NCP

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective Data: Ineffective airway Short term Independent: Short term
“Hindi po ako clearance related to After 8 hrs of nursing -Assess vital signs, -Vital signs After 8 hrs of nursing
makahinga ng increased congestion interventions, the focusing on respiratory assessment can help interventions, the
maayus” as verbalized in the airway passages patient is expected to: rate and rhythm, provide the nurse patient is:
by the patient. secondary to smoke  Patent airway by depth of respirations information on the  Demonstrate
inhalation as expectorating and symmetrical chest extent of airway improved airway
Objectives Data: evidenced by difficulty retained sputum expansions impairment that the patency as
 difficulty of of breathing,  relieved from injury causes to the  Have decreased
breathing presence of dyspnea by patient. This also coughing
 inspiratory and inspiratory and participating in helps set the baseline episodes
expiratory expiratory wheezing, breathing for evaluation of care. Long Term
wheezing sooty sputum exercise, - Obtain history of After 2 – 3 days of
noted production, persistent effective burn exposure. Note - Causative burn injury nursing interventions,
 persistent cough and use of coughing and presence of agent (e.g., flames, the patient
cough  accessory muscles use of oxygen preexisting respiratory chemicals),  have an
 Sooty sputum when breathing. technique as conditions and any duration of exposure, Improved
 use of evidence by history of smoking. and whether exposed ventilation and
accessory absent of nasal in closed or adequate
muscles when flaring, open space predict oxygen lung
breathing shortness of probability of tissue as
 decrease lung breath easy inhalation injury. Type evidenced by
expansion fatigability and of material burned, normal arterial
 burn wounds absence of such as wood, plastic, blood gasses
spread over the Crackles or wool, and clear breath
right anterior suggests type of toxic sounds
and posterior Long Term gas exposure.  Demonstrate
thorax After 2 – 3 days of Preexisting conditions improved airway
 mucosal edema nursing interventions, increase the risk of patency as
 loss of ciliary the patient will respiratory evidenced by
action  have an complications. clear breath
 Improved - Assess gag and sounds
ventilation and swallow reflexes; note - Suggestive of  ABGs and other
adequate upper airway burns, inhalation injury, laboratory
oxygen lung drooling, inability to which may develop values within
tissue as swallow, hoarseness, over several days. normal limits
Laboratory and evidenced by and wheezy Patient verbalized: “
Diagnostic Findings: normal arterial cough. Mabuti na aking
blood gasses paghinga, hindi na
(MRI) of the chest and and clear breath - Auscultate lungs, ganun kabigat tulad
abdomen revealed a sounds noting stridor, - Airway obstruction noong nakaraan”
right pneumothorax  Demonstrate wheezing, crackles, and respiratory
improved airway diminished breath distress can occur very ABGs:
Vital Signs: patency as sounds, and brassy quickly or may be Arterial Blood Ph: 7. 39
T: 37.5 C evidenced by cough. delayed, for example, SaO2: 97%
RR: 27 clear; breath up to 3 days after HC03: 24 mEq/L
BP:130/110 sounds burn.
PR:  ABGs and other - Investigate changes VS
O2 saturation of 94% laboratory in behavior and - Although often T: 37 C
values within mentation, such as related to pain, RR: 20
normal limits restlessness, agitation, changes in BP: 130/110
 VS within and confusion. consciousness PR: 72
normal Limits may reflect
developing, worsening
Tanggalin niyo na yung hypoxia or effects of
breath sounds at abg inhaled toxins,
values, kasi nila niyo na especially carbon
siya dun sa first long monoxide.
term goal niyo
-Observe the patient
Pwede niyo pang mas for other signs of -These surrounding
habaan yung duration inhalation injury such structures are also
for long term goal kasi as damage to the important in air
medyo malala yung circumoral mucosa, exchange and may
lagay ng pasyente, burns along the cause disruptions in
mahaba naman pati nostrils, face or neck. airway clearance
hospital stay niya when injured or
-Monitor 24- hour fluid damaged.
balance, noting
variations or changes. - Fluid shifts or excess
fluid replacement
increase risk of
pulmonary edema.
Note: Inhalation injury
increases fluid
demands as much as
35% or more because
of edema and
- Position the patient fluid shifts.
in semi-Fowler’s or
high Fowler’s position. - Positioning the
patient this way helps
in promoting optimal
lung expansion and
removal of secretions.
It also allows the
patient to be
positioned
- Encourage coughing, comfortably.
deep- breathing
exercises, and -Promotes lung
frequent expansion,
position changes. mobilization, and
drainage of
secretions.
Promote voice rest,
but assess ability to - Increasing
speak and/or hoarseness or
swallow oral decreased ability to
secretions periodically. swallow
suggests increasing
tracheal edema and
may indicate
need for prompt
- Instruct patient and intubation.
significant others on
how to turn patient - These all help in
properly on bed, establishing a patent
coughing and deep airway, maintaining
breathing exercises optimum lung
and use of incentive capacity and promote
spirometer. independence for self-
care.

