NURSING CARE PLAN

NURSING
CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Subject Data: Acute pain After 4 hours of nurse- Independent: After 4 hours of nurse-
“Masakit talaga”as related to patient interaction, the >Provide bed cradle as indicated > Elevation of linens off wounds may help patient interaction, the
verbalized by the patient destruction of patient will be able to reduce pain patient was able to
skin/tissues; edema participate in activities > Wrap digits/extremities in position participate in activities
> Position of function reduces
Objective Data: formation and sleep/rest of function (avoiding deformities/contractures and and sleep/rest
> Pain rating scale of 9/10 manipulation of appropriately and flexed position of affected joints) promotes comfort. Although flexed appropriately and
distraction/guarding injured tissues (e.g. display relaxed facial using splints and position of injured display relaxed facial
behaviors wounds) expressions/body footboards as necessary. joints may feel more comfortable, it can expressions/body
>anxiety/fear, posture. lead to flexion posture.
>restlessness contractures.

> Change position frequently and >Movement and exercise reduce joint
assist with active and stiffness and muscle
passive ROM as indicated fatigue, but type of exercise depends on
location and
> Maintain comfortable extent of injury.
environmental temperature, provide
>Temperature regulation may be lost with
heat lamps, heat-retaining body
major burns.
coverings. External heat sources may be necessary to
prevent
chilling
>Involve patient in determining
schedule for activities, treatments, >Reduces severe physical and emotional
drug administration. distress associated
with dressing changes and debridement
>Enhances patient’s sense of control and
strengthens coping mechanisms.
>Promote uninterrupted sleep
periods >Sleep deprivation can increase perception
of pain/reduce
coping abilities