MUSCULO-SKELETAL SYSTEM

surgical conditions
Year 2GN
 DEFINITION
• A musculoskeletal system (also known as the
locomotors system) is an organ system that
gives animals (including humans) the ability to
move using the muscular and skeletal
systems.
• The musculoskeletal system provides form,
support, stability, and movement to the body.
 ANATOMY
• It is made up of the body's bones (the
skeleton), muscles, cartilage, tendons,
ligaments, joints, and other connective tissue
(the tissue that supports and binds tissues and
organs together).
• The skeletal portion of the system serves as
the main storage system for calcium and
phosphorus and contains critical components
of the hematopoietic system.
 General information

• 1. Trauma in Greek means wound. Alternative term for

physical injury, as in traumatic head injury. Also, trauma is
defined as a Wounds or injuries caused directly by violent
contact of external objects with the body of the animal
(including human).
• 2. Contusion = a bruise.
A bruise or contusion, is caused when muscle, blood
vessels are damaged or broken as the result of a blow to
the skin (be it bumping against something or hitting
yourself with a hammer). In case of contusion, the skin is
not open.
• A purplish, flat bruise that occurs when blood leaks out into
the top layers of skin is referred to as an ecchymosis.
 Management of contusion

• Rest, depending on the size of the lesion, from 5 to

10 days,
• Immediately apply ice to the painful area (1 Hour)
• Compression bandage, but moderately tight.
• Massage therapy and reeducation are
contraindication because they would promote further
bleeding in the muscle
• an ultrasound may be used in case of large and much
pain
• Non steroidal anti pain, anti-edema and anti-
inflammatory, depending on the size of the lesion
 3. Sprain

• Sprain (entorse): A sprain is an injury of the

ligaments caused by an excessive mobilization
of the joint.
• The ligament is usually stretched or distended
but can also be torn (severe sprain) with
complications related to bone avulsions.
 CONT
• A sudden movement or twist often when the foot
rolls in (turn round) can overstretch the supporting
ligaments, causing ligament tears and bleeding
around the joint.
• This type of injury occurs most frequently in activities
that require running, skipping, jumping and change
of direction (such as basketball, volleyball and
football).
• Some people are particularly prone to recurring
ankle sprains. The most sprain is the sprain of the
ankle.
 Symptoms include
• Severe pain in joints, swelling around the joint, hematoma.
• Knowing the symptoms that can be experienced with a sprain
is important in determining that the injury is not really a
break in the bone.
• The nerves in the area become more sensitive, so pain is felt
as throbbing and will worsen if there is pressure placed on
the area.
• Warmth and redness are also seen
• The recurrent sprains and joint instability resulting can lead to
the development of osteoarthritis.
• Diagnosis
• It is important to either rule out a fracture clinically or
radiologically.
 Treatment

• Conservative measures:
• Acutely rest, ice, compression, and elevation (RICE) is often
recommended. Ice can help reduce swelling in cycles of 10–
15 minutes on and 60–90 minutes off. Compression
bandages provide support and compression for sprained
ankles.
• Mobilization:
• A short period of immobilization in a below-knee cast or in
an Air cast leads to a faster recovery at 3 months compared
to a tubular compression bandage.
• Exercise immediately (rotation, extension movement,
kinesitherapy) after a sprain however may improve
function and recovery.
 CONT
• Rehabilitation:
• If an ankle sprain does not heal properly, the joint may
become unstable and may develop chronic pain. Receiving
proper treatment and performing exercises that promote
ankle function is important to strengthen the ankle and
prevent further injury.
• It is not recommended to return to sports or extreme
physical activities until the ankle is healed without pain.
• Prognosis (evolution):
• Most people improve significantly in the first two weeks.
Some however still have problems with pain and instability
after one year (5–30%). Reinjury is also common.
 4. luxation
• Luxation = Complete dislocation of a joint. A
partial dislocation is a subluxation.
• Joint dislocation, or luxation, occurs when
bones in a joint become displaced or
misaligned. It is often caused by a sudden
impact to the joint.
• The ligaments always become damaged as a
result of a dislocation. Although it is possible
for any joint to become subluxed or
dislocated.
 cont
• The most common sites seen in the human
body are: Shoulders, knees, hip, fingers, wrists
(most likely be accompanied by a fracture),
and elbows (most likely be accompanied by a
fracture.)
 Causes:
• The dislocations may be the result of
traumatic injury (sports, fall to the ground,
blow) violent moving of the bone ends.
• Congenital malformations related to
architectural bone ends.
• The dislocations may be pathological lesions
associated with capsular ligaments or bone.
 Signs and symptoms

• Fun shoulder pain, or elbow, or hip.

