I.

Clinical Pathway for Client with 3rd Degree Burns Estimated Length of Hospital Stay: 4 days

Daily Outcomes

Interventions, tests and treatments

Date: ________ Date: ________ Date: ________ Date : ________ Day 1 Day 2 Day 3 Day 4 Absence of dyspnea Maintain patent airway Intake output and body intake output and RR between 12 and 20 and effective breathing weight correlate with body weight correlate bpm pattern, evidenced by expected pattern with expected pattern Lungs clear and clear lungs and ABGs v/s and arterial V/S and arterial auscultation within normal limits pressure and in pressure and in Arterial oxygen Blood pressure, pulse designated limits designated limits saturation <96% by pulse and respirations are urine output increases urine output increases oxymetry stabilized in response to in response to Patent Airway Burns receive initial vasoactive medications vasoactive medications treatment Pain is controlled Pain is controlled and Pain is controlled and ABG levels within Alert and oriented is minimized is minimized normal limits Pain is controlled skin is generally intact, skin is generally HR within normal range Client or family and free of signs of intact, and free of signs Exhibit clear sensorium verbalizes or indicates infection, pressure, and of infection, pressure, Blood pressure higher understanding of trauma and trauma than 90/60 mmHg explanation of ongoing open wounds are pink, open wounds are urine output of 0.5 - 1.0 treatment, condition and reepithelializing, and pink, reepithelializing, ml/kg/hr = 12 24ml/hr transfer free of infection and free of infection demonstrates ability to healed wounds are soft healed wounds are cope and smooth soft and smooth Vital Signs stabilized Assess for ABC and assess for pain level assess for pain assess for pain neurologic status and Weight (q AM) Weigh (q AM) Weigh (q AM) need for cervical Breath sounds q 4H Breath sounds q 4H Breath sounds q 4H immobilization Cardiac Auscultation Cardiac Auscultation Cardiac Auscultation assess baseline V/S Accurate I&O Titrate Oxygen as Accurate I&O Assess pain level Px evaluation (if indicated Px evaluation (if obtain history of indicated) Accurate I&O in absolute indicated) preexisting diseases, figures d/c supplemental O2 if V/S 2H allergies DBE, turning, proper Px assessment hypoxia is resolved positioning Monitor for possible Fluid Resuscitation d/c foley catheter passive and active impending aspiration; Prevent infection V/S q 2H ROM check nares for any V/S q 2H DBE, turning, proper

obstruction give humidified 100% O2 as needed Determine TBSA Determine the weight Position MHBR Cardiac Auscultation Cardiac monitoring if indicated Remove all clothing and jewelries Insert IV (PLR or PNSS); if hypoglycemia is present may use solutions with dextrose Fluid Resuscitation - 2400-4700 mL/day (12002300 mL for the first 8 hours, then the other half for the next 16 hours) Foley Catheter if indicated Accurate I&O in absolute figures Monitor V/S q 2H including respiratory and neurologic status Monitor closely for any neuronal damage; perform neuroassessment Check peripheral pulses Pulse Oximeter LABS :

Establish airway and

Monitor electrolytes especially sodium and potassium levels monitor Pulse Oximeter Wound/Burn Care: - May use hydrotherapy - Exercise affected parts - Topical antibiotics - Light dressings over joints - Burns to face may be left open - Elastic bandage is applied if the burned area is on extremity - Non-adhesive dressing between toes and fingers

positioning passive and active ROM relieving pain and discomfort -analgesics and anxiolytics -nonpharmacologic interventions -take analgesic before painful procedures Wound dressing light dressing; burns to face maybe left open prepare for wound debridement prepare for wound grafting

relieving pain and discomfort -analgesics and anxiolytics -nonpharmacologic interventions -take analgesic before painful procedures Wound dressing light dressing; burns to face maybe left open prepare for wound debridement (if not yet done) prepare for wound grafting (if not yet done) Graft care

