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Nursing Diagnosis: Impaired Physical Mobility May be related to Neuromuscular impairment, pain/discomfort, decreased strength and endurance Restrictive therapies, limb immobilization; contractures Possibly evidenced by Reluctance to move/inability to purposefully move Limited ROM, decreased muscle strength control and/or mass Desired Outcomes Maintain position of function as evidenced by absence of contractures. Maintain or increase strength and function of affected and/or compensatory ...

Nursing Diagnosis: Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs May be related to Lack of exposure/recall Information misinterpretation; unfamiliarity with resources Possibly evidenced by Questions/request for information, statement of misconception Inaccurate follow-through of instructions, development of preventable complications Desired Outcomes Verbalize understanding of condition, prognosis, and potential complications. Verbalize understanding of therapeutic needs. Correctly perform ...

Nursing Diagnosis: Body Image disturbed/Role Performance, ineffective May be related to Situational crisis: traumatic event, dependent patient role; disfigurement, pain Possibly evidenced by Negative feelings about body/self, fear of rejection/reaction by others Focus on past appearance, abilities; preoccupation with change/loss Change in physical capacity to resume role; change in social involvement Desired Outcomes Incorporate changes into self-concept without negating self-esteem. ...

Nursing Diagnosis: Fear/Anxiety May be related to Situational crises: hospitalization/isolation procedures, interpersonal transmission and contagion, memory of the trauma experience, threat of death and/or disfigurement Possibly evidenced by Expressed concern regarding changes in life, fear of unspecific consequences Apprehension; increased tension Feelings of helplessness, uncertainty, decreased self-assurance Sympathetic stimulation, extraneous movements, restlessness, insomnia Desired Outcomes Verbalize awareness of feelings and ...

Nursing Diagnosis:  Impaired Skin Integrity [due to Grafts] May be related to Disruption of skin surface with destruction of skin layers (partial-/full-thickness burn) requiring grafting Possibly evidenced by Absence of viable tissue Desired Outcomes Wound Healing: Secondary Intention (NOC) Demonstrate tissue regeneration. Achieve timely healing of burned areas. Impaired Skin Integrity — Burn Injury Nursing Care Plan (NCP) Nursing Interventions ...

Nursing Diagnosis: Nutrition: imbalanced, less than body requirements May be related to Hypermetabolic state (can be as much as 50%–60% higher than normal proportional to the severity of injury) Protein catabolism Anorexia, restricted oral intake Possibly evidenced by Decrease in total body weight, loss of muscle mass/subcutaneous fat, and development of negative nitrogen balance Desired Outcomes Demonstrate nutritional intake adequate to ...

Nursing Diagnosis: Tissue Perfusion, ineffective/Peripheral Neurovascular dysfunction, risk for Risk factors may include Reduction/interruption of arterial/venous blood flow, e.g., circumferential burns of extremities with resultant edema Hypovolemia Desired Outcomes Maintain palpable peripheral pulses of equal quality/strength; good capillary refill and skin color normal in uninjured areas. 11 Burn Injury Nursing Care Plan (NCP) Impaired Physical Mobility — Burns Nursing Care ...

Nursing Diagnosis: Pain, acute May be related to Destruction of skin/tissues; edema formation Manipulation of injured tissues, e.g., wound debridement Possibly evidenced by Reports of pain Narrowed focus, facial mask of pain Alteration in muscle tone; autonomic responses Distraction/guarding behaviors; anxiety/fear, restlessness Desired Outcomes Report pain reduced/controlled. Display relaxed facial expressions/body posture. Participate in activities and sleep/rest appropriately. 11 Burn ...