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NURSING careplan
On
Burns.
SUBJECT: ADVANCE NURSING PRACTICE
SUBMITTED TO: SUBMITTED BY:
Mrs. ……………………………. Mr. ………………………….
Medical Surgical Nursing Dept. 1st year M.Sc nursing (MSN)
MCI NURSING INST.
Kota (Raj)
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Study material for:- staff Nurse:- AIIMS/ M.Sc.NURSING/B.Sc.NURSING
VISIT REGULAR:- www.mcinursing.com
SUBMITTED ON: 11/01/2010
1. HISTORY TAKING
I. DEMOGRAPHICAL INFORAMATION:
Name: Mr.ramesh
Age: 27 years
Sex: male
Address: Residence no.38
3rd main,anandgiri extn
Uthrahalli.
Religion: Hindu
Marital status: married
Education: 10th standard.
Occupation: driver
Ward: burns ward.
Date of Admission: 15/01/2010
O.P No: N- 526998
DIAGNOSIS: 27% partial thickness superficial burns.
SURGICAL PROCEDURE : he is not undergone any type of surgery
II. CHIEF COMPLIANT/CLIENTS REQUEST FOR CARE:
Mr.ramesh came with 27% partial thickness superficial thermal burns and
admitted in Victoria hospital .he intentionally tried to commit suicide ,poured
kerosene all over the body mainly burned areas are right part of the body ,
neck ,abdomen and right hand also. After first aid and emergency
management patient admitted to the ward
III. PRESENT ILLNESS/ PRESENT HEALTH STATUS:
Patient is conscious but not able to self activites.
IV. PAST HISTORY:
No history of allergy to any medication and food.
Has received immunization upto ages
V. FAMILY HISTORY:
27 yrs 22 yrs
3yrs
he belongs to a middle class family,
Sl
no
Name of the
family member
Age Sex Occupation Education Relation Health
status
1. Mr. Ramesh. 27yrs Male driver 10th self 27%
themal
burns
2. Mrs. Deeptthi. 20
yrs
Female House-wife 9 th wife Healthy
3. Mr. Dikshith. 3
yrs
Male - son Healthy
VI. PSYCHO SOCIAL HISTORY:
Economic history - he belongs to middle class family.
Mother tongue - Kannada
Language known - Kannada
Cultural Group - Friends, relatives and neighbour
Mood - Social and active
VII. NUTRITIONAL HISTORY:
he is taking all types of food both Vegetarian and Non-vegetarian. he takes
two meals in a day.
VIII. ELIMINATION & BOWEL PATTERN:
Bowel- he has regular bowel movement once a day in the morning and no
history of constipation.
Bladder- is catheterised, voids approx. 200ml a day. No history of dysuria,
haematuria.
IX. ENVIRONMENTAL HISTORY:
he lives with his famiy in a concrete house, which has three rooms and a
kitchen. They use toilet for defecation and get supply water from bore well.
They have electricity supply and closed drainage system in their house.
2. PHYSICAL EXAMINATION:
1) GENERAL OBSERVATION:
a) Constituition: Thin built.
b) Stature: Normal
c) State of nutrition: Good
d) Personal appearance: clean
e) Posture: Good
f) Emotional stage: anxious
g) Skin: Pallor and dry skin
h) Cooperativeness: unconsious
2) VITAL SIGNS:
a) Temperature: .36oc
b) Pulse: 100 beats per minutes
c) Respiration: 28 per minutes
d) Blood pressure: 100/60 mmHg
e) Pulse pressure: 40 mmHg
3) HEIGHT: 165 cm
4) WEIGHT: 58 kg
5) SKIN AND MUCUS MEMBRANE:
a) Colour of skin: Pallor
b) Edema: present on burned sites
c) Moist temperature: the skin is generally dry and warm
d) Turgor: good
e) Texture: normal
f) Discharge/ drainage/lesion
6) HEAD:
a) Skull : has no abnormality.
