Objective:

V/S taken
as follows:
T:36.6
P:80
R:16
BP: 120/80

Nursing
Diagnosis
Fluid and
electrolyte
imbalance
r/t burn

Analysis
Burn results to an
unpleasant sensory
and emotional
experience since
there is severe skin
damage that causes
the affected skin
cells to die.
http://www.healthl
ine.com/health/bur
ns

Goal/Objectives

Short term goal:

Intervention

Assess and
monitor vital signs
and note for the
capillary refill and
strength of pulses.

Client will be able to

demonstrate an
improved fluid balance
as evidenced by clients
adequate urinary
Monitor urinary
output, stable vital
output of client.
signs and moist mucous
membranes after one
week of nursing care.

Rationale

It provides as
baseline data for
fluid replacement
therapy.

Fluid replacement
should be
adjusted to ensure
average urinary
output of 30 50
cc/ hour.

Long term goal:

Client will be able to
understand condition
and identify risk factors
Assess for the
potential for further
estimate of wound
fluid volume deficit.
drainage and
insensible loss.

Increased
capillary
permeability,
protein shifts and
inflammatory
process greatly
affect the
circulatory

Evaluation
After 8 hours of
nursing
intervention
does the client
gained back the
lost fluid and
electrolytes
Yes
No

volume and urine

output.

Administer
intravenous fluids.

It helps prevent
fluid deficit and
any loss should
be replacement
effectively.

Monitor laboratory
results like
hemoglobin,
hematocrit, and
electrolyte levels.

It could aid in
determining
blood loss or
RBC destruction
as well as the
need for
electrolyte
replacements.

Pangan, Lorraine P.
1. Diagnosis of patient: Severe Burn Injuries.
2. Purpose of IV Therapy: Dehydration