I.

INTRODUCTION

A burn is an injury caused by heat, cold, electricity, chemicals, light or

radiation. Statistically, it is the second highest unintentional cost of human life
behind automobile accidents.[1] Burns can be highly variable in terms of the tissue
affected, the severity, and resultant complications. Muscle, bone, blood vessel,
epidermal tissue can all be damaged with subsequent pain due to profound injury
to nerve endings. Depending on the location affected and the degree of severity,
a burn victim may experience a wide number of potentially fatal complications
including infection, electrolyte imbalance and respiratory distress. Beyond
physical complications, burns can also result in severe psychological and
emotional distress due to scarring and deformity

The most common system of classifying burns categorizes them as first-,

second-, or third-degree. Sometimes this is extended to include a fourth or even
up to a sixth degree, but most burns are first- to third-degree, with the higher-
degree burns typically being used to classify burns post-mortem. The following
are brief descriptions of these burns:

• First-degree burns are usually limited to redness (erythema), a white

plaque, and minor pain at the site of injury. These burns usually extend
only into the epidermis.
• Second-degree burns additionally fill with clear fluid, have superficial
blistering of the skin, and can involve more or less pain depending on the
level of nerve involvement. Second-degree burns involve the superficial
(papillary) dermis and may also involve the deep (reticular) dermis layer.
• Third-degree burns are which most of the epidermis is lost. They
additionally have charring of the skin, and sometimes produce hard
eschars. An eschar is a scab that has separated from the unaffected part
of the body. These types of burns are often considered painless, because
nerve endings have been destroyed in the burned areas. However, there
is in reality a significant amount of pain involved in a third degree burn.
 Hair follicles and sweat glands may also be lost. Third degree burns result
in scarring. Elastic banding of the skin can smooth the scarred skin. Third
degree burns over large surface areas are often fatal.
• Fourth-degree burns damage bone tissue and may result in a condition
called compartment syndrome, which threatens the life of the limb.
• Fifth-degree burns are burns in which which most of the hypodermis is
lost, charring and exposing the muscle underneath. Sometimes, fifth-
degree burns can be fatal.
• Sixth-degree burns are burn types in which almost all the muscle tissue
in the area is burned away leaving almost nothing but charred bone.
Often, sixth-degree burns are deadly. Sixth-degree burns are the highest
in the burn category.

II. HEALTH HISTORY

Profile of the patient

A. Profile of the Patient

Name of Patient : ? Sex F Age 2 Religion Roman Catholic

Civil Status: single Income ------- Nationality Filipino

Date Adm. 1-29-08 Time 8:45 pm Informant ___________

Temperature 39.5 °F Pulse Rate 92bpm Resp. Rate 35cpm

B. Family and personal health history

This is a case of a 2 y.o. female child, Filipino, Roman Catholic born in ?,

currently residing at ?was admitted for the first time due to burn injury.
Born to a 26 years old, G4P4 mother who had no prenatal check-up done, no
medication taken a supplement, and no maternal illness incurred during the
course of pregnancy.

C. Chief complaint

The patient is diagnose of Superficial partial thickness burn 33% TBSA at

the back perineum, buttocks and lower extremities.

III. DEVELOPMENTAL DATA

In Piaget’s Developmental theory the patient is in Pre-operational stage

(Toddler and Early Childhood). In this period (which has two substages),
intelligence is demonstrated through the use of symbols, language use
matures, and memory and imagination are developed, but thinking is done in
a nonlogical, nonreversable manner. Egocentric thinking predominates

During the anal stage, Freud believed that the primary focus of the libido
was on controlling bladder and bowel movements. The major conflict at this
stage is toilet training--the child has to learn to control his or her bodily needs.
Developing this control leads to a sense of accomplishment and
independence.
According to Freud, success at this stage is dependent upon the way in which
parents approach toilet training. Parents who utilize praise and rewards for
using the toilet at the appropriate time encourage positive outcomes and help
children feel capable and productive. Freud believed that positive experiences
during this stage served as the basis for people to become competent,
productive, and creative adults.

