Identify possible nursing diagnoses that Karen may have and provide a rationale for your choice:
A nursing diagnosis that would be attributed to the patient, Karen in the case study would be risk of deficient fluid volume. Karen’s slightly elevated pulse and respirations and additionally the assessment findings of mild oedema and blister formation show that there is a movement of body fluid into the second and third interstitial spacing. Brown and Edwards (2008) states this is caused by increased capillary permeability. Water, sodium and plasma protein move into the intestinal spacing and surrounding tissue. Furthermore Karen states that she has a headache, feels nauseas and chilled after being over exposed to the sun. Karen has a temperature of 38.5 and an abundant of redness to her body surface after prolonged exposure. Over exposure to ultra violet rays can cause thermal burns which leads to increased fluid loss via evaporation from the injured skin. Assessing the fluid loss, perfusion and oxygenation status, and evaluating the need for fluid and electrolyte replacement that is lost, through fluid and protein shifts can aid in the restoration of intravascular volume.
Another expected nursing diagnosis is acute pain. The sudden onset of pain is a result of the nociceptive tissue damage and the nursing treatment required for the injury tissue. Careful assessment of the wound and surrounding tissue can help determine the level of injury sustained. The pain is variable and cannot be reliably predicted by clinical assessment of the patient. ‘Burn patients experience two kinds of pain continuous background pain, which occurs during the course of the day and night. Secondly, a treatment induced pain which is related to ambulation,...
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On admission, a complete physical assessment was performed along with a blood and metabolic panel. The assessment revealed many positive and negative findings. J.P. was positive for dyspnea and a productive cough. She also was positive for dysuria and hematuria, but negative for flank pain. After close examination of her integumentary and musculoskeletal system, the examiner discovered a shiny firm shin on the right lower extremity with +2 edema complemented by severe pain. A set of baseline vitals were also performed revealing a blood pressure of 124/80, pulse of 87 beats per minute, oxygen saturation of 99%, temperature of 97.3 degrees Fahrenheit, and respiration of 12 breaths per minute. The blood and metabolic panel exposed several abnormal labs. A red blood cell count of 3.99, white blood cell count of 22.5, hemoglobin of 10.9, hematocrit of 33.7%, sodium level of 13, potassium level of 3.1, carbon dioxide level of 10, creatinine level of 3.24, glucose level of 200, and a BUN level of 33 were the abnormal labs.
Determining the seriousness and appropriate treatment of a burn requires its classification. Burns are classified according to three factors, the depth and number of affected tissue layers, the total percentage of the body surface that is involved, and the presence of homeostasis disruption or destruction such as respiratory distress, fluid loss, or loss of blood pressure control (Patton & Thibodeau, 2014). According to Mr. MacPherson’s appearance and symptoms, his burns are classified as second-degree or partial-thickness burns. The evidence for this diagnosis according to Patton and Thibodeau (2014), are his presenting symptoms of severe pain and the appearance of blisters, edema, and fluid loss. This type of bur...
Assessing and managing pain is an inevitable part of nursing and the care of patients. Incomplete relief of pain remains prevalent despite years of research due to barriers such as lack of kn...
Burn injuries may originate in many different environments and by several different causes. The most common type of burn is a thermal or heat exposure burn. The magnitude of the burn has to do directly with the amount of time that the skin was in contact with the heat and the temperature of the heat. Usually thermal burns are cause by flames, hot liquid, steam or a hot object, depending on the severity of the burn, treatments may vary. Burns may also be caused by frostbite, chemical bur...
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Findings. Pain has many different meanings to many people. What is important to know as a nurse or health care provider is that pain is what the patient says it is. It is not the nurse or provider’s place to determine what the patient’s pain is but rather take an in-depth history and assessment. Using this assessment and history can therefore help treat your patient’s pain accordingly. Also pain theories have been proposed and used the implications of nursing practice in regard to pain.
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“Living with Burn Trauma,” an online article, states that “human skin is the largest organ of the body.” It provides many functions which assist humans to survive. What happens if this vital organ is destroyed? This is a question with which thousands of Americans are challenged annually. In the United States alone, 4,000 people die in burn accidents or from complications of burn injuries (“Prevention”). One common misconception is that burn victims have all come into contact with flames. Burns result from fires, electricity, hot liquids, chemicals, and even ultraviolet rays. Seeking medical attention for a proper diagnosis is critical to ensuring quality treatment and management of burns. Burn Centers have been established to help patients adapt to life after burns, which can be a great challenge. In today’s society, hospitals and medical professionals can treat burn victims, but the best remedy for burns is prevention.
The nurse should educate the patient of the importance of pain control and how controlling pain is essential to a patient’s wellbeing and recovery. It needs to be a balance of what the patient says and what the nurse observes and interprets while always respecting the wishes of the patient. Nurses have a variety of assessment tools available to assess pain in their patients. One dimensional pain scales such as visual analog scale, verbal descriptor scale, numeric pain intensity scale and the combined thermometer scale all measure the intensity of the pain (Jensen, 2011). Other pain scales such as McGill pain questionnaire, brief pain inventory, and brief pain impact questionnaire take into account aspects beyond intensity (Jensen 2011). There are additional pain assessments specialized for children, older adults, patients who are unable to respond, and patients with opioid tolerance (Jensen, 2011). The nurse should be familiar with these methods of pain assessment and know the appropriate use of each. Incorrect medication and treatment choices due to inaccurate or poor pain assessment cause patient suffering (Jensen,
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