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NCP for Combustion (Burning) - 5 Nursing Diagnosis and Interventions

Maz CK

NCP for Combustion (Burning) - 5 Nursing Diagnosis and Interventions
A burn is an injury to the skin or other organic tissue primarily caused by heat or due to radiation, radioactivity, electricity, friction or contact with chemicals.

Thermal (heat) burns occur when some or all of the cells in the skin or other tissues are destroyed by:

  • hot liquids (scalds)
  • hot solids (contact burns), or
  • flames (flame burns).(https://www.who.int)

Nursing Diagnosis :

  1. Fluid volume deficit related to active fluid loss
  2. Acute pain related to burn injury
  3. Impaired skin integrity related to open wounds
  4. Hyperthermia related to dehydration and infection
  5. Anxiety related to changes in health status

Nursing Interventions

No.

Nursing Diagnosis

Goal

Interventions

1.

Fluid volume deficit related to active fluid loss

1. Fluid balance

Indicator:

·      Blood pressure within expected range

·      Balance intake and output in 24 hours

·      No peripheral edema

·      No abnormal thirst

·      Skin hydration

·      Hematocrit within normal limits

 

2. Hydration

Indicator:

·      Skin hydration

·      No peripheral edema

·      No abnormal thirst

·      Blood pressure within normal limits

·      Hematocrit within normal limits

 

3. Nutritional status: food and fluid intake

Indicator:

·      Oral food intake

·      Oral fluid intake

·      Total parenteral nutrition

Fluid management:

1.     Maintain accurate intake and output records

2.     Monitor hydration status (moisture of mucous membranes and adequate pulse), if necessary

3.     Monitor vital signs every 15 minutes – 1 hour

4.     Monitor food/fluid intake and calculate daily calorie intake

5.     Collaboration IV fluid administration

6.     Monitor nutritional status

7.     Give oral fluids

 

Hypovolemic management:

1.     Monitor fluid status including fluid intake and output

2.     Monitor laboratory results in accordance with fluid retention (BUN, electrolytes, hematocrit, urine osmolality, albumin, and total protein)

3.     Monitor the patient's response to fluid additions

 

2.

Acute pain related to burn injury

1. Pain level

Indicator:

·       Reporting pain Duration of pain

·       Facial expression when in pain

·       Muscle tension

 

2. Pain control

Indicator:

·      Recognizing pain

·      Shows the causal factor

·      Report changes in pain

·      Report pain control

 

3. Degree of discomfort

Indicator:

·      Pain, anxiety

·      Moaning

 

4. Vital signs

Indicator:

·      Radial pulse

·      Respiratory rate

·      Systolic blood pressure, diastolic blood pressure

Pain Management:

1.    Perform a comprehensive pain assessment including location, characteristics, duration, frequency, quality, and precipitating factors

2.    Observe nonverbal reactions and discomfort

3.    Environmental controls that can affect pain such as room temperature, lighting, and noise

4.    Teach about non-pharmacological techniques: deep breathing, relaxation, and distraction.

5.    Collaborative administration of analgesics to reduce pain

6.    Increase rest

7.    Provide information about pain such as the cause of the pain, how long it will take for the pain to subside and anticipated discomfort from the procedure.

 

Analgesic Administration:

1.    Determine the location, characteristics, quality and degree of pain before administering the drug

2.    Check the doctor's instructions about the type of drug, dosage, and frequency

3.    Check allergy history

4.    Evaluation of analgesic effectiveness

 

Environmental Management:

convenience

1.     Determining the source of discomfort

2.     Provide a safe and clean environment

3.     Facilitate a comfortable patient position

 

3.

Impaired skin integrity related to open wounds

1. Tissue integrity: skin and mucous membranes

Indicator:

·      Skin temperature

·      Sensation

·      Hydration

·      Tissue perfusion

·      Skin integrity

 

2. Wound healing

Indicator:

·      Scar formation

·      The smell of rotten wounds

 

3. Sensory function: skin

Indicator:

·      Loss of sensation

·      Paresthesia

 

 

 

 

 

 

Pressure Management :

1.    Instruct the patient to wear loose clothing

2.    Avoid wrinkles on the bed

3.    Keep skin clean to keep it clean and dry

4.    Patient mobilization (change patient position) every 2 hours

5.    Monitor patient activity and mobilization

6.    Adjust the position to avoid pressure or tension on the wound

7.    skin monitor

 

Injury cure :

1.    Burn treatment with hydrotherapy and debridement

2.    Maintain sterile technique when performing wound care

3.    Compare every change

4.

Hyperthermia related to dehydration and infection

1. Thermoregulation

Indicator:

·      Report temperature discomfort

·      Decrease in skin temperature

·      Skin discoloration, muscle twitching, dehydration

 

2. Vital signs

Indicator:

·      Body temperature, apical heart rate, apical heart rhythm

·      Radial pulse. Respiratory rate, breathing rhythm, systolic blood pressure

 

 

Fever management:

1.    Monitor temperature as often as possible

2.    Monitor skin color and temperature

3.    Monitor BP, pulse, RR

4.    Give treatment to overcome the cause of fever

5.    Improve blood circulation

6.    Increase fluid intake and nutrition

7.    Leukocyte monitor

 

Monitoring vital signs

1.    Monitor presence and quality of pulse

2.    Monitor skin tone, temperature and humidity

3.    Identify possible causes of changes in vital signs

5.

Anxiety related to changes in health status

1. Self-anxiety control

Indicator:

·      Facial expressions

·      Expression of anxiety symptoms

 

2. Anxiety level

Indicator:

·      Facial expressions

·      Body language

 

3. Coping

Decreased anxiety

1.    Use a calming approach

2.    Explain all procedures

3.    Provide factual information about the diagnosis

4.    Involve the family to accompany the patient

5.    Instruct patient to use relaxation techniques

6.    Identify anxiety levels

7.    Encourage patient to express feelings, fears, and perceptions

 

Fluid volume deficit related to Combustion (Burning) 

Acute pain related to related to Combustion (Burning)
















Impaired skin integrity related to Combustion (Burning)

Hyperthermia related to Combustion (Burning)

Anxiety related to Combustion (Burning)









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Combustion Nursing Diagnosis Nursing Interventions