Table of Contents

I. INTRODUCTION ................................................................................................................ 2

II. PERSONAL DATA .............................................................................................................. 4

III. DEVELOPMENTAL DATA ................................................... Error! Bookmark not defined.

IV. PATIENT’S DIAGNOSIS IMPRESSION .............................................................................11

V. ANATOMY AND PHYSIOLOGY ........................................................................................13

VI. PHYSICAL ASSESSMENT ................................................................................................16

VII. ETIOLOGY ........................................................................................................................21

VIII. SYMPTOMATOLOGY........................................................................................................22

IX. PATHOPHYSIOLOGY .......................................................................................................26

X. DOCTOR’S ORDER (verbal order) ....................................................................................29

XI. DIAGNOSTICS AND LABORATORY TESTS ....................................................................34

XII. SPECIAL PROCEDURE ....................................................................................................47

XIII. DRUG STUDIES ................................................................................................................40

XIV. NURSING CARE PLANS ...................................................................................................59

VIII. NURSING THEORIES .......................................................................................................70

XV. RECOMMENDATIONS ......................................................................................................74

a. Patient and Family ..........................................................................................................74

b. Nursing Education ..........................................................................................................74
c. Nursing Practice .............................................................................................................75
d. Nursing Research...........................................................................................................75
XVI. BIBLIOGRAPHY ................................................................................................................76
 2

I. INTRODUCTION

Burns are an injury to the skin or other organic tissue primarily caused by heat or
due to radiation, radioactivity, electricity, friction or contact with chemicals. Burn is
commonly seen in developing countries which cause significant morbidity and mortality.
Burns are also one of the most expensive of traumatic injuries due to the extended
hospital stay and rehabilitation. The injuries result in higher rates of permanent disability
and economic hardship for the individual as well as their families.

Burns are a global public health problem. According to the World Health
Organization, burns account to an estimated 265 000 deaths worldwide each year. The
majority of these occur in low- and middle-income countries and almost half occur in the
South-East Asia Region. According to the Online Electronic Injury Surveillance System
(ONEISS) Department of Health, burn injury cases peaked during months of April to June
2012, accounting to 90,000 deaths nationwide. The Philippines has a total of 4 burn
centers, and the Southern Philippines Medical Center (SPMC) is the principal referral
facility in region XI, receiving at least 90 to 100 cases a year.

Burn wounds can be classified into 6 separate groups based on the mechanism of
injury: scalds, contact burns, fire, chemical, electrical, and radiation. Thermal burn injury
is the most common type of burn injury that necessitates an approach that initially focuses
on the airway, breathing, and circulation of the injured patient. In the SPMC emergency
room, patients with severe thermal injuries are triaged as immediate cases and are
assessed of respiratory and cardiovascular status, monitored for the extent and depth of
burn injury.

For three days, under the supervision of Mrs. Dinna Rose Bayog RN, MN, the
group was exposed to the Emergency Department, specifically in the triage and e-
medicine area, wherein the group has chosen a Second Degree Eletrical Burn Injury as
the case in relation to the concept of Care of Clients with Problems in Cellular Aberration,
 3

Acute Biologic Crisis Including Emergency and Disaster Nursing. This was chosen by the
proponent in order to learn more about the injury and the treatment regimen that are
rendered to achieve the optimum level of care. This case study will also serve as a good
avenue for a student nurse to develop their skills and knowledge in providing care to
clients with cellular aberration and acute biologic crisis.
 4

II. PERSONAL DATA

A. Profile

• Patient’s Code Name : L.C.L.

• Age : 26 years old

• Birth date : March 28, 1991

• Height : 5’6

• Weight : 59 kilograms

• Nationality : Filipino

• Sex : Male

• Educational Background : High School Graduate

• Occupation : Unemployed

• Civil Status : Single

• Religion : Roman Catholic

• Ethnic Background : Bisaya

• Source of Information/Informant/s : G.C

B. Clinical Data

• Date of Admission : December 11, 2017

• Chief Complaint : Burn pain upper extremities

• Vital Signs upon Admission:

o Temperature : 35.7 degree Celsius

 5

o Respiration Rate : 28 cycles per minute

o Cardiac Rate : 120 beats per minute (apical pulse)

no radial & pedal pulse

o Blood Pressure : 130/60 mmHg

• Admitting Physician : Paul Nebres, MD

• Admitting Clerk : no admitting clerk

• Admitting Diagnosis : 2nd Degree Full thickness burn (Head to toe)

• Ward or Unit/Room/Bed No. : Emergency Room / Trauma Section

December 11, 2017 at 6 in the evening, L.C.L was deployed in buhangin to repair

a broken electrical wiring in their electrical company. The informant of the patient said

that he was about to avoid the livewire in front of him, but he did not notice that it was

near his shoulder already. The patient was electrocuted was then brought to to Southern

Philippine Medical Center via the Emergency Management Service of Davao City.
 6

III. DEVELOPMENTAL DATA

Erik Erikson Psychosocial Development

Erik Erickson was born in 1902 in Frankfurt-am-Main, Germany. After completing

high school, he moved to Florence to pursue his interest in art, and in 1927, he
became an art teacher at psychoanalytically enlightened school for children started by
Dorothy Burlingham and Anna Freud in Vienna. The move changed his life and career.
He earned a certificate from the Maria Montessori School, and then embarked on
psychoanalytic training at thVienna Psychoanalytic Institute. By 1936, he had joined
the Institute of Human Relations, part of the department of psychiatry at Yale
University.
He envisioned life as a sequence of levels of achievement. According to him, each
individual passes through eight developmental stages, also known as psychological
crisis. Each stage is characterized by different psychological crises, which must be
achieved or resolved by the individual before he/she can move on to the next stage.
The resolution of the conflicts at each stage enables the person to function effectively
in the society.

The Stages

Hopes: Trust vs. Mistrust (Oral-sensory, Birth-2 years)

Will: Autonomy vs. Shame & Doubt (Muscular-Anal, 2-3 years)

Purpose: Initiative vs. Guilt (Locomotor-Genital, Preschool, 3-5 years)

Competence: Industry vs. Inferiority (Latency, 5-12 years) Fidelity: Identity vs.
Role Confusion (Adolescence, 13-19 years)

Love: Intimacy vs. Isolation (Young adulthood, 20-24, or 20-39 years)

Care: Generativity vs. Stagnation (Middle adulthood, 25-64, or 40-64 years)

Wisdom: Ego Integrity vs. Despair (Late adulthood, 65-death)

 7

Developmental Task & Rationale Justification

Rationale
INTIMACY VS. ISOLATION Intimacy
In young adulthood, people The patient has a girlfriend, and
face the challenge of according to his informant, he does
developing intimate have a good record of being friendly
relationships with others. If in the workplace, wherein he makes
they do not succeed, they good friends.
may become isolated and
lonely. The patient has a job at the age of 26,
GENORATIVITY BS Generativity works as an electrician, and wants to
STAGNATION learn more regarding mechanical
As people reach middle concepts on how to repairs
adulthood, they work to automobiles, according to th patient’s
become productive informant.
members of society, either
through parenting or through
their jobs. If they fail, they
become overly self-
absorbed.
 8

Havighurst’s Developmental Tasks Theory

Havighurst’s main assertion is that development is continuous throughout the

entire lifespan, occurring in stages, where an individual move from one stage to the next
by successful resolution of problems or performance of developmental tasks. These tasks
are typically encountered by most people in the culture where the individual belongs.
When a person successfully accomplishes and masters these tasks, he/she feels the
pride and satisfaction, and consequently earns the approval of society. This success
provides a good foundation which allows to accomplish developmental tasks that he/she
will encounter at later stages. On the other hand, if a person fails, he/she will become
unhappy and is not accorded the desired approval by society, which makes him/her feel
the experience of difficulty when faced with succeeding developmental tasks.
(Psychologynoteshq.com, 2017)

Stage Age Characteristics Result Justification

Early 26  Choose a partner On the The patient has a

Adulthood  Establish a family process girlfriend and a stable
(18-35  Manage a home career. However, he is
years old)  Establish a career still living with her
(Psychologynoteshq.com, mother, and establish
2017) his family of his own.
 9

John H. Westerhoff’s Faith Development Theory

Westerhoff presented two separate theories of faith development in his writings.

