NURSING CARE PLAN

Patient Name: Marler, Randy Age: 22 years old

Diagnoses: 2nd and 3rd degree burn Date Identified: September 01, 2021
Problem: Pain Date Evaluated: September 01, 2021
Chief Complaint: Burn Physician: Dr. Buyog, Dr. Castro, Dr. Chandler
ASSESSMENT NURSING INFERENCES PLANNING INTERVENTION SCIENTIFIC EVALUATION
DIAGNOSES RATIONALE

Subjective Data: Acute pain related to Short term Goal: Independent:

“Sakit akong kamot destruction of Acute pain is of short After 3 hours of 1. Assess 1. Pain is nearly Short term: Goal
ug dughan ngot-ngot skin/tissues; affect duration and nursing intervention reports of always partially met.
man, diri mismo sa the sensory nerve unpleasant sensory the patient will be pain, noting present to
napaso murag ending as evidenced and emotional able to: location and some degree
mahimung matibook by reports of pain. experience character and because of The patient was now
lawas naku associated with ● Report pain intensity (0– varying able to :
maapektuhan sa actual or potential reduced/contr 10 scale). severity of
kasakit ma’am” as tissue damage such olled less than tissue Report the
verbalized by the as burn. It has a 4 based on involvement level of
patient. duration of fewer pain scale. and pain into 4
than 6 months. The destruction
● Display based on
Objective Data: physiological signs but is usually
relaxed facial pain scale
● Grimace face that occur with acute most severe
pain emerge from expressions/b
● Restlessness during
the body’s response ody posture.
● Guarding dressing Display
himself while to pain as a stressor. changes and relaxed
doing the The pain is so strong Long term Goal: debridement. facial
it seems to partially Within 4-7 days of expression
assessment
dominate your nursing intervention 2. Cover wounds 2. Temperature s.
● Tingling
senses, causing you the patient will be as soon as changes and
● Intermittent to think somewhat able to: possible air movement Long term:
pain at chest unclearly. The Goal partially met:
● Sleep/rest unless open- can cause
● Pain scale: 9 reported prevalence air exposure great pain to -Within 7 days of
appropriately.
● Temp.: 37.2 of neuropathic pain burn care exposed nursing intervention
● Reduced pain
● RR: 19 (CNP) following method nerve patients are now
less than 3.
● PR: 119 burns within the last required. endings. able to sleep/rest for
10 years ranges from 3. Elevate about 6 hours every
PQRST Pain
Assessment burned day.
7.3% to 18% CNP extremities 3. Elevation may -He claimed that the
● P- Movement, develops after partial periodically. be required pain is still at the
Pain reliever or complete initially to scale of 4 out of 10.
● Q- stinging peripheral nerve reduce edema
● R- all area injury formation;
which has thereafter,
partial changes in
thickness burn position and
● S- 9/10 elevation
https://
● T- all the time reduce
www.disabled-
discomfort
world.com/health/
and risk of
pain/scale.php
joint
4. Provide a bed contractures.
cradle as 4. To keep
indicated. sheets/blanket
s off legs/feet.
5. Temperature
5. Maintain regulation
comfortable may be lost
environmental with major
temperature, burns.
provide heat External heat
lamps, heat sources may
retaining body be necessary
coverings. to prevent
6. Encourage chilling.
expression of 6. Verbalization
feelings about allows outlet
pain. for emotions
and may
enhance
coping
mechanisms.
7. Provide basic 7. Promotes
relaxation;
 reduces
comfort muscle
measures: tension and
massage of general
uninjured fatigue.
areas. 8. Sleep
8. Promote deprivation
uninterrupted can increase
sleep periods. perception of
pain/reduce
coping
abilities.
9. Concerns of
patient
addiction or
doubts
Dependent regarding
degree of pain
experienced
9. Administer are not valid
analgesics during the
(narcotic and emergent/acut
nonnarcotic) e phase of
as indicated: care, but
morphine and narcotics
ketorolac, should be
Valium decreased as
Lactated soon as
Ringer, feasible and
Plasma 825cc alternative
as prescribed methods for
by the pain relief
physician. initiated.
 NURSING CARE PLAN