However, not all parents provide the support and encouragement that
children need during this stage. Some parents' instead punish, ridicule, or
shame a child for accidents. According to Freud, inappropriate parental
responses can result in negative outcomes. If parents take an approach that
 is too lenient, Freud suggested that an anal-expulsive personality could
develop in which the individual has a messy, wasteful, or destructive
personality. If parents are too strict or begin toilet training too early, Freud
believed that an anal-retentive personality develops in which the individual is
stringent, orderly, rigid, and obsessive.

IV. MEDICAL MANAGEMENT

A. Medical order and rationale
DOCTORS ORDER RATIONALE
01-29-08
 Please admit at A2R under  to provide patient appropriate
the service SS III (burns) and immediate health care
 please secure consent to care  to secure patients care
 TPR every 4hours  to monitor patients condition
 diet as to age  to provide efficient nutrients
 IVF: plain LR I 1L at 35cc/hr  to substitute for fluid loss
 labs: CBC, Chest PA, Au, Na,  to check patients condition and
K, Crea know any abnormalities
 meds
1. ceftazolin 150 mg IVTT every *  to prevent infection
hours
2. Ranitidine 10 mg IVTT every 8  for healing an prevention of lcer
hours
3. Paracetamol 250/5 3ml every 4  for fever
hour
 I & O every shift  to monitor if I &O is within
normal range
 daily wound care, apply  to prevent further infection
bactroban
01-30-08
 diet for age  for proper nutrition
  v/s every 4H and record on a
separate sheet pls
 monitor I&O and record every
shift
 shift with PLR 1L at 30cc/hr
 change dressing
01-31-08
 diet for age
 continue v/s monitoring
 pls. weight diaper of patient
every shift
 IVFTF: PLR 1L at 30cc/hr
 change dressing
 attach lab result without fail
02-01-08
 IVFTF: Plain LR 1L at 30cc/hr
 cont. meds
 pls. follow-up lab results, if no
result then pls. repeat all lab
request
 change dressing
 shift paracetamol po to IV at
120 mg IVTT every 4H RTC
02-02-08
 re-insert IVF
 IVFTF: plain LR 1L @ 30cc/hr
 Repeat CXR-APL now
 Continue meds
 to monitor vital signs of patient
 to check if I&O is within normal
range
 to provide fluid and electrolyte\
 to prevent infection
 for proper nutrition
 to monitor v/s is in normal
range
 to monitor patients output
 to provide fluid and electrolyte
 to prevent infection
 to monitor lab result properly
 for fluid and electrolyte
 for healing
 to follow-up lab result
 to prevent infection
 to treat fever
 to continue IVF treatment
 provide fluid and electrolyte
 to check chest X-ray
 to continue treatment
  Change dressing  to prevent infection
 May give paracetamol  for fever
100mg/ml 1.2 ml RTC
02-03-08
 IVFTF: plain LR 1L @ 30cc/hr  provide fluid and electrolyte
 Continue meds  to continue treatment
 Dressing done  to prevent infection
 Shift cefazolin to ceftazidine  for antibiotic treatment
265mg IVTT every 8H
 Will endorse patient to respi  for co-management
service (Dr. Austria/Aranggo)
02-04-08
 IVFTF: plain LR 1L @ 30cc/hr  provide fluid and electrolyte
 Continue meds  to continue treatment
 Dressing done  to prevent infection
02-05-08
 Please re-insert IVF  to continue IVF treatment
 IVFTF: plain LR 1L @ 30cc/hr  provide fluid and electrolyte
 Continue meds  to continue treatment
 Repeat CBC today  for lab study
B. Drug Study
Generic Date Classification Dose/ Mechanism Specific Contra- Side Nursing
Name of Ordered Frequenc of Action Indication indication Effects/ Precaution
Ordered y/ Route Toxic
Drug Effects

