NCLEX: Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client: HEMATOLOGICAL SYSTEM

Focus topic:  Physiological Integrity: Nursing Care of the Adult Client

E. Evaluation/outcome criteria:

Focus topic:  Physiological Integrity: Nursing Care of the Adult Client

  • Acceptance of chronic disease.
  • Reports at prescribed intervals for follow-up.
  • Remission: reduction of bone marrow activity, blood volume and viscosity (RBC count <6,500,000/mm3; hemoglobin (Hgb) <18 g/dL; Hct <45%; WBC <10,000/mm3).
  • No complications (e.g., thrombi, hemorrhage, gout, CHF, leukemia).

LEUKEMIA (ACUTE AND CHRONIC): a neoplastic disease involving the leukopoietic tissue in either the bone marrow or lymphoid areas; acute leukemia occurs in children, young adults; chronic forms occur in later adult life.

Focus topic:  Physiological Integrity: Nursing Care of the Adult Client

A. Types:

Focus topic:  Physiological Integrity: Nursing Care of the Adult Client

  • Acute nonlymphocytic (ANLL)—also known as acute myelogenous leukemia (AML); seen generally in older age (>60 years).
  • Acute lymphocytic (ALL)—common in children 2 to 10 years.
  • Chronic lymphocytic (CLL)—generally affects the elderly.
  • Chronic myelogenous (CML)—also known as chronic granulocytic leukemia (CGL); more likely to occur between 25 and 60 years.

B. Pathophysiology: displacement of normal marrow cells by proliferating leukemic cells (abnormal, immature leukocytes) → normochromic anemia, thrombocytopenia.

Focus topic:  Physiological Integrity: Nursing Care of the Adult Client

C. Risk factors:

Focus topic:  Physiological Integrity: Nursing Care of the Adult Client

  • Viruses.
  • Genetic abnormalities.
  • Exposure to chemicals.
  • Radiation.
  • Treatment for other types of cancer (e.g., alkylating agents).

D. Assessment:

Focus topic:  Physiological Integrity: Nursing Care of the Adult Client

  • Subjective data:

a. Fatigue, weakness.

b. Anorexia, nausea.

c. Pain: joints, bones (acute leukemia).

d. Night sweats, weight loss, malaise.

  • Objective data:

a. Skin: pallor due to anemia; jaundice.

b. Fever: frequent infections; mouth ulcers.

c. Bleeding: petechiae, purpura, ecchymosis, epistaxis, gingiva.

d. Organ enlargement: spleen, liver.

e. Enlarged lymph nodes; tenderness.

f. Bone marrow aspiration: increased presence of blasts.

g. Laboratory data:

(1) WBC count—abnormally low (<1,000/mm3) or extremely high (>200,000/mm3); differential is important.
(2) RBC count—normal to severely decreased.
(3) Hgb—low or normal.
(4) Platelets—usually low.

E. Analysis/nursing diagnosis:

Focus topic:  Physiological Integrity: Nursing Care of the Adult Client

  • Risk for infection related to immature or abnormal leukocytes.
  • Activity intolerance related to hypoxia and weakness.
  • Fatigue related to anemia.
  • Altered tissue perfusion related to anemia.
  • Anxiety related to diagnosis and treatment.
  • Altered oral mucous membrane related to susceptibility to infection.
  • Fear related to diagnosis.
  • Ineffective individual or family coping related to potentially fatal disease.

F. Nursing care plan/implementation:

Focus topic:  Physiological Integrity: Nursing Care of the Adult Client

  • Goal: prevent, control, and treat infection.

a. Protective isolation if indicated.

b. Observe for early signs of infection:

(1) Inflammation at injection sites.
(2) Vital sign changes.
(3) Cough.
(4) Obtain cultures.

c. Give antibiotics as ordered.

d. Mouth care: clean q2h, examine for new lesions, avoid trauma.

  • Goal: assess and control bleeding, anemia.

a. Activity: restrict, to prevent trauma.

b. Observe for hemorrhage: vital signs; body orifices, stool, urine.

c. Control localized bleeding: ice, pressure at least 3 to 4 minutes after needle sticks, positioning.

d. Use soft-bristle or foam-rubber toothbrush to prevent gingival bleeding.

e. Give blood/blood components as ordered; observe for transfusion reactions.

