Phases of Burn WA PDF

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Summary

Written Assignment for Week 3 ...

Description

Phases of Burn Injury: Patient Care

Time Period:

Goals:

Nursing Dx:

Emergent 24-48/72 hours (Fluid loss up to 72 hrs)

Secure airway, support circulation, pain management, prevent infection, maintain temperature, provide emotional support (Sheridan, 2016)

    

Acute Pain R/T Destruction of skin tissue. Ineffective airway clearance R/T Trauma to upper airway by flame, steam, smoke Disturbed Body Image R/T Situational Crisis; disfigurement Impaired skin integrity R/T Disruption of skin surface with destruction of skin layers Risk for infection R/T Inadequate primary defenses; destruction of skin barrier (Vera, 2013)

Acute Rehab From end of emergent phase – From wound closure to patient to 7 days to months (depends on at highest level of functioning wounds- covered by skin grafts or healed) Reestablish independence, Pain management Family and patient support Treatment of burn wound groups Avoidance/detection/treatment of complications (most common: Psychosocial adjustment Prevention of infection, septicemia, pneumonia, renal disease, heart scars/contractures Resumption of pre-burn failure activities (Sheridan, 2016) (Sheridan, 2016)  Disturbed body image  Ineffective Tissue R/T Situational Crisis; Perfusion R/T reduction of atrial blood flow disfigurement  Imbalanced nutrition R/T  Anxiety R/T memory restricted oral intake of trauma experience  Deficient fluid volume  Chronic pain R/T nerve R/T loss of fluids through damage and poor burn wounds wound healing  Impaired physical  Risk for impaired skin mobility R/T integrity R/T Neuromuscular Disruption of skin impairment surface with (Vera, 2013) destruction of skin layers (Vera, 2013)

Assessment:

Shock from pain/hypovolemia Blisters, Adynamic ileus, (hypomotility of GI tract), Shivering, Altered mental status, Assess for inhalation injury, peripheral pulses, Rule of 9’s to assess % of TBSA damaged (Henderson, 2015)

Reaction to pain and pain level, wound assessment, head-to-toe assessment ever 8 hours, mental status, v/s, breath sounds, bowel sounds, dietary intake, motor ability, i/o, weight pattern, circulatory/grafts/donor site Assessment, COCA of wounds, Lab tests ; CBC (WBCs, Hmg, Hct), CMP: (electrolytes, liver function, kidney function), Nutritional status: body weight, serum albumin/pre-albumin levels, transferrin, urine urea nitrogen. CXR/ bronchoscopy for inhalation injuries (Henderson, 2015)

Continuous assessment Assess response to positioning, splinting, exercise, ability to perform daily wound care (post discharge), Assess for adequate circulation, cyanosis, temperature, adequate pulses Assess patient tolerance for exercise/ADLs, ambulation (Henderson, 2015)

References Matt Vera, RN (July 14, 2013). 11 Burn Injury Nursing Care Plans. Retrieved from https://nurseslabs.com/11-burn-injury-nursing-care-plans/4/

Roger Henderson, MD (July 24, 2015). Burns Assessment and Management. Retrieved from https://patient.info/doctor/burns-assessment-andmanagement Roger Sheridan, MD (September 22, 2016). Medscape; Burn Rehabilitation. Retrieved from http://emedicine.medscape.com/article/318436overview#a2...