(LP)

WITH THE PX nursing care

COMBUSTIO (CUTS FUEL)
A. POLICY CONCEPT
I. DEFINITION
Wounds caused by contact with a high temperature such as heat, hot water,
electricity, chemicals, and radiation, as well as by contact with a low temperature (Arif
et al 1999 Mansjoer capita)
II. etiology
1. Warm (sunburn, hot water, steam heat, fire, explosion stove)
2. medicine-drugs / chemicals (nitras argental, acid / strong base)
3. flow of electricity and lightning
DETERMINE THE AREA OF CUTS FUEL
Extensive burns can be determined by formulas nine "Rule of Nine / formula Wallace"
namely:
1. the Head and Neck
: 9%
2. arms and hands
: 18%
3. Loss front
: 18%
4. the Body Back
: 18%
5. Limbs
: 36%
6. Genetalia
: 1%
For children - son formula modifications in Rule of Nine from Lund and Browder
III. manifestation CLINIC
1. Degrees I (degrees ery THERMA )
Degree burns is very light, mark:
a. available red color of the skin
b. simply the epidermal layer only
c. available pain
2. Degrees II (bullosa)
Elevation II A
Kerusan network of the superficial dermis with no signs of blisters where there is a
buildup of fluid intra- cellular
-

Elevation II B
The same clinical picture but a bit dry blisters over pucatdan, healing quiteold and
joined the granulation tissue
Degree III
On the whole thickness of the skin or layer underneath (muscle and bone) until the
skin will look dry white to black and no longer feels
Classification of burns
1. the Critical / Weight
a. Degrees II> 25%
b. Degrees III> 10% or elsewhere such as the face, hands, feet, accompanied trauma
c. Jalan breath, fractures and prevalence of network
d. Cuts by electrocution
2. Medium
a. Degrees II 15-25%

b. Degrees III <10% except for the face. Hand, foot

3. Light
a. Degrees II <15%
b. Degrees III <2%
IV. pathophysiology
Injured thermis cause da electrolyte fluid balance disorders to shock, which can
cause acidosis, necrosis, acute tubular, and cerebral dysfunction. The conditions can be
found in the early phase / acute / shock which usually lasts until the first 72 hours
With the loss of a functional skin barrier sebagi, cuts very easily infected.Moreover,
with extensive skin loss, there was excessive evaporation of body fluids. This liquid
evaporation accompanied the production of protein and energy, which results in
metabolic disorders.
Networks that are off toxins necrosis (burn toxin, a protein lipid complex), which can
cause sepsis sirs even causing dysfunction and failure of organs such as the liver and
lungs, which ended with the death
Matrade prolonged inflammatory reaction due burns evoke irregular scars
(hypertrophic), contractures, deformities of the joints and so on.
V. COMPLICATIONS
a. hyponatremia (low sodium) for the first 48 hours
b. Hypernatremia (excess sodium): after 48 hours
c. hyperkalemia (excess potassium) after the first 48 hours
d. hypokalemia (low potassium) after the first 48 hours
e. Hypoproteinema (lack of protein)
f. Dehydrasi (dehydrated)
g. hypoxia (low O 2 )
h. Declining circulation
i. Anemia
VI. codes of conduct / THERAPY
A. First Aid In Burn Patients
1. Waive Px of the cause of the fire
2. Undress attached
3. Observe breathing and general conditions
4. Cool the burn with running water, the water used is quite denga temperature passes
20 degrees for 15 minutes
5. Cuts degree I do not need special care, given enough pain reliever analgetik
6. Letakka wound on the cloth / clean and if need further treatment immediately
brought to the hospital
7. When Px should get an IV then, for a while Px dipuasakan because at that point Px
have low intestinal peristaltic
B. codes of Px Combustio In Hospital:
1. Generalities
a. Avoid infection
b. monitor fluid into and out of
c. Caring for other functions
2. Generally Specific
a. Generally closed
Cuts washed

If there are broken Bulla

Cuts are given topical anti biotic thick wrapped to prevent leakage of fluid out
verban
b. publicly (Px hospitalizations)
Cuts dibiarka open after cleaning and anti-biotic nub denganlapisan
Make sure the room is free of mosquitoes and flies
Patients applied close / special nets
Tools woven sterile / clean
Use bernazin zalp sulvadiazin containing cream for direct wound
Provide anti-tetanus drugs
Observe hygiene Px
When enough, should act with skin graft surgery
C.
Medications and Therapy
1. If you have to install the infusion
2. Pmberian anti biotic
3. Symbumatis therapy
Fluid Therapy
1. Adults on Day 1: 4 cc / kg BW / wide cuts
2. Grant Day 2: given the first 8 hours, the rest of the given 6 hours later
3. Ciran given: RL
4. Grants day 3: adapted to the conditions Px, usually RL / 0.5%
Fifth. At of: physiological needs + fluid lost
6. RL: Colloids = 17: 3
7. To determine the fluid lost: 2 cc / kg BW x wide cuts

1.
2.
3.
4.
5.
6.