The first, a four-stage theory where faith grows like the rings of a tree, with each ring
adding to and changing the tree somewhat, yet building on that which has grown before.
Our lives as people of faith can best be understood as a pilgrimage that moves slowly
and gradually through ever-expanding expressions. (Westerhoff, 1976)

Stage Age Characteristics Result Justification

Searching 26 - One becomes aware Achieved The patient has become

Faith that personal beliefs recently religious.
(Adolescent or experience may no According to his
to Early longer be exactly the informant, the patient
Adulthood) same as those of the regularly attends Sunday
group. Mass at Redemptorist
- Beginning to question Church. He is very
some of the hardworking, wherein he
commonly held only stated as a lineman
beliefs or practices. in their company, as he
- Naturally recognizes is now an electrician,
that his or her faith is and has learned much
formed more by about his job.
others than by
personal conviction.
- Discerning whether
or not to develop,
express, and accept
responsibility for a
personal
interpretation of one's
 10

religion as over
against accepting
that which may be
viewed as a group's
interpretation.
- Often there is
experimentation in
which persons try out
alternatives or
commit themselves to
persons or causes
which promise help in
establishing personal
conviction and active
practice of one's faith.
(Westerhoff, 1976)
 11

IV. PATIENT’S DIAGNOSIS IMPRESSION

Impression: 45% TBSA % 2nd Degree Full Thickness Burns

Second-degree full-thickness burns involve the entire epidermis and dermis.

Structures that originate in the subcutaneous layer, such as hair follicles and sweat
glands, remain intact. These burns can be very painful because the pain sensors remain
intact. Tactile sensors may be absent or greatly diminished in the areas of deepest
destruction. These burns appear as mottled pink, red, or waxy white areas with blisters
and edema. The blisters resemble flat, dry tissue paper, rather than the bullous blisters
seen with superficial partial-thickness injury. After healing, in approximately 1 month,
these burns maintain their softness and elasticity, but there may be the loss of some
sensation. Scar formation is usual. These burns heal with supportive medical care aimed
at preventing further tissue damage, providing adequate hydration, and ensuring that the
granular bed is adequate to support re-epithelialization. (Porth’s Pathophysiology, 2012)

Total body surface area (TBSA)

is an assessment of injury to or disease
of the skin, such as burns or psoriasis. In
adults, the Wallace rule of nines can be
used to determine the total percentage of
area burned for each major section of the
body. In burn cases that involve partial
body areas, or when dermatologists are
evaluating the Psoriasis Area and
Severity Index (PASI) score, the patient's
palm can serve a reference point roughly
equivalent to 1% of the body surface
area. For children and infants, the Lund
and Browder chart is used to assess the
burned body surface area. Different percentages are used because the ratio of the
 12

combined surface area of the head and neck to the surface area of the limbs is typically
larger in children than that of an adult.
 13

V. ANATOMY AND PHYSIOLOGY

Function
The Integumentary system protects deeper tissues from mechanical damage
(bumps), chemical damage (acids and bases), ultraviolet radiation (damaging effects of
sunlight), bacterial damage, thermal damage (heat or cold), and desiccation (drying out).
The skin also aids in body heat loss or heat retention as controlled by the nervous system,
aids in the secretion of urea and uric acid through perspiration produced by the sweat
glands, synthesizes vitamin D through modified cholesterol molecules in the skin by
sunlight and lastly, the integumentary system has sensory receptors that can distinguish
heat, cold, touch, pressure, and pain.

Layers of the skin

1. Epidermis - The outermost layer, the epidermis, is composed of stratified
epithelium. Epidermis has 2 components, an outer layer of anucleate cornified cells
(stratum corneum) that covers inner layers of viable cells (Malpighian layers) from
which the cornified surface cells arise by differentiation. The stratum corneum acts
 14

as a barrier to impede the entrance of microorganisms and toxic substances while

allowing the body to retain water and electrolytes. Malpighian layers provide a
continuous production of cornified cells. Malpighian layers can be further
subdivided into the germinal basal cell layer, stratum spinosum, and stratum
granulosum.

2. Dermis - Beneath the epidermis is the dermis, which is composed of a dense

fibroelastic connective-tissue stroma containing collagen and elastic fibers and an
extracellular gel termed ground substance. This amorphous gel comprises an acid
mucopolysaccharide protein combined with salts, water, and glycoproteins; it may
contribute to salt and water balance, serve as a support for other components of
the dermis and subcutaneous tissue, and participate in collagen synthesis. The
dermal layer contains an extensive vascular and nerve network, special glands,
and appendages that communicate with the overlying epidermis. The dermis is
divided into 2 parts. The most superficial portion, the papillary dermis, is molded
against the epidermis and contains superficial elements of the microcirculation of
the skin. It consists of relatively cellular, loose connective tissue with smaller, fewer
collagen and elastic fibers than the underlying reticular dermis. Within the papillary
dermis, dermal elevations indent the inner surface of the epidermis. Between the
dermal papillae, the downward projections of the epidermis appear peglike and are
termed rete pegs. In the reticular portion of the dermis, collagen and elastic fibers
are thicker and greater in number. Fewer cells and less ground substance are
found in the reticular dermis than in the papillary dermis. Thickness of the dermis
varies from 1-4 mm in different anatomic regions and is thickest in the back,
followed by the thigh, abdomen, forehead, wrist, scalp, palm, and eyelid. Thickness
varies with the individual's age. It is thinnest in the very old, where it is often
atrophic, and in the very young, where it is not fully developed.

3. Subcutaneous tissue - The third layer of skin is subcutaneous tissue, which is

composed primarily of areolar and fatty connective tissue. This layer shows great
regional variations in thickness and adipose content. It contains skin appendages,
 15

glands, and hair follicles. Hair follicles extend in deep narrow pits or pockets that
traverse the dermis to varying depths and usually extend into the subcutaneous
tissue. Each hair follicle consists of a shaft that projects above the surface and a
root that is embedded within the skin.

There are 2 types of sweat glands in skin: apocrine and eccrine. Apocrine
glands are epitrichial because they have a duct that opens into a hair follicle.
Apocrine glands are largely confined to the axillary and perineal region and do not
become functional until just after puberty. Eccrine glands are simple, coiled, tubular
glands usually extending into the papillary dermis. Eccrine glands are atrichial
because their duct opens onto the skin surface independently of a hair follicle.
Eccrine glands are found over the entire body surface, except the margins of the
lips, eardrum, inner surface of the prepuce, and glans penis. Sebaceous glands
are simple or branched alveolar glands, usually connected to the hair follicles.
Sebaceous glands unconnected with hair follicles occur along the margin of the
lips, in the nipples, in the glans and prepuce of the penis, and in the labia minora.
Depending on the depth of burn injury, epithelial repair can be accomplished from
local epithelial elements and skin appendages. When skin is burned, the damaged
stratum corneum allows the invasion of microorganisms, and the Langerhans cells,
which mediate local immune responses, also are damaged. In burn patients with
severe injuries, their systemic immune response is diminished, making them
susceptible to serious infections.
 16

VI. PHYSICAL ASSESSMENT

A. Admission Data

Name: L.C.L
Gender: Male Weight: 59 kilograms
Age: 28 y.o. Height: 167.64 cm
Date: December 11, 2017 Blood Pressure: 130/90
Time: 7:00 pm Temperature: 35.7
Arrived Via: Stretcher Pulse: 120bpm
From: Buhangin Road Respiration: 28cpm
Admitting M.D.; Paolo Nebres M.D. Source Providing Information: Patient
Time Notified: - 7:20pm and Watcher
Attending M.D.: Paolo Nebres M.D.

B. Allergies and Reaction

Drugs: none Blood Reaction: No blood transfusions

Food/Other: none done
Signs/Symptoms: n/a Dyes/Shellfish: Not known

The mother of the patient stated that his son does not have any allergies on food and
medications. She also added that his son did not receive any blood transfusions yet, and
has not yet tried of experiencing diagnostic procedure that makes the use of dyes.
 17

C. Medical History

Cardiac Problems: none Muskoskeletal Problems: none

Hypertension: none Stroke: none
Diabetes Problems: none Seizures: none
Cancer Problems: none Glaucoma: none
Respiratory Problems: none Other problems: none
Gastrointestinal Problems: none

The watcher of the patient stated that the patient has no evident records and diagnosis
of having a chronic illness.