Patient Name: Marler, Randy Age: 22 years old

Diagnoses: 2nd and 3rd degree burn Date Identified: September 01, 2021
Problem: Open wounds Date Evaluated: September 08, 2021
Chief Complaint: Burn Physician: Dr. Buyog, Dr. Castro, Dr. Chandler,
ASSESSMENT NURSING INFERENCES PLANNING INTERVENTION SCIENTIFIC EVALUATION
DIAGNOSES RATIONALE

Subjective Data: Goal partially met.

,Maam nabalaka ko Risk for infection The invasion and After 8 hours of Independent: ● The patient is
sa akong paso kay related to multiplication of nursing intervention able to
daku kaayu basig Inadequate primary microorganisms such the patient will be ● Indicators of achieve timely
mainfection ko defenses: as bacteria, viruses, able to : ● Examine sepsis (often wound
ba?” destruction of skin and parasites that wounds daily, occurs with healing free
barrier, traumatized are not normally note and full-thickness and be
tissues present within the ● Achieve timely document burn) afebrile
Objective Data: body. An infection wound healing changes in requiring ● Understand
may cause no free and be appearance, prompt the
● Redness symptoms and be afebrile. odor, or evaluation importance of
● Swelling subclinical, or it may ● Understand quantity of and preventing
● Discharges;s cause symptoms and the drainage. intervention. infection and
erous in the be clinically importance of Note: its risk factors.
burn part, apparent.Burn preventing Changes in
White and patients are at higher infection and sensorium,
charred in risk for all types of its risk factors. bowel habits,
the both infections secondary and
arms to loss of the skin respiratory
● Blisters barrier as well as rate usually
● No odor immunosuppression precede fever
experienced and alteration
because of a of laboratory
systemic studies.
inflammatory ● Abnormal
response triggered vitals show a
by the injured sign of
tissue.Burn wounds infection or
induce metabolic and complication
inflammatory due to full
alterations that thickness
predispose the ● Monitor vital burn.
patient to various signs for
complications. fever,
Infection is the most increased
common cause of respiratory
morbidity and rate and depth
mortality in this in association
population, with with changes
almost 61% of in sensorium,
deaths being caused presence of
by infection. diarrhea,
decreased
platelet count,
and
hyperglycemia
with
glycosuria.
● Implement ● Isolation may
appropriate range from
isolation simple wound
techniques as and/or skin to
indicated. complete or
reverse to
reduce risk of
cross
contamination
and exposure
to multiple
bacterial flora.
● Prevents
cross
contamination
● Emphasize ; reduces risk
 of acquired
and model infection.
good
handwashing
technique for
all individuals
coming in
contact with
patients.
● Prevents
exposure to
infectious
organisms.
● Use gowns,
gloves,
masks, and
strict aseptic
technique
during direct
wound care
and provide
sterile or
freshly
laundered bed ● Prevents
linens or cross-
gowns. contamination
● Monitor from visitors.
and/or limit Concern for
visitors, if risk of
necessary. If infection
isolation is should be
used, explain balanced
the procedure against the
to visitors. patient's need
Supervise for family
visitor support and
socialization
 adherence to ● Early excision
protocol as is known to
indicated. reduce
● Remove scarring and
dressings and risk of
cleanse infection,
burned areas thereby
in a facilitating
hydrotherapy healing.
or whirlpool
tub or in a
shower stall
with handheld
shower head.
Maintain
temperature
of water at
100°F
(37.8°C).
Wash areas
with a mild
cleansing
agent or
surgical soap
● Debride
necrotic or
loose tissue
(including ● Promotes
ruptured healing.
blisters) with Prevents auto
scissors and contamination
forceps. Do . Small, intact
not disturb blisters help
intact blisters protect skin
if they are and increase
smaller than rate of re-
1–2 cm, do epithelializatio
 not interfere
with joint n unless the
function, and burn injury is
do not appear the result of
infected. chemicals (in
which case
fluid contained
in blisters may
continue to
cause tissue
● Provide small destruction).
frequent foods ● To promote
intake that are fast healing
rich in protein, and regain
carbohydrates strength
, vitamins and
minerals.

