Identify possible nursing diagnoses that Karen may have and provide a rationale for your choice:
A nursing diagnosis that would be attributed to the patient, Karen in the case study would be risk of deficient fluid volume. Karen’s slightly elevated pulse and respirations and additionally the assessment findings of mild oedema and blister formation show that there is a movement of body fluid into the second and third interstitial spacing. Brown and Edwards (2008) states this is caused by increased capillary permeability. Water, sodium and plasma protein move into the intestinal spacing and surrounding tissue. Furthermore Karen states that she has a headache, feels nauseas and chilled after being over exposed to the sun. Karen has a temperature of 38.5 and an abundant of redness to her body surface after prolonged exposure. Over exposure to ultra violet rays can cause thermal burns which leads to increased fluid loss via evaporation from the injured skin. Assessing the fluid loss, perfusion and oxygenation status, and evaluating the need for fluid and electrolyte replacement that is lost, through fluid and protein shifts can aid in the restoration of intravascular volume.
Another expected nursing diagnosis is acute pain. The sudden onset of pain is a result of the nociceptive tissue damage and the nursing treatment required for the injury tissue. Careful assessment of the wound and surrounding tissue can help determine the level of injury sustained. The pain is variable and cannot be reliably predicted by clinical assessment of the patient. ‘Burn patients experience two kinds of pain continuous background pain, which occurs during the course of the day and night. Secondly, a treatment induced pain which is related to ambulation, dressing changes and rehabilitation activities’ (Brown and Edwards, 2008). Pain is individual, and there are a number of tools to assist in pain management. A commonly used technique is the PQRSTU mnemonic. Pain, in addition to being a source of outright suffering in patients, can interfere with wound care and therapies as well as lengthen hospitalisation. ‘The amount of pain experienced with burn injuries appears associated with post-traumatic stress and emotional stress. There are practical as well as humanitarian reasons to control burn pain aggressively’. (Patterson, et. al n.d.). Regular reassessment of the patient’s pain levels can lead to improved pain management.
A nursing diagnosis of an imbalance body temperature is a likely occurrence for the patient. Karen’s slightly high temperature of 38:5 and stating she feels chilled highlights there may be a disparity. The human body is able to maintain a constant temperature of between 36:5˚and 37:1˚ under varying environmental conditions. Hyperthermia can exist as a result of exposure to heat causing a rise in body temperature leading to heat stress whereas the thermo regulatory mechanism such as vasodilatation, sweating and increased respiration cannot compensate...