NCP POTENTIAL

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE

EVALUATION

“He is Juswa Risk for Electrical burns Following 8 hours of Independent: Independent: The goal was
Sheshwang, 42 infection are caused by the nursing intervention met after the
year-old from Holy related to contact of electricity the patient should be:  Build trust 1. To 8 hour
Ghost, Baguio City, impaired with a person's skin and establish develop nursing
he was just fixing skin integrity and can be due to Short Term: rapport an open, intervention;
the socket and then secondary to improper use of  Motivated to cooperati the patient
I don’t know what electrical electricity or participate in ve and was far from
happened, I just burn as appliances. They infection effective any signs and
saw him lying on possibly can travel through control. treatment
symptoms of
the floor with burns evidenced your body and  The client  Determine the plan
infection.
on his face and by red damage the skin, client’s level 2. To
should be able
neck” as verbalized sores, tissues, and to demonstrate of discomfort prevent
by the wife of the discharge, affected organs. If the
proper wound
patient. development they are not treated developm
care and ent of
of yellowish- properly, an
Objective: brown crust, infection could grow sanitation. complicat
mild itching, and cause fatal  Manage pain ions and
 Monitor for
 42 Years pain and cases. effectively signs of minimize
Old soreness. using infection and the
 64 kg Infections are a pharmacologic report it to the impact of
 Body major cause of al and non- HCP for complicat
surface area death in some burn pharmacologic assessment ions of
cases which al methods. the
Face 9% anterior resulted from the client's
 Respiratory
development of rate and pulse health
trunk 18% sepsis. Dependent: outcomes
rate are within .
right arm 9% the normal
Burn Injuries are  Assess and
range.
NCP POTENTIAL
 Consider defined in two ways: manage pain Dependent:
the total the extent or Long Term: to ensure
TSBA of the percent of body  Client’s skin is client comfort 1. To
patient surface area maintained through the reduce
involved, and the through the process. the stress
depth or amount of proper healing response
 Burn injuries anatomical tissue process. and
extend up to destroyed.  Intact skin over promote
the deeper other pressure overall
layer of the Burn depth is much points with the  Take note of being.
dermis more difficult to absence of the normal
(Second- define and may be complications ranges of vital
Degree related to degree of from the signs taken
Burn) burn (1st, 2nd, 3rd) wounds. upon
 Blisters are or to skin  Be free of any assessment 2. To
present thickness(superficial infection-related and assess provide for early
 Reduced or moderate partial- signs and the blood detections of
pain thickness, deep symptoms. supply and complications
sensitivity, partial-thickness, or sensation of that are essential
but is painful full-thickness.) skin surfaces for healing burn
with and affected injury.
pressure area on a
 Reduced regular basis
blanching (photograph)
 Slightly
moist 3. Given
 Leathery prophylactic
appearance because the
 Vital signs  Administer possibility of
were taken medications tetanus exists
as follows: like tetanus with any open
vaccine if wound.
➢Temperature: needed.
NCP POTENTIAL
36.0 °c

➢Respiratory rate: 4. To
29 breaths per  Provide prevent further
minute wound care, infection of the
including wound
➢ Pulse rate: 112 cleaning,
beats per minute debridement,
and dressing
➢ Blood pressure: changes
90/70 mmHg  Use 5. To
appropriate reduce pressure
padding or on sensitive
pressure- areas and
reducing enhance
devices when circulation to
indicated compromised
tissues.To
develop an open,
cooperative and
Collaborative: effective
treatment plan
 Health care
team will
administer
antibiotics, Collaborative:
and monitor
signs of 1. To
infections. prevent
the
developm
ent of
complicat
ions and
NCP POTENTIAL
minimize
the
impact of
complicat
ions of
the
client's
health
outcomes
.