NAME:

OWOLABI OLUWAPELUMI DAMILOLA

ASSIGNEMENT
1)      Mr. Ajayi, a 47 years old trader was involved in a road traffic accident during
which he sustained 55% full partial thickness burns to the face, part of the
trunk, and part of the upper thigh. On presentation his weight is 150lb. Mr.
Ajayi is neither diabetic nor Hypertensive patient but he is married with
Children.

a)      For
emergent phase, acute phase, and recovery phase, (in order of priority),
draw 3 nursing care plans to manage each of the phases of Mr. Ajayi’s condition.
(i.e. 9 nursing diagnosis in all)

b)      With
knowledge of Parkland formula, how much fluids of Ringers Lactate should be infused
into the patient in first 8 hours and during the following 16 hours?

ANSWER
A)
NURSING CARE PLAN FOR MR. AJAYI WITH BURNS
EMERGENT PHASE
S/N NURSING OBJECTIVES NURSING SCIENTIFIC EVALUATI
DIAGNOSIS INTERVENTIO RATIONALE ON
NS
1. INEFFECTIVE CLIENT i) ASSESS i) FOR CLIENT
AIRWAY WILL BE RESPIRATORY BASELINE MAINTAIN
CLEARANCE MAINTAIN A RATE, DATA AND TO ED A
RELATED TO PATENT RHYTHM AND HELP DETECT PATENT
 EDEMA AIRWAY DEPTH. DEVELOPING AIRWAY
SECONDARY WITH RESPIRATORY WITH
TO RESPIRATOR DISTRESS. RESPIRATO
CIRCUMFERE Y RATE RY RATE
NTIAL WITHIN ii) ELEVATE ii) PROMOTES WITHIN
BURNSAS NORMAL HEAD OF BED. OPTIMAL LUNG NORMAL
EVIDENCED RANGE (16- AVOID USE OF EXPANSION RANGE (16-
BY BURNED 20C/M), PILLOW AND 20C/M),
AREAS IN WITHIN 8 UNDER HEAD, RESPIRATORY AFTER
NECKAND HOURS OF AS FUNCTION. NURSING
CHEST AND NURSING INDICATED. WHEN HEAD INTERVEN
RESPIRATOR INTERVENTI AND NECK TION.
Y RATE OF ON. BURNS ARE
LESS THAN 12 iii) PRESENT, A
CYCLES PER ENCOURAGE PILLOW CAN
MINUTE DEEP- INHIBIT
BREATHING RESPIRATION.
EXERCISES,
AND iii) PROMOTES
FREQUENT LUNG
POSITIONING EXPANSION
CHANGES. AND
MOBILIZATION.

iv) SUCTION
WITH iv) HELPS
EXTREME MAINTAIN
CARE USING CLEAR
STERILE AIRWAY.
TECHNIQUE. STERILE
TECHNIQUE
REDUCES RISK
OF INFECTION
v) PREPARE
FOR v) THIS IS
INTUBATION REQUIRED
AND WHEN BURN
MECHANICAL INJURY
VENTILATION INTERFERES
IF INDICATED. WITH
RESPIRATORY
FUNCTION AND
OXYGENATION.
2. DEFICIENT CLIENT i) ASSESS i) THIS SERVES CLIENT
FLUID WILL VITAL SIGNS, AS A GUIDE TO MAINTAIN
VOLUME MAINTAIN MONITOR FLUID ED
RELATED TO ADEQUATE URINARY REPLACEMENT ADEQUATE
INCREASED FLUID AND OUTPUT AND NEEDS AND FLUID AND
CAPILLARY ELECTROLY NOTE ITS URINE CAN ELECTROL
PERMEABILIT TE PROPERTIES. APPEAR RED TO YTE
Y AND BALANCE BLACK IN BALANCE
EVAPORATIV AS ASSOCIATION EVIDENCE
E LOSSES EVIDENCED WITH MASSIVE D BY
FROM THE BY MUSCLE APPROPRIA
BURN APPROPRIAT DESTRUCTION TE
WOUND E URINARY BECAUSE OF URINARY
EVIDENCED OUTPUT PRESENCE OF OUTPUT
BY URINARY GREATER BLOOD AND GREATER
OUTPUT LESS THAN RELEASE OF THAN
THAN 20ML 30ML/HOUR ii) MEASURE MYOGLOBIN. 30ML/HOU
PER HOUR AFTER CIRCUMFERE R AFTER
NURSING NCE OF ii) HELPFUL IN NURSING
INTERVENTI BURNED ESTIMATING INTERVEN
ON. EXTREMITIES EXTENT OF TION.
EDEMA AND
FLUID SHIFTS
AFFECTING
CIRCULATING
VOLUME AND
URINARY
OUTPUT.
iii) ELEVATE
BURNED iii) ELEVATION
EXTREMITIES. PROMOTES
VENOUS
RETURN.