b) Hair : hair distributation is equal, scanty and black
c) Movement of the head: limited due to the burns
d) Fore head : skin became red ,oedema,4%area burned
e) Face : anxious expression
7) EYES:
a) Expression : anxious
b) Eye brows : even, equally distributed hair, free from dandruff
c) Eye lids : no lesion or scar, eye lashes equally distributed
d) Lacrimation : clear fluid expressed, no discharge present
e) Conjunctiva : red in colour
f) Sclera : white and moist
g) Cornea : appear smooth, moist and round
h) Iris : PERRLA
i) Pupils : equally reactive
8) EARS:
a) Appearance : no low set ears.
b) Discharge : no discharge, no inflammation
c) Hearing : normal
d) Lesion : no lesion seen
Lower canthus of the right ear burned and skin appeared red
9) NOSE:
a) Appearance : no septal deviation.
b) Discharge : no discharge
c) Patency : both the nostrils are patent
d) Sense of smell : good
10) MOUTH & THROAT:
a) Lips : no cheilosis
b) Tongue : no glossitis
c) Teeth : normal
d) Gums : pink, moist, smooth, no lesion or ulcers
e) Buccal mucosa : no lesions or ulcers
f) Tonsil : normal
g) Taste : normal
h) Palate : fused
i) Floor of mouth : no lesions
11) NECK:
a) General appearance : short and more creased
b) Trachea : in normal position, tracheostomy done
c) Lymph node : no palpable lymph nodes
d) Thyroid gland : firm, smooth and non tender nodes
e) Cyst and tumour : no cysts and tumors noted
f) All venous and arterial pulsation felt
12) CHEST AND RESPIRATORY SYSTEM:
a) Inspection : size and shape normal, chest expansion is restricted
due to the burns, mottled red base and broken epidermis
b) Palpation : swelling due the burns, not lymph nodes palpated
c) Percussion : not done
d) Auscultation : not done .
13) CARDIO VASCULAR SYSTEM:
a) Inspection : Size and shape of the chest is within normal limits
b) Palpation : Not checked
c) Percussion : not checked
d) Auscultation : S1 and S2 heart sounds heard well
14) ABDOMEN:
a) Inspection : 17% area is burned ,skin wet and motteled
b) Palpation : Not done
c) Percussion : Not done
d) Auscultation : Peristalsis heard in the right lower quadrant
15) BACK:
a) Spine and curvature : no lumps or lesion present
b) Movement : unable to move
c) Tenderness : tenderness noted
16) GENITALIA:
17) Normal : No abnormality
18) UPPER EXTREMITIES: right hand is having3% thermal injury
19) LOWER EXTREMITIES: no deformities present.
20) NERVOUS SYSTEM:
Higher function : conscious
Memory : recent and remot memory is good
Orientation : not checked
Insight and judgement : good
General intelligence : not checked
Speech : Normal
Cranial nerves : No abnormality presented
Sensory function : Good sensation, respond to painful stimuli.
Coordination finger to nose : not checked
3. INVESTIGATION:
Investigation Patient’s value Normal value Remarks
Haemoglobin
Red blood cell
PCV
Platelet
ESR
MCV
MCH
MCHC
Glucose
Urea
Creatinine
Calcium
11.1 gm/dl
6.03 milcmm
48.8%
3,94,000/L
14.mm/hr
82FL
28.1pg
33.9%
81mg/dl
23mg/dl
0.7mg/dl
5.8mg/dl
14- 16 mg/dl
4.5- 6.5 ml/ccm
20- 54%
1.5- 4.5 lacs
0-20mm/hr
80-96fl
27-33pg
32-35%
70-110mg/dl
8-25mg/dl
0.6-1.5mg/dl
8.5-10.5mg/dl
reduced
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
4. medication
Medication Dosage,
frequency and
route
Actions Side Effects Nurses
responsibility
Tab
.ciprofloxasin
15mg,qid,oral Interferes with
protein synthesis in
bacterial cell by
binding to ribosomal
sub unit, which
causes misreading of
genetic code;
inaccurate peptide
sequence form in
protein chain,
causing bacterial
death
Confusion ,
depression,
nausea,
anorexia
Monitor I/O,
watch for other
side effects
Tab
ceftriazoneb
sodium
50mg, qid,
oral
Inhibits bacterial cell
wall synthesis, which
renders cell wall
osmotically unstable,
leading to cell death
Headache,
dizziness,
weakness,
paresthesia,
nausea
Asses for
sensitivity to
penicillin,
monitor for
I/O ratio and
watch for side
effects
Heparin
Sodium
1000U.sc Prevents conversion
of fibrinogen to
fibrin and prothrobin
to throbin by
enhancing inhibitory
effects of
antithrobin.
