Mata Kuliah : Bahasa Inggris

Dosen : Baharuddin

MANAGING A CLIENT WITH BURN

Oleh :

Kelompok 1 Kelas II.C

 ANNISA SAFITRI (152974)

 ANDI ULFA WAWO (152972)
 EKA AULIYAH (152976)

UPTD AKPER ANGING MAMMIRI

PROVINSI SULAWESI SELATAN

2016/2017
 PREFACE

First of all, thanks to Allah SWT because of the help of Allah, writer finished
writing the paper entitled “MANAGING A CLIENT WITH BURN” right in the
calculated time. The purpose in writing this paper is to fulfill the assignment that
given by Mr. Baharuddin as lecturer in samantics major. in arranging this paper, the
writer trully get lots challenges and obstructions but with help of many indiviuals,
those obstructions could passed. writer also realized there are still many mistakes in
process of writing this paper.

because of that, the writer says thank you to all individuals who helps in the
process of writing this paper. hopefully allah replies all helps and bless you all.the
writer realized tha this paper still imperfect in arrangment and the content. then the
writer hope the criticism from the readers can help the writer in perfecting the next
paper.last but not the least Hopefully, this paper can helps the readers to gain more
knowledge about samantics major.

Makassar, 28 maret 2017

Kelompok 7

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 TABLE OF CONTENTS

PREFACE .................................................................................................................................. i
CHAPTER I .............................................................................................................................. 1
INTRODUCTION .................................................................................................................... 1
A. BACKGROUND .......................................................................................................... 1
B. PURPOSE ..................................................................................................................... 1
CHAPTER II............................................................................................................................. 2
DISCUSSION ........................................................................................................................... 2
A. MEDICAL CONCEPT ................................................................................................. 2
B. NURSING CONCEPT .................................................................................................. 5
CHAPTER III ......................................................................................................................... 12
CLOSE .................................................................................................................................... 12
A. CONCLUSION ........................................................................................................... 12
B. SUGGESTION ........................................................................................................... 12
REFERENCES ....................................................................................................................... 13

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 CHAPTER I
INTRODUCTION

A. BACKGROUND
A burn is a type of injury to flesh or skin caused by heat, electricity,
chemicals, friction, or radiation. Burns that affect only the superficial skin are
known as superficial or first-degree burns. When damage penetrates into some
of the underlying layers, it is a partial-thickness or second-degree burn. In a
full-thickness or third-degree burn, the injury extends to all layers of the skin.
A fourth-degree burn additionally involves injury to deeper tissues, such as
muscle or bone.
The treatment required depends on the severity of the burn. Superficial
burns may be managed with little more than simple pain relievers, while
major burns may require prolonged treatment in specialized burn centers.
Cooling with tap water may help relieve pain and decrease damage; however,
prolonged exposure may result in low body temperature. Partial-thickness
burns may require cleaning with soap and water, followed by dressings. It is
not clear how to manage blisters, but it is probably reasonable to leave them
intact. Full-thickness burns usually require surgical treatments, such as skin
grafting. Extensive burns often require large amounts of intravenous fluid,
because the subsequent inflammatory response causes significant capillary
fluid leakage and edema. The most common complications of burns involve
infection.

B. PURPOSE
1. General Purpose
Getting a real picture of the nursing care of burns thoroughly
2. Special Purpose
a. Knowing the medical concept of burns
b. Knowing the nursing concept of burns

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 CHAPTER II
DISCUSSION

A. MEDICAL CONCEPT
1. Defenition
Burns are caused by a transfer of energy from a heat source to the
body. The depth of the injury depends on the temperature of the burning
agent and the duration of contact with it (Brunner & Suddarth’s).
2. Etiology
a. Thermal burns
Result from contact with hot substances that cause cell injury by
coagulation, including flame, hot liquids, hot solid objects, and steam.
The longer the skin is in contact with these hot substances the deeper
the wound. Oil-based liquids such as grease and cooking oil have
higher boiling points, and cause deeper burns than scalds with water or
other liquids. Burns from hot solid objects such as solid metal, hot
plastic, glass, or stone are all considered thermal burns.
b. Chemical burns
Destroy tissue and continue to do damage up to 72 hours unless
neutralized. Causes of chemical burns are strong acids, alkalis, and
organic compounds. Acids are commonly found in household cleaners
such as rust removers and bathroom cleaners, and cause protein
coagulation, which results in less extensive injuries. Alkalis such as
oven cleaners and fertilizers cause deeper burns due to liquefaction
necrosis of tissue, which lets the chemical penetrate deeper into
tissues. Organic compounds that cause chemical burns include
gasoline and chemical disinfectants, which can cause severe

