NCMB 312 RLE

CASE SCENARIO:

BURN INJURY
Group 2
MEMBERS:
AGANAN, EDEN JOY CABILDO, JOHN VIRGILIO
AGOY, PATRICIA DAHALAN, FATIMA SUZERAIN
AGUSTIN, JAMES CHRISTIAN DEL MAR, JULIANN NICOLE
ALONZO, JOCELYN DELA CRUZ, MARIA STEPHANY
AMIN, JEFF EROL DELA VEGA, GIRLIE
AMPUAN, THOMAS ADRIAN DOCALLOS, MARY ELISE
ANDRES, JIREH DURAN, JAIMELYN
AQUI, CAMILLE ARIANNE EVANGELISTA, DIANE HERSHEY
ARGANDA, RACHEL GABRAL, ANDREA MAE
AVECILLA, JEOMARI ALEXIS GAMBITO, DANIELA GRACE
BUYOC, ANNE GELEN
TABLE OF CONTENTS:

1 INTRODUCTION

2 REVIEW OF RELEVANT PATIENT RECORDS AND HISTORY

EVALUATION RESULTS INTERPRETATION, ANALYSIS HEALTH

3
IMPLICATIONS & CLINICAL SIGNIFICANCE
 OBJECTIVE OF THE STUDY
BURN INJURY

CHAPTER 1

INTRODUCTION
 BACKGROUND OF THE STUDY
OBJECTIVE OF THE STUDY

The objective of the study is to

provide initial proper care
management to the patient, learn how
to assess wounds that include
estimating the depth and size of the
wounds, and manage for special
problems that may occur during the
procedure
 PURPOSE OF THE STUDY
BACKGROUND OF
THE STUDY

Nas is a 19 years old male who stoked a fire

in a wood-burning stove and was hurt by a
subsequent explosion. He was transported to
the local Burn ICU (BICU). He sustained a
total body surface area (TBSA) thermal
burn. Nas’s burns included bilateral full-
thickness circumferential burns to his arms,
hands, and right leg, anterior portion of
the left leg, feet, genitalia, and deep
partial-thickness burns to his whole head
and anterior trunk.
 SIGNIFICANCE OF THE STUDY
PURPOSE OF THE STUDY

The purpose of this study is to

generate a nursing care plan that
discusses burn injury, its degree
based on the severity, treatment, and
nursing management that would be
beneficial to the patient, the
family, and student nurses.

SIGNIFICANCE OF SIGNIFICANCE OF THE STUDY

TABLE OF CONTENTS
THE STUDY

The significance of this study is to

address the patients with burn
conditions. It will help people and
medical professionals to aid this
kind of condition and help in a way
that will take appropriate efforts to
reduce its mortality and morbidity.
 BURN INJURY

CHAPTER 2

REVIEW OF RELEVANT PATIENT

RECORDS AND HISTORY
DEMOGRAPHIC DATA
Name of Patient: Patient Nas
Sex: Male
Age: 19 years old
Religion: Roman Catholic
Civil Status: Married
Occupation: Student
Address: N/A
Nationality: Filipino
Date Admission: October 29, 2020 Time: 06:40 pm
Diagnosis: Thermal Burn Attending
Physician: Dr. Silver
REASON FOR SEEKING
HEALTH CARE

Chief Complaint:
Total body surface area (TBSA) thermal burn.
HISTORY OF PRESENT
ILLNESS
Character: Flamed thermal burn
Onset: Mins to hours
Location:
Bilateral arms and hands
Bilateral R Leg
Anterior L leg and feet
Genitalia
Head
Anterior trunk
Duration: The symptoms last for 2 weeks
Severity: 8/10 (2nd to 3rd degree burn)
Pattern: Continuous exposure to flame/Prolonged cooling down with water
Associated factors: Breathing problem
PAST MEDICAL HISTORY
Heredo-Familial History
There is no Heredo-Familial History in the patient’s
profile

