Professional Documents
Culture Documents
BALANCE
Irene M. Magbanua, RN
Review Specialist
Water
Water constitutes over 50% of an individual’s weight
Infant- 70-80%
Adult 50-60%
Geriatric 45-55%
Water requirement= 2500cc/day; minimum of 1500 cc/day
2. Tetanus immunization
3. TBSA- Total Body Surface Area
a. Berkow formula
•calculated on the basis of the client’s age
•changes that occur in proportion of the head and legs to the rest
of the body as the individual grows
•arms and trunk have a fixed proportion throughout life
C. Rule of Nine
• useful for immediate appraisal of the burned area
•body is divided into areas, each represents 9% of or multiples
of 9
Classifications of Burns:
1. Major- partial thickness> 25% or full thickness > 10%
2. Moderate- partial thickness 15-25% or full thickness <10%
3. Minor- partial thickness <15% or full thickness < 2%
Categories of burn depth:
1. Partial thickness
a. Superficial Partial Thickness (First degree)
depth: epidermis
cause: sunburn, splashes of hot liquid
sensation: painful
characteristic: erythema, blanching on pressure,
no vesicles
B. Deep Partial Thickness (second degree)
depth: epidermis and dermis
cause: flash, scalding or flame burn
sensation: very painful
characteristic: fluid filled vesicles, red, shiny, wet
after vesicle rupture
2. Full thickness (third and fourth degree)
depth: all skin layers and nerve endings, may
involve muscles, tendons and bones
cause: flame, chemicals, scalding, electric current
sensation: little or no pain
characteristic: wound dry, white, leathery, or
hard tissue
4. Convalescent phase
g. Starts when diuresis is completed and wound healing begins
h. Dry, waxy-white appearance of full-thickness burn changing
to dark brown; wet, shiny, serous exudate in partial
thickness
i. Hyponatremia
Nursing Interventions:
2. Provide relief or control pain
3. Administer analgesic or narcotics (morphine sulfate) 30 mins
before wound care
4. Position burns to alignment
5. Monitor alterations in fluid-electrolyte balance
6. Monitor foley catheter output hourly (30 cc/hr)
7. Weigh daily
8. Administer water or colloids
9. Promote maximal nutritional status
10. Wound care done 1hr before meals
11. Prevent wound infection
• Biologic dressing- used to cover large denuded areas
• Grafts- autograft, allograft, xenograft or heterograft
3. Controlled sterile environment
4. Hydrotherapy not more than 30 mins to prevent electrolyte
loss
5. Sulfamylon, silvadene, silver nitrate, betadine, gentamycin
applied using sterile technique
6. Prevent GI complications
7. Provide client teaching and discharge plan
• Escharotomy- lengthwise incision through eschar to allow
expansion of skin as edema forms
• Fasciotomy- surgical incision done on underlying tissues or
muscles to explore for viability
Care of Client with Problems
Related to the Genitourinary
System
Irene M. Magbanua, RN
Professional Review Specialist
Renal functions: Homeostasis
2. Maintain constancy of internal environment by regulating
water and electrolyte content and acid base balance
3. Conserve appropriate amounts of essential substances vital
to normal cell function
4. Excrete waste products of metabolism, toxic substances, and
drugs in urine
5. Endocrine role- production of renin, erythropoietin and
prostaglandin
6. Metabolism of vitamin D
Manifestations of impaired renal function:
2. Abnormal urinary volume
c. Oliguria-< 500ml/24hr
d. Anuria- <250ml/ 24hr; renal shutdown, decrease filtartion
secondary to renal disease, hypotension, dehydration,
decreased renal blood flow
e. Polyuria- volume >2000ml/24hr
f. Pollakuria- abnormally frequent urination
g. Nocturia- frequent urination at night
h. Isosthernuria- kidneys cannot concentarte urine
i. Strangury- desire to pass urine but not received by micturition
j. Incontinence- true, false, paradoxical overflow; stress related
1. Abnormal urine color Abnormal constituents in urine
2. Abnormal constituents in urine
c. Albuminuria- presence of albumin in the urine secondary to
inflammation and damage to glomeruli
d. Hematuria- presence of blood (RBC) in urine
5. Azotemia- metabolic wastes accumulated in blood,
increased urea, creatinine and uric acid
f. Uremia- symptomatic elevation of metabolic waste products
in urine; a state or complex of symptoms reflecting failure of
kidneys to excrete metabolic wastes and excess substances
1. Fluid, electrolyte and pH imbalance- edema, metabolic
acidosis- failure of kidneys to excrete hydrogen ions with
increased sodium, phosphate and ammonia
Principles:
-Diffusion, Osmosis, Ultrafiltration
Purposes:
1. To remove excessive amounts of drugs or toxins in poisoning
2. To check serious electrolyte or acid base imbalance
3. To maintain kidney function when renal shutdown occurs
4. To temporarily replace kidney function in patients with acute
renal failure and permanently replace in chronic renal failure
Peritoneal Dialysis- introduction of specially prepared dialysate
solution into the abdominal cavity where the peritoneum acts as
a semi permeable membrane between the dialysate and blood in
the abdominal vessels
Nursing Interventions:
a. Weight pt, VS every 15 mins then every hour
b. Patient voids
c. Warm dialysate solution to body temperature
d. Assist in trocar insertion
e. Inflow time, Dwell time and Drain time
f. Observe character of dialysate flow
Complications:
• Peritonitis
•Respiratory Difficulty
•Protein loss