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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 necessary procedures and explain reasons for actions.
- Initiate necessary lifestyle changes and participate in treatment regimen.
Knowledge Deficit — Burn Injury Nursing Care Plan (NCP)
| Nursing Interventions | Rationale |
| Review condition, prognosis, and future expectations. | Provides knowledge base from which patient can make informed choices. |
| Discuss patient’s expectations of returning home, to work, and to normal activities. | Patient frequently has a difficult and prolonged adjustment after discharge. Problems often occur (e.g., sleep disturbances, nightmares, reliving the accident, difficulty with resumption of social interactions, intimacy/sexual activity, emotional lability) that interfere with successful adjustment to resuming normal life. |
| Review and have patient/SO demonstrate proper burn, skin-graft, and wound care techniques. Identify appropriate sources for outpatient care and supplies. | Promotes competent self-care after discharge, enhancing independence. |
| Discuss skin care, e.g., use of moisturizers, sunscreens, and anti-itching medications. | Itching, blistering, and sensitivity of healing wounds/graft sites can be expected for an extended time, and injury can occur because of the fragility of the new tissue. |
| Explain scarring process and necessity for/proper use of pressure garments when used. | Promotes optimal regrowth of skin, minimizing development of hypertrophic scarring and contractures and facilitating healing process. Note: Consistent use of the pressure garment over a long period can reduce the need for reconstructive surgery to release contractures and remove scars. |
| Encourage continuation of prescribed exercise program and scheduled rest periods. | Maintains mobility, reduces complications, and prevents fatigue, facilitating recovery process. |
| Identify specific limitations of activity as individually appropriate. | Imposed restrictions depend on severity/location of injury and stage of healing. |
| Emphasize importance of sustained intake of high-protein/ high-calorie meals and snacks. | Optimal nutrition enhances tissue regeneration and general feeling of well-being. Note: Patient often needs to increase caloric intake to meet calorie and protein needs for healing. |
| Review medications, including purpose, dosage, route, and expected/reportable side effects. | Reiteration allows opportunity for patient to ask questions and be sure understanding is accurate. |
| Advise patient/SO of potential for exhaustion, boredom, emotional lability, adjustment problems. Provide information about possibility of discussion/interaction with appropriate professional counselors. | Provides perspective to some of the problems patient/SO may encounter, and aids awareness that assistance is available when necessary. |
| Identify signs/symptoms requiring medical evaluation, e.g., inflammation, increase or changes in wound drainage, fever/chills; changes in pain characteristics or loss of mobility/function. | Early detection of developing complications (e.g., infection, delayed healing) may prevent progression to more serious/life-threatening situations. |
| Stress necessity/importance of follow-up care/ rehabilitation. | Long-term support with continual reevaluation and changes in therapy is required to achieve optimal recovery. |
| Provide phone number for contact person. | Provides easy access to treatment team to reinforce teaching, clarify misconceptions, and reduce potential for complications. |
| Identify community resources, e.g., skin/wound care professionals, crisis centers, recovery groups, mental health, Red Cross, visiting nurse, Ambli-Cab, homemaker service. | Facilitates transition to home, provides assistance with meeting individual needs, and supports independence. |
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Found through:
desired outcomes for delayed growth and development care plan, knowledge nursing care of burns model Questionnaier
