comprehensive nursing care plan for a patient with second-degree burns

 Here’s a detailed nursing care plan for a patient with second-degree burns: 

**NURSING CARE PLAN**  

**Patient Information**  

- **Name:** [Patient's Name]  

- **Age:** [Age]  

- **Diagnosis:** Second-degree burns  

- **Date:** [Date]  

- **Nurse's Name:** [Nurse's Name]                          

### **ASSESSMENT**  

**Subjective Data:**  

- Complaints of severe pain at the burn site.  

- Reports of discomfort and sensitivity to touch.  

**Objective Data:**  

- Presence of red, moist, and blistered skin.  

- Swelling and weeping of fluid at the burn site.  

- Elevated temperature (if infection is suspected).  

### **NURSING DIAGNOSES**  

1. Acute pain related to tissue damage and exposed nerve endings.  

2. Impaired skin integrity related to second-degree burn injury.  

3. Risk for infection related to open wounds and loss of protective skin barrier.  

4. Fluid volume deficit related to fluid loss from damaged tissues.  

### **PLANNING**  

**Goals/Outcomes:**  

1. The patient will report a decrease in pain to a manageable level within 24 hours.  

2. The burn area will show signs of healing without infection during the hospital stay.  

3. The patient will maintain adequate hydration as evidenced by stable vital signs and urine output.  

4. The patient will verbalize understanding of proper wound care before discharge.  

### **INTERVENTIONS**  

#### **1. Acute Pain**  

- **Assess** the level, location, and characteristics of pain using a pain scale.  

- **Administer** prescribed analgesics (e.g., acetaminophen, ibuprofen, or opioids) as needed.  

- **Apply** cool, sterile compresses to the burn area to provide relief.  

- **Educate** the patient on relaxation techniques (e.g., deep breathing).  

#### **2. Impaired Skin Integrity**  

- **Cleanse** the burn area gently with saline solution or as per protocol to prevent further damage.  

- **Apply** prescribed topical agents (e.g., silver sulfadiazine) to prevent infection and promote healing.  

- **Dress** the wound with sterile, non-adherent dressings to protect the site.  

- **Monitor** for signs of infection (e.g., increased redness, swelling, or foul-smelling drainage).  

#### **3. Risk for Infection**  

- **Maintain** a sterile technique during dressing changes to reduce contamination.  

- **Encourage** good hand hygiene for both patient and caregivers.  

- **Administer** prescribed antibiotics if signs of infection develop.  

- **Educate** the patient about avoiding scratching or disturbing the wound.  

#### **4. Fluid Volume Deficit**  

- **Monitor** intake and output to assess fluid balance.  

- **Encourage** oral fluid intake unless contraindicated, focusing on electrolyte-rich fluids.  

- **Administer** IV fluids as prescribed to restore hydration.  

- **Assess** for signs of dehydration (e.g., dry mucous membranes, decreased urine output).  

### **EVALUATION**  

- Pain is reported as manageable (below 4/10 on the pain scale).  

- Wound shows signs of healing without infection (e.g., reduced swelling and no purulent discharge).  

- Hydration status is maintained as evidenced by stable vital signs and adequate urine output.  

- The patient demonstrates proper wound care techniques and verbalizes understanding of follow-up care.  

Let me know if you need help customizing this care plan for a specific patient or situation!