Assessment Diagnosis Planning Intervention Rationale Evaluation

Pain related to The child will Assess the level of Pain scale provides
physical injury agents verbalize adequate pain frequently using objective
relief from pain and pain scales measurement. Pain is
will be able to always present, but
perform activities of changes location;
daily living (ADLs). intensity may
indicate
complications.
Cover burns as much Temperature
as possible. changes or
movement of air
causes pain.
Change the child’s Change the child’s
position frequently. position frequently.
Perform range-of- Perform range-of-
motion exercises. motion exercises.
Encourage Provides outlet for
verbalization about emotions and helps
pain. the child cope.
Provide diversional Helps lessen focus on
activities. pain.
Promote Sleep deprivation can
uninterrupted sleep increase pain
with use of perception.
medications.
Use analgesics before Helps to reduce pain
all dressing changes and decreases
and burn care. anxiety for
subsequent dressing
changes
Assessment Diagnosis Planning Intervention Rationale Evaluation
Risk for Infection The child will be free Take vital signs Increased
related to trauma of infection during frequently temperature is an
and destruction of healing process early sign of
skin barrier infection.
Use standard Reduces risk of
precautions (gown, wound
gloves, mask) when contamination.
wounds of a major
burn are exposed.
Limit visitors (no one
with an upper
respiratory infection
or other contagious
disease).
Clip hair around Hair harbors
burns. bacteria.
Keep biosynthetic Helps reduce the
burn dressing dry. number of bacteria
introduced to the
burn site.
Do not place the IV in Reduces risk of
any burned area wound
contamination
Administer oral or IV Antibiotics
antibiotics for administered as
diagnosed infections prescribed help to
as prescribed. clear the infection
quickly
Assessment Diagnosis Planning Intervention Rationale Evaluation
Risk for Fluid Volume The child will Monitor vital signs, The child is initially at
Imbalance related to maintain adequate central venous risk for hypovolemic
loss of fluids through urine output. pressure, capillary shock and needs fluid
wounds and to refill time, pulses. resuscitation
subsequent excess
fluid intake
Administer IV and Careful calculation of
oral fluids as fluid needs and
ordered. ensuring proper
intake help keep the
child properly
hydrated
Estimate insensible Losses are increased
fluid losses. during the first 72
hours after burn
injury; may need
replacement. Plasma
is lost through burn
site because of
capillary damage.
Monitor intake and The child is at risk for
output fluid overload during
hydration, and for
edema in the tissues
at the burn site
Weigh child daily. Significant weight
loss or gain can help
determine fluid
imbalances.
Insert urinary Helps maintain
catheter. accurate output
measurement during
critical care stage.
Monitor for Sodium is lost with
hyponatremia and burn fluid and
hypercalcemia potassium is lost
from damaged cells,
causing electrolyte
imbalances