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Nsg. Diagnosis Pain related tissue and muscle injury due burn.
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
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.
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.
S.No. Nsg. Assessment Check Vital 3. signs. Check the skin Integrity
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.
Nsg. Diagnosis Impaired Nutrition: Less Than Body Requirements related to hyper metabolic response to burn injury
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.
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
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