nursing interventions for burn patients
Involving them in distraction and support of the child may be useful. Place a towel roll under the client’s neck or shoulder. Wearing the dressing will assist in decreasing complications, but will not increase self-perception. Obtain routine cultures and sensitivities of wounds and/or drainage. Because of its composition, it is important to monitor the clients fluid intake and output including electrolytes, blood glucose and weight. Report labored respirations, decreased depth of respirations, or signs of hypoxia to physician immediately; prepare to assist with intubation and escharotomies. Medicate for pain before activity or exercise. Applying knee splints prevents leg contractures by holding the joints in a position of function. Rationale: Skin grafts may be carried out with animal skin for the same purposes as homografts or to cover meshed autografts. Going outdoors is acceptable as long as the left arm is protected from direct sunlight. Verbalize acceptance of self in situation. International journal of trauma nursing, 2
Inhalation injuries in addition to cutaneous burns worsen the prognosis. Provide through teaching and complete aftercare instructions for the patient. Investigate reports of deep or throbbing ache, numbness. Using the rule of nines, which is the best estimate of total body-surface area burned? Use space heaters instead of gas heaters. Disturbed body image and disuse syndrome can develop. A client with burns on the lower portions of both legs isn’t likely to have femoral artery occlusion. Ascertaining time of last food intake is important in case intubation is necessary (the nurse would be more alert for the signs of aspiration). Provide medication and/or place in hydrotherapy (as appropriate) before performing dressing changes and debridement. Which statement indicates that a client with facial burns understands the need to wear a facial pressure garment? The following may assist in reducing itch: - Advise child and parent to avoid scratching - short finger nails will assist in this. Identify community resources: skin or wound care professionals, crisis centers, recovery groups, mental health, Red Cross, visiting nurse, Amblicab, homemaker service. Encourage early sitting and ambulation. Sources vary as to whether bath or shower is best. Keep the client in a semi-Fowler’s position and actively raise the arms above the head every hour while awake. Encourage patient to sit up for meals and visit with others. Monitor laboratory studies: serum albumin, prealbumin, Cr, transferrin, urine urea nitrogen. Therefore it is vital that adequate fluid is administered to the patient in combination with ongoing circulatory and fluid balance assessment. According to the Rule of Nines, the arms account for 9% each, the anterior legs account for 9% each, and the anterior trunk accounts for 18%. Many clients have unrealistic expectations of reconstructive surgery and envision an appearance identical or equal in quality to the preburn state. The burned area appears pink, has blisters, and is very painful. The admixture is made up of proteins, carbohydrates, fats, electrolytes, vitamins, trace minerals and sterile water based on individual client needs. Assist and prepare for escharotomy or fasciotomy, as indicated. A deep partial thickness burn involves the destruction of the epidermis and upper layers of the dermis and injury to the deeper portions of the dermis. Which are the priority assessment data to obtain from this client? Provide opportunity for questions and give honest answers. Support patient through small gestures such as providing a birthday cake, combing patient’s hair before visitors, and sharing information on cosmetic resources to enhance appearance. Any dressing applied to fingers, should ensure fingers are taped individually. Option B isn’t appropriate because burns aren’t a disease. To prevent infection, continued care includes further débridement by washing the surface of the wounds with mild soap or aseptic solutions. Although a return to preburn functional levels is rarely possible, burned clients are considered fully recovered or rehabilitated when they have achieved their highest possible level of physical, social, and emotional functioning. Maintain desired position and immobility of area when indicated. Frequently observing for hoarseness, stridor, and dyspnea, Establishing a patent IV line for fluid replacement. Be realistic and positive during treatments, in health teaching, and in setting goals within limitations. Parenteral nutrition may be given as a last resort because it is invasive and can lead to infectious and metabolic complications. Note circulation, motion, and sensation of digits frequently. Assist the family to express their feelings of grief and guilt. Cooling for longer than 20minutes is not beneficial. Communicate plan of care to family and other caregivers. The risk for inhalation injury is greatest when flame burns occur indoors in small, poorly ventilated rooms.