NANDA-NursingPlan Area 11 Safety/Defense

NANDA-Nursing Plan 00220  Risk for thermal injury


Note: This article was translated from Japanese using translation software. Please use at your own risk, as there may be unnatural points in the content or differences in content due to cultural differences.

Area 11 Safety/Defense
Category 2 Bodily injury Bodily harm or injury

00220 Risk for thermal injury

Nursing Diagnosis: Risk for thermal injury
Definition: A condition in which extremes of temperature tend to damage the skin and mucous membranes and can be detrimental to health.

1. What are burns? (Refer to the website of the Japanese Society for Wound Surgery)

Burns | The Japanese Society for Wound Surgery To the general public
https://www.jsswc.or.jp/general/yakedo.html

1) Definition

A type of trauma that damages the skin and mucous membranes due to heat.
The degree of skin damage is determined by the temperature of the contacting heat source and the contact time.
A high temperature + short-term contact is a common burn, but a low temperature of about 44 to 50° C. + long-term contact also causes a burn, which is called a low-temperature burn. Chemical burns are called chemical burns.
Burns can be caused by high-temperature solids, liquids, flames, blasts, electric currents in high-voltage lines, lightning strikes, chemicals (acids and alkalis), hot water bottles, and body warmers.

2) Classification of burns

Burns are classified into degrees I, II, and III, depending on the depth of the burn.
・First degree: Dryness and erythema can be seen. I have pain.
・Second degree:
Superficial II degree (SDB): Moist and blister formation. Skin color is light red. Accompanied by severe pain. Perception remains.
Depth II degree (DDB): wet and blister formation. Skin color is slightly white. Mildly painful. Perception is dulled.
・Level 3: Dry to waxy color, harden to yellow to reddish brown, carbonize to black. Sensation is lost and painless.

3) Severity of burns

Severity is comprehensively judged by the injured area, site, depth, and age. The injured area is calculated using the rule of 9 for adults and the rule of 5 for children.
Artz severity classification is used for severity.

“Classification of Artz”

✩ If you remember the range of moderate symptoms, it is convenient because you can know that more than that is severe and less than that is mild.
✩ Special burns that are classified as severe are also asked in the national exam, so it is a good idea to remember.

1. Severe disease (requires hospitalization at a specialized facility)

(1)For adults (other than the elderly):
①Degree II 30% or more or Degree III 10% or more.
② Special parts (face, limbs, perineum) burns of second degree or higher regardless of area
③Special burns (airway burns, electric shocks, chemical burns) are treated as severe regardless of area or depth.
④Fractures and trauma complications are treated as serious regardless of area or depth.
(2)For children and the elderly:
The range in ① above is different. 20% or more of degree II or 5% or more of degree III are treated as severe.
② to ④ are the same.

2. Moderate (requires hospitalization at a general hospital)

(1)For adults (other than the elderly):
① Degree II 15-30% or Degree III 2-10%.
(2)For children and the elderly:
The range in ① above is different. Grade II 10-20% or Grade III 2-5% are treated as moderate.

3. Mild (outpatient treatment possible)

(1)For adults (other than the elderly):
① Less than 15% of degree II or less than 2% of degree III.
(2)For children and the elderly:
The range in ① above is different. Less than 10% of degree II or less than 2% of degree III are treated as mild.

2. Indications for Nursing Diagnosis “Risk for thermal injury”

・Decline in cognitive function
・ Ages that make it difficult to judge the situation (children)
・Sensory disorders, neuromuscular diseases (muscular atrophy, myopathy), diabetic neuropathy
・Poor judgment due to addiction (drug addiction, alcohol addiction)
Burns from handling fire, heat sources, or oxygen (smoking, abuse, hot water bottles)
・Insufficient knowledge and supervision of what causes burns (many burns in children due to parental carelessness)
・Workers who use special acid or alkali chemicals

3. aim setting

Goal setting by linkage (listed in the second half of the NOC)
* “Linkage” has the role of connecting “NANDA”, “NIC” and “NOC” .


1) Linkage achievements

・Recovery from burns (1107)
(Definition: degree of mental and physical healing associated with severe burns)
・Healing burns (1106)
(Definition: degree of healing of the burn site)
・Tissue integrity: skin and mucosa (1101)
(Definition: Normal physiological function without skin and mucosal tissues)
・Level of dementia (0920)
(Definition: Severity of irreversible impairment of consciousness and cognition with long-term loss of mental, physical and social functioning)
・Personal Safety Behavior (1911)
(Definition: Personal actions that prevent unintentional bodily harm)
・Safe Home Environment (1910)
(Definition: Arranging the physical environment to minimize environmental factors that can cause physical injury in the home)

2) Goal

The goal is to make the patient the subject.
Instead of saying “Nurses can do ○○”,
For example, “The patient will be able to do ○○.”
・Can describe the safe use of devices that cause burns, such as hot water bottles, and can actually use them safely.
・(Family members and other caregivers) can describe and actually create such an environment to prevent burns and frostbite.

