Nursing Care Plan Nursing Diagnosis Ineffective airway clearance related to edema secondary to circumferential burns as evidenced by burned

areas in neck and chest, difficulty of breathing, cyanosis and RR of 10 bpm. Expected Outcome Client will be able to demonstrate clear breath sounds, respiratory rate within normal range, be free of dyspnea and cyanosis within 2 days of nursing intervention. Nursing Intervention 1. Obtain history of injury. Note presence of preexisting respiratory conditions, history of smoking. Evaluation Discharge Planning Goal met, client 1. Patient should finish able to demonstrate any prescription for clear breath antibiotics, even if sounds, normal he/she is feeling well. 2. Assess gag/swallow reflexes; note respiratory rate, If there is any drooling, inability to swallow, free of dyspnea and concern of an allergic hoarseness, wheezy cough. cyanosis as reaction, please call evidenced by: the doctor. 3. Monitor respiratory rate, rhythm, 2. Patients should start Absence of depth; note presence with small, frequent wheezing of pallor/cyanosis and carbonaceous meals. Diet Absence of or pink-tinged sputum. restrictions on dyspnea discharge vary from Absence of 4. Auscultate lungs, noting patient to patient, and cyanosis stridor,wheezing/crackles, diminished will be reviewed with RR of 18 breath sounds, brassy cough. the patient before bpm. discharge. 5. Note presence of pallor or cherry3. Taking naps and red color of unburned skin. engaging in light activity will help. 6. Investigate changes in Patients should avoid behavior/mentation, strenuous activity, ex.., restlessness, agitation, driving, heavy lifting, confusion. and contact sports, until cleared by the 7. Elevate head of bed. Avoid use of doctor at the followpillow under head, as indicated. up visit 8. Encourage coughing/deepbreathing exercises and frequent position changes. 9. Administer humidified oxygen via appropriate mode, e.g., face mask. 10. Prepare for/assist with intubation or tracheostomy, as indicated.

4. Patients may have physical or occupational therapy home visits to assist in their recovery. 5. Inform for follow-up visit.

Nursing Diagnosis Impaired gas exchange related to carbon monoxide poisoning secondary to smoke inhalation as evidenced by difficulty of breathing, severe headache, nausea and vomiting, pale, PR-142 bpm, RR-10 bpm.

Expected Outcome Client will be able to maintain adequate tissue oxygenation within 8 hours of nursing intervention.

Nursing Intervention 1. Note respiratory depth, rate, use of accessory muscles, pursed lip breathing. 2. Auscultate breath sounds, note areas of decreased/adventitious breath sounds as well as fremitus. 3. Monitor vital signs and cardiac rhythm. 4. Evaluate pulse oximetry to determine oxygenation, 5. Review other pertinent laboratory data. (ABGs, CBC, CXR.) 6. Elevate head of bed/position client appropriately, mobilization as indicated to maintain airway. 7. Encourage deep breathing exercises, chest-physiotherapy to promote optimal lung expansion and drainage of secretions. 8. Maintain adequate I/O, for mobilization ofsecretions. 9. Encourage adequate rest and limit activities to within client tolerance. 10. Provide psychological support, active-listening to reduce anxiety. 11. Administer medications as indicated to treat underlying conditions. 12. Keep environment allergen free to reduce irritant effect of dust and chemicals on airways. 13. Emphasize the importance of nutrition in improving stamina and reducing the work of breathing.

