Medications:
Calamba Shaira Ann V.
BSN 3Y1-3S
Pathophysiology: Chemicals in smoke damage to epithelial cell
 down.
that releases chemotactic factors priming of neutrophils
the attaching of neutrophils to site of injury releases of oxygen
radicals and proteases that may that may formulate exudate for
airway cast
Dx: Thermal Burns
Medical history
Ineffective airway clearance related to trauma as
evidenced by direct upper-airway injury by flame
Second degree burn in face
 Check for breathing, and circulation .WOF: signs of smoke
inhalation, and pulmonary damage
 Administer oxygen
 Assess gag and swallow reflexes
 Maintain patent airway semi fowler’s position
 Monitor respiratory rate, rhythm, depth: note presence of
pallor or cyanosis and carbonaceous or pink-tinged sputum.
 Note presence of pallor or cherry-red color of unburned skin.
 Investigate changes in behavior or mentation
 Monitor and graph serial ABGs or pulse oximetry.
 The patient will Demonstrate clear breath sounds,
respiratory rate within normal range
Abea 14 yr old, M
Abea 14-year old boy who stoked a fire
in a wood burning stove and was hurt by a
subsequent explosion. He was
transported to the local burn ICU (BICU).
He sustained an 82% total body surface
area (TBSA) thermal burn. Abe’s burns
included bilateral full thickness
circumferential burns to his legs and feet,
arms, and hands, genetalia and deep
partial thickness burn to his head and
anterior trunk
Risk for infection related to destruction of skin barrier as
Risk for fluid deficit related to loss of fluid in abnormal
routes as evidenced by 82% TSBA and deep partial
thickness
Second degree burn in anterior trunk
 Monitor vital signs, central venous pressure (CVP). Note
capillary refill and strength of peripheral pulses
 Prepare for IVF replacement: Compute parkland formula:
= 11,808 ml 12 bottles of IVF First 8 hrs = 5.904 the next 16
hours run 50% = 2,952
 Monitor Input and Output
 Estimate wound drainage and insensible losses.
 Weigh daily.
 Evaluate changes in mentation.
 Monitor laboratory studies: Hb/Hct, electrolytes, random
urine sodium.
 Insert and maintain indwelling urinary catheter.
 The patient will Demonstrate improved fluid balance &
moist mucous membranes.
 analgesia with I.V. propofol and morphine
 tetanus, ketamine
 silver sulfadiazine
 Mupirocin
Medical Management:
 cervical spine precautions, endotrachealy intubating him
 providing fluid resuscitation
 right brachial arterial line was placed along with right
internal jugular central venous catheter
 urinary catheter
 enteral nasogastic tube was placed in the left nares
 standard wound dressing
 surgical excision and grafting
 retained material (loose debridement)
 prolonged cooling down procedure with water
 ventilator
evidenced by 82% TSBA and deep partial thickness
Burn wounds
 Examine wounds daily, note and document changes in
appearance, odor, or quantity of drainage.
 Examine unburned areas
 Monitor vital signs for fever
 Emphasize and model good handwashing technique
for all individuals coming in contact with patient.
 Use gowns, gloves, masks, and strict aseptic
technique during direct wound care
 Provide sterile or freshly laundered bed linens or
gowns.
 Prevent skin-to-skin surface contact
 Remove dressings and cleanse burned areas in a
hydrotherapy or whirlpool tub wash areas with a mild
water & cleansing agent
 The patient will achieve timely wound healing free of
purulent exudate and be afebrile