Question

Ms. T, a 28 year old runway model has just been admitted to the rehab unit following an extensive stay at the burn unit in a local hospital. She was set on fire by her vengeful estranged husband 8 months ago and has spent many of those months in the hospital. She was burned about 54% of her body, including part of her face; the burn ranged from partial tissue loss to deep tissue loss. She also had contractures of her elbows, hands, and knees, which is why she was admitted to the rehab today. Some skin grafting has been done to part of her body. During admission data gathering, Ms. T. admitted to feeling worthless, guilty because she had been cheating on her husband before they broke up and he'd heard her tell her boyfriend on the phone that she'd married him for his money. She stated that she feels responsible for him killing himself after he burned her, that she should have done things differently. She stated that her famous "so-called friends" have abandoned her, that they don't even pick up her calls anymore. She said she'd heard that some people blame her for everything that happened. She expressed sadness that she'd lost her beauty, her friends, her job, her popularity, her good reputation, money, and even some of her family members. She says she doesn't see any point in continuing to live, that the health care professionals have done their best for her, but she'll still continue to look like a monster.

1. Write a SOAPIE note for this patient; 2 nursing diagnosis needed & address them separately, 1 goal, at least 6 interventions, evaluation.

Answer 1

Number 1 Assessment Subjective data Patient complaints about Impaired Physical Mobility: Limitation in independent, purposeful physical movement of the body or of one or more extremities. Objective data on examination patient have difficulty in movement and looks dull and weak and depressed Number 2

1.Diagnosis Impaired physical mobility related to contractures as manifested by verbalization 2.Diagnosis disturbed body image related to traumatic incident as manifested by frequenty foccusing on apperance

1.Goal to make the patient feel more comfortable 2.Goal To provide her a maximum comfort with her structure

1.Planning *asess the general condition * provide rehabilitation * perform ROM and RAM exercise * provide health education * provide psychological support * provide diversion therapy 2.planning *Assess meaning of loss or change to patient and SO, including future expectations and impact of cultural or religious beliefs. *Acknowledge and accept expression of feelings of frustration, dependency, anger, grief, and hostility. Note withdrawn behavior and use of denial. *Set limits on maladaptive behavior. Maintain nonjudgmental attitude while giving care, and help patient identify positive behaviors that will aid in recovery. *provide health education *Provide hope within parameters of individual situation; do not give false reassurance. * provide psychological support * provide diversional therapy

1.Implimentation * assesed the general condition of patient * provided rehabilitative care and support * performed Rom exercises * provided health education regarding gaining self confidence after a trauma * provide psychological support by explaining possible way of overcoming * provided diversional therapy by playing songs 2.Implimentation *Assessed meaning of loss or change to patient and SO, including future expectations and impact of cultural or religious beliefs. *Acknowledged and accepted expression of feelings of frustration, dependency, anger, grief, and hostility. Note withdrawn behavior and use of denial. *provided limits on maladaptive behavior. Maintain nonjudgmental attitude while giving care, and help patient identify positive behaviors that will aid in recovery. *Be realistic and positive during treatments, in health teaching, and in setting goals within limitations. *Encourage patient and SO to view wounds and assist with care as appropriate. *Provided hope within parameters of individual situation; do not give false reassurance. * provided psychological support by Showing pictures or videos of burn care and/or other patient outcomes, being selective in what is shown as appropriate to the individual situation. Encourage discussion of feelings about what patient has seen. *provided diversion by giving news paper

1.Evaluation patient to be evaluated after a week 2. Evaluation Patient gained confidence