NCP

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjectives: Ineffective airway Short term Independent: Short term
“Hindi po ako clearance related to After 8 hrs of nursing -Assess vital signs, -Vital signs assessment After 8 hrs of nursing
makahinga ng maayus” increased congestion interventions, the focusing on respiratory can help provide the interventions, the
as verbalized by the in the airway passages patient is expected to: rate and rhythm, depth nurse information on patient is:
patient secondary to smoke  Patent airway by of respirations and the extent of airway  Demonstrate
inhalation as expectorating symmetrical chest impairment that the improved airway
Objectives: evidenced by difficulty retained sputum expansions injury causes to the patency as
-Difficulty of breathing of breathing, presence  relieved from patient. This also helps  Have decreased
-inspiratory and of inspiratory and dyspnea by set the baseline for coughing
expiratory wheezing expiratory wheezing, participating in evaluation of care. episodes
noted sooty sputum breathing Long Term
- persistent cough production, persistent exercise, - Obtain history of burn - Causative burn injury After 2 – 3 days of
- Sooty sputom cough and use of effective exposure. Note agent (e.g., flames, nursing interventions,
 - use of accessory accessory muscles coughing and presence of preexisting chemicals), the patient
muscles when when breathing. use of oxygen respiratory conditions duration of exposure,  have an
breathing. technique as and any history of and whether exposed Improved
- decrease lung evidence by smoking. in closed or ventilation and
expansion absent of nasal open space predict adequate
-burn wounds spread flaring, shortness probability of oxygen lung
over the right anterior of breath easy inhalation injury. Type tissue as
and posterior thorax fatigability and of material burned, evidenced by
- mucosal edema absence of such as wood, plastic, normal arterial
-loss of ciliary action Crackles or wool, blood gasses and
suggests type of toxic clear breath
-(MRI) of the chest and Long Term gas exposure. sounds
abdomen revealed a After 2 – 3 days of Preexisting conditions  Demonstrate
right pneumothorax nursing interventions, increase the risk of improved airway
-O2 saturation of 94% the patient will respiratory patency as
 have an complications. evidenced by
VS: Improved clear breath
T: 37.5 C ventilation and - Assess gag and - Suggestive of sounds
RR: 27 adequate swallow reflexes; note inhalation injury,  ABGs and other
BP:130/110 oxygen lung upper airway burns, which may develop laboratory
PR: tissue as drooling, inability to over several days. values within
evidenced by swallow, hoarseness, normal limits
normal arterial and wheezy Patient verbalized: “
blood gasses and cough. Mabuti na aking
clear breath paghinga, hindi na ganun
sounds - Auscultate lungs, - Airway obstruction kabigat tulad noong
 Demonstrate noting stridor, and respiratory nakaraan”
improved airway wheezing, crackles, distress can occur very
patency as diminished breath quickly or may be ABGs:
evidenced by sounds, and brassy delayed, for example, Arterial Blood Ph: 7. 39
clear; breath cough. up to 3 days after SaO2: 97%
sounds burn. HC03: 24 mEq/L
 ABGs and other
laboratory - Investigate changes in - Although often VS
values within behavior and related to pain, T: 37 C
normal limits mentation, such as changes in RR: 20
 VS within normal restlessness, agitation, consciousness BP: 130/110
Limits and confusion. may reflect PR: 72
developing, worsening
hypoxia or effects of
inhaled toxins,
especially carbon
monoxide.

-Observe the patient -These surrounding

for other signs of structures are also
inhalation injury such important in air
as damage to the exchange and may
circumoral mucosa, cause disruptions in
burns along the airway clearance when
nostrils, face or neck. injured or damaged.

-Monitor 24- hour fluid - Fluid shifts or excess

balance, noting fluid replacement
variations or changes. increase risk of
pulmonary edema.
Note: Inhalation injury
increases fluid
demands as much as
35% or more because
of edema and
fluid shifts.

