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Case Presentation (Group A)

Burns are injuries to tissues caused by heat, friction, electricity, radiation, or chemicals.

Burns are characterized by degree, based on the severity of the tissue damage.

A first-degree burn causes redness and swelling in the outermost layers of skin(epidermis).

A second-degree burn involves redness, swelling and blistering, and the damage may

extend beneath the epidermis to deeper layers of skin (dermis).

A third-degree burn, also called a full-thickness burn, destroys the entire depth of skin,

causing significant scarring. Damage also may extend to the underlying fat, muscle, orbone.

The severity of the burn is also judged by the amount of body surface area (BSA)involved. Health care workers use the "rule of nines" to determine the percentage of BSA

affected in patients more than 9 years old: each arm with its hand is 9% of BSA; each legwith its foot is 18%; the front of the torso is 18%; the back of the torso, including the

buttocks, is 18%; the head and neck are 9%; and the genital area (perineum) is 1%. This

rule cannot be applied to a young child's body proportions, so BSA is estimated using thepalm of the patient's hand as a measure of 1% area.

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Related symptoms of a burn:

abdominal pain

cloudy, red, or watery eyes

dizziness

headaches

seizures

unconsciousness, which occurs with severe chemical exposure

visual impairments

Symptoms of an airway burn:

burns to the head, face, and neck

coughing

mucus that is stained black or a dark color

shortness of breath or difficulty breathing

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wheezing

STATISTICS

Nationwide

According to data from the United States Fire Administration, each year more than 4,000

Americans die as a result of fires and more than 23,000 are injured seriously enough torequire hospitalization. Here are some additional facts about burn injuries and deaths:

1.25 million- burn injuries per year.

African Americans and Native Americans = 27 percent of fire deaths.

Twice as many men have died in fires as women.

very young and very old = higher risk of death and injury from fire than other

groups.

In 1998 alone, 3,100 children below 15 years old. were injured and 750 werekilled in fires. Children accounted for 13 percent of all fire injuries and 19 percentof all fire deaths.

Approximately 2,550 older adults (65 and older) were injured and 1,035 killed.

This group accounted for 11 percent of fire injuries and 26 percent of fire deaths.

By a wide margin, the leading cause of residential fires that result in child injuries

and fatalities is children playing. The victims, however, are not necessarily the

instigators of the fire: more than half of children fatalities and injuries occur whenthe child is asleep.

Smoking is the leading cause of death to older adults and the second leading cause

of their injury, behind cooking. As with young children, a large proportion of

older adult fatalities occur while the victim is asleep.

Local

Extrapolated Incidence Population Estimated Used

114,304 86,241,6972
http://www.usfa.fema.gov/statistics/http://www.usfa.fema.gov/statistics/

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GENERAL OBJECTIVES

The general objectives for conducting the case study are for students

to incorporate concepts and enhance knowledge in medical surgical

nursing.

To apply the appropriate nursing management for patients with burn

accurately and efficiently.

Aims to develop the skills that are applied for the care of patient with

this condition.

SPECIFIC OBJECTIVES

Define burn

Discuss briefly the causative factors that may have precipitated the

onset of the condition

Discuss thoroughly the signs and symptoms manifested by patient

Discuss the different drugs, indications, mechanism of action, adverse

effect and contraindications

Discuss the nursing care plan appropriate in providing care to alleviate

the manifestation of the patients symptoms

Identify and provide the health teachings needed for the continuum of

care

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PATIENTS PROFILE

NAME: C.P

SEX: FEMALE

AGE: 74y/o

STATUS: MARRIED

RELIGION: ROMAN CATHOLIC

OCCUPATION: NONE

ADDRESS: Blk. 64 Area I, Sto. Nio II Sapang Palay, Bulacan

ADMISSION: JULY 19, 2010

TIME OF ADMISSION: 2:30pm

ADMITTING DIAGNOSIS: THERMAL BURN

ATTENDING PHYSICIAN: DR. COMIA

NURSING HEALTH HISTORY

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Biographic Data

Pt CP a 74 y/o, female, married and presently residing at B64 Area I Sto. Nio S.Palay SJDM Bulacan. Admitted for the first time at OLSJDM at around 2:30pm.

Chief Complaint

Burn in face, neck, anterior trunk, right hand and left knee.

History of Present Illness

11:00am pt had preparing their food for their lunch. She heated the frying pan

with cooking oil and suddenly she felt syncope and followed by loss of consciousness.

Unexpected happened she tapped the pan with cooking oil. When she awakened she

noticed a burn on her different parts of her body including right hand, anterior trunk, left

knee and etc. and noting the pan placed on her arm. She immediately rushed to the ER onJULY 19, 2010 at around 2:30pm. Hence, for admission and Admitted on surgical ward.

