NURSING MANAGEMENT OF PATIENT WITH 45% 2nd & 3rd

DEGREE FLAME BURN

WE CARE

ON 5TH FEB 2016

AT 3:40 PM

Saud Al-Babtain Centre

The only specialized Burn
Centre in Kuwait
Intensive Care Burns Unit (ICBU) has a bed
capacity of 10.
Sophisticated Burn care equipment available
Highly specialized and trained Doctors
Highly specialized and trained Nurses

INTRODUCTION

Mr. H is a 15 year old male ,Syrian.

He belongs to a middle class family.
He is the 4th among the 6 children in the family
No significant past medical and surgical
history.
He is a student of class 9 addicted to heroin
from the age of 11.

MAIN GOALS IN MANAGEMENT OF

BURNS
Mr. H needs a comprehensive nursing
management for
Maintenance of patent airway.
Adequate fluid volume replacement.
Pain management.
Adequate nutritional support.
Early surgical excision and grafting.
Prevention of infection and associated
complications

Meticulous wound healing.

Psycho social support.

PHYSICAL EXAMINATION

GENERAL APPEARANCE
Well built.
Weight- 85kgs.
Height -170 cm
VITAL SIGNS ON ADMISSION
Temp: 34.6c
HR : 140 b/mt
BP : 78/46 mm of hg.
SPO2 : 100%

HEAD
TO TOE
ASSESSMENT
Head , Face
and Neck

Burns at the back of the

head.
Face had 2nd degree
superficial burn.
Facial edema present.
Eye lashes& eye brows were
burnt.
Had no corneal injury.
Bilateral pupillary reaction
was equal.
Singed nasal hairs present .
NG Tube present.
Ears were burnt.
He was intubated.

ASSESSMENT CONT.
Chest and Abdomen

Deep burn 2nd & 3rd degree

On ventilator bilateral air

entry equal.

On

auscultation crepitus &

ronchi were present

Had

copious purulent

secretions with carbonaceous

material(soots).

ASSESSMENT CONT.
Upper Limbs

Upper limbs had deep 2 burns.

There was 3 burn in some fingers in
distal metaphalanges of both hands.

Lower Limbs

Patches of 2nd degree burn.

Lt. femoral central line.
Rt.femoral arterial line.

ASSESSMENT CONT.
SYSTEM WISE EXAMINATION
Central Nervous System

On Sedations(Inj.Morphine,Inj.Dormicum)
Both Pupils were equally reacting to light.

Respiratory System

On ETT (Mechanical ventillation)

Bilaterally equal chest movement

Cardio Vascular System

Tachycardia HR 140-150/min
BP 78/46mm of Hg .

Gastro Intestinal System

Peristaltic & bowel sounds absent.

On NGT

Genito Urinary System.

On foleys catheter no.16.
High coloured urine output .2530ml/hr.

INTEGUMENTARY ASSESSMENT

Body Temp : 34.6 C

Head , Face & Neck 9%
Anterior Trunk 16%
Posterior Trunk 8%
Rt Upper Limb 4.5%
Lt Upper Limb 6%
Rt Leg %
Lt Leg 1%
Total BSA Burned: 45%

ASSESSMENT OF BURN
RULE OF NINE
LUND & BROWDER CHART

Anatomy of Skin

Functions of Skin
Provide a protective barrier against mechanical, chemical,
thermal and physical injury
Prevents loss of moisture
Reduces harmful effects of UV radiation
Acts as a sensory organ
Helps regulate temperature
An immune organ to detect infection
Production of Vitamin D

How Skin Burns.mp4

BODYS RESPONSE TO A BURN

LOCAL RESPONSE
Zone Of Coagulation
maximum damage
irreversible tissue loss

Zone Of Stasis
Decreased tissue perfusion
Potentially salvageable

Zone Of Hyperaemia
Outermost zone
Increased tissue perfusion
Tissues will invariably recover

SYSTEMIC RESPONSE

BURN INJURY
Normal permeability
of capillary

Increased Capillary
Permeability

Increased capillary
permeability
More fluid
and
antimicrobia
l chemicals

Monocyte
Capillary
wall

Small
amount of
fluid

Small
amount of
fluid

Exudate
Fluid
and
Electrolyte
s
Proteins

Capillary wall

More fluid

Interstitiu
m
Interstitial
spaces
Monocyte
squeezing
through
the
interstitial
space