  • Goal: provide rest, comfort, nutrition.

a. Activity: 8 hours sleep or rest; daily nap.

b. Comfort measures: flotation mattress, bed cradle, sheepskin.

c. Analgesics: without delay.

(1) Mild pain (acetaminophen [Tylenol], tramadol 50 mg without aspirin).
(2) Severe pain (codeine, meperidine HCl [Demerol]).

d. Diet: bland.

(1) High in protein, minerals, vitamins.
(2) Low roughage.
(3) Small, frequent feedings.
(4) Favorite foods.

e. Fluids: 3,000 to 4,000 mL/day.

  • Goal: reduce side effects from therapeutic regimen.

a. Nausea: antiemetics, usually half-hour before chemotherapy.

b. Increased uric acid level: force fluids.

c. Stomatitis: antiseptic anesthetic mouthwashes.

d. Rectal irritation: meticulous toileting, sitz baths, topical relief (e.g., Tucks).

  • Goal: provide emotional/spiritual support.

a. Contact clergy if client desires.

b. Allow, encourage client-initiated discussion of death (developmentally appropriate).

c. Allow family to be involved in care.

d. If death occurs, provide privacy for family, listening, sharing of grief.

  • Goal: health teaching.

a. Prevent infection.

b. Limit activity.

c. Control bleeding.

d. Reduce nausea.

e. Mouth care.

f. Chemotherapy: regimen; side effects.

G. Evaluation/outcome criteria:

Focus topic:  Physiological Integrity: Nursing Care of the Adult Client

  • Alleviate symptoms; obtain remission.
  • Prevent complications (e.g., infection).
  • Ventilates emotions—accepts and deals with anger.
  • Experiences peaceful death (e.g., pain free).

IDIOPATHIC THROMBOCYTOPENIC PURPURA (ITP): potentially fatal disorder characterized by spontaneous increase in platelet destruction; possible autoimmune response; seen predominantly in 2- to 4-year-olds and girls/women ≥10 years old. Remissions occur spontaneously or following splenectomy; in contrast, secondary thrombocytopenia (STP) is caused by viral infections, drug hypersensitivity (i.e., quinidine, sulfonamides), lupus, or bone marrow failure; treat cause.

Focus topic:  Physiological Integrity: Nursing Care of the Adult Client

A. Assessment:

  • Subjective data:

a. Spontaneous skin hemorrhages—lower extremities.

b. Menorrhagia.

c. Epistaxis.

  • Objective data:

a. Bleeding: GI, urinary, nasal; following minor trauma, dental extractions.

b. Petechiae; ecchymosis.

c. Tourniquet test—positive, demonstrating increased capillary fragility.

d. Laboratory data:

(1) Decreased platelets (<100,000/mm3).
(2) Increased bleeding time.

B. Analysis/nursing diagnosis:

Focus topic:  Physiological Integrity: Nursing Care of the Adult Client

  • Risk for injury related to hemorrhage.
  • Altered tissue perfusion related to fragile capillaries.
  • Impaired skin integrity related to skin hemorrhages.

C. Nursing care plan/implementation:

Focus topic:  Physiological Integrity: Nursing Care of the Adult Client

  • Goal: prevent complications from bleeding tendencies.

a. Precautions:

(1) Injections—use small-bore needles; rotate sites; apply direct pressure.
(2) Avoid bumping, trauma.
(3) Use swabs for mouth care.

b. Observe for signs of bleeding, petechiae following blood pressure reading, ecchymosis, purpura.

c. Administer steroids (e.g., prednisone) with ITP to increase platelet count; give platelets for count below 20,000 to 30,000/mm3 with STP; high-dose immunoglobulins.

  • Goal: health teaching.

a. Avoid traumatic activities:

(1) Contact sports.
(2) Violent sneezing, coughing, nose blowing.
(3) Straining at stool.
(4) Heavy lifting.

b. Signs of decreased platelets—petechiae, ecchymosis, gingival bleeding, hematuria, menorrhagia.

c. Use Medic Alert tag/card.

d. Precautions: self-medication; particularly avoid aspirin-containing drugs.

e. Prepare for splenectomy if drug therapy unsuccessful (prednisone, cyclophosphamide, azathioprine [Imuran]).

