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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

NURSING PROCESS : Infection prevention

Burn wound care (ie, wound cleaning, topical antibacterial


CARE OF THE BURN PATIENT DURING therapy, wound dressing, dressing changes, wound
dbridement, and wound grafting)
THE ACUTE PHASE Pain management

Nutritional support
Ns. Heri Kristianto, SKep.,MKep.,Sp.KMB

Assessment Rule of 9
Hemodynamic alterations: vital signs, peripheral pulses, 1%
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

Derajat Luka Bakar


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%

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Zona Kerusakan Jaringan Pin-prick test

Eksisi tangensial Punch biopsi

Laser doppler imaging Contoh analisa LDI

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Cont Diagnostic
Ongoing assessments focus on pain and x-ray
psychosocial responses, daily body weights, caloric arterial blood gases
intake, general hydration, and serum electrolyte, blood analysis
hemoglobin, and hematocrit levels. Assessment for body temperature
excessive bleeding from blood vessels adjacent to 37.2 to 38.3C (99
areas of surgical exploration and dbridement is to 101F) to reduce
metabolic stress and
necessary as well. tissue oxygen demand
Early detection of complications: assessment of Invasive vascular
respiratory and fluid status linesavoided
SwabCulture

Manajemen NURSING DIAGNOSES


Excessive fluid volume related to resumption of
capillary integrity and fluid shift from the interstitial to
Fase Akut Fase Subakut Fase Lanjut intravascular compartment
Risk for infection related to loss of skin barrier and
0-48 (72) jam Sp 14-21 hari Sp 8-12 bulan
impaired immune response
Imbalanced nutrition, less than body requirements,
related to hypermetabolism and wound healing needs
Gangguan ABC SIRS & MODS Skar Hipertrofi
Sepsis kontraktur
Impaired skin integrity related to open burn wounds
Acute pain related to exposed nerves, wound healing,
and treatments

COLLABORATIVE PROBLEMS/
Cont
POTENTIAL COMPLICATIONS
Impaired physical mobility related to burn wound Heart failure and pulmonary edema
edema, pain, and joint contractures Sepsis
Ineffective coping related to fear and anxiety, Acute respiratory failure
grieving, and forced dependence on health care
Acute respiratory distress syndrome
providers
Visceral damage (electrical burns)
Interrupted family processes related to burn injury
Deficient knowledge about the course of burn
treatment

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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 Jenis Resusitasi Cairan


Tujuan resusitasi cairan yaitu
1. Formula Evan Brooke
Memperbaiki deficit cairan, elektrolit dan protein
Prinsip:
Menggantikan kehilangan cairan berlanjut dan
Larutan fisiologik, koloid dan glukosa
mempertahankan keseimbanagan cairan.
Diberikan dalam waktu 24 jam pertama
Mencegah pembentukan edema berlebihan
dengan alasan inefektif Hb dan kehilangan
Mempertahankan haluaran urine pada orang dewasa 30-70 energi yang berlebih
ml/jam
Jumlah cairan yang diberikan berdasar luas
Mengupayakan sirkulasi yang menjamin kelangsungan perfusi luka bakar dan berat badan pasien
sehingga oksigenasi terpelihara
Cara Pemberian:
Hari 1 : jumlah kebutuhan cairan diberikan 8
jam pertama ;sisa diberikan 16 jam sisa
IWL= (25+%LB) x BSA x 24 jam
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

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Pemberian albumin Kasus


Rumus kebutuhan albumin= Ny Tuni
(D-A)x BB x 3.2 kebutuhan albumin: (3-2.9 g/dl)x 50 kg x 3.2
Keterangan: 16 cc
D: kadar albumin yg diharapkan produk 20cc, 50 cc, 100 cc
A: kadar albumin aktual
BB: berat badan

Rumus Baxter/Parkland
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 Kebutuhan cairan 24 jam kedua: jumlah kebutuhan hari pertama
penarikan ke jaringan interstesiil, sulit ditarik ke intravaskuler,
menambah beban kerja jantung, paru dan ginjal,
memperbesar resiko reaksi inflamasi

back

Kasus latihan 5 menit!!!! Rumus Anak-Anak


Silahkan mahasiswa latihan memasukkan rumus !!!!!
Bagaimana pemberiannya????