Dependent:

Administer other
medications as
appropriate:
Subeschar Clysis or
systemic antibiotics ● Tissue
as prescribed by the destruction
physician; and altered
defense
mechanisms
● Tetanus increase risk
Toxoid 0.5cc of developing
● Cefazolin tetanus or gas
● Silver gangrene,
 sulfadiazine
cream especially in
● Furosemide deep burns
● Lactated such as those
Ringer, caused by
Plasma 825cc electricity. It
helps stop
infections
caused by
bacteria. They
do this by
killing the
bacteria or by
keeping them
from copying
themselves or
reproducing.

NURSING CARE PLAN

Patient Name: Marler, Randy Age: 22 years old

Diagnoses: 2nd and 3rd degree burn Date Identified: September 01, 2021
Problem: Anxiety Date Evaluated: September 06, 2021
Chief Complaint: Burn Physician:Dr. Buyog, Dr. Castro, Dr. Chandler
ASSESSMENT NURSING INFERENCES PLANNING INTERVENTION SCIENTIFIC EVALUATION
 DIAGNOSES RATIONALE

Subjective Data: Anxiety related to Anxiety is a vague Within 6 days of Independent: Within 6 days of
“Mag unsa naman situational crisis as feeling of dread or nursing intervention 1. Assess 1. Initially, patients nursing
lang ko ani maam evidenced by apprehension; it is a the patient must be mental status, may use denial intervention the
wala gyod ko mag decreased self- response to external able to: including and repression patient is now able
expect ma ingon ani assurance. and internal stimuli ● Verbalize mood and to reduce and to:
ko kalit ra kaayo ang that can have awareness of affect, filter information ● Verbalize
panghitabo ba” as behavioral, feelings and comprehensio that might be awareness
verbalized by the emotional, cognitive, healthy ways n of events, overwhelming. of feelings
patient. and physical to deal with and content of and healthy
symptoms. them as thoughts. ways to deal
Objective Data: Situational crises are evidenced by 2. Give frequent 2. Knowing what with them
Vital Signs: an unexpected event communicatin explanations to expect as
T= 36.2 ˚C that is usually g with the and usually reduces evidenced
P= 138 bpm beyond the people around information fear and by talking
R= 22 cpm individual's control. It him about about care anxiety, clarifies and
BP= 132/78 mmHg is one of the external what he feels. procedures. misconceptions, communicat
-Restlessness stimuli that could ● Report Repeat and promotes ing with his
-faster arte of speech lead to anxiety. And anxiety/fear information as cooperation. family and
-High voice pitch what happens to the reduced to needed. Because of the healthcare
patient puts him into manageable shock of the provider
a situational crisis level, from initial trauma, about what
that leads him to moderate many people do he feels and
have decreased self anxiety to mild not recall asking for
assurance. or/and to information advice on
-Videbeck, 2019 completely provided during how to feel
eliminate it. that time. better.
3. Demonstrate 3. Helps the ● Anxiety/fear
willingness to patient and SO was
listen and talk know that reduced to
to the patient support is mild level.
when free of available and
painful that the
procedures. healthcare
provider is
interested in the
 person, not just
care of the burn.

