikal Bedah Fakultas Ilmu Keperawatan Universitas Indonesia

November 2022

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Survey

• https://forms.gle/MtfxyF2hCWDL7C2T9

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Terminologi

❑Luka bakar merupakan suatu kondisi trauma yang

disebabkan oleh panas, arus listrik, bahan kimia, dan petir yang mengenai kulit, mukosa, atau jaringan tubuh

manusia.

❑Luka bakar didefinisikan sebagai kondisi cedera akibat

kontak langsung atau terpapar dengan sumber panas,

listrik, zat kimia, atau radiasi

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Anatomi

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Patofisiologi

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Depth of burn

wound (ANZBA,

2016)

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Masalah Keperawatan

• Problem ; Airway, Breathing, Circulation

• Airway : Inhalation injury; singed nasal hair, brassy cough, sooty

expectoration. Incidence 30%, Mortality 80 - 90%

• Breathing : Respiratory distress due to encirled eschar

• Circulation : Lack of perfusion ( hypovolemia shock )

• Treatment:

• Airway resuscitations; secury the airway endotracheal tube/

cricothyroidotomy

• Respiratory distress : Emergency chest escharatomy

• Lack of perfusion : Fluids resuscitations

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Airway

• Airway Resuscitation → Intubasi • Airway Resuscitation →

Chricothyroidotomy, trakeostomi

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Breathing

• Respiratory Distress → Emergency Chest escharatoy

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Circulation

• Resusitasi Cairan BAXTER FORMULA

Adult : 3-4ml (RL) x % burn x Weight (kg)

Children : 2ml (RL) x % burn x Weight (kg) PLUS MAINTENANCE MAINTENANCE : < 1 year : Weight (kg) x 100ml

1 – 3 year : Weight (kg) x 75ml

> 3 year : Weight (kg) x 50ml RATE : First 24 hours

½ in first 8 hrs post injury

½ in second 16 hrs

Urine: 30 – 50 ml/hrs (adult) or 0,5 – 1 ml/kg 1 – 2 ml/kg (Children)

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Rule of Nine

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2. Fase setelah syok berakhir/sub akut (> 72 jam – epithelisasi/awal penutupan luka)

• (3 – 5 d): Interstitial to plasma fluid

shift hemodilution hypervolemia

• Adanya diuresis berlebihan, proses penguapan cairan tubuh disertai panas (evaporatif heat loss)

• Problem:

• SIRS,MODS dan Sepsis

• Hypermetabolic

Treatment: Infection control, wound management, nutritional support

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Fase sub akut

Gangguan metabolisme

• Hipermetabolisme

• SIRS dan MODS (Sepsis)

• Penutupan luka (proses epitelisasi)

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3. Fase Rehabilitasi/Lanjut

• sejak epithelization sampai terjadi maturasi jaringan

• Problem:

• Hypertrophic scarring contracture, and impaired mobility

• Treatment:

• Early, acute phase

• Respiratory rehabilitation

• Late

• Prevention of scarring and contracture

• Functional restoration, and

• Psychoscial treatment

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Fase lanjut

Masalah parut

• Keterbatasan fungsi

• Gangguan penampilan (Body image)

→ (masalah psikososial)

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Nursing Consideration

I. Pengkajian → Rule of Nines

Rule of Palm”

Patient’s palm equals 1% of his body surface area

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Nursing Consideration

II. Derajat kedalaman dan Penyembuhan Luka Bakar (the traditional classification)

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Cont’d

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III → Severity

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IV. Wound

Management

• A. Tujuan

✓ Cegah konversi luka (maintain a physiology wound environment/moisture balance dressing)

✓ Buang jaringan mati

✓ Siapkan granulasi sehat (wound bed preparation/TIME Concept)

✓ Minimalkan infeksi

✓ Siap untuk autografting

✓ Cegah kelainan parut dan kontraktur

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Wound management (Cont’d)

• B. Prinsip

1. Adequat moisture level (not wet – not dry)

– Saline-moistened gauze cannot keep the wound continually moist

2. Maintain normal temperatur

• Lock (1979), body temperature (37°C) significant increase in mitotic activity up to 108%

3. Bacterial balance

– Lawrence(1994), bacteria can penetrate up to 64 layer of gauze

4. Maintain normal pH

– When the skin is broken the wound tissue became alkaline wich subsequently increase the risk bacterial invasion (Hermans,1990) and impaired function of MMP´s (Amstrong,2002)

– pH low, various celluler functions may decline or stop

Semi-occlovise dressing; film, hydrocolloids, foam, alginate are able to keep a wound moist, reduce wound infection, maintain to neutral pH and normal temperature

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First Aid

• Stop the burn process

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Monitoring I/O

• IWL

( 25 + % Burn ) x TBSA x 24 hours

TBSA :

Children : 0,5

Adult : 1

Adult(over weight) : 1,5

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How to care……?? ?