Socio-Economic History
There is no Socio-Economic History in the patient’s
profile

Developmental History
There is no Developmental History in the patient’s profile
CHAPTER 3
EVALUATION RESULTS
INTERPRETATION,ANALYSIS HEALTH
IMPLICATIONS & CLINICAL SIGNIFICANCE
 COMPREHENSIVE PHYSICAL
EXAMINATION
General Appearance
The patient has a sustained total body surface
area thermal burn when he was rushed to BICU, his
arms, hands, and right leg, anterior portion of
the left leg, feet, genitalia was included in the
3rd-degree burn, while his whole head and the
anterior trunk was has a deep partial-thickness
burn.
 COMPREHENSIVE PHYSICAL
EXAMINATION
Vital signs
Temperature: 35.3 C
Normal Values: 36.1 C - 37.2 C
Interpretation: Below Normal
Pulse Rate: 98 bpm
Normal Values: 60-100bpm
Interpretation: Normal range of pulse rate
Respiratory rate: 24 cpm
Normal Values: 12-16 bpm
Interpretation: above normal (abnormal)
Blood Pressure: 130/90 mmHg
Normal Values:
Systolic: Less than 120mmHg
Diastolic: Less than 80mmHg
Interpretation: slightly elevated (abnormal)
 DIAGNOSTIC TESTS
Theoretically (Not specified in the case study)
White blood cell (WBC) count
Neutrophil percentage
Erythrocyte sedimentation rate (ESR)
C-reactive protein (CRP)

Diagnostic Test Results

There is no Diagnostic testing done on the
patient.
 REVIEW OF SYSTEM
Integumentary System
Patient Nas has experienced 73% total body surface
area (TBSA) thermal burn.
 REVIEW OF SYSTEM
Respiratory System
The respiratory system consists of all the organs
involved in breathing. Its primary function is gas
exchange between the external environments. This
exchange balances oxygenation of the blood with the
removal of carbon dioxide and other metabolic wastes
from the circulation. Respiratory system is divided
into upper respiratory tract and lower respiratory
tract.
 REVIEW OF SYSTEM
Digestive System
The digestive system is uniquely constructed to do its job of
turning your food into the nutrients and energy you need to
survive. And when it’s done with that, it handily packages your
solid waste, or stool, for disposal when you have a bowel
movement.
The patient was unable to eat due to his total body surface
area (TBSA) thermal burns. When escharotomies were completed and
patient Nas was stable, an enteral nasogastric tube was placed
in his left nares and feedings began. The patient was weaned
from the ventilator during his second week in the BICU, and
solid foods were introduced gradually.
 CHAPTER 4
SYNTHESIZE FRAMEWORKS,
INFERENCE, ACTION PLANS, AND
CASE REFLECTIONS
 ANATOMY
SKIN
the outer covering of the
body. The skin is the
largest organ of the
body, and it performs a
number of vital
functions. It serves as a
protective barrier
against microorganisms.
It is divided into 3
layers: the epidermis,
dermis and subcutaneous
layer.
 ANATOMY
CLASSIFICATION OF BURNS:

FIRST-DEGREE BURNS (SUPERFICIAL)

it affects only the outer layer of
skin, the epidermis. The burn site is
red, painful, dry, and with no
blisters. Mild sunburn is an
example.
 ANATOMY
CLASSIFICATION OF BURNS:
SECOND-DEGREE BURNS (PARTIAL
THICKNESS)
it involves the epidermis and
part of the lower layer of
skin, the dermis. The burn
site looks red, blistered,
and may be swollen and
painful.