4. Promotes sense
4. Involve the of control and
patient and cooperation,
SO in the decreasing
decision feelings of
making helplessness or
process hopelessness.
whenever
possible.
Provide time
for
questioning
and repetition
of proposed
treatments. 5. Indicators of
5. Investigate extreme anxiety
changes in and delirium in
mentation and which a patient
presence of is literally
hypervigilance fighting for life.
, Although cause
hallucinations, can be
sleep psychologically
disturbances, based,
nightmares, pathological life-
agitation, threatening
apathy, causes must be
disorientation, ruled out.
and labile
affect, all of
which may
vary from
moment to
 moment. 6. Helps the
6. Provide patient stay in
constant and touch with
consistent surroundings
orientation. and reality.
7. The patient may
7. Encourage need to tell the
the patient to story of what
talk about the happened over
burn and over to
circumstances make some
when ready. sense out of a
terrifying
situation.
8. Compassionate
8. Explain to the statements
patient what reflecting the
happened. reality of the
Provide situation can
opportunities help the patient
for questions and SO
and give acknowledge
honest that reality and
answers. begin to deal
with what has
happened.
9. Past successful
9. Identify behavior can be
previous used to assist in
methods of dealing with the
coping and present
handling situation.
stressful
situations. 10. Patients
10. Create a experience
restful severe anxiety
environment, associated with
 use guided burn trauma
imagery and and treatment.
relaxation These
exercises. interventions
are soothing
and helpful for
positive
outcomes.
11. The family may
11. Assist the initially be most
family to concerned
express their about patient’s
feelings of dying and/or
grief and guilt. feel guilty,
believing that in
some way they
could have
prevented the
incident.
12. Family
12. Be empathic relationships
and are disrupted;
nonjudgmenta financial,
l in dealing lifestyle or role
with patients changes make
and family. this a difficult
time for those
involved with
the patient, and
they may react
in many
different ways.
13. Maintains
13. Encourage contact with a
family/SO to familiar reality,
visit and creating a
discuss family sense of
 happenings. attachment and
Remind the continuity of life.
patient of past
and future
events.

Interdependent: 1. Provides a
1. Involve the wider support
entire burn system and
team in care promotes
from continuity of
admission to care and
discharge, coordination of
including activities.
social worker
and
psychiatric
resources.
Dependent:

NURSING CARE PLAN

Patient Name: Marler, Randy Age: 22 years old
Diagnoses: 2nd and 3rd degree burn Date Identified: September 01, 2021
Problem:Disturbed Body Image Date Evaluated: September 05, 2021
Chief Complaint: Burn Physician: Dr. Buyog, Dr. Castro, Dr. Chandler
ASSESSMENT NURSING INFERENCES PLANNING INTERVENTION SCIENTIFIC EVALUATION
DIAGNOSES RATIONALE