Fever,
diarrhea,
pruritius,
anorexia
Watch for the
side effects,
monitor BP,
assess for
allergic
reaction
Tab
.prednisolone
2mg, oral Decrease
inflammation by
suppression of
migration of
polymorphonuclear
leucocytes,
fibroblasts; reversal
to increase capillary
permeability and
lysosomal stability
Poor wound
healing,
mood
changes,
headache,
nauea,
weakness
Monitor I/O,
weight and
assess for the
other reaction
OREMS SELF CARE MODEL:
Universal self care deficits
Assess the breathing pattern of the
patient
Assess the pain level of the patient
Assess the anxiety level of the
patient
Assess the nutritional status of the
patient
Developmental self care deficit
Assess the Mr. Ramesh perform
self care activities with
assistance or without assistance
Health deviation self care deficits
Assess the type of pain and the
breathlessness
Assess the potential factor of
infection
Assess the activity of the patient Self care
Self care
agency
Self
care
demand
s
Nursing
agency
Mr, Ramesh
Mr. Ramesh Mother
Nurse
Conditioning factors
Age 27years
Developmental status young age
Health care delivary- supportive
health care system
Altered breathing pattern
Pain and discomfort
Impaired tissue perfusion
Imapaired nutritional status
Partialy compensatory system
- Administer oxygen to the
patient
- Monitor cardiac function
- Administer medication
Supportive compensatory system
- Give education about self care activities
- Explain about the disease condition and
treatment regimen of this condition
- Education about hygiene and nutrition
Nursing diagnosis
(Problems identified)
1. Skin integrity impaired related to necrotic tissues and skin debris as manifested by peeled off skin.
2. Pain chronic related to deep tissue burns as manifested by excruciating pain.
3. Nutrition imbalanced: less than body requirement.
4. Fluid imbalance risk for shock related to burns as manifested by less urine output.
5. Altered bowel pattern, constipation related to lack of intake of food, fluids and immobility as manifested by
infrequent passage of stools.
6. Ineffective individual coping related to lack of emotional support and worrying about the cost of the
treatment
7. Knowledge deficit regarding disease process, condition, prognosis, treatment regimen as evidenced by lack
of questioning and verbalized misconception.
8. High for, ineffective management for treatment regimen related to lack of knowledge.
Nursing theory
applied
Subjective and
obejective data
Nursing
diagnosis`
Goal Planning Implementation Evaluation
Orems self care
theory model: it is
identified that due to
mode of intervention
in partial
compensatory
system identified
problem of wound
care and take
appropriate action or
intervention
Sub: I have pain
all over body and
it looks ugly
Object: the
patient is seen
with wounds of
burns almost 51
% over the body
Skin integrity
impaired related
to necrotic
tissues and skin
debris as
manifested by
peeled off skin
Client to heal
the skin
integrity
- Daily observation,
assessment, cleansing
of the skin should be
done appropriately
- Monitor the vitals and
check for any
complications.
- Meshed gauze
dressings with
paraffin is soaked and
put on the burns
wound
- Patient should be
isolated to reduce the
chance for infection
- Administer
appropriate drugs as
per the physicians
order
Daily observations and
assessments are made and
cleaning of the wound is
done once in two days.
Monitoring vitals to check
any complications
Dressing pas of meshed
gauzes are applied on the
wound soaked with paraffin
Patient is isolated from the
infections
Administered drugs as per
the physician has prescribed.
