Burns Nursing Care Plan & Management. Description. Burns are caused by a transfer of energy from a heat source to the body. The depth of the injury depends on the temperature of the burning agent and the duration of contact with it. Burns disrupt the skin, which leads to increased . You are assigned five patients on your nursing unit. Which patient is at most risk for pressure ulcers? Contact Our Center. Johns Hopkins Scleroderma Center Johns Hopkins Asthma & Allergy Center Division of Rheumatology, 1st Floor, Room 1B7 5501 Hopkins Bayview Circle. Young children and the elderly continue to have increased morbidity and mortality when compared to other age groups with similar injuries. Inhalation injuries in addition to cutaneous burns worsen the prognosis. Characteristics of Burn. The depth of a burn injury depends on the type of injury, causative agent, temperature of the burn agent, duration of contact with the agent, and the skin thickness. Burns are classi. Thermal burns, which are the most common type,occur because of fires from motor vehicle crashes, accidents in residences, and arson or electrical malfunctions. Children may be burned when they play with matches or firecrackers or because of a kitchen accident. Chemical burns occur as a result of contact with, ingestion of, or inhalation of acids, alkalis, or vesicants (blistering gases). The percentage of burns actually caused by abuse is fairly small, but they are some of the most difficult to manage. Neglect or inadequate supervision of children is fairly common. Effective prevention and educational efforts such as smoke detectors, flame- retardant clothing, child- resistant cigarette lighters, and the Stop Drop and Roll program have decreased the number and severity of injuries. Gender, Ethnic/Racial, and Life Span Considerations. Preschool children account for over two- thirds of all burn fatalities. Clinicians use a special chart (Lund- Browder Chart) for children that provides a picture and a graph to account for the difference in body surface area by age. Serious burn injuries occur most commonly in males, and in particular, young adult males ages 2. Individuals older than 5. The younger child is the most common victim of burns that have been caused by liquids. Preschoolers, school- aged children, and teenagers are more frequently the victims of flame burns. Young children playing with lighters or matches are at risk, as are teenagers because ofcarelessness or risk- taking behaviors around fires. Toddlers incur electrical burns from biting electrical cords or putting objects in outlets. Most adults are victims of house fires or workrelated accidents that involve chemicals or electricity. The elderly are also prone to scald injuries because their skin tends to be extremely thin and sensitive to heat. Because of the severe impact of this injury, the very young and the very old are less able to respond to therapy and have a higher incidence of mortality. In addition, when a child Burns 1. Adolescents are particularly prone to psychological difficulties because of sensitivity regarding body image issues. No specific gender and ethnic/racial considerations exist in burns. Gerontologic Considerations. Elderly people are at higher risk for burn injury because of reduced coordination, strength, and sensation and changes in vision. Predisposing factors and the health history in the older adult in. Malnutrition and presence of diabetes mellitus orother endocrine disorders present nutritional challenges and require close monitoring. Varying degrees of orientation may present themselves on admission or through the course of care making assessment of pain and anxiety a challenge for the burn team. The skin of the elderly is thinner and less elastic, which affects the depth of injury and its ability to heal. Primary Nursing Diagnosis. Resuscitation Goals. Effective fluid resuscitation is one of the cornerstones of modern burn care and perhaps the advance that has most directly improved patient. Brigham PA, McLoughlin E. Burn incidence and medical care use in the United States: estimates, trends, and data sources. J Burn Care Rehabil 1996; 17:95. If treating. Women’s and Children’s Hospital – Guidelines for the Management of Paediatric Burns May 2010 3 CONTENTS DETAIL 1. INTRODUCTION TO THE BURNS SERVICE. Ineffective airway clearance related to airway edema. OUTCOMES. Respiratory status: Gas exchange; Respiratory status: Ventilation; Symptom control behavior; Treatment behavior: Illness or injury; Comfort level. INTERVENTIONS. Airway management; Anxiety reduction; Oxygen therapy; Airway suctioning; Airway insertion and stabilization; Cough enhancement; Mechanical ventilation; Positioning; Respiratory monitoring. Medical Management. MINOR BURN CARE. Minor burn wounds are cared for by using the principles of comfort, cleanliness, and infection control. A gentle cleansing of the wound with soap and water 2 or 3 times a day, followed with a topical agent such as silver sulfadiazine or mafenide, prevents infection. Minor burns should heal in 7 to 1. Oral analgesics may be prescribed to manage discomfort, and as do all burn patients, the patient needs to receive tetanus toxoid to prevent infection. MAJOR BURN CARE. For patients with a major injury, effective treatment is provided by a multidisciplinary team with special training in burn care. In addition to the physician and nurse, the