Jundale G.

Batbatan BSN-III Section: B

NURSING CARE PLAN
Problem: Open burn wounds
Nursing Diagnosis: Risk for infection related to loss of skin barrier and impaired immune response.
Taxonomy: Health perception/Health management pattern.
Cause Analysis: Tissue destruction results from the coagulation, protein denaturation, or ionization of cellular contents.
CUES OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

Subjective: Short term objective: Independent:

The patient verbalize:
Unsa maning sunuga oy
dugay kaayo mauga sigig ga
duga lami kaayo tilaan he he
he… Sige na nalang ta ug
trapo ani kapoy kaayo unya
pagkataud-taud gabasa napod
trapo napod hay
kakapoy.Wala pa ra ba tung
tigtrapo ug tigtabang nako.
Manimaho na gyud ko ani ug
samot.
Objective:
(Not applicable; presence of
signs and symptoms
establishes an actual
diagnosis.)
After 8 hours of duty the Open
burn wound will protected
from contamination of
infectious microorganism that
may affect the wound healing
process. And the burn will be
monitor from any unusual
development and it will be
free of purulent exudates and
debris.
Long term objective:
After 3 days of duty the
patient condition will be
protected from localized or
systemic infection and the
patient will appreciate the fast
healing process of the open
burn wound.
Implement appropriate isolation techniques as
indicated.
Emphasize/model good handwashing technique
for all individuals coming in contact with patient.
Use gowns, gloves, masks, and strict aseptic
technique during direct wound care and provide
sterile or freshly laundered bed linens/gowns.
Provide special care for eyes, e.g., use eye covers
and tear formulas as appropriate.
Examine wounds daily, note/document changes
in appearance, odor, or quantity of drainage.
Examine unburned areas (such as groin, neck
creases, mucous membranes) routinely.
Monitor vital signs for fever, increased
respiratory rate/depth in association with changes
in sensorium, presence of diarrhea, decreased
platelet count, and hyperglycemia with
glycosuria.
Dependent:
Administration of medication depends on
physicians order
-Minimize risk of cross-contamination and spread
of bacterial contamination.
-Prevents cross-contamination; reduces risk of
acquired infection.
-Prevents exposure to infectious organisms.
This measures reduce potential bacterial
colonization of burn wound.
-Eyes may be swollen shut and/or become
infected by drainage from surrounding burns
-Identifies presence of healing (granulation
tissue) and provides for early detection of burn-
wound infection.
-Opportunistic infections (e.g., yeast) frequently
occur because of depression of the immune
system and/or proliferation of normal body flora
during systemic antibiotic therapy.
-Indicators of sepsis (often occurs with full-
thickness burn) requiring prompt evaluation and
intervention.

References: Nursing Care Plans: Guidelines for individualizing patient care 6th edition. Doenges, M &Moorhouse, MF