Red urine, Hct high,hgb low, Na low, lowspecific gravit
Capaillary refill 4 seconds
Burns to face, arms, hands and legs
Risk for Cardiac Output:Decresed 2*Dysrythmias
Crying in pain,unable to move fingers
Administer Morphine 0.2 mg/kg I.V.Not to exceed 15 mg in 24 hours
Immunizations behindschedule
Knowledge Deficit:Immunizations
Mother is 3 weekspost-partum
Include information innurses notes:Give information onimmunizationsduring discharge teaching
Encourage parents toremain at bedside
Encourage parent to express feelings
Nurses notes: recommendsocial worker consult when pt.arrives to floor
Use distraction techiques: music, tv.
Contact clergy for support
Continuous Pulse OXmonitoring
Child only memberof family injuredin fire
Risk for Altered Family Process
Explore parental coping mechanisms::forther's lighter found at scene,possible guilt reaction
Facillitate communicationbetween family, social worker andinvesitgators
Contact granparents for providecare for siblings
Be mindful of signs ofdevelopmental regression
Be mindful of signs ofdevelopmental regression
Administer O2as prscribed
Risk for Ineffective Tissue Perfusion: Peripheral
Perform self-careactivities for patient
Possible respiratory compromisedue to hx of reactive airway disease
Continuous airway monitoring
Have intubation tray at bedside
Risk for Ineffective Airway Clearance
Monitor CBC for WBC levels
Administer Oxacillin 50 mg/kg/24 hours I.V.in divided doses Q6H
Be aware of jehovah's witnesssttus: No blood Products
Risk for Acute Renal Failure
Avoid pressure on sites of skin impairment
Assess site of skin impairment for conditionand degree of burn
Cover pt. with light sheet
Thermoregulation:Ineffective
Low Diastolic blood pressureof 40
Administer Albumin 0.5 g/kg/does in 5%as Prescribed by M.D.
Administer IV fluids as prescribed by M.D.
Continous CardiacMonitoring
Kayexalate PO/Rectal1g/kg/Q6H as longas K+ renains elevated
Use sterile technique for urgentdebriding of burns
Abnormal ClinicalFindings
lllecia BenefieldLeigh McLaughlinMarisa RoskelleyJasmine Walden
Wondershare EdrawMind