D. Evaluation/outcome criteria:

Focus topic:  Physiological Integrity: Nursing Care of the Adult Client

  • Returns for follow-up.
  • No complications (e.g., intracranial hemorrhage).
  • Platelet count greater than 200,000/mm3.
  • Skin remains intact.
  • Resumes self-care activities.

SPLENECTOMY: removal of spleen following rupture due to acquired hemolytic anemia, trauma, tumor, or idiopathic thrombocytopenic purpura.

Focus topic:  Physiological Integrity: Nursing Care of the Adult Client

A. Analysis/nursing diagnosis:

Focus topic:  Physiological Integrity: Nursing Care of the Adult Client

  • Risk for fluid volume deficit related to hemorrhage.
  • Risk for infection related to impaired immune response.
  • Pain related to abdominal distention.
  • Ineffective breathing pattern related to high abdominal incision.

B. Nursing care plan/implementation:

Focus topic:  Physiological Integrity: Nursing Care of the Adult Client

  • Goal: prepare for surgery.

a. Give whole blood, as ordered.

b. Insert nasogastric tube to decrease postoperative abdominal distention, as ordered.

  • Goal: prevent postoperative complications.

a. Observe for:

(1) Hemorrhage—bleeding tendency with thrombocytopenia due to decreased platelet count.

(2) Gastrointestinal distention—removal of enlarged spleen may result in distended stomach and intestines, to fill void.

b. Recognize 101°F temperature as normal for 10 days.

c. Incision: splint when coughing, to prevent high incidence of atelectasis (common complication), pneumonia with upper abdominal incision.

  • Goal: health teaching.

a. Increased risk of infection postsplenectomy.

b. Report signs of infection immediately.

C. Evaluation/outcome criteria:

  • No complications (e.g., respiratory, subphrenic abscess or hematoma, thromboemboli, infection).
  • Complete and permanent remission—occurs in 60% to 80% of clients.

Physiological Integrity: Nursing Care of the Adult Client: IMMUNOLOGICAL SYSTEM

Focus topic:  Physiological Integrity: Nursing Care of the Adult Client

LYME DISEASE: a spirochetal illness (syndrome); most common tick-borne infectious disease in United States; prevalent Northeast, upper Midwest, and coastal northern California. Reporting is mandatory. With early treatment, recovery is usually quick and complete.

Focus topic:  Physiological Integrity: Nursing Care of the Adult Client

A. Stages:

Focus topic:  Physiological Integrity: Nursing Care of the Adult Client

  • Stage I. Rash (erythema migrans) at site of tick bite; bull’s-eye or target pattern; may appear as hives or cellulitis; common in moist areas (groin, armpit, behind knees). Flu-like symptoms may occur (joint pain, chills, fever).
  • Stage II. If untreated, may progress to cardiac problems (10% of clients) or neurological disturbances—Bell’s palsy (10% of clients); occasionally meningitis, encephalitis, and eye damage may result.
  • Stage III. From 4 weeks to 1 year after the tick bite, “arthritis,” primarily large joint, develops in half the clients. If untreated, chronic neurological problems may develop.

B. Assessment (depends on stage): History is important—where do they live or work? Recent travel? Outdoor activities (gardening, hiking, camping, clearing brush)? Knowledge of tick bite and how removed? Pets?

  • Subjective data:

a. Malaise (stage I).

b. Headache (stage I).

c. Joint, neck, or back pain (stages I and III).

d. Weakness (stages II and III).

e. Chest pain (stage II).

f. Light-headedness (stage II).

g. Numbness, pain in arms or legs (stage III).

  • Objective data:

a. Rash—erythema migrans (stage I); at least 5 cm/lesion.

b. Dysrhythmias; heart block (stage II).

c. Facial paralysis (stage II).

d. Conjunctivitis, iritis, optic neuritis (stage II).

e. Laboratory data: Lyme titer—elevated (stages II and III). Often inconclusive.

f. Diagnostic tests: isolation of Borrelia burgdorferi in tissue or body fluid; diagnostic levels of IgM or IgG antibodies in serum or CSF.

