NCP Care of the Patient During the Emergent/Resuscitative Phase of Burn Injury Dr. Aidah Abu ElsoudAlkaissi An-Najah National University Nursing College

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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