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SAINT LOUIS UNIVERSITY

SCHOOL OF NURSING
Bonifacio Street, Baguio City

Nursing Care Plan


Submitted to:
Mrs. Rosemarie Pachao

Submitted by:
BALANAY, Sonia Marie L.
F. NCP PROPER
CUES EXPLANATION OF GOALS AND INTERVENTIONS RATIONALE EVALUATION ACTUAL
THE PROBLEM OBJECTIVES CRITERIA EVALUATION
Subjective: Situation analysis: STO: Dx: Fully met: The
 “Hindi naman Impaired skin After 8 hours of  Vital signs assessed  To establish baseline watcher will
po masakit”. integrity was due to nursing and recorded data. properly
the client tissue interventions, the demonstrate
Objective: trauma on the anterior watcher will be  Inspect the incision  Frequent assessment health teaching
 With dry and thorax caused by able to: every shift using can detect early signs given and with a
intact wound flame burn. 1. Demonstrate REEDA (redness, and symptoms of score of 2/2
dressing at proper way of edema, ecchymosis, infection. of the goals of
anterior thorax. wound care discharge, and LTO such as
 No redness, Health Implication: and proper approximation) maintain the
heat and The skin is a barrier to dressing. wound intact and
discharges infectious agents, Tx: no sign of redness
however, any break in 2. Understand  Administered  For occurrence of around the wound.
around the
dressing. the skin can readily the medications like pain.
 With good skin serve as a portal of importance of Ibuprofen. Partially met:
turgor and entry putting the caring the The watcher will
individual at risk for .
pinkish wound. properly
potential infections.  Carefully dress  To prevent infection. demonstrate health
nailbeds.
 With capillary (Fundamentals of LTO wounds. teaching given and
refill of 1-2 Nursing by Kozier, et. After 3 days of with the score of
 To protect wound
seconds. al.,7th edition, page nursing  Use appropriate 1/2 of the goals of
and or the
633) interventions, the barrier dressings, LTO such as
surrounding area.
Nursing watcher will be wound coverings, maintain the
Diagnosis: able: drainage appliance wound intact.
Impaired skin 1. Maintain the and skin protective
integrity related to wound intact. agents for open Not met:
tissue trauma wounds. The client will not
secondary to flame 2. No redness properly
burn (1st degree around the demonstrate health
burn on anterior wound site. teaching given and
thorax). with the score of
Ed:  To provide a 0/2 of the goals of
 Encourage the LTO.
positive nitrogen
watcher to increase
diet rich in Vitamin balance to aid in
C and E.
skin/tissue healing
and maintain
general good health.

 Encourage early  To promote


ambulation or circulation and
mobilization.
reduces risks
associate with
immobility.

 Encourage watcher  To promote wound


to increase protein
intake. healing.
 Instructed to keep  Moistures harbors
the dressing clean
bacteria and
and dry.
pathogen.

 Taught on proper  To prevent infection.


hand washing
before changing the
dressing or touching
the wound.
RERERENCES:
StudyLib. (2018). Impaired skin integrity related to tissue trauma. Priority Nursing Diagnosis. Retrieved from http://studylib.net/doc/6976670/priority-
nursingdiagnosis-impaired-skin-integrity-r-t-im.

Impaired Skin Integrity: Nursing Diagnosis & Care Plan. (2017, October 06). Retrieved from https://nurselab.com/impaired-skin-integrity/.