C. Analysis/nursing diagnosis:

Focus topic:  Physiological Integrity: Nursing Care of the Adult Client

  • Anxiety related to diagnosis.
  • Pain related to joint inflammation.
  • Fatigue related to viral illness.
  • Impaired physical mobility related to joint pain.
  • Altered thought processes related to neurological deficit.
  • Decreased cardiac output related to dysrhythmias.
  •  Knowledge deficit (learning need) related to treatment and course of disease.

D. Nursing care plan/implementation:

  • Goal: minimize irreversible tissue damage and complications.

a. Medications according to presenting symptoms: stage I—oral antibiotics for 21 days (doxycycline, amoxicillin, cefotaxime); stages II and III—oral (see stage I) or intravenous antibiotics for 21 to 28 days (ceftriaxone).

b. If hospitalized, monitor vital signs q4h for increased temperature, signs of heart failure; check level of consciousness and cranial nerve functioning.

c. Note treatment response: worsening of symptoms during first 24 hours: redder rash, higher fever, greater pain (Jarisch-Herxheimer reaction).

  • Goal: alleviate pain, promote comfort.

a. Medications: salicylates, nonsteroidal anti-inflammatory agents, or other analgesic, as ordered; observe for side effects (GI irritation).

b. Rest: give instructions on relaxation techniques; create a quiet environment.

  • Goal: maintain physical and psychological well-being.

a. Activity: ROM at regular intervals; medicate for pain before exercise; encourage proper posture to reduce joint stress; rest periods between activities and treatments.

b. Referral: occupational or physical therapy as appropriate.

c. Reassurance: give psychological support; encourage discussion of feelings.

  • Goal: health teaching.

a. Information on disease. Transmission from tick not likely if removed before 48 hours of attachment.

b. Instructions for home IV antibiotics with heparin lock, if ordered.

c. Side effects of antibiotics (drug specific); importance of completing therapy.

d. Signs of disease recurrence (later stages of disease: less severe attacks).

e. Preventing subsequent infections: wear proper clothing and tick repellent on clothing (20% to 30% DEET); conduct “tick checks” of self, children, and pets; proper tick removal (use tweezers, steady, gentle traction).

f. Start vaccination series (LYMErix); three injections at 0, 1, and 12 months.

E. Evaluation/outcome criteria:

Focus topic:  Physiological Integrity: Nursing Care of the Adult Client

  • Achieves reasonable comfort.
  • Regains normal physiological and psychological functioning—no irreversible complications; vital signs within normal limits.
  • Resumes previous activity level; returns to work.
  • Adheres to follow-up care recommendations.
  • Knows ways to minimize risk of reinfection.

ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS): the terminal stage of the disease continuum caused by human immunodeficiency virus (HIV), a retrovirus; typically progresses from asymptomatic seronegative status to asymptomatic seropositive status to subclinical immune deficiency to lymphadenopathy (early AIDS) to
AIDS-related complex (middle stage with combination of symptoms) to AIDS; hallmarks of HIV infection include opportunistic infections: Pneumocystis jiroveci (carinii) pneumonia (PCP); cytomegalovirus (CMV); Mycobacterium tuberculosis; hepatitis B; herpes simplex or zoster; candidiasis; may take 7 to 10 years before signs and symptoms occur.

Focus topic:  Physiological Integrity: Nursing Care of the Adult Client

A. High-risk populations:

Focus topic:  Physiological Integrity: Nursing Care of the Adult Client

  • Men, homosexual or bisexual (71%).
  • Injection drug users (IDU)/heterosexual (10%).
  • IDU/homosexual (9%).
  • People who have hemophilia and are recipients of multiple transfusion (1%).
  • Heterosexual (5%).
  • Undetermined/other (4%).

B. Pathophysiology: abnormal response to foreign antigen stimulation (acquired immunity) → deficiency in cell-mediated immunity—T lymphocytes, specifically helper T cells (CD4 cells) and hyperactivity of the humoral system (B cells).

Focus topic:  Physiological Integrity: Nursing Care of the Adult Client                                                                                                                                                

C. Assessment:

  • Subjective data:

a. Fatigue: prolonged; associated with headache or light-headedness.

b. Unexplained weight loss: greater than 10%.

