Ncp Burn&Esrd

8/3/2019 Ncp Burn&Esrd

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Assessment Diagnosis Planning Implementation Rationale EvaluationSubjective:Namamaga ang ibangparte ng katawan ko. Asverbalized by the client.

Objective:- Intake greater

than output- Weight gain- Edema- 140/100mmHg- 103 bpm

Fluid Volume Excessrelated tocompromisedregulatorymechanism as

evidenced by intakegreater than output;edema; weight gainand as verbalized bythe client namamagaang ibang parte ngkatawan ko.

Within the 3 days of nursing interventionthe client will be ableto decrease weight;edema and

normalized intakeand output and averbalization of Hindin masyadongnamamaga itongkatawan ko.

Independent:- Record accurateintake and output(I&O). Includehidden fluids such

as IV antibioticadditives, liquidmedications, icechips, frozen treats.Measuregastrointestinal (GI)losses and estimateinsensible losses,e.g., diaphoresis.

-Weigh daily at sametime of day, on samescale, withsame equipment andclothing.

-Assess skin, face,dependent areas for edema. Evaluatedegree of edema (onscale of +1+4).

-Low output (less than400 mL/24 hr) may befirstindicator of acute failure,

especially in a high-riskpatient.Accurate I&O isnecessary for determining renalfunctionand fluid replacementneeds and reducing riskof fluidoverload.Note: Hypervolemiaoccurs in the anuricphaseof ARF.

-Daily body weight isbest monitor of fluidstatus. Aweight gain of more than0.5 kg/day suggests fluidretention.

-Edema occurs primarilyin dependent tissues of the body,e.g., hands, feet,lumbosacral area.

After 3 days of nursing interventionthe client was able todecrease weight;edema and

normalized intakeand output and averbalization of Hindin masyadongnamamaga itongkatawan ko. And thegoal was met.


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-Monitor heart rate(HR), BP, andJVD/CVP.

Patient can gain up to10 lb (4.5 kg) of fluidbefore pitting edema isdetected.Periorbital edema maybe a presenting sign of

this fluidshift because thesefragile tissues are easilydistended byeven minimal fluidaccumulation

-Tachycardia andhypertension can occur because of (1)failure of the kidneys toexcrete urine, (2)

excessive fluidresuscitation duringefforts to treathypovolemia/hypotensionor convert oliguric phaseof renal failure, and/or (3)changes in the renin-angiotensinsystem. Note: Invasivemonitoring may beneeded for assessing intravascular volume, especially inpatients with


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-Auscultate lung andheart sounds.

-Assess level of consciousness;investigate changes in

mentation, presenceof restlessness.

-Plan oral fluidreplacement withpatient, within multiplerestrictions.Intersperse desiredbeverages throughout24hr. Vary offerings,e.g., hot, cold, frozen.

poor cardiac function.

-Fluid overload may leadto pulmonary edema andHFevidenced by

development of adventitious breathsounds,extra heart sounds.(Refer to ND: CardiacOutput, risk for decreased, following.)

-May reflect fluid shifts,accumulation of toxins,acidosis,

electrolyte imbalances,or developing hypoxia.

-Helps avoid periodswithout fluids, minimizesboredomof limited choices, andreduces sense of deprivation andthirst


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Dependent:-Administer Drugs(e.g. Furosemide) asprescribed.

Collaborative:-Correct anyreversible cause of ARF, e.g., replacebloodloss, maximizecardiac output,discontinue

nephrotoxicdrug, relieveobstruction viasurgery.

- Given early in oliguricphase of ARF in an effortto convert to non-oliguricphase, flush the tubular lumen of debris, reduce

hyperkalemia, andpromote adequate urinevolume.

-Kidneys may be able toreturn to normalfunctioning,preventing or limitingresidual effects.


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Assessment Diagnosis Planning Implementation Rationale EvaluationSubjective:Parang Bumibilis angpagtibok ng puso ko..As verbalized by theclient.

