About
Burns involving all of the epidermis and either part or all of the underlying dermis. May require skin grafting to resurface wounds where the entire dermis has been damaged.
Assess
Blistered or shiny red. Sometimes exposed muscle and bone depending on severity. Assess all body systems for changes and complications from burns. Assess origin of burn ( chemical, fire, etc).
Complications
Hypovolemia; death; infection; sepsis; scarring; contractures; pulmonary edema
Diagnosis
Risk for deficient fluid volume related to losses through altered skin surfaces
Acute pain related to Partial or full thickness skin loss
Disturbed body image related to changes in physical appearance
Goals
- The client will remain free from infections.
- The client will have adequate fluid balance.
- The client will verbalize treatment plan while in the hospital and when returning to the community setting.
- The client will have a patent airway.
Interventions
- Secure a patent airway.
- Utilize strict asepsis to prevent spread of infection to client.
- Administer oxygen as needed; prepare for intubation as necessary.
- Maintain NPO.
- Secure an IV line and administer fluid replacements.
- Monitor for pulmonary edema, infection, impaired airway, shock, and other complications.
- Maintain body temperature.
- Administer analgesics as ordered, especially prior to dressings or treatments.
- Perform dressing changes or assist with procedures as indicated.
- Perform range of motion, apply pressure garments, and maintain mobility to prevent contractures and minimize scarring.
- Monitor for signs/ symptoms of complications.
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