General Directorate of Nursing: Burn Care Functions Duties Policies and Procedures

GENERAL DIRECTORATE OF NURSING
BURN CARE Functions Duties Policies and Procedures
Nursing Standards Organizing Committee for Hospital Services 2005
Ministry of Health, General Nursing Administration Functions & Duties Policies & Procedures ___________________________________________________ SPECIALIZED NURSING: BURNS
TITLE: INDEX NUMBER SNR-BC-002 PAGE NUMBER 1 of 3
RESPONSIBILITIES OF STAFF NURSE IN BURNS UNIT

EFFECTIVE DATE APPLIES TO NURSING APPROVED BY
POLICY: 1. A graduate of Bachelor of Science in Nursing from accredited school, with oneyear experience in Burns Unit. 2. Registered with current license and CPR license. 3. Staff nurse without experience in Burn Unit shall be trained and supervised by senior nurses until she is proficient. 4. Assistant nurse without experience in Burn Unit shall be trained and supervised by senior nurses until she is sufficient. PURPOSE: 1. Provide professional care for burns patient and comply with established nursing standards. 2. To clearly define duties and responsibilities. 3. To guide nursing actions. DUTIES AND RESPONSIBILITIES: 1. Admit and orient new patients and family. 2. Instruct that watchers are not allowed to stay; only pediatric patients can have watchers aged 1 to 12 years old. 3. Check patient chart, information must be clear and consistent.
INDEX NUMBER SNR-BC-002
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4. Take patient medical past, present history and must be properly documented. 5. Assemble patient chart, should be neat and properly arranged. 6. Carryout doctors order properly and correctly. 7. Plan nursing care according to patient problem priorities. 8. Update kardex. 9. Maintain required unit records. 10. Plan patients diet and arrange with dietician. 11. Plan for patient discharge or transfer. 12. Maintain controlled drug records. 13. Check supplies, crash cart content must be complete. 14. Answer telephone politely and deliver message accurately. 15. Observe proper technique (asepsis) in all performance of duties. 16. Make rounds with doctor. Prepare and assist physician during treatment and examination. 17. Administer prescribed medications by following the seven rights. 18. Clean wounds, change dressing aseptically. Bath patient as needed. 19. Make nursing rounds, assess patient condition, answer questions give instructions to obtain nurse-patient interaction, check vital signs (TPR, B/P, and HR). 20. Check functioning medical equipment attached with the patient. 21. Administer fluid therapy. Accurately. 22. Observe and record progress of patient appetite, attitude, activity of daily living or any symptoms. 3
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23. Notify in-charge doctor of any significant changes in patient response to treatment and care. 24. Recognize emergencies and respond with proper protocol e.g. incubation. 25. Record all legal matters about patient and document legibly. 26. Know how to keep confidence in case patient shares her/his private life. 27. Communicate with the head nurse for any request. It should be done through proper channel of communication. 28. To receive and endorse patients pre and postoperatively according to hospital routine.
ORIENTATION OF NEW STAFF IN BURNS UNIT

POLICY: 1. Standard Burns Unit orientation shall be provided to the new staff. 2. Orientation program shall take at least three months. 3. New staff shall have the opportunity to experience all aspect of burn unit. 4. Allow new staff to give opportunity to repeat new learning experiences for purposes of review with a later date. 5. Orientation will be able to complete burn unit checklist for the orientation periods, which will serve as a reference between orientee and mentor. PURPOSE: To familiarize new staff with the burns unit environment, equipment, policy, and procedures. PROCEDURES: First Week Burns Unit Introduction 1. Identify the staff and colleagues. 2. Can locate the duty schedule and follow hours of duty 3. Identify the doctors. 4. Locate the office of Department of Nursing.
ORIENTATION OF NEW STAFF IN BURNS UNIT Other Wards and Departments:
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Location of Emergency Room Main ICU, Operating Room Delivery Room, Maternity I and II. Male surgery, Female Surgery, Orthopedics Surgery Female Medical, Male Medical Ward Pediatric Ward. PICU NICU NICU Isolation SCBU X-ray, CT Scan Department, and MRI Department OPD I and II Laboratory Second Week 1. Location of equipment and supplies. 2. Care of equipment and linen. 3. Use of oxygen cylinders, oxygen flow meter on the wall. 4. Care of drugs and narcotics. 5. Use of narcotics and controlled drug forms. 6. Explain and demonstrate crash cart function. Other Wards and Departments: Send samples to laboratory Pharmacy request Laundry General Store Bio-medical Department Medical secretary office Adinistration office Library Auditorium
ORIENTATION OF NEW STAFF IN BURNS UNIT Third Week 1. Recall the Burns Unit policy and procedures. 2. Setting with and check the cardiac monitors. 3. Carry out assignments and responsibilities. 4. Care of laboratory specimens. 5. Completion of burns unit records. 6. Disposition of contaminated linen.
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7. Clean patients bed, bedside table after discharge. 8. Use of telephone and pager, beeper. Fourth Week Respond to every hospital procedures: CPR Code Blue Fire Procedures Safety Awareness Disaster Plan Second month orientee shall be able to repeat the same with minimum guidance. End third month she/he should be able to perform independently.
TITLE: INDEX NUMBER
BURNS UNIT ATTIRE SUIT

SNR-BC-004 PAGE NUMBER 1 of 3
DEFINITION: An approved uniform used in Burns Unit OBJECTIVE: 1. To provide effective barriers that prevents the dissemination of microorganisms to patient or environment. 2. To protect personnel or patients against exposure to communicable disease and hazardous materials. POLICY: 1. The approved burns unit attire suit consists of head covers, shirt, trousers, and shoe cover. 2. The sterile scrub suite for sterile personnel consists of sterile gown, sterile gloves, and facemask, added to the basic operating room attire. 3. All personnel or visitors are required to change into operating room attire from outside clothes at all times upon entering burns unit. Clean burns attire is donned upon reentrance into OR. 4. All burns unit personnel must wear freshly laundered clean burns unit attire at all times. Burns unit attire should be discarded for laundry and not hang in the locker/cupboard with outside cloths. 5. It is required to change into new burns unit attire if wet/blood stained. 6. Burns unit attire must be worn correctly at all times.
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7. Burns unit attire should no be worn outside burns unit complex. 8. Facemask should be worn in restricted area of burns unit. 8.1 Facemask must be worn over both nose and mouth and conform to facial contour. 8.2 Mask string must be tied tightly and never cross overhead as it can distort contour of mask along cheeks. 8.3 No hanging of mask around neck. 8.4 Must should be kept clean and must be changed whenever necessary. 8.5 Talking should be kept to a minimum. 9. Jewelry should be removed, pierced ear studs must be confined within head cover. 10. Fingernails should kept short, without nail polish and artificial nails. 11. Outside clothes are only allowed in unrestricted area. 12. Shoe inside burns unit should not be worn outside the unit. 12.1 Shoe cover should be removed when outside the burns unit. 12.2 Change shoe cover between dressings and whenever it become wet or torn. 13. All nursing staff to do initial hand wash for 5 minutes between patient bath and sterile dressing. 14. Comfortable supportive shoes should be worn to relieve fatigue. 15. Staff with acute infection, such as cold or sore throat, or skin lesion such as furuncle or any contagious condition, should not be permitted to do the sterile dressing. 16. Only head cover that is provided by the hospital are allowed, white colored-Tarha is allowed as long as it is not worn outside the unit.
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PROCEDURES: 1. Wash hands 2. Remove outside clothes and shoes. 3. Put on head cover first. 3.1 3.2 Confine all hairs in the head cover. Confine earrings or ears studs in the head cover
4. Wear approved scrub suit or attire. 5. Wear approved shoes. 6. Wash hands upon entering burns unit. 7. Wear mask whenever required. 7.1 Hold mask by the strings 7.2 Cover both mouth and nose with mask completely. 7.3 Tie upper strings at back of head first, followed by lower strings behind the neck. Secure the nurse while uncomfortably. 7.4 Press the exterior pliable strip or noseband to contour mask over the bridge of the nose. 7.5 Check mask cover nose and mouth at all times. Check mask is not hanged around the neck or tucked into pocket for further use. 7.6 Remove mask by: 7.6.1 7.6.2 7.6.3 Untie upper string Untie lower string Discard mask in a proper receptacle.
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Ministry of Health, General Nursing Administration Functions & Duties Policies & Procedures ____________________________________________________ SPECIALIZED NURSING BURNS
ISOLATION NURSING, MASK, GOWNS, AND GLOVES

DEFINITION: The patient is taken care of in a separated room for reverse isolation. OBJECTIVE: 1. To prevent transmission of infection. 2. To provide the physical barriers. 3. To prevent soiling of clothing during patient care. 4. To maintain aseptic environment. 5. To reduce the possibility that personnel will become contaminated with any blood or body fluids spills. 6. To reduce the possibility that personnel will become transiently colonized with microorganisms that can be transmitted to other patients. POLICY: 1. All personnel entering the patients room under isolation should use precautions as indicated by the CDC card category of isolation. 2. Sterile gown, gloves, and mask should be used for any sterile procedure. 3. Gowns are never to be used more than once and should be changed if soiled or moist.
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ISOLATION NURSING, MASK, GOWNS, AND GLOVES
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4. Dispose of the contaminated gown within the patients room in the appropriate hamper trolley. 5. Hands must be washed before and after wearing gloves. 6. Mask should be worn only once and replace if it will become moist or damp. 7. Gloves should not be used as a substitute for meticulous hand washing. 8. Mask must be discarded inside the patients room before leaving and never hang around the neck. MATERIALS & EQUIPMENTS: 1. Clean mask. 2. Sterile gown (to perform sterile procedures only). 3. Sterile and non-sterile gloves. PROCEDURE 1. Assess the patients condition. 2. Explain the patient the need of using mask, gown, and gloves. 3. Wear mask fitted to cover nose and mouth and fit tightly against the skin without gaping at the sides. 4. Wear gown and fasten it securely at the neck and waist. Cover the overlap completely at the back. 5. Wear gloves by covering the wrist and cups of gown, if worn. 2. To reduce anxiety. RATIONALE
3. To prevent particles aerosols transmitted by close contact. 4. To maintain sterility. To protect gross-clothing contamination.
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TITLE: INDEX NUMBER
ADMISSION OF BURNS PATIENTS

