Nursing Care Plan: Patient with Electrical Shock Injury

Assessment

• Pain or burning sensation
• Chest pain, palpitations
• Dizziness, headache, weakness
• Numbness, tingling, reduced movement
• History of loss of consciousness
• Details of exposure: household versus industrial source, wet environment, duration, entry and exit points

• Level of consciousness, GCS, pupils
• Airway patency, respiratory rate, oxygen saturation, breath sounds
• Heart rate, rhythm, BP, peripheral pulses, capillary refill
• ECG findings
• Skin: entry/exit wounds, extent and depth of burns, color, edema, blistering
• Musculoskeletal trauma from fall or violent muscle contraction
• Urine output and color, especially dark or tea-colored urine suggesting myoglobinuria
• Labs as ordered: CBC, electrolytes, creatinine, CK, urinalysis for myoglobin, cardiac tests when clinically indicated

1. Nursing Diagnosis: Ineffective Tissue Perfusion - Cardiac

Goals/Expected outcomes

• Patient maintains stable HR, BP, oxygen saturation, and level of consciousness.
• ECG remains normal or dysrhythmia is identified and treated promptly.
• Patient reports no chest pain or palpitations.

Nursing interventions and rationale

2. Nursing Diagnosis: Impaired Skin Integrity

Goals/Expected outcomes

• Burn wounds remain clean and free of infection.
• No increase in burn depth, edema, or tissue necrosis occurs.
• Patient demonstrates correct wound-care instructions before discharge.

Nursing interventions and rationale

3. Nursing Diagnosis: Acute Pain

Goals/Expected outcomes

• Patient reports pain at a tolerable level, for example ≤3/10.
• Patient appears relaxed and can rest or participate in care.
• Vital signs remain near baseline.

Nursing interventions and rationale

4. Nursing Diagnosis: Risk for Ineffective Renal Perfusion / Acute Kidney Injury

Goals/Expected outcomes

• Urine output remains adequate and urine does not become dark.
• Renal function and electrolytes remain within acceptable range.
• Patient has no signs of fluid overload or acute kidney injury.

Nursing interventions and rationale

5. Nursing Diagnosis: Anxiety

Goals/Expected outcomes

• Patient verbalizes reduced anxiety.
• Patient demonstrates understanding of treatments and monitoring.
• Patient participates in care decisions as able.

Nursing interventions and rationale

• Stay with the patient during acute phase and communicate calmly.
• Give short, clear explanations of procedures and monitoring.
• Encourage expression of fears and questions.
• Involve family/support person when appropriate.
• Teach warning signs to report: chest pain, palpitations, breathing difficulty, weakness, worsening pain, reduced sensation, dark urine, fever, or wound drainage.
• Arrange psychological support or follow-up if anxiety, sleep disturbance, or trauma symptoms persist.

Discharge Teaching

• Keep burn dressings clean and dry as instructed.
• Take prescribed pain medicines and complete wound-care plan.
• Avoid returning to electrical work or hazardous exposure until medically cleared.
• Seek emergency care immediately for chest pain, palpitations, fainting, shortness of breath, confusion, worsening weakness, dark urine, fever, wound redness, pus, increasing swelling, or severe pain.
• Attend burn, surgical, cardiac, neurologic, and rehabilitation follow-up as advised.

NANDA-based Nursing Care Plan

Assessment data

• History of electric-current exposure
• Patient had a brief fainting episode/loss of consciousness
• Now conscious, alert, and vital signs currently normal
• Assess for: chest pain, palpitations, dyspnea, headache, dizziness, confusion, seizure activity, burns, entry/exit wounds, muscle pain, numbness, fall-related injury, and urine color/output.
• Check and document: source/voltage if known, duration of contact, AC/DC source, wet/dry surroundings, current pathway, fall/trauma, and duration of unconsciousness.

1. Risk for Decreased Cardiac Output

This is a risk diagnosis, because the patient currently has normal vital signs and no demonstrated dysrhythmia, but the fainting episode requires assessment for an occult arrhythmia.

Expected outcomes

• Patient maintains stable HR, BP, respiratory status, oxygen saturation, and level of consciousness.
• ECG shows no clinically significant dysrhythmia.
• Patient reports no chest pain, palpitations, dizziness, or recurrent faintness during observation.

