NURSING PROCESS :

CARE OF THE BURN PATIENT DURING

THE ACUTE PHASE
Ns. Heri Kristianto, SKep.,MKep.,Sp.KMB
Preface
The acute or intermediate phase of burn care follows the
emergent/ resuscitative phase and begins 48 to 72 hours
after the burn injury
Focus assessment:
Respiratory and circulatory status

Fluid and electrolyte balance

Gastrointestinal function

Infection prevention

Burn wound care (ie, wound cleaning, topical antibacterial

therapy, wound dressing, dressing changes, wound
dbridement, and wound grafting)
Pain management

Nutritional support
Assessment
Hemodynamic alterations: vital signs, peripheral pulses,
electrocardiogram
Assessment of residual gastric volumes and pH in the
patient with a nasogastric tube is also important. Blood
in the gastric fluid or the stools must also be noted and
reported
Wound healing: size, color, odor, eschar, exudate,
abscess formation under the eschar, epithelial buds
(small pearl-like clusters of cells on the wound surface),
bleeding, granulation tissue appearance, status of
grafts and donor sites, and quality of surrounding skin
Rule of 9
1%
Kasus
Ny. Tuni
Hasil pemeriksaan fisik pada Ny Tuni ditemukan
adanya luka bakar pada tangan (9%+9%), dada
(18%), leher dan sebagian wajah (9% asumsi total),
serta kaki kanan (18% asumsi total). Total LB= 53%
An. Toni 5thn
Luka bakar di kedua tangan (5%x4=20%), dada
(6.5%) dan wajah (61/2 %). Total 32%
Derajat Luka Bakar
Zona Kerusakan Jaringan
Pin-prick test
Eksisi tangensial
Punch biopsi
Laser doppler imaging
Contoh analisa LDI
Cont
Ongoing assessments focus on pain and
psychosocial responses, daily body weights, caloric
intake, general hydration, and serum electrolyte,
hemoglobin, and hematocrit levels. Assessment for
excessive bleeding from blood vessels adjacent to
areas of surgical exploration and dbridement is
necessary as well.
Early detection of complications: assessment of
respiratory and fluid status
 Diagnostic

x-ray
arterial blood gases
blood analysis
body temperature
37.2 to 38.3C (99
to 101F) to reduce
metabolic stress and
tissue oxygen demand
Invasive vascular
linesavoided
SwabCulture
 Manajemen

Fase Akut Fase Subakut Fase Lanjut

0-48 (72) jam Sp 14-21 hari Sp 8-12 bulan

Gangguan ABC SIRS & MODS Skar Hipertrofi

Sepsis kontraktur
NURSING DIAGNOSES
Excessive fluid volume related to resumption of
capillary integrity and fluid shift from the interstitial to
intravascular compartment
Risk for infection related to loss of skin barrier and
impaired immune response
Imbalanced nutrition, less than body requirements,
related to hypermetabolism and wound healing needs
Impaired skin integrity related to open burn wounds
Acute pain related to exposed nerves, wound healing,
and treatments
Cont
Impaired physical mobility related to burn wound
edema, pain, and joint contractures
Ineffective coping related to fear and anxiety,
grieving, and forced dependence on health care
providers
Interrupted family processes related to burn injury
Deficient knowledge about the course of burn
treatment
COLLABORATIVE PROBLEMS/
POTENTIAL COMPLICATIONS
Heart failure and pulmonary edema
Sepsis
Acute respiratory failure
Acute respiratory distress syndrome
Visceral damage (electrical burns)
Planning and Goals
Normal fluid balance
Absence of infection
Attainment of anabolic state and normal weight
Improved skin integrity
Reduction of pain and discomfort
Optimal physical mobility
Adequate patient and family coping
Adequate patient and family knowledge of burn treatment
Absence of complications
Achieving these goals requires a collaborative,
interdisciplinary approach to patient management.
Resusitasi Cairan
Tujuan resusitasi cairan yaitu
Memperbaiki deficit cairan, elektrolit dan protein

Menggantikan kehilangan cairan berlanjut dan

mempertahankan keseimbanagan cairan.
Mencegah pembentukan edema berlebihan

Mempertahankan haluaran urine pada orang dewasa 30-70

ml/jam
Mengupayakan sirkulasi yang menjamin kelangsungan perfusi
sehingga oksigenasi terpelihara

