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