NURSING CARE PLAN
Problems identified
1. Pain
2. Risk of infection
3. Inadequate intake of food nutrients
less than body requirement
4. Risk of injury from accidental fall
5. Impaired physical mobility (pt will
be unable to move out of bed due to
painful wounds )
NURSING CARE PLAN
PROBLEM NUMBER ONE
PROBLEM
Pain
NURSING DIAGNOSIS
Pain related to injury to nerve
endings evidenced by verbalization
and frowning on the face.
GOAL
The patient will experience and
report a reduction in pain and will
appear happy and smiling after an
hour of care.
NURSING INTERVENTION
The nurses assessed the degree of pain
They established the aggravating
factors and dealt with them e.g.
movement of the affected limbs or
touching the wounds. And as such the
patient was maintained on complete
bed rest to ensure immobilization.
A bed cradle was used to lift the weight
of the bed linen of the wound
NURSING INTERVENTION
cont’d
Non opioid analgesics i.e.
paracetamol was given to relieve
pain.
The patient was reassured that as
healing takes place the pain will
reduce
EXPECTED OUT COME
The patient reported a reduction in
pain after an hour of interventions
and was happy and smiling.
PROBLEM NUMBER TWO
PROBLEM
Risk for infection
NURSING DIAGNOSIS
Risk for infection related to break in
skin integrity and poor environmental
hygiene evidenced by an open wound
and presence of flies.
GOAL
D.B. will remain free from infection by cross
contamination throughout the period of
hospitalization
NURSING INTERVENTION
The care providers minimized exposure of the
burnt area to exogenous organisms by
covering the wound with clean wet nappies.
A bed cradle was used to lift the bed linen off
the affected part there by preventing cross
infection.
NURSING INTERVENTION
cont’d
Prescribed antibiotics (cloxacillin) was
given as per prescription
The wound is being cleaned twice daily
by use of saline water.
D.B. was isolated from other patients in
order to minimize chances of cross
infection.
The patient is scheduled for skin grafting
on the 10th of November 2008 to further
reduce the risk of infection
EXPECTED OUT COME
Wounds are healing well and there
are no signs of active wound infection
such as pyrexia or pus discharge.
PROBLEM NUMBER THREE
PROBLEM
Inadequate intake of food nutrients
less than body requirements
NURSING DIAGNOSIS
inadequate intake of food nutrients
less than body requirements related
to food selectivity and loss of
appetite evidenced by weight loss as
verbalized by the elder sister
GOAL
The client will establish and maintain
adequate nutrient intake for meeting
the body’s calorie needs within a
period of two months.
INTERVENTIONS
The healthcare provider estimated the
client’s calorie needs
An adequate daily source of calories and
nutrients that the client could easily ingest
and metabolize was provided. Foods such as
HEPS, milk, eggs, nshima with beans, beef
and vegetables were given.
Frequent feeds were given in smaller
amounts to improve the appetite
Adequate fluids were also given to replace
the lost fluids and aid in digestion
Dressings done before meals to promote
appetite
EXPECTED OUT COME
The patient is showing some
improvement in the nutrition status
within a period of one month after
intervention.
PROBLEM NUMBER FOUR
PROBLEM
Impaired physical mobility- as the
patient is unable to move out of bed
due to burns and pain on the lower
limbs.
NURSING DIAGNOSIS
Impaired physical mobility related to
pain evidenced by inability to move
out of bed.
GOAL
D.B will regain and maintain an optimal
ability to move once the wounds heal.
The patient was positioned in any
position of comfort with lower limbs in
functional position
Range of motion exercises’ of the
affected limbs were done by nurses
during wound care and the client was
also encourage to move her ankle joints
and toes whilst in bed.
EXPECTED OUT COME
D.B. is able to move her ankle joints
and toes whilst in bed and there are
no signs of contracture formation.
PROBLEMS NUMBER FIVE
PROBLEM
Altered body image due to loss of
toes
NURSING DIAGNIOSIS
Altered body image related to loss of
skin integrity and toes of the right
foot as observed during physical
examination.
GOAL
GOAL
The client will have a positive perception of
her own appearance and body image.
NURSING INTEVENTIONS
The health care provider assessed the stage
of grief the client was experiencing.
Client was reassured that feelings of grief,
loss, anxiety, anger, fear and guilty are
normal especially where there is loss of body
parts.
NURSING INTEVENTIONS
cont’d
The health care provider assessed the stage
of grief the client was experiencing.
Client was reassured that feelings of grief,
loss, anxiety, anger, fear and guilty are
normal especially where there is loss of body
parts.
Social support is being given by the elder
sister
Realistic expected out come were explained
to the client and relative in view of possible
amputation should skin graft fail.
NURSING INTEVENTIONS
cont’d
The client was involved in decision
making to foster feelings of self
worthy.
The sister was encouraged to include
D.B. in decision making just as she
use to do before the injury. This will
help build self esteem.
The client has been scheduled for
skin grafting in an attempt to
improve the body image
EXPECTED OUT COME
D.B has accepted her condition and
the expected out come of the injury