MAJOR BURN
Increased Capillary
Permeability
Massive fluid, electrolyte & protein
shift from intravascular to
interstitial space
HyponatremiDecrease of circulatory
blood volume
H
yperkalemia
a
HYPOVOLEMIC SHOCK

Edema

Cardiovascular

Increased Capillary Permeability

Loss of intravascular proteins & fluid into the
interstitial compartment.
Peripheral and splanchnic Vasoconstriction
Decreased myocardial contractility
Decreased cardiac output
Systemic hypotension
Organ hypoperfusion

Respiratory

Inhalation injury
Airway obstruction
Broncho constriction
Acute Respiratory Distress Syndrome (ARDS)

Renal
Hemoglobin and myoglobin in
urine
Low renal perfusion
Acute renal failure

Gastrointestinal
Paralytic Ileus
Stress Ulcer
GI Bleeding

Immunological

Immunosuppression
Low immune response

Integumentary
Loss of skin barrier
Increased evaporative water
loss
Hypothermia
Tissue necrosis
Edema

INVESTIGATIONS
NORMAL
VALUES

1st day

2nd week

3rd week

4th week

Last
week

Hb

14-18g/dl

18.5

8.1

8.5

9.8

WBC

3.8-9.8
(10^9/L)

36.29

7.7

9.5

6.6

5.5

PLT

140-440
(10^9/L)

421

132

390

266

568

Na+

134-151
mmol/L

132

142

139

152

138

K+

3.6-5.2
mmol/L

5.6

3.9

5.7

3.5

4.7

UREA

2.5-6.4
mmol/L

4.5

6.9

6.4

5.4

CREAT

15-115
mmol/L

59

59

110

39

45

BILIRUBIN

0-17 umol/

24

18

26

25

ALBUMIN

34-50 g/L

13.6

25

19

26

36

PROTEIN

64-82g/L

41

44

41

46

48

CULTURES
DATE

CULTURE

GROWTH

6. 2.16

BAL c/s

Rhinovirus

10.2.16

wound swab c/s

Face,Lt.leg,Rt.leg

Acinetobacter
baumanii,Pseudomona
s aeruginosa

14.2.16

Blood c/s

Acinetobacter
baumanii
Staphylococcus
haemolyticus ,
Klebsiella pneumonia.

19.2.16

ETT Sec c/s

Acinetobacter
baumanii,
Pseudomonas,
Candida albicans.

22.2.16

Wound swab c/s

Lt.Hand

Acinetobacter
baumanii

MEDICAL & SURGICAL

MANAGEMENT

AIRWAY MANAGEMENT:
Early intubation( was
intubated & on mechanical
ventillation)
CXRs,ABGs,frequent
assessments
Fibroptic Bronchoscopy(was
done on 5/2 &6/2) to suck
out soots
Chest physiotherapy &
suctioning

FLUID RESUSCITATION

Large bore IV cannulas /

central line insertion

Mr.H
LR only
Calculate hours from time of
(Crystalloids)
injury not the time of
admission

received

4ml8545%TSBA =15,300 ml
in24hrs
1st 8hrs received 7,650ml
(from Adan Hosp 3000ml
+4650ml in ICBU )
Next 16hrs received
7,650ml

CIRCULATORY CARE

Check for circulatory impairment in case of

circumferential burn
Escharotomy if necessary
Insertion of Arterial line
- invasive BP monitoring
- ABGs
-monitor cardiac output
Blood investigations like cbc, biochemistry
profile, Coag.profile, ABGs, blood grouping &
cross matching
Continous monitoring of vital signs.
Base line ECG
Watch for :
cardiac overload( diuretics)
Hypotension (Inotrops was
on Inj.Levophed & Dopamine)
Hypovolemia( fluid bolus
depends on CVP,BP,U.O.P)

RENAL CARE

Insertion of foleys
catheter (had foleys cath
no.14)
Monitor urine output
hourly
Expected urine output is
0.5ml/kg/hr
Watch for
haematuria
oliguria (had urine
output 25-30ml)
Fluid bolus.

