BURNS: Therapeutic Procedures

Question 1

Wound Care

■■ Nonsurgical management, such as ?

Answer 1

Wound Care

■■ Nonsurgical management, such as hyperbaric oxygen therapy

Question 2

WOUND CARE

NURSING CARE

Answer 2

Nursing Actions

1. ☐☐ Premedicate the client with analgesic as prescribed prior to all wound care.
2. ☐☐ Remove all previous dressings.
3. ☐☐ Assess for odors, drainage, and discharge. Assess for evidence of sloughing, eschar, bleeding,
4. and evidence of new skin cell regeneration.
5. ☐☐ Cleanse the wound as prescribed, removing all previous ointments. (It is important to
6. cleanse the wound thoroughly.)

Question 3

WOUND CARE

NURSING CARE (Continued)

Debridement (3)

plus (2)

Answer 3

Assist with debridement.

XX Mechanical – Use scissors and forceps to cut away the dead tissue during the hydrotherapy treatment.

XX Hydrotherapy – Place the client in a warm tub of water or use warm running water, as if to shower, to cleanse the wound.

ZZ Use mild soap or detergent to gently wash burns and then rinse with

room-temperature water.

ZZ Encourage the client to exercise his joints during the hydrotherapy treatment.

XX Enzymatic – Apply a topical enzyme to break down and remove dead tissue.

☐☐ Ensure that the client does not become hypothermic during the treatment.

☐☐ Apply a thin layer of topical antibiotic ointment as prescribed and cover with dressing, using surgical aseptic technique.

Question 4

Skin Coverings

Biologic skin coverings are temporarily used to promote __?__. Additionally,

biologic skin coverings promote the __?__ and __?__and provide coverage of __?__

, thus reducing the amount of pain experienced by the client. The provider stipulates whether skin coverings are to be left __?__ by a dressing.

Answer 4

Biologic skin coverings are temporarily used to promote healing of large burns. Additionally,

biologic skin coverings promote the retention of water and protein and provide coverage of

nerve endings, thus reducing the amount of pain experienced by the client. The provider

stipulates whether skin coverings are to be left open or protected by a dressing.

Question 5

Allograft (homograft) –
Xenograft (heterograft) –
Amnion –
Synthetic skin coverings –

Answer 5

1. Allograft (homograft) – Skin is donated from human cadavers and used for partial- and full‑thickness burn wounds.
2. Xenograft (heterograft) – Obtained from animals, such as pigs, for partial-thickness burn wounds.
3. Amnion – Obtained from human placenta; requires frequent changes.
4. Synthetic skin coverings – Used for partial-thickness burn wounds. Many of the synthetic skin coverings are made of materials that are clear enough to see through so that the wound can be visualized without removing the dressing.

Question 6

■■ Permanent skin coverings may be the treatment of choice for burns covering large areas of

the body.

☐☐ Autografts –

• Sheet graft –
• Mesh graft –

☐☐ Artificial skin –

☐☐ Cultured epithelium –

Answer 6

■■ Permanent skin coverings may be the treatment of choice for burns covering large areas of

the body.

☐☐ Autografts – Donor skin from another area of the burn client’s body

• Sheet graft – Sheet of skin used to cover wound
• Mesh graft – Sheet of skin placed in mesher so skin graft has small slits in it; allows graft to be stretched to cover larger areas of the burn wound

☐☐ Artificial skin – synthetic product that is used for partial- and full-thickness burn wounds

(healing is faster)

☐☐ Cultured epithelium – epithelial cells cultured for use when grafting sites are limited

Question 7

Nursing Actions (5)

Answer 7

Nursing Actions

1. ☐☐ Maintain immobilization of graft site.
2. ☐☐ Elevate extremity.
3. ☐☐ Provide wound care to the donor site.
4. ☐☐ Administer analgesics.
5. ☐☐ Monitor for evidence of infection before and after skin coverings or grafts are applied.

• XX Discoloration of unburned skin surrounding burn wound
• XX Green color to subcutaneous fat
• XX Degeneration of granulation tissue
• XX Development of subeschar hemorrhage
• XX Hyperventilation indicating systemic involvement of infection
• XX Unstable body temperature

Question 8

Client Education (5)

Answer 8

Client Education

1. ☐☐ Instruct the client to keep extremity elevated.
2. ☐☐ Instruct the client to report signs and symptoms of infection.
3. ☐☐ Determine the client’s level of pain and provide addition measures to control donor site pain.
4. ☐☐ Instruct the client to continue to perform range-of-motion exercises and to work with a physical therapist to prevent contractures.
5. ☐☐ Provide client instruction on how to assess the wound for infection and how to perform wound care.

Question 9

Care After Discharge (3)

Answer 9

Care After Discharge

1. ◯◯ Initiate referral for home health nursing care.
2. ◯◯ Initiate referral to occupational therapy for evaluation of the home environment and assistance to relearn how to perform ADLs.
3. ◯◯ Initiate referral to social services for community support services.