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/EVALUATION CRITERIAPATIENT WILL: Knowledge: Disease Process (NOC) Verbalize understanding of condition, prognosis, and potential complications. Knowledge: Treatment Regimen (NOC) Verbalize understanding of therapeutic needs. Correctly perform necessary procedures and explain reasons for actions. Initiate necessary lifestyle changes and participate in treatment regimen.

ACTIONS/INTERVENTIONS
Teaching: Disease Process (NIC)

RATIONALE

Independent
Review condition, prognosis, and future expectations. Provides knowledge base from which patient can make informed choices. 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. Promotes competent self-care after discharge, enhancing independence.

Discuss patients expectations of returning home, to work, and to normal activities.

Review and have patient/SO demonstrate proper burn, skin-graft, and wound care techniques. Identify appropriate sources for outpatient care and supplies. 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. 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. Maintains mobility, reduces complications, and prevents fatigue, facilitating recovery process.

Explain scarring process and necessity for/proper use of pressure garments when used.

Encourage continuation of prescribed exercise program and scheduled rest periods.

ACTIONS/INTERVENTIONS

RATIONALE

Teaching: Disease Process (NIC)

Independent
Identify specific limitations of activity as individually appropriate. Emphasize importance of sustained intake of highprotein/ high-calorie meals and snacks. Imposed restrictions depend on severity/location of injury and stage of healing. 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. Reiteration allows opportunity for patient to ask questions and be sure understanding is accurate. Provides perspective to some of the problems patient/SO may encounter, and aids awareness that assistance is available when necessary.

Review medications, including purpose, dosage, route, and expected/reportable side effects. Advise patient/SO of potential for exhaustion, boredom, emotional lability, adjustment problems. Provide information about possibility of discussion/interaction with appropriate professional counselors. 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. Stress necessity/importance of follow-up care/ rehabilitation.

Early detection of developing complications (e.g., infection, delayed healing) may prevent progression to more serious/life-threatening situations.

Long-term support with continual reevaluation and changes in therapy is required to achieve optimal recovery. Provides easy access to treatment team to reinforce teaching, clarify misconceptions, and reduce potential for complications. Facilitates transition to home, provides assistance with meeting individual needs, and supports independence.

Provide phone number for contact person.

Identify community resources, e.g., skin/wound care professionals, crisis centers, recovery groups, mental health, Red Cross, visiting nurse, Ambli-Cab, homemaker service.