UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES
MEDICAL CENTER

PROCEDURE

 PROCEDURE:
   135
EFFECTIVE:
  8/87
REVISION:
  1/03
APPROVED:
  4/05

PROCEDURE FOR BURN WOUND DRESSING AND SKIN GRAFT DRESSINGS ON BURNS

PURPOSE: (BURN WOUND DRESSING) To provide optimum burn wound care promoting wound healing with minimal complications, i.e., conversion from partial thickness wound to full thickness wound, contractions or wound sepsis.

PURPOSE: (SKIN GRAFT DRESSING) To provide optimum care of the autograft to facilitate wound closure. Proper graft care will decrease possibility of scarring and contractures.

EQUIPMENT:

  1. 2B Burn Pack:
    4 sterile bath towels
    2 sterile instrument packs
    100 sterile all-cotton 4x4 gauze sponges
    1 large sterile sheet
  2. Sterile bowl
  3. Brunswick Burn Dressing
    (Brunswick 36" x 36" for legs and trunk.
    Brunswick 18" x 36" for arms, thighs, and smaller wounds)
  4. Kerlix
  5. Sterile gloves
  6. 2" paper tape
  7. 60 cc sterile syringe (Toomey)
  8. Warmed irrigating saline
  9. Sterile table cover (converter)
  10. Large dressing scissors
BURN WOUND DRESSING SKIN GRAFT DRESSING ON BURNS
  1. Rough mesh gauze (when indicated)
  2. Fine mesh gauze (when indicated)
  3. Topical medication ordered
  1. 1 roll fine mesh gauze
  2. Cotton tip applicators
  3. Tribiotic solution as ordered by M.D.

NURSING ACTION:

PROCEDURE STEPS:

  1. Medicate client for discomfort as per physicIan’s order.
  2. Wash hands thoroughly. (Refer to Infection Control Manual - Handwashing.)
  3. Ensure warm environment to client’s comfort.
  4. Following sterile technique, prepare the equipment.

 

KEYPOINT: Burn dressing field should be set up with all needed equipment and dressings to facilitate the procedure.
  1. Open Burn Pack, maintaining sterility and utilizing wrapper as sterile drape for field.
  2. Place sterile bowl on field.
  3. Place other needed dressings, i.e., Brunswick dressings on field.
  4. Apply sterile gloves and arrange sterile dressings on field for easy access.
  5. Sterile sheet in pack is used to drape sterile dressing field.
  6. Cover O.R. table with sheet, then place electronic scale sling on table.
  7. Cover scale sling with sterile convertor (sterile table cover).
  8. Place warmed sterile irrigating saline and client’s ordered topical medication (Silvadene, Mycitracin, burn cream, Tribiotic) on small dressing tray.
  1. Escort client to burn dressing room.

KEYPOINT: Transport by stretcher or wheelchair. If the client has been skin grafted below the waist, do not ambulate for 5 days. Be alert not to apply pressure to grafts when assisting to move.

  1. Removing dressing.

BURN WOUND

STSG
KEY POINT: Client may remain on stretcher or wheelchair, or may stand. KEY POINT: Be alert to location of STSG to avoid holding or scooting on these areas.
  1. Apply non-sterile gloves and isolation gown. Cover hair with hat and apply shoe covers.
  2. Cut off outer dressing with blunt scissors.
  3. Remove outer dressing and discard.
  4. Apply sterile gloves.
  5. Assist client to O.R. table (see Keypoints above).
  1. Weigh daily using kilogram scale. Record weight.

KEY POINT: To ensure accurate weight, always balance scale first.

BURN WOUND

STSG
    1. Remove all dressing prior to weighing.
  1. Remove only outer dressing prior to weighing.
  1. Remove inner dressing and discard.
  1. First day post skin graft:
    2.
  1. Remove dressing down to the fine mesh over STSG.
    2.

KEY POINT: Warm saline may be used to soak dressings that are adhered to the wound to avoid excessive discomfort, bleeding, or damage to granulating tissue.

 

 

 

 

 

 

 
  1. Change sterile gloves.
  2. Soak 4x4 gauze in tribiotic solution
  3. Observe STSG closely for any excessive drainage, odor, and slippage of skin graft or fine mesh.
  4. Apply tribiotic soaked fine mesh to any exposed graft.
  5. Apply tribiotic soaked 4x8 cotton gauze over fine mesh. Squeeze 4x8 gauze so they aren’t dripping wet.
  6. Apply dry 4x8 over tribiotic soaked gauze.
  7. Cover wounds with sterile bulky dressing of Brunswick gauze.
  8. Secure dressing with Kerlix ensuring that movement or circulation is not affected.
  9. Secure ends of Kerlix with paper tape.