LABS : Follow Abnormal Tests if indicated

LABS : as indicated

LABS : Follow abnormal tests

 CBC HCT X-Ray ECG ABG U/A Electrolytes Orient to surroundings Include family in teaching Provide simple brief instructions Evaluate understanding of teaching Assess anxiety Assess fear Assess verbalization of concerns Provide emotional support to client and family Minimize external stimuli such as noise and movement NPO Diet Include family in teaching Review plan of care Provide explanation for all procedures Evaluate understanding of teaching Evaluate verbalization of concerns Provide emotional support to client and family Provide information and on-going support and encouragement Review plan of care Provide explanation for all procedures Evaluate understanding of teaching address spoken and unspoken concerns positive reinforcement when appropriate promote truthful communication Teaching patient selfcare Evaluate understanding of teaching

Knowledge Deficit

Psychosocial

address spoken and unspoken concerns positive reinforcement when appropriate promote truthful communication Listen and provide realistic support

NPO if flatus and gag reflex still not noted Mouth Care- PRN Provide nutrition through TPN, NGT feeding Provide safety precautions Bedrest Turn to sides q2H IV fluids Antibiotics (topical or IV)

Clear liquids if flatus and gag reflex present then progress to full liquids to soft diet to full diet as indicated OoB as tolerated Participate with activities of daily living medication review and adjustment

high calorie, high protein diet include patients preferences and homemade foods OoB as tolerated Promote rest sleep Medication review/adjustment and

Activity Medications

Assess safety needs Bedrest MHBR Antimicrobial ointments (such as

silver sulfadiazine, mafenide, silver nitrate, and povidoneiodine) Antibiotics (such as oxacillin, mezlocillin, and gentamicin) IV pain medications (such as acetaminophen with codeine, morphine, or meperidine) Anabolic steroids, such as oxandrolone, Initiate discharge planning Evaluate support systems Evaluate the environment Patient assessment, contact family Assess risk factors Initiate Health teaching plan -types of burn injury -classification according to depth -risk factors -complications -management

as ordered IV Narcotic Analgesics Albumin as ordered

Titrate IV antibiotics

Consider discharge medications : antibiotics

Review discharge plan with family and patient

Review discharge plan with family and patient

Review all px/family teaching Follow up d/c instructions

review health teaching

Transfer or Discharge Plans

Initiate d/c teaching plan : Monitoring for infection Monitor for hydration Recording wt Limitations of Na intake d/c medications daily activity/exercise physician contact

Nursing Care Plan Emergent Resuscitative Phase: 1. Impaired Gas Exchange related to possible smoke inhalation.

2. Risk for Ineffective Airway Clearance related to tracheobronchial obstruction mucosal edema and loss of cilliary
action.

3. Fluid Volume Deficit related to loss of fluid through abnormal routes burn wounds; hypermetabolic state. 4. Hypothermia related to loss of skin microcirculation and open wounds. 5. Acute Pain related to tissue and nerve injury. 6. Impaired Oral Mucous Membrane related to traumatized tissue. 7. Imbalanced Nutrition: Less than body requirements related to hypermetabolic state and restricted oral intake. 8. Impaired Skin Integrity related to disruption of skin surfaces. 9. Risk for Infection related to destruction of skin barrier. 10. Fear/Anxiety related to situational crisis, memory of trauma experiences, hospitalization procedure and threat of death or
disfigurement. Acute Intermediate Wound Healing Phase: 1. Impaired Skin Integrity related to disruption of skin surfaces. 2. Ineffective Peripheral Tissue Perfusion related to interruption or reduction of arterial or venous blood flow circumferential burns of extremities. 3. Risk for Infection related to destruction of skin barrier. 4. Risk for Peripheral Neurovascular Dysfunction related to interruption or reduction of arterial or venous blood flow circumferential burns of extremities. 5. Impaired Physical Mobility related to neuromuscular impairment, pain and discomfort. Rehabilitative Restorative Phase: 1. Activity intolerance related to pain on exercise, limited joint mobility, muscle wasting and limited endurance. 2. Disturbed Body Image related to altered physical appearance and self-concept 3. Deficient Knowledge about post discharge home care and recovery needs.