ASSESSMENT Subjective: Parang wala ng pakiramdam dito sa paa ko Objective: with pitting edema on the burn area Skin

kin color: red to brown Cold clammy skin on unburned area Capillary refill: 3 secs Weak in appearance Irritable Lab values: Hct-66% Hgb-10

NURSING DIAGNOSIS Ineffective Tissue Perfusion related to decrease blood flow 2 to circumferential burns of lower extremities

SCIENTIFIC EXPLANATION Burn injury Injury to cells and muscles Triggered inflammatory response Release of chemical mediators such as kinins and histamine Increase blood vessel permeability Fluid shift from IV to interstitial space Edema Decrease blood volume Decrease venous return Dec. CO Dec. tissue perfusion

PLANNING Short term goal: After 48 hours of rendering nursing intervention, the patient will be able to: Verbalize understanding of condition, therapy regimen and side effects of medications With good capillary refill of 1-2 secs Skin warm and dry Lab values within normal range: Hct- 40-54% Hgb- 14-18

NURSING INTERVENTIONS Independent: Assess color of the skin, movement of the hands and peripheral pulses and capillary refill on extremities Encourage active ROM exercise of unaffected body parts Elevate the affected extremities

RATIONALE Edema formation readily compresses blood vessels thereby impending circulation and increases edema promotes systemic circulation/venous return

EVALUATION Short term goal: After 48 hours of rendering nursing intervention the goal was met as evidence by: The patient verbalized understanding of the condition, therapy regimen and side effects of medications Good capillary refill of 1-2 secs

Maximizes circulating volume and systemic circulation

Skin warm and dry Lab values: Hct- 33% Hgb- 11

Collaborative: IVF: PLR IL x21gtts/min Maintain fluid replacement and to improve tissue perfusion

Long term goal: After a week of hospitalization, goal was met as evidenced by: Absence of edema on lower extremities

Long term goal:

Vital Signs: T:36 C P:125 bpm R:30 BP:130/90

After a week of hospitalization, the patient will be able to demonstrate increased perfusion as evidenced by: Absence of edema on lower extremities Vital signs within normal range: PR=60-100bpm RR=12-20cpm BP=120/80mm Hg

Vital signs within normal range: PR=65bpm RR=15cpm BP=120/80mmHg

ASSESSMENT Subjestive: Parang wala ng pakiramdam dito sa paa ko

NURSING DIAGNOSIS Impaired skin integrity related to disruption of skin surface and layers secondary to burn

SCIENTIFIC EXPLANATION Burn injury

PLANNING Short term goal: After 8 hours of nursing intervention the patient will be able to : participate in prevention measures and treatment program verbalize feelings of increased selfesteem and ability to manage situation Long term goal: After a week of hospitalization, the patient will be able to demonstrate tissue regeneration and achieve timely wound healing as evidenced by: moist skin healing scar absence of edema on lower

NURSING INTERVENTIONS Independent: Assess or document size, color, depth of wound, necrotic tissue and condition of surrounding skin Assess blood supply and sensation (nerve damage) of affected area.

RATIONALE

EVALUATION Short term goal:

Cell damage

Provides baseline information about the affected skin

After 8 hours of nursing intervention goal was met as evidenced by: Pt displayed timely healing of wounds Pt participated in prevention measures and treatment program Pt verbalized feelings of increased self-esteem and ability to manage situation Long term goal: Within the patients hospitalizatio n, goal was met as

Objective: With open burn wound that appears leathery Skin color: red to brown Presence of eschar Non pitting edema on the burned area VS: T:36 C P:125 bpm R:30 cpm BP:130/90mmHg

Destruction of skin layers

Impaired Skin Integrity

To evaluate actual/potential for impairment of circulation to lower extremities Promotes healing To assist bodys natural process of repair To promote wound healing and to best meet the needs of client To promote healing Moisture potentiates skin breakdown

Clean the wound area with hydrogen peroxide Keep the area clean/dry and stimulate circulation to surrounding areas Apply appropriate wound dressing

Maintain appropriate moisture environment for particular wound Remove wet or wrinkled linens promptly

extremities Use appropriate padding devices To reduce pressure on circulation to compromised tissues To provide a positive nitrogen balance to aid in skin/tissue healing For presence of reduced sensation/circulat ion To control feelings of helplessness and deal with situation

