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S.No. Nsg. Assessment 1.

Vital Signs Checked HR = 140BPM RR= 40BPM T= 37 C Pain Score= 7

Nsg. Diagnosis Pain related tissue and muscle injury due burn.

Expected outcome Pain will be reduce

Nursing Interventions Planning Implementation To Assess for pain Assessd for pain periodically periodically To Provide the comfortable Provided the Position & Pillow. comfortable Position & Pillow.

Evaluation

Pain Reduced Pain score= 4

To Administration the analgesic as per Treatment chart.

Administration the analgesic as per Treatment chart.

S.No. Nsg. Assessment 2 Assess wounds daily for local signs of infectionswelling and redness around wound edges

Nsg. Diagnosis

Expected outcome Risk for Chances of Infection related infection will be to loss of skin reduce barrier and altered immune response

Nursing Interventions Planning Implementation Wash hands with Wash hands with antibacterial antibacterial cleansing agent cleansing agent before and after all before and after all patient contact. patient contact. Use sterile examination gloves for all dressing changes and all care involving patient contact. Maintain proper concentration of topical antibacterial agents used in wound care Use sterile examination gloves for all dressing changes and all care involving patient contact.

Evaluation Reduced the chances of infection.

Applied the Antibacterial agents on wound

S.No. Nsg. Assessment Check the IV line site And Follys catheter site

Nsg. Diagnosis

Expected outcome

Nursing Interventions Planning Implementation To Change I.V. Changed I.V. tubing and lines tubing and lines according to according to hospital policy hospital policy. To Provide Care All Invasive Line Eg. IV, Follys etc. Provided Care All Invasive Line Eg. IV, Follys etc.

Evaluation Reduced the chances of infection.

To Be Given ABTs as per treatment chart

Given the ABTs as per treatment chart.

S.No. Nsg. Assessment Check Vital 3. signs. Check the skin Integrity

Nsg. Diagnosis Decreased Cardiac Output related to fluid shifts

Expected outcome Cardiac output will be maintained

Nursing Interventions Evaluation Planning Implementation Give fluids as Given fluids as C.O. prescribed. prescribed Maintained Monitor Monitor sensorium. sensorium. Document all observations, and particularly note trends in vital sign changes. Maintain accurate intake and output records. Documented all observations, and particularly note trends in vital sign changes. Maintain accurate intake and output records.

S.No. Nsg. Assessment 4 Checked the weight Daily.

Nsg. Diagnosis Impaired Nutrition: Less Than Body Requirements related to hyper metabolic response to burn injury

Expected outcome Nutritious Status Will be Improve

Nursing Interventions Planning Implementation Weight the patient Weight the patient daily with daily with dressings dressings removed. removed. Obtain consultation from dietitian for calculation of nutritional needs based on age, weight, height, and burn size. Obtained consultation from dietitian for calculation of nutritional needs based on age, weight, height, and burn size.

Evaluation Nutrition Status will be improve

Provide the High Calorie & High Protein Diet

Provided the High Calorie & High Protein Diet

S.No. Nsg. Assessment 5

Nsg. Diagnosis

Expected outcome Impaired Participates in Physical activities of Mobility related daily living to pain

Nursing Interventions Planning Implementation Coordinate pain Coordinated pain management and management and other care to allow other care to allow optimal effort optimal effort during periods of during periods of physical exercise. physical exercise Initiate passive and active ROM and breathing exercises during early postburn period. Initiate passive and active ROM and breathing exercises during early postburn period.

Evaluation

Position the Changed the patient to decrease position & edema and avoid decreased edema flexion of burned joints

NURSING CARE PLAN

S.No. Nsg. Assessment 6 Assess patients and familys understanding of burn injury, coping skills, and family dynamics.

Nsg. Diagnosis Anxiety related to fear and the emotional impact of burn injury

Expected Nursing Interventions outcome Planning Implementation Anxiety wiill be Minimization of Explain all reduce patients and procedures to the familys anxiety patient and the family in clear, simple terms. Provide the divert therapy to child Provided the diver therapy to child

Evaluation Anxiety reduced

Give play therapy

Given the play therapy