D. Special Assistive Devices

The patient is not using any of the assistive devices mentioned below, and did not
mention the use of any other devices.

 Wheelchair  Glasses  Venous Access

 Braces  Hearing Aid Device
 Cane/Crutches  Prosthesis  Dentures
 Walker  Glasses  Epidural Catheter
 Contacts  Others

E. Vital Signs

Temp: 35.7 BP: 130/90 cpm RR: 28 PR: Radial pulse is absent Apical HR: 120 bpm O2
Sat.: 94%
Pain Scale: 10/10 all throughout tupper extremities and the torso.
 18

I. Psychosocial History

Recent Stress:

The patient stated “ok na man unta akoang trabaho, wala lang jud napansin na naigo na
diay ang linya sa akoang panit”. The patient’s watcher also added that the night he had
not done something wrong in this company.

Coping Mechanism:

He often goes out alone and wants to spend time all alone. He visits beer houses and
hangout with his co-workers.

Support System:

The patient has good set of friends that he talks to, he goes with his brother, as well as
his mother.

Emotional State:

The patient is currently anxious and restless on his bed as he was ordered to have an
Foley Catheter put on him. The patient is observed to be crying and moaning while the
physical assessment is ongoing, but he is still responsive of the questions asked.

Religion: Roman Catholic

Tobacco Use: The patient never tried of smoking cigarettes and tobacco.

Alcohol Use: The patient only drinks upon occasions like birthdays and weddings, and
only drinks up to two bottles of beer.
 19

Drug Use: The patient have never been engage in using prohibited drugs

II. Neurological

Orientation:
The patient is able to respond when asked about his name in a irritable manner,
but is confused on where he shows signs of lethargy. However, the patient became
restless when pain was infected on both Foley Catheter insertion and Endotracheal
Tubing insertion. The patient is in his anxious state when nurses started checking the
surface area of his skin.

Pupils:

Pupils dilate at 4mm and constrict at 3mm symmetrical movement on both sides.

Extremity Strength

The patient’s extremities are symmetrical in strength, with weakness observed on

upper and lower extremities.

III. Muscoskeletal

Range of Motion

The patient’s ROM on extremities is limited only because of the presence of

scalding that has been ruptured and peeled of all throughout the patient’s body. Pain is
also noted on both upper and lower extremities with a pain scale of 10 out of 10, as
evidenced by face moaning of the patient as blister residue are slowly being peeled of his
skin.
 20

IV. Respiratory

The patient’s respiration is 28 cycles per minute. The pattern of breathing is even,
wherein once the patient feels pain, he does short and fast breaths. An Endotracheal
Tube, with a level of 25mm and 1 rotation, is attached to the patient. The Endotracheal
Tube is then connected into an oxygen source and a bag, valve, and mask.

V. Cardiovascular

The patient’s Apical Rate is 120bpm with a regular pace. However, there was no
palpated pulse on both left and right radial and pedal pulse. The oxygen saturation of the
patient, based on the pulse oximeter readings, would have an average of 94%.

VI. Gastrointestinal

The patient’s oral mucosa is pale and some of the tissues near the lower lip are also burnt
and dry. The patient also complains of being thirsty. The patient’s bowel sounds was not
assessed because the physician performed a venous cut down on bedside.

VII. Integumentary
`
The patient has acquired a 2nd degree superficial full-thickness burn on areas that are as
follows; Head and neck (9%), Anterior (18%) trunk, Left (9%) and Right (9%) arms.
Majority of the scalding are seen as ruptured blister on the patient’s upper
and lower extremities, but some blisters are still intact on the patient’s
chest, legs and shoulder. No necrotic tissue found. Tenderness is also felt
by the patient upon palpation and rush of air unto the ruptured blister.
Capillary Refill is not clearly visible due to the blackening of fingernails due
to burning and smog. He skin is cold and clammy all throughout the body
with fluids coming out from the blisters which are ruptured. Patient skin
turgor on his abdomen cannot be identified due to present of scalds.
 21

VIII. ETIOLOGY

Factors Description Occurrence Justification

Psychological Chronic stress can Present The patient was under
Stress increase the production of stress due to being busy
cortisol, a stress hormone, at work, and the fact the
that can act as a sedative he is always on call in his
and if produced in large company makes him
amounts may contribute to irritable and stressed if
habitual patterns of he will be called on
thought which influence unholy hours.
appraisal and increases
the likelihood of a person
to experience as negative
(such as low self-efficacy,
or a conviction that one
cannot cope with stress)
habits to the point of
suicidal actions or
attempts.
Electrical Heat generation and Present The patient suffered from a
Burn electroporation of cell electrical burn when
membranes associated exposed to a livewire during
with massive current of his work.
electrons. Electrical burns
often cause extensive
deep tissue damage to
electrically conductive
tissues, such as muscles,
nerves, and blood vessels,
despite minimal apparent
cutaneous injury.
 22

VII. SYMPTOMATOLOGY

Present/Abse
Symptoms Rationale Justification
nt
The strata of skin around the Stratum
spinosum are most susceptible to
shear. As the Stratum spinosum tears
away from the connecting tissues
below, plasma from the cells diffuses
out. This plasma solution helps new
cells divide and grow into new
connective tissues and epidermal
layers.

The clear fluid will be reabsorbed as

new cells develop and the swollen Blisters were
appearance will subside. Painful present in the
Blisters
patient’s
(ruptured) blisters located on hands (palmar Present
extremities,
surface) and feet (plantar surface) are some were
due to tissue shearing deeper in the ruptured.
epidermis, near nerve endings. Lower
tissues are more susceptible to
infection.

Source: Uchinuma, E; Koganei, Y;

Shioya, N; Yoshizato, K (1988).
"Biological evaluation of burn blister
fluid". Annals of Plastic Surgery. 20 (3):
225–30. PMID 3358612.
doi:10.1097/00000637-198803000-
00005.
The instant pain that follows a burn
The patient
injury is due to stimulation of skin
was screaming
nociceptors that respond to heat every time he
(thermoreceptors), mechanical was touched
Pain distortion (mechanoreceptors) and a Present by the doctors
selection of stimuli including chemical and nurses
stimuli – exogenous (e.g. hydrofluoric indicating he
acid) and endogenous (e.g. was in a lot of
pain.
inflammatory mediators, notably
 23

histamine, serotonin, bradykinin,

leukotrienes and prostaglandins).
Nerve endings that are entirely
destroyed will not transmit pain, but
those that remain undamaged and
exposed will generate pain throughout
the time and course of treatment.
These immediate pain sensations are
elicited by activity in the unmyelinated
C- and thinly myelinated Aδ-primary
afferent neurons that synapse with
neurons in the dorsal horn of the spinal
cord.

Source: Kidd BL, Urban LA.

Mechanisms of inflammatory pain. Br J
Anaesth 2001; 87: 3–11
Burn injury immediately destroys cells,
or it disrupts their metabolic functions
so completely that cellular death
ensues cellular damage is distributed The patient’s
over a spectrum of injury. Some cells skin was
White or
Present peeling, mostly
charred skin are destroyed instantly others are
in his arms and
irreversibly injured legs.

Source: Herndon D. Total burn care.

2nd ed. London: WB Saunders, 2002
The release of chemical mediators Although
causes an increase in capillary edema wasn’t
permeability and a fluid shift from the present
because of the
intravascular space into the injured
open and
tissues. Injury to the sodium pump in peeling skin.
the cell walls accentuates the The swelling
Swelling increased permeability as sodium Present was not
moves into injured cells it causes an contained
increase in osmotic pressure that within
increases the inflow of vascular fluid intracellular
compartment
into the wound. Finally, the normal
and was
process of evaporative loss of water leaking out of
into the environment is dramatically the patient’s
 24

accelerated (5 to 15 times that of bodily tissues

normal skin) through the burned tissue. and into the
surface of the
burned area.
Source: Herndon T. Total burn care.
Third ed. Philladelphia: Saunders;
2007.
The skin protects against fluid and
electrolyte loss. Burn injury does affect
skin integrity and protection against
fluid loss is lost. Thus, a systemic
dehydration can be provoked by
underestimation of fluid loss through
burn wounds. Combined with the The patient
release of chemical substances into was
the blood, this will lead to increased dehydration as
evidenced by
Dehydration capillary permeability to fluids, leading Present
dry mouth and
to the leaking of fluids from the blood decreased and
vessels into the tissues. The higher the massive fluid
percentage of burned skin, the more shif.
severe the loss of fluid will be and the
greater the dehydration will be.
Source: Baxter CR. Fluid volume and
electrolyte changes of the early
postburn period. Clin Plast Surg.
1974;1(4):693–703. [PubMed]
A sign of shock which is life-threatening
condition that occurs when there's an
insufficient supply of oxygen to the
body. It's possible to go into shock after
a serious burn.

