Medical Surgical Nursing

EMERGENT PHASE Transfer to the nearest hospital Knowledge of circumstances surrounding the burn injury Obtain client‘s pre-burn ...

Sympathetic stimulation during the emergent phase causes reduced GI motility and paralytic ileus Auscultate the abdomen to as ...

Management of Major Burns Initial patient management Intravenous access established & I.V. fluids N/G tube; enteral feeding ...

Electrolytes (saline): 1 mL × body weight × % TBSA burned Glucose (5% in water): 2000 mL for insensible loss Day 1: Half to be ...

Pneumonia is a concern which can result in respiratory failure requiring mechanical ventilation Infection (Topical antibiotics ...

Odor Sloughing of grafts Altered level of consciousness Changes in vital signs Oliguria GI dysfunction such as diarrhea, vomiti ...

Prevent infection Major sources of pathogens: Intestine: Mucosa of intestine normally prevent bacteria in the GI to pass into t ...

Standard wound dressings are multiple layers of gauze applied over the topical agents on the burn wound Wound Débridement 1. N ...

Heterografts (or xenografts): skin taken from Autografts Graft taken from the same person Graft care (goal: not to dislodge t ...

Technically begins with wound closure and ends when the client returns to the highest possible level of functioning Provide p ...

Nursing process: Care of the Patient during the Emergent/Resuscitative Phase of Burn Injury Nursing Diagnosis: Impaired gas exch ...

allows early detection of decreasing respiratory status or complications of mechanical ventilation. Nursing Diagnosis: Ineffecti ...

6. Notify physician immediately of decreased urine output, blood pressure, central venous, pulmonary artery, or pulmonary artery ...

Assess response to analgesic. 3. Provide emotional support and reassurance. administered. 2. Intravenous administration is neces ...

4. Pain increases anxiety. 5. Anxiety levels during the emergent phase may exceed the patient's coping abilities. Medication dec ...

as well as increasing pulse rate. (If hemodynamic monitoring is used, assess for decreasing pulmonary artery and pulmonary arter ...

with unaffected extremity. 3. Remove blood pressure cuff after each reading. 4. Elevate burned extremities. 5. Report loss of pu ...

Nursing Process Care of the Patient during the Acute Phase Assessment Continued assessment of the patient during the early weeks ...

contractures  Ineffective coping related to fear and anxiety, grieving, and forced dependence on health care providers  Interr ...

microorganism growth. Visitors are screened to avoid exposure of the immunocompromised patient to pathogens. Patients can inadve ...