DEFINITION: Any patients admitted to Burns Unit who is in contact with profound trauma of the skin. OBJECTIVES: 1. To properly assess and provide immediate management for further treatment. 2. To administer proper sedation to alleviate suffering. 3. To provide comfort and psychological support. 4. To give proper nursing care for burns patients. 5. To facilitate and increase the effectiveness of emergent burn-phase procedures. POLICY: 1. Admits patients without delay. 2. There must be written order from physician. 3. Must have referral form if patient is referred from other hospital. 4. Patient must have police clearance for medico legal case. 5. Patients with the following categories of burn injuries should be admitted: 5.1 Children Partial Thickness Full Thickness more than 7 % more than 2 %
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ADMISSION OF BURNS PATIENTS 5.2 Adult Partial Thickness Full Thickness -
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more than 10 % more than 2 %
6. Burns complicated by respiratory tract injury, major soft tissue injury, and fracture. 7. Burns complicated by other medical or surgical conditions, which needs close observation. 8. Electrical burns. 9. Strictly no watchers allowed staying with the patient except with pediatrics. No patient shall allow to be loitering outside the hospital. 10. Visitors are entertained only in the visiting area. In case patient is serious, allow relatives to see the patient inside the ward but give them proper scrub suits and two persons at a time only in a limited time. EQUIPMENTS AND MATERIALS: 1. Lund and Browde's Charts 2. Pencil 3. Dressing trolley 4. Sterile gamgee, lap sponge, $ X $ gauze 5. Flammazine and Flamagel 6. Basin 7. Normal Saline 8. Betadine Solution 9. Culture Swab sticks
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ADMISSION OF BURNS PATIENT
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PROCEDURE 1. Render admission bath, if patient is sedated; give full bath with normal saline at the bedside. Call admitting doctor to check and estimate depth and BSA (body surface area) of burns. Do dressing quickly as possible but aseptically. Insert IV lines; collect blood samples for laboratory investigation in case not done in emergency room. Insert Foley catheter if needed. Check patient weight. Initial vital signs and monitor intake and output hourly. Allow doctor to complete patients file, medication notes, BSA form, and doctors order form. Provide clean and comfortable quite room for the patient.
2.
3. 4. 5. 6. 7. 8.
9.
10. Document patient condition and response to treatment.
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PHYSICAL ASSESSMENT O THE BURNS PATIENT

DEFINITION: The initial assessment of burned patient upon admission. OBJECTIVES: 1. To assess severity of the burns. 2. To give appropriate treatment. 3. To render good nursing care POLICY: 1. Doctor and qualified nurses working in burns unit must perform the physical assessment of newly admitted patients. 2. Thorough physical and mental examination must be done immediately after admission. 3. To decide whether patient require hospital treatment of out patient treatment only. PROCEDURE: 1. Stay with the patient side and assist the doctor during examination. 2. Check vital signs, temperature, pulse rate, rhythm and character.
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PHYSICAL ASSESSMENT OF THE BURNS PATIENT PROCEDURE 3. Evaluate mental status for: 3.1 Presence of confusion 3.2 Delirium 3.3 Stupor 3.4 Semi-coma 3.5 Coma 4. Check for status of hydration, assess by checking: 4.1 Skin temperature 4.2 Skin turgor 4.3 Inspect the tongue for dryness 4.4 Jugular venous pulse 5. Check cardiovascular system including apart from pulse. 5.1 Blood Pressure 5.2 Character of heart sound 5.3 Character of peripheral circulation by nail beds blanching. 6. Assess respiratory system adequacy of: 6.1 Air entry 6.2 Character of breathe sounds 6.3 Presence of crepitating and rhonchi 6.4 Oral cavity and nose for presence of soot particles, erythema or ulcers. 7. Examine abdomen for: 7.1 Distention for bowel and bladder 7.2 Presence of bowel sounds 8. Assess muscoloskeletal system for associated fractures. 9. Document all observation noted.
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RATIONALE 3. To assess patient neurological status.
4. To determine earlier as possible for the hydration therapy.
5. To assess cardiovascular system status.
6. To evaluate patient airway entry and differentiate for patient having possible inhalation injury.
7. To assess abdominal peristalsis.
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Ministry of Health, General Nursing Administration Functions & Duties Policies & Procedures SPECIALIZED NURSING BURNS
TITLE:
INDEX NUMBER
CLASSIFICATION OF BURNS ACCORDING TO DEPTH AND BODY SURFACE AREA

DEFINITION: The assessment and evaluation method on the severity of burn injury by application of Lund and Browder charts. OBJECTIVES: 1. To assess severity of the burn injury. 2. To give appropriate treatment needed. 3. To render optimal nursing care services. 4. To provide IV fluid therapy according to the percentage of burns. 5. To classify according to the cause (thermal, electrical, chemical, or irradiation), the extent of the body surface, burned and the depth of tissue damaged or destroyed. POLICY: 1. The physician must categorized depths of burns according to: 1.1 Superficial Burns 1.2 Superficial Partial Burns 1.3 Deep Partial Thickness Burns 1.4 Full Thickness Burns
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CLASSIFICATION OF BURNS ACCORDING TO DEPTH AND BODY SURFACE AREA
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2. Lund and Browder Charts are to be used to determine the extent of burns in the Physical Assessment of burn patient. MATERIALS AND EQUIPMENTS: Lund and Browder chart. PROCEDURE 1. Assess the patients vital signs. RATIONALE 1. Unstable vital signs and hypothermia will lead to more deterioration. 2. To reduce anxiety and to take consent. 3. To estimate depths and BSA involved properly.
2. Explain the procedure. 3. Take the patient to the tank room upon admission. Exposed patient body for the doctor. 4. Provide the doctor chart for grading patient BSA depths. 5. Start initial record in ICU monitoring sheet. 6. Obtain at least two IV cannula for severe cases. If no peripheral access notify the doctor the need to insert central line and follow IVF therapy.
6. To avoid hypovolemic shock and organ failure.
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TITLE:
INDEX NUMBER
FLUID RESUSCITATION IN BURNS

DEFINITION: The Immediate intervention to replace the fluid volume deficit related to increase capillary permeability and evaporative losses from the burn wound. OBJECTIVE: 1. To replace fluid loss. 2. To maintain adequate tissue perfusion and circulating fluid volume. 3. To avoid ischemic damage to injured tissues and also to reduce tissue edema. 4. To prevent shock and damage to the vital organ. POLICY: 1. Doctors and nurses working in Burns Unit must have the knowledge of calculation for fluid resuscitation. of burns victim. 2. All burns patient must be prevented from going into hypovolemic shock. 3. Fluid resuscitation should be given to adult patient of more than 15 % burn and pediatric patients of more than 10 % burn. 4. The basic of resuscitation will depend upon the extent and severity of burns. 5. Nurses must assure a reliable intravenous route or central line for prompt adequate fluid replacement.
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6. Parkland formula must be applied for fluid resuscitation after calculating the size of burns and patients body weight 1st 24 hours Adult: Parkland Formula: 4 X wt. of patient X % of burns To give of the total amount in 1 st 8 hours then remaining in next 16 hours as Ringer Lactate only. Pediatric: Parkland Formula: % of burns X wt. of patient X 3 + maintenance. of the total amount should be given in 1 st 8 hours. 2nd of the total amount should be given in next 16 hours. 2nd 24 hours : Crystalloid + Colloid For Adult and Pedia Evaporated fluids + Maintenance 1 X % of Burns X Weight = Evaporated + Maintenance = Total amount/24 hours.
of the total amount is given as PPF, of the total amount is given as D5NS or D5 NS depends upon patients electrolytes results. (N.B) This formula is only a guideline to fluid resuscitation and it should according to hourly urine output and clinical evaluation. To calculate the maintenance fluid, the following steps are to be considered: 100 mL/kg for each kg 50 mL/kg for each kg 1 10 kg 11 20 kg, be adjusted
Then, the remaining weight 20 mL/kg
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MATERIALS & EQUIPMENTS: 1. Intravenous cannulas 2. I.V stand 3. Type of IV Fluid to be given 4. Infusion pump and IV sets
PROCEDURE 1. Administer fluid therapy according to doctors order. 2. Give accurate amount of fluid by the use of infusion pump. 3. Measure intake and output hourly.
RATIONALE
2. Hypovolemia and hypervolemia will lead to many complications. 3. It provides information about renal perfusion, adequacy of fluid replacement and fluid requirements.
4. Observe the IV line frequently. 5. Monitor vital signs closely.
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Ministry of Health, General Nursing Administration Functions & Duties Policies & Procedures _______________________________________________ SPECIALIZED NURSING: BURNS
TITLE: INDEX NUMBER
BASE LINE INVESTIGATION FOR BURNS PATIENT

SNR-BC- 010
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DEFINITION: A specific investigation for Burn patient on admission done to evaluate patients clinical data to identify imminent problems that may arise. OBJECTIVE: 1. To provide a base line data for comparisons 2. To assist in monitoring patients laboratory results. 3. To identify imminent problems that may arise 4. To give appropriate management and treatment. POLICY: 1. There must be written Physicians order. 2. Each laboratory request must be stamp by the requesting doctors. 3. Burns unit staff nurse shall sent patients specimen CBC, Sickle anemia, BUSE, RBS, LFT, CK, LDH, Total protein, Albumin to the laboratory and a chest X ray is carried out on admission. 4. The Chemistry profiles must be taken once or twice daily during the patients critical phase while fluid resuscitation is in progress.
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BASE LINE INVESTIGATION FOR BURNS PATIENT
INDEX NUMBER
SNR-BC-010
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5. The wound swab for culture and sensitivity must be taken on every parts from different region of the affected burn parts on admission and twice weekly. 6. All investigations results must be noted to doctor immediately. 7. Patients who are intubations, inhalation injuries require periodic CXR studies. 8. The patients nutritional status is monitored through albumin levels and urea nitrogen. MATERIALS AND EQUIPMENTS 1. Blood Investigations Forms and Blood samples container 2. Spirit swabs, Tourniquet and Gloves 3. Swabs for culture and sensitivity PROCEDURE 1. Explain the procedure to the patient 2. Take blood sample needed enough to distribute each required investigations. 3. Call and communicate with radiology departments for portable X ray 4. Take wound swabs for different regions of the body for culture and sensitivity.. 5. Document all investigation done in nursing kardex and nurses notes. 6. Inform doctor immediately when result is back 4. To track the bacterial colonization of the wounds RATIONALE 1. To allay fear and gain cooperation
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Ministry of Health, General Nursing Administration Functions & Duties Policies & Procedures ___________________________________________________ SPECIALIZED NURSING BURNS
TITLE: INDEX NUMBER
ORAL NUTRITIONAL SUPPORT IN BURNS