• Loss of function when limbs are curved.
• On examination, radiography shows a dislocation
(displacement of ending surfaces of the bones) in the
elbow, shoulder, hip, and so on.
• limping when walking (dislocated hip).
• Inability to make movements of abduction, internal and
external rotation, adduction, extension.

Diagnosis of luxation and subluxation is based on history,

physical examination and X-rays.
 Treatment

• A dislocated joint usually can only be

successfully 'reduced' into its normal position
by a trained medical professional.
• Trying to reduce a joint without any training
could result in making the injury substantially
worse.
• It is important to reduce the joint as soon as
possible
 5. Fracture

Introduction to fracture
• A fracture is a disruption or break in the
continuity of the structure of bone
– traumatic injuries account for the majority of
fractures,
– pathologic fractures :from cancer or osteoporosis
 Cont’d
• Bones form the skeleton of the body and
allow the body to be supported against gravity
and to move and function in the world.
• Bones also protect some body parts, and the
bone marrow is the production center for
blood products.
 Classification of fractures

• Fractures are classified into two main groups:

– closed fractures
– open or compound fractures
• Open fractures exist when the break in the
bone communicates with a wound in the skin.
– contaminated
– requiring measures to control potential infection.
• Conditions associated with open fractures:
– Secondary hemorrhage
– infection
– severe damage to soft tissues
– damage to blood vessels and nerves
• The fracture's alignment is described as to
whether the fracture fragments are displaced
in their normal anatomic position.
• If the bones fragments aren't in the right
place, they need to be reduced or placed back
into their normal alignment.
 General signs and symptoms of fracture
1. Pain at or near the seat of fracture.
2. Tenderness or discomfort on gentle pressure
over the affected area.
3. Swelling above the seat of fracture. Swelling
frequently renders it difficult to perceive other
signs of fracture and care must be taken
therefore not to treat the condition as a less
serious injury.
4. Loss of power/ function: the injured part
cannot be moved normally
 Cont’d
5. Deformity of the limb: the limb may assume
an unnatural position and be misshapen
(deformed).
The contracting muscles may cause the broken
ends of the bone to override, thereby producing
shortening of the limb.
6. Irregularity of the bone. If the fracture is near
the skin the irregularity of the bone may be felt.
 Cont’d
7. Crepitus (bony grating) may be heard or felt.
8. Unnatural movement at the seat of the
fracture.
 Cont’d
• Diagnosis
• The radiography
• CT scan for undetected fracture with x-ray
 Treatment
• Initial treatment for fractures of the arms, legs, hands and
feet in the field include splinting the extremity in the position
it is found, elevation and ice. Immobilization will be very
helpful with initial pain control.
• Surgery
• Surgery can include closed reduction and casting, where
under anesthesia, the bones are manipulated so that
alignment is restored and a cast is placed to hold the bones in
that alignment.
• Open reduction means that, in the operating room, the skin is
cut open and pins, plates, or rods are inserted into the bone
to hold it in place until healing occurs (internal fixation)
 Management of fractures