Evaluation Goal met, client able to maintain adequate tissue perfusion as evidenced by stable vital signs stable vital signs t37C, PR-86 bpm, RR-18 bpm. And absence of : DOB Severe headache Nausea and vomiting Paleness

Discharge Planning 1. Review how and when to take these medications, what the drugs are used for, and any possible side effects before leaving the hospital. If there is any concern of an allergic reaction, please advice to call the doctor. 2. Encourage to have nutritious diet with plenty of fluids is important in the healing process. Diet restrictions on discharge vary from patient to patient, and will be reviewed with the patient before discharge. 3. Taking naps and engaging in light activity will help. Patients should avoid strenuous activity, driving, heavy lifting, and contact sports, until cleared by the doctor at the follow-up visit. 4. During recovery, patients may need equipment such as crutches, a wheelchair, or a shower seat. 5. Patients will be told how often theyll need to be seen for follow-up appointments after discharge

Nursing Diagnosis Fluid volume deficit related to increased capillary permeability and evaporative losses from the burn wound as evidenced by confusion, dry mucous membranes, urinary output of 10 cc per hour, T-38.9 C, PR142bpm, BP-80/40 mmhg.

Expected Outcome Client will be able to maintain fluid volume at a functional level after 2 days of nursing intervention.

Nursing Intervention 1. Assess and monitor vital signs and note for the capillary refill and strength of pulses. 2. Monitor urinary output of client. 3. Assess for the estimate of wound drainage and insensible loss. 4. Strictly document the amount and type fluid used during replacement therapy 5. Weigh client daily. 6. Investigate changes in mentation. 7. Observe for presence of gastric distention, hematemesis, and tarry stools. 8. Insert and maintain an indwelling catheter as indicated. 9. Insert and maintain large bore IV cannula. 10. Administer intravenous fluids as indicated. 11. Monitor laboratory results like hemoglobin, hematocrit, and electrolyte levels. 12. Administer medications like diuretics, potassium, and antacids.

Evaluation Goal met, client able to maintain a functional level of fluid volume as evidenced by: moist mucous membranes adequate urinary output (35 cc per hour), stable vital signs (37C, PR-86 bpm, RR-18 bpm, BP-90/60 mmhg)

Discharge Planning 1. Review how and when to take these medications, what the drugs are used for, and any possible side effects before leaving the hospital. 2. A well-rounded, nutritious diet with plenty of fluids is important in the healing process. 3. Activity is important for increasing the circulation, preventing loss of muscle strength, and improving general well-being. 4. Home Care Supplies and Equipment during recovery, patients may need equipment such as crutches, a wheelchair, or a shower. 5. For wound and bandage care, The patients incision should be kept clean and dry. The patient (or a designated person) should gently cleanse the skin around the incision daily with mild soap and water. Steri-strips can be allowed to fall off on their own. Check with the doctor about when to start showering or bathing. All instructions for more specialized wound care will be provided by the nurse or doctor.

SITUATION

A 36 year old man working in a factory was found after the fire had erupted in the building. He sustained a deep-partial burn on his face, neck, chest and right leg. He was brought subsequently to the nearest hospital. On the way to the hospital, the client complained of difficulty of breathing, severe headache, and continuously asking what had happened. After thorough examination it has been found that the client has laryngeal edema due to circumferential burn on the neck, blanch test of 4 seconds, paleness and dry mucous membranes. With vital signs of: t-38.9 pr-142 rr-10bpm bp-80/40 mmhg. urinary output of 10 cc per hour

NURSING CARE PLANS ACCORDING TO PRIORITY OF CARE ACTUAL NURSING DIAGNOSIS 1. Ineffective airway clearance related to edema secondary to circumferential burns. 2. Impaired gas exchange related to carbon monoxide poisoning secondary to smoke inhalation. 3. Fluid volume deficit related to increased capillary permeability and evaporative losses from the burn wound. 4. Infective tissue perfusion related to hypovolemia. 5. Acute pain related to destruction of skin. 6. Altered nutrition less than body requirements related to hypermetabolic state. 7. Impaired skin integrity related to disruption of skin surface/layers 8. Impaired physical mobility related to pain/discomfort. 9. alteration in comfort related to burn injury and treatment. 10. Fear anxiety related to memory of trauma experienced. 11. Knowledge deficit regarding condition related to information misinterpretation. POTENTIAL NURSING DIAGNOSIS. 1. Risk for infection related to burn injury.