Patient Bathing, Burn Wound Care, Topical Agents
Source: Shriners Hospital for Children; Shriners Burns Hospital—Cincinnati; Departmental Policy; Revised: 10/97
Policy: Bathing the patient helps to increase circulation, promote relaxation, provide a general stimulus, and aid in the wound healing process. The outcome of burn wound treatments depends upon the skillful and appropriate use of different dressing techniques and topical agents. Dressing routines should be modified to meet the condition of the burn wound.
Responsibility: Registered Nurse, Licensed Practical Nurse, Nursing Technician, Patient Care Assistants
General Guidelines for Patient Bathing
1. Explain bath/dressing change procedures to the patient and his or her family prior to beginning.
2. In collaboration with the physician, evaluate the need for the patient to receive pain medication prior to bathing and dressing change.
3. Allow the patient as much privacy as possible during the procedure.
4. Prevent chilling by covering the patient with a sheet or blanket until the dressing can be applied.
5. Encourage the parent/guardian/significant other to remain in the room if this person can be emotionally supportive to the patient.
6. Gown, gloves, cap, mask, and eye protection must be worn during the bath/dressing change procedure if the patient has open wounds. Long gloves are to be worn when bathing the patient in the bathtub.
7. Assist the patient into and out of the bathtub.
8. Avoid ecchymosis of lower extremity grafts or donor sites. Minimize unsupported dependent positioning of the lower extremities when removing dressings or ambulating the patient to the tub.
Procedure for Patient Bathing/Dressing Change Bathing/dressing at bedside:
1. Set up clean field with sterile drape, two sterile basins, and dressing supplies.
2. Fill one basin with Hibiclens and sterile water, and the other basin with sterile water.
3. Ensure clean lines, washcloths, and chux are at the bedside.
4. Remove dressings. To prevent chilling, bathe one area at a time.
5. Using washcloths, wash the burned areas with the Hibiclens and water mixture. Rinse with plain water using a clean washcloth. Use a clean washcloth for each area of the body.
6. Wash unburned areas using this same method.
7. Ensure all topical medications are completely removed prior to applying new agents.
8. Apply new topical medications/moisturizers and dressings according to physician’s orders and/or guidelines.
Bathing in the bathtub
1. Set up the dressing tray with necessary dressing supplies.
2. If this is the first patient to use the tub, flush the faucet for 2 to 3 minutes (hot and cold) and spray/shower hose to remove bacteria.
3. Set up tub.
4. Prepare the tub using one-third to one-half bottle of Hibiclens and fill with the desired level of water. The desired temperature of the water should be 100-102°F.
5. Remove outer dressings prior to entering the tub. Attempt to remove all Adaptic as well.
6. Adhered Adaptic may soak off but be sure to remove all pieces from the tub prior to draining the tub to prevent clogging of the drain.
7. To prevent contamination, do not immerse directly in the water any extremity or part of the body that has an IV.
8. Wash all areas of the patient using a clean washcloth for each area of the patient’s body.
9. The patient should remain in the tub for no longer than 7-10 minutes during the first tubbing following grafting, and no longer than 20 minutes thereafter.
10. Apply topical medications and dressings according to physician’s orders and/or guidelines.
CIS Documentation
1. Complete the "Pat Man" section of the flowsheet (documentation component of the computer information system pertaining to dressing changes).
2. Medication for dressing changes can be entered under the "treatment" section of the flowsheet and a "note" can be entered to indicate the patient’s response to the dressing change under the "patient outcome" section.
Acute Nursing Care
1. Patient and family are instructed prior to any procedures.
2. Cover gown or apron, cap, mask, eye protection, and gloves must be worn for all procedures involving open wounds.
Procedure for burn wound care
Contaminated supplies/materials are discarded in the appropriate containers. Dressings are changed bid-tid depending on the topical agent used.
