ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
INDEPENDENT:
SUBJECTIV E: Acute pain After 5 days
related to nursing >Provide bed cradle as > Elevation of linens off Goal met
“Masakit destruction of intervention indicated wounds may help reduce pain
talaga”as skin/tissues; , the patient
verbalized
> Position of function reduces
edema will participate > Wrap digits/extremities in deformities/contractures and
by the formation in activities position of function (avoiding
patient promotes comfort. Although
manipulatio n and sleep/rest flexed position of affected joints) flexed position of injured
of injured appropriatel y using splints and footboards as joints may feel more
tissues, e.g., and display necessary.
OBJECTIVE comfortable, it can lead to
wound relaxed facial
: flexion
debridement expressions/
contractures.
AEB body posture
>Pain rating >Movement and exercise
distraction/g
scale of 9/10 reduce joint stiffness and
uarding
>distraction/ muscle
behaviors; > Change position frequently
guarding fatigue, but type of
anxiety/fear
and assist with active and exercise depends on
behaviors ,
passive ROM as indicated location and
>anxiety/fear restlessness
, extent of injury.
>restlessness >Temperature regulation may
be lost with major burns.
> Maintain comfortable External heat sources may be
environmental temperature, necessary to prevent chilling
provide >Reduces severe physical and
heat lamps, heat-retaining body emotional distress associated
coverings. with dressing changes and
debridement
>Enhances patient’s sense of
> Provide medication and/or place control and strengthens
in hydrotherapy (as appropriate)
before performing dressing changes
and debridement.
>Involve patient in
Assessment Explanation of the Planning Intervention Rationale Evaluation
problem
Infection occur when After 5 days Dx Dx
Objective: the natural defense of nursing  Assess pin sites and skin  It indicate the onset of
mechanisms of an intervention area, nothing reports of local infection or tissue
 HR: 86 individual are , patient will increased pain, burning necrosis, which can lead
 RR:20 inadequate to protect achieve timely sensation, presence of to osteomyelitis.
 T: 37.3 them. wound healing edema, erythema, odor and
 HEENT Microorganisms such be free of drainage.  Minimizes opportunity
: as bacteria, viruses, purulent for contamination.
(+) abrasion fungus, and other drainage or  Observe wounds for
+ 2 over right parasites invade
o erythema, be bullae formation, Tx
forehead susceptible hosts afebrile and be crepitation, bronze  May prevent cross-
through inevitable free of discoloration of the skin, contamination and the
Nursing injuries and infection. frothy or fruity-smelling possibility of infection.
Diagnosis - exposures. People drainage.  IV, topical antibiotics and
Risk for have dedicated cells Tx Tetanus toxoid given
Infection r/t or tissues that deal  Provide sterile pin or prophylactically
inadequate with the threat of wound care according to  Local debridement and
primary infection. These are protocol and exercise cleansing of wounds
defenses known as the immune meticulous handwashing. reduce microorganisms
secondary to system.  Administer antibiotics as and the incidence of
burns prescribed systemic infection.
The human immune  Provide wound or bone
system is crucial for irrigations and apply
survival in a world warm or moist soaks as
full of potentially indicated.
deadly and harmful
microbes. The serious
impairment of this
system can predispose
to severe, even life-
threatening,
infections. Organs and
tissues involved in the
immune system
include the thymus,
bone marrow, lymph
nodes, spleen,
appendix, tonsils, and
Peyer’s patches (in
the small intestine
  Prevent skin-to-skin
surface contact (e.g.,
wrap each burned
finger/toe
separately; do not Edx
allow burned ear to
touch scalp).
Edx
 Educate about
appropriate cleaning,
disinfecting and
sterilizing items.
 Prevents adherence to
surface it may be touching
and encourages proper
healing.
 Knowledge of ways to
reduce or eliminate germs
reduces the likelihood of
transmission.
 Adequate nutrition enables
the body to maintain.

 Encourage intake of
protein- rich and
calorie rich foods.
 ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
INDEPENDENT:
SUBJECTIVE: Impaired Skin After 5 days Postoperative
“ Nasunog talaga ang Integrity, [grafts] nursing Goal met
balat niya” as related to intervention, the > Elevate grafted area if > Reduces
verbalized by the Disruption of skin patient will possible/appropriate. swelling/limits risk of
parentsw surface with achieve timely Maintain graft separation.
destruction of skin healing of burned desired position and Movement of tissue
OBJECTIVE: layers (full- areas. immobility of area when under graft can dislodge
thickness burn) indicated it, interfering with
>HEENT: (+) requiring grafting optimal healing.
abrasion + 2o over AEB Absence of
right forehead viable tissue
> Areas may be
>Chest: (+) axillary
> Maintain dressings over covered by translucent,
newly grafted area and/or nonreactive surface
burn 2o degree
donor material (between graft
site as indicated, e.g., and outer dressing) to
>4 o burn (full
mesh, petroleum, eliminate
thickness burn)
nonadhesive shearing of new
right hand &right
epithelium/protect
forearm
healing tissue.

> Promotes
circulation and
>Keep skin free from prevents
pressure ischemia/necrosis and
graft failure

> Evaluates
> Evaluate color of
grafted and donor site(s); effectiveness of
note presence/absence of circulation and
healing identifies
developing
complications