ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Deficient fluid Short term: Independent: Short term:

“Nauuhaw po volume related After 8 hours of -Reviewed laboratory data. To calculate degree After 8 hours of
ako.”, as to capillary nursing intervention, of fluid deficit. nursing intervention,
verbalized by the damage the patient will the patient had good
patient. secondary to demonstrate good -Wiped wet cotton balls with To moisten the lips. and normal I&O.
burn and normal I&O. water on the lips. goals met.
Objective:
- Dried Skin INFERENCE: Long term: -Provided oral care. To prevent from Long term:
- Dried lips Fluid loss starts After 1 day of injury of dryness. After 1 day of
and mucous immediately nursing intervention, nursing intervention,
- Increased after the burn the patient will -Controlled humidity and Regulate body the patient
body occurs, because maintain fluid ambient air. temp. maintained fluid
temperature heat damage volume at finctional volume at functional
(39.1 C) and increase the level as evidenced -Increased fluid intake as level as evidenced
increasing permeability of by moist lips and indicated. To rehydrate the by moist lips and
pulse rate the capillaries mucous, good skin body. mucous, good skin
(89bpm) which means turgor, and normal -Maintained moderate high turgor, and normal
- Paleness on that plasma is color of foot fingers. back rest position. Promote good color of foot fingers.
the foot able to leak out circulation. Goals met.
fingers of the blood -Established Fluid
- Imbalanced circulation. Resuscitation as required. To replace water
I&O. loss.
-Monitored I&O during the
shift.
To have baseline
Dependent: data for
-Administered IV fluids as per improvement.
doctor’s order.
Maintain fluid
Collaborative: volume.
-Referred to Laboratory for
Urine Specific Gravity, Blood
Volume
Review
improvement.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Infection related Short term: Independent: Short term:
“Kumakati po yung to loss of After 1 hour of -Hand washing and strict First line defense After 1 hour of
mga sugat ko.”, as protective nursing infection control done. against nursing
verbalized by the dermal barrier interventions, the transfer/spread of interventions, the
patient. from patient will microorganisms. patient understood
microorganisms understand -provided strict isolation. techniques and
Objective: secondary to techniques and Prevent cross lifestyle changes to
- Increased burn. lifestyle changes to contamination. promote wellness.
WBC (39) promote wellness. -Maintained sterile technique Goals met
- Greenish INFERENCE: in every procedure. To prevent cross
wounds at The patient has Long term: contamination. Long term:
the upper second degree After 2 days of -Cleansed the affected area After 2 days of
extremities burn with the nursing and changed dressing Reduce the nursing
- Redness on total TBSA of interventions, the regularly. microorganisms. interventions, the
the site of 51%. Our skin patient will have patient had
wound (integument) normalization of WBC -Instructed to increase fluid Help against decreased WBC,
- fever serves as the from 39 to 11 and intake as indicated. infection. from 39 to 18 and
protection from display timely wound displayed wound
any healing. -Encouraged to eat foods rich healing process.
microorganisms. in Vitamin C. Interacts with the Goals partially met.
And since her immune system
skin is and consumed
damaged, she quickly during
has no adequate Dependent: infections.
primary -Administered Antibiotic
defenses/protec drugs as per doctor’s order.
tion against The action of the
infections and Collaborative: drug is to kill
expose to -Referred to Laboratory for bacteria.
pathogens. CBC (WBC)
Review
improvement.