team includes specialists in physical and occupational therapy, respiratory therapy, socialwork, nutrition, psychology, and child life for children. The course of recovery is divided into four phases: emergent- resuscitative, acute- wound coverage, convalescent- rehabilitative, and reorganization- reintegration. The emergent- resuscitative phase lasts from 4. In addition to managing airway, breathing, and circulation, the patient receives fluid resuscitation, maintenance of electrolytes, aggressive pain management, and early nutrition. Wounds are cleansed with chlorhexidine gluconate and care consists of silver sulfadiazine ormafenide and surgical management as needed. To prevent infection, continued care includes further d. Then the physician d. The risk for infection is high during this phase; the physician follows wound and blood cultures and prescribes antibiotics as needed. Wound management includes excision of devitalized tissue, surgical grafting of donor skin, or placement of synthetic membranes. Inpatient rehabilitation takes place during the convalescent- rehabilitative phase. Although principles of rehabilitation are included in the plan of care from the day of admission, during this time, home exercises and wound care are taught. In addition, pressure appliances to reduce scarring, or braces to prevent contractures, are fitted. The reorganization phase is the long period of time that it may take after the injury for physical and emotional healing to take place. Nursing Management: Emergent/Resuscitative Phase. Assessment. Focus on the major priorities of any trauma patient; the burn wound is a secondary consideration, although aseptic management of the burn wounds and invasive lines continues. Assess circumstances surrounding the injury: time of injury, mechanism of burn, whether the burn occurred in a closed space, the possibility of inhalation of noxious chemicals, and any related trauma. Monitor vital signs frequently; monitor respiratory status closely; and evaluate apical, carotid, and femoral pulses particularly in areas of circumferential burn injury to an extremity. Start cardiac monitoring if indicated (eg, history of cardiac or respiratory problems, electrical injury). Check peripheral pulses on burned extremities hourly; use Doppler as needed. Monitor . Note amount of urine obtained when catheter is inserted (indicates preburn renal function and . Assess patient’s support system and coping skills. Interventions. Promoting Gas Exchange and Airway Clearance. Provide humidi. Document intake, output, and daily weight. Elevate the head of bed and burned extremities. Monitor serum electrolyte levels (eg, sodium, potassium, calcium, phosphorus, bicarbonate); recognize developing electrolyte imbalances. Notify physician immediately of decreased urine output; blood pressure; central venous, pulmonary artery, or pulmonary artery wedge pressures; or increased pulse rate. Maintaining Normal Body Temperature. Provide warm environment: use heat shield, space blanket, heat lights, or blankets. Assess core body temperature frequently. Work quickly when wounds must be exposed to minimize heat loss from the wound. Minimizing Pain and Anxiety. Use a pain scale to assess pain level (ie, 1 to 1. Administer IV opioid analgesics as prescribed, and assess response to medication; observe for respiratory depression in patient who is not mechanically ventilated. Provide emotional support, reassurance, and simple explanations about procedures. Assess patient and family understanding of burn injury, coping strategies, family dynamics, and anxiety levels. Provide individualized responses to support patient and family coping; explain all procedures in clear, simple terms. Provide pain relief, and give antianxiety medications if patient remains highly anxious and agitated after psychological interventions. Monitoring and Managing Potential Complications. Acute respiratory failure: Assess for increasing dyspnea, stridor, changes in respiratory patterns; monitor pulse oximetry and ABG values to detect problematic oxygen saturation and increasing CO2; monitor chest xrays; assess for cerebral hypoxia (eg, restlessness, confusion); report deterioratingrespiratory status immediately to physician; and assist as needed with intubation or escharotomy. Distributive shock: Monitor for early signs of shock (decreased urine output, cardiac output, pulmonary artery pressure, pulmonary capillary wedge pressure, blood pressure, or increasing pulse) or progressive edema. Administer . Burn wound care and pain control are priorities at this stage. Assessment. Focus on hemodynamic alterations, wound healing, pain and psychosocial responses, and early detection of complications. Measure vital signs frequently; respiratory and . Use meticulous hand hygiene before and after contact with patient. Caution patient to avoid touching wounds or dressings; wash unburned areas and change linens regularly. Maintaining Adequate Nutrition. Initiate oral . Encourage family to bring nutritious and patient’s favorite foods. Provide nutritional and vitamin and mineral supplements if prescribed. Document caloric intake. Insert feeding tube if caloric goals cannot be met by oral feeding (for continuous or bolus feedings); note residual volumes. Weigh patient daily and graph weights. Promoting Skin Integrity. Assess wound status.
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