Blood pressure of 170/100 mm Hg
Foul-smelling discharge from wound
Pain at site of injury
Urine output of 10 mL/hr
Decreased Tissue Perfusion
Disturbed Body Image
Risk for Disuse Syndrome
Risk for Ineffective Breathing Pattern
Arterial pH. 7.32
Serum potassium.7.5 mmol/L (mEq/L)
Serum sodium. 131 mmol/L (mEq/L)
Allowing the client to eat whenever he or she wants
Beginning parenteral nutrition high in calories
Limiting calories to 3000 kcal/day
Providing a low-protein. high-fat diet
“I am fully recovered when all the wounds are closed.”
“I will eventually be able to perform all my former activities.”
“My goal is to achieve the highest level of functioning that I can.”
“There is never full recovery from a major burn injury.”
“My facial scars should be less severe with the use of this mask.”
“The mask will help protect my skin from sun damage.”
“This treatment will help prevent infection.”
“Using this mask will prevent scars from being permanent.”
Loosen the dressing.
Notify the emergency team.
Document the observation as the only action.
Increased wound pain 30 to 40 minutes after drug application
Presence of small. pale pink bumps in the wound beds
Decreased white blood cell count
Increased serum creatinine level
Changing gloves between wound care on different parts of the client’s body.
Avoiding sharing equipment such as blood pressure cuffs between clients.
Using the closed method of burn wound management.
Using proper and consistent handwashing.
Hepatitis B 10 years ago
Myocardial infarction 1 year ago
Kidney stones within the last 6 month