DEFINITION: The provision of nutrition in solid or liquid form by mouth. OBJECTIVE: 1. To achieve a daily proper nutrition. 2. To prevent malnutrition and weight loss. 3. To promote healing and fight infection. 4. To meet the physiological and psychological needs of burned patients. 5. To supply energy repair tissues aid in growth and development. POLICY: 1. All patients admitted to burns unit must be started on diet as soon as possible. Begin a clear liquid diet progressing to full diet as tolerated. 2. Patients be examined for the presence of diabetes, hyperlipidemias, liver pancreatic or bowel diseases, and alcohol abuse and lactose intolerance. 3. Encourage patients but not forced to ingest increasing amounts of food. 4. Patients on narcotics should be observed for nausea and anorexia. 5. The nutritional requirements should includes carbohydrate, fat, protein, vitamins, minerals, and trace elements.
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6. The diet should be adequate, palatable, and varied including all the nutritional requirements and should be served at regular intervals more frequently than regular meals. 7. Instruct the patient and family of the need for adequate nutritional and encourage their cooperation. 8. Nurses should offer between meal nourishments such as juice, ice cream, custard, sandwiches, and beverages. MATERIALS AND EQUIPMENTS: 1. 2. Intake and output charts. Prescribed food. RATIONALE 1. To make sure the patient can eat by himself or need assistance. 2. To gain cooperation. To honor any dietary requests the patient may have.
PROCEDURE 1. Assess the patient on the ability of feeding independently and feed the patient as required. 2. Explain to patient the importance of good caloric intake and aid him/her menu selection. 3. Allow the patient to rest before each mealtime. 4. Elevate the head of the bed 5. Start with sips of water 6. Place the tray in a secure position. 7. Prepare the food, open box, pour liquids, cut meat, chicken, fish, and bread in small pieces.
4. To avoid aspiration or chocking and promote comfort 5 To observe on the ability of swallowing.
7. To encourage the patient to consume all the food and avoid choking.
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PROCEDURE 8. 9. If patient can eat by himself place a call bell nearby. Encourage a leisurely pace of eating.
RATIONALE
9. To aid digestion.
10. Remove the tray immediately when finished. 11. 12. Provide mouth wash after meal Record calorie and liquid intake in Intake and Output chart. Keep the patient comfortable. Document in nurses notes on patient respond to meal and amount taken.
10. To maintain clean environment. 11. To provide comfort
13. 14.
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TITLE: INDEX NUMBER
DIETARY SUPPORT TABLE

DEFINITION:
Formula exist for estimating the daily metabolic expenditure and caloric requirements of patient with injuries.
OBJECTIVE:
1. To optimize the daily requirement of protein, carbohydrates, fat, and minerals, etc. 2. To determine the nutrition needs. 3. To prevent malnutrition.
POLICY:
1. All patient admitted to Burns must have dietary chart. 2. The dietician must visit the patient at least twice a week. 3. All patients admitted to Burns follow the dietary formula below. 3.1 Calories Adults: [25 kcal x wt (kg)] + [40 % x % burn] For burns over 50 % BSA use a constant of 50 % for the percent burn to prevent over feeding
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Pediatrics: Age (Years) 0 0.5 0.5 1.0 13 4 10 11 14 11 14 1. Protein Adults: For burns greater than 10 % BSA: kilocalories requirements x 20 % 4 = 20 100 x kcal 4 = Protein (gm) Kilocalories kg x 115 kg x 105 kg x 100 kg x 85 kg x 60 (male) kg x 48 (female)
For burns 1 10 % BSA: kilocalories requirements x 15 % 4 = 15 100 x kcal 4 = Protein (gm)
Pediatrics: over age 1 year use adult formula under age 1 year 2 grams protein/kg weight
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2. Carbohydrates Enterally Parenterally 3. Fat: Enterally Parenterally 4. Vitamins: Water Soluble Vitamins (B vitamins, folate, biotin): Adults Pediatrics over 9 months Vitamin C: Adults Pediatrics Infants 0 9 months 1 2 grams/day 500 mg/day 250 mg/day 2 x RDA* 2 x RDA* 30 % - 40 % total kilocalories maximum 2.5 grams/kg/day 40 % - 50 % total kilocalories 50 % - 70 % of non-protein kilocalories
Fat Soluble Vitamins (A, D, E): Adults Pediatrics 4. Minerals Zinc: Adults 2 x RDA RDA RDA
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Pediatrics Infants Trace Elements: Adults Pediatrics Infants
2 x RDA RDA
2 x RDA 2 x RDA RDA
EQUIPMENTS AND MATERIALS: 1. Calculated diet list 2. Patients food 3. Measuring container 4. Meal table 5. Spoon, fork, and knife PROCEDURE 1. Assess the patients condition and explain the need for proper nutrition 2. Help patient to eat assist him if necessary 3. Record the food consumed in intake and output chart 4. Encourage patient to sit or walk after taking meals.
RATIONALE
1. To allay fear and gain cooperation. 2. To ensure all required food are consumed. 3. To monitor intake and output.
4. To help digest food
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Ministry of Health, General Nursing Administration Functions & Duties Policies & Procedures ___________________________________________________ SPECIALIZED NURSING BURNS
TITLE: INDEX NUMBER
HYDROTHERAPY
DEFINITION: Hydrotherapy (tubing or tanking) is the bathing of the burn patient in tub or tank water. OBJECTIVES: 1. To assess the burned area and calculate the percentage of burns. 2. To facilitate the removal of adherent dressing and topical medications. 3. To loosen debris, sloughing eschar and exudates. 4. To provide an opportunity for the patient to practice range of motions exercises. POLICY: 1. Burn wounds must be cleansed initially and daily with a need antibacterial cleansing agent and saline solution. 2. Have the hydrotherapy room cleaned thoroughly before taking the patient to the tank. 3. Patients with the following assessment should not be taken for hydrotherapy: 3.1 Newly grafted patients until 10 days after grafting. 3.2 Patients with core temperature below 36.5 degrees Celsius, and 3.3 All those special cases designed by the physician.
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HYDROTHERAPY
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4. Informed the physiotherapist before taking the patient to the tank room. 5. Two or three nurses should attend the patient for hydrotherapy. 6. Never leave the patient unattended in the water tank. 7. Give the prescribed analgesic before taking the patient to the tank room. 8. Respect the patients feeling and expressions of stress, pain, cold, and fatigue. 9. Fill tub with water of acceptable temperature to the of the tank. MATERIALS AND EQUIPMENTS: 1. Hubbard tank or any other tank. 2. Hoist 3. End bars 4. Sterile blanket and bed sheet 5. Povideine-iodine scrub solution 6. Sterile 4 X 4 gauze sponges 7. Cups, mask, gowns, and sterile gloves 8. Bath lifter PROCEDURE 1. Assess the patient and explain the procedure 2. If the patient has an indwelling catheter, drain and plug it, or maintain a close system. RATIONALE 1. To allay fear and gain cooperation
2. To avoid contamination.
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HYDROTHERAPY
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PROCEDURE 3. Limit therapy to no more than 30 minutes. 4. Don cap, mask, gown, and sterile gloves.
RATIONALE 3. To avoid hypothermia and fatigue.
5. Provide as much privacy as possible. 6. Performed wound cleaning and debridement after opening the dressing 7. Allow physiotherapist to perform exercises. 8. Wash the patients hair with shampoo.
9. Clean the wound with iodine scrub solution, then with normal saline. 10. Remove the patient from tub and shift to sterile field. 11. Dry the patient with towel and gamgee on the wound. Apply the warmer if required. 12. Apply the dressing as general dressing policy with the prescribed topical cream.
9. To avoid irritation.
11. To avoid shivering and hypothermia
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TITLE: INDEX NUMBER
PHYSIOTHERAPY OF BURNED PATIENTS

DEFINITION: A vital service for the burn patient from the day of admission through the entire course of rehabilitation. OBJECTIVE: 1. To maintain or increase the pre-burn level of strength, range of motion, endurance, and coordination. 2. To attain a pre-burn gait pattern. 3. To assist the patient in reaching the highest possible level of function and maximum rehabilitation. 4. To promote good and normal posture. 5. To avoid contractures and deformities. 6. To promote self-care, mobility, positive body image, skin integrity and comfort. 7. To facilitate individual/family coping and learning process. POLICY: 1. There must be a consultation form request per doctors order. 2. The exercises must be done by a physiotherapist, mandatory assigned in burns unit. 3. Passive and active exercises of all limbs and joints are required daily.
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PHYSIOTHERAPY OF BURNED PATIENTS
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4. Cough and deep breathing exercises are encouraged soon after resuscitation whenever possible. 5. Splints/backslabs should be judiciously used as indicated. 6. Prevention of post burn deformities begins along with the early management of burn injuries. 7. Dressing must be removed before starting physiotherapy to any part of the body. 8. If not contraindicated physiotherapy should always be given in the tank room. MATERIALS AND EQUIPMENTS: 1. 4 X 4 gauze 2. Soft paraffin 3. Splints 4. Walker frame PROCEDURE 1. Assess patient vital signs and wound site. 2. Explain the procedure and stay with the patient during physiotherapy. 3. Give the order pain reliever then remove the bandages. 2. To reduce anxiety and gain cooperation. 3. To reduce pain and get the desired joint movement. RATIONALE
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TITLE: INDEX NUMBER
BURNS DRESSING, LOCAL DEBRIDEMENT

DEFINITION: The covering of the wound after the removal of foreign substances and injured tissue. OBJECTIVE: 1. To reduce risk and promote good healing process. 2. To clean the burn wound and prevent infection. 3. To protect the burn wound, absorb exudates and keep patient comfortable. 4. To hold topical agents against the wound. 5. To help preserve position of limb. 6. To conserve patients body heat. 7. To minimize scarring. 8. To prevent mechanical trauma. 9. To reduce pain and allow debridement of burn. 10. To avoid muscle stiffness and contractures. POLICY: 1. Patient to be redressed as required or as ordered. 2. Shall be an aseptic technique.
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3. Masks, sterile gowns, sterile gloves, hair coverings shall be worn. 4. Dressing is to be performed by two burns trained nurses. 5. Procedure to be performed in treatment room or patients room in a closed environment. 6. Procedure to be performed in the minimum amount of time. 7. Narcotic analgesia will be given prior to dressing as ordered by physician. 8. Physiotherapist is performed for physiotherapy after removing the dressing. EQUIPMENTS AND MATERIALS: 1. Sterile gown and gloves, mask and hat. 2. Trolley and cleaning agent. 3. Basic or burns dressing set which includes mosquito forceps, dissecting forceps, and scissor. 4. Gauze swabs, 4 X 4 gauze, lap sponges, and gamgee. 5. Normal saline. 6. Topical agent as ordered, flamazine or flamagel. 7. Bactigras or supratule as ordered. 8. Bandages setonet (size according to patient and area of burn). 9. Ring remover if needed. 10. Tape. 11. Sterile towels. 12. Wound swabs.
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PAGE NUMBER 3 of 3
PROCEDURE 1. Render admission bath, if patient is sedated; give full bath with normal saline at the bedside. 2. Take swab for all old burns cases upon admission before bathing. 3. Call admitting doctor to check and estimate depth and BSA (body surface area) of burns. 4. Do dressing quickly as possible but aseptically. 5. Insert IV lines; collect blood samples for laboratory investigation in case not done in emergency room.
6. Insert Foley catheter if needed. 7. Check patient weight. 8. Put patient on bed comfortably and start normal fluid therapy according to doctors order. 9. Start medication per doctors order. 10. Initial vital signs and monitor intake and output hourly. 11. Allow doctor to complete patients file medication notes, BSA form, and doctors order form. 12. Provide clean and comfortable quite room for the patient. 13. Document patient condition and response to treatment.
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ASSISTING FASCIOTOMY OF CIRCUMFERENTIAL BURNS

