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Burns, Focus Group 4-Endocrine, Immunity, and, Integrity Class A, Acute…
Burns
Clinical Manifestation
hypovolemic shock
paralytic ileus
chills
pain
hypoxia
altered mental status
Etiology
thermal
chemical
electricity
radiation
Types
First degree
superficial partial-thickness
Second degree
Deep partial-thickness
Moderate partial-thickness
Third degree
Full-thickness
Fourth degree
Full-thickness, subdermal
Nursing assessment
Diagnostic assessment
Blood test
Carboxyhemoglobin (COHgb)
ABGs and pulse oximetry
Complete blood count
Serum electrolytes
Albumin, globulin, and albumin/globulin ratio
BUN and creatinine
Serum glucose
Associated test
Burns photographs
MRI scan
Laser Doppler
Chest x-ray
Wound cultures
Urine test
Urinalysis
Physical assessment
General state
Level of consciousness
NRS 7
Vital signs
Blood pressure
110/80 mmHg
Pulse
110 rpm
Respiration rate
18 rpm
Body temperature
Afebrile
Activity/rest
Respiration
Neurosensory
Pain/discomfort
Nutrition/fluid
Elimination
Psychosocial, socio-cultural, and spiritual assessment
Psychosocial
Socio-cultural
Spiritually
Anamnesis
Client identity
Female
37 years
Current medical history
36% burns on both hands, anterior abdomen, and chest
3rd degree burn wound
Past medical history
Family medical history
Skin
Epidemis
Superficial and thinnest asprect of the skin
The area of skin that can most commonly be seen
Contains four key cell types
Keratinocytes
Melanocytes
Langerhans cells
Merkel
Layers Stratum
Basale
Spinosum
Granulosum
Lucidum
Corneum
Epidermis is made up of epithelium (keranised stratified squamous epithelium)
There are several regional distinctions
Dermis
The deepest part of the skin that lies directly below the epidermis
Predominantly composed of dense connective tissue that contains collagen and elsatic fibers
Blood vessels, nerves, lymph vessels, smooth muscles, sweat glands, hair follicles, sebaceous glands, and elastic system
Layers
Reticlular aspect
Papillary aspect
Subcutaneous layer
Functions
Produces and absorbs vitamin D stimultaneously
Transmits sensation
Protects the underlying tissue from injury
Regulates body temperature
Secretes sebum or oily substrance to soften and to reduce water loss from skin
Nursing Care Plan
Complained pain (NRS 7)
External and internal factors aggravate the nerve endings in burn wound causing production of prostaglandin, bradykinin, histamine, and progesterone to react on the specific region causing pain sensation felt by the client
Acute Pain (D.0077)
Goals and objectives
The client will experience pain relief from non-pharmacological strategies
The client will be able to have a pain scale less than 3 out of 10
Nursing Intervention
Analgesics Administration (I.08243)
Pain management (I.08238)
Outcome
Pain level
Display relaxed facial expressions and body posture
Report pain reduced or controlled
Pain control
Participate in activities and rest appropriately
STSG procedure plan
Neuromuscular involvement due to multiple burn wounds on both hands, anterior abdomen, and because of the burns trauma
Risk for Peripheral Neurovascular Dysfunction
Nursing interventions
Peripheral Neuropathy Management (I.06195)
Goals and objectives
Relate signs and symptoms that require medical reevaluation
The client will be able to maintain function as evidenced by sensation/movement within normal range for the individual
36% burns on both hands, anterior abdomen, and chest
Impaired skin integrity related to secondary inflammation response to the burn world
Impaired skin integrity (D.0129)
Goals and objectives
Minimized presence of wound and intact skin
Wound is less than 5 mm in diameter
The client will be able to display improvement in wound healing
Burn healing
Demonstrate tissue granulation
Active timely healing of burn wounds
Nursing interventions
Wound care (I.14564)
First degree burns
Second degree burns
Third and fourth degree burns
Maintaining skin integrity (I.11353)
Burns are skin or other body tissue injuries caused by heat, chemicals, electric current, or radiaton
temperature, type of burner, duration of contact, and type of tissue injured
difficulty maintaining airway and circulation, fluid and electrolyte imbalance, nutritional deficits, risk of infection, disturbed body image, fear, anger, guilt, depression, etc
Nursing Diagnosis
Impaired Skin Integrity (D.0129)
defining characteristics
Altered skin color
Peeling
Acute pain
Abscess
Altered turgor
Disrupted skin surface
Dry skin
Bleeding
Hematoma
Blister
Localized area hot to touch
Foreign matter piercing skin
definition
impaired skin integrity is altered epidermis and/or dermis caused by burn
Risk for Peripheral Neurovascular Dsyfunction
definition
susceptible to disruption in the circulation, sensation, and motion of an extremity, which may compromise health
caused by
burns
Pathophysiology
+Vascular Permeability
Edema
-Blood volume
+Peripheral resistance
-Intravascular volume
+Hematocrit
+Viscosity
Caused by
Flame
thermal burn
Nursing Evaluation and Documentation
SOAP Format
Acute Pain
S: Pain reduced or controlled.
O: The patient shows a relaxed facial expression and posture
A: The client’s problems begin to be resolved as evidenced by reduced pain and can participate in activities as well as sleep and rest properly
P: Continuing pain management and ketorolac medication if needed
Impaired skin integrity
S: Patients know things that help accelerate the healing of burns
O: There has been increased wound healing while minimizing the presence of wounds and intact skin.
A: The client’s problems begin to be resolved as evidenced by the reduction in wounds and intact skin
P: Continuing wound healing treatment with Silver Sulfadiazine cream and Hydrofiber dressing
Risk for Peripheral Neurovasculaer Dysfunction
S: There are no disturbances in circulation, sensation, and movement of the extremities in patient
O: Patient is able to maintain function as evidenced by sensation/movement within normal range
A: After the patient has an STSG procedure, there are no disturbances in circulation, sensation, and movement of the extremities, which could interfere with health related to the trauma of burns to both hands, anterior abdomen, and chest
P: Monitoring patient’s health condition
Focus Group 4-Endocrine, Immunity, and, Integrity Class A
Aisyah Naftalena Pambudi (2106752924)
Ali Fadhilatul Mustajib (2106752956)
Fadhilah Ramadhina (2106753100)
Maissie Lince Trisia (2106709176)
Septira Purnama (2106704502)
Wulan Azahra (2106753132)
Acute Pain (D.0077)
defining characteristics
Proxy report of pain behavior
Reports intensity using standardized pain scale
Reports pain characteristics using standardized pain instrument
Proxy report of activity changes
Positioning to ease pain
Evidence of pain using standardized pain (pain scale) behavior checklist
definition
unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage
related factors
physical injury agent (caused by flame)