Oxacillin 02-03-08 Antibiotics 10 mg Bind to Treatment of Hypersensi Diarrhea, Assess

penicillinase IVTT bacterial cell the following tivity to nausea, patient for
resistant every 8 wall leading infections due penicillins drug infection
penicillin hours to cell death to penicillinace induced appearance
producing hepatitis, of wound,
streptiyloccoci: vomiting, sputum,
respiratory tract intestinal urine, &
infectious, nephrititis, stool at
sinusitis, skin & uricaria. beginning
skin structure and
infections. throughout
therapy.
Obtain
history
before
initiating
therapy to
determine
previous use
of &
reactions to
penicillins.
Generic Date Classification Dose/ Mechanism Specific Contra- Side Nursing
Name of Ordered Frequenc of Action Indication indication Effects/ Precaution
Ordered y/ Route Toxic
Drug Effects

ranitidine 01-29-08 Histamine2 10 mg Competitivel Short term Contraindic Derma: Take drug
antagonist IVTT y inhibits the treatment of ated with rash, with meal
every 8 action of active duodenal allergy to alopecia. and at
hours histamine at ulcer. ranitidine. CNS: bedtime.
the h2 Treatment of Use headache, Therapy
receptor heartburn, acid cautiously malaise, may
basal gastric ingestion, sour with dizziness, continue for
acid stomach. impaired somnolenc 4-6 wks or
secretion renal or e, insomia, longer
that is hepatic vertigo
stimulated function
by food
insulin,
histamine,
cholinergic
antagonist,
gastrin and
pentagastrin
Generic Date Classification Dose/ Mechanism Specific Contra- Side Nursing
Name of Ordered Frequenc of Action Indication indication Effects/ Precaution
Ordered y/ Route Toxic
Drug Effects

ceftazidin 02-03-08 Antibiotics 265 mg Bind to Dermatologic Contraindi Diarrhea, Report

e IVTT bacterial cell infection cause cated with nausea, severe
every 8 wall leading by P. allergy to drug diarrhea,
hours to cell death aeruginosa, S. cephalosp induced difficulty in
Aureus, E. Coli. orins or hepatitis, breathing,
penicillin vomiting, unusual
intestinal tiredness or
nephrititis, fatigue, pain
uricaria. at injection
site.
V. PATHOPHYSIOLOGY

Appreciating the major differences between burn management in children and

adults is important. Children have nearly 3 times the body surface area (BSA)–
to–body mass ratio compared to adults. Fluid losses are proportionately higher in
children than in adults. Consequently, children have relatively greater fluid
resuscitation requirements and more evaporative water loss than adults.

Children younger than 2 years have thinner layers of skin and insulating
subcutaneous tissue than older children and adults. As a result, they lose more
heat and water than adults do, and they lose these more rapidly than adults. In
very young children, temperature regulation is partially based on nonshivering
thermogenesis, which further increases metabolic rate, oxygen consumption, and
lactate production. In addition, because of disproportionately thin skin, a burn that
may initially appear to be partial thickness in a child may instead be full thickness
in depth. Thus, the child's thin skin may make initial burn depth assessment
difficult.
VI. NURSING ASSESSMENT
NURSING SYSTEM REVIEW CHART
Name:____x ________________________________________ Date:__02-04-08____
Temp.:_39.5 C____ Pulse Rate:_92bpm___ Height:_50cm___ Weight:_7 kgs_____
INSTRUCTIONS: Place an [X] in the area of abnormality. Comment at the space provided. Indicate the location of the
problem in the figure using [X].