DEFINITION: The eschar is surgically cut into squares to alleviate stricture and to allow exudates to drain, and permit adequate circulation to underline tissues. OBJECTIVE: 1. To release the pressure on the circumferential burn site. 2. To prevent damage of the organ. 3. To promote blood supply to the peripherals. 4. To allow passive movement of the joints. POLICY: 1. The peripheral pulses should be taken every hourly and if possible with the Doppler Ultrasound Device. 2. The procedure is done under aseptic technique. 3. All constricting jewelries and clothing should be removed. 4. The Inspect dressing is required to be inspected regularly, if mild bleeding occurs to reinforce dressing. 5. The nail beds are required to be inspected for any cyanosis and tips of extremities for cold temperature.
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ASSISTING FASCIOTOMY OF CIRCUMFERENTIAL BURNS
INDEX NUMBER
SNR-BC-016
PAGE NUMBER 2 of 3
MATERIALS AND EQUIPMENTS: 1. Big dressing trolley 2. Basic procedure set 3. Diathermy machine 4. Betadine scrub and solution 5. Sterile gauze 4 X 4, lap sponge 6. Bactigras 7. Creep Bandage 8. Sterile Linen 9. 3 Sterile Gown (1 for the doctor, 1 for the scrub nurse, 1 for circulating nurse). 10. Surgical gloves, surgical blade (size 11 and 20) 11. Silk suture (different sizes). PROCEDURE 1. Assess the patients condition and explain the procedure 2. Place the patient in supine position or as required by the doctor according to the site 3. Bring prepared the trolley on the bed side 4. Wash hands, wear gown, gloves and mask 1. RATIONALE To allay fear and gain cooperation.
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ASSISTING FASCIOTOMY OF CIRCUMFERENTIAL BURNS PROCEDURE 5. Expose only the part of patients body for fasciotomy and wash with normal saline by Circulating Nurse. 6. Scrub Nurse to assist the doctor. 7. Once fasciotomy completed, dress with bactigras and gauze soaked with batadine, apply flammazine and thick dressing. 8. Elevate the post operative site
INDEX NUMBER
SNR-BC-016
PAGE NUMBER 2 of 3
RATIONALE
7. To absorb bleeding. 8. To reduce edema and promote blood circulation.
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Ministry of Health, General Nursing Administration Functions & Duties Policies & Procedures _______________________________________________ SPECIALIZED NURSING BURNS
THERAPEUTIC POSITIONING & PREVENTION OF DEFORMITY AND CONTRACTURES

POLICY: 1. Prevention of post burn deformities can be carried out more effectively if one understands the facts that the position of comfort is the position of contracture, and burn wound will continue to shorten until it has met and equal and opposite force. 2. Prevention of post burn deformities begins along with the early management of burn injuries. 3. Strict program of proper joint positioning, splinting , pressure dressing and physical exercise must be instituted as soon as possible and should be carried on till full maturation of the burn scar, so as to avoid the crippling post burn deformities due to scar contractures. 4. Patient should be examined, and the sites of burn injury at risk for development of complications are indentified and evaluated. 5. Principles of proper positioning and splintage should be continued even when skin grafting is done. The graft are retained with occlusive dressing and splints applied over the dressing are retained with elastic bandages.
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PAGE NUMBER 2 of 3
TABLE TO FOLLOW Region of Body Neck Position of Possible Contracture Flexion Position of Prevention Extension Technique of prevention during wound stage Custom made isoprene conforming splint-purchase on mandibular rami above and on clavicles. Inferiorly retained by two crostraps. Splints avoided tohelp in daily dressing. Splints avoided to facilitate dressings carefully supervised positioning yields good result. Splints are essential padding continuous application 24 hrs. except for interval of dressings. Splint are not contraindicated but early ambulation even in the presence of lower extremity wounds gives good results. Splints are absolutely necessary to keep thumb abducted and flexed well away from the hand continuous application except for interval of dressing.
Axilla
Abduction
90 abduction 15 forward flexion 15 abduction
Hips
Abduction flexion Flexion
Elbow and knees Ankles
Extension
Hands
Depending upon the area of maximum involvement Flexion at wrist extension of meta carpophalangeal joint flexion at interphalangeal joint
90 dorsiflexion 20 extension at wrist; 15 to 20metacarpophalangeal extension, interphalangeal extension
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PAGE NUMBER 3 of 3
PURPOSE: 1. To give good nursing care. 2. Toa void contractures and deformities. 3. To promote good and normal posture. 4. Prevent for another complicated surgery. PROCEDURE: 1. Upon admission make it a rule for the patient to exercise affected joints form time to time, to avoid contracture as early as possible. 2. Send physiotherapy request per doctors order. 3. Stay with the patient during the procedure to lessen anxiety. 4. Encourage positive outcome for the patient. 5. Assist early ambulation. 6. Participate with the patient actively every morning to start the routine. 7. Practice patient early selfcare to achieve optimal goal. 8. Document patient programs to treatment and interventions.
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Ministry of Health, General Nursing Administration Functions & Duties Policies & Procedures _____________________________________________________ SPECIALIZED NURSING: BURNS
CARE OF PATIENT WITH INHALATION INJURY

DEFINITION: The specific nursing care of patient who has inhaled smokes resulting from any kind of burns. OBJECTIVES: 1. To maintain a patent airway, adequate oxygenation and ventilation 2. To identify carbon monoxide poisoning promptly. POLICY: 1. All patients who are burned on the face and neck or those who inhaled flame, steam, or smoke should be observed closely for sign of laryngeal edema and airway obstruction. 2. All patients in closed spaces fires should be assess for the signs and symptoms of carbon monoxide poisoning. 3. The physician should be informed immediately if any sounds of hoarseness and crackles are identified. 4. The arterial blood gas should be checked daily and carboxyhemoglobin level on admission and when condition requires. 5. The chest X-ray must be done on admission as baseline data and when ever needs arises as ordered by doctor.
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CARE OF PATIENT WITH INHALATION INJURY
PAGE NUMBER 2 of 2
6. Oxygen administration should be humidified at all times to patient with inhalation injury. MATERIALS AND EQUIPMENTS: 1. Stethoscope 2. Arterial blood gas results 3. Oxygen with humidifier PROCEDURE 1. Assess the patient for : 1.1 Respiratory Status 1.2 Carbon Monoxide poisoning 1.3 Areas of burns involved 1.4 Signs and symptoms of inhalation injury: laryngeal edema and stridor 1.5 Observe for burns of lips, vocal mucosa, or pharynx, droll gray or black sputum. 2. Administer humidified oxygen as ordered by doctor 3. Obtain arterial blood gases and ensure chest X- ray is done. 4. Observe patients respiratory status every hourly 5. Observe signs of stridor or apnea during sleeping 6. Instruct patient to do deep breathing excises every 4 hourly. 7. Document in the nurses notes on the specific care given, any signs of inhalation injury and the patients condition
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Ministry of Health, General Nursing Administration Functions & Duties Policies & Procedures SPECIALIZED NURSING: BURNS TITLE: CARE OF BURNED LIPS AND MOUTH
EFFECTIVE DATE APPLIES TO NURSING APPROVED BY INDEX NUMBER SNR-BC-019 PAGE NUMBER 1 of 2
DEFINITION: The specific care of burned wound at lips and mouth and establishment of routine care that involves debridment. OBJECTIVE: 1. To prevent infection in oral cavity. 2. To enable patient to eat. 3. To prevent contractures around lips and mouth. POLICY: 1. Mouth care should be given frequently especially before and after meals and as often as necessary. The mouth care cleansing must be thoroughly done and pay attention to the lips. MATERIALS AND EQUIPMENT: 1. Dressing Sets 2. Tongue spatula 3. Sterile gown and gloves 4. Sterile towel 5. Normal saline 6. Sodium Bicarbonate 7. Gauze
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CARE OF BURNED LIPS AND MOUTH
PAGE NUMBER 2 of 2
PROCEDURE 1. Explain the procedure to patient
RATIONALE 1. To allay fears and ensures cooperation. 2. To be organized in doing procedure 3. To create sterile field and protect patients. 4. To remove mucous.
2. Assemble complete equipment to bedside 3. Drape sterile towel around patients neck 4. Swab mucosa and tongue with dissolved Sodium Bicarbonate 5. Remove debris from between patients teeth with a tongue depressor on a wrap-around gauze. 6. Assist patient to clean teeth with toothbrush and toothpaste to prevent caries 7. Provide antiseptic solution to gargle mouth. 8. Document in nursing notes the condition of wound and mouth care procedure that has been given
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TITLE:
CARE OF BURNED EYELIDS

INDEX NUMBER SNR-BC-020 PAGE NUMBER 1 of 2
DEFINITION: The specific dressing required for wound of burned ear. OBJECTIVE: 1. To preserve function. 2. To prevent infection. 3. To promote patients comfort. 4. To render proper eye and eyelid care. POLICY: 1. Burn wounds to eyelids to be cleansed every two to three hours or as required. 2. Staff nurse experienced in burns care must carryout the procedure. MATERIALS AND EQUIPMENTS 1. Dressing set 2. Sterile gown and gloves 3. Sterile towel 4. Normal Saline 5. Prescribed medications
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CARE OF BURNED EYE LIDS PROCEDURE 1. Explain the procedure to patient 2. Assemble complete equipment to bedside 3. Instruct patient to close eye and remove as much loose debris as possible by cleaning eye lashes thoroughly using soaked saline gauze
PAGE NUMBER 2 of 2
RATIONALE 1. To allay fears and ensures cooperation 2. To be organized in procedure
4. Wipe eye with normal saline swab from inner 4. To prevent spread of infection cantus and move away from nose. 5. Repeat the procedure until eyelid is clean 6. Apply antibiotic cream to the conjunctiva sac as ordered by the physician. 5. Antibiotic act as a prophylactic
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TITLE: INDEX NUMBER
CARE OF BURNED EARS

