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Burns 2

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juniperk's version from 2018-03-05 12:49

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Question Answer
What is the goal during the acute phase? Infection control, wound care, wound closure, nutritional support and pain mgmt
What are the 6 nursing considerations for the acute phase?Monitor fluid resuscitation 2. Monitor ABCs 3. HOB > 30degrees 4. EKG monitor (K drops when diuresing begins 5. Monitor for infections 6. Daily weights
What are the nursing care during the acute phase? 7Wound care mgmt 2. Sulfadiazine (Silvadene) 3. Skin grafting 4. Nutritional therapies 5. Infection control- Gown mask glove 6. Heated environment 7. Psychosocial support
key points for hydrotherapy wound carePremedicate. 2. Minimize bleeding and maintain temperature
4 key points for debridement wound care1. Removal of eschar 2. Assess pulses, color, movement, and sensation. 3. Pack wound for 24 hours following 4. topical antimicrobial medications as ordered
4 key points for auto grafting wound care1. Monitor for bleeding, immobilize for 3-7 days post op. 2. elevation of graft site and keep free of pressure 3. Monitor for infection 4. Care of donor site.
What is the lab value for potassium? Ca?K 3.5-5 Ca 8.5-10.5
What is the labe value for Magnesium? Sodium?Mg 1.5-3 Na 135-145
What type of isolation should you practice around open wounds?reverse isolation
What are the S/S of sepsis?Decreased BP, increased HR, Lactic acid, increased temp
Why is it a priority to start early mobility?To prevent immobility contractures.
What are the 4 nursing care key points in rehabilitive phase?Psychosocial evaluation 2. Prevent immobility contractures 3. Assist in returning to work 4. Assess home environment for needs and accessibility
Psychosocial effect- Change in body image - 2 nursing key pointsGive pt time to grieve and accept new image 2. Encourage patient to touch and look at burn sites.
Psychosocial effect- Fear of Pain - 2 nursing key pointsReassurance of pain mgmt 2. Continue to give analgesic
Psychosocial effect- Fear of Lifestyle change - Nursing key pointPossible disabilities
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