CUES/ OBJECTIVES EXPLANATION OF THE
PROBLEM OBJECTIVES
Subjective: Burns are Characterized by
”Nangangati
PASCUA, yung paligid
DWENA MAE Jng severe skin damage in which
paa ANNEX
PR niya tapos nagdry (JULY
II 7-5PM naman 29-31,
many2021)
of the affected cells
na” die. Depending on the cause
and degree of injury, most
Objective: people can recover from
 Localized area hot burns without serious helath
to touch, pinkish consequences. Second-
 Itching surrounding the degree burns are more
wound site serious because the damage
 TSBA: 4-5 % extends beyond the top layer
 2nd Degree Burn on of skin. This type of
bilateral feet extensive damage causes the
 Presenting features of skin to blister and become
wound are dry and extremely red and sore. Some
presence of bliters pop open, giving the
discoloration of skin microorganisms opportunity
surrounding wound to enter the wound site which
area results infections.
 Weight: 20 kg
 Height 3 ft 11 inches/ Impaired skin integrity is
119 cm related to the problem since
 Temperature: 36.6 C the affected system is the
 Blood Pressure: 100.80 skin due to sclading burn.
mmHg The scalding burn is caused
 Pulse Rate: 89 bpm by the hot boiling water that
 RR: 20 cpm with clear was spilled on the patient’s
breath sounds feet that have caused direct
 SPO2: 98% transfer of heat to the skin.
 Pt. Is oriented to time, With this the skin was
place, and person affected and resulted to
 Normal Diet and has a alteration of skin surface
BMI of 14.12 kg/m2 since the skin have acquired
pain, redness, swelling and
Nursing Diagnosis: blisters. If impaired skin
integrity is not addressed
Impaired Skin integrity immediately this may be a
related to Alteration of skin portal of entry for
surface Secondary to Burns microorganisms that may
worsen the condition of the
patient. The immune system
tries to eliminate any
pathogen that the body will
acquire. However, if the
immunesystem fails to do so,
they will host the
microorganisms. And
because of that, if the burns
are not assessed and
observed properly this may
lead to sepsis, may affect the
oxygenation and ventilation
and or may lead to end organ
damage such as the brain,
kidneys, liver and gut.
GOALS AND INTERVENTIONS RATIONALE EVALUATION
Goal: DIAGNOSTICS: GOAL MET IF:
Client will achieve wound  Monitor Vital signs  Monitoring the vital Patient will achieve wound
healing, free signs of signs is important healing free of signs of
infection and maiantain because with this we infection and maintain
optimal physical well-being would know if the optimal physical well-being
as evidenced NCP
by clean,
PROPERand patient’s condition is as evidenced by clean, and
dry skin, no redness, improving or if the dry skin, no redness,
itching/pain surrounding the patient is acquiring itching/pain surrounding the
wound area infection althroughout wound area . And significant
the healing or recovery others and patient are able to
STO: process. acknowledge and comply to
After 4 hours of nursing nursing and medical
intervention the client and  Redness, swelling, interventions.
significant other will be able pain, burning, and
to: itching are indication of GOAL UNMET IF :
 Participate in  Assess site of impaired inflammation and the Patient has slow pace of
prevention measures tissue integrity and its body’s immune system recovery and shows signs of
and treatment program condition. response to localized infection such as redness,
such as maintaining tissue trauma or itching/pain and disocmfort,
clean and intact impaired tissue moisture around the wound
dressing integrity. area with discharge and does
 Understand importance nit comply to some of the
of cleaning the wound medical and nursing
area and keeping the interventions.
 These findings will
wound dry give information on
 Verbalize understaning extent of the impaired
and feelings about the tissue integrity or
condition  Assess characteristics injury. Pale tissue color
of wound, including is a sign of decreased
color, size (length, oxygenation. Odor may
LTO : width, depth), drainage, be a result of presence
After 3 days of Nursing and odor. of infection on the site;
Intervention the client and it may also be coming
significant other will be able from a necrotic tissue.
to: Serous exudate from a
 Demonstrate wound is a normal part
behaviours to promote of inflammation and
healing and prevent must be differentiated
complication recurrent from pus or purulent
 Displays progressive discharge, which is
improvement in wound present in infection.
lesion healing as
evidenced by no  Pain is part of the
redness, no swelling, normal inflammatory
no abnormal process. The extent and
discharges, pinkish depth of injury may
wound area, and no affect pain sensations.
presence of
itching/pain or
 The patient who
discomfort . scratches the skin in
attempts to alleviate
 Assess the patient’s extreme itching may
level of distress.
open skin lesion and
increase risk for
PASCUA, DWENA MAE J
PR ANNEX II 7-5PM (JULY 29-31, 2021)

NCP PROPER
REFERENCES:

Wayne, G. (2019, March 20). Impaired tissue (Skin) integrity – Nursing diagnosis & care plan. Nurseslabs. https://nurseslabs.com/impaired-tissue-integrity/
Nurse’s Pocket Guide,Diagnoses, PrioritiizedInterventions, andRationales. M. Doenges,M. Moorhouse, A. Murr.12 th Edition