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Burns Maya Popbozhikoava

Nursing Interventions Burns


Nursing Interventions
Assess breath sounds, and respiratory rate, rhythm, depth, and Risk factors
Monitor urine output at least hourly and weigh patient daily.
symmetry. Monitor patient for signs of hypoxia. Causes
Maintain IV lines and regulate fluids at appropriate rates, as prescribed
Monitor arterial blood gas values, pulse oximetry readings, and
Elevate head of patients bed and elevate burned extremities. Clinical Manifestation
carboxyhemoglobin levels.
Notify physician immediately of decreased urine output, blood pressure,
Report labored respirations, decreased depth of respirations, or signs Assessment
of hypoxia to physician
immediately. Diagnostics
Studies
Client will maintain adequate tissue oxygenation as evidenced by clear breath The client will restore optimal fluid and electrolyte balance and perfusion of Nursing Diagnosis
sounds; absence of cyanosis; and vital signs, findings, and ABGs within normal limits. vital organs within 4 hours of nursing intervention Medical Management
Expected Outcome
Impaired gas exchange related to carbon monoxide poisoning, smoke inhalation, and upper Fluid volume deficit related to increased capillary permeability and evaporative Nursing Interventions
airway obstruction losses from the burn wound

Assessment
Blood pressure (BP) Assessment Burns Clinical Manifestation
Blood pressure
Pain/Discomfort (BP) Fluid and Electrolyte Alterations
A burn is an injury resulting from
Pain/Discomfort
Respiration Hypovolemia
exposure to heat, chemicals,
I &Respiration
O radiation, or electric current. A Edema
I&O
Neurosensory Pulmonary Alterations
transfer of energy from a source
Neurosensory
Vital signs Loss of skin results in an inability to regulate body
of heat to the human body
Vital signs temperature.
initiates a sequence of
Renal function may be altered as a result of decreased
physiologic events that in the
blood volume
most severe cases leads to
Gastrointestinal Alterations-paralytic ileus (absence of
irreversible tissue
intestinal peristalsis) and Curlings ulcer
destruction
Pathophysiology

Burn injury is a result of heat transfer from one site to


another. Tissue destruction results from coagulation,
protein denaturation, or ionization of cellular contents. Factors determining severity
The skin and the mucosa of the upper airways are sites of Diagnostics Studies
tissue destruction. Deep tissues, including the viscera, The age of the patient Potassium (K) excess
can be damaged by electrical burns or by prolonged Depth of the burn Sodium (Na) deficit Medical Management
contact with a heat source. Disruption of the skin can Extent of Body Surface Area CBC Fluid Replacement Therapy
lead to increased fluid loss, infection, hypothermia, Injured WBC Pain management - Morphine
scarring, compromised immunity, and changes in Gender Hematocrit Hydrotherapy
function, appearance, and body image. The depth of the Presence of inhalation injury Hemoglobin
injury depends on the temperature of the burning agent X-rays
and the duration of contact with the agent. ABGs