iv)
ADMINISTER iv) FLUID
CALCULATED RESUSCITATIO
IV N REPLACES
REPLACEMEN LOST FLUIDS
T OF FLUIDS AND
AND ELECTROLYTES
ELECTROLYT AND
ES. HELPS
PREVENT
COMPLICATION
S SUCH AS
v) SHOCK.
ADMINISTER
PRESCRIBED v) THIS WILL
 MEDICATIONS ENHANCE
SUCH AS URINARY
DIURETICS OUTPUT AND
(E.G CLEAR
MANNITOL) TUBULES
OF DEBRIS.
3. ACUTE PAIN CLIENT i) ASSESS PAIN i) THIS CLIENT
RELATED TO WILL USING A PAIN PROVIDES VERBALIZE
TISSUE AND VERBALIZE INTENSITY BASELINE FOR D
NERVE DECREASED SCALE FROM EVALUATING DECREASE
INJURY AS PAIN LEVEL 1-10. EFFECTIVENES D PAIN
MANIFESTED WITHIN 12 S OF PAIN LEVEL
BY HIS HOURS OF RELIEF AFTER
SECOND- NURSING ii) PROVIDE MEASURES. NURSING
DEGREE INTERVENTI DIVERSIONAL INTERVEN
BURNS ON. ACTIVITIES ii) THIS HELPS TION.
EVIDENCED AND REFOCUS
BY PATIENT’S EMOTIONAL ATTENTION,
VERBALIZATI SUPPORT. LESSEN
ON. CONCENTRATI
ON ON PAIN,
REDUCE FEAR
AND ANXIETY.
iii) EXPLAIN
PROCEDURES iii) KNOWING
AND PROVIDE WHAT TO
FREQUENT EXPECT
INFORMATION PROVIDES
AS OPPORTUNITY
APPROPRIATE, FOR CLIENT TO
ESPECIALLY PREPARE SELF
DURING AND
WOUND ENHANCES
DÉBRIDEMEN SENSE OF
T. CONTROL.

iv) COVER iv)

WOUNDS AS TEMPERATURE
SOON AS CHANGES AND
POSSIBLE AIR
UNLESS OPEN- MOVEMENT
AIR CAN CAUSE
EXPOSURE GREAT PAIN
BURN CARE TO EXPOSED
METHOD NERVE
REQUIRED. ENDINGS.
 v)
ADMINISTER v) IV METHOD
IV IS OFTEN USED
PRESCRIBED INITIALLY TO
OPIOID MAXIMIZE
ANALGESICS DRUG EFFECT
SUCH AND DUE TO
AS MORPHINE ALTERED
TISSUE
PERFUSION.

ACUTE PHASE
S/N NURSING OBJECTIVES NURSING SCIENTIFIC EVALUATIO
DIAGNOSIS INTERVENTIONS RATIONALE N
1. IMPAIRED PATEINT i) ASSESS i) PROVIDES PATEINT
SKIN WILL EXTENT COLOR, BASELINE ACHIEVED
INTEGRITY ACHIEVE DEPTH OF INFORMATIO TIMELY
RELATED TO TIMELY WOUND AND N ABOUT HEALING OF
BURN HEALING OF NOTE NEED FOR BURNED
INJURY BURNED CONDITION OF SKIN AREAS
EVIDENCED AREAS SURROUNDING GRAFTING BEFORE
BY BEFORE SKIN. CIRCULATIO DISCHARGE.
DISRUPTION DISCHARGE. N IN THE
IN SKIN AFFECTED
LAYERS AREA.

ii) PROVIDE ii) PROMOTES

APPROPRIATE WOUND
WOUND CARE HEALING
AND INFECTION AND
CONTROL REDUCES
MEASURES. RISK OF
INFECTION
AND GRAFT
FAILURE.

iii) KEEP SKIN iii)

FREE FROM PROMOTES
PRESSURE. CIRCULATIO
N AND
PREVENTS
 NECROSIS.

