Nursing 213

N213: Health Differences Across the Lifespan 3 Study Guide • CBC and metabolic panels o Arterial blood gases, carboxyhemoglobin, urinalysis (myoglobinuria), 12-lead EKG if over 35 years old, and bronchoscopy Nursing diagnosis for burns: • Impaired tissue integrity related to destruction of body tissues • Pain related to loss of tissue integrity • Altered nutrition less than body requirements related to increased nutritional needs • Fluid volume deficit related to loss of tissue integrity and fluid shifts • Ineffective airway clearance related to inhalation of heat and gasses • Risk for infection related to loss of tissue integrity • Risk for altered body temperature related to loss of protective mechanisms • Knowledge deficit related to injuries, care, and treatment plan Nursing interventions for burns: • First priority is prevention of fluid loss and shock; fluids must be replaced by giving Lactated Ringers solution in the following formula: o Children: 3ml/kg for each percentage of BSA burned o Adults: 2ml/kg for each percentage of BSA burned; give ½ over the first eight hours and the second half over the following 16 hours • Continuous fluid replacement of crystalloid, switching to colloid fluids; monitor for s/s of fluid overload • Continually monitor electrolytes, potassium, sodium, calcium, andmagnesium • Insert a Foley Catheter to monitor output of fluids • If inhalation burns, provide adequate respiratory support; monitor pulse oximetry and ABGs; provide oxygen if needed; watch patient for hypoxemia (tachycardia, tachypnea, cyanosis, and restlessness with anxiety); elevate head of bed in high-fowlers position • Clean thermal burns with sterile normal saline, apply compresses, and prepare for debridement if needed; clean chemical burns with large amounts of water and check if antidote is needed; electrical burns may need CPR; initiate cardiac monitoring and treat any tissue burns; check for internal injuries • Monitor for s/s infection, increased WBCs, and drainage of wounds; obtain woundcultures • Give antibiotics per MD orders • Assure hygiene in patient’s room: clean linens, hand washing, and protective garments • Give pain medications per MD orders; intravenous pain medications are more appropriate because they bypass impaired circulation and are more effective and safer Review laboratory reports: o

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