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PRESENTED BY:
LENNY RONALYN QUITORIANO BSN II-ANGELICA
IS
ml/day
1,200 1,000 300 2,500
ISF
EDEMA (Dropsy)
in the interstitial fluid volume of about 2 L or more due to increase transudation of fluid from capillaries 2 to: Increased HP [pregnancy, CHF] Decreased OP [malnutrition, end-stage liver dse, nephrotic syndrome]
CELL OVERHYDRATION
excess of water in the ECC w/ a normal amount of solute or a deficient amount of solute occurs in prolonged and excessive diuresis, forcing hypotonic fluids to produce diuresis in the presence of renal impairment fluid overload from production of adrenal corticoid hormones [Cushings syndrome]
CELL OVERHYDRATION
Symptoms Weight gain & edema Cough, moist rales, dyspnea [fluid congestion in lungs] CVP, bounding pulse,neck vein engorgement [fluid excess in the vascular system] Bulging fontanelles Hg and Hct Nausea & vomiting
CELL OVERHYDRATION
Management Restrict fluids to lower fluid volume Diuretics or hypertonic saline Continuous assessments to prevent skin breakdown Record daily weight to assess progress of treatment
CELL DEHYDRATION (DHN) loss of body fluids, particularly from the extracellular fluid compartment water loss > water intake Causes Fever Insufficient water intake Diarrhea, vomiting Excess urine output [Diabetes insipidus, diuretics] Excessive perspiration, burns Hemorrhage, shock, metabolic acidosis
ECF Vol.
Inc
ICF Vol.
N
Water Shift
No net change
Conditions
Hypertonic
Hypotonic Contraction Isotonic Hypertonic Hypotonic
Inc
Inc Dec Dec Dec
Dec
Inc
ICF ECF
ECF ICF
N No net change Diarrhea Dec ICF ECF Diabetes insipidus Inc ECF ICF Addisons dse
Potassium major cation of ICF Chloride - major anion of ICF Protein in ICF > ISF
BURNS
BURNS wounds caused by excessive exposure to the following agents or causes: Causes of Burns: Thermal [moist or dry heat] Electrical Chemical [strong acids and strong alkali Radiation [UV, x-rays, radium, sunburns]
BURNS
CLASSIFICATION OF BURNS
Superficial Partial thickness (1st degree) Outer layer of dermis Erythema, pain up to 48 hrs Healing 1-2 wks [sunburn] Deep Partial thickness (2nd degree) Epidermis & dermis Blisters & edema, frequently quite painful Healing 14-21 days Full thickness (3rd degree) Epidermis, dermis, subcutaneous fat Dry, pearly white or charred in appearance Not painful Eschar must be removed; may need grafting
BURNS
STAGES OF BURNS
BURNS
STAGES OF BURNS
BURNS
STAGES OF BURNS
BURNS
ASSESSMENT
1. Assess extent of body surface burned Greater morbidity & mortality for burns affecting face, hands & perineum Assess for dyspnea, stridor, hoarseness
2. Assess extent of burn injury Rule of nine immediate appraisal Lund-Browder chart more accurate Berkows method based on clients age & changes that occur in proportion of head & legs to the rest of the body as one grows
BURNS
ASSESSMENT 9%
9%
Front=18% Back=18%
9%
1% 18% 18%
BURNS
ASSESSMENT
3. Assess depth of burn Major burns 2nd degree over 30% of body Hospitalization - eyes, face, neck, hands, perineum, genitalia
4. Assess unique contributing factors Age of client Health history Diabetes, preexisting ulcers Tetanus immunization
BURNS
EMERGENCY MANAGEMENT
Stop the burning process Remove patient from source of injury Advise client to roll on the ground if clothing is in flame [STOP-DROP-ROLL] Throw a blanket over the client to smother the flame Remove clothing only if hot or for scald burn Immerse affected part in cold water [10 min] Irrigate copiuosly w/ large amount of running water w/ chemical burns [except w/ phosphorus] Interrupt power source w/ electrical burn
BURNS
MANAGEMENT
BURNS
METHODS OF TREATING BURNS
Open method or Exposure method Face, neck, perineum, trunk Allowing exudate to dry in 3 days
Occlusive Less pain, absorption of secretion, comfort, transportability, accelerated debridement Aesthetic considerations Semi-open method Covering of wound w/ topical antimicrobials: Silver sulfadiazine 1% (Flamazine) Silver nitrate 0.5% soln Mafenide acetate (sulfamylon acetate)
BURNS
BIOLOGIC DRESSING (Skin Graft)
BURNS
FLUID REPLACEMENT
Types of fluids:
Colloids Blood Plasma & plasma expanders Electrolytes Lactated Ringers Non-electrolyte D5W
BURNS
FLUID REPLACEMENT
EVANS Formula:
C 1ml x % burns x kgBW E - 1ml x % burns x kgBW Glucose 5% for insensible loss 2,000ml D5W Administer soln 1st 24 hrs [1st 8hrs], [16hrs] BROOKE Formula: [Administer as in Evans] C 0.5ml x % burn x kgBW E - 1.5ml x % burns x kgBW Water 1000ml D5W
BURNS
FLUID REPLACEMENT