iv) ADMINISTER iv) THIS IS

PRESCRIBED BENEFICIAL
TOPICAL TO WOUND
WOUND HEALING
DÉBRIDEMENT AND TO
OINTMENT AND PREVENT
ANTIBACTERIAL INFECTION.
AGENT.

v) SKIN
v) PREPARE OR GRAFTS
ASSIST WITH COULD BE
SURGICAL OBTAINED
GRAFTING OR FROM LIVING
BIOLOGICAL PERSONS,
DRESSINGS. CADAVERS,
ANIMAL SKIN
OR
ARTIFICIAL
SKIN
(INTEGRA)
FOR THE
PURPOSE OF
PROTECTING
GRANULATIO
N TISSUE
AND
STIMULATIN
G THE
REGENERATI
ON OF
DERMAL
TISSUE.
2. IMBALANCE CLIENT i) AUSCULTATE ii) TO NOTE CLIENT
D WILL BOWEL SOUNDS BOWEL DEMONSTR
NUTRITION: DEMONSTR AND WEIGH SOUNDS AND ATED
LESS THAN ATE DAILY. KNOW WHEN ADEQUATE
BODY ADEQUATE ORAL NUTRITIONA
REQUIREME NUTRITION FEEDINGS L INTAKE
NTS AL INTAKE CAN BE THAT MET
RELATED TO TO MEET INITIATED. METABOLIC
HYPERMETA METABOLIC WEIGHT IS NEEDS
BOLIC STATE NEEDS AS AN EVIDENCED
EVIDENCED EVIDENCED INDICATOR BY STABLE
BY WEIGHT BY STABLE OF WEIGHT
LOSS WEIGHT NUTRITIONA THROUGHO
THROUGHO L NEEDS AND UT
UT ADEQUACY HOSPIATLIZ
HOSPITALIZ OF DIET ATION.
ATION. THERAPY.

ii) FIND OUT ii) PROVIDES

FOOD LIKES PATIENT
AND DISLIKES SENSE OF
AND CONTROL,
ENCOURAGE ENHANCES
FAMILY TO PARTICIPATI
BRING FOOD ON IN CARE
FROM HOME. AND MAY
IMPROVE
INTAKE.
iii) PROVIDE
SMALL, iii) THIS
FREQUENT HELPS
MEALS AND PREVENT
SNACKS. GASTRIC
DISCOMFORT
AND MAY
ENHANCE
INTAKE.
iv) PROVIDE
ORAL HYGIENE iv) CLEAN
BEFORE MEALS. MOUTH AND
CLEAR
PALATE
ENHANCES
TASTE AND
HELPS
PROMOTE A
GOOD
APPETITE.
v) INSERT AND
MAINTAIN v) THIS
SMALL FEEDING PROVIDES
TUBE FOR CONTINUOUS
ENTERAL SUPPLEMENT
FEEDINGS AND AL FEEDINGS
SUPPLEMENTS, WHEN
IF NEEDED. PATIENT IS
UNABLE TO
 CONSUME
TOTAL DAILY
CALORIE
REQUIREMEN
TS ORALLY.
3. RISK FOR CLIENT i) MONITOR i) THIS CLIENT WAS
INFECTION WILL VITAL SIGNS COULD BE ABLE TO
RELATED TO ACHIEVE FOR FEVER AND INDICATOR ACHIEVE
DESTRUCTIO TIMELY INCREASED OF SEPSIS TIMELY
N OF SKIN WOUND RESPIRATORY WHUCH WILL WOUND
BARRIER HEALING RATE. HELP IN HEALING
AND FREE OF PROMPT FREE OF
TRAUMATIZ PURULENT EVALUATION PURULENT
ED TISSUES. EXUDATE AND EXUDATE
AND BE INTERVENTI AND BE
AFEBRILE ON. AFEBRILE
THROUGHO THROUGHO
UT ii) IMPLEMENT ii) TO UT
HOSPITALIZ APPROPRIATE REDUCE RISK HOSPITALIZ
ATION. ISOLATION OF CROSS- ATION.
TECHNIQUES. CONTAMINA
TION AND
EXPOSURE
TO MULTIPLE
BACTERIAL
FLORA.

iii) USE STRICT iii) PREVENTS

ASEPTIC EXPOSURE
TECHNIQUE TO
AND PROPER INFECTIOUS
PPE DURING ORGANISMS.
WOUND CARE.

iv) PREVENTS
iv) EXPLAIN CROSS-
ISOLATION CONTAMINA
PROCEDURE TO TION FROM
VISITORS AND VISITORS
MAKE SURE WHILE STILL
THEY ADHERE PROVIDING
TO FAMILY
PROTOCOL. SUPPORT.

v) ADMINISTER v) IT HELPS
PRESCRIBED CONTROL
 TOPICAL BACTERIAL
ANTIMICROBIAL GROWTH
AGENTS SUCH SILVER
AS SILVER SULFADIAZIN
SULFADIAZINE E IS A
BROAD-
SPECTRUM
ANTIMICROB
IAL THAT
MAY ALLOW
THE WOUND
TO HEAL
WITHOUT
NEED FOR
SKIN
GRAFTING.

