Professional Documents
Culture Documents
BALANCE
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; inaccurate
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
a. Starts when diuresis is completed and wound healing begins
b. Dry, waxy-white appearance of full-thickness burn changing
to dark brown; wet, shiny, serous exudate in partial
thickness
c. Hyponatremia
Nursing Interventions:
1. Provide relief or control pain
2. Administer analgesic or narcotics (morphine sulfate) 30 mins
before wound care
3. Position burns to alignment
4. Monitor alterations in fluid-electrolyte balance
5. Monitor foley catheter output hourly (30 cc/hr)
6. Weigh daily
7. Administer water or colloids
8. Promote maximal nutritional status
9. Wound care done 1hr before meals
10. Prevent wound infection
• Biologic dressing- used to cover large denuded areas
• Grafts- autograft, allograft, xenograft or heterograft
11. Controlled sterile environment
12. Hydrotherapy not more than 30 mins to prevent electrolyte
loss
13. Sulfamylon, silvadene, silver nitrate, betadine, gentamycin
applied using sterile technique
14. Prevent GI complications
15. 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
Renal functions: Homeostasis
1. Maintain constancy of internal environment by regulating
water and electrolyte content and acid base balance
2. Conserve appropriate amounts of essential substances vital
to normal cell function
3. Excrete waste products of metabolism, toxic substances, and
drugs in urine
4. Endocrine role- production of renin, erythropoietin and
prostaglandin
5. Metabolism of vitamin D
Manifestations of impaired renal function:
1. Abnormal urinary volume
b. Oliguria-< 500ml/24hr
c. Anuria- <250ml/ 24hr; renal shutdown, decrease filtartion
secondary to renal disease, hypotension, dehydration,
decreased renal blood flow
d. Polyuria- volume >2000ml/24hr
e. Pollakuria- abnormally frequent urination
f. Nocturia- frequent urination at night
g. Isosthernuria- kidneys cannot concentarte urine
h. Strangury- desire to pass urine but not received by micturition
i. Incontinence- true, false, paradoxical overflow; stress related
2. Abnormal urine color Abnormal constituents in urine
3. Abnormal constituents in urine
a. Albuminuria- presence of albuminin the urine secondary to
inflammation and damage to glomeruli
b. Hematuria- presence of blood (RBC) in urine
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 peritonem acts as a
semipermeable membrane between the dialysate and blood in the
abdominal vessels
Nursing Interventions:
a. weight, 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