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Burns

Maya Popbozhikoava

Burns Nursing Interventions


Assess breath sounds, and respiratory rate, rhythm, depth, and symmetry. Monitor patient for signs of hypoxia. Monitor arterial blood gas values, pulse oximetry readings, and carboxyhemoglobin levels. Report labored respirations, decreased depth of respirations, or signs of hypoxia to physician
immediately.

Nursing Interventions
Monitor urine output at least hourly and weigh patient daily. Maintain IV lines and regulate fluids at appropriate rates, as prescribed Elevate head of patients bed and elevate burned extremities. Notify physician immediately of decreased urine output, blood pressure,

Risk factors
Causes Clinical Manifestation Assessment Diagnostics Studies Nursing Diagnosis

Client will maintain adequate tissue oxygenation as evidenced by clear breath sounds; absence of cyanosis; and vital signs, findings, and ABGs within normal limits. Impaired gas exchange related to carbon monoxide poisoning, smoke inhalation, and upper airway obstruction Assessment Assessment Blood pressure (BP) Blood pressure (BP) Pain/Discomfort Pain/Discomfort Respiration Respiration I& O I&O Neurosensory Neurosensory Vital signs Vital signs

The client will restore optimal fluid and electrolyte balance and perfusion of
vital organs within 4 hours of nursing intervention Fluid volume deficit related to increased capillary permeability and evaporative losses from the burn wound

Medical Management

Expected Outcome
Nursing Interventions

Burns
A burn is an injury resulting from exposure to heat, chemicals, radiation, or electric current. A transfer of energy from a source of heat to the human body initiates a sequence of physiologic events that in the most severe cases leads to irreversible tissue destruction

Clinical Manifestation
Fluid and Electrolyte Alterations Hypovolemia Edema Pulmonary Alterations Loss of skin results in an inability to regulate body temperature. Renal function may be altered as a result of decreased blood volume Gastrointestinal Alterations-paralytic ileus (absence of intestinal peristalsis) and Curlings ulcer

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. The skin and the mucosa of the upper airways are sites of tissue destruction. Deep tissues, including the viscera, can be damaged by electrical burns or by prolonged contact with a heat source. Disruption of the skin can lead to increased fluid loss, infection, hypothermia, scarring, compromised immunity, and changes in function, appearance, and body image. The depth of the injury depends on the temperature of the burning agent and the duration of contact with the agent.

Factors determining severity The age of the patient Depth of the burn Extent of Body Surface Area Injured Gender Presence of inhalation injury
Diagnostics Studies

Potassium (K) excess Sodium (Na) deficit CBC WBC Hematocrit Hemoglobin X-rays ABGs

Medical Management

Fluid Replacement Therapy Pain management - Morphine Hydrotherapy