EENT:
[ ] impaired vision [ ] blind [x] pain __________________
[ ] reddened [ ] drainage [ ] gums __________________
[ ] hard of hearing [ ] deaf [ ] burning __edema___________
[ x] edema [ ] lesion [ ] teeth __________________
Assess eyes, ears, nose throat for abnormalities. __________________
[ ] no problem __________________
X ______
RESPIRATORY: __________________
[ ] asymmetric [ ] tachypnea [ ] apnea __________________
[ ] rales [ ] cough [ ] barrel chest __________________
[ ] bradypnea [ ] shallow [ ] rhonchi __________________
[ ] sputum [ ] diminished [ ] dyspnea __________________
[ ] orthopnea [ ] labored [ ] wheezing __________________
[ ] pain [ ] cyanotic __________________
Assess resp. rate, rhythm, pulse blood breath sounds, comfort __________________
[ x] no problem __________________
__________________
CARDIOVASCULAR: __________________
[ ] arrhythmia [ ] tachypnea [ ] numbness __________________
[ ] diminished pulses [ ] edema [ ] fatigue __________________
[ ] irregular [ ] bradycardia [ ] murmur __________________
[ ] tingling [ ] absent pulses [ ] pain __________________
Assess heart sound, rate, rhythm, pulse, blood pressure. _plain LR 1L @30cc/hr
circulation, fluid retention, comfort __________________
[ ] no problem __________________
__________________
GASTROINTESTINAL TRACT: __________________
[ ] obese [ ] distention [ ] mass __________________

[ ] dysphagia [ ] rigidity [ ] pain __________________

Assess abdomen, bowel habits, swallowing bowel sounds, comfort. __________________
[x] no problem __________________
__________________
GENITO-URINARY AND GYNE: __________________
[ ] pain [ ] urine color [ ] vaginal bleeding __________________
[ ] hematuria [ ] discharge [ ] nocturia _____________ _____
assess urine frequency, control, color, odor, __________________
comfort, gyne bleeding, discharge __________________
[x] no problem __________________
__________________
NEURO: ___burn___________
[ ] paralysis [ ] stuporous [ ] unsteady __________________
[ ] seizures [ ] lethargic [ ] comatose __________________
[ ] vertigo [ ] tremors [ ] confused ____burn__________
[ ] vision [ ] grip __________________
assess motor, function, sensation, LOC, strength __________________
grip, gait, coordination, speech ___burn_ __________
[x] no problem __________________

__________________
MUSCULOSKELETAL AND SKIN: __________________
[ ] appliance [ ] stiffness [ ] itching __________________
[ ] petechiae [x] hot [ ] drainage __________________
[ ] prosthesis [ ] swelling [ ] lesion __________________
[ ] poor turgor [ ] cool [ ] deformity __________________
[ ] wound [ ] rash [ ] skin color
[ ] flushed [ ] atrophy [x] pain
[ ] ecchymosis [ ] diaphoretic [ ] moist
assess mobility, motion, gait, alignment, joint function
skin color, texture, turgor, integrity
[ ] no problem
NURSING ASSESSMENT II
SUBJECTIVE OBJECTIVE
COMMUNICATION: [ ]Glasses [ ]
[ ]Hearing loss Comments “dili na languages
[x]Visual changes lagi kakita iyang [ ]Contact lenses [ ]
[ ]Denied isa ka mata kay hearing aid
Naghubag” R L
Verbalized by the Pupil size 2-3 mm □speech difficulties
Father of the Reaction PERRLA
patient
OXYGENATION:
[ ]Dyspnea Comments: “wala Resp. [x] regular [ ]irregular
[ ]Smoking history gaubo akong anak” Described: Breathing are regular
[ ]Cough as verbalize by the
[ ]Sputum father R equal expansion
[x]denied L equal expansion
CIRCULATION: Heart rhythm [x] regular □ irregular
[ ]Chest pain Comments: “sakit Ankle edema ___none_________
[x]Leg pain daw ang iyang tiil Pulse Car. Rad. DP. Fem*
[ ]Numbness of sa may sunog dapit” R + + + +
Extremities as verbalized by L + + + +
[ ]Denied patients father Comments: all pulse are palpable
*If applicable
NUTRITION:
Diet diet for age_ [ ]Dentures [ x ]none
[ ]N [ ]V Comments:
Character ” kusog pa man Full partial with
[ ] Recent change in giyapon siya patient
Weight, appetite mukaon” Upper [x] [ ] [ ]
[ ]Swallowing verbalized by Lower [x] [ ] [ ]
Difficulty the patients
[x]denied father
ELIMINATION:
Usual bowel pattern urinary frequency Comments Bowel sounds
1 x a day________ diaper_____ Patient has irregular audible
[ ]Constipation [ ]urgency Elimination process Abdominal
Remedy [ ]dysuria distention
None [ ]hematuria Present □yes □no
date of last BM [ ]Inconsistence Urine* (color,
02-05-08 [ ]Polyuria consistency, Odor)
[ ]Diarrhea [ ] foly in place _______________
Character [x ]denied ___no foley in __
___placed_______
_______________
If foley is in place
 Bfiefly described the patient’s ability
MGT. OF HEALTH & ILLNESS: to follow treatments (diet, meds, etc.)
[ ]Alcohol [x]denied for chronic health problems (if
(amount frequency) present)
______none_____________ The patient is closely monitored and
□SBE Last Pap Smear n/a compliant to medications.
LMP__n/a__________
SKIN INTEGRITY:
□Dry Comments “wala man Dry cold pale
□Itching sad kapangatul ang Flushed x warm
□Other iyang lawas ”as Moist cyanotic
□denied by the patients *rashes, ulcers, decubitus(described
father size, location, drainage) superficial
partial thickness burn.
ACTIVITY/SAFETY:
[ ]Convulsion Comments: “dili LOC and orientation Patient is highly
[ ]Dizziness lagi siya maka- conscious and well oriented
[x]Limited motion lihok-lihok kay Galt: [ ]walker [ ]cane [
Of joints sakit daw” as ]others
Limitation in verbalized by the [x]Steady [ ]unsteady_______
ability to patients father [ ]Sensory and motor losses in face
[x]ambulate or extremities
[x]bathe self No sensory or motor losses in
[ ]other extremities
[ ]denied [ ]ROM limitations Patient has
limited range of motion due to burn
injury
COMFORT/SLEEP/AWAKE:
[x]Pain Comments: “sakit [x]Facial grimaces
(location) lagi ang parte sa [ ]Guarding
Frequency lawas na nasunog” [x]Other signs of pain Verbalization of
Remedies) verbalized by the pain and crying
[ ]Nocturia patients father [ ]Siderail release form signed (60+
[ ]Sleep difficulties years)
[ ]denied Not applicable
COPING:
Occupation none Observed non-verbal behavior
Members of Household 6 patient is compliant to this treatment
Most supportive person father plan