 ANATOMY
CLASSIFICATION OF BURNS:
THIRD-DEGREE BURNS (FULL-THICKNESS)
destroy the epidermis and dermis.
They may go into the innermost layer
of skin, the subcutaneous tissue.
Because third-degree burns damage
nerve endings, you probably won’t
feel pain in the area of the burn
itself, rather adjacent to it. The
burn site may look white or blackened
and charred.
PATHOPHYSIOLOGY (THEORETICAL)
PATHOPHYSIOLOGY (CLIENT-BASED)
 DRUG GENERIC NAME: PROPOFOL

STUDY BRAND NAME: DIPRIVAN

DRUG CLASS: GENERAL ANESTHETICS

Propofol 40 mg IV every 10 seconds until onset
DOSAGE: >0.1-0.2 mg/kg/minute IV should immediately
follow
MECHANISM OF A short-acting anesthetic given for induction and
ACTION: maintenance of general anesthesia.
Induction and maintenance of general anesthesia,
USAGE:
and for sedation.
SIDE/ADVERSE EFFECT: None for this patient.

Patient must be intubated and ventilated.

NURSING Monitor: HR, ECG, Pulse Ox, BP.
Discard tubing after 12 hours.
CONSIDERATION: Maintain strict aseptic technique.
 DRUG GENERIC NAME: MORPHINE

STUDY BRAND NAME: ASTRAMORPH

DRUG CLASS: OPIOID ANALGESICS

Propofol 2.5-5 mg IV q4h as needed, infused over
Morphine DOSAGE: 4-5 minutes
MECHANISM Opium alkaloid acts as agonist at specific opioid
receptors in the CNS to produce analgesia, and
OF ACTION: sedation.
Indicated on patients with moderate to severe acute
USAGE: and chronic pain.

SIDE/ADVERSE EFFECT: None for this patient.

NURSING Dilute administer IV slowly.

Avoid antihistamines, sedatives,
CONSIDERATION: tranquilizers, during medication.
 DRUG GENERIC NAME: KETAMINE

STUDY BRAND NAME: KETALAR

DRUG CLASS: GENERAL ANESTHETICS

Propofol 1-4.5 mg/kg slow IV once
Morphine DOSAGE: >0.1-0.5 mg/min IV continuous infusion
Ketamine MECHANISM Depresses the central nervous system by blocking the
effects of the excitatory neurotransmitter, glutamic
OF ACTION: acid at the NMDA receptors.
Induction of anesthesia prior to administration of
USAGE: other general anesthetic agents.

SIDE/ADVERSE EFFECT: None for this patient.

NURSING Patient must be ventilated.

CONSIDERATION: Monitor cardiovascular system.
 DRUG GENERIC NAME: SILVER SULFADIAZINE

STUDY BRAND NAME: SILVADENE

DRUG CLASS: ANTIBACTERIALS

Propofol DOSAGE: 1% cream topical bid.
Morphine
MECHANISM Acts on the cell membrane and cell wall to produce
Ketamine OF ACTION: its bactericidal effect.
Silver USAGE: Indicated on patients with 2nd and 3rd-degree burns.
Sulfadiazine
SIDE/ADVERSE EFFECT: None for this patient.

Monitor renal function studies and CBC periodically.

NURSING Assess burned tissue for infection.
CONSIDERATION: Therapy is continued until burn is healed or skin graft is
performed.
 DRUG GENERIC NAME: MUPIROCIN

