Medical Surgical Nursing

(Tina Sui) #1

  • Electrolytes (saline): 1 mL × body weight × % TBSA burned

  • Glucose (5% in water): 2000 mL for insensible loss

  • Day 1: Half to be given in first 8 hours; remaining half over next 16 h.

  • Day 2: Half of previous day's colloids and electrolytes; all of insensible fluid
    replacement.

  • Maximum of 10,000 ML over 24 hr. Second- and


Nursing Diagnosis in the Emergent Phase



  • Impaired gas exchange related to carbon monoxide poisoning, smoke inhalation, and


upper airway obstruction



  • Goal: Maintenance of adequate tissue oxygenation

  • Ineffective airway clearance related to edema and effects of smoke inhalation

  • Goal: Maintain patent airway and adequate airway clearance

  • Fluid volume deficit related to increased capillary permeability and evaporative losses


from the burn wound



  • Goal: Restoration of optimal fluid and electrolyte balance and perfusion of vital


organs



  • Hypothermia related to loss of skin microcirculation and open wounds

  • Goal: Maintenance of adequate body temperature

  • Pain related to tissue and nerve injury and emotional impact of injury

  • Goal: Control of pain

  • Anxiety related to fear and the emotional impact of burn injury

  • Goal: Minimization of patient's and family's anxiety

  • Collaborative Problems:

  • Acute respiratory failure, distributive shock, acute renal failure, compartment


syndrome, paralytic ileus, Curling's ulcer



  • Goal: Absence of complications


ACUTE PHASE OF BURN INJURY



  • Lasts until wound closure is complete

  • Care is directed toward continued assessment and maintenance of the CV and


respiratory systems

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