Collaborative:
- Provide the patient
with oxygen therapy -Humidified oxygen
when needed. therapy helps meet
the needs of the
patient for tissue
perfusion and reduces
-Monitor serial ABGs. the risk for hypoxia.

Baseline is essential
for further assessment
of respiratory
status and as a guide
- Provide or assist with to treatment.
chest physiotherapy
and incentive - Chest physiotherapy
 spirometry, as drains dependent
indicated. areas of the lung,
and incentive
spirometry may be
done to improve lung
expansion, thereby
promoting respiratory
function and
Dependent: reducing atelectasis
- Prepare for, or assist
with, intubation or
tracheostomy and - Intubation and
mechanical mechanical support is
ventilation, as required when airway
indicated. edema or
circumferential burn
injury interferes with
respiratory function
and oxygenation

Comment:

- Ilagay mo yung about sa sooty sputum, then add mo din yung edema sa diagnosis
- Okay naman yung diagnosis, kaso parang gusto ni sir maiksi lang kapag may secondary to… gusto naman ni maam kriza ay may as evidenced by…
hahahaha.
- Identify mo yung sa planning yung long term at short term goal mo
 Ilagay mo yung duration ng nursing intervention, ilang oras?
 Medyo mahirap maachieve agad ang clear breath sound sa lagay ng pasyente dahil malubha yung condition so more likely na long term goal
siya
  Coughing episodes, di ko alam… kasi siguro dapat turuan pa nga siyang magcough para maexpectorate yung plema (kasi may sooty sputum)
 Madaming lung complication si pasyente, so yung ABG ay dapat ay within tolerable range lang, di kasi kaya sa isang shift lang
 Pwede ka pang magdadag ng goals mo (both short term at long term
- Dagdagan mo pa yung mga intervention mo, madami ka pang makukuha sa nanda
- Identify mo kung ano diyan yung independent, dependent, at collaborative
- Lagyan mo ng vital signs yung evaluation as well as ABG results kasi indicated yun sa planning mo
- Pwede ka din magdadag ng mga statement ni client to prove na effective ang intervention