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 coagulation necrosis and produce a layer of thick, nonviable tissue
called eschar, which is normally present in full-thickness burns.
c. Electrical burns
Electrical burns are classified as low voltage (under 1,000 volts) or
high voltage (1,000 volts or higher). Electrical injuries can cause death
by producing ventricular fibrillation or paralysis of the respiratory
muscles; dysrhythmias can occur with low voltage, but are more
commonly seen in high-voltage injuries. The extent of damage from
an electrical burn may initially appear minor—the patient may only
have small entry and exit wounds. Extensive damage can appear
within several days to weeks, a phenomenon known as the iceberg
effect because the skin surface shows little injury and hides massive
injury beneath. Instead of conducting the electricity, bones, muscle,
tendon, and fat respond to electrical injury by producing heat. Most
injuries occur to muscles surrounding the long bones.
d. Radiation burns
Result from exposure to sunlight, tanning booths, X-rays, or nuclear
emissions or explosions. Ionizing radiation can produce tissue damage
directly by striking a vital molecule such as DNA. Sunburn is usually a
first-degree or superficial burn, but radiation therapy can cause full-
thickness burns.
e. Smoke and inhalation burns
Can occur concurrently with thermal or chemical burns. If the patient
has thermal burns, the signs of inhalation burns are facial burns,
hoarseness, soot in the nose or mouth, carbon in the sputum, lip
edema, and singed eyebrows or nasal hair. Manufacturing of illegal
methamphetamine can cause thermal and chemical burns and
associated inhalation burns. Regardless of the cause of the inhalation
injury, the patient needs immediate respiratory interventions such as

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 bronchoscopy, endotracheal intubation, and measurement of
carboxyhemoglobin (COHgb) levels.
f. Frostbite
Frostbite is temporary or permanent tissue damage resulting from
exposure to very cold temperatures. Any area left uncovered in very
cold temperatures can become frostbitten, but the most commonly
affected areas are the fingers, toes, chin, earlobes, cheeks, and
nose.Blood flow to the skin's outer layer is reduced and the skin tissue
freezes and begins to die. Without treatment, frostbite can progress to
necrosis, gangrene, hypothermia, and cardiac arrest. Because frostbite
causes damage to the skin, some patients are treated in the ICU as burn
patients, although initial treatment for frostbite is different than that
for burns.
3. Pathophysiological concept
Burns caused by the transfer of energy from a heat source to the body.
Heat can be transferred through conduction or radiation electromagnetic.
Burns can be classified into thermal burns, radiation burns and chemical
burns.
The first result was a shock burns with shock and pain. Capillaries
exposed to high temperatures damaged and permeability rising. Blood
cells in it were damaged so that it can happen anemia. The increased
permeability causing edema and cause bullae containing electrolytes. It
leads to reduced intravascular fluid volume. Skin damage from burns
caused fluid loss due to excessive evaporation, infiltration of liquids into
the bull formed on the second-degree burns, and the discharge of scab
third degree burns.
If the burn area is less than 20%, usually mechanism compensation
body is still able to handle it, but if more than 20%, will hypovolemic
shock occurs with typical symptoms such as restlessness, pallor, cold,

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 sweaty, small and fast pulse, blood pressure decreased, and reduced urine
production. Swelling occurs slowly, the maximum occurred after 8 hours.

B. NURSING CONCEPT
1. Assessment
The emergency management of a patient with a burn injury begins
with the initial assessment and treatment of life-threatening injuries.
Stabilize the patient's cervical spine if this hasn't already been done. The
true mechanism of injury may not be clear (for example, the patient may
have been burned and propelled in an explosion).
Follow these specific aspects of the ABCDE (Airway, Breathing,
Circulation, Disability, and Exposure/Environmental control)
 Activity / Rest
Signs : - Decreased strength, resistance
- Limited range of motion
- Disorders of muscle mass, changes in tonus
 Circulation
Signs : - Hypotension (Shock)
- Decreased peripheral pulse distal in the injured ekstremity
- Tachycardia, dysrhythmias (electric shock)
- Establishment of tissue edema (all burns)
 Elimination
Signs : - urine output decreased during the emergency phase
- Diuresis (after the capillary leak and transfer of fluid into the
circulation)
- Decreased intestine peristaltic
 Food / Fluids
Signs : - General Edema
- Anorexia, nausea / vomiting

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 Neurosensori
Symptoms: Area free, tingling
Signs : - change orientation, effects, behavioral
- Decreased tendon reflexes in the injured extremity
- Convulsion (electric shock)
- Rupture of membranes timpanik (electric shock)
- Paralysis (injury to the flow of electricity)
 Pain
Symptoms: A variety of painful, example of the first-degree burns are
extremely sensitive to touch, pressure, movement and temperature
changes, second degree burns are very painful, while the response to
third-degree burns do not exist (no pain)
 Respiratory
Symptoms: locked in an enclosed space (possible inhalation injury)
Signs : - Hoarseness, cough wheezing, unable to swallow oral secretions,
cyanosis
- Development of thorax may be limited to the trap wound
burn
- The sound of breathing, splashing (pulmonary edema),
stridor (laryngeal edema), airway secretions (rhonchi)