Burn shock is a unique combination of The patient’s

Cold and
Present skin was cold
Clammy skin distributive and hypovolemic shock
to touch.
manifested by intravascular volume
depletion, low pulmonary artery
occlusion pressures, elevated
systemic vascular resistance, and
depressed cardiac output. Reduced
cardiac output is a combined result of
 25

decreased plasma volume, increased

afterload, and decreased contractility.

Source: Inancsi WI, Guidotti TL.

Occupation related burns: five-year
experience of an urban burn center. J
Occup Med. 1987. 29:730.
 26

VIII. PATHOPHYSIOLOGY

Predisposing Factor:
Psychological Stress

Abnormal increase of
Cortisol Pain

Stimulation of
Thermoreceptors
Inability to focus on
tasks
White or
Charred Skin
polymorphonuclear
Coagulative necrosis of leucocytes
the epidermis and parts activation
of the dermis.

Increased
Increased Increased formation of
production of production of Reactive
TNF-α interleukin-6 Oxygen
Species

Pain Produce Inflammatory arachidonic

mediators (Histamine) acid hydrolysis

Vascular Vasodilation rapid formation of

prostaglandin

Increased Inhibition of
Vascular Cell membrane norepinephrine release
Permeability injury

Activation of Adrenergic
Nervous system
 27

Increased extravascular
osmotic activity

Fluid shift from intravascular

to interstitial Swelling or formation
Rupture of
of blisters
Blisters

Increased in Decreased vascular Cardiac

hematocrit and blood colloidal osmotic Dehydration Derangement
concentration. pressure

Edema in non-
affected areas
Thombosis

Inflammatory cells and

necrotic debris
Hypoxia to vital organs production

Damage to the
columnar epithelia

Cold Clammy Burn Shock

Skin
Distal obstruction and
potential infection.

Prognosis

If not treated: If treated:

Multiple organ failure Main Principles of care

 Thermal injury and adherence of irritants to the upper
28
respiratory tract results in the release of inflammatory
Respiratory mediators and ROS, increased vascular permeability,
and edema formation. The edema in the upper
respiratory tract can progress to airway obstruction
and bronchospasm that peaks at 24 hours.

The effects of burn injury on the gastrointestinal tract

include gastric dilation and decreased peristalsis. Wound Closure
These effects are compounded by immobility and
narcotic analgesics. Burn victims are observed
carefully for vomiting and fecal impaction. Acute
Gastrointestinal ulceration of the stomach and duodenum(called
Curling’s ulcer) is a potential complication in burn
victims and is thought to be the result of stress and
gastric ischemia. Prevention of
Septic
Complications

Renal insufficiency can occur in burn patients as

a result of the hypovolemic state, damage to the
kidneys at the time of the burn, or drugs that are
administered. Immediately after a burn, there is
Renal often a short period of relative anuria, followed Adequate
by a phase of hypermetabolism characterized Nutrition
by increased urine output and nitrogen loss.

Control of the
external
A hallmark of burn injury is tachycardia, environment.
increased myocardial oxygen consumption, and
Cardiac increased cardiac output. Cardiac stress is
largely mediated by an increased catecholamine
response immediately following burn injury.

When the skin is no longer intact, the body is

open to bacterial infection. Destruction of the
Integumentary skin also prevents the delivery of cellular Burn Wound
components of the immune system to the site of Healing
injury.

Acidosis
Stasis
normalization

Secondary
hypovolemic
Shock

Recovery
Death
 29

IX. DOCTOR’S ORDER (verbal order)

Date/Time Verbal Order Rationale Remarks

December  Remove all Exposing the surface The patient was received

11, 2017/ clothing from the area of the patient’s with only wrearing

7:02pm patient and body enables the easy underwear and

monitor vital signs way of a rapid basketball short. The

of the patient q15 assessment of the type nurse directly removed

minutes. and amount of burnt both garments.

area in the body.

Clothing can also be a

source of irritation on

the burnt areas.

Monitoring the vital

signs of burn patients

enable s

December  Perform rapid Assessment of the A resident doctor

11, 2017/ initial assessment Total Body Surface performed TBSA, with a

7:05pm (TBSA) of Area (TBSA) suggests student nurse noting the

respiratory and of which emergency findings. 45% of the

cardiovascular procedure should be patient’s body scalded.

status. done to the patient, as

well as measure the

 30

December  Administer and Placing 1 or 2 large- The nurse was not able to

11, 2017/ Begin IV Therapy bore peripheral lines get a patent and running

7:07pm Lactated Ringer’s and administer IV line on both upper

Fast Drip. crystalloids, such as extremities. Thus, the

Lactated Ringers nurse inserted one on the

solution, to Great saphenous vein on

compensate the lost dorsal aspect of the right

fluids in the blood due foot.

to the tendency to

cross intracellularly due Fluid requirement (mL) =

to increased (4 mL of crystalloid) × (%

permeability in the TBSA burned) × body

vascular membranes. weight (kg)

December  Insert Foley Having a Foley Two female E.R. nurses

11, 2017/ Catheter and Catheter attached to were able to successfully

7:30pm Attach to Urobag. the patient would allow inserta Foley Catether to

healthcare providers to the patient’s bladder with

measure the urine only inflicting pain on a

output of the patient in minimal time to the

order to look for signs patient.

of dehydration(dark

yellow urine) and

bleeding(hematuria). It
 31

also helps to monitor

the effectiveness of IV

fluid replacement

December  Attach Early intubation rather Patient Endotracheal

11, 2017/ Endotracheal than observation is Tubing placement is

8:00pm Tubing for recommended in checked through

Anaphylactic patients with signs of auscultation of

Shock Prophylaxis upper airway injury in symmetrical lung sounds,

order to prevent the and with a level of 25mm

patient on oxygen and with 1 rotation.

air deprivation upon the

possible onset of

anaphylactic shock

prior to burns.

December  Connect Bag VBM application can

11, 2017/ Valve mask (BVM) support higher

8:12pm to E.T. tubing, as respiratory rates (16-20

well as 6 Liters of breaths/min) and

oxygen to the smaller tidal volumes

BVM. (7-8 mL/kg). This

procedure is important

on High-frequency
 32

flow-interruption

ventilation

December  Prepare in Severe burn victims The physician started his

11, 2017/ instruments and should have at least 2 venous cut-down on the

7:30pm patient on lines in place; if right upper chest of the

bedside for necessary, venous patient, with all

central venous catheters may be instruments and incision

line cut-down. placed through burned area in a sterile condition.

skin or via venous Therefore, the physician

cutdown using the left found a vein of insertion

internal jugular vein,in and inserted a venous

order to centralize the catheter in place.

fluid distribution on the

vascularities and

promote faster fluid

balancing.