IWL= (25+%LB) x BSA x 24 jam

Jenis Resusitasi Cairan

1. Formula Evan Brooke

Prinsip:
Larutan fisiologik, koloid dan glukosa

Diberikan dalam waktu 24 jam pertama

dengan alasan inefektif Hb dan kehilangan
energi yang berlebih
Jumlah cairan yang diberikan berdasar luas
luka bakar dan berat badan pasien
Cara Pemberian:
Hari 1 : jumlah kebutuhan cairan diberikan 8
jam pertama ;sisa diberikan 16 jam sisa
Hari 2 : jumlah kebutuhan koloid dan larutan
saline ditambah 2000 ml glukosa
Rumus Evan Brooke
Kasus
Ny. Tuni bb=50kgTotal LB= 53%
1cc x 50 kg BB x 53= 2650cc (koloid)
1cc x 50 kg BB x 53= 2650cc (NaCl)
2000 cc glukosa
Pantau urine output > 50 cc/ jam
Cara pemberian:
8 jam 1325 koloid, 1325 NaCl, 1000 glukosa
16 jam 1325 koloid, 1325 NaCl, 1000 glukosa
Pemberian albumin
Rumus kebutuhan albumin=
(D-A)x BB x 3.2
Keterangan:
D: kadar albumin yg diharapkan
A: kadar albumin aktual
BB: berat badan
Kasus
Ny Tuni
kebutuhan albumin: (3-2.9 g/dl)x 50 kg x 3.2
16 cc
produk 20cc, 50 cc, 100 cc
2. Formula Baxter/Parkland
Prinsip:
Syok yang terjadi jenis hipovolemia

Hanya memberikan RL+elektrolit, koloid diperlukan bila

setelah sirkulasi mengalami pemulihan
Penurunan efektifitas Hb karena perlekatan eritrosit, trombosit,
leukosit, dan komponen sel lain pada dinding pembuluh darah
Pemberian koloid tidak efektif karena adanya gangguan
permeabilitas dan kebocoran plasma, menyebabkan
penarikan ke jaringan interstesiil, sulit ditarik ke intravaskuler,
menambah beban kerja jantung, paru dan ginjal,
memperbesar resiko reaksi inflamasi
Rumus Baxter/Parkland

Kebutuhan cairan 24 jam kedua: jumlah kebutuhan hari pertama

back
Kasus latihan 5 menit!!!!
Silahkan mahasiswa latihan memasukkan rumus !!!!!
Bagaimana pemberiannya????
Rumus Anak-Anak
Kasus
Toni: BB 17 kg, 32% LB
Cincinati 4 x 17 kg x 32= 2040 cc

Galveston 5000 cc x (32% x 0.7 )= 1120

2000 cc x (32% x 0.7 )= 448

Total 1568 cc
 Bacteria: Staphylococcus, Proteus, Pseudomonas,
Escherichia coli, and Klebsiella
Fungi: Candida albicans
Eschar
Burn wound sepsis has these characteristics:
10 bacteria per gram of tissue
Inflammation
Sludging and thrombosis of dermal blood vessels
 Hidrotherapy (20-30menit)
The temperature of the water is maintained at
37.8C (100F), and the temperature of the room
should be maintained between 26.6 and 29.4C
(80 to 85F).
Kultur luka
Topical Antibacterial Therapy
It is effective against gram-negative organisms,
Pseudomonas aeruginosa, Staphylococcus aureus, and
even fungi.
It is clinically effective.
It penetrates the eschar but is not systemically toxic.
It does not lose its effectiveness, allowing another
infection to develop.
It is cost-effective, available, and acceptable to the
patient.
It is easy to apply, minimizing nursing care time.
 Silver sulfadiazine (Silvadene), silver nitrate, and
mafenide acetate (Sulfamylon).
Many other topical agents are available, including
povidoneiodine ointment 10% (Betadine), gentamicin
sulfate, nitrofurazone (Furacin), Dakins solution, acetic
acid, miconazole, and chlortrimazole. Bacitracin may be
used for facial burns or on skin grafts initially.
A newer product used in burn wound care is Acticoat
Antimicrobial Barrier dressing. Acticoat is a silver-
coated dressing approved for treatment of burn
wounds and donor sites.
MEBO
Wound Dressing

Kulit
STSG & FTSG
Perawatan: 5-7 hari jika eksudasi minimal
24-48 jam jika eksudasi berlebihan
Skin substitute epicell, alloderm, integra
Stem cell
Bahan selain kulit: biological dressing & sintetik dressing
Kassa
Tulle grass
Biological dressing: Plasenta
Biological dressing: Cellulose
Sintetik dressing
Hidrofiber
Hyalomatrix
Calcium alginate
Metode lain
Vakum
Madu
Pressure bandage
Plaster fiksasi
Perban elastik
Garment khusus
Silicones sheet
Dressing Changes
20 menit sebelumnya analgesik
Proteksi diri
Steril
Moist menurunkan nyeri saat ganti balutan
Cuci luka wound assessment
Debridement, escarotomi, topical therapy
Secondery dressing
Kasus
Tuni skin graft?
Toni ditemukan bula?