Past Medical History

Pt. CP had never experienced hospitalization except on her first admission onOLSJDM on July 19, 2010.

But her previous illness was UTI. She consulted on the near health center. She

prescribed a medication to treat the illness. But the SO cant recall the name of the Drug.

Family History

Pt had known history of hypertension, DM and asthma on the paternal side and no

known to the maternal side.

Socio-economic

Pt remains only on their house together with her husband and 12 y/o grandson.

She always preferred of cooking. Both of them had no job. Her daughter and son living

with their own family and working outside the country sustain their daily needs every3months worth 10,000 only. For them this is not enough on their daily needs. Thats why

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foods that are usually prepared are fried fish and sometimes fried chicken. Pt likes fried

food.

Pt CP always attending Sunday church and when times she had a problem sheinvolves her whole family as a part of her coping mechanism to stress or sometimes she

smoke to trim down problem. She consumed 2 sticks/day for 58 years or diverts her

attention on household choirsHer rest and sleep is still normal according to her. She had her rest for

13hours/day including night and day rest or nap.

GORDONS 11 HEALTHFUNCTIONAL PATTERN

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GENERAL SURVEY

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Physical assessment

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COURSE IN THE WARD

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DAY1 (July 19, 2010) 2:30 pm

On the first day patient was admitted at surgery ward secure consent foradmission. The doctor requested to monitor Vital Signs and I&O every shift and recorded

properly, Diet as Tolerated with IV Fluid requested PLR 1L q 6hrs, PLR 1L q 6hrs AND

PLR 1L q 8Hhrs, requested for Laboratory Exams like ECG, CBC, BT, FBS andCREATININE, patient was refer for clearance pin to debiduct for pass debridement

under GA on Wed July 21, 2010 once CP cleared L/O Dr. Velasquez. Refer OR inform

Anesthesiologist. With Medications of Cefuroxime 750mg IV q8 (-) ANST (3:20 4:10),Tramadol 200mg in D5W 500cc to run at 20ugtts/min, Ketanov 30mg IV q8 (-) ANST,

ATS 4,500 units IM now (-) ANST, Tetanus Toxoid 1 Amp IM now.

DAY2 (July 20, 2010) 8:00 am

At day 2, doctor requested to fast drip PNSS 500cc then regulated @ 40gtts, and the doctor hold Tramadol. Follow up CBC.

July 20, 2010 4:15pm

Patient has an IVF of PLR 1L regulated @ 30gtts/min, patient was

medically cleared for debridement under GA.

DAY3 (July 21,2010) 7:00 am

At this point of time patient adviced for debridement and was placed on

NPO.

July 21, 2010 1: 45 pm

Post Operative Orders:

Monitored Vital Signs every 30 minutes for 2 hours and then every 1 hour

until stable, with o2 inhalation via Nasal Cannula @ 2 LPM, I and O taken and recorded,with diet as tolerated. Patient has an IV Fluid of D5W 1L to run for 12 hrs. With

medication of Cloxacillin 500mg 1cap every 6 hrs, Celecoxib 200mg 1cap BID after

meals, patient was encourage deep breathing.

DAY 4 ( July 23, 2010)

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Continue Medication

DAY 5 ( July 24, 2010)

Continue Medication

DAY 6 ( July 24 2010)

At this time patient was able to Bath with application of Flemniazine,

patient also requested to increase protein intake and drink 1 glass of sustagen BID.

Doctor ordered Diclofenac STAT.

DAY 7 (July 25, 2010) 1:30 pm

Patient was given Paracetamol 1 ampule TIV now because of fever 38.9 c.

DAY 8 ( July 26, 2010)

HAMA

Course in the O.r

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DAY3 (July 21,2010) 7:00 am

At this point of time patient adviced for debridement and was placed onNPO.

July 21, 2010 1: 45 pm

Post Operative Orders:

Monitored Vital Signs every 30 minutes for 2 hours and then every 1 hour

until stable, with o2 inhalation via Nasal Cannula @ 2 LPM, I and O taken and recorded,

with diet as tolerated. Patient has an IV Fluid of D5W 1L to run for 12 hrs. Withmedication of Cloxacillin 500mg 1cap every 6 hrs, Celecoxib 200mg 1cap BID after

meals, patient was encourage deep breathing.

Procedural

Definition

Debridement is the process of removing dead (necrotic) tissue or foreign material from

and around a wound to expose healthy tissue.