the person and his contact number

that can be reach any time father
 SPECIAL PATIENT INFORMATION

54 kg daily weight none PT/OT N/A

130/80 mmhg BP q Shift none Irradiation
Not taken Neuro vs Urinalysis Urine test
routine urinalysis
Not taken CVP/SG. Reading N/A none 24 hour urine
collection
Date Diagnostic/Laborator Date Date I.V: Date
ordered y done ordered Fluids/Blood Disc.
Exams
Jan.29, hematology Jan.31,
2008 2008
Jan.29, Chest x-ray Jan.31,
2008 2008
VII. NURSING MANAGEMENT

ASSESSMENT NURSING OBJECTIVE INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS

Subjective: Risk for At the end of >monitor v/s, cvp. Note >serves as a guide
defiecient fluid 8 hours the capillary refill and to fluid replacement
“nahadlok gali mi volume r/t loss patient will strength of peripheral needs and assass
basig of fluid demonstrate pulses cardiopulmonary
madehydrate Through improved response
siya tungod sa abnormal fluid balance >monitor urinary output >generally fluid
iyang mga route like burn as evedince and specifies gravity. replacement should
sunog”as wounds. by Observe urine color and be titrated to ensure
verbalized by the individually hematest as indicated average urinary
father adequate output of 30-
urinary output 50ml/hr(in adults)
with normal >estimate wound >increase capillary
specific drainage and insensible permeability, protein
gravity,stable losses shift, inflammatory
v/s, moist process and
Objective: mucous evaporative losses
membrane greatly affect
- burn wonds
circulatory volume
- dry mucous and urinary output
>observe gastric >stress ulcer occurs
membrane
distention, tarry stool in up to half of all
severely burn client
>administer medication >to enhance urinary
as indicated: output and prevent
diuretics necrosis
ASSESSMENT NURSING OBJECTIVE INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS

Subjective: Risk for At the end of >monitor v/s, cvp. Note >serves as a guide At the end of 8
defiecient fluid 8 hours the capillary refill and to fluid replacement hours the
“nahadlok gali mi volume r/t loss patient will strength of peripheral needs and assass patient was
basig of fluid demonstrate pulses cardiopulmonary demonstrate
madehydrate Through improved response improved fluid
siya tungod sa abnormal fluid balance >monitor urinary output >generally fluid balance as
iyang mga route like burn as evedince and specifies gravity. replacement should evedince by
sunog”as wounds. by Observe urine color and be titrated to ensure individually
verbalized by the individually hematest as indicated average urinary adequate
father adequate output of 30- urinary output
urinary output 50ml/hr(in adults) with normal
with normal >estimate wound >increase capillary specific
specific drainage and insensible permeability, protein gravity,stable
gravity,stable losses shift, inflammatory v/s, moist
v/s, moist process and mucous
Objective: mucous evaporative losses membrane
membrane greatly affect
- burn wonds
circulatory volume
- dry mucous and urinary output
>observe gastric >stress ulcer occurs
membrane
distention, tarry stool in up to half of all
severely burn client
>administer medication >to enhance urinary
as indicated: output and prevent
Diuretics necrosis
ASSESSMENT
NURSING OBJECTIVE INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE: Acute pain r/t At the end of >cover wound as soon >temperature At the end of 8
“sakit daw kayo destruction of 8 hours the as possible unless changes and air hours the
iyang mga sunog skin/ tissue patient will be open-air exposure burn movement can cause patient was be
samot na kung edema able to report care method required great pain to expose able to report
malihok” formation reduced pain, nerve endings reduced pain,
verbalized by the display >elevate burned >elevation may display relaxed
father relaxed facial extremities require initially to facial
expression reduce edema expression
participates in formation participates in
OBJECTIVE: activities and > maintain comfortable >temperature activities and
-report of pain sleep/rest environmental regulation may be sleep/rest
- distraction/ appropriately. temperature provide lost with major burn. appropriately.
guarding heat lamp, heat External heat
ASSESSMENT NURSING OBJECTIVE INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE: Risk for at the end of >implement dependent on at the end of 8
“ginahilantan infection r/t 8 hours the appropriate isolation type/extent of wound hours the patient
lagi ni siya, ug inadequate patient will technique as indicated and the choice of was be able to
basig primary be able to wound treatment achieve timely
mainfectiction defense achieve > emphasize/model >prevents cross wound healing
siya tungod sa destruction of timely wound good handwashing contamination, free from
inyang mga skin barriers healing free technique for all reduce risk of exudates and
sunog” from individuals coming in acquired infection was afebrile
verbalized by exudates contact with client
the father and be >use gown, gloves, >prevent exposure
afebrile mask and strict aseptic to infectious
OBJECTIVE: technique during direct organism
-febrile- 39.5 C wound care and
-break in skin provide sterile or
surface freshly laundrered bed
linens/gowns
>monitor and limit >prevebt cross
visitors, if necessary. If contamination from
isolation is used, visitors, concern for
explain procedure to risk of infection
visitors. should be balanced
against client needs
for family support
and socialization
>place IV/ invasive >decrease risk of
lines in non burned infection at insertion
areas site
 “ginahilantan lagi ni siya, ug basig mainfectiction siya tungod
sa inyang mga sunog” verbalized by the father
S
-febrile- 39.5 C
-break in skin surface
O
Risk for infection r/t inadequate primary defense destruction of
A skin barriers

LONGTERM: at the end of 8 hours the patient will be able to

P achieve timely wound healing free from exudates
SHORT TERM: at the end of 1 hour the patient will be afebrile

1. implement appropriate isolation technique as indicated

2. emphasize/model good handwashing technique for all

individuals coming in contact with client

3.use gown, gloves, mask and strict aseptic technique during

direct wound care and provide sterile or freshly laundrered bed
linens/gowns
I
4. monitor and limit visitors, if necessary. If isolation is used,
explain procedure to visitors.

