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    FNCP Finaaaal

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    SoniaMarieBalanay
    The nursing care plan is for a client with impaired skin integrity related to a first degree burn on the anterior thorax caused by a flame burn. The goals are to maintain an intact wound with no redness after 8 hours and 3 days of nursing interventions. Interventions include assessing vital signs and the wound, administering medications, dressing the wound with appropriate barriers, encouraging diet and activity changes, and providing instructions on hand washing and wound care. The watcher's demonstration of health teaching and achievement of goals will be evaluated.

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    FNCP Finaaaal

    Uploaded by

    SoniaMarieBalanay
    635 views5 pages
    The nursing care plan is for a client with impaired skin integrity related to a first degree burn on the anterior thorax caused by a flame burn. The goals are to maintain an intact wound with no redness after 8 hours and 3 days of nursing interventions. Interventions include assessing vital signs and the wound, administering medications, dressing the wound with appropriate barriers, encouraging diet and activity changes, and providing instructions on hand washing and wound care. The watcher's demonstration of health teaching and achievement of goals will be evaluated.

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    FNCP

    Original Title

    FNCP-FINAAAAL (3)

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    The nursing care plan is for a client with impaired skin integrity related to a first degree burn on the anterior thorax caused by a flame burn. The goals are to maintain an intact wound with no redness after 8 hours and 3 days of nursing interventions. Interventions include assessing vital signs and the wound, administering medications, dressing the wound with appropriate barriers, encouraging diet and activity changes, and providing instructions on hand washing and wound care. The watcher's demonstration of health teaching and achievement of goals will be evaluated.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    635 views5 pages

    FNCP Finaaaal

    Uploaded by

    SoniaMarieBalanay
    The nursing care plan is for a client with impaired skin integrity related to a first degree burn on the anterior thorax caused by a flame burn. The goals are to maintain an intact wound with no redness after 8 hours and 3 days of nursing interventions. Interventions include assessing vital signs and the wound, administering medications, dressing the wound with appropriate barriers, encouraging diet and activity changes, and providing instructions on hand washing and wound care. The watcher's demonstration of health teaching and achievement of goals will be evaluated.

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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/.

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