2. Data analysis

No Data Focus Etiology Problem

1. Subjective Data: Burn Pain
- Patient said pain in the
burn area tissue destruction
Objective Data :

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 - Patient appear Stimulates the
grimaced and frowned hypothalamic release of
P : pain increased if it vasoactive substances
moved
Q: Stimulates free nerve
R : on the left hand and endings
left thigh
S:8 sensation of pain
T : 10 minutes
continuous
- Patient seem to keep
the painful burns
2. Subjective Data : Burn (combustion) Risk of infection
Patient said his body
warm tissue destruction
Objevtive Data :
- Temperature : 37,5 °C Loss of skin barrier
- Leukocytes:
19 000 (4000-10000) Damage to the immune
- Lymphocytes: 12 (20- response
40)

Risk of infection

3. Subjective Data : burns Impaired of physical

Patient said she could mobility
not do ADL tissue destruction
independently

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Objective Data :
- Patient looks weak
- ADL assisted the
family
pain
Patients unable to do
ADLs independently
Impaired mobility

3. Nursing diagnosis
1. Pain related to tissue injury and nerve injury .
2. Risk of infection related to loss of skin barrier and impaired immune
response
3. Impaired physical mobility related to pain due to burns.

4. Intervention

GOAL Intervention Rational

DX.No
I After performed
implementation for 2 x24
hours are expected that pain
is decrease or can be adapted
to the expected result :
a. Patient do not winced
and frowned
b. Scale of pain is decrease
become 4-5
1. close the wound as soon as
possible
2. Give basic comfort
measures, such as: massage
area without pain.
3. Teach pain management
 Changes in
temperature and air
movement can
cause severe pain in
the exhibition of the
nerve endings
 increase relaxation,
decrease muscle
tension and general
fatigue
 increase relaxation

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II After implementation for 2 x
24 hours is expected no
infection with expected
result :
a. temperature : 36,5-37ºC
b. leucosytes : 4.000-
10.000/mm3
c. Limphosytes : 20-40
III After implementation for 2 x
24 hours is expected that
techniques such as
relaxation breathing and
imagination
4. increase the period of
uninterrupted sleep
5. collaborations : give
analgesics as indicated
1. measure vital signs
2. Encourage good hand
washing for everyone
before contact with
patients.
3. check the combustion
everyday,record the
changes in appearance and
smell
4. do wound care and wound
dressing daily
5. use gloves and masks
during treatment aseptic
technique
6. collaborations : give
antibiotics as indicated
1. Adjust the position of the
patient carefully to prevent
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 lack of sleep can
increase the
perception of pain
 help to reduce pain
 as an indicator of
sepsis
 prevent cross-
contamination
lowers the risk of
infection
 detect self-infection
of burns
 reduce the risk of
infection
 prevent exposure to
infectious
organisms
 to control the
pathogen or against
pathogens to
prevent sepsis
 the correct setting
 patient experienced greater
physical mobility with
expected result :
a. patient participated in the
activities of daily living
b. patient is not weak
fixed positions on the burn
area
2. help the patient to sit and
early ambulation
3. encourage self-care until
an appropriate level of
patient tolerance
4. encourage families to help
the patient activity
position will reduce
the risk of flexion
contractour
 Early mobility
encourage increased
use of muscles
 self-care and
independence
would accelerate the
increase in activity
 reduce stress in
patients

 do range of motion
will minimize
muscle atrophy

4. Implementation
Implementation or execution is the initiative of a plan of action to achieve
a specific goal. Implementation phase begins after the plan of action in the
apartment and continued in nursing orders to help clients achieve the
expected goals. The goal of the implementation is to assist clients in
achieving the stated goals, which include improving health, disease
prevention, health restoration and manifest coping. Planning nursing
measures will be implemented properly, if the client has a desire to adapt
the implementation of nursing actions. During the implementation phase,
the nurse must perform data collection and choose the most appropriate
nursing actions to client needs.

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5. Evaluation
Evaluation is an intellectual action to complete the nursing process that
indicates how far nursing diagnosis, plan of action, and the
implementation has been achieved.

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 CHAPTER III
CLOSE

A. CONCLUSION
1. Burns are caused by a transfer of energy from a heat source to the body.
The depth of the injury depends on the temperature of the burning agent
and the duration of contact with it.
2. Classifications of burn are first-degree burn, second-degree burn, third-
degree burn and fourth-degree burn.
3. Etiology of burn are thermal burns, chemical burns, electrical burns,
radiation burns, smoke and inhalation burns and frostbite.
4. There ara 6 nursing diagnosis that may appear in burns
a. Acute Pain
b. Impaired Physical Mobility
c. Disturbed Body Image
d. Anxiety
e. Impaired Skin Integrity
f. Knowledge Deficit

B. SUGGESTION
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
....................................

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 REFERENCES

Monk DN, Plank LD, Franch-Arcas G, Finn PJ, Streat SJ, Hill GL. Sequential changes in the
metabolic response in critically injured patients during the first 25 days after blunt
trauma. Ann Surg 1996;223:395-405.

Bessey PQ, Jiang ZM, Johnson DJ, Smith RJ, Wilmore DW. Posttraumatic skeletal muscle
proteolysis: the role of the hormonal environment. World J Surg 1989;13:465-70.

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