• Fracture management can be divided into no

operative and operative techniques.
• The no operative technique consists of a closed
reduction if required, followed by a period of
immobilization with casting or splinting.
• Closed reduction is needed if the fracture is
significantly displaced or angulated.
• If the fracture cannot be reduced, surgical
intervention may be required
 Indications of operative techniques
• Failed no operative (closed) management
• Unstable fractures that cannot be adequately
maintained in a reduced position
• Patients with fractures that are known to heal poorly
following no operative management (e.g., femoral
neck fractures).
• Large avulsion fractures that disrupt the muscle-
tendon or ligament function of an affected joint (e.g.,
patella fracture)
 Cont’d
• Impending pathologic fractures
• Multiple traumatic injuries with fractures involving the pelvis,
femur, or vertebrae
• Fractures in individuals who are poor candidates for no
operative management that requires prolonged
immobilization (e.g., elderly patients with proximal femur
fractures)
• Fractures in growth areas in skeletally immature individuals
that have increased risk for growth arrest.
• Nonunion or malunions that have failed to respond to no
operative treatment
• Unstable and complicated fractures
 Contraindications
Contraindications to surgical reconstruction :
•Active infection (local or systemic) or osteomyelitis
•Soft tissues that compromise the overlying fracture or the
surgical approach because of poor soft-tissue quality due
to soft-tissue injury or burns.
•Medical conditions that contraindicate surgery or
anesthesia (e.g., recent myocardial infarction)
•Cases in which amputation would better serve the limb
and the patient.
• Rules for open fracture treatment:
– Tetanus immunization
– Prophylactic antibiotic therapy
– Surgical debridement and irrigation
– Don’t put stitches on open fractures
– Cover the wound after cleaning
– Immobilization
– Elevate the limb to avoid the edema
• The primary goal in treatment of an upper
extremity fracture
– preserve mobility and restore range of motion
– enabling the individual to perform skilled and
delicate work.
• In fractures of a lower extremity, the
objectives of surgery are:
• to restore alignment and length and provide
stability of the extremity for weight bearing
• Treatment of fractures usually includes three distinct
phases:
– Reduction
– Immobilization
– Rehabilitation
• The methods of treating fractures include:
– Skin and Skeletal traction
– External fixation
– Closed reduction (CR) with immobilization.
– Open reduction and internal fixation (ORIF)
• Reduction can be accomplished with or without
surgery
 Skin Traction
• Skin traction is far less invasive than skeletal traction.
• It involves applying splints, bandages, or adhesive
tapes to the skin directly
• Once the material has been applied, weights are
fastened to it.
• The affected body part is then pulled into the right
position using a pulley system attached to the
hospital bed.
 Cont’d
• In skin traction, assessment of the skin is a priority
since pressure points and skin breakdown may
develop quickly.
• Assess key pressure points every 2 to 4 hours.
 Indications for skin traction
• Repairing of soft tissues, such as the muscles and
tendons.
• When need to apply less force to avoid irritating or
damaging the skin and other soft tissues
• The treatment of children’s fractures
• Adult fractures or dislocations
• Temporary measure prior to more definitive
treatment such as open reduction or skeletal
traction.
 Contraindications
• Fractures which require more than 5 to 7lbs.
(2.7 to 3.2kg) of longitudinal force.
• Continuous traction exceeding three to four
weeks.
 Skeletal Traction
• Skeletal traction involves placing a pin, wire, or screw
in the fractured bone.
• After one of these devices has been inserted, weights
are attached to it so the bone can be pulled into the
correct position.
• This type of surgery may be done using a general,
spinal, or local anesthetic to keep from feeling pain
during the procedure.
 Cont’d
• Skeletal traction is most commonly used to treat
fractures of the femur, or thighbone.
• It’s also the preferred method when greater force
needs to be applied to the affected area.
• The force is directly applied to the bone, which
means more weight can be added with less risk of
damaging the surrounding soft tissues.
 Cont’d
• The forces are usually exerted on the distal
fragment to align it with the proximal
fragment.
• Allows the use of up of 5 to 45 lb (2.3 to 20.4
kg) as long as three to four months.
• Too much weight can result in delayed union
or nonunion.
 Closed Reduction

• Closed Reduction:
– manipulating the fragments into position without
incising the skin
• The treatment of choice because
– it decreases the opportunity for infection
– improves results (bone union of the fracture)
– minimizes the recovery period.
 PROCEDURAL CONSIDERATIONS

• The choice of anesthesia depends on the site

of fracture and the patient’s condition.
• Closed reduction may take place before an
open procedure to reduce the fracture site.
• Skeletal traction may also be applied to the
fracture site.
 OPERATIVE PROCEDURE

• The surgeon uses manual traction to

manipulate the fragments into alignment.
• Reduction is confirmed using radiography
• After reducing the fracture the surgeon
immobilizes it with casting material.
 External Fixation
• External fixation of fractures provides rigid fixation
and reduction with the ability to manage severe soft
tissue wounds.
• External fixation is often the preferred treatment for
an open fracture because of the increased chance of
infection in patients.
• Advantages of external fixation:
– the absence of casting material
– fracture stabilization at a distance from the injury
site.
 Indications for external fixation
– Severe open fractures
– Complex fractures with extensive soft tissue
damage
– Joint fractures
– Infected nonunion
– Fracture stabilization to protect arterial or nerve
anastomoses
 Cont’d
• External fixation provides a bridge between
fracture reduction and insertion of an internal
fixators.
– Ongoing assessment for pin loosening and
infection is critical
– Infection signaled by exudate, erythema,
tenderness, and pain may require removal of the
device.
– cautious pin care should be implemented
 PROCEDURAL CONSIDERATIONS.

