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NURSING DIAGNOSIS 4
Acute pain related to burn trauma.
Patient outcomes
Relief of pain.
Identifies factors that contribute to pain. Verbalizes improved comfort level.
Physiological parameters within normal limits and remain stable after administration of narcotic analgesia.
Nursing interventions
Monitor physiological responses to pain, such as increased blood pressure increased heart rate, restlessness and nonverbal cues. Use validated tools in each patient to assess pain and anxiety
Assess response to analgesics or other interventions
Evaluate effectiveness of interventions
Administer analgesic and/or anxiolytic medication as ordered; administer IV during critical care phases
Medicate patient before bathing, dressing changes and major procedures as needed
Use nonpharmacological pain-reducing methods as appropriate
Rationales
Pain responses are variable and unique to each patient
Facilitate pain relief. Intramuscular/ intravenous, during critical care phases, medications not consistently absorbed
Assist patient to perform at higher level as needed of the function
Reduce need for narcotics