  • Fever: prolonged or night sweats longer than 2 weeks.

a. Lymphadenopathy.

b. Skin or mucous membrane lesions: purplish-red, nodules (Kaposi’s sarcoma).

c. Cough: persistent, heavy, dry.

d. Diarrhea: persistent.

e. Tongue/mouth “thrush”; oral hairy leukoplakia.

f. Diagnostic tests (with permission of client): enzyme-linked immunosorbent assay (ELISA); Western blot test.

g. Laboratory data: decreased—CD4 T lymphocytes, hematocrit, WBCs, platelets. Seropositive—syphilis, hepatitis B; ELISA— positive; Western blot test—positive (mean time for seroconversion is 6 weeks after infection).

D. Analysis/nursing diagnosis:

  • Risk for infection related to immunocompromised state.
  • Fatigue related to anemia.
  • Altered nutrition, less than body requirements, related to anorexia.
  • Impaired skin integrity related to nonhealing viral lesions, Kaposi’s sarcoma.
  • Diarrhea related to infection or parasites.
  • Risk for activity intolerance related to shortness of breath.
  • Ineffective airway clearance related to pneumonia.
  • Visual sensory/perception alteration related to retinitis.
  • Risk for altered body temperature (fever) related to opportunistic infections.
  • Social isolation related to stigma attached to AIDS.
  • Powerlessness related to inability to control disease progression.
  • Altered thought processes related to dementia.
  • Ineffective individual coping related to poor prognosis.
  • Risk for violence, self-directed, related to anger, panic, or depression.

E. Nursing care plan/implementation:

  • Goal: reduce risk of infection; slow disease progression.

a. Observe signs of opportunistic infections: weight loss, diarrhea, skin lesions, sore throat.

b. Monitor vital signs (including temperature).

c. Note secretions and excretions: changes in color, consistency, or odor indicating infection.

d. Diet: monitor fluid and electrolytes; strict measurement; encourage adequate dietary intake (high calorie, high protein, low bulk); 5 to 10 times recommended dietary allowance (RDA) for water-soluble vitamins (B complex, C); favorite foods from home; enteral feedings. Six small meals/day.

e. Protective isolation, if indicated, for severe immunocompromise.

f. Antiviral medications, as ordered: nucleoside reverse transcriptase inhibitors (e.g., zidovudine [Retrovir]); nonnucleoside reverse transcriptase inhibitors (e.g., nevirapine [Viramune]); protease inhibitors (e.g., indinavir sulfate [Crixivan]); drug toxicity and numerous side effects likely (rash, GI upset); large number of pills and tight administration schedule; costly; potential for drug resistance.

  • Goal: prevent the spread of disease.

a. Frequent hand washing, even after wearing gloves.

b. Avoid exposure to blood, body fluids of client; wear gloves, gowns; proper disposal of needles, IV catheters.

  • Goal: provide physical and psychological support.

a. Oral care: frequent.

b. Cooling bath: 1:10 concentration of isopropyl alcohol with tepid water; avoid plastic-backed pads if client has night sweats.

c. Encourage verbalization of fears, concerns without condemnation; may suffer loss of job, lifestyle, significant other.

d. Determine status of support network: arrange contact with support group.

e. Observe for severe emotional symptoms (suicidal tendencies).

f. Address issues surrounding death to ensure quality of life: advance directive prepared and on file; “code blue” status; reassurance of comfort and pain control.

  • Goal: health teaching.

a. Avoidance of environmental sources of infection (kitty litter, bird cages, tub bathing).

b. Precautions following discharge: risk-reducing behaviors; condoms (latex), limit number of sexual partners, avoid exposure to blood or semen during intercourse.

c. Family counseling; availability of community resources.

d. Information on disease progression and life span.

e. Stress-reduction techniques: visualization, guided imagery, meditation.

f. Expected side effects with drug therapy; importance of compliance.

F. Evaluation/outcome criteria:

  • Relief of symptoms (e.g., afebrile, gains weight).
  • Resumes self-care activities; returns to work; improved quality of life.
  • Accepts diagnosis; participates in support group.
  • Progression of disease slows; improved survival probability.
  • Retains autonomy, self-worth.
  • Permitted to die with dignity.

ANIMAL-BORNE DISEASES (Infectious Diseases: Animal-Borne).