DEFINITION: The specific dressing required for wound of burned ear. OBJECTIVE: 1. To prevent deformities and infection. 2. To prevent chondritis and deterioration or loss of cartilage due to infection 3. To promote good healing 4. To initiate ear care. POLICY: 1. Care must be taken to prevent patient from lying on the affected ear to prevent any pressure on injured portion of cuticle. 2. Frequent change of dressing or change dressing every 6 hourly is important to keep the wound dry. MATERIALS AND EQUIPMENTS: 1. Dressing Sets 2. Cotton tip applicator. 3. Sterile gown and gloves 4. Sterile towel
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CARE OF BURNED EARS 5. Normal Saline PROCEDURE 1. Explain the procedure to patient 2. Assemble complete equipment to bedside 3. Place sterile green towel on top of the pillow or mattress. 4. Clean pinea and folds using cotton tip applicator 5. Clean wound at ear aseptic technique 6. Apply prescribed ointment or saline packs as ordered by the physician 7. Place wet normal saline gauze in between the pinea and the head and close the dressing the burn ears. 8 Document dressing and observation of wound,
PAGE NUMBER 2 of 2
RATIONALE 1. To allay fears and ensures cooperation. 2. To be organized in doing procedure 3. To provide barrier between the pillow and the ear.
7. To prevent pinea sticking to the side of head.
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Ministry of Health, General Nursing Administration Functions & Duties Policies & Procedures _______________________________________________________ SPECIALIZED NURSING: BURNS TITLE: CARE OF BURNED FACE
DEFINITION: The specific dressings required for burned wound of face establish a routine of face care by keeping moist dressing. OBJECTIVE: 1. To remove all exudates. 2. To prevent infection. 3. To prevent deep scarring. 4. To give patient a sense of well-being. 5. To protect and examine patients eyes. POLICY: 1. Facial burned wounds are to be cleared every 2 to 4 hours in the acute phase, less frequently as the area heals. Faces are usually left exposed. Mens faces must be showed daily. 2. Procedure to be performed in a warm environment (not less than 26 degrees Centigrade). i.e. treatment room or patients own room with door closed. 3. The accumulation of crust and exudates must be removed during dressing.
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CARE OF BURNED FACE MATERIALS AND EQUIPMENT: 1. Dressing Sets 2. Sterile gown and gloves 3. Sterile towel
PAGE NUMBER 2 of 2
PROCEDURE 1. Explain the procedure to patient 2. Assemble complete equipment to bedside. 3. Drape sterile towel around patients neck. 4. Clean the whole face with saline. 5. Shave hair off around face, forehead, ears, and neckline. 6. Check scalp for burn areas and shave affected areas. 7. Carefully remove exudates to stop from drying out cracking. 8. Pay particular attention to nose, ears, eyes, and lips. 9. Apply saline packs or ointment as ordered to the face. 10. Repeat dressing until wound clean 11. Document in nurses notes of procedures and condition of wound observed. Ministry of Health, General Nursing Administration
RATIONALE 1. To allay fear and gain cooperation. 2. To be organized in procedure 3. To create a sterile field.
5. To prevent infection
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Functions & Duties Policies & Procedures ___________________________________________________ SPECIALIZED NURSING BURNS TITLE: CARE OF BURNED NECK AND CHEST
DEFINITION: The specific nursing care of patient with burned neck and chest in maintaining the respiratory status and prevention of neck contractures. OBJECTIVE: 1. To take the necessary precautions to maintain airway patency and eliminate respiratory difficulty. 2. To preserve a cosmetic appearance. 3. To reduce scarring and contractures. 4. To evaluate the need of escherotomy 5. To promote good healing POLICY: 1. The patients neck shall be kept in a hyperextend position all the time to prevent neck from contracting. 2. Patient should not use any pillows when lying down on bed. 3. Customize cervical collar should be applied if ordered. 4. The physician must be informed immediately if any restriction of chest movement during breathing. 5. The patients head should not be supported when in sitting position.
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CARE OF BURNED NECK AND CHEST MATERIALS AND EQUIPMENT: 1. Rolled sterile bath towel 2. Shaving set 3. Wash basin with water 4. Customized Cervical collar PROCEDURE 1. Explain the procedure to patient 2. Assemble complete equipment to bedside 3. Shave the neck, remove loosens debris. 4. Clean the wound in neck and chest aseptic technique in dressing procedure 5. Apply splint or neck collar as ordered. 6. Place rolled towel under shoulders when patient lies supine extend the neck. 7. Observe patients respiratory rate, rhythm and chest expansion every half an hour until patients stable. 8. 9. Instruct patient to do deep breathing exercise every 4 hourly. Document in nurses notes the wound condition, respiratory status and patients respond to exercise.
PAGE NUMBER 2 of 2
RATIONALE 1. To allay fears and ensures cooperation. 2. To be organized in doing procedure 3 To keep wound clean and prevent potential infection.
8. To prevent contractures. 7. To assess patient respiratory status 8. To facilitate a good expansion of chest
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Ministry of Health, General Nursing Administration Functions & Duties Policies & Procedures SPECIALIZED NURSING: BURNS
TITLE: CARE OF BURNED HANDS IN POLYTHENE BAGS

DEFINITION: A specific care and dressing of wound at burned hands. OBJECTIVES: 1. To prevent infection. 2. To preserve function. 3. To decrease and prevent edema. 4. To prevent the deepening of partial thickness burns to full thickness. 5. To enable patient to mobilize his/her hands. 6. To enable patient to self care especially feeding. POLICY: 1. The wound care should be carried out as required or at least 12 hourly. 2. Staff nurse experienced in burns care must perform the procedure. MATERIALS AND EQUIPMENT: 1. 1 large sterile bowl/basin 2. 1 pair sterile gloves
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CARE OF BURNED HANDS IN POLYTHENE BAGS 3. 2 small clean plastic bag 4. 2 small bandage 5. Sterile gauze 4 X 4 6. Tape MATERIALS AND EQUIPMENT 1. Flamazine or Flamagel 2. Betadine and water 3. 2 sterile towels 4. Sterile forceps and scissors PROCEDURE 1. Explain the procedure to patient 2. Assemble complete equipment to bedside. 3. Add betadine in water 4. Don gloves, wash patient hands and gently exercise the patients hands. Perform debridement on loose skins and blister. 5. Apply flammazine sparingly to both side of hands 6 Apply polythene bag and make sure patients can move his hands 7 Apply 4 X 4 gauze to wrists loosely
PAGE NUMBER 2 of 3
RATIONALE 1. To allay fear and gain cooperation. 2. To be organized in procedure
5. To provide antiseptic and promote healing 6. To encourage mobilization 7. To absorb exudates and not allow bag to slip.
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CARE OF BURNED HANDS IN POLYTHENE BAGS PROCEDURE 8. Bandage the bags securely at the wrist. 9. Keep hands elevated at all times 10. Teach patient's to perform fingers and hands exercise. Inform patient to perform every hourly. 11. Document in nurses notes on condition of wound and care given.
PAGE NUMBER 3 of 3
RATIONALE 8. To keep bag in position 9. To reduce edema and encourage venous return 10 To reduce the risk of fingers and hands contractures.
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Ministry of Health, General Nursing Administration Functions & Duties Policies & Procedures _______________________________________________ SPECIALIZED NURSING: BURNS TITLE: CARE OF BURNED HANDS IN CLOSED DRESSING
DEFINITION: The specific dressing requiresfor hands and the fingers and individually dress to prevent contractures. OBJECTIVE: 1. To prevent infection. 2. To preserve function. 3. To promote healing. POLICY: 1. Closed dressing can be used lightly when minimal dressing is required. 2. Procedure is to be performed using aseptic technique in treatment room on patients own room with door closed. MATERIALS AND EQUIPMENT: 1. Dressing Sets 2. Sterile gown and gloves 3. Sterile towel 4. Narrow stocking or gauze. 5. Fine scissors
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CARE OF BURNED HANDS IN CLOSED DRESSING
PAGE NUMBER 2 of 2
PROCEDURE 1. Explain the procedure to patient 2. Assemble complete equipment to bedside. 3. Clean wounds on the hands and dry completely 4. Perform debridement of loose skin using fine scissors and forceps. 5. Cover wound with paraffin gauze and betadine soaked with gauze. 6 Apply light gauze and wear stockinet to each finger individually. 7. Elevate the hand
RATIONALE 1. To allay fear and gain cooperation 2. To be organized in procedure
6. To prevent contractures and allow movement. 7. To prevent edema
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Ministry of Health, General Nursing Administration Functions & Duties Policies & Procedures _________________________________________________ SPECIALIZED NURSING: BURNS TITLE: CARE OF BURNED FEET AND LEGS
DEFINITION: The optimum care given to patient with burned feet and legs by keeping the leg elevated and prevention of trauma to the feet. OBJECTIVE: 1. To promote good healing of wound.. 2. To prevent contractures and abnormality. POLICY: 1. The dressing is done in aseptic technique. 2. The dressing is changed every 4 to 6 hourly or when ever necessary. 3. The dressing to the burns to toes should be done individually and separate them with rolls of gauze before application of bandage. 4. Passive exercises of leg are carried out during the dressing. MATERIALS AND EQUIPMENTS: 1. Dressing Sets and Sterile towels 2. Sterile gown and gloves 3. Normal Saline 5. Pillows to elevate legs 6. Splints
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CARE OF BURNED FEET AND LEGS
PAGE NUMBER 2 of 2
PROCEDURE 1. Explain the procedure to patient 2. Assemble complete equipment to bedside. 3. Clean the wound with normal saline 4. Bandage toe to groin. 5. Elevate the limbs as high as possible to patient comfort.
RATIONALE 1. To allay fear and gain cooperation. 2. To be organized in procedure 4. To provide even pressure for venous return.
6. To prevent foot drop and 6. Apply splint as ordered. knee contractures 7. To provide good muscle 7 Provide regular passive exercise to patient tone and prevent deep venous thrombosis. 8. Document in nurses notes on the wound condition and the respond to passive exercise.
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TITLE: INDEX NUMBER
CARE OF BURNED GENITALIA

