ASSESSMENT

ASSESSMENT
ASSESSMENT NURSING NURSING
NURSING PLANNING
PLANNING
PLANNING NURSING
NURSING
NURSING RATIONALE
RATIONALE
RATIONALE
DIAGNOSIS
DIAGNOSIS
DIAGNOSIS INTERVENTIONS
INTERVENTIONS
INTERVENTIONS
Objective:
Objective:
Objective:
ASSESSMENT Impaired
Acute
Ineffective
NURSING skinpain related
ShortShort
Short
term term
term
goal:
PLANNING goal:
goal: Independent:
Independent:
Independent:
NURSING RATIONALE
 Pain integrity toTissue
destruction
related
DIAGNOSIS Perfusion
to of INTERVENTIONS  Edema formation
 With
Objective: open
with
scale
pitting
disruption
of the
related
Deficient skin
of skin
fluidlayer
to 2° After
Short After
After
term 8 hours
48
8 hours
goal: hours
of nursing
ofofeffective Independent:
  Assess
 Cover
Assess
or wound
document
color as
of size, readily
Temperature
 Provides baseline
 burn
with edema
7/10 onsurface
burn
volume decrease
and injury
layers
related blood intervention
rendering
nursing intervention
the
nursing
patient the color,
soon
thedepth
skin,
as possible
of wound,  compresses
changes
information
Baseline can
blood
data causeabout
wound the burn secondary
flow to2°burn
to will intervention,
patient
be
nausea and to abnormal fluid After 8 hours of rendering able will
to : report
the patient
that necrotic
unless
movement
tissue
 Monitor vitalopen and
area
of vessels
great
the
thereby
pain
affected
to skin
that area
vomiting Minorloss 2°circumferential
third nursingwill
pain be
wasable
interventionreduced
to:the as client condition
exposure
the hands
signs, of surrounding
and burn
andcare impending
expose nerve
appears
 Skin
 irritable burncolor: burns
degree burn of lower evidenced by:
will be able to demonstrate skinisperipheral
required
capillary refill circulation
endings
 Allow for and
close
 leatheryredwound
confused to extremities improved  fluidparticipate
 Verbalize
balance in as pulses and increases
observationedema of renal
 Skin
urine color:
brown
on both evidenced by: prevention
 understanding
pain scale of 3-  Assess
Elevate
capillary
blood
 Monitor urine burned
supply
refill and  Reduce
 To edema
evaluate
function and prevent
red toCold
output palm
of  no measures of
5/10
complaintscondition,
andof nausea sensation
extremity
on extremities
output (nerve damage)
color formation
urinaryactual/potential
and
retention
brown clammy
15 ml/hour andtreatment
therapyprogram
vomiting regimen of affected
periodicallyarea.  promotes
discomfort
forsystemic
impairment of
 Presence
darkskinGrimace
on  absence  andnoofgrimaces
side effects
irritability  Encourage circulation/venous
circulation to
ofyellow
eschar
unburned  capillary
verbalize
of medications
feelings
refill of 1-  Assist
activewith ROM active return
Movement
lower extremities
Deterioration and
in the
 Nonurinearea
Irritable of
2secs increased
absence of
self- and
exercise
passive
 Investigate of ROM exercise reduce
level of conciousness
 pitting
 Capillary
capillary esteem
 Withirritability
andgoodability  Clean asunaffected
indicated
the wound
changes in body area with muscle
may Promotes
fatigue healing
 indicate
Vital
edema
Signs:
refill:
on
refill 3secs 3 secs to
Long term goal:capillary
manage refill of hydrogen
parts
mentation peroxide inadequate circulating
theburned
Weak in situation
1-2 secs  Encourage  Maximizes
Verbalization
volume
T:36
area
C
Vital Signs: appearance After 1-2 days of nursing  Keep
 expression
Elevate
the areathe
clean/dry
of circulating
allows
 To assistvolume body’s
P:125bpm
 Irritable Long term
intervention,  goal:
Skinpatient
the warm willand andfeeling
stimulate
affected aboutcirculation
pain to andoutlet
systemic
natural
of emotion
process of
VS: R:30cpm
T:36 C dry
demonstrate improved fluid surrounding
extremities areas circulation
and enhance
repair
BP:130/90mmHg
P:125bpm  Lab values: balanceasAfter a week
evidenced by:of coping
T:36 C
R:30cpm hospitalization,
 Lab values the  Apply appropriate wound
Dependent: mechanism
 To promote
P:125 bpm
BP:130/90mmHg Hct-66% patient
within
 adequate urine will normal
be able Dependent:
dressing  Allows wound healing
for close
R:30 cpm Hgb-10 to demonstrate
output range:
of 60ml/hr – Provide
 Insert
 basic
indwelling Promotes
and toof
 observation best meet
renal
BP:130/90mmHg
Lab results: tissue
100ml/hr regeneration comfort measure
urinary catheter  Maintain
relaxation
the fluid
needs
and
function and prevent of
HCT=66% and Hct-
 appropriate achieve 40-54%
LOC timely  IVF: suchPLR as massage
IL on replacement
reduces
urinaryclientmuscle
and to
retention
woundHgb-
 Vital signs within healing
14-18 as x21gtts/min
the un injured area improve
tension tissue
evidenced
normal range:by:  Maintain
and frequent
appropriate  perfusion
To promote
 resuscitation
Fluid
Vital Signs: moisture
position environment
 Administer PLRS changes for healing
replaces loss of fluids
T=36.5-37.5
moist skinC particular
1L 158 wound
gtts/min and electrolytes
T:36 C Long term goal:
P=60-100bpm
healing scar for first 8 hours
P:125 bpm R=12-20cpm
absence of edema  Remove wet or wrinkled  Moisture
R:30 After a week of
BP=140-100/80- linens promptly
Administer potentiates skin
on lower
BP:130/90 hospitalization,
90mmHg the PLRS1L breakdown
extremities
patient will be able to 79gtts/min for the
demonstrate increased Dependent:
 Usenext 16 hours padding
appropriate  To reduce
perfusion as evidenced devices pressure on
by:  Administer  For pain
circulation
relief to
 Absence of Tramadol 50mg IV measure
compromised
edema on lower q8 PRN tissues
extremities
 Vital signs
ASSESSMENT NURSING PLANNING NURSING RATIONALE
DIAGNOSIS
INTERVENTIONS

Objective: Imbalanced Long term goal: Independent:

Nutrition: Less
 Weight After 2 days of rendering  Provide small,  Helps prevent gastric
Than Body
loss Requirements nursing intervention the client frequent meals and distension or
 BMI is will be able to demonstrate snacks. discomfort and may
related to
below Hypermetabolic nutritional intake adequate to enhance intake.
normal state (can be as meet metabolic needs as  Encourage patient  Calories and proteins
much as 50%– evidenced by stable to view diet as a are needed to maintain
60% higher than weight/muscle-mass treatment and to weight, meet
normal measurements, positive nitrogen make food or metabolic needs, and
proportional to balance, and tissue beverage choices promote wound
the severity of regeneration. high in calories healing.
injury) Possibly and protein.
evidenced by
 Encourage patient  Sitting helps prevent
Decrease in total
body weight, to sit up for meals aspiration and aids in
loss of muscle and visit with proper digestion of
mass/subcutaneo others. food. Socialization
us fat, and promotes relaxation
development of and may enhance
negative nitrogen intake.
balance

 Provide oral
 Clean mouth and clean
hygiene before palate enhances taste
meals. and helps promote a
good appetite.

Dependent:

 Refer to dietitian  Useful in establishing

or nutrition individual nutritional
support team. needs (based on