While caring for Marion there are three nursing problems that should be looked into so that a good place can be prepared for her during my shift. The first is the environment the injury and the medication.
Before the start of the shift I have to make sure that her bed is clean. If the environment is dirty then the infections on Marions body will get worse and so the environment is one of the nursing problems. Due to the extent of the burns and their degree the environment must be checked all the time and that is a problem I have to deal with.
Before I start the shift the other problem I will deal with is the injured part on Marion. This part can get worse if it is exposed and the environment relates to it regarding infections and other things pertaining cleanliness of the burnt part. I have to administer the prescribed drugs and pain killers.
The other thing I have to check is the prescriptions by the doctor that will be offered when I start the shift. This is because Marion has to take some different medication throughout the day. These medications range from those that are meant to prevent infections to those that are meant to reduce pain. Making sure that Marion takes her medication at the right time is crucial if she is to recover quickly.
Task 2
Nursing Care Plan: Marion
Note: Dot points may be used in the care plan. Add more lines to table if required (use Tab button)
Nursing problem/issue
Goal of care
Nursing interventions/actions
Rationale
Expected outcome of care
The pain that is related to the injury (LeMone 2014)
Marion will finally be able to verbalize relief that is adequate from the intense pain and she will be able to do activities that are related to daily living soon enough and in my shift we will practice verbal relief.
Frequently check Marions levels of pain during the shift.
Cover the burns the best way possible
Change Marions position some times during the day and perform some exercises for her.
Encourage Marion to verbalize her pain (Laurie et al. 2010).
Provide Marion with activities that will divert her attention from the burns.
Make sure Marion gets sleep that is uninterrupted by giving her the necessary medicine
Use analgesics before burning care and the dressing changes
The pain scale gives a measurement that is objective. The pain is always there but does not remain in the same place and it changes its location. Intensity may signify some complications.
Movement of air in the room and changes in temperature will make Marion feel pain (LeMone 2014).
Reduce stiffness of joints and also prevent contractures.
Provide Marion with outlets for strong emotions and will help her to cope with the situation.
Helps to reduce Marions focus on the pain.
For Marion deprivation of sleep can increase her pain perception.
Will help Marion to reduce anxiety for the dressing changes that will follow.
Marion will be able to verbalize relief that is adequate from her pain and she will be able to perform activities related to daily living (Laurie et al. 2010).
The risk of Marion getting infested due to trauma and also skin barrier destruction
Marion will slowly be freed of all infections as the healing process goes on.
Take important signs frequently.
Use the standard precautions when Marions wounds are exposed. Also visitors who come to visit Marion will be limited and restricted.
Clear all hair around Marions burns
Make sure not to place any IVs on Marions burns
Keep her biosynthetic dressing dry at all times
Administer antibiotics for the infections that have been diagnosed as the doctors have prescribed to her.
Increased body temperature shows that Marion has new infections.
Reduces the likelihood of her wounds being contaminated.
Hair keeps bacteria.
Help eliminate bacteria that have been introduced in her wounds.
Reduce wound contamination risks for her
The antibiotics will clear infections much faster.
Marion either stays free of infections that are secondary or her infections diagnosed and then treated as soon as possible.
Risk of Fluid Volume Imbalance since she is losing a lot of body fluids through her wounds and then due to excess intake of fluids
She will maintain a good level of urine output.
Monitors important signs in her pulses capillary refill time and her central venous pressure.
Estimate Marions fluid losses.
Administer oral fluids.
Insert a urinary catheter
Monitor her output and intake.
Monitor for hypercalcemia and hyponatremia.
Marion is at a high risk of shock and she needs fluid resuscitation.
Careful calculation of her fluid needs and also ensuring good intake will help Marion to be well hydrated most of the times.
Marion is at high risk of fluid overload when she is being hydrated and for edema on the burn site and her bodily tissues.
Marion has lost a considerable amount of plasma due to damages on her capillaries. These losses increased three days after she was burned and she may need fluid replacements.
A significant gain in weight or loss can help me find out about her fluid imbalances.
Helps keep output measurements that are accurate especially during the critical care stages.
Potassium was lost when her cells were burned and also sodium was lost when her bodily fluids were burnt and this causes electrolyte imbalances for Marion (Avni et al. 2010).
She maintains a normal level of urine output. Also burn edema is not excessive.
Altered Peripheral Tissue Perfusion that is related to the mechanical reductions of blood flow in Marions arteries
Marion will continue to maintain perfusion that is adequate in the burned extremities
Elevate her extremities by performing hourly pulse checks and notify the nearest physician when she has no pulse or it has reduced.