STUDY BRAND NAME: BACTROBAN

DRUG CLASS: ANTIBACTERIALS

Propofol DOSAGE: 2% ointment topical tid for 10 days
Morphine
MECHANISM OF ACTION: Inhibits bacterial protein synthesis.
Ketamine Indicated on patients with secondary infected
Silver USAGE: traumatic skin lesions.
Sulfadiazine SIDE/ADVERSE EFFECT: None for this patient.
Mupirocin
Instruct the patient on the correct application of mupirocin.
Assess lesions before and daily during therapy.
Advise the patient to apply medication exactly as directed for the
full course of therapy.
NURSING
If a dose is missed, apply as soon as possible unless it is almost
CONSIDERATION: time for the next dose.
Avoid contact with eyes.
If no clinical response is seen in 3-5 days, condition should be
re-evaluated.
NURSING CARE PLAN
ASSESSMENT
Objective Data:
Deep partial-thickness burns Vital Signs:
to head & anterior trunk
Bilateral full-thickness
T: 35.3°C
circumferential burns to
PR: 125bpm
arms, hands, right leg,
RR: 30cpm
anterior left leg & genitalia
BP: 130/90mmHg
TBSA: 73%
Absent pedal and radial SPo2: 95%
pulses bilaterally Pain: 8/10
Edema on both extremities
 PLANNING
SHORT TERM:
DIAGNOSIS After 2 hours of rendering LONG TERM:
proper nursing intervention After 2 weeks of
Ineffective the patient will be able hospitalization, the
Tissue Perfusion to:
Present improvement of
patient will be able to:
Demonstrate increased
related to vital signs (bp, rr, pr) perfusion as
Demonstrate improved
circumferential perfusion as manifested
individually
appropriate (Skin warm
burns to by palpable pedal and and dry, peripheral
radial pulses. pulses present and
extremities AEB Demonstrate palpable, free of pain
Absent pedal and understanding of risk and discomfort and
factors or conditions, absence of edema).
radial pulses therapy regimens, and Demonstrate tissue
bilaterally. side effects of
medications (through
regeneration as
manifested by restored
verbal or action
tissue to normal
response)
state.
NURSING INTERVENTION RATIONALE
Independent:
Monitor and assess vital signs, intake and Baseline data is important to keep monitored.
output, color, sensation, movement, Edema formation can readily compress blood
peripheral pulses, and capillary refill on vessels, thereby impeding circulation and
extremities with circumferential burns. increasing venous stasis or edema. Comparisons
Compare with findings of unaffected limb. with unaffected limbs aid in differentiating
localized versus systemic problems (hypovolemia
or decreased cardiac output).(Vera, 2020)

Maintain fluid replacement per protocol. Maximizes circulating volume and tissue
perfusion. (Vera, 2020)

Check for irregular pulses. Cardiac dysrhythmias can occur as a result of

electrolyte shifts, electrical injury, or
release of myocardial depressant factor,
compromising cardiac output.(Vera, 2020)

Elevate affected extremities, as appropriate. Promotes systemic circulation and venous return
Remove jewelry or arm bands Avoid taping that may reduce edema or other deleterious
around a burned area. effects of constriction of edematous tissues.
Prolonged elevation can impair arterial
perfusion if blood pressure (BP) falls or tissue
pressures rise excessively. (Vera, 2020)
NURSING INTERVENTION RATIONALE
Monitor electrolytes, especially sodium, Losses or shifts of these electrolytes affect
potassium, and calcium. Administer cellular membrane potential and excitability,
replacement therapy as indicated. thereby altering myocardial conductivity,
potentiating risk of dysrhythmias, and
reducing cardiac output and tissue perfusion.
(Vera, 2020)

Avoid use of IM/SC injections. Altered tissue perfusion and edema formation
impair drug absorption. Injections into
potential donor sites may render them unusable
because of hematoma formation. (Vera, 2020)
DEPENDENT:
Assist and prepare for escharotomy or Enhances circulation by relieving constriction
fasciotomy, as indicated. caused by rigid, nonviable tissue (eschar) or
edema formation. (Vera, 2020)

Assist in inserting Nasogastric tube, as

indicated.

Assist in wound dressing and cooling down Proper wound care prevents infection and other
procedure as indicated. complications, and also helps speed up the
healing process with less scarring. (Nurse’s
Pocket Guide by Doenges et al. 15th ed pp.
916.)
NURSING INTERVENTION RATIONALE
Administer topical antibiotic ointments such as To treat minor wounds (e.g., cuts, scrapes,
Mupirocin, as indicated. burns) and to help prevent or treat mild skin
infections. (Nurse’s Pocket Guide by Doenges et
al. 15th ed pp. 916.)

