2003 64772 NCP BURN docx PDF

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ASSESSMENT Subjective: “ Parang wala ng pakiramdam dito sa paa ko” Objective:  with pitting edema on the burn area  Skin color: red to brown  Cold clammy skin on unburned area  Capillary refill: 3 secs  Weak in appearance  Irritable  Lab values:

NURSING DIAGNOSIS Ineffective Tissue Perfusion related to decrease blood flow 2° to circumferential burns of lower extremities

SCIENTIFIC EXPLANATION Burn injury Injury to cells and muscles Triggered inflammatory response Release of chemical mediators such as kinins and histamine Increase blood vessel permeability Fluid shift from IV to interstitial space Edema

PLANNING Short term goal: After 48 hours of rendering nursing intervention, the patient will be able to:  Verbalize understanding of condition, therapy regimen and side effects of medications  With good capillary refill of 1-2 secs  Skin warm and dry

NURSING INTERVENTIONS Independent:  Assess color of the skin, movement of the hands and peripheral pulses and capillary refill on extremities  Encourage active ROM exercise of unaffected body parts  Elevate the affected extremities

RATIONALE

Short term goal:  Edema formation readily compresses blood vessels thereby impending circulation and increases edema

 promotes systemic circulation/venous return

 Maximizes circulating volume and systemic circulation

 Skin warm and dr  Lab values:

 Lab values within normal range:

Collaborative:

Dec. CO Dec. tissue perfusion

After 48 hours of renderi nursing intervention the goal was met as evidence by:  The patient verbalized understanding of condition, therapy regimen and side effects of medications  Good capillary re of 1-2 secs

Decrease blood volume Decrease venous return

EVALUATION

Hct- 40-54% Hgb- 14-18

Hct-66% Hgb-10 Long term goal:

 IVF: PLR IL x21gtts/min

 Maintain fluid replacement and to improve tissue perfusion

Hct- 33% Hgb- 11 Long term goal: After a week of hospitalization, goal was met as evidenced by:

Vital Signs: T:36 C P:125 bpm R:30 BP:130/90

ASSESSMENT Subjestive: “ Parang wala ng pakiramdam dito sa paa ko”

 Absence of edem on lower extremit  Vital signs within normal range: PR=65bpm RR=15cpm BP=120/80mmHg

After a week of hospitalization, the patient will be able to demonstrate increased perfusion as evidenced by:  Absence of edema on lower extremities  Vital signs within normal range: PR=60-100bpm RR=12-20cpm BP=120/80mm Hg

NURSING DIAGNOSIS Impaired skin integrity related to disruption of skin surface and layers secondary to burn

SCIENTIFIC EXPLANATION Burn injury

Cell damage

PLANNING Short term goal: After 8 hours of nursing intervention the patient will be able to :

NURSING INTERVENTIONS Independent:  Assess or document size, color, depth of wound, necrotic tissue and condition of surrounding skin

RATIONALE

EVALUATIO Short term goal:

 Provides baseline information about the affected skin

After 8 hours of nursing intervent goal was met as evidenced by:

Objective:  With open burn wound that appears leathery  Skin color: red to brown  Presence of eschar  Non pitting edema on the burned area VS: T:36 C P:125 bpm R:30 cpm BP:130/90mmHg

Destruction of skin layers

 participate in prevention measures and treatment program

Impaired Skin Integrity

 verbalize feelings of increased selfesteem and ability to manage situation Long term goal:  After a week of hospitalization, the patient will be able to demonstrate tissue regeneration and achieve timely wound healing as evidenced by:   

moist skin healing scar absence of edema on lower extremities

 Assess blood supply and sensation (nerve damage) of affected area.

 To evaluate actual/potential for impairment of circulation to lower extremities

 Clean the wound area with hydrogen peroxide

 Promotes healing

 Keep the area clean/dry and stimulate circulation to surrounding areas

 To assist body’s natural process of repair

 Apply appropriate wound dressing

 To promote wound healing and to best meet the needs of client

 Maintain appropriate moisture environment for particular wound

 To promote healing

 Remove wet or wrinkled linens promptly

 Moisture potentiates skin breakdown

 Use appropriate padding devices

 To reduce pressure on circulation to compromised tissues

 Pt display timely healing o wounds  Pt participat in preven measures treatment program  Pt verbal feelings o increased self-estee and abilit manage situation Long term goal:  Within th patient’s hospitaliz n, goal w met as evidenced by:  the patien demonstr tissue regenerat

