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    Impaired Skin Integrity

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    VINCE ONATO
    The nursing diagnosis was impaired skin integrity related to a burn on the patient's face. The goal was to decrease the patient's pain to below 5/10 within 8 hours by applying sterile dressings and administering antibiotics. Evaluation found the goal was met as pain decreased to 1/10. Upon discharge, the injury decreased in size and increased granulation tissue. The patient demonstrated understanding of the healing process and injury prevention plans.

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    Impaired Skin Integrity

    Uploaded by

    VINCE ONATO
    283 views2 pages
    The nursing diagnosis was impaired skin integrity related to a burn on the patient's face. The goal was to decrease the patient's pain to below 5/10 within 8 hours by applying sterile dressings and administering antibiotics. Evaluation found the goal was met as pain decreased to 1/10. Upon discharge, the injury decreased in size and increased granulation tissue. The patient demonstrated understanding of the healing process and injury prevention plans.

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    nursing care plan

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    impaired skin integrity

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    The nursing diagnosis was impaired skin integrity related to a burn on the patient's face. The goal was to decrease the patient's pain to below 5/10 within 8 hours by applying sterile dressings and administering antibiotics. Evaluation found the goal was met as pain decreased to 1/10. Upon discharge, the injury decreased in size and increased granulation tissue. The patient demonstrated understanding of the healing process and injury prevention plans.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    283 views2 pages

    Impaired Skin Integrity

    Uploaded by

    VINCE ONATO
    The nursing diagnosis was impaired skin integrity related to a burn on the patient's face. The goal was to decrease the patient's pain to below 5/10 within 8 hours by applying sterile dressings and administering antibiotics. Evaluation found the goal was met as pain decreased to 1/10. Upon discharge, the injury decreased in size and increased granulation tissue. The patient demonstrated understanding of the healing process and injury prevention plans.

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    ASSESSMENT EXPLANATION OF THE GOAL/OBJECTIVES IMPLEMENTATION RATIONALE EVALUATION

    PROBLEM
    S> “Nagsakit dayta buo The nursing diagnosis is STO: After 8 hours of Dx: STO: Goal met, After 8
    nga kannigid nga sakak Impaired Skin Integrity nursing intervention, the >Assess the site of impaired >Redness, swelling, pain, hours of nursing
    tissue integrity and its burning, and itching are
    pirmi ta nalaplap na” since our skin is our first patient will report altered condition indications of inflammation and
    intervention patient
    line of defense against pain at the site of tissue the body's immune system reports a pain scale of
    O> Facial Grimace noted threats from the external impairment and a pain response to localized tissue 1/10.
    > Local pain, having a pain environment. A break in scale of less than 5/10. trauma or impaired tissue
    scale of 5/10 tissue integrity is usually integrity.
    >Assess changes in body >Fever is a systemic
    > Tenderness on the burn repaired by the body very temperature and the patient’s manifestation of inflammation
    site well. However, there are level of pain and may indicate the presence
    > Guarding behavior on circumstances that it of infection. Pain is part of the
    the burn site doesn't repair it at all and normal inflammatory process.
    > Exposed skin, red in replaces the damaged Thx:
    Ind:
    color tissue with connective >Perform sterile dressing >To avoid the spread of
    > Vital signs are as tissue. When tissue technique during wound care infection on the affected site.
    follows: integrity is left untreated, >Apply wet dressing first, and >Saturating dressings will ease
    BP – 140/80 mmHg it could cause local or dry dressing after the removal by loosening
    BT – 36.9°C systemic infection. adherents and decreasing pain,
    especially with burns.
    PR – 81 bpm Dep:
    RR – 20 cpm > Administer antibiotics as per >To treat or prevent some
    SPO2 – 95% doctor’s order types of bacterial infection.
    They work by killing bacteria or
    preventing them from
    reproducing and spreading.
    NURSING DIAGNOSIS: > Monitor proper regulation of >To ensure that there is
    Impaired Skin Integrity IV fluid adequate fluid for the patient
    related to tissue trauma to avoid dehydration
    LTO: Upon discharge, Ed: LTO: Goal met, upon
    injured site will decrease >Instruct and educate the >To avoid complications of the discharge, the injured part
    patient to always perform injury and avoid the spread of
    in size and will increase proper hygiene and hand infection
    totally healed and
    granulation tissue, and washing technique decreased in size, and the
    patient will be able to patient demonstrates
    demonstrate >Educate the patient regarding >To have enough knowledge preparation plans for
    understanding of plan to the tissue healing processes for the patient to prevent safety and does have
    and to have planning for safety further injuries and to learn
    heal tissue and prevent and risks that might happen. about tissue healing and proper knowledge about his
    injury. wound care injury on how it will heal.
    Reference: https://nurseslabs.com/impaired-tissue-integrity/#signs_and_symptoms

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