Nursing 213

N213: Health Differences Across the Lifespan 3 Study Guide • Give Tetanus toxoid immunization if needed • Monitor core body temperature and maintain adequate temperatures with either cooling or heating blankets • Prepare patient for debridement; this procedure is painful and can cause blood loss and increased metabolic demands; nurse may also be needed to assist withgrafting: o Biosynthetic dressings: a synthetic dressing that replicates theskin o Autografts: Grafts made from the patient’s own skin taken from another part of the body o Biologic dressings: Transplanted from a human cadaver or other mammal and used to cover large burn areas • Provide for daily care and treatment of burns; must be cleansed with normal saline, soap, and water or wound cleanser; may need a topical agent, such as Silvadene, and then dressed lightly with gauze; wound care should be performed one to two times daily; make sure dressings are placed lightly over wound • Elevate the injured body part and keep pressure off wound areas; physician may perform escharotomy to prevent compartment syndrome • Assess bowel functions and keep patient NPO until bowel sounds return • Provide high calorie diet including TPN if necessary • Give vitamin, mineral, and electrolytes per MD order • Give H2 blockers to prevent gastric ulcers due to NPO status • If patient’s face is burned, use care with access to mirrors; encourage patient to talk about body image disturbances • Refer to community support group for burn patients • Teach patient and family about wound care, infection symptoms, and skincare Expected outcomes for burns: • Remains free of complications, including infection, compartment syndrome, and fluid loss • Demonstrates healing of burns • Maintains adequate fluid volume levels and stable output • Maintains patent airway and adequate oxygenation • Verbalizes acceptance of body image • Verbalizes comfort and pain relief • Patient and family verbalizes knowledge of wound care, signs of infection, and rehabilitation Frostbite When the skin is exposed to cold, wet temperatures for long periods of time it can result in frostbite. This happens because the tissues freeze. Ice begins to form in the cells and the membranes begin to rupture, causing the body to release histamines that cause red blood cells to clump and occlude the

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