Insert urinary catheter, as indicated. To monitor urine output. (Nurse’s Pocket Guide
by Doenges et al. 15th ed pp. 917.)

Administer fluids, electrolytes, nutrients and To promote optimal blood flow, perfusion and
oxygen, as indicated. function. (Nurse’s Pocket Guide by Doenges et al.
15th ed pp. 917.)
COLLABORATIVE:
In-depth wound care may include debridement and
Refer to wound care specialists if arterial or
various specialized dressing that provide optimal
venous ulcerations are present.
moisture for healing , prevention of infection
and further injury.(Nurse’s Pocket Guide by
Doenges et al. 15th ed pp. 918.)

To maximize tissue perfusion and reduce risk of

Assist significant others or the patient to
perfusion complications. (Nurse’s Pocket Guide by
change position at timed intervals, rather than
Doenges et al. 15th ed pp. 918.)
using presence pain as a sign to change
positions.

To maintain optimal perfusion. (Nurse’s Pocket

Refer to a dietitian for a well-balanced diet or
Guide by Doenges et al. 15th ed pp. 919.)
other modifications, as indicated.
 EVALUATION

SHORT TERM GOAL:

After 2 hours of rendering proper nursing
intervention the short term goal was
LONG TERM GOAL:
completely/partially met as evidenced by, After 2 weeks of hospitalization, the
the patient was able to: long term goal was completely/partially
met as evidenced by, the patient was
Present improved vital signs within normal able to:
range:
T: 35-37°C Demonstrate increased perfusion as
PR: 60-100bpm
individually appropriate (Skin warm and
RR: 22-24cpm
dry, peripheral pulses present and
BP: 120/80mmHg
SPo2: 95-100% palpable, free of pain and discomfort
Demonstrate improved perfusion as and absence of edema).
manifested by palpable pedal and radial
pulses Demonstrate tissue regeneration as
Demonstrate understanding of risk factors manifested by restored tissue to normal
or conditions, therapy regimens, and side state.
effects of medications (through verbal or
action response)
NURSING CARE PLAN
ASSESSMENT
SUBJECTIVE:
“sobrang masakit po tuwing gagalaw po
DIAGNOSIS
ako at tuwing mag lilinis po kayo ng Chronic pain related to
sugat” as verbalized by patient.
Pain scale of 8/10 full thickness burn
injury and treatments as
OBJECTIVE: evidenced by patient
TBSA: 73 %
Facial Grimace verbalization of pain
Guarding behaviour with a scale of 8/10,
Crying
Restlessness facial grimace, guarding
Anxious behaviour.
BP: 130/90
HR: 98 bpm
RR: 24 cpm
 PLANNING
SHORT TERM GOALS:
After 30 minutes of LONG TERM GOALS:
intervention the client will After 2 weeks of
be able to: intervention the client
Report decrease of pain will be able to:
from 8/10 to 2/10 Report eradication or
Display decrease decrease intensity of
restlessness, anxiety pain
Decrease BP from 130/90 to Display no restlessness
120/80 mmHg and anxiety with relaxed
Decrease RR from 24 to 18 facial expression
cpm Have normal BP, HR, and
Decrease HR from 98 to 85 RR
bpm
NURSING INTERVENTION RATIONALE
INDEPENDENT:
Assess pain level using intensity scale, Pain assessment data provide a baseline for
noting characteristics. Observe for assessing response to intervention. (Brunner
nonverbal indicators of pain every 8 & Suddarth edition by Smeltzer et al. 10th
hours. ed pp. 1729.)

Assess RR, BP, HR and patient's response It might cause respiratory depression, low
before and during administration of BP, PR and sedation. (Brunner & Suddarth
analgesic medication such as morphine edition by Smeltzer et al. 10th ed pp. 241.)
every 15 minutes.

