Nursing care map
Nursing activities
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Treatment
Pain caused by burnt skin
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Assess pain using painscore
Help patient feel comfortable
Provide gentle nursing care
Organize the environment to be quiet
Organize activities such as watching TV, listening to music
Suggest ways to relieve pain, such as talking to a comfortable sleeping position.
Give the pills according to the treatment plan
Unwell due to fever
Assess body temperature every 4 hours
Let the patient drink a lot of water 2,000-3,000 cc per day (8-12 glasses)
Wipe the body to reduce fever, do not turn on the air conditioner or fan while wiping
Place the Ice bag or cold towel on the forehead to Helps to remove heat from the body
Take care of general hygiene
Organize the environment for ventilation and convenience
There is an infection on the skin. due to Skin is damaged by electric shock
Place the patient in a room separate from the patient. Other people who have been infected
Measure the vital signs, observe the patient's level of consciousness to assess for infection in the bloodstream
Care for the patient using a clean, sterile room. Jana who cleaned the table
Bed and patient bed
Educate the relatives on how to act while they visit the sick
Assess the signs of infection. of close burns
Administer antibiotics according to the treatment plan
Clean the burn
Wash the wound with sterile saline and dry the wound
Advise the patient to a high protein diet
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Risk of water and electrolyte imbalance in the body
Assessment of dehydration
Take care of intravenous fluid replacement
Make a note of vital signs every 1 hour. in the first 4 hours and every 2 hours in the 8 hours
Check urine and take notes every hour
Follow up on red blood cell count and electrolytes
Record the amount of water entering the body and the water excreted from the body
Chance of heart palpitations, arrhythmias
Save and follow up on 12 lead ECG at first exposure
People find the cause of arrhythmia
Prepare heart rhythm medication for irregular heartbeat
Prepare emergency equipment
Observe the symptoms of Emboli blockage in different parts of the body.
Coordinating the doctor and providing care The nurse joins the doctor's treatment plan
Advise the patient not to strain the stool, if symptomatic, should report to the doctor for drainage.
Risk of hypothermia Usually because the skin is covered with peeling from burns
Check the correct temperature every hour
Clean the wound in the bath by Hydrotherapy
Control the temperature in the room to be suitable for In the case of Ong Air
Try to cover the wound to prevent heat loss through the open wound. The wound should be closed only as needed
May cause warmth with External
Complaining pain in the body painScore9/10
- Provide information on treatment guidelines Found some skin burns, peeling off the black color all over the area.
- Introduce the patient's relatives to know the characteristics Both arms are thick and thick, and the long hair is at the tip of the silk.
atagram 250u IM. and TT 0.5 ml IM 3. Tramol 1 amp vein stat
Ringer's lactate solution 800 cc/hr 8 hr
Retained Foley’ cathter; keep urine output 2 cc/kg/hr 6.Wet dressing
Cefazolin 1 gm vein ทกุ 6 hr
11 Schemes, Schemes
healthperception and health management - pain in the body with burns, some skin peels off black, both Area of both arms, legs, chest
Dan and Dan, my ends burned Scheme
Driving elimination -depletion of the body due to renal impairment Scheme
Activity and exercise -Inability to satisfy needs Normal daily routine Schemes
nutrition and metabolism -no problematic data found
Sleep andrest - No problematic data found.
cognitive and perceptual
the patient is constantly aware of the day time placev and able to answer questions with complete sentences visual acuity acuity is normal able to tell the area of pain
Role-relationship - The problematic data was not found Scheme
self perception and self concept No problematic data found.Pattern
have stress due to loss appearance
Provide information on treatment guidelines
Explain to thepatient and relativesto understand on the treatment of patient care duringsevere disease so that the patient and his orher relatives receive the right medical care
Introduce thepatient's relatives to know the characteristics of the characteristics of the
Give attention and care to the patient.always
The routine is impaired due to burn wounds on both arms
Care and teach relatives about nutrition
Assess the patient's ability to perform routine tasks
Teach and recommend how to practice oneself for Apply to daily lifeof the patient
Promote the practice of routine self- appointment