Subjective Data: Disturbed Body Body image is how a Within 5 days of DEPENDENT: Goal Met:
´´Pangit na kaayo Image related to person feels about nursing interventions 1. Assess 1. Traumatic After 8 hours of
tan.awon ang ang disfigurement as his or her body and the patient must be meaning of episodes nursing interventions
part ng napaso sa evidenced by what they do about able to; loss or result in the patient is now
akoa ma'am maong negative feelings those feelings. Some ● Incorporate change to sudden, able to verbalize
dili ko ganahan mag about the body. may feel inferior changes into patient and unanticipated acceptance of self in
tan.aw pangit nako about their bodies self-concept SO, including changes, the situation.
kaayo tambok na and try to improve without future creating ``Na realize nako
gani ko ingon ani pa them through a negating self- expectations feelings of nga dili raman diay
gyod ´´ as verbalized variety of means esteem as and impact of grief over kaayo siya lain tapos
by the patient. called appearance evidenced by cultural or actual or dawat man ug
management verbalizing religious perceived suportado man kos
behaviors. As a acceptance of beliefs. losses. This akong pamilya ani
Objective Data: significant self in the necessitates akong sitwasyon
● face and neck component of one’s situation. support to karon ug naa
are burned self-concept, body ● Talk/ work through paman pud diay koy
and appear to image disturbance communicate to optimal daghan option para
be partial can have an intense with family/SO resolution. ma improve ang
thickness. impression on how about the appearance ani like
● nasal hairs, individuals see their situation, 2. Acknowledge 2. Acceptance of reconstructive
eyelashes, overall selves.For changes that and accept these feelings surgery. Nag plano
and eyebrows the patient the burn have expression of as a normal mi mag ingon ana
are singed. affected 53% of the occurred. feelings of response to nalang mi after nako
● circumferentia his body all the burn ● Develop frustration, what has maulian. Salamat
l full-thickness area are disfigured realistic dependency, occurred maam sa
burns of both from its original goals/plans anger, grief, facilitates pagpasabot`` stated
arms. appearance and the for the future and hostility. resolution. It is by the client.
● combination patient become such as Note not helpful or
of partial- and really sad and consulting to withdrawn possible to
 full- thickness worried about it. reconstructive behavior and push the
burns -Rehabil 2016 surgery. use of denial. patient before
covering the they are ready
majority of the to deal with
patients the situation.
anterior and Denial may be
posterior prolonged and
chest. be an
● TBSA burn is adaptive
estimated at mechanism
53% because the
● Weight is patient is not
85kg ready to cope
● Height 164 cm with personal
● BMI of 31 problems.
(Obese) 3. The patient
● Irritability 3. Set limits on and SO tend
maladaptive to deal with
behavior. this crisis in
Maintain a the same way
nonjudgmenta in which they
l attitude while have dealt
giving care, with problems
and help in the past.
patients Staff may find
identify it difficult and
positive frustrating to
behaviors that handle
will aid in behavior that
recovery. is disrupting
and not
helpful to
recuperation
but should
realize that
the behavior
is usually
 directed
toward the
situation and
not the
caregiver.
4. Enhances
4. Be realistic trust and
and positive rapport
during between
treatments, in patient and
health nurse.
teaching, and
in setting
goals within
limitations. 5. Promotes
5. Encourage acceptance of
the patient reality of injury
and SO to and of change
view wounds in body and
and assist image of self
with care as as different.
appropriate. 6. Promotes
positive
6. Provide hope attitude and
within provides
parameters of opportunity to
individual set goals and
situations; do plan for the
not give false future based
reassurance. on reality.
7. Helps begin
the process of
7. Assist the looking to the
patient to future and
identify the how life will be
extent of different.
actual change
 in appearance
and body 8. Words of
function. encourageme
8. Give positive nt can support
reinforcement development
of progress of positive
and coping
encourage behaviors.
endeavors
toward
attainment of
rehabilitation 9. Allows the
goals. patient and
9. Show pictures SO to be
or videos of realistic in
burn care expectations.
and/or other Also assists in
patient demonstration
outcomes, of importance
being of and/or
selective in necessity for
what is shown certain
as appropriate
to the devices and
individual procedures.
situation.
Encourage
discussion of
feelings about
what the
patient has 10. To open lines
seen. of
10. Encourage communicatio
family n and provide
interaction ongoing
with each support for the
other and with patient and
 rehabilitation family.
teams. 11. Promotes
ventilation of
11. Provide a feelings and
support group allows for
for SO. Give more helpful
information responses to
about how SO the patient.
can be helpful 12. Reinforcing
to the patient. teaching can
12. Provide help the
through patient
teaching and achieve self-
complete care.
aftercare
instructions
for the patient.
Stress the
importance of
keeping the
dressing dry
and clean.

INTERDEPENDENT
: 13. Helpful in
13. Refer to identifying
physical and ways/devices
occupational to regain and
therapy, maintain
vocational independence
counselor, . The patient
psychiatric may need
counseling, further
clinical assistance to
specialist resolve
psychiatric persistent
nurse, social emotional
 services,and problems.
psychologist,
as needed. 14. Reconstructiv
14. Provide e surgery can
referral to a help the
reconstructive patient gain
surgeon for self-esteem
the patient and
disfigured by confidence.
burns.

