Student Nurses’ Community
NURSING CARE PLAN - Burn ASSESSMENT SUBJECTIVE: “Nasunog ang balat ko” (I got burned) as verbalize by the patient OBJECTIVE: • • • Irritability Absence of viable tissue V/S taken as follows T: 37.2 ˚C P: 85 R: 19 BP: 110/ 80 DIAGNOSIS Disturbed body image related to traumatic event. INFERENCE A burn is a type of injury that may be caused by heat, cold, electricity, chemicals, light, radiation, or friction. Burns can be highly variable in terms of the tissue affected, the severity, and resultant complications. Muscle, bone, blood vessel, and epidermal tissue can all be damaged with subsequent pain due to profound injury to nerves. Depending on the location affected and the degree of severity, a burn victim may experience a wide number of potentially fatal complications including shock, infection, electrolyte imbalance and respiratory distress. Beyond physical PLANNING After 8 hours of nursing interventions the patient will incorporate changes into selfconcept without negating selfesteem. INTERVENTION Independent • Acknowledge and accept expression of feeling of frustration, dependency, anger, grief, and hostility. RATIONALE EVALUATION After 8 hours of nursing interventions the patient was able to incorporate changes into selfconcept without negating selfesteem.
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Acceptance of these feelings as a normal response to what has occurred facilitates resolution. It is not helpful or possible to push patient before ready to deal with the situation. Enhances trust and rapport between patient and the nurse.
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Be realistic and positive during treatments, in health teaching, and in setting goals within limitations. Encourage patient to view wounds and assist with care as appropriate.
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Promotes acceptance of reality of injury and of change in body and image of self as different. Promotes positive attitude and provides opportunity to set goals and plan for future based on
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Provide hope within parameters of individual situation; do not give false reassurance.
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Student Nurses’ Community
complications, burns can also result in severe psychological and emotional distress due to scarring and deformity. It is generally accepted that a burn affecting more than one percent of the body surface, (approximately area of the casualty's palm) should be assessed by a medical practitioner. reality. Words of encouragement can support development of positive coping behaviors.
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Give positive reinforcements of progress and encourage endeavors toward attainment of rehabilitation goals. Encourage family interaction with each other.
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Maintains lines of communication and provides ongoing support for the patient. Helpful in identifying ways to regain and maintain independence.
Dependent • Refer to physical therapist.
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