- Position the patient in - Positioning the

semi-Fowler’s or high patient this way helps
Fowler’s position. in promoting optimal
lung expansion and
removal of secretions.
It also allows the
patient to be
positioned
comfortably.

- Encourage coughing, -Promotes lung

deep- breathing expansion,
exercises, and frequent mobilization, and
position changes. drainage of
secretions.

Promote voice rest, but - Increasing hoarseness

assess ability to speak or decreased ability to
and/or swallow
swallow oral secretions suggests increasing
periodically. tracheal edema and
may indicate
need for prompt
intubation.

- Instruct patient and - These all help in

significant others on establishing a patent
how to turn patient airway, maintaining
properly on bed, optimum lung capacity
coughing and deep and promote
breathing exercises independence for self-
and use of incentive care.
spirometer.

Collaborative: -Humidified oxygen

- Provide the patient therapy helps meet
with oxygen therapy the needs of the
when needed. patient for tissue
perfusion and reduces
the risk for hypoxia.

-Monitor serial ABGs. Baseline is essential for

further assessment of
respiratory
status and as a guide
to treatment.

- Provide or assist with - Chest physiotherapy

chest physiotherapy drains dependent
and incentive areas of the lung,
spirometry, as and incentive
 indicated. spirometry may be
done to improve lung
expansion, thereby
promoting respiratory
function and
reducing atelectasis

Dependent
- Prepare for, or assist - Intubation and
with, intubation or mechanical support is
tracheostomy and required when airway
mechanical ventilation, edema or
as indicated. circumferential burn
injury interferes with
respiratory function
and oxygenation

Comment:

- Ilagay mo yung about sa sooty sputum, then add mo din yung edema sa diagnosis
- Okay naman yung diagnosis, kaso parang gusto ni sir maiksi lang kapag may secondary to… gusto naman ni maam kriza ay may as evidenced by…
hahahaha.
- Identify mo yung sa planning yung long term at short term goal mo
 Ilagay mo yung duration ng nursing intervention, ilang oras?
 Medyo mahirap maachieve agad ang clear breath sound sa lagay ng pasyente dahil malubha yung condition so more likely na long term goal
siya
 Coughing episodes, di ko alam… kasi siguro dapat turuan pa nga siyang magcough para maexpectorate yung plema (kasi may sooty sputum)
 Madaming lung complication si pasyente, so yung ABG ay dapat ay within tolerable range lang, di kasi kaya sa isang shift lang
 Pwede ka pang magdadag ng goals mo (both short term at long term
 - Dagdagan mo pa yung mga intervention mo, madami ka pang makukuha sa nanda
- Identify mo kung ano diyan yung independent, dependent, at collaborative
- Lagyan mo ng vital signs yung evaluation as well as ABG results kasi indicated yun sa planning mo
- Pwede ka din magdadag ng mga statement ni client to prove na effective ang intervention

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective: Acute Pain related to After 8 hrs of Nursing Independent: After 8 hrs of Nursing
“Puro kayo tanong eh Burn Wounds as intervention the patient - Assess reports of severity of tissue intervention the patient
ang sakit na nga ng evidenced by v, will: pain, noting location involvement and will:
mga sugat ko at gusto narrowed focus, facial  Report pain and character and destruction but is  Display relaxed
ko na lang din mask of pain, reduced/controll intensity (0–10 scale). usually most severe facial
magpahinga” as restlessness ed. during dressing expressions/bod
verbalized by the  Display relaxed changes and y posture.
patient facial debridement. Changes  Participate in
expressions/bod in location, character, activities and
“masakit nga raw sugat y posture. intensity of pain may sleep/rest
ni kuya hanggang  Participate in indicate developing appropriately
ngayon after nung activities and complications (limb  Report pain
debridement” as sleep/rest ischemia) or herald reduction
verbalized by the SO appropriately. improvement and/or Patient Verbalized:
of the patient return of nerve “Makakatulog na ako
function and nito dahil d na
- visual analog scale sensation. gasyanong sumasakit
score for pain was 7 - Change position - Movement and ang sugat ko”
frequently and assist exercise reduce joint
Objective: with active and passive stiffness and muscle Patient visual analog
-burn wounds were ROM as indicated. fatigue, but type of scale score for pain is 2
spread over the right exercise depends on
anterior and posterior location and extent of VS
thorax, bilateral hips, injury. T: 37 C
bilateral lower limbs, RR: 20
and upper right limbs, -Movement and -Temperature BP: 130/110
with a total burn exercise reduce joint regulation may be lost PR: 72
surface area of 17 stiffness and muscle with major burns.
percent (TBSA). fatigue, but type of External heat sources
- Narrowed focus exercise depends on may be necessary to
-facial mask of pain location and extent of prevent chilling.
- restlessness injury.
-fatigue
- Encourage expression - Verbalization allows
VS: of feelings about pain. outlet for emotions
and may enhance
coping mechanisms.