Cover the wounds with gauze impregnated Temperature changes and air movement can
with topical agent. cause great pain to exposed nerve endings.
(Nurse's Pocket Guide 15th ed. pp. 647)

Provide bed cradle and elevate linens off Helps to reduce pain (Nurse's Pocket Guide
wound. 15th ed. pp. 644)

Promote uninterrupted rest intervals by Increase the patient's strength and

scheduling the treatment and care tolerance for activity. (Nurse's Pocket
activities. Guide 15th ed. pp. 643)
NURSING INTERVENTION RATIONALE
Educate patient the use of nonpharmacologic Helps lessen concentration on pain,
techniques before, after, and, during promotes relaxation,and enhances sense of
painful activities; before pain occurs or control. (Brunner & Suddarth edition by
increases. Such as deep breathing, music Smeltzer et al. 10th ed pp. 1729.)
therapy, guided imagery.

Explain the procedure and provide frequent Reduce severe physical and emotional
information as appropriate, especially distress associated with painful
before wound debridement procedures.(Doenges et. al 8th ed pp.675)

Encourage expression of feelings about pain Verbalization allows outlet for emotions
and may enhance coping mechanisms (Nurse's
Pocket Guide 15th ed. pp. 646)

Educate the patient the usual pain Knowledge reduces fear of the unknown and
trajectory in burn recovery and option for provides some measure of control to the
pain control. Allow patient as much control patient. (Brunner & Suddarth edition by
as possible regarding pain management. Smeltzer et al. 10th ed pp. 1729.)

Provide emotional support and reassurance Fear and anxiety increase the perception of
pain. (Nurse's Pocket Guide 15th ed. pp.
646)
NURSING INTERVENTION
RATIONALE
DEPENDENT:
IV methods can maximize the pain relief
Administer morphine via IV before the
effect of medication. (Brunner & Suddarth
painful procedure as needed.
edition by Smeltzer et al. 10th ed pp.
241.)
COLLABORATION:
Refer to a structured support group, May be necessary to lessen anxiety and
psychiatric clinical nurse specialist, improve client's coping skills in order to
psychologist, or spiritual advisor for reduce pain levels. (Nurse's Pocket Guide
counseling, as indicated. 15h ed. pp. 647)
 EVALUATION

SHORT TERM GOALS:

After 30 minutes of intervention LONG TERM GOALS:
the client was able to: After 2 weeks of intervention the
Report decrease of pain from client was able to:
8/10 to 6/10(Partially met) Report decreased intensity of
Display decrease restlessness, pain (Fully met)
anxiety(Fully met) Display no restlessness and
Decrease BP from 130/90 to anxiety with relaxed facial
120/90 mmHg(Partially met) expression (Partially met)
Decrease RR from 24 to 18 cpm Have normal BP, HR, and RR
(Fully met) (Fully met)
Decrease HR from 98 to 90 bpm
(Partially met)
NURSING CARE PLAN
ASSESSMENT
OBJECTIVE:
Full thickness burn on:
Anterior and posterior of both arms and DIAGNOSIS
hands : 18%
Anterior and posterior of right leg: 18%
Anterior portion of the left leg and Risk for infection
feet: 9%
Genitalia: 1% related to burn injury
Partial thickness burn on: and postsurgical
Anterior and posterior head: 9%
Anterior trunk: 18% procedure as evidenced by
TBSA: 73 % full thickness burn with
Grafted burn wounds except genital burns
Post- Operative of 24hours Grafted area: 73 % TBSA, grafted burn
whitish
may appear edematous
wounds and knowledge
no signs of infections deficit about wound care.
BP: 130/90
HR: 98 bpm
RR: 24 cpm
SPO2: 95%
 PLANNING
LONG TERM:
After 2 weeks of intervention:
The post-operative wound/burns
SHORT TERM: will show progressive
After 1 hour of improvement or healing such as
health education the re-epithelization, wounds are
pink, warm, moist and no signs
patient will be able of bleeding
to enumerate and The patient will not experience
Demonstrate ways to complications, such as
infection, sepsis and
prevent wound
contracture
infection and The patient will maintain
complication, and optimal nutrition/ physical
promote healing. well being.
The patient will verbalize
feelings of increased self-
esteem.
NURSING INTERVENTION RATIONALE
INDEPENDENT:
1. Demonstrate to client and family wound care
For patients and families to have a sense
procedures, and educate about signs and symptoms
of control and for early detection and
of infection.
treatment of infection.
a. Ways to prevent infections,
b. Wound care techniques
c. Non-pharmacological pain management