 Provide optimum nutrition, including foods with vitamin C and adequate protein intake

 To provide a positive nitrogen balance to aid in skin/tissue healing

 Emphasize importance of proper fit of clothing and shoes

 For presence of reduced sensation/circulat ion

 Assist pt to learn stress reduction and alternate therapy techniques

Collaborative:  Assist with debridement

ASSESSMENT Subjective: “Nanghihina ako”

NURSING DIAGNOSIS Deficient fluid volume related to abnormal fluid loss 2° third

SCIENTIFIC EXPLANATION Burn injury

PLANNING Short term goal:

NURSING INTERVENTIONS Independent:

and achie timely wound healing a evidenced by:   

 To control feelings of helplessness and deal with situation

moist ski healing s absence edema lower extremiti

 To remove nonviable, contaminated or infected tissue

RATIONALE

EVALUATION Short term goal:

 Baseline data Injury to cells and muscle

After 8 hours of rendering nursing intervention the client

 Monitor vital signs, and

After 8 hours of rendering an effective

Objective: degree burn  with nausea and vomiting  irritable  confused  urine output of 15 ml/hour  dark yellow urine  capillary refill 3secs Vital Signs: T:36 C P:125bpm R:30cpm BP:130/90mmHg Lab results: HCT=66%

Damage renal function

will be able to demonstrate improved fluid balance as evidenced by:  no complaints of nausea and vomiting  absence of irritability  capillary refill of 12secs

Decrease GRF

Long term goal:

Platelet aggregation

Presence of azotemia

Irritation in GI lining and alteration in nervous system

Resulting to n/v, alterd loc, weakness and wt.loss

capillary refill  Monitor urine output color

 Investigate changes in mentation

 Allow for close observation of renal function and prevent urinary retention

 Deterioration in the level of conciousness may indicate inadequate circulating volume

After 1-2 days of nursing intervention, the patient will demonstrate improved fluid balance as evidenced by: Collaborative:  adequate urine output of 60ml/hr – 100ml/hr  appropriate LOC  Vital signs within normal range: T=36.5-37.5 C P=60-100bpm R=12-20cpm BP=140-100/8090mmHg

 Insert indwelling urinary catheter

 Administer PLRS 1L 158 gtts/min for first 8 hours  Administer PLRS1L 79gtts/min for the next 16 hours

nursing intervention, the goal was met as evidenced by:  no complaints of n/v  no irritability  capillary refill of 2 secs V/S as follows: T:36 C P:120bpm R:20cpm BP:110/70 Long term goal:

 Allows for close observation of renal function and prevent urinary retention  Fluid resuscitation replaces loss of fluids and electrolytes

After 1-2 days of nursing intervention, goal was met as evidenced by:  patient demonstrated improved fluid balance as evidenced by:  urine output of 75ml/hour  

appropriate LOC Vital signs

within normal range: T=36 C P=120bpm R=20cpm BP=110/70mmH g

ASSESSMENT Subjective: “Mahapdi itong dalawang kamay ko” Objective:  Pain scale of 7/10  Minor burn wound on both palm

NURSING DIAGNOSIS Acute pain related to destruction of the skin layer 2° burn injury

SCIENTIFIC EXPLANATION Burn Injury

Trigger inflammatory response

PLANNING Short term goal: After 8 hours of effective nursing intervention the patient will report that pain was reduced as evidenced by:  pain scale of 35/10

Release of chemical mediators such as prostaglandins

NURSING INTERVENTIONS Independent:

RATIONALE

Short term goal:

 Cover wound as soon as possible unless open area exposure burn care is required

 Temperature After 8 hours of rendering changes can cause nursing interventions goal great pain to was met as evidenced by: expose nerve  pain scale of 4/10 endings

 Elevate burned extremity periodically

 Reduce edema formation and discomfort

 Assist with active and passive ROM as indicated

 Movement and exercise reduce muscle fatigue

 no grimaces  absence of irritability

EVALUATION

 no grimaces  absence of irritabil

 Grimace

Edema formation

 Encourage expression of feeling about pain

 Verbalization allows outlet of emotion and enhance coping mechanism

 Provide basic comfort measure such as massage on the un injured area and frequent position changes

 Promotes relaxation and reduces muscle tension

 Irritable Vital Signs: T:36 C P:125bpm R:30cpm BP:130/90mmHg

Compression of nerve endings

Pain

Collaborative:  Administer Tramadol 50mg IV q8 PRN

 For pain relief measure...