RECOVERY/REHABILITATION PHASE
S/ NURSING OBJECTIVES NURSING SCIENTIFIC EVALUATIO
N DIAGNOSIS INTERVENTION RATIONALE N
S
1. IMPAIRED CLIENT i) ASSESS i) EDEMA MAY CLIENT
PHYSICAL WILL CIRCULATION, COMPROMISE INCREASED
MOBILITY INCREASE MOTION, AND CIRCULATION TO STRENGTH
RELATED STRENGTH SENSATION OF EXTREMITIES, AND
TO PAIN AND AFFECTED POTENTIATING FUNCTION
AND FUNCTION PARTS TISSUE OF
DECREASED OF FREQUENTLY. NECROSIS AND AFFECTED
STRENGTH AFFECTED DEVELOPMENT BODY PART
EVIDENCED BODY PART OF WITH
BY LIMITED WITH CONTRACTURES. ABSENCE OF
RANGE OF ABSENCE CONTRACTU
MOTION. OF RES
CONTRACT ii) KEEP LINENS ii) THIS THROUGHO
URES DRY AND PREVENTS SKIN UT
THROUGHO WRINKLE- IRRITATION OR HOSPITALIZ
UT FREE. BREAKDOWN. ATION.
HOSPITALIZ MASSAGE SKIN
ATION. AND BONY
PROMINENCES
ROUTINELY.
 iii) MAINTAIN iii) PROVIDES
AFFECTED FOR
JOINT IN STABILIZATION
PRESCRIBED OF PROSTHESIS
POSITION AND AND REDUCES
BODY IN RISK OF
ALIGNMENT FURTHER
WHEN IN BED. INJURY.

iv) PERFORM iv) THIS

ROM ENHANCES
EXERCISES MAINTENANCE
CONSISTENTLY OF MUSCLE AND
, INITIALLY JOINT
PASSIVE, THEN FUNCTIONING
ACTIVE. AND PREVENTS
PROGRESSIVELY
TIGHTENING
SCAR TISSUE
AND
CONTRACTURES.

v) ENCOURAGE v) THIS
PATIENT PROMOTES
PARTICIPATION INDEPENDENCE,
IN ALL ENHANCES SELF-
ACTIVITIES AS ESTEEM, and AND
INDIVIDUALLY FACILITATES
ABLE. RECOVERY
PROCESS.
2. DISTURBED CLIENT i) i) ACCEPTANCE CLIENT
BODY WILL ACKNOWLEDG OF THESE VERBALIZE
IMAGE VERBALIZE E AND ACCEPT FEELINGS AS A D
RELATED ACCEPTAN EXPRESSION NORMAL ACCEPTANC
TO CE OF SELF OF FEELINGS RESPONSE TO E OF SELF IN
ALTERED IN OF WHAT HAS SITUATION
PHYSICAL SITUATION FRUSTRATION, OCCURRED THROUGHO
APPERANCE THROUGHO ANGER AND FACILITATES UT
EVIDENCED UT GRIEF RESOLUTION. HOSPITALIZ
BY HOSPITALIZ . ATION.
NEGATIVE ATION.
FEELINGS ii) ASSIST ii) IT HELPS
ABOUT PATIENT TO BEGIN PROCESS
BODY. IDENTIFY OF LOOKING TO
 EXTENT OF THE FUTURE
ACTUAL AND HOW LIFE
CHANGE IN WILL BE
APPEARANCE DIFFERENT.
AND BODY
FUNCTION.

iii) GIVE iii) WORDS OF

POSITIVE ENCOURAGEME
REINFORCEME NT CAN SUPPORT
NT OF DEVELOPMENT
PROGRESS AND OF POSITIVE
ENCOURAGE COPING
ENDEAVORS BEHAVIORS.
TOWARD
ATTAINMENT
OF
REHABILITATI
ON GOALS.