2. Use asepsis in all aspects of patient care:

a. Meticulous hand hygiene before and after
patient care. Aseptic technique minimizes the risk of
b. Use clean or sterile gloves for wound care, cross-contamination and spread of bacterial
c. Wear an isolation gown or protective plastic contamination.(Brunner & Suddarth edition
apron for patient care. by Smeltzer et al. 10th ed pp. 1728.)
d. Wear a mask and hair cover when wounds are
exposed and during sterile procedures.

3. Monitor for systemic and localized signs and To provide early detection and treatment of
symptoms of infection such as fever, inflammation, infection. (Doenges et. al 8th ed pp.677)
purulent drainage, or discoloration every shift.

4. Inspect the wound, graft site & surrounding skin To determine the effectiveness of treatment
for color, odor, exudate, size and depth using and detect infection. (Doenges et. al 8th
tongue depressor and tape measure and signs of re- ed pp.677)
epithelialization every before wound care.
NURSING INTERVENTION RATIONALE
5. Remove old dressing, perform gentle cleaning Water softens and aids in removal of
on wounds in a hydrotherapy. Maintain a dressing, and removes nonviable tissue.
temperature of water at 15-29.4‘C. Wash areas Hydrotherapy helps relieve pain.(Nurse's
with mild cleansing agents once a day every Pocket Guide 15th ed. pp. 505)
morning (OD). Wash the perineal area as needed.

6. Perform wound debridement using sterile To promote healing and prevent

scissors and forceps to remove remaining topical contamination.(Doenges et. al 8th ed pp.677)
agent, exudate, and non-viable tissue as
prescribed treatment.

7. Apply several layers of dry dressings with Less dressing layer over joints allows
lighter dressing over joints. Apply dressing on mobility. Individually wrapped hands and
fingers of hand and foot individually and change toes’ fingers to avoid skin to skin contact
dressing on perineal area every bowel movement. and contractures. (Doenges et. al 8th ed
pp.677)

8. Encourage the patient to eat food rich in To promote healing and strengthen immunity.
zinc, copper, Vit. C and A, proteins and calories (Nurse's Pocket Guide 15th ed. pp.911)
such as fish, whole milk, eggs, potatoes, pasta
etc.

9. Provide adequate 2-3 liters for hydration per To reduce and replenish cellular water loss
day. and enhance circulation. (Nurse's Pocket
Guide 15th ed. pp. 911)
NURSING INTERVENTION RATIONALE
10. Encourage adequate periods of rest and To limit metabolic demands, maximize energy
sleep. available for healing. (Nurse's Pocket Guide
15th ed. pp. 911)

11. Encourage and assist patient with To reduce stress on pressure points and
repositioning every 2 hours. enhance circulation to tissues. (Doenges et.
al 8th ed pp. 675)

12. Provide regular linen changes every after These measures reduce potential bacterial
wound care and assist patient with personal colonization of burn wound. (Brunner &
hygiene. Suddarth edition by Smeltzer et al. 10th ed
pp. 1728.)

13. Exclude plants and flowers in water from Plants, flowers and stagnant water is a
patient’s room. potential source of bacterial growth.
(Brunner & Suddarth edition by Smeltzer et
al. 10th ed pp. 1728.)