1. Burns
a. Superficial—Bacitracin may be applied for comfort or the wound left open to air.
b. Partial thickness—If blisters are present, they are debrided. Bacitracin Dan Adaptic is applied and wrapped with Kerlix or Kling. Change bid.
c. Full thickness—Eschar is placed in Silver Sulfadiazine and wrapped with burn dressing and bulky bandage. Change bid or tid.
2. Grafts
The physician applies Autografts in the Operating Room. The autograft is harvested from a donor site and is processed (meshed) if applicable, then placed on the excised area and stapled in place. The newly grafted area may either be placed in a "dry dressing" if small spots, in a wet stent, or "wet dressing."
a. Dry dressings are to be kept dry. Assess for odor, drainage or redness around the dressing.
b. Wet dressings—are applied by the Operating Room team. Fine mesh gauze (FMG) is applied, followed by wet burn dressings, red rubber catheters, more wet burn dressings, secured with bulky bandage. Lastly, splints and ace wraps are applied. Small graft dressings or simple dressings may be secured with spandex and staples. (See Application of Wet Dressings.)
1) Wet the dressings every two hours with DAB. DAB alternating with Sulfamylon, or Hibiclens solution as ordered, by using the red rubber catheters and an irrigating syringe. An appropriate amount for the site is used.
2) "Wet dressings" are usually changed on post operative day (POD) #1 for sheet grafts, POD #2 for mesh grafts, POD #5 for acute patients, and POD #1 and POD #5 for rehab patients. If Ketamine will be used for these dressing changes, refer to policy.
3) On POD #1 and POD #2, the grafted sites are placed back in a "wet dressing."
4) In the morning prior to POD #5 dressing change, grafted areas should be irrigated with Hibiclens solution to enhance removal of the fine mesh gauze from the graft during the dressing change. On POD #5, the grafted areas are placed in a dry dressing. Mesh grafts may be placed back in wet dressings per physician discretion. The topical agent to be used with the dry dressing will be ordered by the physician. Change BID. In general, patients that were in DAB or Hibiclens soaks will be placed in a Bacitracin/Adaptic dry dressing. Patients that were in a DAB alternating with Sulfamylon soak, or who have Psuedomonas recovered from the graft sites will be placed in a Bacitracin/Silver Sulfadiazine 3:1 mix and dry dressings. Autografts, which are meshed 4:1, will remain in wet soaks beyond POD #5 (change daily) to allow the interstices to close. Monitor progress daily and consult with the attending physician to determine the appropriate time point to change to "dry dressings."
c. On POD #5, the grafted sites will be covered entirely with the topical ordered and Adaptic. Then on POD#6, the topical agent and Adaptic are spotted on only the open areas of the graft. A moisturizing lotion will be applied to the healed areas.
d. On POD#5, staples are to be removed, unless the graft appears loose or fragile. The physician may order only every other staple removed or elect to leave all the staples intact. Grafts are to be trimmed to eliminate overlap, crusted edges and graft loss. Metzenbaum scissors may be used for this purpose.
e. Grafts are washed.
f. Examine grafts for color, percent intact, presence of drainage, presence of hematomas or seromas.
3. Homografts (Cadaver Skin)
Homografts are applied in the Operating Room by the OR team. Homograft is used when skin for autografting is not available. It is applied to the excised area, stapled in place, and a "wet dressing" is applied as above.
a. Wet the dressing every two hours with DAB, DAB alternating with Sulfamylon, or Hibiclens as ordered.
b. The dressings are changed on POD #2 and POD #5.
c. On POD #2, the grafted sites are examined and placed back in a "wet dressing."
d. On POD #5, the homograft sites are placed in a dry dressing. The physician will order topical treatment. Change BID.
e. On POD #5, the homografts are covered entirely with the topical agent ordered and Adaptic.
f. If the homograft begins to vascularize and adhere, treat the same as an autograft.
g. Homograft sites are washed.
4. Donor sites
a. Biobrane. Biobrane is a porous laminated synthetic dressing used as a temporary wound covering. It is designed for use in the treatment of the burn patient as a covering over donor sites. It is applied in the operating room (OR) by the OR team after a donor site is harvested. It is stapled in place and a Normal Saline Soak (NSS) is applied.
