Question

Phases of Burn Injury: Patient Care

	Emergent	Acute	Rehab
Time Period:
Goals:
Nursing Dx:
Assessment:
Interventions:

Answer 1

Phases of burn injury: patient care

	Emergent	Acute	Rehab
Time period	First 24-48 hours	Fluid mobilization and diuresis endswhen burn wound are covered and completely healed	Begins when the wound is covered or healed and patient can begin some self care activity.
Goals	Airway, fluid management and wound care	Wound care, prevent infection, promote healing, electrolyte and acid-base balance	Assist patient to regain functional role in the society and to acheive cosmetic or functional reconstruction.
Nursing Diagnosis	Ineffective breathing pattern, Ineffective airway clearance, Impaired fluid and electrolyte balance,	Risk of Infection, Acute pain, Imapired mobility, Nutritional imbalance less than body requirements.	Ineffective coping, Disturbed body image, Activity intolerance, self care deficits
Assessment	Assess the percentage of burn, Check for any signs of inhalational injuries,presence of edema, increased pulse, falling B.P, increased respirations and scanty urine	Check the color, size,odour,eschar,exduate, granulation tissue., assess the pain level and functional mobility.	Assess the ability to perform sel care activities, muscle strength, acitivity tolerance and the wound condition. Assess self concept and self perception,coping abilities,
Intervention	Stop the burn and place the patient in a safe area. Remove clothings, jwelleries adherent to skin and wash with cool water. Estimate the burn size by rule of nine. Mainatin airway, breathing and circulation. Fluid resuscitation is done. Place a foley's catheter and keep patient nill per oral.	Treatment with antimicrobial medications and ointments like silver sulphadiazine. May need surgical management like debridement. so prepare patient for surgical procedure. Use of pressure garments. Perform adequate hand washing. Keep patient in clean and safe environment. Monitor for signs of infection. Maintain the nutritional status of the patient by TPN and intravenous fluids. MInimize oain and anxiety but use of adequate analgesics. Provide emotional suppport.	Discharge planning is done including dressing and wound procedure, exercise, ADL and medications.Followup visits and emotional adjustment is also involved in discharge planning. Early ambulation is promoted. Educate about complications of immobility. Use splints to prevent contractures. Monitor signs of vascular insufficiency, skin breakdown and nerve compression. Assist patient to develop effective coping strategies. Patient should be included in their care planning. Initiate patient and family about burn management. Incorporate physical therapy to prevent muscular atrophy. Promote a healthy body image and self concept. Be attentive to patients concerns, worries and fears and communicate with them patiently. Provide verbal and written instructions regarding wound care, nutritions, pain management and prevention of complications. Provide refferal to support groups or self help groups.