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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

Kultur luka
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).

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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

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Wound Dressing Kassa

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

Tulle grass Biological dressing: Plasenta

Biological dressing: Cellulose Sintetik dressing


Hidrofiber
Hyalomatrix
Calcium alginate

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Metode lain
Vakum
Madu

Pressure bandage
Plaster fiksasi
Perban elastik
Garment khusus
Silicones sheet

Dressing Changes Kasus


20 menit sebelumnya analgesik Tuni skin graft?
Proteksi diri Toni ditemukan bula?
Steril
Moist menurunkan nyeri saat ganti balutan Perlukah fasciotomi/eskarotomi?
Cuci luka wound assessment Bolehkan pakai balutan tekan?
Debridement, escarotomi, topical therapy
Secondery dressing

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PENATALAKSANAAN NUTRISI Resusitasi Saluran Cerna

Waktu: sedini mungkin Mulai sedini mungkin


Route pemberian nutrisi: Enteral Gut Feeding
Kecukupan energi Mulai 15 ml / jam , ditingkatkan bertahap
Komposisi Viskositas 0,8 1 kcal / ml
Nutrient spesifik Nutrisi lengkap ; KH , Protein , Lemak
BERLEBIHAN !!!!!

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

Waktu

Kesimpulan: meta analisis pada 27 penelitian


Fase Akut Fase Subakut Fase Lanjut memperlihatkan risiko infeksi pada pemberian
dengan pipa makan lebih rendah dibandingkan
nutrisi parenteral.
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

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Kecukupan Energi Komposisi


KEBUTUHAN KALORI ESPEN
Pada fase akut dan fase awal masa kritis 20 25 kkal/kg/hari Protein : 1.5 - 4 gr/kg/hr
Pada fase anabolik 25 30 kkal/kg/hari
20 25% Kalori total
Kebutuhan kalori total (Xie 1993)
1000 kkal X LPT(m2) + (25 x %LPT)

(TB cm x BB kg) 1/2


LPT (m2) =
3600
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
Kebutuhan kalori total dicapai pada hari ke 4 (Oetoro, dkk, 2001)
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.

Lemak :
Karbohidrat : 20 30% total kalori

50 65% total kalori 2 -3% total kalori merupakan asam lemak essential

4 5 mg/kg BB/menit 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. Wolfe R.R, relation of metabolic studies to clinical nutrition-the example of burn injury Am J. Clin Nutr. 1996; 64:800-8
1996; 64:800-8 Tassiopoulos KA, Nutritional support of the patient with severe burn injury nutrition 1999; 15: 956 957
Tassiopoulos KA, Nutritional support of the patient with severe burn injury nutrition 1999; 15: 956 Abadia D, et al Pharmacological nutrition after burn injury, J. Nutr 1998, 128 : 797 803
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.
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


NUTRITION SPESIFIC
Working Group on
Metabolism and Clinical Nutrition
Konsensus Nutrisi Enteral

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.

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Pain Scale

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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

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Uses appropriate coping strategies to


deal with postburn problems
Participates in decision making regarding care
Verbalizes reactions to burns, therapeutic procedures,
losses Resolves grief over losses resulting from burn injury
Identifies coping strategies used effectively in previous and circumstances surrounding injury (eg, death of
stressful situations others, damage to home or other property)
Accepts dependency on health care providers during States realistic objectives for plastic surgery, further
acute phase
Verbalizes realistic view of problems resulting from
medical intervention, and results
burn injury and plans for future Verbalizes realistic abilities and goals
Cooperates with health care providers in required Displays hopeful attitude toward future
therapy

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

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