Burns

Student activity--Concepts

Concept: Imbalanced Nutrition
Goal: pt. maintaining normal weight based on BMI, wound healing. Pt. able to verbalize importance of
adequate nutrition complication and fluid intake
Goal for today: Pt. weight remains the same or increased
Interventions:
a. determine daily caloric needs
b. weigh daily
c. measure I&Os hourly
d. monitor lab values including electrolytes, albumin
e. assess needs for enteral feeding or TPN
Concept: Fluid Volume Excess
Goal: Peripheral/pitting edema decreased to/equal to 1+ with no pulmonary edema by discharge
Goal for today: Peripheral edema reduced to 2+ and to prevent further edema or pulmonary edema
Interventions: Ascorbic Acid 66mg/kg is also administered to reduce the amount of fluids needed.
Mechanism of action is unknown.
a. monitor vs, with special attention to breath sounds
b strict I&Os (hourly)
c. Daily weight
d. Monitor serum electrolytes, BUN, Cr
e. Monitor hemodynamic status
f. give prescribed meds per doctors order
g. Monitor skin integrity
h. rotate and turn q2hours
Concept: Fluid Volume Deficit
Goal: Pt will have UOP > or equal 30ml/hrElectrical burn is 75-100ml/hr.
Goal for today: Pt will have improved skin turgor
Interventions:
a. increase fluidssome burn clients require more fluids and is individualized. The Parkland Formula is
a starting point
b. administer po fluids
c. monitor I & Os
d. administer meds as prescribed
e. check breath sounds
f. skin turgor
g. check electrolytes & CBC
h. check vs q4hours
Concept: Risk of Infectionsepsis is the main cause of death in burns
Goal: demonstrate appropriate wound care, have client and family verbally demonstrate proper hygiene
Goal for today: maintain temp less than 100.0 F. WBC below 11,000
Interventions:
a. monitor for MRSA and other signs of infection
b. use proper isolation techniques
c. Monitor lab values/ VSq 4hours
d. Teach client/ family about proper hygiene
e. Shave hair around affected areas to prevent infection
f. Debride
g. Administer medications/ antibiotics/ silvadene
Concept: Impaired physical Mobility
Goal: Patient will be able to ambulate 50 feet with assistance by discharge date
Goal for today: Patient will not succumb to falls
Interventions:
a. PROM q shift
b. pain medications
c. PT consult
d. OT consult
Concept: Impaired Skin Integrity
Goal: Optimal wound heeling
Goal for today: Continue assess
Interventions:
a. Check cap refill and pulse
b. Change burn dressing using topical and dressing material ordered
c. frequently assess dressing integrity: reinforce as needed
d. Maintain sterile technique each dressing change
e. With each change observe burn for evidence of healing and/or infection. Alert MD for any changes
Concept: Powerlessness
Goal: Patient will demonstrated increased feelings of control over his/her life situation by active
participation in care and self-care activities
Goal for today: Patient will verbalize feelings
Interventions:
a. Assess for behaviors that may indicated feeling of powerlessness
b. Assist client to meet spiritual needs
c. Inform client of scheduled procedures/ tasks so they know what to expect
d. Encourage client participation in support groups
e. Include client in the planning and care
Concept: Acute Pain
Goal: Pain will be controlled or reported if greater than 3 on a scale or 1-10
Goal for today: Patient will maintain a comfortable pain level
Interventions:
a. keep skin free from pressure
b. continue to assess pain level, and give ordered medications as ordered
c. elevate burned extremities periodically
d. maintain comfortable environment
e. encourage communication with patient about level pain
Concept: Prevention
Goal: prevent from happening, safety at home with a safety plan, communication with interdisciplinary
group
Goal for today: Pt. verbalizes safety plan, knowledge of family support
Interventions:
a. Education: steps in burn prevention at home, emergency procedures, fire dept.
b. Referrals: Case management, social services
Concept: Community Based Care American Burn Association
Interventions:
a. RN care to arrange home health visit x 3 days a week to assist in ADL, wound care and medical needs
b. RN to manage pt. pain at 3/10 prior to dressing change
c. Pt to weigh themselves daily
d. Pt. will avoid exposure to people with colds or infection and following aseptic technique
e. Pt. will maintain adequate Kcal, nutrition and fluids required for healing through nutritional assistance
programs.