NURSING care plan On Burns.
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 Name of the Age Sex Occupation Education Relation Health
no family member status
1. Mr. Ramesh. 27yr Male driver 10th self 27%
s themal
burns
2. Mrs. Deeptthi. 20 Female House-wife 9 th wife Healthy
yrs
3. Mr. Dikshith. 3 Male - son Healthy
yrs
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.
1. 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
2. INVESTIGATION:
Investigation Patient’s value Normal value Remarks
Haemoglobin 11.1 gm/dl 14- 16 mg/dl reduced
Red blood cell 6.03 milcmm 4.5- 6.5 ml/ccm Normal
PCV 48.8% 20- 54% Normal
Platelet 3,94,000/L 1.5- 4.5 lacs Normal
ESR 14.mm/hr 0-20mm/hr Normal
MCV 82FL 80-96fl Normal
MCH 28.1pg 27-33pg Normal
MCHC 33.9% 32-35% Normal
Glucose 81mg/dl 70-110mg/dl Normal
Urea 23mg/dl 8-25mg/dl Normal
Creatinine 0.7mg/dl 0.6-1.5mg/dl Normal
Calcium 5.8mg/dl 8.5-10.5mg/dl Normal
3. medication
Medication Dosage, Actions Side Effects Nurses
frequency and responsibility
route
Tab .ciprofloxa 15mg,qid,oral Interferes with Confusion , Monitor I/O,
sin protein synthesis in depression, watch for other
bacterial cell by nausea, side effects
binding to ribosomal anorexia
sub unit, which
causes misreading of
genetic code;
inaccurate peptide
sequence form in
protein chain,
causing bacterial
death
Tab 50mg, qid, Inhibits bacterial cell Headache, Asses for
ceftriazoneb oral wall synthesis, which dizziness, sensitivity to
sodium renders cell wall weakness, penicillin,
osmotically unstable, paresthesia, monitor for I/O
leading to cell death nausea ratio and watch
for side effects
Heparin 1000U.sc Prevents conversion Fever, Watch for the
Sodium of fibrinogen to diarrhea, side effects,
fibrin and prothrobin pruritius, monitor BP,
to throbin by anorexia assess for
enhancing inhibitory allergic
effects of reaction
antithrobin.
Tab .prednisol 2mg, oral Decrease Poor wound Monitor I/O,
one inflammation by healing, weight and
suppression of mood assess for the
migration of changes, other reaction
polymorphonuclear headache,
leucocytes, nauea,
fibroblasts; reversal weakness
to increase capillary
permeability and
lysosomal stability
OREMS SELF CARE MODEL:
Universal self care deficits Developmental self care deficit Health deviation self care deficits
Assess the breathing pattern of the Assess the Mr. Ramesh perform Assess the type of pain and the
patient self care activities with breathlessness
Assess the pain level of the patient assistance or without assistance
Assess the anxiety level of the Assess the potential factor of
patient infection
Assess the nutritional status of the Assess the activity of the patient
patient Self care
Altered breathing pattern
Mr, Ramesh Self care Self care
agency demands Pain and discomfort
Mr. Ramesh Mother
Impaired tissue perfusion
Nurse
Nursing Imapaired nutritional status
agency
Conditioning factors Supportive compensatory system
Partialy compensatory system
Age 27years - Give education about self care activities
- Administer oxygen to the
Developmental status young age patient - Explain about the disease condition and
treatment regimen of this condition
Health care delivary- supportive - Monitor cardiac function
health care system - Education about hygiene and nutrition
- Administer medication
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 Subjective Nursing Goal Planning Implementation Evaluation
applied and diagnosis`
obejective
data
Orems self care Sub: I have Skin integrity Client to - Daily observation, Daily observations and Client
theory model: it pain all over impaired heal the assessment, assessments are made verbalized
is identified that body and it related to skin cleansing of the and cleaning of the about the
due to mode of looks ugly necrotic integrity skin should be wound is done once in wound
intervention in tissues and done two days. healing in the
partial Object: the skin debris as appropriately body
compensatory patient is seen manifested Monitoring vitals to
system identified with wounds by peeled off - Monitor the vitals check any complications
problem of of burns skin and check for any
almost 51 % complications. Dressing pas of meshed
wound care and
over the body gauzes are applied on
take appropriate - Meshed gauze the wound soaked with
action or dressings with paraffin
intervention paraffin is soaked
and put on the
burns wound
- Patient should be
Patient is isolated from
isolated to reduce
the infections
the chance for
infection
- Administer Administered drugs as
appropriate drugs per the physician has
as per the prescribed.