KEY POINT: Do not tape an extremity circumferentially as it may act as a tourniquet.

  1. Prepare for application of sterile dressing.
  1. Remove contaminated gloves.
  2. Uncover sterile dressing field, pour sterile saline into sterile bowl.

KEY POINT: Be careful not to splash or spill saline on sterile field.

  1. Open topical medications as ordered. Pour aqueous solution into bowl.
  2. Change isolation gown, hands, and apply sterile gloves.
  1. Apply sterile burn wound dressing.
  1. Wash wounds with sterile saline soaked 4x4’s. Wash from cleaner to contaminated areas.

KEY POINT: Use separate bowl of saline for clean and contaminated areas.

  1. Gentle cleansing should be done on face and granulation tissue. Slight pressure may be used when cleaning eschar and areas needing debridement.

KEY POINT: Cleaning of wound should not be done so vigorously as to cause excessive bleeding. Be sure to cleanse between fingers, toes, and skin folds.

  1. Apply saline soaked 4x4’s to wounds on face to soak throughout dressing change.

KEY POINT: The face is very vascular; soaking exudate and eschar will reduce bleeding and discomfort. Ensure saline use is uncontaminated from remainder of burn wound.

  1. Debride any blisters or loose necrotic tissue gently.
    2.

KEY POINT: Be aware to change gloves after washing contaminated areas, especially buttocks and genital area.

  1. Change sterile gloves after washing contaminated area.

KEY POINT: Be alert not to transfer bacteria from one area of burn wound to another.

  1. Observe wounds closely for changes, i.e., infection.

KEY POINT: Observe wounds for signs of infection, i.e., excessive drainage, color of wound and drainage, odor, sloughing of grafts, and cellulitis. Observe for eparation of eschar, granulation tissue and conversion of wound to full thickness.

  1. Wearing sterile gloves, assist with active and passive

KEY POINT: Range of Motion Exercises.R.O.M. should not be done to joints with unstable skin grafts. Special attention should be taken for neck, elbow, and hand R.O.M.

  1. Change sterile gloves and apply topical medication.

KEY POINT: When using Silvadene, apply generously, approximately 1/4 inch thick. Do not apply Silvadene near ear canal or close to eyes.

  1. Place dry sterile 4x4 gauze over wound after applying medication. Gauze is to be placed ensuring two burn surfaces do not touch (i.e., gauze between toes, fingers).

KEY POINT: Rough mesh gauze can be used on wounds needing debridement. Fine mesh gauze is used on granulation tissue.

  1. Cover with a sterile bulky dressing of Brunswick gauze.
  1. Secure dressing with Kerlix, ensuring movement or circulation is not affected.

KEY POINT: Fingers should be wrapped separately to assist with R.O.M. Dermonet may be used to secure finger dressings.

  1. Tape ends of Kerlix dressings with paper tape.

KEY POINT: Do not tape on extremity circumferentially as it may reduce blood flow and cause devitalization of tissue.

  1. Ace bandages are to be applied to affected legs over bulky dressing.

KEY POINT: External support will assist in reducing venous stasis and bleeding. Wrap from toes to above knees.

 9.
  1. Follow above outlined procedure 1 through 6.
  2. Remove dressing down to fine mesh over STSG.
  3. Change sterile gloves.
  4. Fill sterile syringe with sterile saline.
  5. Gently irrigate fine mesh with saline.
  6. Using cotton tipped applicator for counter traction, gently remove fine mesh gauze from STSG.

KEY POINT: Continue to apply saline to fine mesh where it is adhered to graft.  

  1. Observe STSG closely for signs of infection or slippage of graft.

KEY POINT: Moistened sterile applicator may be used to gently replace slipped graft.

  1. Change sterile gloves.
  2. Apply tribiotic soaked fine mesh smoothly over STSG.
  3. Apply tribiotic soaked 4x8 cotton gauze over fine mesh.

KEY POINT: Squeeze 4x8 gauze so they aren’t dripping wet.

  1. Apply dry 4x8 gauze over tribiotic soaked gauze.
  2. Cover wounds with sterile bulky dressing of Brunswick gauze.
  3. Secure dressing with kerlix ensuring that movement or circulation is not affected.
  4. Secure ends of Kerlix with paper tape.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REFERENCES:

Sheridan, RL. Evaluating and managing burn wounds. Dermatology Nursing. 12(1): 17-8, 21-8, quiz 30-1, 2000 Feb.

Richard R. Assessment and diagnosis of burn wounds. Advances in Wound Care. 12(9): 468-70, 1999 Nov-Dec.

Atkins S. Burns assessment and initial management. Nursing Times, 95(35): 46-8, 1999 Sep 1-7.

RESOURCE PERSON(S):  Joyce Randof, RN, MNSc, BC

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