5. place IV/ invasive lines in non burned areas

at the end of 8 hours the patient was be able to achieve timely

wound healing free from exudates and was afebrile
E

B. actual nursing management

“sakit daw kayo iyang mga sunog samot na kung malihok”
 S verbalized by the father

-report of pain
- distraction/ guarding behavior
O
-anxiety
-fear
-restlessness
-crying

Acute pain r/t destruction of skin/ tissue edema formation

A

LONGTERM: At the end of 8 hours the patient will be able to

P report reduced pain.
SHORT TERM: at the end of 2 hours the patient will be able to
display relaxed facial expression participates in activities and
sleep/rest appropriately.
1. cover wound as soon as possible unless open-air exposure
burn care method required

2. elevate burned extremities

3. maintain comfortable environmental temperature provide

heat lamp, heat retaining body covering
I

4. change position frequently and assist with active passive

range of motion

5. administer analgesics(narcotics/ nonnarcotics) as indicated

At the end of 8 hours the patient was be able to report reduced

pain, display relaxed facial expression participates in activities
E
and sleep/rest appropriately

“nahadlok gali mi basig madehydrate siya tungod sa iyang mga

sunog”as verbalized by the father
S
- burn wonds
 O - dry mucous membrane

Risk for defiecient fluid volume r/t loss of fluid

A
Through abnormal route like burn wounds.

LONGTERM: At the end of 8 hours the patient will demonstrate

P improved fluid balance as evedince by individually adequate
urinary output with normal specific gravity
SHORT TERM: at the end of 2 hours the patient will be able to
have stable v/s, moist mucous

1. monitor v/s, cvp. Note capillary refill and strength of

peripheral pulses

2. monitor urinary output and specifies gravity. Observe urine

color and hematest as indicated

I
3. estimate wound drainage and insensible losses

4. observe gastric distention, tarry stool

5. administer medication as indicated:

Diuretics

At the end of 8 hours the patient was demonstrate improved

fluid balance as evedince by individually adequate urinary
E
output with normal specific gravity,stable v/s, moist mucous
membrane

VIII. Referrals and follow-up:

• Refer the client to the hospital for follow-up check-up

 • Follow-up check-up should be made to facilitate total healing process of
the patient

• Instruct the client to communicate with the doctor if some clarifications or

problem regarding the disease is needed.

• Follow-up the medications that the patient should maintain in order to

avoid improper medications

IX. Evaluation and Implications:

After two days of duty in the hospital and taking care of the patient, I was able to
help in the healing process of the patient and give some teaching regarding the
proper things to do in management of wound care and proper healing.

X. BIBLIOGRAPHY
http://www.nlm.nih.gov/medlineplus/burns.html
http://www.medicinenet.com/burns/article.htm
http://familydoctor.org/online/famdocen/home/healthy/firstaid/after-
injury/638.html

LICEO DE CAGAYAN UNIVERSITY

COLLEGE OF NURSING
NCM501202
A CARE STUDY
x
 Name of Client
Submitted to
x
Name of faculty
As Partial Requirement for NCM501x
Submitted by
x
Name of Student
RATING SCALE
A. Written WEIGHT RATING
I. introduction 5
a. overview of the case
b. objective of the study
c. scope and limitation of the study
II. Health History 5
a. profile of patient
b. family and personal health history
c. history of patients illness
d. chief complain
III. developmental data 5
IV. medical management 20
a. medical orders and rationale (10)
b. drug study (10)
V. Pathophysiology with anatomy and physiology 10
VI. Nursing assessment 10
VII. Nursing Management 30
a. Ideal nursing management (NCP) (10)
b. actual nursing management (SOAPIE) (20)
VIII. referral and follow-up 5
IX. Evaluation and implication 5
X. documentation 5
a. documentation of evidence of care for 1 week rotation
b. organization/grammar/bibliography
TOTAL SCORE 100
EQUIVALENT GRADE