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  • Nursing Diagnosis Fvd2

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    ghellers
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    The document provides nursing goals, interventions, and rationale for treating a patient with a full thickness burn injury covering 52% of their total body surface area who is experiencing fluid volume deficit related to increased capillary permeability and evaporation fluid loss from the burn. The goals are to stabilize vital signs, maintain adequate urine output and electrolyte balance through IV fluid administration using the Parkland formula and ongoing assessment and monitoring. The rationale explains the physiologic effects of severe burns that can lead to fluid shifts, electrolyte imbalances, and increased insensible fluid loss if not properly treated.

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    The document provides nursing goals, interventions, and rationale for treating a patient with a full thickness burn injury covering 52% of their total body surface area who is experiencing fluid volume deficit related to increased capillary permeability and evaporation fluid loss from the burn. The goals are to stabilize vital signs, maintain adequate urine output and electrolyte balance through IV fluid administration using the Parkland formula and ongoing assessment and monitoring. The rationale explains the physiologic effects of severe burns that can lead to fluid shifts, electrolyte imbalances, and increased insensible fluid loss if not properly treated.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Scarica in formato DOCX, PDF, TXT o leggi online su Scribd
    Segnala contenuti inappropriati
    79 visualizzazioni2 pagine

    Nursing Diagnosis Fvd2

    Caricato da

    ghellers
    The document provides nursing goals, interventions, and rationale for treating a patient with a full thickness burn injury covering 52% of their total body surface area who is experiencing fluid volume deficit related to increased capillary permeability and evaporation fluid loss from the burn. The goals are to stabilize vital signs, maintain adequate urine output and electrolyte balance through IV fluid administration using the Parkland formula and ongoing assessment and monitoring. The rationale explains the physiologic effects of severe burns that can lead to fluid shifts, electrolyte imbalances, and increased insensible fluid loss if not properly treated.

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    Attribution Non-Commercial (BY-NC)
    Scarica in formato DOCX, PDF, TXT o leggi online su Scribd
    Segnala contenuti inappropriati
    di 2

    CUES NURSING DIAGNOSIS GOALS AND NURSING RATIONALE EVALUATION

    OBJECTIVES INTERVENTION
    Goal: Assessment:
    Objective: Fluid volume deficit After 6-8 hours of - Measure vital Compensatory mechanisms BP 100/60, urine
    related to increased nursing signs, including result in peripheral output >30ml/hr CVP 6
    - Full Thickness capillary permeability intervention, the CVP . vasoconstriction with a weak
    thready pulse, drop in
    burn with burn and evaporate fluid loss patient will establish
    systolic blood pressure,
    injury of 52% from burn injury adequate fluid orthostatic hypotension and
    TBSA volume, electrolyte reduced CVP.
    - Edema at balance.
    affected areas The physiologic effects of Alterations in mental status
    the burn complicate tissue
    - Assess for
    - Decreased Objectives: neurological status can occur from severe Awake, lethargic,
    damage that occurs after After series of volume depletion and stupor
    urinary output the burn insult.
    nursing altered sodium levels,
    Coagulation factors are patients are also at risk for
    affected, protein is interventions, the
    patient will: seizures.
    Findings: denatured and cellular
    - Urine output content is iconized. These - Have stabilized - Hyperkalemia;
    factors, coupled with the vital signs Cell lysis causes potassium No signs of
    moderate, dark Arrhythmia, slow cardiac
    dilation of the capillaries - Maintain urine rate, diarrhea, twitching,
    shifts from intravascular hyperkalemia and
    concentrated to interstitial space.
    and small vessels lead to output of at GI hypermotility hyponatremia present.
    - Excess increased capillary least 30 cc/hr
    potassium permeability and fluid shift - Maintain serum - Hyponatremia;
    levels from the intravascular sodium levels Bounding pulse, Normal ratio is 10:1 to
    - Decreased space to interstitial space. tachycardia, weakness, 15:1. Ratios greater than
    - Maintain serum Ratio 12:1 after fluid
    In addition to protein and pallor, headache, edema 20:1 are associated with
    serum Sodium electrolyte shifts, an potassium replacement.
    level levels dehydration.
    increased insensible water - BUN/ creatinin
    - Elevated loss occurs. In the healthy - Have stable
    ratio.
    hematocrit adult, this loss is hematocrit
    estimated at 30-50 ml/hr. levels
    Weight: The burn patient‘s
    insensible fluid loss may
    BP – 80/60 Independent:
    be as much as 300 to 3000
    ml per day. - Measure and Fluid volume deficit
    (Critical Care Nursing by record urine reduces glomerular Intake equal to output.
    Urden, p.970) output hourly; filtration and renal blood
    report urine flow causing oliguria.
    output less than
    30ml for 2
    consecutive hours.

    - Weigh patient Changes in weight can


    daily. provide information on Patient able to
    fluid balance and the maintain weight.
    adequacy of volume
    replacement.

    Dependent:
    Initiate and administer Initial goal is to correct
    IV therapy using circulatory volume deficit. 0.9% NSS administered
    Parkland formula:
    - Isotonic saline Isotonic saline will rapidly
    (0.9%) initially. expand extracellular fluid
    volume.

    - Follow subsequent Correction of water deficit


    IV therapy as is usually accomplished by D5 ½ NSS infusing at
    ordered, a hypotonic solution. ___/hr.
    depending on
    state of Reference: Medical
    hydration, Surgical Nursing by
    serum
    Brunner and Suddarth
    electrolyte levels
    Critical Care Nursing by
    Urden and Stacy

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