Assessment

Objective:
- 74.5% BSA
2nd degree
burn on
cheeks,
jawline, both
upper and
lower
extremities,
abdomen
and chest.
- Presenting
features of
wounds are
blister
formation
anderythem
a.

Nursing
Diagnosis
Impaired
skin
integrity
related to
trauma
[burn
injuries]

Scientific
Analysis
Burns are
characterized by
severe skin
damage in
which many of
the affected
cells die.
Depending on
the cause and
degree of injury,
most people can
recover from
burns without
serious health
consequences.
Second-degree
burns are more
serious because
the damage
extends beyond
the top layer of
skin. This type
of extensive
damage causes
the skin to
blister and
become
extremely red
and sore. Some
blisters pop
open, giving the

Goals/Objectives

Intervention

After 1 hour of
intervention the
patient will:
- Participate in
prevention
measures and
treatment
program of
wound care
Long term goal:
- Demonstrate
tissue
regeneration.
- Achieve timely
healing of
burned areas.

Assist in
wound care.

Periodically
monitor site
of wound.

Remove wet
and soiled
linens and
clothing.
Maintain
linens wrinkle
free.
Emphasize
importance
of good
hygiene,
wound care
and wound
dressing
Encourage
diet that has
high amounts
of vitamins A,
C, D and
increased

Rationale

Evaluation

To be able to After 1 hour

assess the
of
wound and
intervention
ensure
the patient
asepsis in
will:
wound care. - Participate in
To identify
prevention
risk for
measures
infection and
and
monitor
treatment
wound
program of
healing.
wound care
To prevent
Long term
infection and goal:
further skin
- Demonstr
damage.
ate tissue
Minimize the
regenerati
risk of skin
on.
ulcerations
- Achieve
To prevent
timely
infection and
healing of
to enhance
burned
understandin
areas.
g and
cooperation.
To provide a
positive
nitrogen
balance to
aid in skin
and tissue

burn a wet
appearance.

protein
intake.

healing and
to maintain
general good
health.

Discuss
importance
of early
detection of
skin changes
and/or
complications
.
Emphasize
importance
of adequate
rest periods
and
immobilizatio
n of affected
body part.

Enhances
patients
understandin
g and
cooperation.

Encourage
patient to
verbalize
feelings and
discuss how
or if it affects
self-esteem.

Rest
decreases
bodys
overall
demand in
oxygen and
promotes
wound
healing
Increases
patients selfesteem and
to help
patient deal
with the
situation.

Maintain
dressings over
newly grafted
area and/or
donor site as
indicated: me
sh, petroleum,
non adhesive.

Areas may be
covered by
translucent,
nonreactive
surface
material
(between
graft and
outer
dressing) to
eliminate
shearing of
new
epithelium
and protect
healing
tissue.