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Assessment

Nursing Diagnosis Disturbed body image related to traumatic event.

Scientific Explanation A burn is a type of injury to flesh caused by heat, electricity, chemicals, light, radiation or friction. Most burns affect only the skin (epidermal tissue and dermis). Rarely, deeper tissues, such as muscle, bone, and blood vessels can also be injured. Burns may be treated with first aid, in an out-ofhospital setting, or may require more specialized treatment such as those available at specialized burn centers.

Planning

Intervention

Rationale

Evaluation

Subjective cues: “Nasunog halos buong katawan ko” as verbalized by the patient Objective cues: • Irritability • Absence of viable tissue • Vital signs as follows: BP: T: PR: RR:

STO: After 2-3 days in giving nursing intervention , the patient will be able to verbalize acceptance of self in situation, relief of anxiety and adaptation to altered body image and will be able to verbalize understandi ng of body changes.

Independent: *Acknowledge and accept expression of feelings of frustration, anger, grief and hostility. *Acceptances of these feelings are normal response to what has occurred to facilitate resolution. It is not helpful to push the patient to be ready to deal with the situation. *Enhances trust and rapport between patient and the nurse.

STO: After 2-3 days of giving nursing interventions the patient was able verbalized acceptance of self in situation relief anxiety and adaptation to altered body image and was able verbalized understanding of body changes.

*Be realistic and positive during treatments in health teaching and in setting goals within limitations. *Encourage patient to view wounds and assist with care and as appropriate

*Provides hope with parameters of individual situation, do not give false reassurance.

*Promotes acceptance and reality of injury and of change of body and image of self as different. *Promotes positive attitude and provides opportunities to set goals and plan for future based on reality.

LTO: • After 10 days of giving nursing intervention . the patient will be able to recognize and incorporate body image change into self concept in accurate manner without negating self esteem. and will be able to acknowledg e self as an individual who has responsibilit y to self. Give positive reinforcemen t of progress and encourage endeavors toward attainment of rehabilitation goals. LTO: After 10 days the patient was able to recognized and incorporated body image into selfconcept in accurate manner without negating selfesteem and was able to acknowledge self as an individual who has responsibility for self. . • • Maintains line of communicati on and provides ongoing support for the patient. Encourage family interaction with each other. • Words of encourageme nt can support development of positive coping behaviors. Dependent: • Refer to physical therapist. • Helpful in identifying ways to regain and maintain independenc e.