Student Nurses Community

ASSESSMEN
T

DIAGNOSIS

SUBJECTIVE:

Disturbed
body image
related to
traumatic
event.

Nasunog ang
balat ko (I
got burned)
as verbalized
by the
patient.
OBJECTIVE:
Irritability
Absence of
variable
tissue
V/S taken as
follows:
T: 37.2 C
P: 85
R: 19
BP: 110/80

INFERENCE

A burn is a
type of injury
that maybe
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

NURSING CARE PLAN Burn

PLANNING

INTERVENTIO
N

RATIONALE

After 8
Independent:
Acceptance of
hours of
Acknowledge
these feelings
nursing
and accept
as a normal
intervention
expression of
response to
s the
feeling of
what has
patient will
frustration,
occurred
incorporate
dependency,
facilitates
changes
anger, grief,
resolution. It is
into selfand hostility.
not helpful or
concept
possible to

Be
realistic
and
without
push patient
positive
negating
before ready to
during
self-esteem.
deal with the
treatments, in
situation.
health
teaching, and Enhances trust
in setting
and rapport
goals within
between
limitations.
patient and the
nurse
Encourage
Promotes
patient to
view wounds
acceptance of
and assist
reality of injury
with care as
and of change
appropriate.
in body and

EVALUATIO
N
After 8
hours of
nursing
intervention
s the
patient will
incorporate
changes
into selfconcept
without
negating
self-esteem.

Student Nurses Community

the profound
injury to the
nerves.
Depending on
the location
affected and
the degree of
severity, a
burn victim
may
experience
wide number
of potentially
fatal
complications
including
shock,
infection,
electrolyte
imbalance,
and
respiratory
distress.

image of self as
Provide hope
different.
within
parameters of
Promotes positive
individual
attitude and
situation; do
provides
not give false
opportunity to
reassurance.
set goals and
plan for future.