GI/NUTRITIONAL CARE
Insert

NG tube (with NGT no:14)

NPO if distented abdomen &
connect to free drainage
Start early feeding with clear fluids
& then adjust as per tolerance
Start with prophylactic Antacids to
prevent stress ulcers( was on
inj.Losec 40mg bd)
Weight checking
Blood sugar checking & administer
Insulin for hyperglycemia( was Blood
sugar checking q6h. on sliding
scale )
Assess for constipation administer
laxatives
Stool for occult blood if drop in Hb,to
R/O gastric bleeding

SKIN AND WOUND CARE

Check

the Body temperature

Watch for Hypothermia
Cover with warm blankets
Administer warm iv fluids

Keep the room warm

Use warm saline

Clean & gently remove the burnt
skin
Escharatomy in case of
circumferential burn
Dress the wound immediately with
appropriate ointments & dressing
material as per Doctor advice
Elevate burned extremities
Head /Neck no pillows. Use only
rolled towels.
Administer sedations & round o clock
analgesics as per Doctors order
Inj.T

T upon admission

DRUG THERAPY

ANALGESICS &
SEDATIONS

Inj. Morphine 3-5 mg/hr

Inj. Remifentanyl 200-400mcg/hr
Inj. Dormicum 3-5 mg/hr
Inj. Pethidine 50-100mg
Inj. Ketamine 50mg
Inj. Propofol 50-80mg/hr
Inj. Adol 1gm PRN
Nurses
responsibilities - Assess the

following:pulse, blood pressure, and cardiac

functionCNS; orientation, affect, reflexes,Pupil
size;Respiration and adventitious sounds;Bowel
sounds and reported output;Bladder palpation
and voiding pattern.Check liver and renal
function tests

DRUG THERAPY Cont

ANTIBIOTICS & ANTIFUNGAL

Inj.
Inj.
Inj.
Inj.
Inj.

Teicoplanin 400mg OD 21 days

Meronem 1gm Q8h 14 days
Colistin 1 MIU Q8h 21 days
Fortum 1GM BD 8 days
Caspofungin 50MG OD 7 days

Nurses responsibilities - Monitor vital signs and

symptoms of infection to determine antibacterial
effectiveness, Monitor for hypersensitivity reaction,
culture and sensitivity before starting therapy ,
Administer drug around the clock, encourage
fluids ,monitor renal function hepatic function and
hearing

DRUG THERAPY Cont

OTHER MEDICATIONS
Inj.Losec(antacid prophylaxis)
Inj.Clexane(VTE prophylaxis)
Eye medications oint. Duratears, Gtts.
Optifresh, oint. Maxitrol (prevents corneal
ulcers, for eye lubrication)
Nebulisations Ventolin, Atrovent, Pulmicort,
Acetylcysteine (bronchodilators, to loosen
the secretions)

WOUND MANAGEMENT

ESCHARATOMY
DRESSING
DEBRIDEMENT & BRUSHING
SKIN GRAFTING

ESCHAROTOMY
To release the tension & maintain adequate
circulation in deep circumferential burns. Was
done on admission
Rt. UPPER LIMB

DIATHERMY MACHINE

CARE AFTER ESCHAROTOMY

Elevate the escharotomy site

Check for 5 Ps
-Pain
-Pallor
-Pulselessness
-Paraesthesia
-Paralysis.
Watch for bleeding.Inform surgeon in case of bleeding
- Compressive dressing
- Cauterization
- Surgical ligation

DRESSING MATERIALS USED

HOMO GRAFT

Homograft-skin graft
obtained from living
persons or cadavers
Temporary covering for
extensive burns
To protect granulation
tissues
Control bacterial
growth
Homograft done on
15/2 &18/2

DEBRIDEMENT &
BRUSHING
DEBRIDEMENT - Removal
of dead tissues & slough
to achieve timely wound
healing

Debridement and
Brushing for 10 days
from 22/2/16 to 8/3/16
until the wound is clean
& ready for skin graft.

WOUND AFTER BRUSHING &

VaccumAssisted Closure
Therapy ( VAC )
It is a therapeutic technique
using a vacuum dressing to
promote healing in acute or
chronic wounds.

VAC THERAPY

SKIN GRAFTING cont

Autograft- a skin graft from another part
of the patients own skin.

STSG VIDEO CLIP

STSG Video.avi

CARE AFTER SKIN GRAFT

Elevation of grafted area

Immobilization with P.O.P slab
Inspection of the grafted area for
circulation & bleeding
First post op dressing within 2 - 5days

Remove the overlying dressing with care

Clip removal on 7th post op day

CARE OF DONOR SITE

Compressive dressing with silvercel/

mepilexAg /paraffin gauze.
Watch for bleeding.
Use of fluidized bed if donor site is back.
Dressing can be changed after 4-7 days.
Do not remove the dressing. Leave it, till
dry.
Apply liquid paraffin & keep it uncovered.

