Children with Moderate and Major Burns (ATI)

Jamie R Pascual
Mind Map by Jamie R Pascual, updated more than 1 year ago
Jamie R Pascual
Created by Jamie R Pascual about 4 years ago
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Wound Care, Debridement, Skin Covering
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Children with Moderate and Major Burns (ATI)
1 WOUND CARE
1.1 List 3 Nursing Interventions
1.1.1 1. Pre-medicate with an analgesic as prescribed
1.1.1.1 2. Remove previous dressing.
1.1.1.1.1 3. Assess/Monitor for odors, drainage and discharge
1.1.1.1.1.1 4. Cleanse the wound as prescribed. Remove all previous ointments.
2 DEBRIDEMENT
2.1 List 3 Nursing Interventions
2.1.1 1. Administer hydroxyzine or diphenhydramine for pruritus.
2.1.1.1 2. Provide hydrotherapy (place the client in a warm bath of water, or use warm running water, as if to shower) to cleanse the wound.
2.1.1.1.1 3. Enzymatic: Apply a topical enzyme to break down and remove dead tissue.
2.1.1.1.1.1 4. Apply a thin layer of topical antibiotic ointment as prescribed and cover with a dressing using surgical aseptic techniques.
3 SKIN COVERING
3.1 List 3 Nursing Interventions
3.1.1 1. Maintain immobilization of the graft site.
3.1.1.1 2. Elevate the extremity.
3.1.1.1.1 4. Administer pain med.
3.1.1.1.1.1 5. Monitor for signs of infection before and after skin coverings of grafts are applied.
3.1.1.1.1.1.1 Discoloration of unburned skin surrounding burn wound.
3.1.1.1.1.1.2 Green color to subcutaneous
3.1.1.1.1.1.2.1 Degeneration of granulation tissue
3.1.1.1.1.1.2.1.1 Development of subeschar hemorrhage.
3.1.1.1.1.1.2.1.1.1 Hyperventilation indicating systemic involvement of infection.
3.1.1.1.1.1.2.1.1.1.1 Unstable body temperature.
3.1.1.1.2 3. Provide wound care to donor site.
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