ncp burn.docx

8/13/2019 NCP BURN.docx

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ASSESSMENT NURSING

DIAGNOSISSCIENTIFIC

EXPLANATIONPLANNING NURSING

INTERVENTIONSRATIONALE EVALUATION

Subjective:

“ Parang wala ng pakiramdam dito sa

paa ko”

Objective:

with pitting

edema onthe burn

area

Skin color:

red to brown

Coldclammy

skin onunburned

area

Capillary

refill: 3 secs

Weak in

appearance

Irritable

Lab values:

Hct-66%

Hgb-10

IneffectiveTissue Perfusion

related todecrease blood

flow 2° to

circumferential burns of lowerextremities

Burn injury

Injury to cells andmuscles

Triggeredinflammatory response

Release of chemical

mediators such askinins and histamine

Increase blood vessel

permeability

Fluid shift from IV tointerstitial space

Edema

Decrease blood volume

Decrease venous return

Dec. CO

Dec. tissue perfusion

Short term goal:

After 48 hours ofrendering nursing

intervention, the patient

will be able to:

Verbalizeunderstanding

of condition,therapy regimen

and side effectsof medications

With good

capillary refill of1-2 secs

Skin warm and

dry

Lab valueswithin normal

range:

Hct- 40-54%Hgb- 14-18

Long term goal:

Independent:

Assess color ofthe skin,

movement of

the hands and peripheral pulses andcapillary refill

on extremities

Encourageactive ROM

exercise ofunaffected body

parts

Elevate theaffected

extremities

Collaborative:

IVF: PLR ILx21gtts/min

Edema formation

readilycompresses blood

vessels thereby

impendingcirculation andincreases edema

promotes systemic

circulation/venousreturn

Maximizes

circulating volumeand systemic

circulation

Maintain fluid

replacement and toimprove tissue

perfusion

Short term goal:

After 48 hours of rendnursing intervention t

goal was met as evide

by: The patient

verbalizedunderstanding

condition, therregimen and s

effects ofmedications

Good capillary

of 1-2 secs

Skin warm an

Lab values:

Hct- 33%

Hgb- 11

Long term goal:

After a week ofhospitalization, goal w

met as evidenced by:

Absence of edon lower extre



Vital Signs:

T:36 CP:125 bpm

R:30BP:130/90

After a week ofhospitalization, the

patient will be able todemonstrate increased

perfusion as evidenced by:

Absence ofedema on lower

extremities

Vital signs

within normalrange:

PR=60-100bpmRR=12-20cpm

BP=120/80mmHg

Vital signs witnormal range:

PR=65bpmRR=15cpm

BP=120/80mm



ASSESSMENT NURSINGDIAGNOSIS

SCIENTIFICEXPLANATION

PLANNING NURSINGINTERVENTIONS

RATIONALE EVALUAT

Subjestive:

“ Parang wala ng

pakiramdam ditosa paa ko”

Objective:

With open burn

woundthat

appearsleathery

Skin color:red to

brown

Presence

of eschar

Non

pittingedema on

the burnedarea

VS:

T:36 C

P:125 bpmR:30 cpm

BP:130/90mmHg

Impaired skin

integrity related todisruption of skin

surface and layerssecondary to burn

Burn injury

Cell damage

Destruction of skinlayers

Impaired Skin

Integrity

Short term goal:

After 8 hours of nursing

intervention the patientwill be able to :

participate in prevention

measures andtreatment program

verbalize feelings

of increased self-esteem and ability

to managesituation

Long term goal:

After a week of

hospitalization, the patient will be able

to demonstratetissue regeneration

and achieve timelywound healing as

evidenced by:

moist skin

healing scar absence of edema

on lower

Independent:

Assess or document size,

color, depth of wound,necrotic tissue and

condition of surroundingskin

Assess blood supply and

sensation (nerve damage)of affected area.

Clean the wound area with

hydrogen peroxide

Keep the area clean/dryand stimulate circulation to

surrounding areas

Apply appropriate wounddressing

Maintain appropriatemoisture environment for

particular wound

Remove wet or wrinkledlinens promptly

Provides baseline

information aboutthe affected skin

To evaluate

actual/potentialfor impairment of

circulation tolower extremities

Promotes healing

To assist body’snatural process of

repair

To promotewound healing

and to best meetthe needs of

client

To promotehealing

Moisture potentiates skin breakdown

Short term goa

After 8 hours

nursing intervegoal was met a

evidenced by:

Pt disptimely

healingwound

Pt

participin prev

measurtreatme

program

Pt verbfeeling

increasself-est

and abmanag

situatio

Long term goa

Within patient

hospitan, goalmet as



extremities

Use appropriate padding

devices

Provide optimum nutrition,including foods with

vitamin C and adequate protein intake

Emphasize importance of proper fit of clothing and

shoes

Assist pt to learn stress

reduction and alternatetherapy techniques

Collaborative:

Assist with debridement

To reduce

pressure oncirculation to

compromisedtissues

To provide a positive nitrogen

balance to aid inskin/tissue

healing

For presence ofreduced

sensation/circulation

To control

feelings ofhelplessness and

deal withsituation

To remove

nonviable,contaminated or

infected tissue

eviden by:

the patdemon

tissueregene

and achtimely

woundhealing

eviden by:

moist s

healing

absenc

edema

lowerextrem



ASSESSMENT NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATION

PLANNING NURSING

INTERVENTIONS

RATIONALE EVALUA

Subjective:

“ Nanghihina ako”

Objective:

with

nausea and

vomiting irritable

confused

urineoutput of

15 ml/hour

dark

yellowurine

capillary

refill 3secs

Vital Signs:

T:36 C

P:125bpmR:30cpm

BP:130/90mmHg

Lab results:

HCT=66%

Deficient fluidvolume related

to abnormal fluidloss 2° third

degree burn

Burn injury

Injury to cells andmuscle

Platelet

aggregation

Damage renal

function

Decrease GRF

Presence of

azotemia

Irritation in GI

lining and

alteration in

nervous system

Resulting to n/v,

alterd loc,

weakness and

wt.loss

Short term goal:

After 8 hours of renderingnursing intervention the client

will be able to demonstrateimproved fluid balance as

evidenced by:

no complaints of nauseaand vomiting

absence of irritability

capillary refill of 1-2secs

Long term goal:

After 1-2 days of nursing

intervention, the patient will

demonstrate improved fluid balance as evidenced by:

adequate urineoutput of 60ml/hr –

100ml/hr

appropriate LOC

Vital signs within

normal range:

T=36.5-37.5 CP=60-100bpm

R=12-20cpmBP=140-100/80-

90mmHg

Independent:

Monitor vitalsigns, and

capillary refill

Monitor urine

output color

Investigate

changes inmentation

Collaborative:

Insert indwelling

urinary catheter

Administer PLRS

1L 158 gtts/minfor first 8 hours

Administer

PLRS1L79gtts/min for the

next 16 hours

Baseline data

Allow for closeobservation of renal

function and prevent

urinary retention

Deterioration in thelevel of conciousness

may indicateinadequate circulating

volume

Allows for closeobservation of renal

function and preventurinary retention

Fluid resuscitationreplaces loss of fluids

and electrolytes

Short term goa

After 8 hours rendering an ef


evidenced by:

no comn/v

no irrita

capillar2 secs

V/S as foll

T:36 CP:120bp

R:20cp

BP:110

Long term goa

After 1-2 days


evidenced by:

patientdemon

improv balance

eviden

urin

of75m



appLO

Vitawith

norrang

T=36 C

P=120bR=20cp

BP=11g



ASSESSMENT NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATION

PLANNING NURSING

INTERVENTIONS

RATIONALE EVALUATION

Subjective:

“Mahapdi itong

dalawang kamayko”

Objective: Pain

scale of7/10

Minor

burnwound

on both palm

Grimace

Irritable

Vital Signs:

T:36 CP:125bpm

R:30cpmBP:130/90mmHg

Acute pain related

to destruction ofthe skin layer 2°

burn injury

Burn Injury

Trigger

inflammatory

response

Release ofchemical mediators

such as prostaglandins

Edema formation

Compression of

nerve endings

Pain

Short term goal:

After 8 hours of effective

nursing intervention the patient will report that

pain was reduced as

evidenced by:

pain scale of 3-5/10

no grimaces

absence of

irritability

Independent:

Cover wound as

soon as possibleunless open area

exposure burn care

is required

Elevate burnedextremity

periodically

Assist with activeand passive ROM

as indicated

Encourageexpression of

feeling about pain

Provide basiccomfort measure

such as massage onthe un injured area

and frequent position changes

Temperature

changes can causegreat pain to

expose nerve

endings

Reduce edemaformation and

discomfort

Movement andexercise reduce

muscle fatigue

Verbalizationallows

outlet of emotionand enhance

copingmechanism

Promotesrelaxation and

reduces muscletension

Short term goal:

After 8 hours of rende

nursing interventions gwas met as evidenced b

pain scale of 4

no grimaces

absence of irrita



Collaborative:

AdministerTramadol 50mg IV

q8 PRN

For pain reliefmeasure

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