Assessment Subjective: Masakit lahat nung nasunug sakin , as verbalized by the client.

Nursing Diagnosis Acute pain related to damaged free nerve endings secondary to burn.

Inference 1st degree burn Exposed dermis Damage to the free nerve endings Hypersensitivity of nerve endings Transmission of pain impulses into the brain Pain perception

Planning Short-term Goal: After 2 hours of progressive nursing interventions, the client will be able to relieve pain from a pain scale of 8 to 4. Long-term Goal: After 8 hours of continuous nursing interventions, the client will be able to reduce pain from a scale of 8 to 2.

Intervention ASSESSMENT:  Perform a comprehensive assessment of pain to include location, characteristics, onset, frequency, quality and severity.  Assess client s vital signs.

Rationale

Evaluation STG: Goal met as evidenced by a pain scale of 4 out of 10. LTG: Goal met as evidenced by a pain scale of 2 out of 10.

 To assess etiology and degree of severity of the problem.

Objective:  Pain scale of 8 out of 10  Pricking pain radiating from the burned leg downward.  Pain relieved at rest  (+) facial grimace  (+)restlessness  (+) irritability  Protective behaviour over the area

 Accept patient s description of pain.  Encourage verbalization of feelings about pain.  Provide client a calm and quiet environment.  Provide comfort measures (back rub, change in position etc.)  Provide diversional activities (listening to music, socialization etc)  Provide recreational activities (playing cards, etc.) COLLABORATIVE:  Provide client/client s relative health teachings:  Inform about existing conditions.  Inform conditions that requires

 To obtain baseline data, v/s are usually altered during episodes of acute pain.  Pain is a subjective experience and cannot be felt by others.  To assist patient to explore methods for control of pain.  To limit stress to a minimum level.  To provide nonpharmacological pain management.  To relieve pain by distracting pain perception.  To relieve pain by distracting pain perception.

 To increase awareness.  To prevent aggravation of

 

 

attention of health care providers. Encourage splinting during cough and ambulation. Encourage to minimize strenuous activities. Encourage adequate rest periods. Encourage high caloric and high CHON diet. Encourage proper hygiene. Advice proper referral.

condition.
 To minimize pain.

 To decrease tension to the painful area.  To prevent fatigue.  To hasten tissue repair.  To prevent infection.  To follow-up condition once outside the hospital.  To maintain acceptable level of pain using the pharmacological way.

 Administer analgesics as ordered by the doctor.