The need Fa'ali

0-3 months
: 125cc / kg BW
3-6 months
: 115cc / kg BW
6-9 months
: 110cc / kg BW
9-12 months
: 100cc / kg BW
1-5 years
: 100cc / kg BW
5-10 years
: 50cc / kg BW
Dilution giving the same way as adults

Fluid formula:
dilution x 20 (macro)
24 (h) x 60 (minutes)

B.

CASE REVIEW
Nursing care
I. REVIEW
Research is sistematisuntuk approach data collection and data analysis, to be known
problems faced by Px
a. Data Collection, covers:
1. identity of the patient

Px identity includes name, age, sex, religion, marital status, nationality, occupation,
address, education, date of MRS and medical diagnosis
2. primary complaint
Usually in the burn would increase heat in the body and accompanied the burning
pain in daerajh, sometimes even breathing disorders
3. history of diseases now
Usually terjaid because contact with high temperature, such as hot water, heat,
electricity, chemicals, and radiation
4. previous disease history
In theory it burns no relation to previous disease history, but if the patient has a
history of diseases such as DM then able to influence the healing
5. patterns of health functions
a. patterns and perceptions Affairs on healthy living
In this case the pattern is usually the patient's perception of safety in working less
attention, such as the patient does not wear gloves when working, do not wear a face
mask / goggles, so tat like healthy living and lead Px Px less susceptible combustio
b. patterns of nutrition and metabolism
Pad Px combustio usually experience decreased appetite disturbances in Px with
combustio create a diit TKTP
c. Pola elimination
Typically an interruption of elimination, if the district burns genetalia
d. relaxation and sleep patterns
Familiarity sleep patterns and relaxation experience interference due to pain, such
great pains in muscles and bones
e. patterns of sensory and cognitive
Patterns of normal sensory senses include but are feeling great pain in burn area
f. patterns of self perception and self-concept
At Px with burns disease usually suffer from disorders of perception or self-concept,
the patient is usually anxious and often think about the situation / ask illness
g. patterns and training activities
Usually activities and training experience changes or interruptions due to illness, so Px
needs to be helped either by the nurse or family
h. patterns of sexual reproduction
Usually when Px already married and has a child, will experience disruption in sexual
reproduction
i. patterns and role relationships
At Px combustio usually good relationship with the family Px and Px relationships with
others better
j. patterns of handling stress
At Px combustio usually experience stress due to anxiety and fear occur disability /
death handled by means of express way in the near future or caregivers
k. Pola order values and beliefs
Usually Px always pray for the safety of himself up to help daro moral people around
him
6. Supporting screening
a. Conditions General
Condition, consciousness, temperature, pulse, respiration BB and TB
b. Head and neck
Variants signs of trauma hair color and hair hygiene

Eyes
: skelera, conjunctiva, and cornea
Nose
: clean design and a polyp or not
Mouth : design, cleanliness is bleeding or not, lip mucosa moist or dry
Ears
: clean design, the hearing
Neck : thyroid gland is enlarged or not, there is swelling or not

c.

thorax
Thorax in the form Px burns are usually normal
d. Lung
Px chest usually symmetrical form, is there any movement of the lungs or not, the
voice or not
e. Heart
Inspection: iktus visible or not visible cardiac pulsation or not
palpation: iktus palpable or not, whether or not vibration
Percussion: right and left border restrictions
Auskultasi: Voice 1, 2, 3, and 4
f. Abdomen
Inspection: peristaltic design, umbilitus
Percussion: pentulan fluid wave, limit timapi dim
Auskultasi: normal peristaltic or not
g. Inguinal
Genetalia
Anus: no redness or not, the blisters or not
h. spine: there is a difference or not
i. Skin: available variants in skin texture, skin color, skin turgor decreased
j. persyarafan system: the difference or not
k. Ekstrimitas: akral warm or cold, no edema, feet pain while running or not
l. endocrine system
7. Inspection Supporting
Radiology
Inspection laboratory: HB

- Hematocrit
-Electrolyte
II. ANALYSIS OF DATA
1. subjective data
- Px heat
- Px pain in the affected area fire
2. Objective Data
Px visible pain
Masjid facial grimace
Px usually weak and lethargic
The existence of the local press pain
Anorexia
TTV: Px burns at temperatures usually occur enhancement, improvement usually
occurs RR, TD or there is no improvement, the pulse is usually normal (regular / regular)
3. Possible Cause

4.
a.
b.
c.
d.
e.
f.
g.