• External fixators are applied using sterile

technique
• the patient is administered a general or
regional anesthetic.
• Radiographic imaging ensures fracture
reduction and proper pin placement.
• The incision site is small to allow introduction
of pins.
• Irrigation and debridement at the fracture site
• a power drill and a periosteal elevator may be
used
• An appropriate-size pin cutter should also be
available to shorten the pins if the need
arises.
• The dressing consists of an antibacterial
ointment, antibiotic-impregnated gauze.
 Internal Fixation
• Indications of Internal fixation:
– Displaced fractures long bone fractures
– Intra-articular fractures
– Unstable fractures
– Fractures with nerve injuries or vascular injuries
– Fracture neck of femur in adults
 Internal Fixation

– Fractures with multiple fragments

– Multiple fractures
– Spinal fractures
• Methods of internal fixation:
– Application of compression plates and screws
– insertion of pins, intramedullary rods, nails, or
wiring
 Benefits of Internal Fixation

• Earlier functional recovery

• More predictable fracture alignment
• No casts application
• Early motion
– Avoid stiffness
– Potentially faster time to healing
 OPEN REDUCTION AND INTERNAL FIXATION
• Open reduction and internal fixation is a method of
providing exposure of the fracture site to correct the
fracture.
• Surgeons use open reduction and internal fixation
when:
– they are unable to reduce a fracture by closed
methods
– skeletal traction is not indicated.
 Cont’d
• The advantages:
– Anatomic alignment of the fracture can usually be
obtained and verified through direct observation.
– Excellent results can be obtained with internal
fixation of a fracture soon after it occurs.
– This method provides firm immobilization
– Provides close approximation of the fragments so that
the gap between the ends is not too great for the
callus to bridge.
– Healing seems to take place faster.
– The patient starts non–weight-bearing exercises and
progresses to ambulation early.
 Fracture Healing
• Broken bones heal by a process referred to as union.
• Union of bones takes place in a series of steps:
• Fracture hematoma:
– blood changes from a liquid to a semisolid clot.
– This occurs in the initial 72 hours after injury.
• Granulation tissue:
– The hematoma converts to granulation tissue
(consisting of new blood vessels, fibroblasts, and
osteoblasts)
– This produces the basis for new bone substance
called osteoid during days 3 to 14 post-injury.
 Cont’d
• Callus formation:
– Callus is primarily composed of cartilage, osteoblasts,
calcium, and phosphorus.
• Ossification:
– Ossification of the callus occurs from 3 weeks to 6 months
after the fracture and continues until the fracture has
healed.
– Callus ossification is sufficient to prevent movement at
the fracture site when the bones are gently stressed.
– However, the fracture is still evident on x-ray.
– During this stage of clinical union, the patient may be
allowed limited mobility or the cast may be removed
 Cont’d
• Consolidation:
– the distance between bone fragments diminishes
and eventually closes.
– During this stage ossification continues.
– This phase can occur up to 1 year after injury
• Remodeling:
– Excess bone tissue is resorbed in the final stage
of bone healing, and union is complete.
 The polytraumatized patient
Definition:
• The polytraumatized are multiple lesions of
the musculoskeletal, abdominal or chest
viscera, or skull.
• Polytrauma is a specific medical term that
describes the condition of someone who has
sustained multiple traumatic injuries in an
accident.
•The multiplicity of lesions, their extent explains
the shock of those injured a state that imposes
its own emergency treatment, the first element
of both the assessment and treatment of
injuries.
 Causes:
The incidence of trauma is related to accidents.
Signs and symptoms include:
• State of shock on the clinical results in:
• A pale skin and cold
• A rapid and shallow breathing,
• A rapid pulse above 100 beats / min,
• A lowered or a collapse of the BP,
• The patient is sometimes calm, sometimes very
agitated and anxious.
• It may complain of thirst.
 Cont’d
• Bleeding (may be internal), can contribute to
dominate this state of shock:
• The detection of blood, a blood count or
hematocrit is essential in emergencies.
 Treatment:
The shock actually imposes emergency treatment. It
includes:
•A local team and adapted to these serious injuries,
•Taking an intravenous line for hydration and blood
transfusions if required,
•Oxygen therapy,
•Treatment of pain by analgesics but also by
immobilization of fracture
•Calming anxiety of the patient.
•Prevention of tendon retraction
 Cont’ d
• Prevention of Urinary infection
• Support for rectal evacuation
• Assistance and rehabilitation
 Nursing Management at the arrival of a
polytraumatized patient:

1. Assess the degree of possible shock

2. Gestures of first aid may be necessary
3. Assess neurological status:
• Level of consciousness and its evolution since the
accident,
• Trouble in speaking,
• Unilateral pupillary dilatation
• spontaneous mobility of the limbs
• Sensitivity of the skin
 Fracture of the rib cage

• The rib fracture is the complete failure of one or more

ribs.
• The fracture can be easy if the rib is broken into two
pieces or complicated if the rib is broken into more
than 2 pieces.
• The rib fracture is secondary to a direct blow to the
chest in persons of all ages.
• It can also occur during a violent effort in athletes or
during a violent coughing in someone with
osteoporosis or not.
 Treatment

• The reduction of pain (analgesia).

• It is indeed impossible to immobilize a fractured rib,
can results into pain or stop breathing.
• The healing process will be spontaneous.
• However, maintaining a slight decrease movements
of the chest and removes the jerks caused by
coughing or laughing.
• Wearing a chest strap (corset plaster) will play as a
buffer/defense and prevent the onset of pain.
corset plasters
 BUNS
• Cellular destruction of the layers of the skin and the
resultant depletion of fluids and electrolytes.
• These are the skin injuries resulting from various
injurious factors :
• Exposure to thermal, electrical, chemical, and/or
radiation sources.
Types of Burns according to Etiology
1.Thermal burn
•Most common type and caused by flame, scalding,
contact (hot metals, grease)
2. Smoke inhalation:
particulate products of a fire, Gases, superheated
air.
Their inhalation causes respiratory tissue damage

71
 Cont’d
3. Chemical: caused by
• Tissue contact,
• Ingestion or inhalation of acids or alkaline.
4. Electrical: injury occurs from
• direct damage to nerves and vessels when an
electric current passes through the body.
5. Radiation Burns:
This is caused by exposure to:
 ultraviolet rays,
 x-rays and
 Radioactive sources.
72
 Burn classification as to depth

1. Superficial Partial thickness (1st degree)

Outer layer of the skin (Epidermis) is involved
Erythematous and painful up to 48 hrs
Blanch to the touch. Tissue damage is minimal with
no blistering or scarring.
Healing 1-2 weeks
 Cont’d
2. Secondary-degree burns: 2 categories of burns
 (1)Superficial partial-thickness: involve the
Epidermis and dermis.
injury-thin walled,
Edema, fluid-filled blisters that develop within
minutes of injury.
Tactile and pain sensors are intact (frequently quite
painful)
Healing: 3 to 4 weeks & Scar formation is unusual.
 Cont’d
(2) Deep partial-thickness:
It involve entire dermis
Hair follicles and sweat glands are not involved.
The burn is waxy white surrounded by margins of
superficial partial thickness injury.
 Cont’d
Third-degree burns
Involve destruction of the entire epidermis, dermis,
and often underlying subcutaneous fat are involved
Dry, pearly white or charred in appearance
Not painful
Eschar must be removed; may need grafting
77
 Zones of Burn Injury
Zone of coagulation:
This is the point of maximum damage.
 In this zone there is irreversible tissue loss
due to coagulation of the constituent proteins.
Zone of stasis:
•The surrounding zone of stasis is characterized
by decreased tissue perfusion.
•The tissue in this zone is potentially
salvageable.
 Cont’d
Zone of hyperemia:
•The outermost zone where tissue perfusion
is increased.
•The tissue recover unless there is severe
sepsis or prolonged hypo-perfusion.
 ESTIMATION OF BURNS
• Various methods are utilized for estimating the
extent of burn injury
1. The Rule of Nines in adults
 Head and Neck: 9%
 Anterior trunk: 18%
 Posterior trunk:18%
 Upper arms: 18% ( 9% each x 2)
 Lower extremities: 36% (18% each X 2)
 Perineum: 1%
 Cont’d
2. Lund and Browder or Berkow method:
• Modifies percentages for body segments according
to age
• Provides a more accurate estimate of the burn size
• Uses a diagram of the body divided into sections,
with the representative % of Total Body Surface Area
(TBSA) for all ages.
CALCULATION OF TBSA