Purpose

An open wound or ulcer can not be properly evaluated until the dead tissue or foreign

matter is removed. Wounds that contain necrotic and ischemic (low oxygen content)tissue take longer to close and heal. This is because necrotic tissue provides an ideal

growth medium for bacteria, especially forBacteroides spp. and Clostridium perfringens

that causes the gas gangrene so feared in military medical practice. Though a wound maynot necessarily be infected, the bacteria can cause inflammation and strain the body's

ability to fight infection. Debridement is also used to treat pockets of pus called

abscesses. Abscesses can develop into a general infection that may invade the

bloodstream (sepsis) and lead to amputation and even death. Burned tissue or tissueexposed to corrosive substances tends to form a hard black crust, called an eschar, while

deeper tissue remains moist and white, yellow and soft, or flimsy and inflamed. Eschars

may also require debridement to promote healing.

Surgical debridement

Surgical debridement (also known as sharp debridement) uses a scalpel, scissors, or other

instrument to cut necrotic tissue from a wound. It is the quickest and most efficient
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method of debridement. It is the preferred method if there is rapidly developing

inflammation of the body's connective tissues (cellulitis) or a more generalized alized

infection (sepsis) that has entered the bloodstream. The physician starts by flushing thearea with a saline (salt water) solution, and then applies a topical anesthetic or antalgic

gel to the edges of the wound to minimize pain. Using forceps to grip the dead tissue, the

physician cuts it away bit by bit with a scalpel or scissors. Sometimes it is necessary toleave some dead tissue behind rather than disturb living tissue. The physician may repeat

the process again at another session.

Anesthesia

Anesthesia may be used for deep pressure ulcers or other wounds. Local anesthesia will

numb the area. General Anesthesia will allow you to sleep through the procedure

Forceps in Surgeon's Hand

Risk Factors for Complications During the Procedure

Bleeding

Infection Pre-existing medical conditions

Smoking

Diabetes

Use of steroid or other immunosuppressive medications

Poor nutrition Poor circulation

Immune disorders

LABORATORY
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BLOOD CHEMISTRY

RESULT NORMAL INTERPRETATIONFBS 4.90mmol/L 3.8 6.0 Normal

CREATININE 46.6mmol/L 36.4 123.8 Normal

HEMATOLOGY

RESULT NORMAL INTERPRETATIONHEMOGLOBIN 110 F = 120 150 g/L

M = 140 170 g/LDecreased level wouldsuggest anemia, acuteblood loss, and severe

hemorrhageHEMATOCRIT 0.35 F = 0.37 0.47

M = 0.40 0.50Decreased level would

suggest anemiaWBC 10.7 5-10x109 Normal

DIFFERENTIAL COUNT

RESULT NORMAL INTERPRETATIONSEGMENTERS 0.62 0.50-0.70 Normal

LYMPHOCYTES 0.38 0.20-0.40 Normal

ANATOMY PHYSIOLOGY

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The skin is made up of three layers and is the largest organ of the body

(1) Epidermis

(a) The surface or outer layer

(b) Serves as a barrier between our body and the environment

(2) Dermis

(a) Thick layer of collagen connective tissue below the thin epidermis

(b) Contains the important support structures and sensory nerves, i.e.,

hair follicles, sweat glands, oil glands

(3) Subcutaneous

(a) Layers of fat tissue and soft tissue beneath the dermis

(b) Serves as a barrier for shock absorption and insulation

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(4) Functions of the skin

(a) A protective barrier sealing fluids inside and preventing bacteria

and other microorganisms from entering the body

(b) Important sensory organ providing input to the brain on generaland specific environmental data; serving as a primary role in

temperature regulation

(5) When heat or caustic chemicals come in contact with the skin, damaging

its chemical and cellular components, you have burn-damaged tissue andinflammatory responses to the skin

PATHOPHYSIOLOGY

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Predisposing factorPrecipitating factor- older adult -cook

Exposure to heat

Cellular damage

Inflammatory response

Loss of capillary permeability increaseWBC

Fluid shifting( intravascular to interstitial space)

phagocytosis

Blister formation hypothalamus leukotrienrelease of inflammatorybradykinin mediators

Skin is pink and moist feverProstaglandin

pain

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DRUG INDEX

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NURSING CARE PLAN

D PLA ON EVA

Subjective:

Objective:

-

-

-

ASSESSME

NT

DIAGNOSI

S

PLANNIN

G

INTERVETIO

N

EVALUATIO

N

Subjective:

Objective:

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ASSESSMENT

DIAGNOSIS

PLANNING

INTERVETION

EVALUATION

- Subjective:

Objective:

-

ASSESAPE

NT

DIAGNOSI

S

PLANNIN

G

INTERVETIO

N

EVALUATIO

N

Subjective:

Objective:

-

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DISCHARGE PLANNING

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