ASSESSMENT NURSING PLANNING IMPLEMENTATION/ NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION

 2nd and 3rd Impaired gas Goal: 1. Provide humidified oxygen. 1. Humidified oxygen Goal Met if
degree exchange Maintenance provides moisture to injured there is
burns all related to of adequate tissues, supplemental absence of
over the carbon tissue oxygen increases alveolar dyspnea,
neck, chest, monoxide oxygenation. oxygenation. respiratory
abdomen, poisoning, rate is
2. These factors provide
and left arm. smoke between 12 to
baseline data for further
Based on inhalation, 20
2. Assess breath sounds, and assessment and evidence of
the rule of and airway breaths/min,
respiratory rate, rhythm, depth, increasing respiratory
nines the obstruction. when lungs
and symmetry. Monitor patient compromise.
TBSA is are clear on
31.5%. for signs of hypoxia. 3. These signs indicate auscultation,
possible inhalation injury and arterial oxygen
risk of respiratory saturation is
 Vital Signs 3. Observe the following: dysfunction. greater than
a) Erythema or blistering of 96% by pulse
lips or buccal mucosa oximetry and
Temperature: arterial blood
36.6 degrees b) Singed nostrils gas levels are
Celsius c) Burns of face, neck, or within normal
chest limits.

Pulse rate: d) Increasing hoarseness

126bpm e) Soot in sputum or
 tracheal tissue in
respiratory secretions
Respiration rate:
12cpm 4. Monitor arterial blood gas
values, pulse oximetry readings,
and carboxyhemoglobin levels.
Blood pressure:
104/60 mmHg
5. Report labored respirations,
or signs of hypoxia to physician
immediately.
6. Prepare to assist with
intubation and escharotomies.
7. Monitor mechanically
ventilated patient closely.
4. Increased PaCO2 and
decreasing PaO2 and O2
saturation may indicate
need for mechanical
ventilation.
5. Immediate intervention is
indicated for respiratory
difficulty.
6. Intubation allows
mechanical ventilation.
Escharotomy enables chest
excursion in circumfrential
chest burns.
7. Monitoring allows early
detection of decreasing
respiratory status or
complications of mechanical
ventilation.