Medical Surgical Nursing

Nursing Process

Care of the Patient during the Rehabilitation Phase

Assessment
Information about the patient's educational level, occupation, leisure activities, cultural
background, religion, and family interactions is obtained early. The patient's self-
concept, mental status, emotional response to the injury and hospitalization, level of
intellectual functioning, previous hospitalizations, response to pain and pain relief
measures, and sleep pattern are also essential components of a comprehensive
assessment. Information about the patient's general selfconcept, self-esteem, and coping
strategies in the past are valuable in addressing emotional needs. Ongoing physical
assessments related to rehabilitation goals include range of motion of affected joints,
functional abilities in activities of daily living, early signs of skin breakdown from
splints or positioning devices, evidence of neuropathies (neurologic damage), activity
tolerance, and quality or condition of healing skin. The patient's participation in care
and ability to demonstrate self-care in such areas as ambulation, eating, wound
cleaning, and applying pressure wraps are documented on a regular basis. In addition to
these assessment parameters, specific complications and treatments require additional
specific assessments; for example, the patient undergoing primary excision requires
postoperative assessment. Recovery from burn injury involves every system of the
body. Therefore, assessment of the patient with a burn injury must be comprehensive
and continuous. Priorities vary at different points during the rehabilitation phase.
Understanding the pathophysiologic responses to burn injury forms the framework for
detecting early progress or signs and symptoms of complications. Early detection leads
to early intervention and enhances the potential for successful rehabilitation.

Diagnosis
Nursing Diagnoses
Based on the assessment data, priority nursing diagnoses in the long-term rehabilitation
phase of burn care may include the following:

 Activity intolerance related to pain on exercise, limited joint mobility, muscle

wasting, and limited endurance

 Disturbed body image related to altered physical appearance and self-concept

 Deficient knowledge about postdischarge home care and follow-up needs

Collaborative Problems/Potential Complications
Based on the assessment data, potential complications that may develop in the
rehabilitation phase include:

 Contractures

 Inadequate psychological adaptation to burn injury

Planning and Goals

The major goals for the patient include increased participation in activities of daily
living; increased understanding of the injury, treatment, and planned followup care;
adaptation and adjustment to alterations in body image, self-concept, and lifestyle; and
absence of complications.
Nursing Interventions