BURNS: NURSING CARE: MODERATE & MAJOR BURNS

Question 1

MODERATE & MAJOR BURNS (6)

Nursing Care

Answer 1

■■ Maintain airway and ventilation. A nasogastric tube may be indicated for clients at risk

for aspiration.

■■ Assist client to cough and deep breathe every hour.

■■ Suction every hour or as needed.

■■ Keep head of bed elevated at all times.

■■ Provide humidified supplemental oxygen as prescribed.

■■ Monitor vital signs.

Question 2

**MODERATE & MAJOR BURNS **

MAINTAIN CARDIAC OUTPUT

3 main interventions to maintain Cardiac Output

Nursing Care

Answer 2

1. Initiate intravenous access using a large-bore needle. If a large area of the body is burned, a central venous catheter is inserted.
2. Fluid replacement is important during the first 24 hr.
3. Monitor for manifestations of shock.

Question 3

1. Size of large-bore needle?

MODERATE & MAJOR BURNS

MAINTAIN CARDIAC OUTPUT

Initiate intravenous access using a large-bore needle. If a large area of the body is burned, a central venous catheter is inserted.

(1/3 main interventions to maintain Cardiac Output)

Nursing Care

Answer 3

1.???

Question 4

1. Rapid fluid replacement is needed during the ___?___phase to maintain ___?___ and prevent ___?___

MODERATE & MAJOR BURNS

MAINTAIN CARDIAC OUTPUT

Fluid replacement is important during the first 24 hr.

(2/3 main interventions to maintain Cardiac Output)

Nursing Care

Answer 4

Rapid fluid replacement is needed during the emergent phase to maintain **tissue perfusion **and prevent hypovolemic (burn) shock.

Question 5

1. Fluid resuscitation is based on individual client needs evaluation of (4)

MODERATE & MAJOR BURNS

MAINTAIN CARDIAC OUTPUT

Fluid replacement is important during the first 24 hr.

(2/3 main interventions to maintain Cardiac Output)

Nursing Care

Answer 5

Fluid resuscitation is based on individual client needs (evaluation of

1. urine output,
2. cardiac output,
3. blood pressure,
4. status of electrolytes).

Question 6

1. Isotonic crystalloid solutions such as __(2)__ are used for fluid replacement is important during the first 24 hr.

MODERATE & MAJOR BURNS

MAINTAIN CARDIAC OUTPUT

(2/3 main interventions to maintain Cardiac Output)

Nursing Care

Answer 6

Isotonic crystalloid solutions, such as

1. 0.9% sodium chloride or
2. lactated Ringer’s solution,are used.

Question 7

1. Colloid solutions such as __(2)__ maybe before or after the first 24 hrs of burn recovery

MODERATE & MAJOR BURNS

MAINTAIN CARDIAC OUTPUT

Fluid replacement is important during the first 24 hr.(2/3 main interventions to maintain Cardiac Output)

Nursing Care

Answer 7

Colloid solutions, such as albumin, or synthetic plasma expanders (Hespan, Plasma-Lyte),may be used after the first 24 hr of burn recovery.

Question 8

1. Maintain urine output of __?_mL/hr or
2. _?__mL/kg/hr

MODERATE & MAJOR BURNS

MAINTAIN CARDIAC OUTPUT

Fluid replacement is important during the first 24 hr.(2/3 main interventions to maintain Cardiac Output)

Nursing Care

Answer 8

Maintain urine output of

1. 30 mL/hr
2. (0.5 to 1.0 mL/kg/hr)

Question 9

1. Monitor for manifestations of shock

MODERATE & MAJOR BURNS

MAINTAIN CARDIAC OUTPUT

(3/3) main interventions to maintain Cardiac Output)

Nursing Care

Answer 9

1. Alterations in sensorium (confusion)
2. Increased capillary refill time
3. Urine output less than 30 mL/hr
4. Rapid elevations of temperature
5. Decreased bowel sounds
6. Blood pressure may remain normotensive, even in hypovolemia.