Client
verbalized
about the
wound healing
in the body
Nursing theory
applied
Subjective and
objective data
Nursing
diagnosis
Goal Planning Implementation Evaluation
Orems self care
theory model: it
is identified that
due to mode of
intervention in
partial
compensatory
system identified
problem of
chronic pain and
take appropriate
action or
intervention
Sub: I am having
severe pain and
also numbness in
certain areas of
the body
Obj: he is having
2nd degree burn
and due to that
severe pain can
be manifested by
crying attitude
Pain chronic
related to deep
tissue burns as
manifested by
excruciating
pain
Client to
relieve the pain
to certain
extend
- Assess the kind of pain
the patient is having
- Continue the pain
management therapy
as prescribed by the
physician continuous
IV infusion of
morphine or any
analgesics to be given
for the patient
- Certain
nonpharmacological
therapies such as
relaxation tapes,
music, visualization to
be given for the
patient.
- Pain found in
changing dressing
- Assessed the pain is
during dressing and
removing the dressing.
- Continuing the pain
therapy by the
analgesics provided by
the physician
- Music and relaxation
tapes is given to the
patient
- Pain to reduce ,
dressings is removed
Clients pain is
reduced to certain
extend.
should be removed
slowly and carefully.
carefully and slowly
Nursing
theories applied
Subjective and
objective data
Nursing
diagnosis
Goal Planning Implementation Evaluation
Orems self care
theory model: it
is identified that
due to mode of
intervention in
partial
compensatory
system identified
problem of
decreased
nutrition and
take appropriate
action or
intervention
Sub: I am not
able to have food
properly
Obj: the patient
is dehydrated
and cannot
swallow food
due to striction
of the
eosophagus
Nutrition
imbalanced:
less than body
requirement
To balance the
nutrition
needed for the
patient and the
uptake of IV
fluids.
- Daily caloric need
should be calculated
with the
collaboration with
the dietician and
provide soft food
especially juice.
- If the patient is anable
to eat then nasogastric
tude should be put
and liquids diet
should be considered
- IV fluids should be
calculated and
administerd to the
patient.
- Assess the input and
output of the patient
- Patient should be
weighed in regular
basis for any
- daily caloric need is
calculated and is
administered as
collaborated with the
dietician
- nasogastric tube is put
and liquid diet is
given for the patient
- IV fluids is calculated
needed for the patient
and is administered
accordingly
- Assessed the input
and output chart daily
- Patient is weight
regularly and checked
for the progress.
Balanced caloric
nutrition is met for
the patient
progress.
Nursing theory
applied
Subjective and
objective data
Nursing
diagnosis
Goal Planning Implementation Evaluation
Orems self care
theory model: it
is identified that
due to mode of
intervention in
partial
compensatory
system identified
problem of
decrease fluid in
boby and take
appropriate
action or
intervention
Sub: I am feeling
thirsty and my
skin is having
burning pain and
it is too hot
Obj: clients has
second degree
burn, most of the
body fluid got
dehydrated
Fluid
imbalance risk
for shock
related to burns
as manifested
by less urine
output
Client to
balance the
fluid amount in
the body
-To assess the fluid in in
the body
- To rehydrate the body
with fluids by
administering IV
fluids
- Calculate the fluid
given to the body by
assessing the weight
of the body and the
time the injury has
occurred.
- Administer drugs to
the patient and check
for any complications
such as edema
formation.
- Check for the intake
and output chart.
Assessed the condition of
the patient
Rehydration has started
Calculated the body
fluids to be administered
and almost 10 pints of
fluids is administered.
Drugs such as anti
diuretic drugs to reduce
the complications
Checking daily the input
and output chart
Clients body fluids
is balanced to an
extend.
Conclusion.
Mr. Ramesh aged 27 years admitted with 27 % partial thickness burns and he is been
taken care off , now he has improved his fluid status and his wound is better than before
now he is mobilising with assistance, and he is improving day by day.
Bibliography.
Lewis SM,Heitkemper MM,Dirksen SR.medical surgical nursing,assessment and management of clinical problems.6th ed.missouri:mosby;2004.p.515-540
Suzane cs,Brenda gb,jonice lh, Textbook of Medical-Surgical Nursing.10th ed.wolters klwwer; 2004.p1703-26.
Silverstri LA..comprehensive review of nclex.rn.examination .3rd ed.pennylvania:saunders;2006.p.543-560