Nursing interventions with rationale

1. Monitor vital signs, level of consciousness, peripheral perfusion, and oxygen saturation at frequent intervals.
   Detects early circulatory or neurologic deterioration.
2. Obtain a 12-lead ECG immediately and maintain continuous cardiac monitoring/telemetry as prescribed.
   Electrical current can cause conduction disturbances. Syncope after exposure is a risk feature that needs monitoring.
3. Assess and promptly report chest pain, palpitations, dyspnea, dizziness, recurrent syncope, new confusion, or abnormal ECG findings.
   These may indicate dysrhythmia or cardiac injury.
4. Maintain IV access and ensure emergency equipment is available.
   Allows rapid treatment if an arrhythmia or cardiopulmonary instability occurs.
5. Administer oxygen, IV fluids, and prescribed medications only as ordered; prepare for ACLS interventions if the patient becomes unstable.
   Supports oxygenation and circulation during deterioration.
6. Document characteristics of the electrical exposure and fainting episode.
   Voltage, path through the body, contact time, and loss of consciousness guide risk assessment.

2. Risk for Falls

Expected outcomes

• Patient remains free from falls or trauma.
• Patient calls for assistance before getting out of bed.
• Patient verbalizes precautions to prevent another fall.

Nursing interventions with rationale

1. Keep the patient on bed rest or supervised activity until medically cleared.
   Prevents injury if dizziness or syncope recurs.
2. Raise side rails as appropriate, keep the bed low and locked, and place the call bell within reach.
   Reduces environmental fall risk.
3. Assist with transfers, ambulation, toileting, and standing.
   Postural changes may precipitate dizziness or another syncopal episode.
4. Assess for dizziness, weakness, visual changes, headache, and orthostatic symptoms before mobilization.
   Identifies signs suggesting continued instability.
5. Educate the patient not to stand or walk alone and to call staff immediately for chest symptoms, palpitations, dizziness, or weakness.
   Promotes early reporting and prevents secondary injury.

3. Risk for Ineffective Cerebral Tissue Perfusion

Expected outcomes

• Patient remains oriented to person, place, time, and situation.
• GCS and pupillary responses remain unchanged from baseline.
• No recurrence of loss of consciousness, seizure, confusion, or focal weakness occurs.

Nursing interventions with rationale

1. Perform and document serial neurologic observations: GCS, orientation, pupils, limb strength, sensation, and speech.
   Detects delayed neurologic impairment or consequences of head trauma from the fall.
2. Ask about headache, vomiting, confusion, visual disturbance, weakness, numbness, and seizure-like activity.
   These symptoms require urgent escalation.
3. Assess for head injury and determine whether the patient fell during the fainting episode.
   Syncope can cause traumatic injury.
4. Maintain oxygenation and hemodynamic stability; position safely, with head elevation only if appropriate and ordered.
   Supports cerebral oxygen delivery.
5. Notify the provider immediately of decreasing GCS, new focal neurologic deficits, seizure, persistent headache, vomiting, or recurrent loss of consciousness.
   These changes may require urgent imaging and medical review.

4. Impaired Skin Integrity

Expected outcomes

• Burn/skin area remains clean, protected, and free from infection.
• No increase in redness, edema, drainage, or tissue damage occurs.

Nursing interventions

• Inspect and document location, size, color, depth, drainage, and pain of all burns or suspected entry/exit sites.
• Cover with clean, dry sterile dressing as ordered.
• Monitor circulation, sensation, movement, color, temperature, pain, and swelling distal to the injury.
• Use aseptic technique for wound care.
• Verify tetanus status and administer prophylaxis if prescribed.
• Refer/escalate for significant, deep, circumferential, or high-voltage burns.

5. Acute Pain

Expected outcomes

• Patient reports pain at a tolerable level, such as 0-3/10.
• Patient rests comfortably and participates in care.

Nursing interventions

• Assess pain score, location, quality, and onset regularly.
• Reassess pain after medications/interventions.
• Administer prescribed analgesics.
• Provide positioning, calm reassurance, and explanation before procedures.
• Report severe or worsening pain, especially pain out of proportion to visible injury, because electrical injury can damage deeper tissues.

Immediate notification/escalation criteria

• Recurrent fainting, seizure, confusion, or reduced consciousness
• Chest pain, palpitations, abnormal ECG, bradycardia, or tachycardia
• Dyspnea, hypoxia, or respiratory distress
• New weakness, numbness, severe headache, or vomiting
• Significant burns, severe swelling, reduced pulses, or increasing limb pain
• Dark urine or reduced urine output, which can suggest muscle breakdown.