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Burns NCP

The nursing care plan addresses unstable vital signs and ineffective airway clearance in a patient with burns. The objectives are to maintain a patent airway and adequate clearance after 8 hours of intervention. Interventions include monitoring vital signs, maintaining a patent airway through positioning and suctioning, providing humidified oxygen, encouraging turning, coughing, deep breathing and incentive spirometry, suctioning as needed, and keeping the environment allergen-free. The plan is evaluated after 8 hours.

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Kristian Jonas Lao
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679 views3 pages

Burns NCP

The nursing care plan addresses unstable vital signs and ineffective airway clearance in a patient with burns. The objectives are to maintain a patent airway and adequate clearance after 8 hours of intervention. Interventions include monitoring vital signs, maintaining a patent airway through positioning and suctioning, providing humidified oxygen, encouraging turning, coughing, deep breathing and incentive spirometry, suctioning as needed, and keeping the environment allergen-free. The plan is evaluated after 8 hours.

Uploaded by

Kristian Jonas Lao
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

Nursing Care Plan (Burns)

CUES NEEDS NURSING OBJECTIVES INTERVENTION RATIONALE EVALUATION


DIAGNOSI/BA
CKGROUND
KNOWLEDGE

Objective: P Ineffective
General: Dependent: After 8 hours of
H Airway
Y Clearance After 8 hours of 1. Monitor vital signs especially ● To evaluate the nursing
Unstable VS:
S related to nursing
Respiration. degree of Interventions, the client
I edema and intervention,
>Cardiac rate: 126bpm O effects of the patient will compromise has maintain patent
L smoke maintain patent
and have a airway with a respiratory
O inhalation airway and
>Respiratory rare: G adequate baseline data. rate of 17.
12cpm I airway
GOAL PARTIALLY MET
C clearance.
2. Maintain patent airway ● A patent airway
>Blood Pressure: N through proper patient
positioning, removal of is crucial to
104/60mmHg E
E secretions, and artificial respiration.
D airway if needed.
>Rule of 9: 31.5% S
3. Provide humidified oxygen. ● Humidity
>With pitting edema on liquifies
burn area secretions and
facilitates
>Skin color: Red to
expectoration.
Brown
>Weak in appearance 4. Encourage patient to turn, ● These activities
cough, and deep breathe. promote
>Irritable
Encourage patient to use mobilization
incentive spirometry. Suction and removal of
>Grimace face
as needed. secretions.
>Patient is intubated and
on mechanical ventilator.
5. Keep environment allergen ● To prevent
free. allergic
reaction.
Independent:

● Administer medication such ● Medications

as propofol as prescribed by may help

the physician. relieve the


immediate
symptoms.

Collaborative:

1. Discuss condition of patient with ● To provide


the family and other members of the further
health care team.
information
about the
current
condition of the
patient.

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