Adult Burn Scenarios You are admitting a 40-year-old Latino male 3 hours post pa

Question

Adult Burn Scenarios You are admitting a 40-year-old Latino male 3 hours post partial thickness scald burn. The burns are on the anterior torse and neck,right upper extremity and the right side of the face. There are large blisters on the torso and upper extremity. In addition, there are splash marks on the left lower and extremities without blisters and have intact skin. There is a 22G PrV in the left arm and Normal Saline 09% is infusing at 70 mh / hour. The transport team placed wet saline dressings prior to transport. Wi. 43 Skg Ht. 96cms, T 101,3, 8P138/84, P-89, Re26.Create a nursing care plan based on the scenarios Two nursing diagnosis Four interventions with rationales 2- Two outcome

Explanation / Answer

Nursing diagnosis:
1. Ineffective airway clearance related to edema
2. Fluid volume deficit related to increased capillary permeability and evaporative losses from burn wound
Outcomes:
1. Maintenance of patent airway and adequate airway clearance
2. Restoration of optimal fluid and electrolyte balance and perfusion of vital organs
Intervention:
1. Provide humidified oxygen and monitor ABG, pulse oximetry
2. Maintain proper position to promote removal of secretions and for optimal chest expansion.
3. Elevate head of bed and burnt extremities
4. Note and report signs of hypovolemia or hypervolemia
Evaluation:
1. Absence of dyspnoea
2. Clear lung sounds on auscultation

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