DEFINITION: To promote hygiene and comfort. OBJECTIVES: 1. To reduce the risk of infection. 2. To keep patient comfortable. 3. To enable patient to mobilize comfortably. 4. To promote good healing. POLICY: 1. Dressings are changed four hourly in the acute phase, they must always be changed after defecation. 2. Use aseptic technique. 3. The procedure is to be carried out by a burns trained nurse. EQUIPMENTS AND MATERIALS: 1. As per general dressing procedure. 2. Setonet stockinette to make net pants X 2.
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CARE OF BURNED GENITALIA 3. Wool gauze pad and tape PROCEDURE 1. Prepare equipment as per general dressing policy. 2. Explain procedure to patient 3. Cleanse with saline and apply flammazine to burned areas. 4. Apply dressing making sure patient can pass urine, if patient is catheterized apply pad to perineum area.
PAGE NUMBER 2 of 2
RATIONALE To decrease patient exposure time. To allay fears.
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Ministry of Health, General Nursing Administration Functions & Duties Policies & Procedures SPECIALIZED NURSING: BURNS
CARE OF THE PATIENTS WITH FLAME BURNS

DEFINITION: To provide nursing care, pain management for the flame burns. POLICY: 1. Result from conflagrations when patient has direct contact from burning object, or from industrial accidents involving flammable liquids. 2. A burn of different distributions occurs when a patient tries to beat out the flames of burning clothing with his/her hands. 3. Most of the serious injuries of flames are due to clothing burns, due to ignition of clothing. 4. Following at severe flame burns patient may pass into a state of shock, and it is the recognition and management of this condition, which is the surgeons most urgent duty during the first few days after such an injury. 5. Usually involves large areas of the body and may involve the lungs as a result of smoke inhalation. 6. Estimating body surface area burn is done by the use of Rule of 9 and the LundBrowders chart. 7. Depths of the burns are classified as: 7.1 rficial Burns 7.2 rficial to Facial-Thickness Burns 7.3 Full-Thickness Burns
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CARE OF PATIENTS WITH FLAME BURNS
PAGE NUMBER 2 of 3
8. Qualified nurse working in Burns Unit must be manageable to initiate immediate measures of burns. PURPOSE: 1. To give good nursing care. 2. To prevent infection. 3. To promote healing. 4. To prevent contractures. 5. To prevent further damage of skin. EQUIPMENTS AND MATERIALS: 1. Pencil 2. Lund and Browders Chart 3. Dressing trolley 4. Basin 5. Betadine Solution 6. 4 X 4 gauze 7. Lap sponge 8. Gamgee 9. Sterile gown, gloves, and mask 10. Flammazine and flamigel cream
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CARE OF PATIENTS WITH FLAME BURNS PROCEDURE:
PAGE NUMBER 3 of 3
1. Admit patient, listen endorsement from endorsing nurse. 2. Give full bath as required, ensure the sedation is given as ordrer. 3. Expose affected parts and assist doctor during examination. 4. Prepare fasciotomy setting if needed. 5. Dress with flammazine cream only; apply thick gauze, close with crepe bandage 6. Insert IV cannula; collect blood samples in case not done in emergency room. 7. Insert Foleys catheter for intake and output. 8. Put patient on bed and start IV fluids therapy. 9. Elevate burned extremities to promote venous return. 10. Monitor vital signs hourly. 11. Inspect dressing hourly and reinforce if mild bleeding occur. 12. Inform doctor for profuse bleeding. 13. Gather patient for past and present history if patient is stable and can be able to recall the incident. 14. For children, involve parents for interview. 15. Administer medication per doctors orders. 16. Give routine analgesic per doctors prescription. 17. Check patient weight daily and record. 18. Assist patient for ambulation. 19. Encourage positive outcomes for every treatment and procedures. 20. Document patient progress to treatment and care.
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TITLE: INDEX NUMBER
CARE OF PATIENTS WITH THERMAL BURNS

POLICY: 1. The patients consultant plastic surgeon or designee shall be notified upon admission. 2. Based on the size of the body surface area of burn is done by the use of rule of nines and the Lund-Browdies chart. Obtain an accurate estimation of the extent and depth of the wound. 3. Usually those who have large burns and are extremely young or old that will require volumes in excess of predictions. 4. The most common and occur as a result of the transfer of energy from a heat source to the body: e.g. flames contact and scald burns. 5. Treated in the same may as burns of skin structures. 6. Caused by flame or fine results in a dry burn that can be much deeper than is visually apparent. 7. Treatment of thermal burns depends on the severity of the injury. 8. Depths of burns classified as first degree, second degree, and third degree. 9. Qualified nurse working in burns unit must be knowledgeable to initiate emergency measures of burns. 10. Information given to the relatives concerning visiting times, regulations, dress codes within the unit. Cardiovascular and respiratory status should be assessed immediately; any signs of inhalation burns injury must be repeated to the physician without delay. PURPOSE: 1. 2. 3. 4. 5. To provide good quality nursing care. To prevent infection. To promote healing process. To prevent impending contractures. To prevent further damage of the skin.
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CARE OF PATIENTS WITH THERMAL BURNS
PAGE NUMBER 2 of 2
6. To provide relatives with information concerning patients treatment and hospital/ unit regulation. EQUIPMENTS / MATERIALS NEEDED: 1. 2. 3. 4. 5. Lund BrowdersChart Blood drawing Equipment Dressing Trolley Burns Dressings IV Set-Ups for both peripheral and central lines
PROCEDURE: 1. Prepare all equipment needed in the bed available upon receiving information about the admission. 2. Set up necessary dressings materials in the dressing room according to the percentage and severity of the burn. 3. Receive patient from endorsing staff listen attentively. Dont hesitate to ask for further history if the notify patients. 4. Bring patient in the dressing room soon assess patients burn by using the rule of nines and the Lund Browders chart. 5. Pasture laboratory studies, Chart obtary. 6. Give full bath or bedside bath to patients based according to situation. 7. Do dressing aseptically and as possible use appropriate wound dressing cream and to allow loose closed dressing with gauge and crepe bandage. 8. Put patient in a comfortable position and start monitoring and neurological status and vital signs. 9. Give IV fluid therapy by using the Pasbland formula and start medication according to the practice order.
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CARE OF PATIENTS WITH ELECTRICAL BURNS

DEFINITION: The specific care rendered to patient with electrical burns. The damage is due to passage of electricity through the tissues, and the amount of destruction depends on the strength of the current and the time during which contact is maintained. Electrical burns occur most commonly on the hands. The horny layer of skin is raised and loose. The majority of electrical burns are due to contact with the domestic electrical supply (220-240 volts AC); burns caused by contact with the high voltage grid system (11000 66000 volts AC), are occasionally seen. Firm contact with wet skin will allow more current to pass than light contact with dry skin. The skin component of an electrical burn is clearly demarcated, and corresponds with the area of contact. Deep to the skin, the damage decreases with increasing depth. Because of their fluid content blood vessels form, good conductors and thrombosis of digital or other vessels may occur with serious consequences. When this loose skin is removed, the area of skin destruction is seen as a dead white area with a narrow surrounding rim of bright red. In domestic supply accidents, although the burn may be deep, the area of deep damage corresponds approximately with the area of superficial damage and extension under intact skin is limited. In high-tension injuries, the current gains entrance through the skin and passes up the center of the limb, as it would up the core of conducting cable, causing extensive necrosis of vessels, muscles and nerves.
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PAGE NUMBER 2 of 4
OBJECTIVE: 1. To provide effective nursing care. 2. To prevent infection and promote healing. 3. To prevent damage of the organ. 4. Early detection and avoidance of nerve paralysis. POLICY: 1. A thorough Physical Assessment should be carried out on admission and identify the entry and exit wound on the body and any signs of bone fracture. 2. The patients ECG is closely monitored to identify any presence of cardiac arrhythmias. 3. The patients oxygen saturation should be assess continuously using Pulse oximetry 4. The wound care rendered will depends on the severity of the skin damage caused by the electrical burn. 5. The patient should be kept warm using thermal blanket and overhead warmer to prevent hypothermia. 6. The specific investigation such as 12 lead ECG; ABG and Chest X-ray should be carried out on admission as base line data. 7. The surgeon should not embark on the excision of an electrical burn unless he is able and prepared to perform a flap repair on the spot.
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PAGE NUMBER 3 of 4
MATERIALS AND EQUIPMENTS: 1. Dressing Sets 2. Sterile gown and gloves 4. Sterile towel 5. Normal Saline 6. Cardiac Monitors, Pulse oxymetry PROCEDURE 1. Assemble all equipment needed in the patients room 2. Assess patient thoroughly by history taking and assist doctor in physical assessment 3. Dress the wound with bactigras only and allow loose closed dressing with gauze and crepe bandage 4. Monitor patient closely every 30 minutes on vital signs and any signs of hypothermia. 4.1 Observe for any bluish discoloration of the nail beds. 4.2 Check radial pulse and brachial pulse every 30 minutes and report to the doctor if absent. 4.3 Observe patient mental status. 4. To identify signs of shock or hypothermia early. RATIONALE
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CARE OF PATIENTS WITH ELECTRICAL BURNS PROCEDURE 5. Encourage patient to move his/her finger from time to time. 6. Elevate patient affected hand with pillows. 7. Administer intravenous fluid therapy and medication as ordered by physician 8. Perform dressing of the wound accordingly. 9. Document in nurses notes patients condition and type of wound dressing
PAGE NUMBER 4 of 4
RATIONALE
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CARE OF PATIENTS WITH CHEMICAL BURNS

DEFINITION: The specific care rendered to patient with chemical burns of gaseous, liquid or solid that has come direct contact with skin and epithelial surfaces. Chemicals capable of causing burn injuries are usually strong acids such as hydrochloric acid, chromic acid or sulfuric acid or strong bases, such as sodium hydroxide. . OBJECTIVE: 1. To provide good nursing care. 2. To prevent infection and promote healing. 3. To prevent further damage of skin. POLICY: 1. Neutralization of one chemical substance with another should be undertaken only by physician who are familiar with specific chemical involved. 2. Injuries caused by Chemical agents containing sodium or potassium may continue to burn in the presence of water, so the wound should be covered with mineral oil before transfer the patient to a Burn Unit
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CARE OF PATIENTS WITH CHEMICAL BURNS
PAGE NUMBER 2 of 2
MATERIALS AND EQUIPMENTS: 1. Normal Saline 2. Calcium Salts 3. Mineral oil 4. Dressing Set 5. Sterile gown and gloves PROCEDURE 1. Assess the type of chemical involve on admission 2. Place patient in comfortable position for dressing. 3. Assemble all complete materials needed for dressing. 4. Exposed the affected part. 5. Chemical burns Clorox, dye, 5.1 Flush with copious amounts of water or normal saline. 6. Hydrochloric burns, 6.1 Administer topical calcium salts. CARE OF PATIENTS WITH CHEMICAL BURNS
INDEX NUMBER SNRBC-031 PAGE NUMBER 3 of 3
RATIONALE
3. To be organized in procedure
5.1 To mechanically remove surface chemicals and cool skin. 6.2 To buffer the acid and limit injury.
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PROCEDURE 7. Sodium or potassium 7.1 Coat affected area with mineral oil. 8. Observe the wound closely for further occurrence of any destruction to tissues resulting from the delayed effect of chemical burn. 9. Monitor vital signs of patient closely. 10. Commence intravenous therapy according to physicians order. 11. Administer medication or specific application of medication as per physicians order. 12. Document in nurses notes on patients condition and on the wound condition.
RATIONALE 7.1 To inhibit further destruction of causative agent action.
9. To identify any deviation of vital signs immediately
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CARE OF PATIENTS WITH RADIATION BURNS