Prolonged inflammatory reaction

problem:
ineffectiveness of the airway
lack of fluid volume requirements
Risks of infection
Nyeri
Risks perfusion changes in peripheral tissues
Risks physical mobility disorders
Ansietas (aid)

III. DIAGNOSIS nursing

1. the ineffectiveness of the airway in relation to smoke inhalation, burns around the
face, neck and hot trauma
2. lack of fluid volume in relation to the transfer of fluid from the cavity into the
intraskuler intertinal
3. Risks of infection in relation to damage skin protection, network traumatic
4. Nyeri relating to damage the skin / tissue edema formation
5. Risks relating to changes in perfusion of peripheral tissues with burns
6. Risks relating to physical mobility disorders burning, pain, loss of strength and
resistance
7. Fears / ansietas relating to the threat of death or disability
IV. Intervention
1. Diagnosis I
Ineffectiveness of the airway in relation to smoke inhalation, burns around the neck,
and hot trauma
PURPOSE:
Road breath effectively in 1 hour
KH:
Sounds obvious breath
The frequency of breathing in normal range
No cyanosis
Intervention:
a. Consider reflex nuisance / swallow, observe the flow of saliva, inability to swallow,
congested, coughing wheezing
R /: Suspected inhalation injury
b. Beware frequency, rhythm, depth of inhalation, noting the pale / cyanosis and
carbonaceous sputum or pink
R /: takepnea, drug use help, cyanosis, and sputum showed there diotres perunbahan
respiratory / pulmonary edema and the need for intervention medikl
c. Elevate the head of the bed, avoid using a pillow under the head, according to
indications
R /: Increase paruoptimal expansion / respiratory function
d. Encourage coughing / breathing exercises and positions are often
R /: to increase lung expansion, mobilization, and drainage Sekret
e. Supervise 24 hour fluid balance, note the variations / changes
Transfer liquid or excess fluid replacement increases the risk of pulmonary edema
f. Collaborate with physicians in providing therapy
R /: O 2 improve hypoxia / acidosis, moisturizing lower airway drying and reduce the
viscosity of sputum
2. Diagnosis II

Lack of fluid volume in relation to the transfer of fluid from the intravascular into the
cavity inhalation intestisial
PURPOSE:
Requirement fulfilled fluid within 1 x 24 hours
KH:
Individual urinary tract adekuat
The vital signs stable
mucous membranes moist
Intervention:
a. Monitor vital signs
R /: provides guidelines for fluid replacement and examine the cardiovascular
response
b. urinary Monitor
R /: general fluid replacement should difitrasi to convince the average urinary 30-50
ml / hour (in adults)
c. Arrangement diagnosis and the loss of unseen
R /: increased capillary permeability, transfer protein, an inflammatory process, and
the loss through large areporasi of injury affecting circulation and urinary volume,
particularly for 24-72 hours after the first fire
d. Preserve posting a cumulative amount and type of fluid inclusion
R /: quick succession with different types of fluid inclusion and speed fluctuation of
the grant require tabulation tight to prevent imbalance and excess fluid
3. Diagnosis III
Risk of infection with respect to damage skin protection, network traumatic
PURPOSE:
Infection does not occur
KH:
Wound healing on time
Independent oksidat purulent
There is no infection, signs of infection = the heat, rubor, Dolor, Tumor, fungsiolazea
Intervention:
a. Implementation of precise isolation techniques suitable indication
R /: to reduce the risk of cross-contamination multiple bacterial flora
b. Emphasize the importance of good hand washing techniques to prevent crosscontamination
R /: reduce the risk of infection
c. Shave / hair tie around the burned area covers 1 inch border (including eyebrow
hair), shaving facial hair (men) and give the shampoo on the head two days once
R /: hair good media for bacterial growth, but acts as a protective eye brow eye,
regularly washing down the release of bacteria into the burn
d. Check the wound every day, watch / record changes in the appearance, smell, or
quality of drainage
R /: to identify the healing (granulation tissue) and early detection of infection burns
4. Diagnosis IV
Pain in connection with damage to the skin / tissue, edema formation
PURPOSE:
Pain decreases within 2 x 24 hours

KH:
Px say pain is reduced
Showing facial expressions
TTV normal
Intervention:
a. Perform therapeutic communication with Px and family
R /: to the cooperative action
b. distraksi Teach techniques and relaxasi
R /: Px distracts the source of pain
c. Px Change position often and vulnerable to passive and active movements
appropriate indication
R /: motion exercises reduce stiffness in joints and muscle fatigue but the type of
training depends on the location and wide injury
d. Examine complaints of pain, note the location / character and intensity (scale of 010)
R /: pain almost always have some degree of severity of involvement in networks or
damage but usually most severe for replacement dressings and debridement
V. IMPLEMENTATION
Implementation of the management and the realization of the plan of action,
covering several sections, namely nursing plan validation, providing nursing care and data
collection (Lismidar 1990)
The implementation is done according to a plan of action that was compiled by
looking at the situation and condition Px
VI. EVALUATION
Evaluation is the systematic comparison of the plan of action from health problems
Px with its intended purpose, is done by means of continuity involving Px and other
health team (Efendi 1995)
LIBRARY LIST
Mansjoer Arief et al (1999), Capita SELEKTA Medicine, Jakarta, Media Aescolapius
FKUI
Guidelines for Diagnosis and Therapy, LAB / UPF Surgical Science, 1994, District
General Hospital Doctor Soetomo, Surabaya
Martynn E Doenges (2001), Nursing Care Plan, Jakarta, EGC
Nasrul Effendi, (19 950, Introduction to Nursing Process, Jakarta, EGC
Suriadi, and Rita Yuliani PCS, PCS (2001) Nursing Care on Children, Jakarta, PT dawn
Interpratama
Standart Surgical Diseases Nursing Care (1999), RS Siti Khodijah,, Sidoarjo, The