Objective:- 103 bpm- 140/100mmHg- Edema

Decreased cardiacoutput related to fluidoverload asevidenced bytachycardia with a

heart rate of 103 bpmand as verbalized bythe patient parangbumibilis ang pagtibokng puso ko.

Within 30 minutes of nursing interventionthe client will be ableto decreased heartrate within the normal

range and willverbalized Hindi nmabilia ang pagtiok ngpuso ko.

Independent:- Monitor BP and HR.

-Observe ECG or telemetry for changesin rhythm

- Fluid volume excess,combined withhypertension (oftenoccurs in renal failure)

and effects of uremia,increasescardiac workload andcan lead to cardiacfailure. In ARF,cardiac failure isusually reversible.

- Changes inelectromechanicalfunction may becomeevident in response to

progressing renalfailure/accumulation of toxins and electrolyteimbalance.For example,hyperkalemia isassociated withpeaked Twave, wide QRS,prolonged PR interval,flattened/absentP wave. Hypokalemia

is associated with flatT wave,peaked P wave, and

After 30 minutes of nursing interventionthe client was able todecreased heart ratewithin the normal

range and hasverbalized Hindi nmabilia ang pagtiok ngpuso ko. And the goalwas partially met.


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- Auscultate heart

sounds.

-Assess color of skin,

mucous membranes,and nailbeds.Note capillary refilltime.

-Investigate reports of muscle cramps,numbness/tinglingof fingers, with muscletwitching,

hyperreflexia.

appearance of Uwaves. ProlongedQT interval may reflectcalcium deficit.

-Development of

S3/S4 is indicative of failure. Pericardialfriction rub may beonly manifestation of uremicpericarditis, requiringpromptintervention/possiblyacutedialysis.

- Pallor may reflect

vasoconstriction or anemia. Cyanosis isa late sign and isrelated to pulmonarycongestion and/or cardiac failure.

- Neuromuscular indicators of hypocalcemia, whichcanalso affect cardiac

contractility andfunction.


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- Maintain bedrest or encourage adequaterest and provideassistance with careand desired activities.

Dependent:- Administer medications asindicated:Inotropic agents, e.g.,digoxin (Lanoxin);

Collaborative:- Monitor laboratorystudies (e.g.Potassium, etc.)

- Reduces oxygenconsumption/cardiacworkload.

- May be used toimprove cardiac outputby increasingmyocardial contractilityand stroke volume.Dosagedepends on renalfunction andpotassium balance toobtain therapeuticeffect without toxicity.

- During oliguricphase, hyperkalemiais present but oftenshifts to hypokalemiain diuretic or recoveryphase. Anypotassium valueassociated with ECGchanges requiresintervention. Note: Aserum level of 6.5

mEq or higher constitutes a medicalemergency.


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Assessment Diagnosis Planning Implementation Rationale EvaluationSubjective:Medyo nahihirapanakong huminga. Asverbalized by the client.

Objective:- Cyanosis- 35cpm

Ineffective airwayclearance related toinhalation of chemicals asevidenced by

tracheobronchialobstruction; cyanosis;respiratopry rate of 35cpm and averbalization of Medyo nahihirapanakong huminga.

Within 30 minutes of nursing interventionthe client will have noobstruction; nocyanosis; respiratory

rate within the normalrange and averbalization of hindina ako nahihirapanghuminga.

Independent:- Obtain history of injury. Note presenceof preexistingrespiratory conditions,

history of smoking.

- Assess gag/swallowreflexes; note drooling,inability toswallow, hoarseness,wheezy cough.

- Monitor respiratoryrate, rhythm, depth;note presence of pallor/cyanosis andcarbonaceous or pink-

tinged sputum.

- Causative burningagent, duration of exposure, andoccurrence in closed

or open space predictprobability of inhalation injury. Typeof material burned(wood, plastic,wool, and so forth)suggests type of toxicgas exposure.Preexisting conditionsincrease the risk of respiratorycomplications.

- Suggestive of inhalation injury.