DEFINITION: The specific care rendered to patient with burns due to the emanation of energy in the form of electromagnetic waves. Acute phase, within one or two days of the irradiation the affected area becomes red and swollen and may blister. In most instances the burn is of partial thickness depths and heals slowly over the course of a few months. Chronic phase- the healed post irradiated skin is always abnormal to a greater or lesser degree. In a typical case, it is atrophic, hairless, indurate and white with red spidery. Atrophic skin may later breakdowns, forming a simple ulcer, or undergoes malignant changes and become a squamous cells carcinima OBJECTIVES: 1. To provide good nursing care. 2. To prevent infection. 3. To lessen skin irritation. 4. To avoid further damage of the skin. POLICY: 1. The radiation burn wound requires irrigation under running water. 2. They may be due to excessive doses of radiation during radiotherapy, or radio diagnosis, or to accidents involving nuclear energy.
80
CARE OF PATIENTS WITH RADIATION BURNS MATERIALS AND EQUIPMENTS: 1. Basin 2. Water PROCEDURE 1. Provide quite room 2. Apply soothing applications 3. Monitor vital signs at least every hour and report any abnormality to the doctor. 4. Explain to patient to avoid another contact with radiation. 5. Document nurse note legibly and correctly.
PAGE NUMBER 2 of 2
RATIONALE 1. To promote rest 2. To allay irritation.
81
Ministry of Health, General Nursing Administration Functions & Duties Policies & Procedures
SPECIALIZED NURSING: BURNS

TITLE: INDEX NUMBER
CARE OF PATIENTS WITH ESCHARECTOMY

DEFINITION: The surgical debridement of slough which forms after the destruction of tissue resulting from burns injuries. OBJECTIVES: 1. To enhance natural healing. 2. To promote regeneration and repair of the tissues. 3. To prevent infection. 4. To promote epithelialization of the skin layers. POLICY: 1. All patients with escharectomy must undergo hydrotherapy daily 2. The doctor must be informed if bleeding occurs or any notice of gangreneous tissue. 3. When the remaining eschar starts to loosen, separation of it should be done by daily debridement.
82
CARE OF PATIENTS WITH ESCHARECTOMY
PAGE NUMBER 2 of 2
MATERIALS AND EQUIPMENTS: 1. Sterile dressing trolley 2. Basic procedure set. 3. Sterile gown, gloves, and mask 4. Surgical blades different sizes 5. Sterile gauze 4 X 4 lap sponge 6. Normal Saline 7. Flammazine or any other topical cream or ointment as ordered. PROCEDURE 1. Explain the procedure to patient 2. Assemble complete equipment to bedside 3. Perform desloughing , debridement and remove loose skin 4. Clean the wound aseptically with normal saline. 5. Apply flammazine or any other topical cream or ointment as ordered. 6 Document in nurses notes the condition of the wound and the specific medication applied to the wound. Ministry of Health, General Nursing Administration Functions & Duties Policies & Procedures 83 RATIONALE 1. To allay fears and ensures cooperation. 2. To be organized in doing procedure 3. Slough, debris and loose skin can be a source for bacteria growth.
___________________________________________________ SPECIALIZED NURSING BURNS TITLE PREPARATION OF GRAFT SITE

DEFINITION: To prepare the operation site before applying the skin graft. OBJECTIVE: To ensure that recipient area is ready for the application of skin. POLICY: 1. To prepare a burn wound prior to operative procedure for skin grafting. 2. Dressing shall be performed in order to keep area clean prior to grafting. 3. Procedure to be carried out by a trained nurse. MATERIALS AND EQUIPMENTS: 1. Swabs for culture and sensitivity. 2. As per general dressing equipment.
PREPARATION OF GRAFT SITE
PAGE NUMBER 2 of 2
84
PROCEDURE 1. Take swabs from each area. 2. Assemble equipment on a sterile surface.
RATIONALE 1. To exclude the presence of hemolytic streptococcus group D and M.R.S.A 2. To reduce patients exposure time. 3. To allay fears. 4. To ensure a bacteriologically clean bed for grafts.
3. Explain procedure to patient. 4. Clean recipient bed with saline + betadine and gauze swabs.
5. Dry gently. 6. Apply saline gauze, dry gauze, and bandage loosely. 7. Document in nurses notes on the preparation of graft
5. To prevent infection.
85
Ministry of Health, General Nursing Administration Functions & Duties Policies & Procedures ___________________________________________________ SPECIALIZED NURSING BURNS TITLE: PREPARATION OF DONOR SITE
DEFINITION: To prepare the donor site for healthy skin graft. OBJECTIVE: 1. To reduce risk of infection. POLICY: 1. To ensure clean donor bed prior to operative procedure for skin grafting. 2. To be performed in hydrotherapy pool or room by qualified burns nurse prior to operation. 3. Area may be any part of body. MATERIALS AND EQUIPMENTS: 1. 3.1 disposable razor. 2. Soap, water, and hibiscrub.
86
PREPARATION OF DONOR SITE
PAGE NUMBER 2 of 2
PROCEDURE 1. Soap donor area
RATIONALE 1. To soften skin easier to shave. 2. To avoid damage to skin surface, thus preventing infection. 3. To allay fears.
2.
Gently shave hairy areas.
3. 4. 5.
Clean and rinse donor area well. Dry donor area Cover prepared area with a sterile towel.
87
Ministry of Health, General Nursing Administration Functions & Duties Policies & Procedures _______________________________________________ SPECIALIZED NURSING: BURNS TITLE: TRANSPORT OF PATIENT TO OPERATING ROOM
EFFECTIVE DATE APPLIES TO NURSING APPROVED BY INDEX NUMBER SNR-BC- 036 PAGE NUMBER 1 of 2
POLICY: 1. There shall be written order from treating doctor. 2. Anesthetist must see and examine patient prior to the date of operation. 3. Patient file must be complete. 3.1 Operative Checklist 3.2 Consent 3.3 Anesthesia Form 3.4 Recovery Form 3.5 Progress Note 4. Insert IV cannula and must be done 9-8. 5. Patient must wear or gown with OR cap and wrist tag. 6. Pre-medication must be done by 2 nurses one to give and one as witness. 7. Patient must be transported per stretcher with side rails up. 8. Qualified nurse working in burns unit only must transport the patient in OR with the messenger. 9. Provide privacy during transport. PURPOSE: 1. To provide safety of the patient during transport. 2. To ensure continuity of care by verbal communication between ward and operating room. 88
TRANSPORT OF PATIENT TO OPERATING ROOM
PAGE NUMBER 2 of 2
3. To ensure quality patient care by efficient patient movement between areas. PROCEDURE: 1. Receive call from operating room to dispatch the patient. 2. Assist patient from bed to trolley. 3. Give pre-medication per anesthetist order. 4. Assess and secure IV lines and drainage bag. 5. Burns unit staff shall dispatch patient through stretcher to operating room. 6. Operating room staff shall receive the patient and transfer to OR stretcher. 7. Burns unit staff shall give complete report of patient to receiving nurse before returning to bed.
89
Ministry of Health, General Nursing Administration Functions & Duties Policies & Procedures
SPECIALIZED NURSING: BURNS

TITLE: INDEX NUMBER
CARE OF POSTOPERATIVE DONOR SITE

DEFINITION: To protect and promote healing of donor site OBJECTIVE: 1. To prevent need for subsequent grafting of donor site. POLICY: 1. As per general dressing policy. 2. Check dressing daily (but do not open). EQUIPMENTS AND MATERIALS: 1. Normal Saline 2. Betadine solution 3. Bactigras 4. Sterile 4 X $ gauze 5. Gamgee
90
CARE OF POSTOPERATIVE DONOR SITE
PAGE NUMBER 2 of 2
PROCEDURE 1. Explain procedure to patient 2. Dressing left intact until 8th to 11th day depending on the doctors order. Apply extra padding over dressing if there is excess exudate. 3. While dressing do not remove the bactiges which is adherent to the wound, as it will pull the thin epithelium layer cause bleeding, the loose bactiges should be trimmed. The following dressing is done every 3 4 days as per doctors order. 4. On the 8th to 11th day the dressing are removed to the layer of paraffin gauze as per doctors order. Wash with betadine and saline. Pat dry and paint with betadine. If the area is left exposed use a bed cradle. Wash daily and trim loose dressing.
RATIONALE 1. To allay fears.
4. If bandage is stuck soak the dressing with normal saline for 1 2 hours then remove.
5. Firmly bandage.
5. To prevent slipping and friction damage. To prevent excess pain.
6. When donor site is healed, massage often with non-scented moisturizer.
6. To avoid excess trauma to donor site.
7. Rinse with saline
7. To prevent dryness and scaling so that the site may be used again in case of severe burns.
91
Ministry of Health, General Nursing Administration Functions & Duties Policies & Procedures ___________________________________________________ SPECIALIZED NURSING BURNS TITLE: CARE OF POST OPERATIVE GRAFT SITES
DEFINITION: Limited access to site to promote good healing and prevent infection. OBJECTIVE: To ensure healthy and infection free skin graft. POLICY: 1. Staff nurse experience in burns care must carryout the procedure. 2. The first dressing should be performed after 4 days post operative skin graft upon physician orders. 3. Elevate the site of the graft. MATERIALS AND EQUIPMENTS 1. Dressing set 2. Betadine solution 3. 4 X 4 sterile gauze 4. Sterile cotton pledged 5. Sterile gloves and gown
92
CARE OF POSTOPERATIVE GRAFT SITES PROCEDURE 1. First preoperative dressing is done at the bedside, outer dressing are removed with gloves and scissors. 2. Using set up and equipment for general dressing: P & P remove all dressing carefully, without pulling on grafted areas. 3. The patient is showered or bathed according to physician instructions. 4. Remove paraffin gauze from grafted area with sterile cotton buds. Gently roll gauze diagonally from corner to corner. 5. Sutures can usually be removed. At first dressing change, as per doctors order. 6. Trim dead tissue from around the graft edges if necessary. 7. Any fluid collection should be pricked with sterile needle and squeeze the fluids. 8. Cleanse the graft site with normal saline and betadine. 9. Redress if necessary with paraffin gauze, gauze swabs, soaked betadine, and the required gauze bandages. 10. Position the patient to elevate the graft site if possible. 11. Repeat dressing changes to graft site daily if graft infected. If graft is left exposed, rest limb on sterile towel and cover with bed cradle. Use overhead heater to dry out exudates. Perform graft care as often as necessary to keep graft free from exudates.
PAGE NUMBER 2 of 2
RATIONALE
2. To prevent displacement of graft. 3. To loosen inner dressings. 4. To prevent displacement of graft. 5. To prevent further scarring.
To aid venous return.
93
TITLE: INDEX NUMBER
CARE OF INFECTED DONOR SITE

