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4350199
Children with Moderate and Major Burns (ATI)
Descrição
Wound Care, Debridement, Skin Covering
Sem etiquetas
ati
children moderate & major burns
2nd year college
Mapa Mental por
Jamie R Pascual
, atualizado more than 1 year ago
Mais
Menos
Criado por
Jamie R Pascual
mais de 8 anos atrás
15
0
0
Resumo de Recurso
Children with Moderate and Major Burns (ATI)
WOUND CARE
List 3 Nursing Interventions
1. Pre-medicate with an analgesic as prescribed
2. Remove previous dressing.
3. Assess/Monitor for odors, drainage and discharge
4. Cleanse the wound as prescribed. Remove all previous ointments.
DEBRIDEMENT
List 3 Nursing Interventions
1. Administer hydroxyzine or diphenhydramine for pruritus.
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.
3. Enzymatic: Apply a topical enzyme to break down and remove dead tissue.
4. Apply a thin layer of topical antibiotic ointment as prescribed and cover with a dressing using surgical aseptic techniques.
SKIN COVERING
List 3 Nursing Interventions
1. Maintain immobilization of the graft site.
2. Elevate the extremity.
4. Administer pain med.
5. Monitor for signs of infection before and after skin coverings of grafts are applied.
Discoloration of unburned skin surrounding burn wound.
Green color to subcutaneous
Degeneration of granulation tissue
Development of subeschar hemorrhage.
Hyperventilation indicating systemic involvement of infection.
Unstable body temperature.
3. Provide wound care to donor site.
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