Assessment

Subjective:
The client
verbalized:
maiinit at
masakit
yung mga
paso
Objective:
The client
exhibited
facial
grimace.
The client
rates pain
10/10.
Total burn
injuries:
74.5% BSA;
Second
degree burn
VS:
BP:130/90
Temp:37.8
RR:27
PR:88

Nursing
Diagnosi
s
Acute
pain
related to
trauma
[burn
injuries]

Scientific
Analysis

Goals/Objectiv
es

Burn
After 2 hours of
patients
nursing
experience intervention:
pain that is Client is
multifacete
knowledgeabl
d and
e about the
constantly
pain she
changing
experiences.
as the
Client
individual
identifies
undergoes
proper
repeated
intervention
procedures
to alleviate
and wound
the pain.
manipulatio Client will
n.
verbalize
decrease in
pain as
manifested by
pain scale of
4/10
Display
relaxed facial
expressions/b
ody posture.
Participate in
activities and
sleep/rest
appropriately.

Interventions
Perform a
comprehensive
assessment of pain
which includes
location,
characteristic,
onset, duration,
frequency, quality
or intensity and
precipitating
factors of pain.
Teach use of non
pharmacologic
techniques

Cover wounds as
soon as possible
unless open-air
exposure burn care
method required.
Elevate burned
extremities
periodically.

Rationale
Pain is subjective
and must be
described by the
client to plan
effective
treatment.

Evaluation

After 2 hours of
nursing
intervention:
Client is
knowledgeabl
e about the
pain she
experiences.
Client
identified
proper
intervention
To stimulate
to alleviate
release of
the pain.
endorphins and
Client
enhance
verbalized
therapeutic effects
decrease in
of pain relief
pain as
medications.
manifested by
Temperature
pain scale of
changes and air
4/10
movement can
Display
cause great pain to
relaxed facial
exposed nerve
expressions/b
endings.
ody posture.
Elevation may be
Participate in
required initially to
activities and
reduce edema
sleep/rest
formation;
appropriately.
thereafter, changes
in position and

Provide bed cradle

as indicated.
Wrap digits or
extremities in
position of function
(avoiding flexed
position of affected
joints) using splints
and foot boards as
necessary.

Change position
frequently and
assist with active
and passive ROM
as indicated.

Administer
analgesics (narcotic
and nonnarcotic) as
indicated:
morphine; fentanyl
(Sublimaze, Ultiva);
hydrocodone
(Vicodin, Hycodan);

elevation reduce
discomfort and risk
of joint
contractures.
Elevation of linens
off wounds may
help reduce pain.
Position of function
reduces deformities
or contractures and
promotes comfort.
Although flexed
position of injured
joints may feel
more comfortable,
it can lead to
flexion
contractures.
Movement and
exercise reduce
joint stiffness and
muscle fatigue, but
type of exercise
depends on
location and extent
of injury.
The burned patient
may require
around-the-clock
medication and
dose titration. IV
method is often
used initially to
maximize drug

oxycodone(OxyCon
tin, Percocet).

Maintain
comfortable
environmental
temperature,
provide heat lamps,
heat retaining body
coverings.
Provide medication
and/or place in
hydrotherapy (as
appropriate) before
performing
dressing changes
and debridement.

effect. Concerns of
patient addiction or
doubts regarding
degree of pain
experienced are
not valid during
emergent/acute
phase of care, but
narcotics should be
decreased as soon
as feasible and
alternative
methods for pain
relief initiated.
Temperature
regulation may be
lost with major
burns. External
heat sources may
be necessary to
prevent chilling.
Reduces severe
physical and
emotional distress
associated with
dressing changes
and debridement.