Nursing Interventions for Burns (Emergent/Resuscitative Phase)

burns 

  • Assess circumstances surrounding the injury: time of injury, mechanism of burn, whether the burn occurred in a closed space, the possibility of inhalation of noxious chemicals, and any related trauma.
  • Monitor vital signs frequently; monitor respiratory status closely; and evaluate apical, carotid, and femoral pulses particularly in areas of circumferential burn injury to an extremity.
  • Check peripheral pulses on burned extremities hourly; use Doppler as needed.
  • Monitor fluid intake (IV fluids) and output (urinary catheter) and measure hourly. Note amount of urine obtained when catheter is inserted (indicates pre-burn renal function and fluid status).
  • Assess body temperature, body weight, history of pre-burn weight, allergies, tetanus immunization, past medical surgical problems, current illnesses, and use of medications.
  • Arrange for patients with facial burns to be assessed for corneal injury.
  • Continue to assess the extent of the burn; assess depth of wound, and identify areas of full and partial thickness injury.
  • Assess neurologic status: consciousness, psychological status, pain and anxiety levels, and behavior.
  • Provide humidified oxygen, and monitor arterial blood gases (ABGs), pulse oximetry, and carboxyhemoglobin levels.
  • Assess breath sounds and respiratory rate, rhythm, depth, and symmetry; monitor for hypoxia.
  • Observe for signs of inhalation injury: blistering of lips or buccal mucosa; singed nostrils; burns of face, neck, or chest; increasing hoarseness; or soot in sputum or respiratory secretions.
  • Report labored respirations, decreased depth of respirations, or signs of hypoxia to physician immediately; prepare to assist with intubation and escharotomies.
  • Monitor mechanically ventilated patient closely.
  • Institute aggressive pulmonary care measures: turning, coughing, deep breathing, periodic forceful inspiration using spirometry, and tracheal suctioning.
  • Maintain proper positioning to promote removal of secretions and patent airway and to promote optimal chest expansion; use artificial airway as needed.
  • Monitor vital signs and urinary output (hourly), central venous pressure (CVP), pulmonary artery pressure, and cardiac output.
  • Note and report signs of hypovolemia or fluid overload.
  • Maintain IV lines and regular fluids at appropriate rates, as prescribed. Document intake, output, and daily weight.
  • Elevate the head of bed and burned extremities.
  • Monitor serum electrolyte levels (eg, sodium, potassium, calcium, phosphorus, bicarbonate); recognize developing electrolyte imbalances.
  • Notify physician immediately of decreased urine output; blood pressure; central venous, pulmonary artery, or pulmonary artery wedge pressures; or increased pulse rate.
  • Provide pain relief, and give antianxiety medications if patient remains highly anxious and agitated after psychological interventions.
  • Administer IV opioid analgesics as prescribed, and assess response to medication; observe for respiratory depression in patient who is not mechanically ventilated.
  • Provide emotional support, reassurance, and simple explanations about procedures.
  • Assess patient and family understanding of burn injury, coping strategies, family dynamics, and anxiety levels. Provide individualized responses to support patient and family coping; explain all procedures in clear, simple terms.

 

 

Sources:

http://nurseslabs.com/burn-injury-nursing-management/

http://rnspeak.com/medical-and-surgical-nursing/burns-nursing-intervention/

http://www.nursinginpractice.com/article/burn-wound-and-scar-management

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