Professional Documents
Culture Documents
kin color: red to brown Cold clammy skin on unburned area Capillary refill: 3 secs Weak in appearance Irritable Lab values: Hct-66% Hgb-10
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 Decrease blood volume Decrease venous return Dec. CO Dec. tissue perfusion
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 Lab values within normal range: Hct- 40-54% Hgb- 14-18
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 Edema formation readily compresses blood vessels thereby impending circulation and increases edema promotes systemic circulation/venous return
EVALUATION Short term goal: After 48 hours of rendering nursing intervention the goal was met as evidence by: The patient verbalized understanding of the condition, therapy regimen and side effects of medications Good capillary refill of 1-2 secs
Collaborative: IVF: PLR IL x21gtts/min Maintain fluid replacement and to improve tissue perfusion
Long term goal: After a week of hospitalization, goal was met as evidenced by: Absence of edema on lower extremities
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
PLANNING Short term goal: After 8 hours of nursing intervention the patient will be able to : participate in prevention measures and treatment program 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
NURSING INTERVENTIONS Independent: Assess or document size, color, depth of wound, necrotic tissue and condition of surrounding skin Assess blood supply and sensation (nerve damage) of affected area.
RATIONALE
Cell damage
After 8 hours of nursing intervention goal was met as evidenced by: Pt displayed timely healing of wounds Pt participated in prevention measures and treatment program Pt verbalized feelings of increased self-esteem and ability to manage situation Long term goal: Within the patients hospitalizatio n, goal was met as
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
To evaluate actual/potential for impairment of circulation to lower extremities Promotes healing To assist bodys natural process of repair To promote wound healing and to best meet the needs of client To promote healing Moisture potentiates skin breakdown
Clean the wound area with hydrogen peroxide Keep the area clean/dry and stimulate circulation to surrounding areas Apply appropriate wound dressing
Maintain appropriate moisture environment for particular wound Remove wet or wrinkled linens promptly
extremities Use appropriate padding devices To reduce pressure on circulation to compromised tissues To provide a positive nitrogen balance to aid in skin/tissue healing For presence of reduced sensation/circulat ion To control feelings of helplessness and deal with situation
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 alternate therapy techniques
evidenced by: the patient demonstrated tissue regeneration and achieved timely wound healing as evidenced by: moist skin healing scar absence of edema on lower extremities
ASSESSMENT Subjective: Nanghihina ako Objective: 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%
NURSING DIAGNOSIS Deficient fluid volume related to abnormal fluid loss 2 third degree burn
SCIENTIFIC EXPLANATION Burn injury Injury to cells and muscle Platelet aggregation
PLANNING Short term goal: After 8 hours of rendering nursing intervention the client will be able to demonstrate improved fluid balance as evidenced by: no complaints of nausea and vomiting absence of irritability capillary refill of 12secs Long term goal: After 1-2 days of nursing intervention, the patient will demonstrate improved fluid balance as evidenced by:
NURSING INTERVENTIONS Independent: Monitor vital signs, and capillary refill Monitor urine output color
RATIONALE Baseline data Allow for close observation of renal function and prevent urinary retention Deterioration in the level of conciousness may indicate inadequate circulating volume
EVALUATION Short term goal: After 8 hours of rendering an effective 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:
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 Allows for close observation of renal function and prevent urinary retention Fluid resuscitation replaces loss of fluids and electrolytes
Administer PLRS 1L 158 gtts/min for first 8 hours Administer PLRS1L 79gtts/min for the next 16 hours
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
ASSESSMENT Subjective: Mahapdi itong dalawang kamay ko Objective: Pain scale of 7/10 Minor burn wound on both palm Grimace Irritable Vital Signs: T:36 C P:125bpm R:30cpm BP:130/90mmHg
NURSING DIAGNOSIS Acute pain related to destruction of the skin layer 2 burn injury
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
NURSING INTERVENTIONS Independent: Cover wound as soon as possible unless open area exposure burn care is required Elevate burned extremity periodically Assist with active and passive ROM as indicated Encourage expression of feeling about pain
RATIONALE
Temperature After 8 hours of rendering changes can cause nursing interventions goal great pain to was met as evidenced by: expose nerve endings pain scale of 4/10 Reduce edema formation and discomfort Movement and exercise reduce muscle fatigue Verbalization allows outlet of emotion and enhance coping mechanism Promotes relaxation and reduces muscle tension no grimaces absence of irritability
Edema formation
Compression of nerve endings Provide basic comfort measure such as massage on the un injured area and frequent position changes
Pain