NURSING CARE PLAN

Patient Name: Marler, Randy Age: 22 years old

Diagnoses: 2nd and 3rd degree burn Date Identified:
Problem: Cyanosis Date Evaluated:
Chief Complaint: Burn Physician: Dr. Buyog, Dr. Castro, Dr. Chandler
ASSESSMENT NURSING INFERENCES PLANNING INTERVENTION SCIENTIFIC EVALUATION
DIAGNOSES RATIONALE
Subjective Data: Adequate Short term: Independent: Short term:
Ineffective tissue oxygenation is
perfusion related to critical for the patient
“Grabi ang pagka interruption in blood with burn injury. Burn Within 8 hours of 1. Assess - Can readily Goal met
sunog sakong panit, flow as evidenced by causes hemolysis of nursing interventions color, compress blood
dili na kaayo nako both radial and RBCs and decreases the patient would be sensation, vessels, thereby
ma feel ang pulso able to: movement, impeding circulation Within 8 hours of
palmar arch pulses circulating oxygen for
sakong kamot, as peripheral and increasing nursing interventions
are barely palpable tissue perfusion and
verbalized by the pulses, and venous stasis. the patient are able
proper cell function.
client. capillary refill Comparisons with to:
In its state, an
individual has a on extremities unaffected
reduction in oxygen with
● Identifies
concentration and circumferentia
factors that
consequently in l burns.
improve
cellular metabolism, circulation ● Identifies
due to a deficit in such as: factors that
capillary blood improve
Objective Data: supply. circulation
-Elevate 2. Check for such as:
affected limb irregular
-Restlessness Reference: to help pulses
minimise -Cardiac -Elevate
swelling and dysrhythmias can affected limb
- Capillary refill; Nurseslabs.com( Mat occur as a result of to help
improve blood
sluggish t Vera,2021) electrolyte shifts, minimise
flow
electrical injury, or swelling and
release of improve blood
-Circumferential full-
-Active/ myocardial flow
thickness burn both
Passive ROM depressant factor,
of arms
compromising
cardiac output
-Combination of
partial and full- -Passive
thickness burns ROM
covering the majority
of anterior and
posterior chest Long term:

-Both radial and Within 2-3 weeks of 3. Check Hgb - A variety of tests Long term:
palmar arch pulses nursing interventions level are available
are barely palpable the patient would be depending on the
able to: cause of the Within 2-3 weeks of
impaired tissue nursing interventions
-Numbness or perfusion. the patient is able to:
tingling

● Verbalizes or
-Hemoglobin results: demonstrates
9 indicate below normal ● Verbalize,
normal range. sensations -Pulse oximetry is a “Medyo
and useful tool to detect malihok na
4.Use pulse
movement as changes in nako akong
oximetry to
appropriate. oxygenation. kamot”.
monitor
oxygen ● Demonstrate
Electrolytes saturation and s normal
results: pulse rate sensations
and
movement
-Potassium 8mEq/L
(hyperkalemia)
-This saturates
5.Maintain circulating
oxygenation hemoglobin

-This ensure
adequate perfusion
of vital signs
6. Maintain
optimal
cardiac output

-Low levels reduce

the uptake of oxygen
at the alveolar-
7. Refer capillary membrane
patient to and oxygen delivery
diagnostic to the tissues
testing as
indicate

- Losses or shifts of
these electrolytes
affect cellular
membrane potential
and excitability,
8. Monitor
thereby altering
electrolytes,
myocardial
especially
conductivity,
sodium,
potentiating risk of
potassium,
dysrhythmias, and
and calcium.
reducing cardiac
Administer
output and tissue
replacement
perfusion.
therapy as
indicated.
 - If BP readings must
be obtained on an
injured extremity,
leaving the cuff in
place may increase
edema formation and
reduce perfusion,
and convert partial
9. Obtain BP thickness burn to a
in unburned more serious injury.
extremity
when
possible.
Remove BP
cuff after each
reading, as
indicated.
-Sufficient fluid
intake maintains
adequate filling
pressures optimizes
cardiac output
needed for tissue
perfusion
10. Check for
optimal fluid
balance.
Administer IV
fluids as
ordered

-Reduce renal
perfusion may take
place due to vascular
occlusion.
11.Note urine -Indicators of
output decreased perfusion
and/or increased
pressure within
enclosed space,
such as may occur
with a circumferential
burn of an extremity
(compartment
syndrome).

