Nursing Diagnosis 1: Risk for Deficient Fluid Volume
Risk for Deficient Fluid Volume related to evaporative loss of fluids and capillary damage through the burn wound as evidenced by weakness shown and abnormalities in PTR, BP, SpO2 due to flame burn at work on the entire right leg. Nursing Assessment:
(1) Temp 35.8°C in tympanic is below normal as pt sustained a flame burn at work causing heat loss from the body with risk of hypovolemic shock and dehydration. (2) BP 80/60 mmHg showing pt as in hypotension as partial-thickness burn on his entire right leg with 10% TBSA burn: blisters 3+, oedema 2+, red & moist skin, ↓ROM due to blood loss from flame burn. (3) Patient is alert and orientated with GCS: 15/15, E4V5M6. (4) Patient is tachypnoeic and tachycardiac showing by RR: 30/min, SpO2: 94%, bounding pulse. (5) Patient had the primary survey and inhalation injury was excluded Subjective data:
(1) Patient complained of severe pain over the burned areas. (2) Patient is restless.
(1) Patient will resume normal and have the stable vital signs within 24 hours after treatment. (2) Patient will maintain hydration level and elastic skin turgor. Nursing Interventions:
1) Monitor vital signs Q1H(TPR, BP, SpO2, CVP) and change to Q4H if readings return to normal baseline. Rationale: The vital signs can use as a guide for predict the fluid replacement needs or accesses cardiovascular response , especially by checking the BP to prevent hypovolemic shock which is about the “severe fluid loss makes the heart unable to pump enough blood to the body in the situation”. (MedlinePlus Medical Encyclopedia). 2) Administered O2 2L/min prn via nasal cannula if SpO2 of patient is