 Begin Lactated Continuing the IV This is a continuation of

Ringer’s Solution therapy for LR solution the Fluid recusitation

IV Therapy for able to maintain the wherein an patient burnt

both right leg line tissue perfusion in the

 33

and venous cut- early phase of burn more than 20% of Total

down line. shock, in which Body Surface Area.

hypovolemia may

occurs due to steady

fluid extravasation from

the intravascular

compartment.
 34

X. DIAGNOSTICS AND LABORATORY TESTS

Clinical
Test Rationale Nursing Responsibilities
significance

Arterial An arterial blood An arterial blood gas Implementation

Blood Gas gas (ABG) test (ABG) test is done to:
measures the 1. Use a heparinized blood
acidity (pH) and  Check for severe gas syringe to draw the
the levels of breathing problems sample.
oxygen and and lung diseases, 2. Perform an arterial
carbon dioxide in such as asthma, puncture or draw blood
the blood from an cystic fibrosis, or from an arterial line.
artery. This test is chronic obstructive 3. Eliminate air from the
used to check pulmonary disease sample, place it on ice
how well your (COPD). immediately, and
lungs are able to  See how well prepare to transport for
move oxygen into treatment for lung analysis.
the blood and diseases is 4. Note the flow rate of
remove carbon working. oxygen therapy and
dioxide from the  Find out if you need method of delivery.
blood. extra oxygen or 5. Note the patient’s rectal
help with breathing temperature.
(mechanical
Nursing Interventions
ventilation).
 Find out if you are
1. After applying pressure
receiving the right
to the puncture site for 3
amount of oxygen
to 5 minutes and when
when you are using
bleeding has stopped,
oxygen in the
tape a gauze pad firmly
hospital.
over it.
 Measure the acid-
2. If the puncture site is on
base level in the
the arm, don’t tape the
blood of people
entire circumference
who have heart
because this may
failure, kidney
restrict circulation.
failure, uncontrolled
3. If the patient is receiving
diabetes, sleep
anticoagulants or has a
disorders, severe
coagulonopathy, apply
pressure to the
 35

infections, or after a puncture site longer

drug overdose. than 5 minutes if
necessary.
4. Monitor vital signs and
observe for signs of
circulatory impairment.

Pulse a noninvasive Pulse oximetry is 1. Some machines have a

Oximetry method for particularly convenient pleth wave. A steady,
monitoring a for noninvasive level, even wave form
ensures that the
person's oxygen continuous
numerical reading is
saturation (SO2). measurement of blood accurate.
Though its oxygen saturation. In 2. The pulse rate on the
reading of SpO2 contrast, blood gas oximeter should
(peripheral levels must otherwise correspond to the
oxygen be determined in a patient’s actual pulse. If
saturation) is not laboratory on a drawn it doesn’t, monitor the
patient, check the
always identical blood sample. Pulse
oximeter, and
to the more oximetry is useful in reposition the probe.
desirable reading any setting where a 3. Factors that interfere
of SaO2 (arterial patient's oxygenation with accuracy include:
oxygen is unstable, including o Elevated
saturation) from intensive care, carboxyhemoglobin or
arterial blood gas operating, recovery, methemoglobin levels
o Lipid emulsions and
analysis, the two emergency and dyes
are correlated hospital ward settings, o Excessive light
well enough that pilots in unpressurized o Excessive patient
the safe, aircraft, for movement
convenient, assessment of any o Hypothermia
noninvasive, patient's oxygenation, o Hypotension
o Vasoconstriction
inexpensive and determining the
o Medications such as
pulse oximetry effectiveness of or dapsone,
method is need for supplemental vasopressors.
valuable for oxygen. Although a 4. Use the bridge of the
measuring pulse oximeter is used nose if the patient has
oxygen saturation to monitor compromised
in clinical use. oxygenation, it cannot circulation in his
extremities.
determine the
 36

metabolism of oxygen, 5. If an automatic blood

or the amount of pressure cuff is used
oxygen being used by on the same extremity
as the saturation probe
a patient. For this
is placed, the cuff will
purpose, it is interfere with oxygen
necessary to also saturation readings
measure carbon during inflation.
dioxide (CO2) levels. It 6. If the light is a problem,
is possible that it can cover the probes.
also be used to detect 7. If patient movement is
the problem, move the
abnormalities in
probe or select a
ventilation. different probe.
8. Notify the physician of
any significant change
in the patient’s
condition.

CBC A complete blood 1. Explain test procedure.

count (CBC) is a A complete blood
Explain that slight
blood test used to count is a common
blood test that's done discomfort may be felt
evaluate your
overall health and for a variety of when the skin is
detect a wide reasons:
punctured.
range of
 To review overall 2. Encourage to avoid
disorders,
including anemia, health. A doctor stress if possible
infection and may recommend a
because altered
other diseases. complete blood
count as part of a physiologic status
routine medical influences and changes
examination to
normal hematologic
monitor a general
health and to values.
screen for a variety 3. Explain that fasting is
of disorders, such not necessary.
as anemia or
However, fatty meals
leukemia.
may alter some test
 37

results as a result of
 To diagnose a
lipidemia.
medical
condition. A doctor 4. Apply manual pressure
may suggest a and dressings over
complete blood
puncture site on
count if you're
experiencing removal of dinner.
weakness, fatigue, 5. Monitor the puncture
fever, inflammation, site for oozing or
bruising or
bleeding. A hematoma formation.
complete blood 6. Instruct to resume
count may help normal activities and
diagnose the cause
diet.
of these signs and
symptoms. If a
doctor suspects an
infection, the test
can also help
confirm that
diagnosis.

 To monitor a
medical
condition. If
diagnosed with a
blood disorder that
affects blood cell
counts, a doctor
may use complete
blood counts to
monitor your
condition.

 To monitor
medical
treatment. A
complete blood
count may be used
to monitor your
 38

health on
medications.

Electrolytes The electrolyte Electrolyte 1. Immediately after blood is

panel is used to measurements may be drawn, pressure is applied
identify an used to help (with cotton or gauze) to
electrolyte, fluid, investigate conditions the puncture site.
or pH imbalance that cause electrolyte 2. Resume your normal
(acidosis or imbalances such as activities and any
alkalosis). It is dehydration, kidney medications withheld
frequently disease, lung before the test.
ordered as part of diseases, or heart 3. Blood may collect and clot
a routine conditions. Repeat under the skin (hematoma)
physical. It may testing may then also at the puncture site; this is
be ordered by be used to monitor harmless and will resolve
itself or as a treatment of the on its own. For a large
component of a condition causing the hematoma that causes
basic metabolic imbalance. swelling and discomfort,
panel (BMP) or a apply ice initially; after 24
comprehensive hours, use warm, moist
metabolic panel compresses to help
(CMP). These dissolve the clotted blood.
panels can
include other
tests such as
BUN, creatinine,
and glucose.
The plasma Patient Preparation
thrombin time test  To detect a
Coagulation
measures how fibrinogen 1. Explain to the patient that
profile
quickly a clot deficiency or the plasma thrombin time
forms when a defect. test determines whether
standard amount  To help diagnose blood clots normally.
of bovine DIC and hepatic 2. Notify the laboratory and
thrombin is added disease. physician of drugs the
 39

to a platelet poor  To monitor the patient is taking that may

plasma sample effectiveness of affect test results; it may
from the patient heparin or be necessary to restrict
and to a normal thrombolytic them.
plasma control agents. 3. Tell the patient that the test
sample. After requires a blood sample.
thrombin is 4. Explain who will perform
added, the the venipuncture and
clotting time for when.
each sample is 5. Explain to the patient that
compared with he may feel slight
the other and discomfort from the
recorded. tourniquet and the needle
Because puncture.
thrombin rapidly 6. Inform the patient that he
converts need not to restrict food
fibrinogen to a and fluids.
fibrin clot, the test
(also known as Nursing Interventions
the thrombin
clotting time test) 1. Apply pressure to the
venipuncture site until
allows a quick but bleeding has stopped.
imprecise 2. If a hematoma develops at
estimation of the venipuncture site,
plasma fibrinogen apply direct pressure. If
levels, which are the hematoma is large,
a function of monitor pulses distal to the
phlebotomy site.
clotting time.
3. Tell the patient that he may
resume any medication
that was discontinued
before the test is ordered.
 40

XI. DRUG STUDIES

Generic Name

LACTATED RINGER
’S SOLUTION
Classification HYPERTONIC
NON-PYROGENIC
PARENTERAL FLUID, ELECTROLYTE AND NUTRIENT REPLENISHER
Contents:
Electrolytes 1000 ml
Sodium 130 mmol
Potassium 4 mmol
Calcium 2.7 mmol
Chloride 109 mmol
Lactate 28 mmol
Osmolality 273 most
Dosage and Frequency 500 mg IVTT, q12
Mechanism of action Lactated Ringer’s Injection, USP is a sterile, nonpyrogenic solution for fluid
and electrolyte replenishment in single dose containers for intravenous
administration. It contains no antimicrobial agents. Composition, osmolarity,
pH, ionic concentration and caloric content
Indications  Lactated Ringer’s Injection, USP is indicated as a source of water
and electrolytes or as an alkalinizing agent.
Contraindications & As for other calcium-containing infusion solutions, concomitant
Cautions
administration of ceftriaxone and Lactated Ringer’s Injection, USP is
contraindicated in newborns (≤ 28 days of age), even if separate infusion
lines are used (risk of fatal ceftriaxone-calcium salt precipitation in the
neonate’s bloodstream).

