Page 317 - Critical Care Nursing Demystified

302 CRITICAL CARE NURSING DeMYSTIFIED

Nursing Diagnoses for Burns Expected Outcomes
Impaired gas exchange due to thermal The patientʼs VS will be stable
injury to airway and fluid translocation The SaO and ABGs will be baseline
from intravascular space 2
Fluid volume deficit due to excessive The patient will have baseline BP
loss of fluid from the intravascular The patient will have stable weight
space
The intake will equal the output

Nursing Interventions (Early)
Assess the ABCs, especially respiratory status, of the patient looking for signs/
symptoms of carbon monoxide poisoning or inhalation of superheated air (nasal,
eyelash, naris singeing; soot or sputum in mouth; stridor and hacking, productive
cough).

Prepare the patient for possible hyperbaric oxygenation therapy if carbon
monoxide poisoning. Hyperbaric oxygenation uses pressure to break the bonds
to the hemoglobin molecule.
Prepare for early intubation and ventilation if airways swell.

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Monitor temperature for signs of hyperthermia or hypothermia. Hyperthermia
can indicate infection; hypothermia can indicate large heat loss from burned area.
Assess the cause, location, size, and depth of burn to determine prognosis and
treatment regimen.
Administer large amounts of fluid, calculated based on the burn area, to pre-
vent burn shock.
Monitor labs for H&H, serum sodium, and potassium. H&H can show if
anemia is resulting from bleeding from burned area. Serum sodium and potas-
sium loss from the intravascular space may need to be supplemented.

Perform neurologic and circulatory checks to determine level of conscious-
ness and circulatory compromise in extremities.

Administer analgesics (like morphine) to control pain from injured areas.
Monitor intake and output to determine fluid balance status.
Perform weight check to get a baseline for fluid retention or loss.
Monitor urinary output via indwelling urinary catheter to determine if fluid
replacement is adequate. Output should be at least 30 to 50 mL/hr.
Apply cool NSS dressings to burns that are less than 10% to protect the areas
from injury/infection.