iv) TO
iv) ENCOURAGE FACILITATE
FAMILY COMMUNICATIO
INTERACTION N AND PROVIDE
WITH EACH ONGOING
OTHER AND SUPPORT FOR
WITH PATIENT AND
REHABILITATI FAMILY.
ON TEAM.

v) PROMOTES
v) VENTILATION OF
RECOMMEND FEELINGS AND
CONTACT ALLOWS FOR
WITH MORE HELPFUL
SURVIVOR RESPONSES TO
SUPPORT PATIENT.
PERSON OR
GROUP FOR
CLIENT.
3. DEFICIENT CLIENT i) REVIEW i) THIS PROVIDES CLIENT WAS
KNOWLEDG WILL CONDITION, KNOWLEDGE ABLE TO
E ABOUT VERBALIZE PROGNOSIS, BASE FROM VERBALIZE
PROGNOSIS, UNDERSTA AND FUTURE WHICH PATIENT UNDERSTAN
TREATMENT NDING OF EXPECTATIONS CAN MAKE DING OF
AND CONDITION, WITH PATIENT. INFORMED CONDITION,
DISCHARGE PROGNOSIS, CHOICES. PROGNOSIS,
NEEDS AND AND
RELATED POTENTIAL POTENTIAL
TO COMPLICAT ii) REVIEW AND ii) THIS COMPLICATI
UNFAMILIA IONS HAVE PATIENT PROMOTES ONS
RITY WITH THROUGHO DEMONSTRATE COMPETENT THROUGHO
CONDITION UT PROPER BURN, SELF-CARE UT
EVIDENCED HOSPITALIZ SKIN-GRAFT, AFTER HOSPITALIZ
BY ATION. AND WOUND DISCHARGE, ATION.
PERSISTENT CARE ENHANCING
QUESTIONIN TECHNIQUES. INDEPENDENCE.
G.

iii) iii) THIS HELPS

ENCOURAGE TO MAINTAIN
CONTINUATIO MOBILITY,
N OF REDUCES
PRESCRIBED COMPLICATIONS,
EXERCISE AND
PROGRAM AND FACILITATING
MEDICATIONS. RECOVERY
PROCESS.

iv) EMPHASIZE iv) OPTIMAL

IMPORTANCE NUTRITION
OF SUSTAINED ENHANCES
INTAKE OF TISSUE
HIGH-PROTEIN REGENERATION
AND HIGH- AND GENERAL
CALORIE FEELING OF
MEALS. WELL-BEING.

v) PROVIDE v) PROVIDES
PHONE EASY ACCESS TO
NUMBER FOR TREATMENT
WARD AND TEAM TO
IDENTIFY REINFORCE
COMMUNITY TEACHING OR
RESOURCES CLARIFY
SUCH AS MISCONCEPTION
WOUND CARE S AND SUPPORT
PROFESSIONAL INDEPENDENCE.
S, RECOVERY
 GROUPS OR
VISITING
NURSE.

B) Volume LR (Lactate Ringers) = 4mls X %BSA X Kg

1 pound (lb.) is equal to 0.45359237 kilograms (kg)
150lbs = 0.45359237 x 150
68.0389kg
= 4 x 55 x 68.0389
=14,968.558
Approximately 14,970ml

Half of this will go into Mr. Ajayi over the next 8 hours, while the remaining half will go in
the next 16 hours.
7,485ml will be infused in the first 8hours and the remaining in the next 16 hours.
936 ml hourly for the first 8 hours.

The remaining in the next 16 hours.

That is 468ml hourly

REFERENCES
Angel Garcia. (2020, January 24). Nursing Care Plan For The Patient With Burn Injury - Acute

Pain Related To Tissue and Nerve Injury | PDF | Pain | Burn. Retrieved October 17, 2021,

from Scribd website: https://www.scribd.com/document/444122034/Nursing-Care-Plan-

for-the-patient-with-burn-injury-Acute-Pain-related-to-tissue-and-nerve-injury

Junah Marie Rubinos Palarca. (n.d.). Nursing Care Plans For Burned Patient | PDF | Breathing |

Burn. Retrieved October 17, 2021, from Scribd website:

https://www.scribd.com/document/123158933/nursing-care-plans-for-burned-patient

Vera, M., BSN, & R.N. (2013, July 14). 11 Burn Injury Nursing Care Plans. Retrieved from

Nurseslabs website: https://nurseslabs.com/11-burn-injury-nursing-care-plans/10/