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective Data: Acute Pain related to After 8 hrs. of nursing Independent: After 8 hrs of Nursing
“Puro kayo tanong eh burn wounds as intervention the patient - Assess reports of severity of tissue intervention the patient
ang sakit na nga ng evidenced by will: pain, noting location involvement and will:
mga sugat ko at gusto narrowed focus,  Report pain and character and destruction but is  Display relaxed
ko na lang din facial mask of pain, reduced/controlled intensity (0–10 scale). usually most severe facial
magpahinga” as and restlessness . during dressing expressions/body
verbalized by the  Display relaxed changes and posture.
patient. facial debridement.  Participate in
expressions/body Changes in location, activities and
“Masakit nga raw posture. character, intensity sleep/rest
sugat ni kuya  Participate in of pain may indicate appropriately
hanggang ngayon activities and developing  Report pain
after nung sleep/rest complications (limb reduction
debridement” as appropriately. ischemia) or herald Patient Verbalized:
verbalized by the SO improvement and/or “Makakatulog na ako
of the patient. return of nerve nito dahil d na gasyanong
function and sumasakit ang sugat ko”
Visual analog scale - Change position sensation.
score for pain was 7 frequently and assist - Movement and Patient visual analog
 with active and exercise reduce joint scale score for pain is 2
Objective Data: passive ROM as stiffness and muscle
 burn wounds indicated. fatigue, but type of VS
were spread exercise depends on T: 37 C
over the right location and extent RR: 20
anterior and of injury. BP: 130/110
posterior PR: 72
thorax, -Movement and -Temperature
bilateral hips, exercise reduce joint regulation may be
bilateral lower stiffness and muscle lost with major
limbs, and fatigue, but type of burns. External heat
upper right exercise depends on sources may be
limbs, with a location and extent of necessary to prevent
total burn injury. chilling.
surface area
of 17 percent - Encourage
(TBSA). expression of feelings - Verbalization
 narrowed about pain. allows outlet for
focus emotions and may
 facial mask of enhance coping
pain mechanisms.
 restlessness - Explain procedures
 fatigue and provide frequent - Empathic support
information as can help alleviate
VS: appropriate, pain and/or promote
Mataas ng rr, hr, at BP especially during relaxation. 
wound debridement.

- Provide basic
comfort measures: - Promotes
deep breathing relaxation; reduces
exercise, massage of muscle tension and
uninjured areas, general fatigue
frequent position
changes.

- Provide diversional
activities appropriate - Helps lessen
for age and condition. concentration on
pain experience and
refocus attention.
- Promote
uninterrupted sleep - Sleep deprivation
periods. can increase
perception of
pain/reduce coping
Dependent abilities.
- Cover wounds as
soon as possible - Temperature
unless open-air changes and air
exposure burn care movement can cause
method required. great pain to
exposed nerve
endings.
- Wrap digits or
extremities in - Position of function
position of function reduces deformities
(avoiding flexed or contractures and
position of affected promotes comfort.
joints) using splints Although flexed
and foot boards as position of injured
necessary. joints may feel more
comfortable, it can
lead to flexion
contractures.
 - Provide medication - Reduces severe
and/or place in physical and
hydrotherapy (as emotional distress
appropriate) before associated with
performing dressing dressing changes and
changes and debridement.
debridement.

- Administer
analgesics (narcotic - The burned patient
and nonnarcotic) as may require around-
indicated: morphine the-clock medication
and dose titration. 
Subjective Data Deficient Fluid Short Term: Independent: Short term:
“Nanghihina po nurse Volume related to After 8 hrs of nursing -Monitor heart rate - Tachycardia and After 8 hrs of nursing
ang aking kapatid” compromised intervention the patient (HR), BP, and hypertension can intervention the patient :
mechanism (renal will: JVD/CVP. occur because of: (1)  Have equal
“Hindi po gasyano failure) as evidenced  Have equal intake failure of the kidneys intake and
nag-iihi ang aking by oliguria, and output to excrete urine, (2) output
kapatid” as verbalized weakness, nausea,  Increase range of excess fluid  Increase range of
by the SO nausea, vomiting, motion resuscitation during motion
edema on both  Vital Signs within efforts to treat  Vital Signs within
Objective Data extremities, normal ranges hypovolemia and/or normal ranges
 weakness decrease range of Long term: hypotension or “Medyo ayus naman
 nausea motion, restlessness, After 1-2 days of nursing convert ngayon ang kalagayan ng
 vomiting urine output 400 intervention the patient aking kapatid hindi tulad
 2+ edema on mL/24 hrs, Urine: will: - Decrease in output kanina na nanghihina” as
both Sodium Lvl of 40  Maintain equal - Accurately record (to less than 400 ml verbalized by the SO of
extremities mEq/L intake and output intake and output per 24 hours) may the Patient
 decrease  Absence of edema (I&O) noting to indicate acute
range of Pwede ding related  Maintain normal include “hidden” failure, especially in Long term:
motion to third spacing ranges of vital signs fluids such as IV high-risk patients. After 1-2 days of nursing
 restlessness secondary to burn antibiotic additives, Accurate monitoring intervention the patient:
  urine output injury liquid medications, of I&O is necessary  Maintain equal
400 mL/24 hrs frozen treats, ice for determining renal intake and
chips. Religiously function and fluid output
Laboratory Findings: measure replacement needs  Absence of
 Urine: Sodium gastrointestinal losses and reducing risk of edema
Lvl of 40 and estimate fluid overload.  Maintain normal
mEq/L insensible losses ranges of vital
(sweating), including signs
VS wound drainage, -to Measures the “Mayus naman na ang
T: 37.5 C nasogastric outputs, kidney’s ability to aking pakiramdam nurse,
RR: 27 and diarrhea. concentrate urine. nakakaihi na rin ako ng
BP:130/110 madalas, nawala na rin
PR: - Monitor urine - Daily body weight is ang pamamanas ng aking
specific gravity. best monitor of fluid binti at hindi na ako
status. A weight gain nanghihina”
of more than 0.5
- Weigh daily at same kg/day suggests fluid Diagnostic Study:
time of day, on same retention Urine Output 900 mL/24
scale, with same hrs
equipment and - Edema occurs Urine Sodium lvl: 20
clothing. primarily in mEq/L
dependent tissues of
the body, (hands, Vital Signs:
- Assess skin, face, feet, lumbosacral T: 37 C
dependent areas for area). Patient can RR: 20
edema. Evaluate gain up to 10 lb (4.5 BP: 130/110
degree of edema (on kg) of fluid before PR: 72
scale of +1–+4) pitting edema is
detected

