Question

Design a Care Plan for a patient with a thermal burn injury (not chemical, electrical, or due to radiation) using one of the following nursing diagnoses:

1. Impaired Tissue Integrity

2. Acute Pain

3. Disturbed Body Image.

- Cite your sources. Remember to provide interventions and rationales relevant to the patient's situation. The Goals should be realistic and measurable.

Answer 1

"NURSING CARE PLAN FOR ACUTE PAIN"

Acute Pain is unpleasant sensory and emotional that arise from tissue damage in the body and sudden onset of pain from mild to severe with a duration of less than six months.Pain is associated with the destruction of tissue and controlling of injured tissue that is wound debridement.

Possibly confirmed by: Report of pain, alteration in muscle tone,anxiety restlessness,distraction behaviors,edema formation.

Desired outcomes can be reduced pain,relaxed body posture and desired sleep and rest.

Nursing assessment:

Nursing intervention	Rationale
Diagnosis or report of pain, its location and intensity by measuring with scale of 0-10 scale	Pain is present of some degree because of severity of tissue involved in damaging and more severe during dressing.Changes in location and intensity that indicate the limb ischemia or it may return to normal function.

Therapeutic interventions

Nursing Interventions	Rationale
Cover wound as soon as possible	Temperature changes and exposure to air may cause pain
Elevated burned extremities	To reduce edema formation elevation must be required.
Wrap extremities in position of function with the help of splints and foot boards	Reduce deformities and Promote comfort Flexed position of injured joints that can feel more comfortable or it may lead to flexion contractures
Change position frequently	Movement can reduce joint stiffness and muscle fatigue that is depend on location
Maintain normal environment temperature by body coverings	External heat sources is necessary to prevent chilling
Provide medication before performing dressing changes	Reduce pain severity
Explain detailed information about procedures during wound debridement	By knowing the procedure to patient they can self and enhance sense of control
Encourage stress management techniques such as progressive rehalation,deep breathing	Refocus attention and promote relation
Promote sleep	Sleep deprivation can increase pain
Administer analgesic like morphine and hydrocodone	Intravenous administration can maximize drug effect at injured area Concern of patient addiction is isn'tvalid during acute phase.