In patients older than 28 days (including adults), ceftriaxone must not be

administered simultaneously with intravenous calcium-containing solutions,
 41

including Lactated Ringer’s Injection, USP, through the same infusion line
(e.g., via Y-connector).
If the same infusion line is used for sequential administration, the line must
be thoroughly flushed between infusions with a compatible fluid.

 Lactated Ringer’s Injection, USP is contraindicated in patients with

a known hypersensitivity to sodium lactate.
Drug to Drug Caution is advised when administering Lactated Ringer’s Injection, USP to
Interactions
patients treated with drugs that may increase the risk of sodium and fluid
retention, such as corticosteroids.

Caution is advised when administering Lactated Ringer’s Injection, USP to

patients treated with drugs for which renal elimination is pH dependent. Due
to the alkalinizing action of lactate (formation of bicarbonate), Lactated
Ringer’s Injection, USP may interfere with the elimination of such drugs.

•Renal clearance of acidic drugs such as salicylates and barbiturates may

be increased.

•Renal clearance of alkaline drugs, such as sympathomimetics (e.g.,

ephedrine, pseudoephedrine) and dextroamphetamine (dexamphetamine)
sulfate, may be decreased.
Renal clearance of lithium may also be increased. Caution is advised when
administering Lactated Ringer’s Injection, USP to patients treated with
lithium.

Because of its potassium content, Lactated Ringer’s Injection, USP should

be administered with caution in patients treated with agents or products that
can cause hyperkalemia or increase risk of hyperkalemia, such as potassium
sparing diuretics (amiloride, spironolactone, triamterene), with ACE
inhibitors, angiotensin II receptor antagonists, or the immunosuppressants
tacrolimus and cyclosporine.
 42

 Caution is advised when administering Lactated Ringer’s Injection,

USP to patients treated with thiazide diuretics or vitamin D, as these
can increase the risk of hypercalcemia
Nursing 1. As directed by a physician. Dosage, rate and duration of administration
Considerations
are to be individualized and dependent upon the indication for use, the
patient’s age, weight, concomitant treatment and clinical condition of the
patient as well as laboratory determinations.

2. All injections in VIAFLEX plastic containers are intended for intravenous

administration using sterile and nonpyrogenic equipment.

3. After opening the container, the contents should be used immediately

and should not be stored for a subsequent infusion. Do not reconnect any
partially used containers.

4. Parenteral drug products should be inspected visually for particulate

matter and discoloration prior to administration whenever solution and
container permit. Do not administer unless the solution is clear and seal is
intact.

5. When making additions to Lactated Ringer’s Injection, USP, aseptic

technique must be used. Mix the solution thoroughly when additives have
been introduced. Do not store solutions containing additives.

6. Additives may be incompatible with Lactated Ringer’s Injection, USP. As

with all parenteral solutions, compatibility of the additives with the solution
must be assessed before addition, by checking for a possible color change
and/or the appearance of precipitates, insoluble complexes, or crystals.
Before adding a substance or medication, verify that it is soluble and/or
stable in water and that the pH range of Lactated Ringer’s Injection, USP is
appropriate.
 43

Generic Name

LIDOCAINE

Classification Therapeutic Class: Anesthetic – topical or local, Antiarrythmics Pregnancy

Risk: Category A
Dosage and Frequency Depending on the need of the Physician on area of incision.
Mechanism of action When administered intramuscularly or intravenously, Lidocaine suppresses
the automaticity and spontaneous depolarization of the ventricles during
diastole by altering the flux of sodium ions across the cell membrane with
little or no effect on the heart. Locally, it produces local anesthesia effect by
inhibiting the transport of ions across the neural membranes. Thus, initiation
and conduction of normal nerve impulses is prevented.
Indications Intravenous – ventricular arrhythmias

Intramuscular – self-injected or when IV is unavailable during transport to

local facilities

Local – infiltration or mucosal or topical anesthetic

 Patch – used when pain is present due to post-herpetic neuralgia

Contraindications & Used cautiously in patients with:
Cautions
Liver diseases
Congenital heart failure
Patient weighing less than 50 kilograms
Geriatric patients
Respiratory depression
Shock
Heart block
Pregnancy and lactation
 44

Drug to Drug These are some of the many drugs that can increase the adverse effects of
Interactions lidocaine:
 propofol (Diprovan)
 amiodarmone (Cordarone)
 ciprofloxacin (Cipro)
 clarithromycin (Biaxin)
 erythromycin
 cimetidine (Tagamet)
 carbamazepine
 divalproex (Depakote)
 phenytoin (Dilantin)*
 valproic acid (Depakene

Side effects  Drowsiness

 Dizziness
 Nervousness
 (mucosal use) decreased or absent gag reflex
 Bradycardia
 Hypotension
 Burning sensation

Nursing 1. When Lidocaine is administered as an antiarrhythmic the nurse should

Considerations monitor the ECG continuously. Blood pressure and respiratory status
should be monitored frequently during the drug administration.
When administered as an anesthetic, the numbness of the affected part
should be assessed.

2. Serum Lidocaine levels should be monitored frequently during prolonged

use. Therapeutic serum lidocaine levels range from 1.5 to 5 mcg/ml.
If signs of overdose occur (listed above), stop the infusion immediately and
monitor the patient closely.

3. For throat sprays, make sure that the patient’s gag reflex is intact before
allowing the patient to eat or drink.
When IM injections are used, the medication should be administered in the
deltoid muscle only while frequently aspirating to prevent IV injection.

4. For direct IV injection only 1% and 2% solutions are used.

Undiluted IV loading dose of Lidocaine is administered at 1 mg/kg

at a rate of 25 to 50 mg over 1 minute. The dose may be repeated after 5
minutes.
 45

Tramadol hydrochloride
(Ultram, Zydol)

Classification Central nervous system (cns) agent;

Analgesic;
Narcotic (opiate) agonist
Pregnancy Category: C
Dosage and Frequency 50 mg/ml of injection solution (50 ml per 1 ml ampoule, 100 mg per 2 ml
ampoule)
Mechanism of action Centrally acting opiate receptor agonist that inhibits the uptake of
norepinephrine and serotonin, suggesting both opioid and nonopioid
mechanisms of pain relief. May produce opioid-like effects, but causes less
respiratory depression than morphine.
Indications  Tramadol hydrochloride tablets, USP are indicated for the
management of moderate to moderately severe pain in adults.
Contraindications & Hypersensitivity to tramadol or other opioid analgesics; patients on MAO
Cautions inhibitors; patients acutely intoxicated with alcohol, hypnotics, centrally
acting analgesics, opioids, or psychotropic drugs; substance abuse;
patients on obstetric preoperative medication; abrupt discontinuation;
alcohol intoxication; pregnancy (category C); lactation; children 75 y.
Drug to Drug Drug: Carbamazepine significantly decreases tramadol levels (may need up
Interactions to twice usual dose). Tramadol may increase adverse effects of mao
inhibitors. tricyclic antidepressants, cyclobenzaprine, phenothiazines,
selective serotonin-reuptake inhibitors (ssris), mao inhibitors may enhance
seizure risk with tramadol. May increase CNS adverse effects when used
with other cns depressants.
Herbal: St. John’s wort may increase sedation.

