Nursing during the burn shock period

1. Nursing assessment ① Whether there is respiratory insufficiency: mouth breathing, hoarseness, gong sounds in the lungs, progressive cyanosis, etc. ② Whether there is insufficient blood volume: impaired consciousness, thirst, decreased blood pressure, weak pulse, low skin temperature, oliguria, etc.

2. Nursing measures

(1) Respiratory tract care: Keep the respiratory tract unobstructed and use an airway or tracheal intubation; if carbon monoxide poisoning is suspected, pure oxygen should be given; maintain good Position, turn over regularly, encourage deep breathing and expectoration, and suction if necessary.

(2) Fluid rehydration monitoring: Avoid drinking water after injury to prevent acute gastric dilatation and gastric bleeding. If thirst is severe, take burn drink orally under close observation. Develop a fluid rehydration plan based on the calculated fluid volume and implement it within 1 hour after injury. The following are simple and valuable evaluation criteria for fluid therapy: ① The casualty is conscious, quiet, has no obvious thirst, and is breathing steadily. ②Systolic blood pressure>11.0kPa, pulse pressure>2.66kPa. ③Adult pulse rate score, strong. ④Urine output should be >30ml/h for adults, >20ml/h for children, and >1ml (kg.h) for infants; for those with hemoglobinuria, the urine output should be >50ml/h; but for patients with cardiovascular disease and elderly patients, the urine output should be >20ml /h is enough. ⑤The blood electrolyte value is normal collected from the examination website. ⑥No symptoms such as nausea, vomiting, abdominal distension, and abdominal pain.

Nursing during the infection period

1. Nursing assessment ① Whether or not sepsis: Sepsis caused by burn infection is one of the main causes of death in burn patients. If the wound worsens, is not fresh, appears in brown or green patches, has purulent secretions and odor, and the edge skin is dissolved; there may be confusion, delirium, change of orientation; chills, high fever, or lack of body temperature, golden color The incubation period of Staphylococcus infection can last several days; increased pulse, decreased blood pressure; increased white blood cells and blood culture (+), etc., indicate the presence of burn infection sepsis. ② Whether there are digestive tract complications: including abdominal distension and paralytic intestinal obstruction, hemorrhagic gastritis, acute gastric dilatation, stress ulcer, etc.

2. Nursing measures

(1) Control infection: strict isolation, aseptic operation; preventive application of antibiotics and TAT; conduct wound and blood cultures regularly and at any time; conduct careful Treat the wounded with personal hygiene; once sepsis occurs, treat it as systemic purulent infection.

(2) Prevent and treat gastrointestinal complications: perform gastrointestinal decompression early and monitor gastric juice; correct blood volume deficiency; give antacids and histamine H2 receptor antagonists; once gastric In case of bleeding, give gastric lavage with ice salt water, hemostatic drugs, and fresh blood transfusion.