Professional Documents
Culture Documents
Katrina Lao NEW NCP
Katrina Lao NEW NCP
DIAGNOSIS INTERVENTION
2nd and 3rd Impaired gas Goal: 1. Provide humidified oxygen. 1. Humidified oxygen Goal Met if
degree exchange Maintenance provides moisture to injured there is
burns all related to of adequate tissues, supplemental absence of
over the carbon tissue oxygen increases alveolar dyspnea,
neck, chest, monoxide oxygenation. oxygenation. respiratory
abdomen, poisoning, rate is
2. These factors provide
and left arm. smoke between 12 to
baseline data for further
Based on inhalation, 20
the rule of and airway 2. Assess breath sounds, and assessment and evidence of breaths/min,
nines the obstruction. respiratory rate, rhythm, depth, increasing respiratory
when lungs
TBSA is and symmetry. Monitor patient compromise. are clear on
31.5%. for signs of hypoxia. 3. These signs indicate auscultation,
possible inhalation injury and arterial oxygen
risk of respiratory saturation is
Vital Signs 3. Observe the following: dysfunction. greater than
a) Erythema or blistering of 96% by pulse
lips or buccal mucosa oximetry and
Temperature: arterial blood
36.6 degrees b) Singed nostrils gas levels are
Celsius c) Burns of face, neck, or within normal
chest limits.