1) Remove the NSS 12 hours after surgery then leave open to air.
2) Observe the Biobrane donor site every eight hours for any drainage, bleeding, or redness.
3) If seromas, blisters, or hematomas develop, the nurse should aspirate the contents and notify the physician.
4) If the Biobrane is non-adherent due to excessive amounts of drainage or fluid buildup, the physician may wish to remove the Biobrane and place the donor site in a topical dressing.
5) On POD #5, staples are removed and any loose Biobrane is trimmed.
6) The dressing after POD #5 should be left to peel off and should be trimmed as needed during a 10-14 day period.
7) Patients may take tub baths after POD #5 when Biobrane is in place.
b. N-terface. N-terface is a silicone non-adhering dressing, which may be applied to a donor site, that is to be incorporated in the same "wet dressing" as the graft site. It is applied in the Operating Room by the OR team.
1) On POD #2, when the "wet dressing" is removed, the N-terface is examined. If intact, the wet dressing is re-applied. If not, new N-terface is applied followed by a wet dressing.
2) On POD #5, when the "wet dressing is removed, the N-terface is removed; the donor site is gently washed and placed in a dry dressing. The physician orders topical treatment. Dressings are then changed bid.
c. Aquaphor/Adaptic. Aquaphor is a petroleum, mineral oil-based ointment. It assists the skin’s natural healing process and can be used for very dry skin, minor cuts, and donor sites.
1) Aquaphor/Adaptic donor site dressings need to be changed postoperatively within two hours.
2) On the first dressing after OR, the donor site need only be rinsed with Hibiclens and sterile water, followed by sterile water without a washcloth. This prevents any further trauma to the donor site. Aquaphor/Adaptic is then applied and secured with bulky bandage.
3) The Aquaphor/Adaptic donor sites are then changed bid after this. The donor site is washed.
4) As the donor site heals, apply Aquaphor/Adaptic to open areas only and Eucerin cream to the healed areas. Plain Aquaphor (no Adaptic) may be applied to the healed donor site if the child is itching and Eucerin is not effective.
d. Kaltostat (brand of Calcium Alginate dressing). Kaltostat is a brown seaweed extract, which is wet, spun into a strong fiber, and is highly absorbent. It is applied in the Operating Room by the OR team to newly harvested donor sites, after being moistened with sterile Normal Saline. When placed on a wound, it reacts with exudate to form a protective gel. The alginate fiber gel matrix allows trauma-free removal with little or no damage to newly formed tissue. It is contraindicated for wounds involving muscle, tendon, bone, or full thickness burns. A gauze dressing is placed over the Kaltostat and secured with Kerlix or a dry stent.
1) Post operative:
a) The dressing is left dry for 24 hours.
b) The outer dressing should be removed daily. If the Kaltostat has a foul odor, it should be removed and new Kaltostat applied. If foul drainage is noted, new Kaltostat or a topical agent and Adaptic may be applied at the discretion of the attending physician.
c) If Kaltostat is placed on a scalp donor site, it is removed POD #2 or sooner followed with Bacitracin and Adaptic dressing at the physician’s discretion.
d) After five days, the dressing may be soaked at bath time once daily. After bathing, the Kaltostat is gently patted dry and trimmed as it becomes separated, and a single layer of burn dressing applied. The wound is wrapped with bulky bandage. If the patient is ambulatory, the wound should be wrapped with an ace bandage.
e) After seven days, the Kaltostat should be trimmed daily after the bath when it becomes separated. If Kaltostat comes off before the donor site is epithelialized, the wound should be treated according to the Bacitracin and Adaptic protocol.
f) All Kaltostat should be removed from donor sites prior to discharge. A normal saline soak
should be applied 24 hours prior to discharge and irrigated every two hours to aid in removal. If the donor site is not epithelialized, the wound should be treated according to the Bacitracin and Adaptic protocol.
