Questions and Answers
Why is it important to observe wound separation of eschar and cellulitis?
To assess the risk of infection
What is the purpose of debridement in wound care?
To prevent electrolyte loss
What should be avoided when dressing a wound?
Breaking blisters
Which topical antibacterial agent requires monitoring for hypersensitivity and other adverse reactions?
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Why is it necessary to keep dressings wet with silver nitrate solution?
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What should be assessed at regular intervals when administering gentamicin?
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Why should gentle care be taken when handling silver nitrate?
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In burn care, what is the purpose of applying topical antibacterial agents?
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What is the reason for monitoring acid/base balance and renal function with Mafenide cream?
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What is the significance of administering an analgesic 30 minutes before dressing application?
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Study Notes
Burn Care Phases
- There are 4 stages in burn care: Emergent, Shock, Fluid remobilization, and Convalescent phases
- Each phase has distinct characteristics, assessments, and interventions
Emergent Phase
- Remove person from source of burn
- Assess when and how burn occurred
- Provide IV route if possible
- Transport immediately
- Thermal burns: smother burn beginning with head
- Smoke inhalation: ensure patent airway
- Chemical burns: remove clothing that contains chemical; lavage with copious amounts of water
- Electrical burns: note victim position; identify entry/exit routes, maintain airway
Shock Phase
- Characterized by hypovolemic state
- Plasma to interstitial fluid shift causes hypovolemia
- Assessment findings: Dehydration, decreased blood pressure, elevated pulse, decreased urine output (oliguria)
- Diagnostic tests: hyperkalemia, hyponatremia, elevated hematocrit, metabolic acidosis, hyperglycemia
Fluid Remobilization Phase
- 3-5 days post-burn: interstitial fluid returns to the vascular bed
- Assessment findings: Capillary membrane integrity returns, edema fluid shifts back into vessels, blood volume increases, blood pressure increases, increased urine output (unless renal damage), hypokalemia
Convalescent Phase
- Starts when diuresis is completed and wound healing and coverage begins
- Assessment findings: Full thickness burn: dry, waxy-white appearance changing to dark brown; Partial thickness burn: wet, shiny and serous exudate
- Nursing interventions:
- Monitor alterations in fluid shifts and electrolytes
- Administer IV fluids as ordered
- Monitor EKG (r/t K+ imbalance)
- Monitor Foley catheter (for at least 30 mL/hour)
- Weigh daily
- Monitor circulation status regularly
- Promote maximum nutritional status
- Provide relief and control pain
- Position burned areas in proper alignment
- Promote healing
- Place in controlled sterile environment
- Wound care at least once a day
- Provide daily tubing for removal of previously applied cream
Consensus Formula
- Lactated Ringer's 2-4 ml x wt in Kg x % body surface area (BSA) burned
- Half to be given in the first 8 hours after the burn; remaining fluid to be given over next 16 hours
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Description
Test your knowledge on nursing interventions during the convalescent phase of burn injuries, including monitoring fluid shifts, administering IV fluids, and wound assessment. Learn about common crystalloid solutions used in burn care.