- Explain procedures - Empathic support

and provide frequent can help alleviate pain
information as and/or promote
appropriate, especially relaxation.
during wound
debridement.

- Provide basic comfort - Promotes relaxation;

measures: deep reduces muscle
breathing exercise, tension and general
massage of uninjured fatigue
areas, frequent
position changes.

- Provide diversional
activities appropriate - Helps lessen
for age and condition. concentration on pain
 experience and refocus
attention.
- Promote
uninterrupted sleep - Sleep deprivation can
periods. increase perception of
pain/reduce coping
Dependent abilities.
- Cover wounds as
soon as possible unless - Temperature changes
open-air exposure burn and air movement can
care method required. cause great pain to
exposed nerve
endings.
- Wrap digits or
extremities in position - Position of function
of function (avoiding reduces deformities or
flexed position of contractures and
affected joints) using promotes comfort.
splints and foot boards Although flexed
as necessary. position of injured
joints may feel more
comfortable, it can
lead to flexion
contractures.
- Provide medication
and/or place in - Reduces severe
hydrotherapy (as physical and emotional
appropriate) before distress associated
performing dressing with dressing changes
changes and and debridement.
debridement.

- Administer analgesics
 (narcotic and - The burned patient
nonnarcotic) as may require around-
indicated: morphine the-clock medication
and dose titration.
Subjective Deficient Fluid Volume Short Term: Independent: Short term:
-“Nanghihina po nurse related to After 8 hrs of nursing -Monitor heart rate - Tachycardia and After 8 hrs of nursing
ang aking kapatid” Compromised intervention the patient (HR), BP, and JVD/CVP. hypertension can intervention the patient :
mechanism (renal will: occur because of: (1)  Have equal
-“Hindi po gasyano failure) as evidenced  Have equal failure of the kidneys intake and
nag-iihi ang aking by oliguria, weakness, intake and to excrete urine, (2) output
kapatid” as verbalized nausea, nausea, output excess fluid  Increase range
by the SO vomiting, edema on  Increase range resuscitation during of motion
both extremities, of motion efforts to treat  Vital Signs
OBJECTIVES decrease range of  Vital Signs hypovolemia and/or within normal
-weakness motion, restlessness, within normal hypotension or ranges
-nausea urine output 400 ranges convert “Medyo ayus naman
-vomiting mL/24 hrs, Urine: Long term: ngayon ang kalagayan ng
- 2+ edema on both Sodium Lvl of 40 After 1-2 days of nursing - Accurately record - Decrease in output aking kapatid hindi tulad
extremities mEq/L intervention the patient intake and output (to less than 400 ml kanina na nanghihina” as
-decrease range of will: (I&O) noting to include per 24 hours) may verbalized by the SO of
motion  Maintain equal “hidden” fluids such as indicate acute failure, the Patient
-restlessness intake and IV antibiotic additives, especially in high-risk
output liquid medications, patients. Accurate Long term:
Diagnostic Study:  Absence of frozen treats, ice chips. monitoring of I&O is After 1-2 days of nursing
- urine output 400 edema Religiously measure necessary for intervention the patient:
mL/24 hrs  Maintain normal gastrointestinal losses determining renal  Maintain equal
-Urine: Sodium Lvl of ranges of vital and estimate insensible function and fluid intake and
40 mEq/L signs losses (sweating), replacement needs output
including wound and reducing risk of  Absence of
VS drainage, nasogastric fluid overload. edema
T: 37.5 C outputs, and diarrhea.  Maintain normal
RR: 27 ranges of vital
BP:130/110 - Monitor urine specific -to Measures the signs
PR: gravity. kidney’s ability to “Mayus naman na ang
concentrate urine. aking pakiramdam
nurse, nakakaihi na rin
- Weigh daily at same - Daily body weight is ako ng madalas, nawala
time of day, on same best monitor of fluid na rin ang pamamanas
scale, with same status. A weight gain ng aking binti at hindi na
equipment and of more than 0.5 ako nanghihina”
clothing. kg/day suggests fluid
retention Diagnostic Study:
Urine Output 900 mL/24
- Assess skin, face, - Edema occurs hrs
dependent areas for primarily in dependent Urine Sodium lvl: 20
edema. Evaluate tissues of the body, mEq/L
degree of edema (on (hands, feet,
scale of +1–+4) lumbosacral area). Vital Signs:
Patient can gain up to T: 37 C
10 lb (4.5 kg) of fluid RR: 20
before pitting edema is BP: 130/110
detected PR: 72