SKIN GRAFTING
Lt. hand before skin
graft

Lt. hand after skin

graft.

5 DAYS AFTER SKIN GRAFT

CLIP REMOVAL

SURGICAL TREATMENT AND

DRESSINGS
1. Homograft Lt. hand,
chest, abdomen, Rt.flank
2. Homograft chest and
abdomen
3. Debridement and
Brushing

15.2.16
18.2.16
22/2,23/2,25/2,28/2,
29/2,3/3,6/3,8/3

4. Split Thickness Skin

Graft both hands
5. Debridement &STSG
Chest and abdomen

9.3.16

17.3.16

AFTER 20th DAY OF SUCESSFUL

LAST SKIN GRAFT

NURSING MANAGEMENT

ROLE OF BURN NURSES

Burn nurse is the co-ordinator of all

patient care activities.
Should possess a broad based knowledge
in multisystem organ failure .
Burn nurse is a specialist in wound
dressing.
He is responsible for noting subtle
changes in wound or grafts to prevent
infection.
Main focus is pain control and aseptic
wound care.

B-Breathing

[Airway
[Airway

Obstruction ]]
Obstruction

U-Urinary output

[0.5
[0.5

1.5ml/ kg/hr]
kg/hr]
1.5ml/

R-Resuscitation with
fluid

Curreri
N-Nutrition [[ Curreri
Sutherland formula]
formula]
Sutherland

S- Sepsis

&
&

NUTRITION
CURRERI FORMULA FOR CALORIE
25kcalwt(kg) +40kcal %BSA
Mr.H
25kcal85kg+40kal45%
3900kcal/day

SUTHERLAND FORMULA FOR PROTEIN

1gmwt(kg) +3gm %BSA
Mr.H
1gm85kg+3gm45%
220gm/day

POSITIONING OF BURN PATIENT

Aim: To prevent contracture.

Head and neck: Extended (no pillow)
Hand : Elevation and apply splint in
functional position.
Axilla : Abducted.
Knee : Extended.
Foot : Dorsiflexed with foot support.

NURSING CARE PLAN-1

ASSESSMENT
Assessed on: 05/02/16
Objective Data:
Presence of soot .Singe nasal hairs, Mucous edema, Deep burn of
neck& thorax.
On Ventilator
MODE - SIMV-VC
FiO2 50% ,TV-500 , RR-12 , PEEP-5 , PS-10
ABG RESULT Respiratory Acidosis
PH- 7.289, PCo2- 6.69, pO2- 11.39, HCO3- 23.6,SPO2-95%
Wheezing and crackle sounds were present on auscultation

NURSING CARE PLAN-1(continues)

DIAGNOSI
S

GOAL

Ineffective
airway
clearance
related to
inhalation
injury and
full
thickness
burn on the
neck and
chest.

1. Patient
will
maintain
normal
respirator
y function
.
2. Patient
will be
free from
soot.

INTERVENTION
1. Assess breath sounds,
rate, rhythm and depth
of respiration.
2. Monitor serial ABG ,
Pulse oximetry and
serial Chest X-Ray.
3. Elevate the head of bed
to 45.
4. Initiate frequent chest
physiotherapy and
suctioning
5. Assist in bronchoscopy
and bronchial lavage.
6. Administer nebulization
as advised by
physician .

RATIONALE
1. Evaluate respiratory
status and for
further medical
intervention.

EVALUATION

2. Assess oxygenation
and ventilation

Goals 1 & 2
were met.
Patient
maintained
normal
respiratory
function & was
free from soot .

3. Promote optimal
lung expansion.

Extubated on
11/2/16

4. Helps maintaining
clear airway, sterile
technique reduces
risk of infection.
5. It helps to assess
the extent of lung
injury and wash out
the soot.
6. Helps loosen the
secretion and dilate
bronchi.

NURSING CARE PLAN-2

ASSESSMENT
Assessed on :05/02/16
Objective Data
Hypothermia
Temperature 34. 6C
Shivering.

NURSING CARE PLAN-2(continues)

DIAGNOSIS

GOAL

NTERVENTION

RATIONALE

EVALUATION

Impaired
thermoregula
tion related
to skin
damage.