2) Infection
a) If the donor site becomes infected, the Kaltostat should be removed and the donor site treated with Silver Sulfadiazine or Bacitracin and Adaptic as indicated.
Be careful: When removing the outer dressing, please be advised that the outer dressing may adhere to Kaltostat. Therefore, apply pressure with Kaltostat as the outer dressing is removed. This will assist in the adherence of Kaltostat to the donor site.
b) Op-site. Op-site may be used on donor sites that are small and that are in areas to which Op-site will adhere. Op-site is applied in the operating room by the physician and wrapped with a bulky bandage and an ace wrap.
1) 24 hours postoperatively, remove the ace wrap and bulky bandage; examine the donor site for bleeding or serum collection. If fluid/air is present, aspirate with a 25-guage needle.
2) Reapply the bulky bandage and an ace wrap.
3) If the Op-site does not adhere, it should be removed. New Op-site may be applied or the donor site may be placed in Aquaphor/Adaptic.
4) Trim loose edges as the Op-site peels away from healing skin.
5. Application of wet dressings following grafting
a. Overview: The usual protocol for skin graft care using the wet technique is to keep the graft moist for five days following surgery. Wet dressing changes are performed at two days (48 hours). On day five (120 hours) the skin grafts are placed in a dry dressing and finally, when the interstices of the mesh have closed, Eucerin is applied to the healed skin grafts.
b. Wet dressing change supplies:
1) 4" roll of FMG (single sheets may be used on small grafts)
2) bulky bandage rolls (usually 1 for each upper extremity, 2 for each lower extremity)
3) Burn dressings (as many containers as needed)
4) Sterile scissors
5) Weck blade (one for each extremity)
6) two sterile basins
7) ace wraps (3" or 4")
8) Forceps
9) Staple remover (POD #5)
10) Topical agent (Bacitracin, Bacitracin/AgSd 3:1 mix) buttered on Adaptic (POD #5)
11) 4" ´ 8" gauze dressings (if fingers or toes are involved in the dressing)
12) Hibiclens
13) Warm sterile water
14) Sterile protective sheet
15) Two irrigating syringes
c. The nursing technician or RN will set up the sterile field on the dressing cart, placing the burn dressing unfolded in one of the basins. The dressing cart is covered with sterile protective sheeting. H202, a 10cc syringe, a 20 gauge Angiocath, and sterile bowl should be available on the bottom shelf of the dressing cart. The ace wraps should be placed on the bottom shelf of the dressing cart. Weck blades should be taped with red tape to the center of the drape covering the dressing (clearly visible) or placed on the dressing tray.
d. The dressing change will be a combined physician and nursing team effort. The nursing staff should have the burn dressings, FMG and bulky bandage wet down, and have placed one-half strength Hibiclens into the other basin, prior to removing the dressings. The dressings should be generously irrigated with the Hibiclens solution to facilitate removal. The physician removes the previously applied dressings, utilizing a Weck blade (Be careful!), removing the dressing down to the fine mesh. Sterile gloves are not required. Remember to save the splints if they are to be used. The red rubber catheters are reused. The FMG is then removed, using forceps and frequent irrigation with Hibiclens and water solution. The wound is cultured, utilizing the usual swab technique. If there is blood beneath the graft, it should be aspirated or removed by utilizing the one-half strength H202 from the sterile bowl in the 10cc syringe and the Angiocath.
e. Re-applying the dressing-on POD #2:
1) Wet FMG is applied over the grafted area circumferentially. Irrigating the FMG with sterile water via an irrigating syringe will facilitate the application of the FMG.
2) A layer of wet burn dressings.
3) The red rubber catheters are applied.
4) Another layer of wet burn dressings.
5) Wet bulky bandage is wrapped over the above layer to secure the dressings.
6) The splints are padded and applied. Splints may need to be revised to ensure proper fit.
7) The entire area is wrapped with an Ace bandage or secured in a spandex stent.
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