ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
INDEPENDENT:
SUBJECTIV Acute pain After 5
E: related to days >Provide bed cradle as > Elevation of linens off Goal met
destruction nursing indicated wounds may help reduce
“Masakit of intervention pain
talaga”as skin/tissues; , the patient > Wrap digits/extremities in > Position of function
verbalized edema will position of function reduces
by the formation participate (avoiding deformities/contractures
patient manipulatio in activities flexed position of affected and
n of injured and joints) using splints and promotes comfort.
tissues, e.g., sleep/rest footboards as necessary. Although flexed position
OBJECTIVE wound appropriatel of injured
: debridement y and joints may feel more
AEB display comfortable, it can lead to
>Pain rating distraction/g relaxed flexion
scale of 9/10 uarding facial contractures.
>distraction/ behaviors; expressions/ > Change position >Movement and exercise
guarding anxiety/fear body frequently and assist with reduce joint stiffness and
behaviors , posture active and muscle
>anxiety/fear restlessness passive ROM as indicated fatigue, but type of
, exercise depends on
>restlessness location and
extent of injury.
> Maintain comfortable >Temperature regulation
environmental temperature, may be lost with major
provide burns.
heat lamps, heat-retaining External heat sources may
body coverings. be necessary to prevent
chilling
>Reduces severe physical
> Provide medication and/or and emotional distress
place in hydrotherapy (as associated
appropriate) before with dressing changes and
performing dressing debridement
changes and debridement. >Enhances patient’s sense
>Involve patient in of control and strengthens
Assessment Diagnosis Planning Intervention Rationale Evaluation
Risk for After 5 >Implement appropriate >Dependent on Goal met
Objective: Infection r/t days of isolation techniques as type/extent of wounds and
inadequate nursing indicated. the choice of
> HR: 86 primary intervention wound treatment (e.g.,
>RR:20 defenses , patient will open versus closed),
>T: 37.3 secondary achieve > Examine wounds daily, > Identifies presence of
>HEENT: to burns timely note/document changes in healing (granulation
(+) abrasion wound appearance, odor, or quantity tissue) and
+ 2o over healing be of drainage provides for early
right free of detection of burn-wound
forehead purulent infection.
drainage or >Monitor vital signs for >Indicators of sepsis
>Chest: (+) erythema, fever, increased respiratory (often occurs with full-
axillary be afebrile rate/depth in association with thickness
burn 2o and be free changes in sensorium, burn) requiring prompt
degree of infection. presence of diarrhea, evaluation and
decreased platelet count, and intervention.
>4 o burn hyperglycemia with
(full glycosuria.
thickness
burn) right > Examine unburned areas > Opportunistic infections
hand (such as groin, neck creases, (e.g., yeast) frequently
&right mucous membranes) and occur
forearm vaginal discharge routinely because of depression of
the immune system and/or
proliferation of normal
body flora during systemic
antibiotic therapy.

> Prevent skin-to-skin >Prevents adherence to

surface contact (e.g., wrap
each
burned finger/toe separately;
do not allow burned ear to
touch scalp).
surface it may be touching
and
encourages proper healing.
 ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
INDEPENDENT:
SUBJECTIVE: Impaired Skin After 5 days Postoperative
“ Nasunog talaga Integrity, nursing Goal met
ang balat niya” [grafts] related intervention, > Elevate grafted area if > Reduces
as verbalized by to the patient will possible/appropriate. swelling/limits risk
the parentsw Disruption of achieve timely Maintain of graft separation.
skin surface healing of desired position and Movement of tissue
OBJECTIVE: with burned areas. immobility of area when under graft can
destruction of indicated dislodge it,
>HEENT: (+) skin layers interfering with
abrasion + 2o (full-thickness optimal healing.
over right burn) requiring
forehead grafting AEB > Maintain dressings > Areas may be
Absence of over newly grafted area covered by
>Chest: (+) viable tissue and/or donor translucent,
axillary burn 2o site as indicated, e.g., nonreactive surface
degree mesh, petroleum, material (between
nonadhesive graft and outer
>4 o burn (full dressing) to
thickness burn) eliminate
right hand shearing of new
&right forearm epithelium/protect
healing tissue.
>Keep skin free from
pressure > Promotes
circulation and
prevents
ischemia/necrosis
> Evaluate color of and
grafted and donor graft failure
site(s); note
presence/absence of > Evaluates
healing effectiveness of
circulation and
identifies
developing