Nursing Diagnosis: Pain, acute
May be related to
- Destruction of skin/tissues; edema formation
- Manipulation of injured tissues, e.g., wound debridement
Possibly evidenced by
- Reports of pain
- Narrowed focus, facial mask of pain
- Alteration in muscle tone; autonomic responses
- Distraction/guarding behaviors; anxiety/fear, restlessness
Desired Outcomes
- Report pain reduced/controlled.
- Display relaxed facial expressions/body posture.
- Participate in activities and sleep/rest appropriately.
11 Burn Injury Nursing Care Plan (NCP)
- Impaired Physical Mobility — Burns Nursing Care Plan (NCP)
- Knowledge Deficit — Burns Nursing Care Plan (NCP)
- Disturbed Body Image — Burns Nursing Care Plan (NCP)
- Fear/Anxiety — Burns Nursing Care Plan (NCP)
- Impaired Skin Integrity — Burns Nursing Care Plan (NCP)
- Imbalanced Nutrition — Burns Nursing Care Plan (NCP)
- Ineffective Tissue Perfusion — Burns Nursing Care Plan (NCP)
- Acute Pain — Burns Nursing Care Plan (NCP)
- Risk for Infection — Burns Nursing Care Plan (NCP)
- Risk for Deficient Fluid Volume — Burns Nursing Care Plan (NCP)
- Risk for Ineffective Airway Clearance — Burns Nursing Care Plan (NCP)
Acute Pain — Burn Injury Nursing Care Plan (NCP)
| Nursing Interventions | Rationale |
| Cover wounds as soon as possible unless open-air exposure burn care method required. | Temperature changes and air movement can cause great pain to exposed nerve endings. |
| Elevate burned extremities periodically. | Elevation may be required initially to reduce edema formation; thereafter, changes in position and elevation reduce discomfort and risk of joint contractures. |
| Provide bed cradle as indicated. | Elevation of linens off wounds may help reduce pain. |
| Wrap digits/extremities in position of function (avoiding flexed position of affected joints) using splints and footboards as necessary. | Position of function reduces deformities/contractures and promotes comfort. Although flexed position of injured joints may feel more comfortable, it can lead to flexion contractures. |
| Change position frequently and assist with active and passive ROM as indicated. | Movement and exercise reduce joint stiffness and muscle fatigue, but type of exercise depends on location and extent of injury. |
| Maintain comfortable environmental temperature, provide heat lamps, heat-retaining body coverings. | Temperature regulation may be lost with major burns. External heat sources may be necessary to prevent chilling. |
| Assess reports of pain, noting location/character and intensity (0–10 scale). | Pain is nearly always present to some degree because of varying severity of tissue involvement/destruction but is usually most severe during dressing changes and debridement. Changes in location, character, intensity of pain may indicate developing complications (e.g., limb ischemia) or herald improvement/return of nerve function/sensation. |
| Provide medication and/or place in hydrotherapy (as appropriate) before performing dressing changes and debridement. | Reduces severe physical and emotional distress associated with dressing changes and debridement. |
| Encourage expression of feelings about pain. | Verbalization allows outlet for emotions and may enhance coping mechanisms. |
| Involve patient in determining schedule for activities, treatments, drug administration. | Enhances patient’s sense of control and strengthens coping mechanisms. |
| Explain procedures/provide frequent information as appropriate, especially during wound debridement. | Empathic support can help alleviate pain/promote relaxation. Knowing what to expect provides opportunity for patient to prepare self and enhances sense of control. |
| Provide basic comfort measures, e.g., massage of uninjured areas, frequent position changes. | Promotes relaxation; reduces muscle tension and general fatigue. |
| Encourage use of stress management techniques, e.g., progressive relaxation, deep breathing, guided imagery, and visualization. | Refocuses attention, promotes relaxation, and enhances sense of control, which may reduce pharmacological dependency. |
| Provide diversional activities appropriate for age/condition. | Helps lessen concentration on pain experience and refocus attention. |
| Promote uninterrupted sleep periods. | Sleep deprivation can increase perception of pain/reduce coping abilities. |
| Administer analgesics (narcotic and nonnarcotic) as indicated, e.g., morphine; fentanyl (Sublimaze, Ultiva); hydrocodone (Vicodin, Hycodan); oxycodone(OxyContin, Percocet). | The burned patient may require around-the-clock medication and dose titration. IV method is often used initially to maximize drug effect. Concerns of patient addiction or doubts regarding degree of pain experienced are not valid during emergent/acute phase of care, but narcotics should be decreased as soon as feasible and alternative methods for pain relief initiated. |