NCP Care of the Patient During the Emergent/Resuscitative Phase of Burn Injury

1. NCPCare of the Patient During the Emergent/Resuscitative Phaseof Burn Injury Dr. Aidah Abu ElsoudAlkaissi An-Najah National University Nursing College

2. Nursing Diagnosis: Impaired gas exchange related to carbon monoxide poisoning, smoke inhalation, and upper airway obstruction • Goal: Maintenance of adequate tissue oxygenation

3. Nursing Diagnosis: Ineffective airway clearance related to edema and effects of smoke inhalation • Goal: Maintain patent airway and adequate airway clearance

4. Nursing Diagnosis: Fluid volume deficit related to increased capillary permeability and evaporative losses from the burn wound • Goal: Restoration of optimal fluid and electrolyte balance and perfusion of vital organs

5. Nursing Diagnosis: Hypothermia related to loss of skin microcirculation and open wounds • Goal: Maintenance of adequate body temperature

6. Nursing Diagnosis: Pain related to tissue and nerve injury and emotional impact of injury • Goal: Control of pain

7. Nursing Diagnosis: Anxiety related to fear and the emotional impact of burn injury • Goal: Minimization of patient’s and family’s anxiety

8. Collaborative Problems: Acute respiratory failure, distributive shock, acute renal failure, compartment syndrome, paralytic ileus, Curling’s ulcer • Goal: Absence of complications

9. Nursing Diagnosis: Fluid volume excess related to resumption of capillary integrity and fluid shift from interstitial to intravascular compartment • Goal: Maintenance of optimal fluid balance

10. Nursing Diagnosis: Risk for infection related to loss of skin barrier and impaired immune response • Goal: Absence of localized or systemic infection

11. Nursing Diagnosis: Altered nutrition, less than body requirements, related to hypermetabolism and wound healing • Goal: Attainment of anabolic nutritional status

12. Nursing Diagnosis: Impaired skin integrity related to open burn wounds • Goal: Demonstration of improved skin integrity

13. Nursing Diagnosis: Pain related to exposed nerves, wound healing, and treatments • Goal: Reduction or control of pain

14. Nursing Diagnosis: Impaired physical mobility related to burn wound edema, pain, and joint contractures • Goal: Achievement of optimal physical mobility

15. Nursing Diagnosis: Ineffective individual coping related to fear and anxiety, grieving, and forced dependence on health care providers • Goal: Use of appropriate coping strategies to deal with postburn problems

16. Nursing Diagnosis: Altered family processes related to burn injury • Goal: Achievement of appropriate patient/family processes

17. Nursing Diagnosis: Knowledge deficit about the course of burn treatment • Goal: Verbalization of understanding of the course of burn treatment by patient and family

18. Collaborative Problems: Congestive heart failure, pulmonary edema, sepsis, acute respiratory failure, ARDS, visceral damage (electrical burns) • Goal: Absence of complications