Example Care Plan_Burn Injury (First, Second, Third degree)

The phases of burn injury are emergent/resuscitation/burn shock, acute, and rehabilitative. During the acute phase of a burn injury, the capillaries seal and electrolytes remobilize with the fluid. At this time, the nurse should assess the laboratory results for:

After ensuring airway patency, obtaining baseline vitalsigns, and establishing an IV of Lactated Ringer’s solution, the patient’s condition stabilizes. Because airway obstruction may still occur, the nurse must assess frequently for airway patency. How long after injury should frequent airway assessments be made?

Admission assessment of a 54.4 kg patient shows partialthickness and full-thickness burns over one half the back, the perineal area, and the posterior aspect of both legs and feet. Based on the standard fluid replacement formula, what is the maximum fluid the patient will receive over the first 24 hours based on this presentation?

During the later stages (after the first 3 days) of a burn injury, the nurse would expect the patient to show signs of:

During the initial treatment phase, fluid replacement at 4 mL/kg/percent of burns is given over the first 24 hours. The calculated amount of solution is divided so that:

During the initial stages (first 3 days) of a burn injury, the nurse would expect the patient to show signs of:

Which parameter is commonly used as a guideline for adequate fluid replacement?

A 28-year-old woman is admitted to the ED after a house fire. She has second- and third-degree burns over approximately 30% of her body-surface area, including her face. Endotracheal intubation is performed, and IV lines are established. The goals of IV therapy for this patient would be based on all of the following except:

Cold, pain, apprehension, and episodes of infection potentiate a catabolic state in the burn patient. The nursing care plan should address appropriate nutritional support, which requires large amounts of:

The American Burn Association (ABA) recommendsthat all of the following burn injuries be referred to a burn center except:

A burn ICU nurse receives a new admission with burns over 30% of the body. The client is sedated, receiving IV pain medication, and edematous. Which of the following is the nurse’s main concern?

A client with burns over 36% of the body is admitted to the burn unit. The nurse immediately checks for IV patency, and searches for a secondary IV site with the intent to start a second large-bore IV. Why?