Irregular burns-use the patient’s hand to

estimate 0.5% of the body surface area
Acute Burn Injury exceeding 20% of (TBSA)
• Patients with burns in excess of 20% TBSA are at risk
for developing burn shock.
• The physiological response to the burn injury includes
both cellular and systemic disturbances:
 Extensive fluid redistribution (Hypovolemia)
 Electrolyte imbalances(Hyperkalemia, Hyponatremia)
 Inflammatory response
 Impaired immunity
 Burns Requiring Hospitalization
 Greater than 10% total body surface area in
children
 Any burn in the very young
 Full thickness burns
 Burns to the face, hands, feet, or perineum
 Circumferential burns
 Inhalation injuries

84
 Burn Management
1.EMERGENT PHASE:
• Begins at the time of injury and ends with the
restoration of the capillary permeability ( with 48-
72 hours)
• The goal is to prevent hypovolemic shock and
preserve the vital body organ function
• Emergency and pre-hospital care

85
 Burn Management
2.RESUSCITATIVE PHASE
• Begins with the initiation of fluids and ENDS when
capillary integrity returns to near-normal and large
fluid shifts have decreased
• The goal is to prevent shock by maintaining
adequate circulating blood volume to maintain vital
organ perfusion.

86
 Burn Management
3. ACUTE PHASE
• Begins when the client is hemodynamically stable,
capillary permeability is restored and diuresis has
begun.
• Emphasis is placed on restorative therapy and the
phase continues until wound closure is achieved
• The focus is on infection control, wound care, wound
closure, nutritional support, pain management and
physical therapy.

87
 Burn Management
4.REHABILITATIVE PHASE
• The final phase of Burn care, restoration of
functions, cosmetic surgery.
• Goals of this phase – patient independence and
restoration of maximal function.

88
 Medical Management
1.Supportive therapy:
•Fluid management (lVFs),
Catheterization
2. Wound care:
Hydrotherapy,
Debridement (enzymatic or surgical)

89
 Medical Management
3. Drug therapy
a. Topical antibiotics:
mafenide (Sulfamylon),
silver sulfadiazine (Silvadene),
silver nitrate,
povidone-iodine (Betadine) solution
b. Systemic antibiotics: gentamicin
c. Tetanus toxoid or hyper-immune human tetanus
globulin
d. Analgesics
4. Surgery: excision and grafting 90
 Nursing Management

1. Emergent phase (time of injury)

Remove person from source of burn.
1) Thermal: smother burn beginning with the head.
2) Smoke inhalation: ensure patent airway.
3) Chemical: remove clothing that contains chemical;
lavage area with copious amounts of cold water.
4) Electrical: note victim position, identify entry/exit
routes, maintain airway.

91
 Nursing Management
1. Emergent phase (time of injury)
• Cool the burned area for several minutes (10min of
exposure)
• DON’T USE ICE!!
• Wrap in dry, clean sheet or blanket to prevent further
contamination of wound and provide warmth and
conserve body heat.
• Assess how and when burn occurred.

92
 Nursing Management
1. Emergent phase (time of injury)
• Remove constricting clothes and jewelry
• Cover the wound with a sterile dressing or clean,
dry cloth.
• Provide IV route only, if possible
• Transport immediately to a hospital or burn
facility/unit.

93
 Nursing Management

2. Resuscitative and Shock phase (first 24—48

hours)
• Provide appropriate fluid resuscitation based on
the Parkland formula
• 4 mL Plain LR x %TBSA of burns x kg body weight

94
 Nursing Management, Cont’d….
Parkland formula
Ringers Lactate: 4 mL/kg/% burn in the first 24 h
after burn.

50% of this volume is infused in the first 8 hours,

starting from the time of injury, and the other 50%
is infused during the last 16 hours of the first day.

