NURSING DIAGNOSIS
- Pain related to burn injury characterized by facial expressions and verbalization
- Fluid volume deficit related to increased capillary leak and large fluid shift from intra vascular to interstitial space
- Self care deficit related to pain characterized by verbalization and facial expressions
- Imbalance nutrition related to low intake of food characterized by vomiting, blister and facial oedema
- Sleep pattern disturbance related to pain and discomfort characterized by verbalization, treatment
- Anxiety and fear related to burn injury secondary to treatment
- Disturbed body image related to burn injury, withdrawal role to relationship
- Impaired skin integrity related to open wounds
- Knowledge deficit regarding prognosis and treatment
- Risk for infection related to impaired skin integrity
Acute pain related to burn injury characterized by clients crying, clenched fists, grimacing
- Assess the level of pain
- Give comfortable position
- Provide comfort devices
- Administer intravenous analgesics
- Provide emotional support and reassurance
- Promote rest
Fluid volume deficit related to increased capillary leak and large fluid shift from intra vascular to interstitial space as characterized by altered sensorium
- Assess hypovolemia every 1 hour to 36 hour
- Monitor urine output at least hourly and weigh patient daily
- Maintain IV lines and regulate fluids at appropriate rates as prescribed
- Monitor serum electrolytes level
- Elevate head of patient’s bed and elevate burned extremity
Imbalance nutrition related to burn injury , low intake of food as characterized by blister, slough and facial oedema
- Assess the nutrition status of the client
- Monitor intake output of the client
- Check the weight of the client
- Encourage the client to take liquid diet
- Administer IV fluids
- Administer anti emetics and proton pump inhibitor as prescribed by physician
- Health teaching regarding diet regimen
Disturbed body image related to burn injury, withdrawal, role relationship
- Assess the anxiety level of the client
- Reassure the patient and his family members
- Develop a good interpersonal relationship
- Provide information and explanation regarding prognosis and treatment
- Encourage the family members to give care and support also
- Teach the client to accept the condition
- Reassure the client
- Encourage the family members for their support
Knowledge deficit regarding prognosis and treatment characterized by verbalization
- Assess the knowledge level of the client
- Encourage the client and family members to explore their doubts
- Explain importance of client participation in early ambulation
- Explain the length of time involved in burn recovery
- Health teaching regarding burn injury
Risk for infection related to loss of skin barrier and impaired immune response
- Use aseptic technique in all aspects of patients care
- Reduce the number of attendants
- Use sterile dressings
- Evacuate the blisters and remove the devitalized tissue
- Monitor vital signs and temperature
- Monitor the total leukocyte count
- Administer antibiotics as prescribed by physician
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