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Learn about the nursing care management of patients with burn injury in this nursing study guide. What is Burn Injury?A nurse who cares for a patient with burn injury should be knowledgeable about the physiologic changes that occur after a burn, as well as astute assessment skills to detect subtle changes in the patient’s condition.
ClassificationBurns are classified according to the depth of tissue destruction as superficial partial-thickness injuries, deep partial-thickness injuries, or full-thickness injuries.
PathophysiologyTissue destruction results from coagulation, protein denaturation, or ionization of cellular components.
Statistics and EpidemiologyA burn injury can affect people of all age groups, in all socioeconomic groups.
Clinical ManifestationsThe changes that occur in burns include the following:
PreventionTo promote safety and avoid burns, the following must be done to prevent burns:
ComplicationsThere are a lot of consequences involved in burn injuries that may progress without treatment.
Assessment and Diagnostic FindingsVarious methods are used to determine the TBSA affected by burns.
Medical ManagementBurn care is a delicate task any nurse can have and being knowledgeable in the proper sequencing of the interventions is very essential.
Nursing ManagementNursing management in burn care requires specific knowledge on burns so that there could be a provision of appropriate and effective interventions. Nursing AssessmentThe nursing assessment focuses on the major priorities for any trauma patient; the burn wound is a secondary consideration.
Acute Phase The acute or intermediate phase begins 48 to 72 hours after the burn injury. Burn wound care and pain control are priorities at this stage.
Rehabilitation Phase Rehabilitation should begin immediately after the burn has occurred. Wound healing, psychosocial support, and restoring maximum functional activity remain priorities. Maintaining fluid and electrolyte balance and improving nutrition status continue to be important.
DiagnosisNursing diagnoses for burn injuries include:
Planning & GoalsMain Article: 11 Burn Injury Nursing Care Plans To implement the plan of care for a burn injury patient effectively, there should be goals that should be set:
Nursing Priorities
Nursing InterventionsNursing care of a patient with burn injury needs to be precise and effective. Promoting Gas Exchange and Airway Clearance
Restoring fluid and Electrolyte Balance
Maintaining Normal Body Temperature
Minimizing Pain and Anxiety
Monitoring and Managing Potential Complications
Restoring Normal fluid Balance
Preventing Infection
Monitor culture results and white blood cell counts.
Maintaining Adequate Nutrition
Promoting Skin Integrity
Relieving Pain and Discomfort
Encourage the patient to use analgesic medications before painful procedures.
Promoting Physical Mobility
Strengthening Coping Strategies
Supporting Patient and Family Processes
Monitoring and Managing Potential Complications
Promoting Activity Tolerance
Improving Body Image and Self-Concept
Teaching Self-care
EvaluationIn a patient with burn injury, the expected outcomes are:
Gerontologic ConsiderationsThe following are interventions you must consider when caring elderly people with burn injury.
Discharge and Home Care GuidelinesThe focus of rehabilitative interventions is directed towards outpatient care, home care, or care in a rehabilitation center.
Documentation GuidelinesThe nurse should document the following data to ensure that each care documented is a care that is done.
Practice Quiz: Burn InjuryLet’s reinforce what you’ve learned with this 5-item NCLEX practice quiz about burn injury. Please visit our nursing test bank for more NCLEX practice questions. 1. A full-thickness burn is: A. Classified by the appearance of blisters. B. Identified by the destruction of the dermis and epidermis. C. Not associated with edema formation. D. Usually very painful because of exposed nerve endings. 2. Fluids shifts during the first week of the acute phase of a burn injury that cause massive cell destruction result in: A. Hypernatremia B. Hypokalemia C. Hyperkalemia D. Hypercalcemia 3. As the first priority of care, a patient with burn injury will initially need: A. A patent airway established. B. An indwelling catheter inserted. C. Fluids replaced. D. Pain medication administered. 4. During the acute phase of burn injury, the nurse knows to assess for signs of potassium shifting: A. Within 24 hours B. Between 24 to 48 hours. C. At the beginning of the third day. D. Beginning on day 4 or day 5. 5. The leading cause of death in fire victims is believed to be: A. Cardiac arrest B. Carbon monoxide intoxication C. Hypovolemic shock D. Septicemia Answers and Rationale 1. Answer: B. Identified by the destruction of the dermis and epidermis.
2. Answer: C. Hyperkalemia
3. Answer: A. A patent airway established.
4. Answer: A. Within 24 hours
5. Answer: B. Carbon monoxide intoxication
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