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
around the however, any break in 2. Understand  Administered  For occurrence of around the wound.
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 3-4 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. around the demonstrate health
wound site. teaching given and
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/.