Fluid overload may

lead to pulmonary
edema and HF
-Auscultate lung and evidenced by
heart sounds. development of
adventitious breath
sounds, extra heart
sounds.

- May reflect fluid

shifts, accumulation
of toxins, acidosis,
- Assess level of electrolyte
consciousness. imbalances, or
Investigate changes in developing hypoxia.
mentation, presence
of restlessness. - Helps avoid periods
without fluids,
- Scatter desired minimizes boredom
beverages of limited choices,
throughout the 24- and reduces sense of
hour period and give deprivation and
various offering (hot, thirst.
cold, frozen).

- Patient with CNS

involvement may be
- Use appropriate dizzy and/or
safety measures confused.
(raising side rails and
restraints.

Collaborative:
- Kidneys may be
- Correct any able to return to
reversible cause of normal functioning,
ARF: replace blood preventing or
loss, maximize limiting residual
cardiac output, effects.
discontinue
nephrotoxic drug,
relieve obstruction
via surgery.
-to see if the renal
-Monitor laboratory failure is controlled
and diagnostics study or worsen and create
such as Urinalysis, a plan of action
CBC, and Chest X- bases on the needs
rays. of the patient

- Fluid management
is usually calculated
Independent: to replace output
Administer and/or from all sources plus
restrict fluids as estimated insensible
indicated. losses (metabolism,
diaphoresis).
Prerenal failure
(azotemia) is treated
with volume
replacement and/or
vasopressors.

- to convert to non-
-Administer oliguric phase, flush
medication as the tubular lumen of
ordered such as debris, reduce
diuretics and hyperkalemia, and
Vasodilators. promote adequate
 urine volume, to
decrease SVR and
increase renal blood
flow

-to lower tract

obstruction and
-Insert indwelling provides means of
catheter, as accurate monitoring
indicated. of urine output
during acute phase

- Done to reduce
volume overload,
correct electrolyte
-Prepare for renal and
replacement therapy acid- base
(RRT) as indicated, imbalances, and
such as hemodialysis remove toxins.
(HD), peritoneal
dialysis (PD), or
continuous renal
replacement therapy
(CRRT).

Comment:

- Di ako sigurado kung tama bang dalawang pang respi or airway ang unang dalawang priority, kasi pwede mom o silang ipagcombine sa iisang care
plan, daanin mo nalang sa nursing intervention
- I suggest na pain dahil sa 2nd dgree burn, at deficient fluid volume dahil sa edema (may renal failure pa)
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