Assessment Explanation of the Problem Objectives Nursing interventions Rationale Evaluation

S A burn injury is damage to Goal: Reduced pain level Dx Goal fully met if within the 48
“my son had an electric shock your body’s tissues caused by within 48 hours from 7 to 10 hours of nursing
and has burns on his fingers” heat, chemicals, electricity, from the scale of 1 to 10 after Assess reports of pain, noting >Pain is nearly always interventions the patient
as verbalized by father. sunlight or radiation. Scalds receiving pain medications. location and character and present to some degree rated the pain from 7 to 10
O from hot liquids and steam, Short term objectives: intensity (0–10 scale). because of varying severity of to 1 to 10 from the scale of 1
building fires and flammable Educate the significant others tissue involvement and to 10
 Burns noted on the liquids and gases are the of patient for 10 minutes destruction but is usually Goal partially met if within
fingertips of the right most common causes of with regards to most severe during dressing the 48 hours of nursing
second and third burns. A major burn is a a. Reducing sun changes and debridement. interventions the patient
fingers, another on catastrophic injury, requiring exposure of the Changes in location, rated the pain from 7 to 10 to
the dorsum of the painful treatment and long patient. character, and intensity of 5 to 10 from the scale of 1 to
left hand, and a third period of rehabilitation. It’s b. Not popping the pain may indicate developing 10.
on the chest, about commonly fatal or blisters. complications (limb ischemia)
22% burns noted. permanently disfiguring and c. Encouraging to or herald improvement Goal partially met if within
 With guarding incapacitating (both provide emotional and/or return of nerve the 48 hours of nursing
behavior and with emotionally and physically). support function and sensation. interventions the patient
facial grimacing. To reduce pain. rated the pain from 7 to 10
 Rated pain from 7 to Provide basic comfort > Promotes relaxation; to 7 to 10 from the scale of 1
10 from the scale of Gulanick, M., & Myers, J. L. Long term objectives: measures: massage of reduces muscle tension and to 10
1 to 10. (2016). Nursing Care Plans: The patient will be able to uninjured areas, frequent general fatigue.
Diagnoses, Interventions, and move the affected parts position changes.
Outcomes. Elsevier Health without pain within 72 hours Short term objectives fully
Nursing Diagnosis Sciences. after starting pain Monitor vital signs >Abnormal vital signs can be met if after educating the 3
Acute pain related to medications. a sign of symptom of distress ways of reducing pain to the
destruction of skin tissues significant others of the
secondary to nerve injury patient for 10 minutes the
s/o of the patient will
verbalize the 3 ways to
reduces pain such as
Reducing sun exposure of the
patient, Not popping the
blisters and Encouraging to
provide emotional support.

Tx
Cover wounds as soon as
possible unless open-air
exposure burn care method
required.
Elevate burned extremities
periodically.
Provide diversional activities
appropriate for age and
condition.
Edx
Encourage expression of
feelings about pain.
Educate patient and the
significant others of the
patient to not remove the
blisters.
>Temperature changes and
air movement can cause
great pain to exposed nerve
endings.
> Elevation may be required
initially to reduce edema
formation; thereafter,
changes in position and
elevation reduce discomfort
and risk of joint contractures.
> Helps lessen concentration
on pain experience and
refocus attention.
> Verbalization allows outlet
for emotions and may
enhance coping mechanisms.
>It helps promote wound
healing and reduce pain.
Short term objectives
partially met if after
educating the 3 ways of
reducing pain to the
significant others of the
patient for 10 minutes the
s/o of the patient is able to
verbalize the at least 2 ways
to reduces pain such as
Reducing sun exposure of the
patient and Not popping the
blisters.
Short term objectives not
met if after educating the 3
ways of reducing pain to the
significant others of the
patient for 10 minutes the
s/o of the patient is able to
verbalize at least 1 ways to
reduces pain such as
Reducing sun exposure of the
patient.
Long term objectives fully
met if after the 72 hours of
nursing interventions the
patient will be able to move
the affected parts without
pain.
Educate the significant others
of the patient to be
responsible on administering
pain medications.
>Pain medications help Long term objectives partially
reduce the pain met if after the 72 hours of
nursing interventions the
patient will be able to move
the affected parts with
minimal pain.
Long term objectives not met
if after the 72 hours of
nursing interventions the
patient Is not able to move
the affected parts without
pain.