Side effects  ADVERSE EFFECTS:

 46

 CNS: Drowsiness, dizziness, vertigo, fatigue, headache,

somnolence, restlessness, euphoria, confusion, anxiety,
coordination disturbance, sleep disturbances, seizures.
 CV: Palpitations, vasodilation.
 GI: Nausea, constipation, vomiting, xerostomia, dyspepsia,
diarrhea, abdominal pain, anorexia, flatulence.
 Body as a Whole: Sweating, anaphylactic reaction (even with first
dose), withdrawal syndrome (anxiety, sweating, nausea, tremors,
diarrhea, piloerection, panic attacks, paresthesia, hallucinations)
with abrupt discontinuation.
 Skin: Rashes
 Special Senses: Visual disturbances.
 Urogenital: Urinary retention/frequency, menopausal symptoms.

Nursing 1. Assess for level of pain relief and administer prn dose as needed but not
Considerations to exceed the recommended total daily dose.

2. Monitor vital signs and assess for orthostatic hypotension or signs of

CNS depression.
Discontinue drug and notify physician if S&S of hypersensitivity occur.

3. Assess bowel and bladder function; report urinary frequency or retention.

4. Use seizure precautions for patients who have a history of seizures or

who are concurrently using drugs that lower the seizure threshold.

5. Monitor ambulation and take appropriate safety precautions.

Control environment (temperature, lighting) if sweating or CNS effects
occur.

6. WARNING: Limit use in patients with past or present history of addiction

to or dependence on opioids.

7. Exercise caution with potentially hazardous activities until response to

drug is known.

8. Understand potential adverse effects and report problems with

bowel and bladder function, CNS impairment, and any other bothersome
adverse effects to physician.
 47

XII. SPECIAL PROCEDURE

PROPHYLACTIC ENDOTRACHEAL INTUBATION

DEFINITION:

Endotracheal Intubation is the insertion of a tube, as into the trachea for purposes

of anesthesia, lung ventilation or prevention of entrance of foreign material into the airway.

As to the case of patient LCL, endotracheal intubation or as to prophylactic intubation is

done to treat hypoxemia and prevents drying and sloughing of the mucosal lining of the

tracheobronchial tree. If the patient is awake, oxygen administration by non breather face

mask may be sufficient; intubation may be required if the patient is stuporous,

unconscious or with significant burn injuries to the face or upper airway area.

Large burn injury (more than40% TBSA) may result in generalized tissue edema

even in the absence of inhalation injury,, requiring prophylactic incubation for airway

protection.Because laryngeal edema typically resolves in 3 to 5 days after the burn injury,

tracheostomy is avoided for upper airway distress unless there is acute obstruction or

prolonged need for ventilatory support.

PROCEDURE:

Endotracheal intubation is a procedure by which a tube is inserted through the

mouth down into the trachea (the large airway from the mouth to the lungs). In emergency

situations, the patient is often unconscious at the time of this procedure.

The doctor often inserts the tube with the help of a laryngoscope, an instrument

that permits the doctor to see the upper portion of the trachea, just below the vocal cords.

During the procedure the laryngoscope is used to hold the tongue aside while inserting
 48

the tube into the trachea. It is important that the head be positioned in the appropriate

manner to allow for proper visualization. Pressure is often applied to the thyroid cartilage

(Adam's apple) to help with visualization and prevent possible aspiration of stomach

contents.

NURSING INTERVENTIONS:

It is the physician’s responsibility to insert an endotracheal tube but it doesn’t mean

that nurses do not have a big role during this emergency procedure.

1. If the patient is in respiratory distress, oxygenate patient using bag valve mask. Attach

patient to a pulse oximeter for monitoring. Make sure to ask for reinforcement of nurses

to help you in this procedure. Delegate tasks immediately (E.g. medication nurse, nurse

who will assist the physician and prepare the laryngoscope, nurse who will assess the

condition of the patient and checks vital signs, and etc.). One nurse cannot perform all

the tasks simultaneously written below.

2. Ensure that the emergency cart is accessible to the room or the area of the patient.

3. If the patient has no intravenous access, immediately insert a line (or ask other nurse

or intravenous therapist) for premedication purposes.

4. Position the patient and the height of bed comfortable to the physician who will insert

the tube. Align patient’s head on a neutral position. Hyperextended the head to a

comfortable degree.

5. Consider premedication, optional for most patients-usually given 2-3 minutes prior to

induction. Prepare and administer the sedative medication as ordered by the physician.

6. Prepare the laryngoscope and blades. Ensure that the batteries and bulbs are working.

Ask the physician what size or type of blade he/she preferred to use.
 49

7. Assist the physician during insertion. When the tube is already in place, inflate the cuff

to the desired cuff pressure using a syringe. Check the tube position and the level in the

lip line (e.g. 20 cm, 21 cm, 22 cm, and 23 cm)

8. Fix the tube in place partially using a tape, to ensure that the tube is steady.

Assessment should be done first if the tube is in the correct place.

9. Continue to oxygenate patient using bag valve or the manual resuscitator.

10. Verify tube position immediately. Auscultate both lung fields. Assess if both chest are

rising equally.

11. Check also the pulse oximeter to assess patient’s oxygenation.

12. If the endotracheal tube is correctly place, secure tube in position using either a

leukoplast, an ET holder, or ET ties. Suction patient’s secretions as needed.

13. Attach patient to mechanical ventilator. Check the physician’s orders for the

mechanical ventilator settings.

14. The physician would request a standard chest x-ray to confirm ET placement.

Correspondingly, the physician would order an ABG test one hour after attaching the

patient to the mechanical ventilator.

15. When ABG results are out, the physician would typically adjust the mechanical

ventilator settings according to the patient’s response.

 50

Nursing Management for patients with endotracheal tube:

1. Assess the client’s respiratory status at least every 2 hours or frequently as indicated.

2. Assess nasal and oral mucosa for redness and irritation.

3. Secure the endotracheal tube with tape or ET holder to prevent movement or deviation

of the tube in the trachea.

4. Place the patient in a side lying position or semi fowler’s if not contraindicated to avoid

aspiration. Reposition patient every 2 hours.

5. Ensure the ET for placement. Note lip line marking and compare with desired

placement (18cm, 20cm, and 22cm).

6. Closely monitor cuff pressure, maintaining a pressure of 20 to 25 mmHg to minimize

the risk of tracheal necrosis.

7. Move oral endotracheal tube to the opposite of the mouth every 8 hours or depending

on the protocol of the hospital. This is to prevent irritation to the oral mucosa.

8. Provide oral care at least every 4 hours using antibacterial or antiseptic solution. Use

bite block to avoid patient from biting down.

9. Communicate frequently with the client. Give patient means to communicate using

white board or communication board.

 51

CENTRAL VENOUS LINE CUT-DOWN

DEFINITION:

Central venous line placement is typically performed at four sites in the body: the

right or left internal jugular vein (IJV), or the right or left subclavian vein (SCV).

Alternatives include the external jugular and femoral veins. A long catheter may be

advanced into the central circulation from the antecubital veins as well.

The subclavian vein is a continuation of the axillary vein draining the arm. It begins

at the lateral border of the first rib and ends at the thoracic inlet where it meets the IJV to

form the brachiocephalic vein. The SCV passes over the first rib and apical pleura and

runs along the underside of the clavicle parallel with the subclavian artery but is separated

from the artery at the anterior scalene muscle, with the vein passing over the muscle.

Central venous catheterization via the internal jugular vein has a lower incidence

of pneumothorax compared to catheterization via the subclavian vein, and it can be easily

compressed after catheter removal or after unintentional arterial puncture. Ultrasound can

be a valuable adjunct for IJV cannulation, because the incidence of anatomical variants

may be as high as 8.5%. Subclavian vein catheterization is more comfortable for awake

patients and less prone to contamination from respiratory secretions, particularly in

patients with tracheotomies.

 52

PROCEDURE:

The physician will:

1. Explain to the patient what you are about to do.

2. Choose the site for insertion: the jugular and femoral veins carry less bleeding risk and

low risk of pneumothorax; the subclavian vein is a cleaner site and is technically more

difficult . Put on the gloves and gown. Clean and drape the site.

3. Tilt the head end of the bed down by 10°–15°.

4. Draw up 10 ml of lidocaine; raise a bleb on the skin with a 27-gauge needle.

5. Infiltrate local anesthetic all around the site, working down toward the vein. Pull back

on the plunger before injecting each time to ensure that you don’t inject into the vein.

6. Have the assistant open the central line pack and take all of the items out. Ensure that

the wire moves freely on its reel – you will need to advance the wire one-handed.