Provide optimum nutrition, including foods with vitamin C and adequate protein intake Emphasize importance of proper fit of clothing and shoes Assist pt to learn stress reduction and alternate therapy techniques

evidenced by: the patient demonstrated tissue regeneration and achieved timely wound healing as evidenced by: moist skin healing scar absence of edema on lower extremities

Collaborative: Assist with debridement To remove nonviable, contaminated or infected tissue

ASSESSMENT Subjective: Nanghihina ako Objective: with nausea and vomiting irritable confused urine output of 15 ml/hour dark yellow urine capillary refill 3secs Vital Signs: T:36 C P:125bpm R:30cpm BP:130/90mmHg Lab results: HCT=66%

NURSING DIAGNOSIS Deficient fluid volume related to abnormal fluid loss 2 third degree burn

SCIENTIFIC EXPLANATION Burn injury Injury to cells and muscle Platelet aggregation

PLANNING Short term goal: After 8 hours of rendering nursing intervention the client will be able to demonstrate improved fluid balance as evidenced by: no complaints of nausea and vomiting absence of irritability capillary refill of 12secs Long term goal: After 1-2 days of nursing intervention, the patient will demonstrate improved fluid balance as evidenced by:

NURSING INTERVENTIONS Independent: Monitor vital signs, and capillary refill Monitor urine output color

RATIONALE Baseline data Allow for close observation of renal function and prevent urinary retention Deterioration in the level of conciousness may indicate inadequate circulating volume

EVALUATION Short term goal: After 8 hours of rendering an effective nursing intervention, the goal was met as evidenced by: no complaints of n/v no irritability capillary refill of 2 secs V/S as follows: T:36 C P:120bpm R:20cpm BP:110/70 Long term goal:

Damage renal function Decrease GRF Presence of azotemia

Investigate changes in mentation

Irritation in GI lining and alteration in nervous system

Collaborative: adequate urine output of 60ml/hr 100ml/hr appropriate LOC Vital signs within normal range: T=36.5-37.5 C P=60-100bpm R=12-20cpm BP=140-100/8090mmHg Insert indwelling urinary catheter Allows for close observation of renal function and prevent urinary retention Fluid resuscitation replaces loss of fluids and electrolytes

Resulting to n/v, alterd loc, weakness and wt.loss

Administer PLRS 1L 158 gtts/min for first 8 hours Administer PLRS1L 79gtts/min for the next 16 hours

After 1-2 days of nursing intervention, goal was met as evidenced by: patient demonstrated improved fluid balance as evidenced by: urine output of 75ml/hour

appropriate LOC Vital signs within normal range:

T=36 C P=120bpm R=20cpm BP=110/70mmH g

ASSESSMENT Subjective: Mahapdi itong dalawang kamay ko Objective: Pain scale of 7/10 Minor burn wound on both palm Grimace Irritable Vital Signs: T:36 C P:125bpm R:30cpm BP:130/90mmHg

NURSING DIAGNOSIS Acute pain related to destruction of the skin layer 2 burn injury

SCIENTIFIC EXPLANATION Burn Injury

PLANNING Short term goal: After 8 hours of effective nursing intervention the patient will report that pain was reduced as evidenced by: pain scale of 35/10

NURSING INTERVENTIONS Independent: Cover wound as soon as possible unless open area exposure burn care is required Elevate burned extremity periodically Assist with active and passive ROM as indicated Encourage expression of feeling about pain

RATIONALE

EVALUATION Short term goal:

Trigger inflammatory response

Temperature After 8 hours of rendering changes can cause nursing interventions goal great pain to was met as evidenced by: expose nerve endings pain scale of 4/10 Reduce edema formation and discomfort Movement and exercise reduce muscle fatigue Verbalization allows outlet of emotion and enhance coping mechanism Promotes relaxation and reduces muscle tension no grimaces absence of irritability

Release of chemical mediators such as prostaglandins

no grimaces absence of irritability

Edema formation

Compression of nerve endings Provide basic comfort measure such as massage on the un injured area and frequent position changes

Pain

Collaborative: Administer Tramadol 50mg IV q8 PRN For pain relief measure