14. Monitor white blood cell (WBC) count, Increased WBC indicates infection. Culture
culture and sensitivity results and sensitivity indicate microorganism
present and appropriate antibiotics to be
used. (Brunner & Suddarth edition by
Smeltzer et al. 10th ed pp. 1728.)
NURSING INTERVENTION RATIONALE
DEPENDENT:
Report signs of poor healing, poor graft take Early intervention for poor healing wound
or trauma to the physician. healing or graft take is essential. Grafted
or healed burn wounds are susceptible to
trauma. (Brunner & Suddarth edition by
Smeltzer et al. 10th ed pp. 1728.)

Report to physician the decreased bowel These signs may indicate sepsis. (Brunner &
sounds, tachycardia, decrease blood pressure, Suddarth edition by Smeltzer et al. 10th ed
decrease urine output, fever and flushing. pp. 1728.)

Apply topical antimicrobial agent on burn To prevent infection, protect grafts and
area and grafts every after wound care. promote optimal conditions for its
(Silver sulfadiazine) adherence to the recipient site. It also
prevents drying of wounds which can cause
further tissue destruction. (Doenges et. al
8th ed pp.677)
COLLABORATION:
Collaborate with dietary services to ensure Dietitians will create a specific diet plan
nutritional needs are met. for the patient that includes the proper
food, calories, and nutrients like protein
and vitamins. High-calorie and high-protein
diets facilitate wound healing. (Cleveland
et. al)
 EVALUATION

LONG TERM:
SHORT TERM: After 2 weeks of intervention:
The patient was able to display progressive
After 1 hour of health improvement in wound or lesion healing such
as re-epithelization, wounds are pink,
education the patient was warm, moist and no signs of bleeding.(Fully
able to enumerate and met)
The patient did not experience
Demonstrate ways to prevent complications, such as infection, sepsis
wound infection and and contractures(Fully met)
The patient maintained optimal nutrition/
complication, and promote physical well being.(Partially met)
healing. (Fully met) The patient verbalized feelings of
increased self- esteem.(Partially met)
DISCHARGE PLAN
Be well informed about the medication, especially on how to
apply it and when to apply it.

M
Mupirocin - this helps prevent certain bacteria growth,
apply to a gauze before applying it to the perineum area,
change the gauze with medication every bowel movement
4% Chlorhexidin PRN or Pro Re nata means taken as needed
Follow the prescription given by the physician regarding
ointment medications.

Advise the patient to avoid smoking. It can cause poor

E
blood circulation and reduce healing.
Encourage the patient to do some regular exercise helps
prevent arms and legs from becoming fixed in a rigid
position.
Exercise as your provider recommends.
DISCHARGE PLAN
T
Pain Medication may be prescribed.
Take 30 to 45 minutes prior to dressing changes or
scheduled appointments in the Burn Unit.
Antibiotics may be prescribed.
Teach the patient to keep the wound clean and dry.
Family education – regarding wound care
Avoid exposure to sun, and to extreme hot and cold temperatures.
Keep the involved area elevated as much as possible--this will

H
relieve some discomfort and reduce the swelling to the affected
area.
Follow activity restrictions, such as not driving or operating
machinery, as recommended by your healthcare provider or
pharmacist, especially if you are taking pain medicines.
Advise the patient to drink enough fluids to keep your urine light
yellow in color, unless you are told to limit fluids.
Advise the patient to avoid getting hot and sweaty.
DISCHARGE PLAN
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Follow up check-up at the Outpatient Department after one
week.
Advise to call the physician if:
The patient develops a fever.
There’s noticeable increased swelling around the burn.
A pus is seen coming from, or around the burn.

D
Advise the patient to drink warm milk or tea (without
caffeine) with honey to prevent having trouble sleeping.
Encourage the patient to follow the High Energy High Protein
Guidelines or Diet to avoid losing weight while recuperating
Encourage the family, friends, relatives, and the patient as well

S
to pray for faster and continuous healing.
“Come, let us return to the Lord. For He has torn us, but He
will heal us; He has wounded us, but He will bandage us.”
Hosea 6:1
 BURN INJURY CASE STUDY

THANK YOU!
GROUP 1 and 2