-Auscultate lung and Fluid overload may

heart sounds. lead to pulmonary
edema and HF
evidenced by
development of
adventitious breath
sounds, extra heart
sounds.

- Assess level of - May reflect fluid

consciousness. shifts, accumulation of
Investigate changes in toxins, acidosis,
mentation, presence of electrolyte imbalances,
restlessness. or developing hypoxia.

- Scatter desired - Helps avoid periods

beverages throughout without fluids,
the 24-hour period and minimizes boredom of
give various offering limited choices, and
(hot, cold, frozen). reduces sense of
deprivation and thirst.

- Use appropriate - Patient with CNS

safety measures involvement may be
(raising side rails and dizzy and/or confused.
restraints.

Collaborative:

- Correct any reversible - Kidneys may be able

cause of ARF: replace to return to normal
blood loss, maximize functioning,
cardiac output, preventing or limiting
discontinue residual effects.
nephrotoxic drug,
relieve obstruction via
surgery.

-Monitor laboratory -to see if the renal

and diagnostics study failure is controlled or
such as Urinalysis, CBC, worsen and create a
and Chest X-rays. plan of action bases on
the needs of the
patient
Independent: - Fluid management is
Administer and/or usually calculated to
restrict fluids as replace output from all
indicated. sources plus estimated
insensible losses
(metabolism,
diaphoresis). Prerenal
failure (azotemia) is
treated with volume
replacement and/or
vasopressors.

-Administer medication - to convert to non-

as ordered such as oliguric phase, flush
diuretics and the tubular lumen of
Vasodilators. debris, reduce
hyperkalemia, and
promote adequate
urine volume, to
decrease SVR and
increase renal blood
flow

-Insert indwelling -to lower tract

catheter, as indicated. obstruction and
provides means of
accurate monitoring of
urine output during
acute phase

-Prepare for renal - Done to reduce

replacement therapy volume overload,
(RRT) as indicated, correct electrolyte and
 such as hemodialysis acid- base imbalances,
(HD), peritoneal and remove toxins.
dialysis (PD), or
continuous renal
replacement therapy
(CRRT).

Comment:

- Di ako sigurado kung tama bang dalawang pang respi or airway ang unang dalawang priority, kasi pwede mom o silang ipagcombine sa iisang care
plan, daanin mo nalang sa nursing intervention
- I suggest na pain dahil sa 2nd dgree burn, at deficient fluid volume dahil sa edema (may renal failure pa)
- Tumingin ka dito sa page 740: https://drive.google.com/file/d/11jdHDHxS1V_6J-Ivg0MfF5Bsk5bCIUKj/view?usp=sharing
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