Perlukah fasciotomi/eskarotomi?
Bolehkan pakai balutan tekan?
PENATALAKSANAAN NUTRISI

Waktu: sedini mungkin

Route pemberian nutrisi: Enteral
Kecukupan energi
Komposisi
Nutrient spesifik

Robert RW: Am.J. Clin Nutr 1996;64: 800-8

Resusitasi Saluran Cerna

Mulai sedini mungkin

Gut Feeding
Mulai 15 ml / jam , ditingkatkan bertahap
Viskositas 0,8 1 kcal / ml
Nutrisi lengkap ; KH , Protein , Lemak
BERLEBIHAN !!!!!
 Waktu

Fase Akut Fase Subakut Fase Lanjut

0-48 (72) jam Sp 8-12 bulan

Goal: inflamasi Kecukupan nutrisi imunitas

Cegah stres ulser Penyembuhan luka
Cegah trans bakteri
Stres metabolisme

MORBIDITAS
MORTALITAS
 Kesimpulan: meta analisis pada 27 penelitian
memperlihatkan risiko infeksi pada pemberian
dengan pipa makan lebih rendah dibandingkan
nutrisi parenteral.
 Kecukupan Energi
KEBUTUHAN KALORI ESPEN
Pada fase akut dan fase awal masa kritis 20 25 kkal/kg/hari
Pada fase anabolik 25 30 kkal/kg/hari
Kebutuhan kalori total (Xie 1993)
1000 kkal X LPT(m2) + (25 x %LPT)

(TB cm x BB kg) 1/2

LPT (m2) =
3600

Kebutuhan kalori total dicapai pada hari ke 4 (Oetoro, dkk, 2001)

Komposisi

Protein : 1.5 - 4 gr/kg/hr

20 25% Kalori total

Gottschlich, MM et al, Differential effects of three enteral dietary regiments on selected outcome
variables in burn patient. J PEN 1990, 14; 225-236
Tassiopoulos KA, Nutritional support of the patient with severe burn injury nutrition 1999; 15: 956
957
Heimburger CD & weinsier L.R. Critical illness in Handbook of clinical nutrition 1997. 445 457
Mosby, St Luvis
Oetoro S, Permadhi I, Witjaksono F. Penatalaksanaan nutrisi pada luka bakar dalam luka bakar
pengetahuan klinik praktis ( yefta Moenadjat ed ) FKUI. Jakarta 2003, 100-109.
 Karbohidrat :
50 65% total kalori

4 5 mg/kg BB/menit

Wolfe R.R, relation of metabolic studies to clinical nutrition-the example of burn injury Am J. Clin Nutr.
1996; 64:800-8
Tassiopoulos KA, Nutritional support of the patient with severe burn injury nutrition 1999; 15: 956
957
Oetoro S, Permadhi I, Witjaksono F. Penatalaksanaan nutrisi pada luka bakar dalam luka bakar
pengetahuan klinik praktis ( yefta Moenadjat ed ) FKUI. Jakarta 2003, 100-109.
 Lemak :
20 30% total kalori

2 -3% total kalori merupakan asam lemak essential

As. L. Omega 6 : As. L. Omega 3 = 2-3:1

Wolfe R.R, relation of metabolic studies to clinical nutrition-the example of burn injury Am J. Clin Nutr. 1996; 64:800-8
Tassiopoulos KA, Nutritional support of the patient with severe burn injury nutrition 1999; 15: 956 957
Abadia D, et al Pharmacological nutrition after burn injury, J. Nutr 1998, 128 : 797 803
Oetoro S, Permadhi I, Witjaksono F. Penatalaksanaan nutrisi pada luka bakar dalam luka bakar pengetahuan klinik
praktis ( yefta Moenadjat ed ) FKUI. Jakarta 2003, 100-109.
 Vitamin dan Mineral

Rodriguez, CJG, Nutrition support of the septic patient, in from nutritional support to pharmacologic nutrition in
the ICU (Vincent, Jl. Ed), Spring Verlag Berlin Heidelberg, 2000: 348-60.
Tassiopoulos KA, Nutritional support of the patient with severe burn injury nutrition 1999; 15: 956 957.
NUTRITION SPESIFIC
Working Group on
Metabolism and Clinical Nutrition
Konsensus Nutrisi Enteral
Pain Scale
The three aspects of treatment of septic shock
Treatment of septic shock

Hemodynamic Infection
stabilization control

Fluids Vasoactive Antibiotics Source

Resuscitation agents control

Modulation of the
septic response

Corticosteroids Low-dose CRRT Nutritional

vasopressin support
EXPECTED PATIENT OUTCOMES
Cont
Cont
Uses appropriate coping strategies to
deal with postburn problems

Verbalizes reactions to burns, therapeutic procedures,

losses
Identifies coping strategies used effectively in previous
stressful situations
Accepts dependency on health care providers during
acute phase
Verbalizes realistic view of problems resulting from
burn injury and plans for future
Cooperates with health care providers in required
therapy
 Participates in decision making regarding care
Resolves grief over losses resulting from burn injury
and circumstances surrounding injury (eg, death of
others, damage to home or other property)
States realistic objectives for plastic surgery, further
medical intervention, and results
Verbalizes realistic abilities and goals
Displays hopeful attitude toward future
Absence of complications
Lungs clear on auscultation
Exhibits no dyspnea or orthopnea and can breathe easily when
standing, sitting, and lying down
Exhibits no S3 or S4 heart sounds or jugular venous distention
Exhibits urine output; central venous, pulmonary artery, and
pulmonary artery wedge pressures; and cardiac output within
normal or acceptable limits
Exhibits normal blood, sputum, and urine culture results
Maintains arterial blood gas values within normal or acceptable
limits
Has normal lung compliance
Has no visceral organ damage
Has stable cardiac rhythm