Focus topic:  Physiological Integrity: Nursing Care of the Adult Client


Focus topic:  Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client


Physiological Integrity: Nursing Care of the Adult Client: INTEGUMENTARY SYSTEM

Focus topic:  Physiological Integrity: Nursing Care of the Adult Client

BURNS: wounds caused by exposure to excessive heat, chemicals, fire, steam, radiation, or electricity; most often related to carelessness or ignorance; 10,000 to 12,000 deaths annually; survival best at ages 15 to 30 years and in burns covering less than 20% of total body surface.

Focus topic:  Physiological Integrity: Nursing Care of the Adult Client

A. Pathophysiology:

  • Emergent phase (injury to 72 hours): shock due to pain, fright, or terror → fatigue, failure of vasoconstrictor mechanisms → hypotension. Capillary dilation, increased permeability →plasma loss to blisters, edema → hemoconcentration→ hypovolemia → hypotension →decreased renal perfusion → potential shutdown.
  • Acute phase (3 to 5 days): interstitial-to-plasma fluid shift → hemodilution → hypervolemia → diuresis.

B. Assessment:

  • Subjective data: how the burn occurred.
  • Objective data:

a. Extent of body surface involved: “rule of nines”—head and both upper extremities, 9% each; front and back of trunk, 18% each; lower extremities, 18% each; and perineum, 1%. Requires adjustment for variation in size of head and lower extremities according to age.

b. Location—facial, perineal, and hand and foot burns have potentially more complications because of poor vascularization.

c. Depth of burn (Burn Characteristics According to Depth of Injury):

(1) First degree (superficial)—epidermal tissue only; not serious unless large areas involved.
(2) Second degree (shallow or deep partial thickness)—epidermal and dermal tissue, hospitalization required if more than 10% of body surface involved (major burn).
(3) Third degree (full thickness)—destruction of all skin layers; requires immediate hospitalization; involvement of 10% of body surface considered major burn.
(4) Fourth degree (deep penetrating)—muscles (fascia), bone.

d. Indications of airway burns (e.g., singed nasal hair, progressive hoarseness, sooty expectoration); edema may occur in 1 hour; increased mortality rate.

e. Poorer prognosis—infants, due to immature immune system and effects of fluid loss; elderly, due to degenerative diseases and poor healing.

f. Medical history—presence of hypertension, diabetes, alcohol abuse, or chronic obstructive pulmonary disease increases complication rate.

Physiological Integrity: Nursing Care of the Adult Client


C. Analysis/nursing diagnosis:

  • Impaired skin integrity related to thermal injury.
  • Pain (depending on type of burn) related to exposure of sensory receptors.
  • Fluid volume excess or deficit related to hemodynamic changes.
  • Risk for infection related to destruction of protective skin.
  • Impaired gas exchange related to airway injury.
  • Body image disturbance related to scarring, disfigurement.
  • Ineffective individual or family coping related to traumatic experience.

D. Nursing care plan/implementation:

  • Goal: alleviate pain, relieve shock, and maintain fluid and electrolyte balance.

a. Medications: give opioid analgesic and anxiolytics incrementally.

b. Fluids: IV therapy; colloids, crystalloids, or 5% dextrose according to burn formula.

c. Monitor hydration status:

(1) Insert indwelling catheter.

(2) Note: color, odor, and amount of urine hourly.

(3) Strict intake and output; hourly for 36 hours with large burns.

(4) Check hematocrit: normal: men greater than 40%; women greater than 37%. Increased Hct with intravascular fluid depletion.

(5) Weigh daily.

  • Goal: prevent physical complications.

a. Vital signs: hourly; central venous pressure (CVP) for signs of shock or fluid overload with clients who are at-risk.

b. Assess respiratory function (particularly with head, neck burns); patent airway; breath sounds.

c. Give medications as ordered—tetanus booster; antibiotics to treat documented infection; sedatives and analgesics; antipyreticsavoid aspirin; H2 blockers.

d. Isolation: protective; contact isolation (hand washing, protective clothing).

e. Positioning: turn q2h; prevent contractures.