Patient will
maintain
normal
body
temperatur
e.

1.

Assess the core body

temperature

1.

Evaluate body
temperature status

Goal was met .

2.

Maintain warm
environment by using
room heater and warm
blankets.

2.

Warm environment
helps to maintain
patient body
temperature.

3.

Use warm saline to clean

the wound .

3.

Prevents the patient

from shivering.

4.

Cover the body surface

expect the area being
dressed.

4.

Helps to prevent
temperature loss
from the body.

5.

Rapid dressing of the

exposed areas.

5.

Helps to minimize
the heat loss from
the wound.

6.

Give IV fluids through fluid

warmer.

6.

7.

Keep the nasal

temperature probe

Warm iv fluids
increases the
internal body
temperature.

7.

Aids in close
monitoring of
temperature.

Patient gained
normal body
temperature
after 2nd day of
admission.

NURSING CARE PLAN-3

ASSESSMENT
Assessed On :- 05/02/16
Objective Data:
Concentrated urine
Increased serous fluid oozing from the wound
Weak peripheral pulse
Reduce CVP -3 cm of h2o

NURSING CARE PLAN-3(continues)

DIAGNOSIS

GOAL

INTERVENTION

Deficient fluid
volume secondary
to fluid shifts into
the interstitium
and evaporative
loss of fluids from
the injured skin.

Patient will
achieve improved
fluid volume
balance and
adequate urinary
output with
normal specific
gravity .

1. Monitor vital
signs, CVP and
strength of
peripheral
pulses.
2. Monitor urine
output hourly
and its color,
maintain strict
I/O chart.
3. Weighing daily
without
dressing.
4. Estimate
wound
drainage
5. Monitor lab
studies CBC,
Electrolytes,
Urea,
Creatinine,
Random urine
Sodium etc.
6. Administer
calculated IV
replacement of
fluids,
electrolytes,

RATIONALE
1. Serves as a
guide to fluid
replacement
needs and
access
cardiovascular
response.
2. Evaluate fluid
loss and
replacement.
3. Accuracy of
value.
4. Guides fluid
replacement
needs.
5. Evaluate need
for fluid and
electrolyte
replacement .
6. Helps to
prevent
complications
like shock,
acute kidney
injury.

EVALUATION
Goal was met.
Patient achieved
normal fluid
volume balance
and adequate
urinary output
with normal
specific gravity .

NURSING CARE PLAN-4

ASSESSMENT
Assessed On :- 11/02/16
Subjective Data:
Patient complained about pain.
Objective Data:
Pain- 10 on Pain Rating.
Restlessness, facial mask of pain.

NURSING CARE PLAN- 4(continues)

DIAGNOSIS

Acute pain
related to
burn
trauma .

GOAL

Patient will
verbalize
improved
comfort
level .

INTERVENTION

1.

Monitor physiological
responses to pain
such as increased BP
increased HR, and
restlessness.

2.

Medicate patient
before dressing
changes and major
procedures as
needed.

3.

Explain procedures
and provide frequent
information as
appropriate,
especially during
wound debridement.

4.

Use non
pharmacological pain
reducing methods as
appropriate.

RATIONALE

EVALUATION

1.

Pain responses
variable are unique
each patients.

2.

Reduces severe
physical and
emotional distress
associated with
dressing changes
and debridement.

Goal was met.

Patient
verbalized
pain is
controlled and
displayed
relaxed facial
expressions.

3.

Helps to alleviate
pain, promote
relaxation, prepare
self and enhances
sense of control.

4.

Reduce need for

narcotics.

NURSING CARE PLAN-5

ASSESSMENT
Assessed On :- 10/02/016
Objective Data:
Burn on chest , neck, face, both hands and legs.
Skin grafting- both hands, Homo grafting on left arm,
chest & right flank.
Temperature is 40 C
Heart Rate is 155 b/min
PCT : 27( normal value 0.5 )
10/2/201 Wound swab
Acinetobacter
6
c/s
baumanii
face,Lt.Leg,
Pseudomonas
Rt.Leg
Aeruginosa
22/2/2016 Wound swab c/s
Lt. Hand

Acinetobacter baumanii

NURSING CARE PLAN-5(continues)

DIAGNOSIS

GOAL

INTERVENTION

RATIONALE

EVALUATION

Sepsis related
to
severe
infection
secondary
to
loss of skin,
impaired
immune
response and
invasive
therapies.