95
 Nursing Management, Cont’d
Evaluation of Fluid Resuscitation
Urine output reflects adequate perfusion and
renal function
Children: >1ml/kg/hour
Adolescent: 0.5-1ml/kg/hour
Adult: 30-50 mL per hour
B/P, pulse, resp rate returning to
normal range

97
 Nursing Management, Cont’d….

Fluid remobilization or diuretic phase (2—5 days

post burn)
• Monitor and treat potential complications like
acute renal failure, paralytic ileus, Curling’s
ulcer and hypokalemia

98
 Management of Hyperkalaemia
 Serum potassium levels above 6.0 mEq/l and/or
abnormal ECG are indications of the need for
immediate treatment.
 Intravenous administration of 500 ml of 10%
dextrose with 1-20 units of regular insulin will
lower the serum potassium level by approximately
2mEq/liter.

99
Consequences of over resuscitation
(Fluid Creep)
Causes Consequences
Massive edema formation
Overestimation of
Pulmonary edema
burn size
Extremity compartment
Inaccurate
syndrome
calculation of fluids intra-abdominal
IV fluids not hypertension (IAH) and
decreased in a abdominal compartment
timely manner. syndrome (ACS)

100
 Nursing Management

4. Convalescent phase
Starts when diuresis is completed and
wound healing and coverage begin.

101
 GENERAL NURSING INTERVENTIONS IN
THE HOSPITAL
Provide relief/control of pain.
•Opioids are the mainstay of pain control in burn
patients.
•These drugs have a significant effect on the
cardiovascular system.
•Use of these drugs is associated with decreased
blood pressure.
 Cont’d

Monitor: RR, HR, BP & oxygen saturation

Administer morphine sulfate IV and monitor
vital signs closely.
Administer analgesics/narcotics 30 minutes
before wound care.
Position burned areas in proper alignment
 Cont’d
2. Monitor alterations in fluid and electrolyte
balance.
a. Assess for fluid shifts and electrolyte
alterations
b. Monitor Foley catheter output hourly (30 cc
per hour desired).
c. Weigh daily.
d. Monitor circulation status regularly.
e. Administer/monitor crystalloids/colloids
104
 Cont’d
3. Promote maximal nutritional status.
• Severe burn injury is followed by a profound
hypermetabolic response that persists up to 24
months after injury.
• A 50-fold elevations in plasma catecholamines,
cortisol and inflammatory cells lead to whole body
catabolism, elevated resting energy expenditures and
multi-organ dysfunction.
• Aggressive, early enteral feeding improves outcomes
in severely burned patients, in part, by mitigating the
degree and extent of hypermetabolism

105
 Cont’d

Promote maximal nutritional status, Cont’d….

a. Monitor tube feedings if parenteral Nutrition is
ordered.
NPO immediately after injury!!! ONLY when oral intake
permitted, provide high-calorie, high-protein, high-
carbohydrate diet with vitamin and mineral
supplements.
c. Serve small portions.
d. Schedule wound care and other treatments at least
1 hour before meals.
106
 Cont’d

4. Prevent wound infection.

a. Place client in controlled sterile environment.
b. Use hydrotherapy for no more than 30 minutes to
prevent electrolyte loss.
Observe wound for separation of eschar and cellulitis.

107
108
 Cont’d

4. Prevent wound infection, Cont’d…..

For Immediate Post-burn wound care, the followings
are required:
Tetanus prophylaxis
Debride all bullae and necrotic tissue
Cleanse with mild water-based antiseptic
Apply thin layer antibiotic cream
Dress with petroleum gauze and dry gauze

109
 Cont’d
5. Prevent GI complications.
a. Assess for signs and symptoms of paralytic ileus.
b. Assist with insertion of NG tube to
prevent/control Curling’s/stress ulcer; monitor
patency/drainage.
C. Administer prophylactic antacids through NG tube
and/or IV cimetidine to prevent stress ulcer.
d. Monitor bowel sounds.
e. Test stools for occult blood.

110
 Rehabilitation
Methods of coping and re-socialization:
 Ensure optimum nutrition
 Initiate physical therapy to regain and maintain
optimal range of motion and achieve wound coverage
 Provide psychosocial support to promote mental
health.
• Encourage post-discharge follow-up for several
years
• Ensure appropriate referral to cosmetic surgeon,
psychiatrist, occupational therapist, nutritionist and
physical therapist

111
END !