12.Investigate
reports of
deep or
throbbing
ache,
numbness - Promotes systemic
circulation and
venous return that
may reduce edema
or other deleterious
effects of constriction
of edematous
tissues. Prolonged
elevation can impair
arterial perfusion if
blood pressure (BP)
falls or tissue
pressures rise
 excessively.

13. Elevate
affected
extremities, as
appropriate. -These facilitate
Remove perfusion when
jewelry or arm interference to blood
bands. Avoid flow transpires or
taping around when perfusion has
a burned gone down to such a
area. serious level leading
to ischemia damage
due to burns.

14. Consider
the need for
potential
embolectomy,
vasodilator
therapy,
thrombolytic
therapy, and -Improves blood flow
fluid rescue. in constricted blood
vessels that help
maintain the
structural integrity of
the skin’s connective
 tissue.

Dependent: -These medications

facilitate perfusion
for most causes of
impairment.

1.Give
hyperbaric
Oxygen
therapy as
necessary per
doctor’s order

-These reduce blood

viscosity and
2.Administer coagulation.
medications
as prescribed
to treat
underlying
problems.
Note the
response.
-These enhance
arterial dilation and
improve peripheral
blood flow.
*Antiplatelet/
Anticoagulants

-These improve
cardiac output

*Peripheral
vasodilators

helps wound healing

by bringing oxygen-
rich plasma to tissue
starved for
oxygen,prevents
"reperfusion injury,
*Inotropes
helps block the
action of harmful
bacteria and
strengthens the
body's immune
system, and
encourages the
formation of new
Collaborative : collagen (connective
tissue) and new skin
cells.
1. Skin Burns
Hyperbaric oxygen
therapy (HBOT)
 NURSING CARE PLAN

Patient Name: Marler, Randy Age: 22 years old

Diagnoses: 2nd and 3rd degree burn Date Identified:
Problem:Damaged tissue epidermis, dermis, and subcutaneous tissue Date Evaluated:
Chief Complaint: Burn Physician: Dr. Buyog, Dr. Castro, Dr. Chandler
ASSESSMENT NURSING INFERENCES PLANNING INTERVENTION SCIENTIFIC EVALUATION
 DIAGNOSES RATIONALE

Impaired skin
Subjective Data: integrity related to Burns are 1.Determine - Prior assessment of Short term:
burn trauma as characterized by Short term: etiology (acute or wound etiology is
evidenced by severe skin damage chronic wound, critical for proper
“Ang nasunog nako combination of in which many of the burn, identification of Goal met
nga panit ma’am kay partial and full- affected cells die. Within 8 hours of dermatological nursing
hapdos ug sakit thickness burns Depending on the nursing interventions lesion). interventions.
siya”, as verbalized the patient would be Within 8 hours of
covering the majority cause and degree of
by the patient. able to: nursing
of anterior and injury, most people
posterior chest can recover from
burns without serious interventions the
health patient
2. Assess site of - Redness, swelling,
consequences.
impaired tissue pain, burning, and
Third-degree burns -Participate in integrity and its itching are indication
are more serious prevention measures is able to:
condition of inflammation and
because the damage and treatment of the body’s immune
Objective Data: extends beyond the wound care system response to
top layer of skin.
localized tissue
-Circumferential full- trauma or impaired
thickness burn both tissue integrity. Participate in
of arms

