© Borgis - New Medicine 2/2014, s. 67-71
*Veronika Rajki1, 2, Henriett Hirdi1, Judit Mèszáros3
Specifics of the nursing care of patients undergoing skin grafting, particularly the aspects of transfusiology
1PhD student, Doctoral School, Semmelweis University, Budapest, Hungary
2Faculty of Health Sciences, Institute of Applied Health Sciences, Semmelweis University, Budapest, Hungary
Head of Faculty: prof. Zoltán Zsolt Nagy, PhD
3Semmelweis University Faculty of Health Sciences
Head of Faculty: prof. dr. Zoltan Nagy
Aim. The authors’ aim was to collect experiences and most recent knowledge in nursing of burned patients around skin transplantation and to compare them with former experiences and knowledge on the same hospital ward and also with the professional materials.
Material and methods. One of the authors spent some weeks in a County Teaching Hospital, in Western Hungary with the aim of collecting experiences about the recent nursing practice of burned patients before and after skin transplantation. We used documentation analysis, observation and evaluation of completed nursing tasks.
Results. The authors got a lot of information in connection with the local practical routine in the following themes: pain-killing after skin grafting, wound care after skin grafting, artificial feeding of the patients after skin transplantation, the indication and application of transfusion in the care of patients after burn, and other aspects of routine nursing care.
Conclusions. The authors found deficiencies in writing the nursing care plan. Our experiences prove that the quality of patients’ care is excellent but there are some deficiencies in recording the nursing care plan. In this hospital field the results of the medical and nursing activities among burned patients are excellent. The authors hope that this institute visit may improve the whole of the nursing education.
Annually lots of people are injured in burning in Hungary. Both adults and children are affected. Among 100 000 people there are approximatelly 1-1.5 fatal cases, 11-13 cases with hospital admission and 40-50 cases which need out-patient care if we see the statistical data of child injuries (data from 2005) (5.)
Children under 5 and adults over 65 years are mainly affected in this kind of injury. The causes of the burns frequency of these two age groups are the following: the possibility of their escape is limited and they can’t realize the danger properly.
In the whole population men are injured in burns more often (their ratio is 70%), but the mortality rate of women is the double of men’s.
Nowadays the care of burns with bigger surface is also successful as the result of the changes in the attitude towards burn care in the last 2.5 decades. Burn Centers have been established all around the world, and in Hungary as well, where the medical stuff are very well skilled in the care of burn injuries. Most of the Burn and Plastic Surgery Wards have already started their own intensive care departments for the care of the severely injured patients. The number of beds in these department amount to the 15-30% of the total number of hospital beds of the whole ward (5).
The incidence and the most frequent causes of the burn injuries among children and adults
1. Sunburn: There are no exact statistic data about its incidence, because only the severest cases of sunburn are cared by medical staff.
2. Scald: (60-70%). This is the most frequent type, the role of the parents and educational experts are very important in its prevention.
3. Flameburns: (15-20%). It’s a kind of severe burn injury after short contact with very high temperature. The burn of the respiartory tract is also accompanying with it. During the inhalation of the flame the respiratory tract is also injured just like the skin. In the case of flameburns of the face the eyes can also suffer.
4. Electrical burns: (2.5-3%). Externally the alteration is slight, but internally the necrosis of blood vessels, muscles, tendons, and bones can occur. Electric burn is an indication for surgery/skin grafting, sometimes care in ICU is necessary.
5. Contact burns: (2-5%). In childhood this type of burns is a very common form of injury at home after direct contact with a hot machine, a heater or other hot things. In the significant proportion of cases the damage is on the palms and soles of the feet, it often occurs in the form of deeply penetrating injury.
6. Chemical burns (1-2%). These are damage induced by acidic or alkaline agents. The surface of acidic burn injuries can slough quickly, the alkaline burn injuries penetrate increasingly deeper and deeper into the tissue owing to the affected tissue liquefaction. A corrosive substances in eyes can cause severe corneal injuries (5).
Before skin transplantation the selection of the donor place is needed. Semi-thick skin graft means: 0.25 to 0.5 mm or 0.55 to 0.75 mm, and full-thickness skin graft means: 0.8 to 1.1 mm. Free transposition of skin is applied. The highest risk of the freely transplanted skin is hematoma, this hinders revascularization. For its prevention the frequent perforation and sewing under the strain is recommended → the blood can flow through the dilated gaps.