- Tachypnea, use of accessory muscles,presence of cyanosis, and changesin sputum suggest

developingrespiratorydistress/pulmonary

Within 30 minutes of nursing interventionthe client has noobstruction; nocyanosis; respiratory

rate within the normalrange and averbalization of hindina ako nahihirapanghuminga. And thegoal was


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- Investigate changesin behavior/mentation,e.g.,

restlessness,agitation, confusion.

- Elevate head of bed.Avoid use of pillowunder head, asindicated.

- Encouragecoughing/deep-breathing exercisesandfrequent positionchanges.

edema and need for medical intervention.

- Although oftenrelated to pain,changes in

consciousnessmay reflectdeveloping/worseninghypoxia.

- Promotes optimallungexpansion/respiratoryfunction.When head/neckburns are present, apillow can inhibit

respiration, causenecrosis of burned ear cartilage, andpromote neckcontractures

- Promotes lungexpansion,mobilization anddrainage of secretions.


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-Suction (if necessary)with extreme care,maintainingsterile technique.

-Promote voice rest,but assess ability tospeak and/or swallow oralsecretions periodically.

Dependent:- Administer humidified oxygen viaappropriate mode,e.g.,face mask asordered.

Collaborative:- Prepare for/assist

with intubation or tracheostomy, asindicated.

- Helps maintain clear airway, but should bedonecautiously because of mucosal edema andinflammation.

Sterile techniquereduces risk of infection.

- Increasinghoarseness/decreasedability to swallowsuggests increasingtracheal edema andmay indicate needfor prompt intubation.

- O2 correctshypoxemia/acidosis.Humidity decreasesdrying of respiratorytract and reducesviscosity of sputum.

-Intubation/mechanical

support is requiredwhen airwayedema or


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circumferential burninjury interferes withrespiratoryfunction/oxygenation.


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Assessment Diagnosis Planning Implementation Rationale EvaluationSubjective:Nauuhaw ako sobrasobra. As verbalized bythe client.

Objective:- Cyanosis- 35cpm

Fluid Volume deficitrelated to burns asevidenced by generalburn wounds; thrist;dry mucous

membranes and averbalization of Nauuhaw ako sobrasobra.

Within 30 minutes of nursing interventionsthe client will be ableto have moist mucousmembranes; no thrist

and a verbalization of Hindi n ako nauuhawkagaya ng dati.

Independent:- Estimate wounddrainage andinsensible losses

- Maintain cumulativerecord of amount andtypes of fluidintake.

- Measurecircumference of burned extremities asindicated.

- Increased capillarypermeability, proteinshifts,inflammatory process,

and evaporativelosses greatlyaffect circulatingvolume and urinaryoutput, especiallyduring initial 2472 hr after burn injury.

- Massive/rapidreplacement withdifferent types of fluidsand fluctuations in rate

of administrationrequire closetabulation to preventconstituent imbalancesor fluidoverload.

- May be helpful inestimating extent of edema/fluid shiftsaffecting circulatingvolume and urinary

output.

Within 30 minutes of nursing interventionsthe client was able tohave moist mucousmembranes; no thrist

and a verbalization of Hindi n ako nauuhawkagaya ng dati. Andthe goal was partiallymet.


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Dependnet:- Administer calculatedIV replacement of fluids,electrolytes, plasma,albumin as prescribed.

Collaborative:-Assist in inserting

indwelling urinarycatheter.

- Fluid resuscitationreplaces lostfluids/electrolytes andhelps preventcomplications, e.g.,shock, acute tubular

necrosis (ATN).Replacement formulasvary (e.g.,Brooke, Evans,Parkland) but arebased on extent of injury, amount of urinary output, andweight. Note: Onceinitial fluidresuscitation has beenaccomplished, a

steadyrate of fluidadministration ispreferred to boluses,whichmay increaseinterstitial fluid shiftsand cardiopulmonarycongestion.

- Allows for close

observation of renalfunction andprevents urinary


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retention. Retention of urine with itsbyproductsof tissue-celldestruction can lead torenaldysfunction andinfection.

Ncp Burn&Esrd

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