Reference: prevention
-Combination of
partial and full-
Nurseslabs.com( Mat - Inspect for any measures and
thickness burns
t Vera,2021) signs of
covering the majority
haemorrhage and
of anterior and treatment
3. Assess apply direct pressure
posterior chest
characteristics of to any external
Long term: wound, including wounds. program of
-TBSA estimated color, size Haemorrhage is rare
53% (length, width, in isolated burn
After 3-5 weeks of injuries, but in
depth), drainage, wound care
nursing interventions multitrauma burn
the patient’s wound
-Skin and tissue be able to : and odor. injuries, consider the Participate in
color changes potential for internal prevention
bleeding, which may
lead to shock
-Skin warmth to measures and
touch, wet and with treatment
dischargers
-Achieve timely of wound care.
healing of burned - These findings will
areas. give information on
the extent of the
impaired tissue
integrity or injury.
Pale tissue color is a
sign of decreased
oxygenation. Odor Long term:
4. Inspect for any may be a result of
obvious bleeding presence of infection
-stop with direct on the site; it may Goal met
pressure. also be coming from
a necrotic tissue.

After 1 week of
nursing interventions
- Pain is part of the the patient is able to:
normal inflammatory
process. The extent
and depth of injury
may affect pain
sensations. -Demonstrate tissue

regeneration
5. Assess the - Since the severity
patient’s level of of tissue damage
distress. may not be visible in
patients with
inhalation burns,
assessing for singed
nasal hairs or sooty
mucus can help
determine respiratory
compromise (refer to
the Picmonic on
"Burns Assessment")

6 Ensure Airway
Patency

-Systematic
inspection can
identify impending
problems early and
provide early
treatment
7. Assistive - Inadequate
breathing devices nutritional intake
such as places the patient at
endotracheal risk for skin
intubation and breakdown and
mechanical compromises healing
ventilation further causing
impaired tissue
integrity.

- Healing does not

transpire in the
appearance of
necrotic tissue.

8. Assess
patient’s
nutritional status;
refer for a
nutritional
consultation
and/or institute
dietary
supplement.

- Each type of wound

is best treated based
on its etiology. Skin
wounds may be
covered with wet or
dry dressings, topical
9. Pay special creams or lubricants,
attention to all hydrocolloid
high-risk areas dressings or vapor-
such as bony permeable
prominences, membrane dressings
skin folds, such as Tegaderm.
sacrum, and
heels

- This technique
reduces the risk of
10.Identify a plan infection in impaired
for debridement tissue integrity.
when necrotic
tissue (eschar or
slough) is present
and if compatible
with overall
patient
management
goals.
 -Saturating dressings
will ease the removal
by loosening
adherents and
decreasing pain,
especially with
burns.

11. Provide tissue

-This is to prevent
care as needed.
exposure to
chemicals in urine
and stool that can
strip or erode the
skin causing further
impaired tissue
integrity.

12. Keep a sterile

dressing
technique during
wound care.
-Mechanical damage
to skin and tissues
as a result of
pressure, friction, or
shear is often
associated with
external devices.
13. Wet
thoroughly the
dressings with
sterile normal
saline solution
before removal.

-A high-protein, high-
caloric diet may be
needed to promote
healing.

14. Tell patient to

avoid rubbing and
scratching.
Provide gloves or
clip the nails if
necessary.
- Nutrition plays an
important role in
maintaining an intact
skin and in
promoting wound
healing.

15. Encourage a
diet that meets
nutritional needs.
 - Nutrition plays an
important role in
maintaining an intact
skin and in
promoting wound
healing

16.Discuss
relationship
between
adequate
nutrition
consisting of
fluids, protein,
vitamins B and C, - Early assessment
iron, and calories. and intervention help
prevent the
development of
serious problems

17. Educate
patients about
proper nutrition,
hydration, and
methods to
maintain tissue
integrity.
 -Accurate
information
increases the
patient’s ability to
manage therapy
independently and
18.Teach skin
reduce the risk for
and wound
infection.
assessment and
ways to monitor
for signs and
symptoms of
infection,
complications,
and healing.

19.Instruct
patient,
significant others,
and family in the
proper care of the
- This is to prevent
wound including
further impaired
hand washing,
tissue integrity
wound cleansing,
complications.
dressing
changes, and
application of
topical
medications).
20. Educate the
patient the need
to notify the
physician or
nurse.