Question

A 2-year-old child is admitted to a hospital burn unit with partial- and full-thickness burns involving 35% of body surface area. After admission assessment and review of the primary health care provider's prescriptions, the priority nursing intervention should focus on which action?

Answer 1

BURNS

• A burn is an injury caused by thermal , chemical, electrical or radiation energy
• A scald is a burn caused by contact with a hot liquid or steam but the term burn is often used to include scalds
• Most burns heal without any problem but complete healing in terms of cosmetic outcome is often dependent or appropriate care.

CLASSIFICATION

• Burns are classified according to the depth of tissue destruction as superficial partial thickness injuries, deep partial thickness injuries or full thickness injuries.

1. Superficial partial thickness

The epidermis is destroyed or injured and a portion of the dermis may be injured.

2. Deep partial thickness

A deep partial thickness burn involves destruction of the epidermis and upper layers of the dermis and injury to the deeper portions of the dermis

3. Full thickness

A full thickness burn involves total destruction of the epidermis and dermis and in some cases the destruction of underlying tissue, muscle and bone

NURSING ASSESSMENT

• Focus on the major priorities of any trauma patient
• Assess circumstances surrounding the injury
• Monitor vital signs frequently
• Start cardiac monitoring if indicated
• Check peripheral pulses
• Monitor fluid intake and output and measure hourly
• Obtain history

NURSING CARE PLAN

• Maintenance of adequate tissue oxygenation
• Maintenance of patient airway and adequate airway clearance
• Restoration of optimal fluid and electrolyte balance and perfusion of vital organs
• Maintenance of adequate body temperature
• Control of pain
• Minimization of patients and family anxiety

NURSING PRIORITIES

• Maintain patent airway or respiratory function
• Restore hemodynamic stability or circulating volume
• Alleviate pain
• Prevent complications
• Provide emotional support for patients
• Provide information about condition, prognosis and treatment.

NURSING INTERVENTION

• Promoting gas exchange and airway clearance
• Restoring fluid and electrolyte balance
• Maintaining normal body temperature
• Minimizing pain and anxiety
• Monitoring and managing potential complications
• Preventing infection
• Monitor culture results and white blood cell counts
• Maintaining adequate nutrition
• Promoting skin integrity
• Relieving pain and discomfort
• Promoting physical mobility