NURSING DIAGNOSIS Objective: Risk for infection  With open related to burn wound destruction of that appears skin

barrier leathery secondary to  Skin color: red burns to brown  Presence of eschar  Laboratory values: Hgb- 10mg/dl Vital Signs: T= 36 C P=125 bpm R=30 cpm BP=130/90mmHg

ASSESSMENT

Short term: After 8 hours of rendering nursing intervention, the patient Cell damage will be able to verbalize understanding of and Destruction of skin willingness to follow layers up prescribed regimen Long term: After a week of rendering effective nursing intervention, the patient will be able to:  be free of sign and symptom r/t infection  demonstrate tissue regeneration and achieve timely wound healing as evidenced by: y moist skin y healing scar y free of exudates/discha rges

SCIENTIFIC EXPLANATION Burn injury

PLANNING

INTERVENTION  Monitor vital signs especially temperature

RATIONALE - Reflective of inflammatory process/ infection requiring evaluation and treatment - To evaluate presence/ character of infection.

EVALUATION Short term: After 8 hours of rendering nursing intervention, goal was met as evidenced by :  patient was able to verbalize understanding of and willingness to follow up prescribed regimen 

Note risk factors for occurrence of infection.  Emphasize/model good handwashing technique for all individuals coming in contact with the patient  Use strict aseptic technique during wound care  Prevent skin-toskin surface contact

Open burn wound

Risk for infection

- Prevents crosscontamination; reduces risk of acquired infection

Long term: After a week of rendering effective nursing intervention, goal was met as evidenced by:  absence of sign - Prevents exposure and symptom r/t to infectious infection organisms  demonstrated tissue regeneration and - Prevents achieve timely adherence to wound healing surface it may be as evidenced by: touching and y moist skin encourages proper y healing scar healing y free of

odor. note/document changes in appearance. or quantity of drainage  Clean the wound area with hydrogen peroxide .Water softens and aids in removal of dressings and eschar.Identifies presence of healing (granulation tissue) and provides for early detection of burn-wound infection .It promotes healing . .To control general infections and reduce risk of infection  Assist with debridement  Administer cefuroxime as ordered  Apply Silver sulfadiazine .Early excision is known to reduce scarring and risk for infection to facilitate healing .To promote healing y y exudates/dischar ges patient remained afebrile Hgb.y y be afebrile Laboratory values within normal range: Hgb=14-18 mg/dl  Examine wounds daily.16mg/dl Collaborative:  Remove dressings and cleanse burned areas in a hydrotherapy  Excise and cover burn wounds quickly .