NURSING CARE PLAN FOR TISSUE INJURY

ASSESSMENT NURSING INFERENCE OBJECTIVES NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
Subjective: Burns are Short Term Assist in wound To be able to assess After 4 hrs.
“Mahapdi mga Impaired skin characterized by Goal: care. the wound and Of nursing
sugat ko” integrity related to severe skin ensure asepsis in intervention
as verbalized by trauma [burn damage in which After 1 hour of wound care. s, the
the patient. injuries] many of the intervention the patient was
affected cells die. patient will: Periodically To identify risk for able
Objective: Depending on the  Participate in monitor site of infection and maintain
cause and degree prevention wound. monitor wound core
 74.5% BSA of injury, most measures and healing. temperature
2nd degree people can treatment within
burn on recover from program of Remove wet and To prevent normal
cheeks, burns without wound care soiled linens and infection and range.
jawline, both
serious health clothing. further skin
upper and Long term goal:
consequences. damage. T: 37.2
lower  Demonstrate
extremities, tissue
abdomen and Second-degree Maintain linens Minimize the risk Goal met
regeneration.
chest. burns are more wrinkle free. of skin ulcerations
 Achieve
 Presenting serious because timely
features of the damage healing of Emphasize To prevent
wounds are extends beyond burned areas. importance of good infection and to
blister the top layer of hygiene, wound enhance
formation skin. This type of care and wound understanding and
anderythema extensive damage dressing cooperation.
. causes the skin to
T: 37.2 Encourage diet that To provide a
blister and
P: 70 has high amounts of positive nitrogen
become
R: 19 vitamins A, C, D balance to aid in
extremely red and
BP: 110/90 and increased skin and tissue
sore. Some protein intake. healing and to
blisters pop open, maintain general
 good health.
giving the burn a
wet appearance. Discuss importance Enhances patient’s
of early detection of understanding and
skin changes and/or cooperation.
complications.

Emphasize Rest decreases

importance of body’s overall
adequate rest demand in oxygen
periods and and promotes
immobilization of wound healing
affected body part.

Encourage patient Increases patient’s

to verbalize self-esteem and to
feelings and discuss help patient deal
how or if it affects with the situation.
self-esteem.

Maintain dressings Areas may be

over newly grafted covered by
area and/or donor translucent,
site as indicated: nonreactive surface
mesh, petroleum, material (between
non adhesive. graft and outer
dressing) to
eliminate shearing
of new epithelium
and protect healing
tissue.