Nursing Care Plan Concept Map Example

Job Burns
Four year-old
female
Red urine, Hct high,
hgb low, Na low, low
specific gravit
Tonsils @ 2+
Capaillary refill 4 seconds
Hgb 10
Burns to face, arms, hands and legs
Rectal temp 35.8
Hyperkalemia K=5.9
Risk for Cardiac Output:
Decresed 2*Dysrythmias
Crying in pain,
unable to move fingers
Position for comfort
pain
Administer Morphine 0.2 mg/kg I.V.
Not to exceed 15 mg in 24 hours
Immunizations behind
schedule
Knowledge Deficit:
Immunizations
Mother is 3 weeks
post-partum
Respirator rate 32
Fear/Anzoety
Include information in
nurses notes:
Give information on
immunizations
during discharge teaching
Encourage parents to
remain at bedside
Caregiver Role Strain
Encourage parent to express feelings
Nurses notes: recommend
social worker consult when pt.
arrives to floor
Use distraction techiques: music, tv.
Assess family resources
Contact clergy for support
Immpbility
Continuous Pulse OX
monitoring
Child only member
of family injured
in fire
Risk for Altered Family Process
Explore parental coping mechanisms::
forther's lighter found at scene,
possible guilt reaction
Facillitate communication
between family, social worker and
invesitgators
Contact granparents for provide
care for siblings
ABG's QH or prn
Be mindful of signs of
developmental regression
Be mindful of signs of
developmental regression
Administer O2
as prscribed
Risk for Ineffective Tissue Perfusion: Peripheral
Seif-Care Deficit
Perform self-care
activities for patient
Possible respiratory compromise
due to hx of reactive airway disease
Continuous airway monitoring
Have intubation tray at bedside
Risk for Ineffective Airway Clearance
Hx of Asthma
Monitor CBC for WBC levels
Administer Oxacillin 50 mg/kg/24 hours I.V.
in divided doses Q6H
Monitor temp Q2H
Be aware of jehovah's witness
sttus: No blood Products
Risk for Infection
Impaired skin integrity
Risk for Acute Renal Failure
Monitor Urinary
Send UA for myoglobin
Avoid pressure on sites of skin impairment
Assess site of skin impairment for condition
and degree of burn
Cover pt. with light sheet
Monitor temp Q2H
Thermoregulation:
Ineffective
Low Diastolic blood pressure
of 40
Fluid Volume: Deficient
Administer Albumin 0.5 g/kg/does in 5%
as Prescribed by M.D.
Administer IV fluids as prescribed by M.D.
Monitor B/P Q15 min
Run EKG
Continous Cardiac
Monitoring
Kayexalate PO/Rectal
1g/kg/Q6H as long
as K+ renains elevated
Use sterile technique for urgent
debriding of burns
Map Key:
Abnormal Clinical
Findings
Nursing Diagnosis
Nursing Inteventions
Burns: Nursing Care Plan
lllecia Benefield
Leigh McLaughlin
Marisa Roskelley
Jasmine Walden
Monitor urine output
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