※ I think that the following goals can be cited as action goals for nurses.
・Remove things that cause burns and frostbite, and create a safe living (recuperation) environment according to the level of understanding and recognition of the target person. (Creating a safe environment according to the cognitive abilities of infants and the elderly)
・Use according to the precautions for using the product so as not to touch the same part such as a hot water bottle, warmer, or carpet for a long time.

4. nursing plan

1 >> Observation plan 《OP》

・Cognitive impairment (Hasegawa score of 19 or less, MMSE score of 21 or less)
・Symptoms of dementia (hallucinations, delusions)
・Arrangement of things in the room (Is there anything that could cause burns within reach?)
→→→Gas stove, oven, cigarette, stove, warmer, hot water bottle, carpet, kotatsu, electric blanket, hair dryer, iron, hair iron, lighter, incense stick, candle, etc.
・Arrangement of things in the room (Is there anything that could cause frostbite within reach?)
→→→Dry ice, freezer that children can open and close
・The arrangement of objects in the room (Are there objects that can cause chemical burns within reach?)
→→→Chemicals (kitchen heater, herbicide, etc.)
・Presence or absence of skin numbness and degree
Disturbed consciousness, restlessness, delirium
・Use of psychotropic drugs and sleep-inducing drugs (dangers cannot be avoided or not noticed)
・Attention disorder
・Recognition of caregivers (parents too)
・The mental state of the caregiver
・Child/elderly abuse (neglect/neglect), etc.
・Child/elderly abuse (physical and psychological abuse) pouring hot water, burning cigarettes
・Situation at the scene of the fire (whether or not smoke was inhaled) If there is soot on the face, there is a high possibility of airway burns
– Signs of burns
・Pain
・ Blisters
・Redness, blackness
・ Dyspnea, decreased SPO2

2 >> Action plan 《TP》

・Persons receiving oxygen therapy should be kept away from fire (ignition and burns).
・For those who are receiving oxygen therapy at home, adjust the environment so that they can stay 2 meters away from fire, such as in the kitchen.
・Improve the environment that causes fires.
・Do not place an ashtray to avoid smoking in bed.
・Separate smoking areas. (Outside)
・Do not place flammable objects near fire. (There is a curtain near the stove, etc.)
・Do not place anything that could be set on fire around the house. (Paper and combustible garbage)
・Enclose the kerosene stove so that you do not get close to it.
・Instruct caregivers to change the position of kotatsu, carpets, hot water bottles, and other items that cause low-temperature burns from time to time while using them and to observe the skin.
・Remove dry ice, chemicals, etc. placed within reach to a place out of reach. .
・For freezers and ovens that can be easily opened by children, take measures such as moving them to a position where children cannot open them or using a child lock.

3 >> Education plan 《EP》

・Instruct people on oxygen therapy to keep away from fire (ignition and burns).
・Explain to avoid actions that cause fires.
・Explain to avoid smoking in bed.
・Explain not to put flammable objects around the fire. (There is a curtain near the stove, etc.)
・Explain not to place anything that could be set on fire around the house. (Paper and combustible garbage)
・Explain that candles and incense sticks at Buddhist altars should be lit only when visiting (worship) and extinguished after the visit.
・Recommend measures such as putting up an enclosure to keep people away from kerosene stoves. (Explain to caregiver)
・Instruct caregivers to change the position of kotatsu, carpets, hot water bottles, and other items that cause low-temperature burns from time to time while using them and to observe the skin.
・Teach children not to play with fire alone.

References

T. Heather Hardman Shigemi Kamitsuru. (2016). NANDA-I Nursing Diagnosis Definition and Classification 2015-2017. Igaku Shoin.
Okaniwa, Yutaka. (2012). Review book for nurses and nursing students. Medic Media Co., Ltd.
Yutaka Okaniwa. (2019.3). Year Note 2020. Medic Media Co., Ltd.
Yuko Kuroda (Translation). (2015). Nursing Outcome Classification (NOC) Original 5th Edition Indicators and Measurement Scales for Measuring Outcomes. Elsevier Japan K.K.
Yamaguchi Toru, Kitahara Mitsuo, Fukui Tsuguya. (2012). Today’s treatment guidelines.
Yumiko Ohashi, Hajime Yoshino, Naoki Aikawa, Sumi Sugawara. (2008). Nursing Learning Dictionary (3rd Edition). Gakken Co., Ltd. (Gakken).

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