Courtesy: Lucia anik

Indonesian Enterostomal therapy nurse education program Jakarta 2019

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Konvensional methode Exposed Therapy (Terbuka)

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Advance Wound Management

 SHOCK /ACUTE PHASE

 The principles of wound management is to avoid wound degradation in a conducive manner

 Restoration of tissue perfusion (shock management)

 Wound toilet/cleaning

 Moist dressing

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…….Wound Management

 Wound toilet/cleaning

 Warmer water

 Use non irritant agent; the use of baby soap inspite of using antiseptics solution (povidon iodine, chlorhecxidine, etc) or Salinesaline

 Moist dressing

 Gauszed

 Moisturizer cream

 Elastic bandage (occlusive dressing)

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…….Wound Management

Sub Acute /Wound Care Phase

• The principle of wound management is to remove necrotic tissue to promote healing

• Debridement , escharectomy

• Early excision day 3 to 4 following injury in moderat burn, before day 10 in severe critical burn

• Use topycal therapy to support autolitic debridement; SSD, Hydrogel (third degree of burn)

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……Sub acute Phase

• The principles of wound management concerned to healing processes

• Spontaneuous epithelization (partial thickness burn/second degree)

• Skin substitute, tulle grass,

• Aquacell (Ag, burn)

• Skin grafting (full thickness burn/

third degree

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Advantages of skin subtitutes for superfisial burn

• Restores skin barrier fucntion

• Decreases pain, increase mobility

• Can decrease scar

• Can remain in place until wound reepithelializes

Advantages of tulle grass

• Covered of wound and facility to drainage

• Matrix to epithelization process

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Wound Care

• The principles:

• Wound toilet

• Debridement Depends on is requirement

• Change dressing

• Consider the painful dressing

• Prevention of contracture

Johnson (1988), traditional wound care practices of using frequent wet to dry dressing, it

actually lowers the wound surface temperature by 2- 5°C, with corresponden adverse effect on mitotic activity

- Frequent undressing of wound significantly reduce wound temperature and delays healing

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……Wound Care

Blister Management

• Bila blister ukuran besar (> 3cm) diaspirasi dg spuit steril tanpa membuang lapisan epidermis diatasnya (dipertahankan sebagai biological dressing)

• Occlusive dressing dg Tulle grass/absorb dressing dan kassa steril tebal

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• Tujuan

• Mencegah kontraktur

• Mempercepat penyembuhan

• Mengurangi masa perawatan

• Indikasi

• LB derajat II tidak sembuh dalam 3 minggu

• LB derajat III setelah dilakukan eksisi

• Terdapat granulasi yang luas (diameter > 3cm)

SKIN GRAFT

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 Prinsip perawatan post operasi skin graft:

 Menjaga kesterilan

 Luka operasi dan luka donor tidak tergeser

 Tidak terjadi infeksi

 Perawatan daerah skin graft:

 Balutan luka dibuka (diintip) hari ke 5 – 7 (kecuali terdapat tanda-tanda infeksi segera buka)

 Hati-hati dalam mobilisasi,pertahankan skin graft agar tidak tergeser

 Elastic bandages may be applied 6 – 12 month to prevent hypertrophic scarring

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Evaluation/ Outcame Criteria

• Return of vital signs to pre-burn level

• Minimal or no hypertrophic scarring

• Free of infection; demonstrates wound care

• Maintains functional mobility of limb; no contractures

• Adjust to change in body image; no depression

• Regains independence; returns to work, social activities

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Referensi

• Abd Elalem, S. M., Shehata, O. S. M. H., & Shattla, S. I. (2018). The effect of self-care nursing intervention model on self-esteem and quality of life among burn patients. Clin Nurs Stud, 6(2), 79-90.

• ANZBA., 2016. Australia and New Zealand Burn Association Emergency Management of Severe Burn (EMSB), Australia

• Carvile K.(2007). Wound Care Manual (5th ed.). Australia: Silver Chain Nursing Association California: Addison-Wesley Publishing Company,Inc

• Guest JF, Fuller GW, Edwards J. Cohort study evaluating management of burns in the community in clinical practice in the UK: costs and outcomes.

BMJ Open 2020;10:e035345. doi: 10.1136/bmjopen-2019-035345

• Judy Knighton, RN, BScN, MScNR. WOUND CARE FOR THE ADULT BURN PATIENT, 2010

• Li-Na Xu, Hai-Xia Wang, Ling Zhao, Biosynthesis of AgNPs and their

effective wound healing activity in nursing care in children after surgery, Journal of Drug Delivery Science and Technology, Volume 55, 2020, 101425, ISSN 1773-2247, https://doi.org/10.1016/j.jddst.2019.101425.

• Probst, Sebastian, et al. "Wound Curriculum for Nurses: Post-

registration qualification wound management-european qualification framework level 6." Journal of wound care 28.Sup2a (2019): S1- S33.