Wednesday, May 20, 2015

Nursing Diagnoses for Burns

 Five examples of nursing diagnoses for burns include:
  • Impaired physical mobility related to neuromuscular impairment, pain/discomfort, and restrictive therapies as evidenced by limited ROM and muscular strength
  • Disturbed body image related to traumatic event and disfigurement as evidenced by self-reported negative feelings about self and worry concerning others' reactions
  • Imbalanced nutrition related to hyper-metabolic state as evidenced by decreased body weight and loss of muscle mass
  • At risk for ineffective tissue perfusion related to reduction/interruption of arterial/venous blood flow from circumferential burns
  • Acute pain related to tissue damage as evidenced by report of pain and non-verbal pain responses (ex. grimacing, guarding, fetal position, etc.)
Detailed Nursing Diagnosis Example
  • Impaired skin integrity related to disruption of skin surface and destruction of skin layers as evidenced by absence of viable tissue
    • Actual and potential: at times the absence of viable tissue will be obvious but other times the integrity of the tissue will be questionable
      • Impaired skin integrity is both an actual and potential problem
    • Related to: absence of viable tissue that is capable of being a barrier between the internal environment of the body and the external environment surrounding the body
    • Plan and outcome: provide alternative barriers to act as a barrier between the internal and external environments of the body
      • alternative barriers need to aid in wound healing and prevent infection
      • assessments should identify progress of wound healing and identify early infection or tissue necrosis
    • Nursing interventions: Assessment, wound care, and infection prevention
      •  Assess and document wound characteristics, size, color, depth, changes, and note condition of surrounding tissue and necrotic tissue
      • Remove necrotic tissue and unnecessary xenograft (underlying tissue must be healed and xenograft must be dried out) from wound bed
      • Change wound dressings, apply antibiotic ointments, maintain skin grafts and synthetic dressings
      • Administer antibiotic therapies as ordered
For further nursing diagnoses concerning burns please see the site below.
http://nurseslabs.com/11-burn-injury-nursing-care-plans/

Vera, Matt. 11 Burn Injury Nursing Care Plans. Nurseslabs.com, n.d. Web. 20 May 2015. <http://nurseslabs.com/11-burn-injury-nursing-care-plans/>. 

1 comment:

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