(1) Head and neck burns—use pillows under shoulders only for hyperextension of neck.
(2) Hand burns—splints.
(3) Arm and hand burns—keep arms at 90-degree angle from body and slightly above shoulders.
(4) Ankle and foot burns—splints; elevate to prevent edema.
(5) Splints to maintain functional positions.
(6) ROM exercises according to therapy guidelines; usually several times per day; active exercises most beneficial.

f. Diet: begin oral fluids at once; food as tolerated—high protein, high calorie for energy and tissue repair (promote positive nitrogen balance); enteral feedings if protein and calorie goals not met.

g. Observe for: constriction (circumferential or chest wall burns); check peak inspiratory pressure in client who is intubated—report increased pressure; check pulses in burned extremities every 1 to 2 hours for 24 hours— report loss of pulses.

  • Goal: promote emotional adjustment and provide supportive therapy.

a. Care by same personnel as much as possible, to develop rapport and trust.

b. Involve client in care plans.

c. Answer questions clearly, accurately.

d. Encourage family involvement and participation.

e. Provide diversional activities and change furnishings or room adornments when possible, to prevent perceptual deprivation related to immobility.

f. Point out signs of progress (e.g., decreased edema, healing) because client and family tend to become discouraged and cannot see progress.

g. Encourage self-care to highest level tolerated.

h. Anticipate psychological changes:

(1) Acute period—severe anxiety: medicate with anxiolytics as ordered; maintain eye contact; explain procedures.

(2) Intermediate period—reactions associated with pain, dependency, depression, anger; give medications to decrease pain; explain procedures; have open, nonjudgmental attitude; use consistent approaches to care; contract with client regarding division of responsibilities; encourage self-care.

(3) Recuperative period—grief process reactivated. Anxiety, depression, anger, bargaining, as client tries to cope with altered body image, leaving security of hospital, finances. Encourage verbalization; refer to support group to assist adaptation.

  • Goal: promote wound healing—wound care:

a. Open method—exposure of burns to air; useful in burns of face; thin layer (2 to 4 mm) topical antimicrobial ointment applied.

b. Closed method—dressings applied to burned areas, changed 1 to 3 times/day; give PO pain medication 30 minutes before change; IV pain medication during dressing change; tubbing facilitates removal.

c. Multiple dressing change—common approach; dressings changed twice daily to q4h depending on wound condition.

d. Topical antimicrobial therapies (Topical Antimicrobials Used in Burn Care).

e. Tubbing and débridement.

(1) Hydrotherapy—body-temperature bath water; loosens dressings so some float off; soak 20 to 30 minutes; encourage limb exercises; do not leave unattended; loss of body heat may occur, with chilling and poor perfusion resulting.
(2) Removal of eschar (débridement)—done with forceps and curved scissors; medicate for pain before; use sterile technique; only loose eschar removed, to prevent bleeding; examine wound for: infection, color change, decreased granulation— report changes immediately. Chemical débridement also done; agent digests necrotic tissue.

f. Wound coverage, to decrease chances of infection:

(1) Temporary and semipermanent wound coverings (Wound Coverings).
(2) Autograft—client donates skin for wound coverage.

(a) Types—free grafts (unattached to donor site) and pedicle grafts (attached to donor site).
(b) Procedure—general anesthesia; donor sites shaved and prepared; graft applied to granulation bed; face, hands, and arms grafted first.
(c) Post–skin-graft care:

(i) Sheet grafts: roll cotton-tipped applicator over graft to remove excess exudate; maintain dressings; aseptic technique; mesh grafts: irrigate as ordered.
(ii) Third to fifth day—graft takes on pink appearance if it has taken.
(iii) Padding, then splints applied to immobilize grafted extremities.
(iv) Pressure garments worn up to 18 months to decrease hypertrophic scarring.

  • Goal: health teaching.

a. Mobility needs: exercise; physical therapy; occupational therapy; splints, braces.

b. Community resources: mental health practitioner or psychotherapist if needed for problems with self-image or sexual role; referrals as needed.

c. Techniques to camouflage appearance: slacks, turtlenecks, long sleeves, wigs, makeup.

E. Evaluation/outcome criteria:

  • Return of vital signs to preburn levels.
  • Minimal to no hypertrophic scarring.
  • Free of infection; demonstrates wound care.
  • Maintains functional mobility of limbs; no contractures.
  • Adjusts to changes in body image; no depression.
  • Regains independence; returns to work, social activities.

Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client




Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.