Patient will be
free from
infection ,
purulent
exudates and

1. Monitor vital signs for

fever, increase
respiratory rate.
2. Draw blood samples for
CBC, PCT and C/S twice
weekly or as indicated.
3. Examine wounds daily,
note and document
changes in appearance
and odor.
4. Photograph wound daily
and at periodic intervals.
5. Cleans burned areas
with Hibiscrub and saline
daily aseptically.
6. Debridement of necrotic
tissues by brushing and
use Hydrogen Peroxide
as indicated using sterile
techniques.
7. Administer topical
agents or IV as
indicated.

1. Indicators of
sepsis.

Goal was met.

Sepsis was
resolved with
proper wound
care &
antibiotic
therapy
Patient
achieved
timely wound
healing, free
from purulent
exudates and
afebrile.

a febrile.

8. Use gown, gloves, mask

and strict aseptic
technique during direct
wound care.
9. Implement contact
isolation techniques.

2. To have baseline
data and may
indicate choice of
next steps of
treatment
3. Indicators of
sepsis.
4. Documentation of
healing process.
5. Promotes healing.
6. Promotes healing,
prevents autocontamination.
7. Antibiotics help to
control bacterial
growth and to
prevent drying of
wound which can
cause further
tissue destruction.
8. Prevents exposure
to infectious
organisms.
9. Reduce risk of

NURSING CARE PLAN-6

ASSESSMENT
Assessed On :- 16/02/16
Objective Data:
Loss of muscle mass and subcutaneous fat.
Restricted oral intake.
Serum Albumin level 18.2
Serum protein level - 58
Decrease in total body weight.
- On admission - 85 kg.
- After 4 weeks 61 kg.

NURSING CARE PLAN-6(continues)

DIAGNOSIS

GOAL

INTERVENTION

RATIONALE

EVALUATION

Imbalanced
nutrition less
than body
requirements
related to
paralytic ileus
and metabolic
demands
secondary to
physiological
stress and
wound healing.

Patient will
achieve
nutritional
intake
adequate to
meet metabolic
needs with
normal serum
albumin and
protein levels.

1. Assess abdomen
and bowel sounds.

1.

Evaluate
resolution of
decreased
gastric mobility.

2.

Facilitate early
detection of
development G
I ulcer

3.

Prevent stress
ulcer
development.

Goal was partially

met. Patients
nutritional status
slightly improved
with ALBUMIN
being in normal
range. His
PROTEIN level
was in low range
and his glucose
level remained
high.

4.

Calorie and
protein should
be adequate
to promote
healing.

5.

Helps to
calculate
according to
the need of the
patient.

6.

Assess
tolerance and
response to
feeding
interventons.

2. Assess NGT
aspiration for
colour and
quantity.

3.

Administer stress
ulcer prophylaxis

4. Initiate enteral
feeding and
evaluate tolerance.
5. Refer to dietician
to plan a protein
and calorie rich
diet
6.Monitor weight
daily.

Body wt.70kg.

LATE COMPLICATIONS

Disfigurement due to scars and keloids.

Contracture of the joints.
Chronic ulcers.
Psychological upset

PROGNOSIS

Even with advances in burn care over

recent decades the mortality remains
high among severely burned patients.
Wound sepsis and pneumonia are the
major causes of increased death.

DURING TREATMENT

AT PRESENT..

CONCLUSION
Call it medical technology or call it
triumph of human spirit, Mr H is a true
burn survivor not a burn victim. By 20
March 2016 (after 45 days) his long ordeal
was finally over and surgeons concluded,
his acute recovery was complete and can
be shifted to ward. The team work of
treating surgeons, highly skilled nurses
and therapists not only saved his life, but
restored his quality of life to some extent.

REFERENCES

1.Stander M, Wallis LA ; The emergency management and treatment of

severe burns. Emerg Med Int. 2011;2011:161375. Epub 2011 Sep 4.

2.Journal of Burn Care & Research:March/April

2013 - Volume 34 - Issue - p S1S63

3.Ahrns-Klas K. Burns. In: Sole M, Klein D, Moseley M,

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4.Doenges M, Moorhouse M, Murr A.In: Nursing Diagnosis Manual:

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thank u
Achieving success through integrity and
teamwork.

Achieving success
through integrity
and teamwork.

WE ARE PROUD TO BE BURN

NURSES