University:
The Pennsylvania State University
Course:
NURS 100 | Nursing
Academic year:

2024
Views:

114

Pages:

5
Author:

Aaron B.

BURNS TREATMENT AND RESUSCITATION FLUID UNDERSTANDING Treatment for burn wounds OBJECTIVE 1. Prevent infection 2. Provides a sense of comfort 3. Prevent dehydration / meet the body's water needs to maintain organ function and prevent complications due to excessive resuscitation EQUIPMENT Wound Care Set 1. Anatomical tweezers 2 2. Cut the tissue 3. Rolled gauze 4. NaCl 0.9% 5. Bioplacenton ointment 6. Gloves Fluid resuscitation equipment 1. Electrolyte fluid (Asering, Ringer lactate, NaCl 0.9%) 2. Colloid fluids (albumin, plasma and blood) 3. Glucose fluid (D5%) 4. Venous catheter (abocath) no. 20-18 5. Catheter tube (Transfusion Set) 1 6. Tourniquet 1 7. Sufficient plaster/hypafix 8. Ikamesetin ointment 1 9. Crooked 1 10. Alcohol swab 11. Plaster scissors 1 12. Sterile gauze 13. Cover the base PROCEDURE A. Pre-Interaction Stage 1. Greet/greet clients 2. Introduce yourself 3. Explain the purpose of the action 4. Explain the procedural steps 5. Ask the client's readiness 6. Wash your hands B. Orientation Stage 1. Greeting as a therapeutic approach 2. Explain the objectives and procedures for the action to the family/client 3. Ask the client for readiness before the activity is carried out C. Work Phase 1. Read tasmiyah 2. Maintain client privacy 3. Adjust the patient's position 4. Wash your hands 5. Wear gloves 6. Assess the emergency of burns (ABCD assessment) 7. Assess the degree and extent of burns 8. Perform fluid resuscitation if the burn is >30% 9. Install an infusion 10.EVANS Formula:In the first 24 hours, electrolytes are given: normal saline 1 ml/kgBW/% burns, colloid: 1 ml/kg BW/% burns, glucose in water 2000 ml. and for the second 24 hours, electrolytes are given: normal saline, half of the requirements for the first 24 hours, colloids: half of the requirements for the first 24 hours, glucose in water 2000 ml 11.BROOKE Formula:in the first 24 hours electrolytes are given: Ringer's lactate 1.5 ml/kgBW/% of burns, colloids: 0.5 ml/kg BW/% of burns, glucose in water 2000 ml. and for the second 24 hours, electrolytes are given: half to three quarters of the requirements for the first 24 hours, colloids: half to three quarters of the requirements for the first 24 hours,glucose in water 2000 ml 12.PARKLAND Formula:In the first 24 hours, electrolytes are given in the form of Ringer's lactate 4 ml/Kg BW/% of burn area. And in the second 24 hours, colloids are given at 20-60% of the calculated plasma volume. 13. Patient observation 14. Treat burns 15. Install the mat and base 16. Open sterile equipment and ensure that it is not contaminated 17. Remove the old dressing using tweezers 18. Clean the wound with gauze and 0.9% NaCl 19. Clean necrotic tissue with necrotomy scissors 20. If there are bullae, they must not be solved 21. Apply sufratule/ointment to the wound area 22. Cover the wound with gauze and 0.9% NaCl 23. Cover the wound with dry gauze 24. Bandaging wounds 25. Tidy up the patient 26. Taking off gloves 27. Wash your hands D. Termination Stage 1. Tidying up clients 2. Evaluate actions 3. Read the tahmid and say goodbye to the client 4. Tidy up the tools 5. Wash your hands 6. Record activities on the nursing record sheet