Before incision lubrication of the donor area with vaseline is required. The lower surface of the blade should be lubricated with lubricant too. When simple skin piercing equipment is used, the area of donor skin must be stretched. The graft is placed onto the recipient location. Mesh-grafting: This is the procedure of Vandeput and Tanner from 1967. The skin graft is meshed with the Mesh graft dermatome, so the surface of the piece of skin can be enlarged threefold. The well prepared wound surface can be epithelialising within 7-15 days (1).
| ||Number of beds||ICU beds||Resp||Fluid||Physician (e.g. specialist)||Health care||ADM (1999)|
|ADM (2002) Tot/Bpts||OP (2002)|
|ADM (2003) Tot/Bpts||OP (2003)|
|Chief physician directing the department
|Szent István Hospital Dept. of Burn and Plastic Surgery||31||4||4||3||7 plastic surgeon|
+ 2 anaesthesiologists
|39||770/ 341||1435/ 443||942/ 392||1569/ 473||837/ 364||1659/ 394||839/ 338||1531/ 563||888/ 315||1747/ 437||Dr. GáMonbor Mèszáros (2001-)|
|Central Army Hospital, Dept of Burns||10||2||2||2||6 surgeons (3 plastic surgeons)|| ||155/|
|422/ 422||164||450/ 280||85||464/ 195||142||520/ 320|| || ||Dr. András Szűcs|
|Szent János Hospital, Burn Unit of the Dept. of Ped. Surg.||6||Avail.at Cent. ICU||Avail. At Cent. ICU||3 + 2 pneumatic||4 peg. surgeons (3 plastic surgeon. 1 resident)||9||X/ 64||X/ 143 + 145rec||X/ 85||X /145||X/ 93||X/ 160||X /53||X/ 94||X/57||X/154||Dr. Sándor Győri|
|Univ. of Pècs, Burn and Plast. Surg. Dept.||16||2 + Cent. ICU||Cent. ICU||2||5 surgeons (3 plastic surgeonr)||18||477/ 165||720/ 180||395/ 184||868/ 122||307/ 147||782/ 106||312/ 163||655/ 114||X/131||543/ 305|| |
|Petz A. Hosp. Győr Dept. of Burn and Plast Surg.||19||3||1||2||4 surgeons (2 plastic surgeons, 1 traumatol.)||26||314/ 228||842/ 303||335/ 234||737/ 316||401/ 232||858/ 354||366/ 227||1056/ 346||295/ 201||1104/ 276||Dr. Pèter Jakabos|
|Univ. of Szeged, Dept of Derm. Burn and Plastic Surgery Unit||20||1||1||1||4 plastic surgeons||18||743/ 76||685/ 107||827/ 80||817/ 105||823/ 59||3149/ 101||737/ 85||893/ 103||895/ 101||993/ 113||Dr. Klára Kapitány (1995-)|
|Univ of Debrecen, Dept of Derm. Burn and Derm. surgery Unit||28||4||1||2||2 surgeons (1 plastic surgeon) 1 int-anest, 1 surgeon in training for board exam||18||1187 /295||2120 /211||1352 /237||2294 /186||1455 /260||2420 /209||1395 /251||2299 /178||1356/ 209||2461/ 176||Dr. István Juhász|
|Miskolc,Dept. of Traumatology, Burn Unit||16||4||1||1||1 surgeon||9||101/ 80||216/ 83||189/ 102||172/ 148||197/ 132||178/ 151||173/ 115||181/ 151|| || ||Dr. Sarolta Tarr|
|Miskolc, Dept. of Pediatric, Surg. Burn Unit||8||Cent. ICU||Cent.ICU||0||1 plastic surgeon + rotation system ped. Surgeons + 3 surgeons in training for board exam||11||101 /80||71 /55||X/ 109||X/ 113||X/ 108||X/ 83||X/ 114||X/ 91||223/ 103||201/ 107||Dr. Rózsa Papp|
|Bethesda Hospital National Center for Children with Burn Inj.||6||4||4||1||2 surgeons (2 plastic surgeons)||9||The Department started its work in April 2002.||122/ 83||X/ 77||276/ 135||268/ 171||Dr. Éva Csorba|
Fig. 1. Presents the situation of burn centers in Hungary in 2004. These figures are reported by the respective departments.
Tot: Total number of patients/year; Bpts: patient with burn injuries; Adm: Number of Admission/year; Op: Number of operations/year
Knowing the nurse education, the themes of nursing research, and reading the nursing literature it can be stated that the discussion of skin transplantation from the aspect of its nursing care is undeservedly rare. Mainly the medical relations of burns are known and can be read about. That’s why we think that it is important to deal with this theme in order to improve the quality of higher level nursing education.
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