Medical Surgical Nursing

contractures

 Ineffective coping related to fear and anxiety, grieving, and forced dependence

on health care providers

 Interrupted family processes related to burn injury

 Deficient knowledge about the course of burn treatment

Collaborative Problems/Potential Complications
Based on the assessment data, potential complications that may develop in the acute
phase of burn care may include:

 Heart failure and pulmonary edema

 Sepsis

 Acute respiratory failure

 Acute respiratory distress syndrome

 Visceral damage (electrical burns)

Planning and Goals
The major goals for the patient may include restoration of normal fluid balance,
absence of infection, attainment of anabolic state and normal weight, improved skin
integrity, reduction of pain and discomfort, optimal physical mobility, adequate patient
and family coping, adequate patient and family knowledge of burn treatment, and
absence of complications. Achieving these goals requires a collaborative,
interdisciplinary approach to patient management.

Nursing Interventions
Restoring Normal Fluid Balance
To reduce the risk of fluid overload and consequent heart failure and pulmonary edema,
the nurse closely monitors IV and oral fluid intake, using IV infusion pumps to
minimize the risk of rapid fluid infusion. To monitor changes in fluid status, careful
intake and output and daily weights are obtained. Changes, including those of blood
pressure and pulse rate, are reported to the physician (invasive hemodynamic
monitoring is avoided because of the high risk of infection). Low-dose dopamine to
increase renal perfusion and diuretics may be prescribed to promote increased urine
output. The nurse's role is to administer these medications as prescribed and to monitor
the patient's response.

Preventing Infection
A major part of the nurse's role during the acute phase of burn care is detecting and
preventing infection. The nurse is responsible for providing a clean and safe
environment and for closely scrutinizing the burn wound to detect early signs of
infection. Culture results and white blood cell counts are monitored.
Clean technique is used for wound care procedures. Aseptic technique is used for any
invasive procedures, such as insertion of IV lines and urinary catheters or tracheal
suctioning. Meticulous hand hygiene before and after each patient contact is also an
essential component of preventing infection, even though gloves are worn to provide
care.
The nurse protects the patient from sources of contamination, including other patients,
staff members, visitors, and equipment. Invasive lines and tubing must be routinely
changed according to recommendations of the CDC. Tube feeding reservoirs, ventilator
circuits, and drainage containers are replaced regularly. Fresh flowers, plants, and fresh
fruit baskets are not permitted in the patient's room because of the risk of