4350199
Beschreibung
Mindmap von Jamie R Pascual, aktualisiert more than 1 year ago
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Erstellt von Jamie R Pascual
vor mehr als 8 Jahre
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|
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.
- 4. Cleanse the wound as prescribed.
Remove all previous ointments.
- 3. Assess/Monitor for odors,
drainage and discharge
- 2. Remove previous dressing.
- 1. Pre-medicate with an analgesic as prescribed
- List 3 Nursing
Interventions
- 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.
- 4. Apply a thin layer of topical antibiotic ointment as prescribed and cover
with a dressing using surgical aseptic techniques.
- 3. Enzymatic: Apply a topical enzyme to
break down and remove dead tissue.
- 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.
- 1. Administer hydroxyzine or
diphenhydramine for pruritus.
- List 3 Nursing Interventions
- 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.
- Unstable body temperature.
- Hyperventilation indicating systemic involvement of infection.
- Development of subeschar hemorrhage.
- Degeneration of granulation tissue
- Discoloration of unburned skin surrounding burn wound.
- 5. Monitor for signs of infection before and
after skin coverings of grafts are applied.
- 3. Provide wound care to donor site.
- 4. Administer pain med.
- 2. Elevate the extremity.
- 1. Maintain immobilization of the graft site.
- List 3 Nursing Interventions
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