Nursing care in severe burn injury: case report and literature review
Keywords:
ENFERMERÍA DE CUIDADOS CRÍTICOS; PROCESO DE ENFERMERÍA; QUEMADURAS; TERMINOLOGÍA NORMALIZADA DE ENFERMERÍA., CRITICAL CARE NURSING; NURSING PROCESS; BURNS; STANDARDIZED NURSING TERMINOLOGY., ENFERMAGEM DE CUIDADOS CRÍTICOS; PROCESSO DE ENFERMAGEM; QUEIMADURAS; TERMINOLOGIA PADRONIZADA EM ENFERMAGEM.Abstract
Introduction: Extensive burns constitute complex medical emergencies that compromise multiple physiological systems.
Objective: To describe a case and the associated literature regarding the systematic application of the nursing process in a patient with extensive burns and multiple associated complications. Case presentation: A 27-year-old woman, a nurse working in rural service, sustained burn trauma following an air accident with subsequent explosion. She was admitted with second- and third-degree burns covering 90 % of total body surface area, airway involvement, hypovolemic shock, and severe metabolic disturbances. Emergency nasotracheal intubation, invasive mechanical ventilation, aggressive fluid resuscitation, and intensive multidisciplinary management were required. The nursing care process was applied using NANDA-NOC-NIC taxonomy, prioritizing four critical domains: Elimination/Exchange (respiratory function), Comfort (pain control), Safety/Protection (skin integrity), and Nutrition (fluid-electrolyte balance).
Conclusions: The systematic implementation of the nursing process through standardized taxonomies allows the establishment of clear care priorities in the severely burned patient. Comprehensive management should sequentially focus on: ensuring airway patency with protective mechanical ventilation, controlling pain through validated scales and multimodal analgesia, preventing infections through rigorous aseptic techniques and preventive isolation, and restoring fluid-electrolyte balance through calculated resuscitation. This structured approach optimizes clinical outcomes in highly complex situations.
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