Medical Surgical Nursing

o Reports minimal pain
o Gives no physiologic, verbal, or nonverbal cues that pain is moderate or
severe
o Uses pain control measures such as nitrous oxide, relaxation, imagery,
and distraction techniques to cope with and alleviate pain and
discomfort
o Can sleep without being disturbed by pain
o Reports that skin is comfortable, with no pruritus or tightness
 Demonstrates optimal physical mobility and function
o Improves range of motion of joints daily
o Demonstrates preinjury range of motion of all joints
o Has no signs of calcification around the joints
o Participates in activities of daily living
 Uses appropriate coping strategies to deal with postburn problems
o Verbalizes reactions to burns, therapeutic procedures, losses
o Identifies coping strategies used effectively in previous stressful
situations
o Accepts dependency on health care providers during acute phase
o Verbalizes realistic view of problems resulting from burn injury and
plans for future
o Cooperates with health care providers in required therapy
o Participates in decision making regarding care
o Begins to manage grief over losses resulting from burn injury and
circumstances surrounding injury (eg, death of others, damage to home
or other property)
o States realistic objectives for plastic surgery, further medical
intervention, and results
o Verbalizes realistic abilities and goals
o Displays hopeful attitude toward future
 Relates appropriately in patient/family processes
o Patient and family verbalize feelings regarding change in family
interactions
o Family emotionally supports the patient during the hospitalization
o Family states that their own needs are being met
 Patient and family verbalize understanding of the treatment course
o State rationales for the various aspects of treatment
o State realistic time period for recovery
 Absence of complications
o Lungs clear on auscultation
o Exhibits no dyspnea or orthopnea and can breathe easily when standing,
sitting, and lying down
o Exhibits no S 3 or S 4 heart sounds or jugular venous distention
o Exhibits adequate urine output
o Exhibits normal blood, sputum, and urine culture results
o Maintains arterial blood gas values or O 2 saturation within normal or
acceptable limits
o Has normal lung compliance
o Has no visceral organ damage
o Has stable cardiac rhythm