physicians order
Nursing Subjective Nursing Goal Planning Implementation Evaluation
theory and objective diagnosis
applied data
Orems self Sub: I am Pain chronic Client to - Assess the kind of - Assessed the pain Clients pain is
care theory having severe related to relieve the pain the patient is is during dressing reduced to
model: it is pain and also deep tissue pain to having and removing the certain extend.
identified that numbness in burns as certain dressing.
due to mode certain areas manifested extend - Continue the pain
of intervention of the body by management - Continuing the pain
in partial excruciating therapy as therapy by the
compensatory Obj: he is pain prescribed by the analgesics provided
system having 2nd physician by the physician
identified degree burn continuous IV
problem of and due to that infusion of
chronic pain severe pain morphine or any
and take can be analgesics to be
appropriate manifested by given for the - Music and
crying attitude relaxation tapes is
action or patient given to the patient
intervention
- Certain
nonpharmacologica
l therapies such as
relaxation tapes, - Pain to reduce ,
music, visualization dressings is
to be given for the removed carefully
patient. and slowly
- Pain found in
changing dressing
should be removed
slowly and
carefully.
Nursing Subjective Nursing Goal Planning Implementation Evaluation
theories and objective diagnosis
applied data
- Daily caloric
need should be
Orems self Sub: I am not Nutrition To balance - daily caloric need Balanced caloric
calculated with
care theory able to have imbalanced: the nutrition is calculated and is nutrition is met
the collaboration
model: it is food properly less than needed for administered as for the patient
with the dietician
identified that body the patient collaborated with
Obj: the and provide soft
due to mode of requirement and the the dietician
patient is food especially
intervention in uptake of IV
dehydrated juice.
partial fluids. - nasogastric tube is
and cannot
compensatory - If the patient is put and liquid diet
swallow food
system anable to eat then is given for the
due to striction
identified nasogastric tude patient
of the
problem of should be put and
eosophagus
decreased liquids diet should
nutrition and be considered - IV fluids is
take calculated needed
appropriate - IV fluids should for the patient and
action or be calculated and is administered
intervention administerd to the accordingly
patient.
- Assessed the input
- Assess the input and output chart
and output of the daily
patient
- Patient should be - Patient is weight
weighed in regular regularly and
basis for any checked for the
progress. progress.
Nursing Subjective Nursing Goal Planning Implementation Evaluation
theory and objective diagnosis
applied data
-To assess the fluid Assessed the
in in the body condition of the
Orems self Sub: I am Fluid Client to patient Clients body
care theory feeling thirsty imbalance balance the - To rehydrate the fluids is balanced
model: it is and my skin is risk for fluid amount body with fluids Rehydration has to an extend.
identified that having shock related in the body by administering started
due to mode of burning pain to burns as IV fluids
intervention in and it is too manifested
partial hot by less urine - Calculate the fluid
compensatory output given to the body
system Obj: clients by assessing the Calculated the body
identified has second weight of the body fluids to be
problem of degree burn, and the time the administered and
decrease fluid most of the injury has almost 10 pints of
in boby and body fluid got occurred. fluids is administered.
take dehydrated
appropriate - Administer drugs
action or to the patient and
Drugs such as anti
intervention check for any
diuretic drugs to
complications
reduce the
such as edema complications
formation.
- Check for the
Checking daily the
intake and output
input and output chart
chart.
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
