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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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