Check her eschar.
Eschar can be made up of the peripheral circulation in her edematous extremity (Pavoni et al. 2010).
Elevation will help Marion to reduce dependent edema because it promotes venous return. Dependent edema can constrict Marions peripheral circulation.
Marion has no episodes of perfusions that are poor on her burned extremity.
Ineffective Patterns of breathing that are as a result of fatigue after smoke inhalation
Marion will demonstrate or maintain her improvements when it comes to breathing patterns
Provide for Marion through pulmonary care
Elevate the head of the bed she is sleeping in (Salinas et al. 2011).
Keep at her bedside an intubation tube.
Administer corticosteroids as has been prescribed.
Monitor closely Marions quality of respirations the sound of breathing pulse oximetry and her mucus secretions (Wade 2010).
Reduces airway edema
The pulmonary case helps to remove secretions and prevent her from getting infections (Jeschke et al. 2008).
Nasal flaring dyspnea and air hunger may develop.
Pulmonary edema cane is caused by excess fluid replacement (Mariano et al. 2008).
Marion has a regular breathing pattern.
Impaired physical mobility because of the serious burns
Marion will remain a good range of motion
Arrange occupational and physical therapy.
Exercises good positioning and ailment preventing contractures (Kallinen et al. 2012).
Marion maintains a range of motion that is good without contractures (Wade 2010).
Nutrition during shift
Marion will maintain her weight and also demonstrate hydration and serum albumin that is adequate (Palmieri et al. 2009)
Encourage her to take meals with the others
Give her multivitamin supplements
Substitute juices and milk with water
Provide her with opportunities to choose the meals that she enjoys and likes (Ratnapalan 2011).
Socialization will improve her intake of food and fluids
Encourage intake
Vitamin C which will increase her intake of zinc (Murray et al. 2008). Zinc will make her heal faster.
Provide evaluation that is objective.
Marion maintains her weight serum albumin and hydration that is adequate (Brusselaers et al. 2010).
Task 3
Marion has been prescribed with Fentanyl via a transdermal patch because it is a good solution to relieve her pain. This is because the level of her burns gives her tremendous pain and this is why this prescription is very important to her. This medication relieves pain for a long time and it is used where other types of pain relievers have failed. Patients with burns have extra ordinary pain and that is why this prescription is very important to her (LeMone 2014). This class of medication belongs to the opiate class or the narcotics class and it changes the way the nervous system and the brain respond to pain like the one Marion is experiencing.
The mineral and vitamin supplements have been provided to give Marion the nutrients she needs for speedy recovery. Currently Marion needs a lot of nutrients that normal food cannot provide and this is one of the reasons why she has been prescribed with the supplements (LeMone 2014). For Marion she will get all the health benefits that come with the supplements and this will strengthen her immune system and also help in the generation of new blood and this will help her wounds to heal quicker. For a normal person who is not suffering from such a severe need of nutrients such supplements would not work to their full potential.
An aperient has been prescribed to Marion so that is can relieve constipation that has been caused by the administering of Fentanyl which is a narcotic (LeMone 2014). Since Marion is getting huge amounts of narcotics in her she will most of the time constipate because of Fentanyl and the lack of exercises. The aperient will relieve constipation and make Marion feel fresh and this will help her be comfortable as she continues to recover from the burns. The aperient will also relax the digestive system for Marion and this will help her body absorb all the nutrients that her body needs at this time especially the supplements. By doing this Marion will recover quicker than if she was in an uncomfortable position because of constant constipation.
Task 4
Marions Progress
Marion will continue with the nasal prong oxygen til review the next morning since she continues to need more oxygen. She also continues to take antibiotics with the analgesia changed to morphine. Her dressings should remain intact for the next three days until the decision is reviewed by her physician.
Marion has vital signs of 02 saturations and a pain score of 3-4 which is still high since the burns are still not fully recovered yet. She can drowse but can be easily awakened and aroused. Her dressing is still intact but some wounds are still oozing.
At the end of my shift Marion became more drowsy and it became harder to arouse her. Maybe it is because she has been tired of staying awake during my shift. He urine output has dropped at the end of my shift. Also the vital signs have increased with her temperatures reaching 37.8 degrees centigrade. All this shows that Marion has been doing well but sometimes her wounds get infected a little bit and this is why her temperatures are rising at the end of my shift (LeMone 2014). The next nurse should administer her antibiotics to prevent her from being infected.
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