DEFINITION: Prevention of further infection and promote healing OBJECTIVE: 1. To clear wound exudates. 2. To promote a clean flat granulation bed. POLICY: 1. Staff nurse experienced in burns care must carryout the procedure. 2. Dressing is to be changed every alternate day. 3. To keep the donor site dry and free from any profuse oozing. EQUIPMENTS AND MATERIALS: 1. Dressing set 2. Sterile 4 X 4 gauze 3. Iodine solution 4. Normal Saline 5. Basin 6. Prescribed ointment
94
CARE OF INFECTED DONOR SITE
PAGE NUMBER 2 of 2
PROCEDURE 1. Explain procedure to patient 2. Patient to be washed in burns tank. 3. Assemble equipment.
RATIONALE 1. To allay fears.
3. To reduce patient exposure time.
4. Gently remove outer dressing.
5. Apply dressing making sure patient can pass urine, if patient is catheterized apply pad to perineum area.
6. Use half strength hydrogen peroxide to loosen inner dressing (tube bathing is preferable).
6. To avoid excess trauma to donor site.
7. Rinse with saline
7. To prevent further irritant action of hydrogen peroxide. 8. To prevent slipping, cross infection, and unnecessary pain.
8. Apply paraffin gauze and a topical agent (if prescribed) cover with dry gauze and then bandage. 9. Dress daily.
95
Ministry of Health, General Nursing Administration Functions & Duties Policies & Procedures _______________________________________________ SPECIALIZED NURSING BURNS
TITLE: INDEX NUMBER
ELIMINATION CARE OF BOWEL

SNR-BC 040 PAGE NUMBER 1 of 2
POLICY: 1. The genitalia and perineum needs special nursing care. 2. It is imperative that nurses know about individual habits and use knowledge implement and individualized nursing plan. 3. Staff nurses must recognize bowel potential problems that may or may not recognized by the patient and must be discussed with the patients. 4. Check for fecal impaction on any patient who has not had a stool for 24 hours. 5. Maintain adequate fluid intake. 6. Offer balance diet. OBJECTIVES: 1. All personnel entering the patients room under isolation should use precautions as indicated by the CDC card category of isolation. 2. Sterile gown, gloves, and mask should be used for any sterile procedure. 3. Gowns are never to be used more than once and should be changed if soiled or moist. 4. Dispose of the contaminated gown within the patients room in the appropriate hamper trolley.
96
ELIMINATION CARE OF BOWEL
INDEX NUMBER SNR-BC 040
PAGE NUMBER 2 of 2
5. Hands must be washed before and after wearing gloves. 6. Mask should be worn only once and replace if it will become moist or damp. 7. Gloves should not be used as a substitute for meticulous hand washing. 8. Mask must be discarded inside the patients room before leaving and never hang around the neck. MATERIALS & EQUIPMENTS: 1. Clean mask. 2. Sterile gown (to perform sterile procedures only). 3. Sterile and non-sterile gloves. PROCEDURE 1. Assess the patients condition. 2. Explain the patient the need of using mask, gown, and gloves. 3. Wear mask fitted to cover nose and mouth and fit tightly against the skin without gaping at the sides. 4. Wear gown and fasten it securely at the neck and waist. Cover the overlap completely at the back. 5. Wear gloves by covering the wrist and cups of gown, if worn. Ministry of Health, General Nursing Administration Functions & Duties Policies & Procedures 2. To reduce anxiety. To eliminate the patients feeling of being sick. 3. To protect from inhaling. To prevent particles aerosols transmitted by close contact. 4. To maintain sterility. To protect gross-clothing contamination. RATIONALE
97
_______________________________________________ SPECIALIZED NURSING BURNS TITLE: SOCIAL WORKER AND REHABILITATION SERVICES
POLICY: 1. The social worker is to assist the burn patient and the family in resolving personal, interpersonal and practical problems related to the injury. 2. The social worker must visit the burns unit daily. 3. The social worker must work to gain specific knowledge about the clinical management of burn patients. 4. To have an understanding of the characteristic responses and their social implications. 5. Mask should be worn only once and replace if it will become moist or damp. PURPOSE: 1. To keep the burn team better understand the patient in relation to a specific social and emotional background. 2. To facilitate communications among team members. 3. To assist the patient and family with problems precipitated by the burn injury. 4. To relieve social and emotional difficulties that stand in the way of optimal use of medical care. 5. To identify community resources and encourage the use of these resources. SOCIAL WORKER AND REHABILITATION SERVICES 98
EQUIPMENT: 1. Social worker male/female according to the patient. 2. Family members. PROCEDURE: 1. Assess patient condition. 2. The social worker must introduce himself to the patient. 3. Explain to the patient through Islamic and Scientific knowledge.
99
TITLE: INDEX NUMBER
DISCHARGE INSTRUCTIONS FOR THE PATIENTS WITH A BURN

POLICY: 1. There must be written doctors order. 2. Patient must be fit for discharge. 3. Written discharge summary must be done by the doctor and must be sent for typing. 4. For medico-legal case, inform admission office before sending patient home. 5. For non-Saudi patient, inform sponsor (kopil) about patient discharge. PURPOSE: 1. To prepare the patient and family physically and psychologically before discharge. 2. To promote the highest possible level of independence patient and his/her family by encouraging self-care activities. 3. To provide continuity of care between the hospital and the community by facilitating effective communication. 4. To encourage a safe, ordered transfer home. PROCEDURES: 1. Discuss the patient discharge plan with others involved in his/her care. This includes the patient, family or significant others.
100
DISCHARGE INSTRUCTIONS FOR A PATIENTS WITH A BURNS
PAGE NUMBER 2 of 2
2. Take OPD appointment and inform patient appointment date, time and send summary for typing and translation. 3. Inform patient family about the time of discharge if patient is child. 4. Give instructions about home medications. 5. Instruct patient the importance of continuous exercise at home, as well as next visit in physiotherapy. 6. Do dressing before sending patient home. 7. Write patient discharge in admission and discharge note, statistic form. 8. Document properly in nurses note patient discharge. 9. For LMC cases call admission office about the discharge. 10. Send patient file in medical records after doctor completed admission and discharge form.
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General Directorate of Nursing: Burn Care Functions Duties Policies and Procedures

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GENERAL DIRECTORATE OF NURSING

BURN CARE Functions Duties Policies and Procedures

Nursing Standards Organizing Committee for Hospital Services 2005

RESPONSIBILITIES OF STAFF NURSE IN BURNS UNIT

RESPONSIBILITIES OF STAFF NURSE IN BURNS UNIT

INDEX NUMBER SNR-BC-002

RESPONSIBILITIES OF STAFF NURSE IN BURNS UNIT

INDEX NUMBER SNR-BC-002

ORIENTATION OF NEW STAFF IN BURNS UNIT

ORIENTATION OF NEW STAFF IN BURNS UNIT Other Wards and Departments:

INDEX NUMBER SNR-BC-003

INDEX NUMBER SNR-BC-003

BURNS UNIT ATTIRE SUIT

SNR-BC-004 PAGE NUMBER 1 of 3

BURNS UNIT ATTIRE SUIT

INDEX NUMBER SNR-BC-004

BURNS UNIT ATTIRE SUIT

INDEX NUMBER SNR-BC-004

ISOLATION NURSING, MASK, GOWNS, AND GLOVES

ISOLATION NURSING, MASK, GOWNS, AND GLOVES

INDEX NUMBER SNR-BC-005

ADMISSION OF BURNS PATIENTS

SNR-BC-006 PAGE NUMBER 1 of 3

ADMISSION OF BURNS PATIENTS 5.2 Adult Partial Thickness Full Thickness -

INDEX NUMBER SNR-BC-006

more than 10 % more than 2 %

ADMISSION OF BURNS PATIENT

INDEX NUMBER SNR-BC-006

10. Document patient condition and response to treatment.

PHYSICAL ASSESSMENT O THE BURNS PATIENT

INDEX NUMBER SNR-BC-007

RATIONALE 3. To assess patient neurological status.

4. To determine earlier as possible for the hydration therapy.

5. To assess cardiovascular system status.

7. To assess abdominal peristalsis.

CLASSIFICATION OF BURNS ACCORDING TO DEPTH AND BODY SURFACE AREA

SNR-BC-008 PAGE NUMBER 1 of 2

CLASSIFICATION OF BURNS ACCORDING TO DEPTH AND BODY SURFACE AREA

INDEX NUMBER SNR-BC-008

6. To avoid hypovolemic shock and organ failure.

FLUID RESUSCITATION IN BURNS

SNR-BC-009 PAGE NUMBER 1 of 3

FLUID RESUSCITATION IN BURNS

INDEX NUMBER SNR-BC-009

Then, the remaining weight 20 mL/kg

FLUID RESUSCITATION IN BURNS

INDEX NUMBER SNR-BC-009

4. Observe the IV line frequently. 5. Monitor vital signs closely.

BASE LINE INVESTIGATION FOR BURNS PATIENT

BASE LINE INVESTIGATION FOR BURNS PATIENT

ORAL NUTRITIONAL SUPPORT IN BURNS

SNR-BC-011 PAGE NUMBER 1 of 3

ORAL NUTRITIONAL SUPPORT IN BURNS

INDEX NUMBER SNR-BC-011

ORAL NUTRITIONAL SUPPORT IN BURNS

INDEX NUMBER SNR-BC-011

10. To maintain clean environment. 11. To provide comfort

DIETARY SUPPORT TABLE

SNR-BC-012 PAGE NUMBER 1 of 4