Administer the prescribed tetanus toxoid vaccine.
Assess wounds for signs of infection.
Encourage the client to cough and breathe deeply.
Wash hands on entering the client’s room.
Acute phase of the injury
Autodigestion of collagen
Granulation of burned tissue
Administers a laxative
Documents the finding
Increases the IV flow rate
Repositions the client onto the right side
Administering morphine 4 mg intravenously.
Administering hydromorphone (Dilaudid) 4 mg intramuscularly.
Applying ice to the burned area
Avoiding tactile stimulation
“Because the graft is my own skin. there is no chance it won’t ‘take.'”
“For the first few days after surgery. the donor sites will be painful.”
“I will have some scarring in the area when the skin is removed for grafting.”
“I am still at risk for infection after the procedure.”
Avoiding sharing equipment such as blood pressure cuffs between clients
Changing gloves between wound care on different parts of the client’s body
Using the closed method of burn wound management
Using proper and consistent handwashing
Decreased blood pressure
Allowing family members to change his dressings
Discussing future surgical reconstruction
Performing his own morning care
Wearing the pressure dressings as ordered
“It is normal to feel depressed.”
“I will be able to go back to work immediately.”
“I will not feel anger about my situation.”
“Once I get home. things will be normal.”