Question

Part 1.

You are a nurse caring for a 26 year old male involved in a burn incident that involves the left upper limb and the left lower limb. What do you think will be the problems of the patient during the acute and rehabilitative phase? What can be implemented? How will you be able to help him recover from the incident and to fully regain his optimum health and functioning?

Formulate a plan of care for the patient (ADPIRE fomat).

As a nurse what will be your contributions to help prevent or minimize accidents that can cause burn injuries?

Part 2.
Nursing Care Plan (ADPIRE format) to address the following possible nursing diagnoses associated with AKI and ESRD.
1. Fluid volume excess
2. Decreased cardiac output
3. Risk for infection

Answer 1

Part 1-- Problems During acute & Rehabilitate Phase-----

In Acute phase--

Infection

Alteration of cardiovascular & Respiratory Status..( Like- breathing problem, dyspnea etc..)

Neurological alteration.. ( Like- Headache,delirium,sleep disturbance, Dizziness etc..)

Fluid & Electrolyte Disturbances

Limitation of Range of Motion..

In Rehabilitate Phase --

Abnormal flexion & fixation of joint ( Joint contracture )

Most susceptible involving joints are groin,popliteal fossae,knees, ankle etc..

Headache & Dizziness also occour..

Formation of any kind of Blister..

Ithchiness & Mild Pain

Implementation & Nursing Consideration --

In acute phase--

Fluid therapy should be done according to patient's need..

Daily care of the wound ( Daily Shower, removal of debridement, observe for any redness & swelling)

Proper Nutrition therapy should be given..

Patient should be kept in proper & good psychological Support.. ( emotional support, health teaching should be provided to the patient & also the family member,console the Patient)

Respiratory status should be maintained ( oxygenation therapy, vitals signs check )

In rehabilitation Phase--

Encourage the Patient for performing self care activity..

Always encourage the patient

Plan about any possible reconstruction surgery

Health teaching should be given about the possible health Care..

Care plan in ADPIRE format --

A= Assessment

Fluid volume status & Intake-Output Chart should be assessed..

D= Diagnosis

Fluid Volume deficit related to shifting of fluid due to severe burn Injury as evidenced by disbalance of Intake- Output Chart..

P= Plan

I= Intervention

R= Rationale

Plan -1) Intake-Output chart should be assessed..

R= To get baseline data

I= Intake-Output chart is assessed..

Plan-2) Iv fluid should be given according to need..

R= To maintain the fluid Volume..

I = Iv fluid is given to the patient..

Plan-3) Comfort Possition should be Maintained..

R= For assuring Proper Circulation..

I = Comfort Possition is maintained..

E= Evaluation

Fluid Volume status is improved to some extent..

To minimize or prevent Accidents that can cause burn injuries,, As a nurse I should maintain the following management --

Health teaching should be given about the Various sources of Burn injury ( Like- thermal burn,smoke & Inhalation Injury, Ekectrical burn Injury etc.. )

Patient should be instructed to avoid any type of smoking..

Patient Should be instructed to avoid the heavy exposure of Chemicals..

Part-2) Nursing Care Plan in ADPIRE format --

1.. Fluid Volume Excess

A= Assessment

Intake-Output chart should be assessed..

D= Diagnosis

Imbalanced fluid volume related to disbalance of kidney function as evidenced by disbalance of Intake-Output chart..

P= Planning
R= Rational
I = Intervention

Plan-1) Intake output chart should be assessed.

R- To get baseline data

I- Intake output chart is assessed..

Plan-2) Fluid Intake should be restricted..

R- To Maintain fluid volume

I- Fluid Intake is restricted..

Plan-3) Capillary refill should be checked..

R- To assess the proper circulation.

I- Capillary refill is assessed..

E- Evaluation

Fluid volume is maintained to some extend..

2.. Decrease Cardiac Output --

A- Assessment

Saturation level should be essessed..

D- Diagnosis

Impaired cellular metabolism related to deficit oxygen supply as evidenced by decrease of Oxygen saturation level in the blood..

P= Planning
R= Rational
I = Intervention

Plan-1) Oxygen saturation level should be assessed..

R- To get Baseline data

I- Oxygen Saturation level is assessed..

Plan-2) Oxygen should be given according to the need..

R- To maintain the Oxygen volume in the blood..

I- Oxygen is given to the Patient..

Plan -3) Proper position should be given to the patient..

R- For proper circulation..

I- Possition is given to the Patient..

E- Evaluation

Oxygen level is maintained to some extend..

3..Risk for Infection

A- Assessment

Any kind of Redness & Swelling

D- Diagnosis

Risk for infection related to the disease condition..

P= Planning
R= Rational
I = Intervention

Plan -1) Any kind of redness, swelling should be assessed.

R- To get baseline data..

I - Redness & Swelling status is assessed..

Plan-2) Aseptic technique should be maintained before doing any procedure..

R- To maintain sterilization

I- Aseptic technique is maintained..

Plan-3) Hand washing should be done before & after of every procedure..

R - To prevent the Contamination of any infectious agent..

I - Hand washing is done..

E- Evaluation

Risk for infection is reduced to some extend..