BSN III-D
BSN III-D
OBJECTIVESGeneral Objectives:
Specific Objectives:
OVERVIEW OF THE DISEASE
BURN
A burn is an injury to the tissues of the body. It is defined as damage to the skin caused by excessive heat or caustic chemicals.
Classification
- first degree: only involves epithelial layer. Often very painful but resolves with no residual scarring. Skin is red and painful but blisters are not present
- - second degree: involves epithelium and part of dermis. Pain and scarring vary according to depth of burn. In superficial second-degree burns damage is limited to epidermis and uppermost part of dermis. Deep second-degree burns spare only the deepest portion of dermis
- - third degree: full thickness. Usually painless due to destruction of cutaneous innervation. Leads to scarring. Usually dry and have milky white or tanned leather appearance
Other classifications A description of the traditional and current
classifications of burns.Nomenclature
Traditional nomenclature
Depth Clinical findings
Superficial thickness First-degree Epidermis
involvementErythema, minor pain, lack of blisters
Partial thickness — superficial
Second-degree
Superficial (papillary) dermis Blisters, clear fluid, and pain
Partial thickness — deep
Second-degree
Deep (reticular) dermis
Whiter appearance, with decreased pain. Difficult to distinguish from full thickness
Full thicknessThird- or fourth-degree
Dermis and underlying tissue and possibly fascia, bone, or muscle
Hard, leather-like eschar, purple fluid, no sensation (insensate)
Assessment of extent
Body surface area (BSA) involved can be estimated from
Lund & Browder chart Wallace rule of nine
Area % BSA
Head 9
Each upper limb 9
Each lower limb 18
Front of trunk 18
Back of trunk 18
Perineum 1
Criteria for referral to burns unit
> 10% BSA in child > 15% BSA in adult Inhalation injuries Burns involving the airway Electrical burns Chemical burns Special areas - eyes, face, hands
Escharotomy Deep circumferential burns of
torso can impair respiration In a limb can reduce distal
vasculature In both situations escharotomies
should be considered No anaesthetic is required Burn should be incised into
subcutaneous fat Release of underlying soft tissue
should be ensured On chest should be performed
bilaterally in anterior axillary line Bleeding may be significant and
transfusion may be required
Special situations
Respiratory burnsSmoke inhalations should
be suspected if: Explosion in enclosed
environment Flame burns to the face Soot in mouth or nostrils Hoarseness or stridor
Intubation may be required
Blood carboxyhaemoglobin levels can give indication of extent of lung injury
Electrical burns Most electrical burns are flash burns
and are superficial Do not occur by electrical conduction Flash from an electrical burn can reach
4000 ºC Low-tension burns are usually small
but full thickness High-tension burns usually have an
entry and exit wound Current passes along path of least
resistance (e.g. blood vessels, fascia, muscle)
Extent of tissue destruction can often be underestimated
High-tension burns can be associated with cardiac arrhythmias
Myonecrosis and myoglobinuria can also occur
Chemical burns Commonest acids involved are
hydrochloric, hydrofluoric and sulphuric
Acid burns may penetrate deeply down to bone
First aid treatment involves liberal irrigation with running water
Calcium gluconate may be useful in hydrofluoric acid burns
Commonest alkalis are sodium hydroxide and cement
Again can cause deep-dermal or full-thickness burns
Personal Data
Age: 41Birthday: April 4, 1967Sex: FemaleCivil Status: Married
Present Health History
Past Health History
Drug Study
Name of Drug
Pharmacological Mechanism
Indica- tion
Dosage and prepara- tion
AdverseReaction
Nursing Responsi-bilities
1.Amoxicillin Inhibits cell-wall synthesis during bacterial multiplication
For skin and and soft tissue
500 mg. TID
Nausea, vomiting diarrhea & skin rashes
-Before giving meds. Assess pt. for any allergic reaction.
2.Mefenamic acid For pain 500 mg. q 4 prn
Diarrhea,drowsiness
-Monitor pt.- Instruct pt. to take meals after taking drugs
3.Tegretol To stabilize neuronal membranes and limit seizures act by either increase efflux or decrease influx of Na ions across cell membrane in the motor complex during generation of nerve impulses
For epilepsy
200 mg. BID
Dizziness, fatigue, drowsiness, skin reactions, nausea & vomiting
-Watch for worsening of seizures -monitor pt.
4.Silver sulfadiazine
Inhibits cell wall synthesis during bacterial multiplication
For the wound Apply TID Skin reaction e.g itching
-Clean first the wound & remove dead skin or other debris
5.Omepr-azole
Binds to an enzyme on gastric parietal cells in the presence of acidic gastric pH, preventing the final transport of hydrogen ion into the gastric lumen.
Prevention of relapse of duodenal ulcer
20 mg. 1 cap OD
Headache , diarrhea, constipation, abdominal pain, nausea, vomiting
-Assess pt. routinely for epigastric or abdominal painAdminister doses before preferably in the morning
6.Fluc- lox
Inhibits the action of bacteria causing infection
for treatment of skin infection
50 mg. QID
Hypersensensitivity sp. Skin rashes
-Monitor pt.-note for skin sensitivity
7.Carvedil-ol
Inhibit NE-induced depolarization in the artery but not vein
For hypertensi-on
25 mg. ½ OD
Dizziness, headache, tiredness, nausea, abdominal pain, diarrhea, constipation & vomiting
-monitor v/s of the pt.-watch for any sign and symptoms
8.Nifedipi-ne
Calcium beta blocker
Treatment of essential hypertension
5 mg. SL stat
Headache, tiredness, & dizziness
-monitor v/s
Nursing Care Plan
Nursing Care PlanAssessment Nursing
DiagnosisPlanni- ng
Intervention Rationale Evaluation
S:”Nahihirapan akong gumalaw kasi dumidikit and damit ko sa sugat kaya sya sumasakit” as vervalized by the pt.
O:-with slight facial grimace
-Risk for infection r/t altered body defenses as evidenced by presence of broken skin and traumati-zed tissue
-At the end of the nursing intervention, pt. will demonstrate technique to prevent/reduce risk of infection
>emphasize/model good hand washing technique for all individual coming in contact with client.
>prevents cross-contamination, reduces risk acquired infection.>prevent skin-to-skin surface contact e.g touching of others hand into
The affected site of the body>reccomenduse of mask, & gloves during direct wound wound care and provide sterile or freshly bed linens.>examine wounds daily,note /document appearance, odo, or quantity of drainage
>
>prevents exposure to infectious organism
>identifies presence of healing and provides detection of burn-wound infection. Infection in partial-thickness burn may cause conversion of
burn to full thickness injury>monitor v/s including temperature
>provided clean, well ventilated environment
>provides info.for baseline data;frequent temp.elvation indicates that the body is responding to a new infectious process.
>reduces number of pathogen presented
>goal met; seen S.O performing proper hand washing before and after contact to the pt.>’’naghuhugas na ako ng kamay kasi para maiwasan ang pagkakaron inpeksyon”as verbalized
Presented to:
Presented by:
Ms. Jennifer Rosales RN
Karen Joy M. SerenoMechelle RentoyJoseph Villanueva
RichardBSN III-D