MANAGEMENT OF THE DRESSING OF A SEVERELY BURNED PATIENT BY THE NURSING TEAM

Riviére J.R., Huc M., Trouvillíez A., Palanque A.R., Bernaras F.

Centre Felix Lagrot, Toulouse, France

SUMMARY. The scientific knowledge of wound healing conditions and their evolution and complications leads to the elaboration of adaptable and evolutive wound dressing protocols. The authors consider dressings for the severely burned patient, and the necessity of the collaboration of the entire medical and paramedical team.

Management of severely burned patients has two the hydroelectrolytic phase, with control of the vital functions the metabolic phase, with control of hypermetabolism and bacterial aggression. This is centred on the preservation and restoration of the cutaneous capital.
The burn as a localized disease cannot be dissociated from the burn as a generalized disease.
The local treatment of the burn constitutes a difficult experience for the patient as well as for the nursing team, involving the Centre's conception and work organization, and rigorous and laborious specific care.

Dressing is integrated into: an adapted logistic environment (closed oligoseptic unit, adjustable thermal environment and precise hygienic protocols) a sophisticated technical environment (operating theatre, therapeutic bathroom, fluidized bed) an appropriate human environment (psychological care, reassuring relationship).

Dressing is a therapeutic method which aims to

- prevent infection
- facilitate healing
- diminish pain
- limit the care load
- avoid limitation of movement.

The strategy of dressing in our centre is to compromise between two methods, the semi-open method and the open method.
The semi-open method includes the application of topical products and/or anti-Inflammatory products, antiseptics, products inducing epithelialization, and gauze and bandage. The burn wound is placed in a hydrophilic medium. This is an analgesic and anti-infection method. It ensures ventilation and relative thermal protection of the burn. It also limits water and electrolyte losses more than the open method.
The open method consists of the exposure of the burn wound to warm dry air on a fluidized bed. This is also an anti-infection method, favouring the development of a crust which separates spontaneously. It is however painful and leads to thermal, water and electrolyte losses.
The closed method consists of the application of topical products, gauze and bandage. The burn is placed in a hydrophobic medium. This method used to be our first method of dressing but is now applied only in a few cases, as it favours infection and deepening of the lesions.

The dressing is adapted to every stage of the burn, and prevents contamination of healthy or healing zones. It facilitates wound follow-up.
The choice of dressing depends on the priorities as well as on the major septic risks and water and temperature losses. This also depends on the site and depth of bums and the risk of maceration. These criteria lead to the application of different products.

The dressings of the severely burned patient
We will now consider the dressings from the arrival of the patient until chemical or surgical escharotomy is achieved, the dressings of excised zones, and the autograft. the care are to preserve the immobility of the autograft, to prevent local infection, to preserve the cutaneous capital by preventing points of pressure and friction, facilitating manipulations of the patient, and to diminish pain.

All burned victims immediately receive a shower and are shaved meticulously on arrival. We use a homograft polyvidone iodine as an antiseptic. First-degree burns are systematically left exposed to air as they heal spontaneously. Superficial burns benefit from the use of synthetic skin substitues such as Inerpan which diminishes pain immediately and also diminishes the burned surface area. The site of the burn sometimes requires the use of specific treatment, such as Biafine.

a) face burns

For second-degree burns, a mask of Vaseline and Elase is applied, covered by a single layer of Antiblotulle. For third-degree burns, Betatulle is applied.

b) posterior burns

Whatever their depth, they are treated by the open method with an Interface and/or sterile Metalline and fluidized bed.
The fluidized bed prevents pressure points and maceration of the lesions. The bed is filtered once weekly, or more frequently when necessary, to remove the agglomerations caused by the exsudate. The the same. agglomerations may hinder proper functioning of the bed. This is also protected by placing a Metalline between two bed sheets.

c) anterior zones

There are two approaches:

- semi-open dressings: with Betatulle for pain less and septic burns
- occlusive dressings: with topical grease and Antibiotulle for painful, septic burns and/or in the later stage.

The objective of the excision is to eliminate necrosis, to avoid primary and secondary infection, to favour the elaboration of healthy granulation tissue, and to prepare for re-covering the wound.
The semi-open method of dressing is chosen.
The dressings are changed every other day in the operating room.

The decision to apply an autograft depends on the state of the granulation tissue. The objectives of

a) The autograft "sandwich": an autograft under

This technique is reserved for the most severely burned patients. On the day of the operation, the autograft (expanded 1/6) and the adjacent homograft (expanded 111.5) are covered by an interface, a bandage or gauze only. It is worth noting that the homograft is sometimes used as a provisional cover for an excised zone. On the first and second day, the nurse cheeks the setting of the graft through the interface, which may be removed if any doubt exists. From the third day until complete healing, the nurse exposes the graft to air and disinfects it, carefully removing the clips and the crusts. The posterior zones, the back and the flanks are covered immediately, while the other zones are pulverised by Hexomedine and covered by an interface and bandage by the end of the afternoon.

b) The simple dermo-epidermal graft expanded 1/1.5 or 1/3 The surveillance and treatment protocols remain
c) The simple dermo-epidermal autograft This technique is reserved for the coverage of the fingers, hands and articular zones. The dressing protocols are also identical.
d) The full-thickness skin autograft

This is used for covering the face and neck. On the day of the operation, a compressive mask of Aquaplast is placed on the graft. From this day until the eighth day, the nurse ensures attentive surveillance of compression and disinfection, twice daily, through the mask. On the eighth day the mask is removed, the autograft disinfected, the crusts removed, and the graft exposed to air, and then re-covered by the end of the day.

e) The donor site of a simple dermo-epidermal graft

The donor site may be covered by a layer of tulle gras and impregnated with potassium permanganate, and disinfected twice daily with the same product. The nurse ensures a local check-up in order to detect any separation of the graft or maceration, and checks that epithelialization is taking place. Healing is spontaneous by the tenth day, or delayed if local infection exists. The use of synthetic skin substitutes (Inerpan) has improved the results of treatment of the donor sites. As soon as haemostasis is achieved (by applying warm humid gauze), Inerpan is applied and protects the donor site until spontaneous healing is achieved. There is no need to change the dressing. This also has the advantage of diminishing pain.

Nursing team-patient care relationship
The dressing is recorded in a technical protocol which shows our theoretical knowledge, competence, professional experience and care organization. Our analysis and permanent evaluation enables us to collaborate closely with the whole medical te4m. The heavy care load depends mainly on the type of dressing used. In spite of the fact that the care of these patients implies a laborious, physical and psychological effort by the nursing team, it also provides more motivation and gratification. Is this not a way to be considered, respected and recognized in performing our role of collaboration? Even if the care given to the patient is applied with the close collaboration of the entire team and even if we master the wound dressing protocol, the suffering of the burn victim remains, and preoccupies our role in management. How can we develop competence in this psychological matter?

RESUME. La cormaissance scientifique des conditions de guérison des 1ésions, de leur évolution et des complications permet 1'é1aboration de protocoles de pansements adaptables et évolutifs. Les auteurs consid&rent les pansements pour les grands brOlés, et la nécessité de la collaboration de toute 1'&quipe médicale et paramédicale