7. Flush each port of the central line with saline or heparin saline, and close off each line

except the distal (usually brown) line; the wire threads through this line.

8. Attach a syringe to the large needle provided, and then proceed as follows:

– right femoral line: find the arterial pulse and enter the skin 1 cm medial to this, at

a 45° angle to the vertical and heading parallel to the artery. Advance slowly, aspirating

all the time, until you enter the vein

 53

– right jugular line: palpate the carotid artery with your left hand, covering the artery

with your fingers. Insert the needle 0.5–1 cm laterally to the artery, aiming at a 45°angle

to the vertical. In men, aim for the right nipple; in women, aim for the iliac crest. Advance

slowly, aspirating all the time, until you enter the vein. If you fail to aspirate blood after

entering 3–4 cm, withdraw, re-enter at the same point, but aim slightly more medially

9. When the needle is in the vein, ensure that you can reliably aspirate blood. Remove

the syringe, keeping the needle very still, and immediately put your thumb over the end

of the needle.

10. Insert the wire into the end of the needle, and advance the wire until at least 30 cm

are inserted. The wire should advance very easily – do not force it.

11. Keeping one hand on the wire at all times, remove the needle, keeping the wire in

place. Make a nick in the skin where the wire enters the skin. Insert the dilator over the

wire and push into the skin as far as it will go. Remove the dilator.

12. Insert the central line over the wire. Keep one hand on the wire at all times. When the

central line is 2 cm away from the skin, slowly withdraw the wire back through the central

line until the wire tip appears from the line port. Hold the wire here while you insert the

line. Leave a few centimeters of the line outside the skin. Withdraw the wire and

immediately clip off the remaining port.

13. Attach the line to the skin with sutures. Tie loosely so as not to pinch the skin; this

causes necrosis and detachment of the line. Clean the skin around the line once more,

dry, and cover with occlusive dressings.

14. Ensure that you can aspirate blood from each lumen of the line, then flush each lumen

with saline or heparin saline.

 54

15. Order a chest x-ray to check for line position and pneumothorax if a jugular or

subclavian line has been inserted. Femoral lines do not require an x-ray.

NURSING INTERVENTIONS:

1. Flush lumens on catheter with saline.

2. Obtain chest radiograph to confirm position of catheter and exclude pneumothorax.

3. Use sterile technique when injecting drugs or connecting tubing to lumens of catheter.

4. Routinely replace sterile dressings, cleansing the site with chlorhexidine before

applying a new dressing.

5. Examine the insertion site daily for signs of infection.

6. While the catheter is in place, leave sterile caps in place at all times and cleanse ports

with alcohol before connecting anything to them.

7. When preparing to remove the catheter, place the patient in Trendelenburg’s position.

Ask the patient to exhale as the catheter is removed, to prevent air embolism, and apply

pressure over the site for 1 to 2 minutes for hemostasis.

URINARY CATHETERIZATION

DEFINITION:

Urethral catheterization is a routine medical procedure that facilitates direct drainage

 55

of the urinary bladder. It may be used for diagnostic purposes (to help determine the
etiology of various genitourinary conditions) or therapeutically (to relieve urinary retention,
instill medication, or provide irrigation). Catheters may be inserted as an in-and-out
procedure for immediate drainage, left in with a self-retaining device for short-term
drainage (eg, during surgery), or left indwelling for long-term drainage for patients with
chronic urinary retention. Patients of all ages may require urethral catheterization, but
patients who are elderly or chronically ill are more likely to require indwelling catheters,
which carry their own independent risks.

PROCEDURE:

1. Place the patient in the supine position with legs extended and flat on the bed.

2. Prepare the catheterization tray and catheter and drape the patient appropriately using
the sterile drapes provided. Place a sterile drape under the patient’s buttocks and the
fenestrated (drape with hole) drape over the penis.

3. Apply water-soluble lubricant to the catheter tip.

4. With your non-dominant hand, grasp the penis just below the glans and hold upright.

5. If the patient is uncircumcised, retract the foreskin. Replace the foreskin at the end of
the procedure.

6. With your dominant hand, cleanse the glans using chlorhexidine soaked cotton balls.
Use each cotton ball for a single circular motion.

7. Place the drainage basin containing the catheter on or next to the thighs.

8. With you non-dominant hand, gently straighten and stretch the penis. Lift it to an angle
of 60-90 degrees. At this time you may use the urojet to anesthetize the urinary canal,
which will minimize the discomfort.

9. With your dominant hand, insert the lubricated tip of the catheter into the urinary
meatus.

10. Continue to advance the catheter completely to the bifurcation i.e. until only the
 56

inflation and drainage ports are exposed and urine flows (this is to ensure proper
placement of the catheter in the bladder and prevent urethral injuries and hematuria that
result when the foley catheter balloon is inflated in the urethra).

Note: If resistance is met during advancement of the catheter: Pause for 10-20 seconds.
Instruct the patient to breathe deeply and evenly. Apply gentle pressure as the patient
exhales

11. If you still meet resistance, stop the procedure and repeat above steps.

12. Attach the syringe with the sterile water and inflate the balloon. It is recommended to
inflate the 5cc balloon with 7-10cc of sterile water, and to inflate the 30cc balloon with
35cc of sterile water. Improperly inflated balloons can cause drainage and leakage
difficulties.

13. Gently pull back on the catheter until the balloon engages the bladder neck.

14. Attach the urinary drainage bag and position it below the bladder level. Secure the
catheter to the thigh. Avoid applying tension to the catheter.

15. Remove drapes and cover patient. Ensure drainage bag is attached to bed frame.
Remove your gloves and wash hands.

Note: Never inflate a balloon before establishing that the catheter is in the bladder and
not just in the urethra. If the patient reports discomfort, withdraw the fluid from the balloon
and advance the catheter a little further, then re-inflate the balloon.

NURSING INTERVENTIONS:

1. Be sure to wash hands before and after caring for a patient with an indwelling
catheter
2. Clean the perineal area thoroughly, especially around the meatus, twice a day
and after each bowel movement. This helps prevent organisms for entering the
bladder
3. Use soap or detergent and water to clean the perineal area and rinse the area
well
 57

4. Make sure that the patient maintains a generous fluid intake. This helps
prevent infection and irrigates the catheter naturally by increasing urinary
output
5. Encourage the patient to be up and about as ordered
6. Record the patient’s intake and output
7. Note the volume and character of urine and record observations carefully
8. Teach the patient the importance of personal hygiene, especially the
importance of careful cleaning after having bowel movement and thorough
washing of hands frequently
9. Report any signs of infection promptly. These include a burning sensation and
irritation at the meatus, cloudy urine, a strong odor to the urine, an elevated
temperature and chills
10. Plan to change indwelling catheters only as necessary. The usual length of time
between catheter changes varies and can be anywhere from 5 days to 2 weeks.
The less often a catheter is changed, the less the likelihood than
an infection will develop
58
 59

XIII. NURSING CARE PLANS

Date/Time Cues Need Diagnosis Objectives Intervention Evaluation

December Subjective cues: C Pain related to Within the 8- 1. Cover wounds as soon as possible
11, 2017/ “Sakit tanan nako O skin and nerve hour span of unless open-air exposure burn care method  The patient
7:00pm lawas” as G injuries and nursing required. R> Temperature changes and air was able to
verbalized by the N ruptured intervention the movement can cause great pain to exposed verbalize a
patient I blisters as client will be nerve endings. score of 7/10,
Pain scale of 10/10 T evidenced by able to: 2. Elevate burned extremities periodically. with minimal
Objective cues: I 2nd degree R> Changes in position and elevation irritability
2nd degree thermal V thermal burns,  Verbalize a reduce discomfort and risk of joint noted.
burn 45% TBSA E score of 6 contractures. -Goal met.
Guarding position - Rationale: below out of 3. Provide bed cradle as indicated. R>
Skin tenderness P The instant 10 in a pain Elevation of linens off wounds may help
throughout the body E pain that scale of 1-10 reduce pain.
Moaning, crying R follows a burn as 10 as the 4. Change position frequently and assist
C injury is due to highest in two with active and passive ROM as indicated.
Vital signs: E stimulation of hours. R> Movement and exercise reduce joint
Temp: 35.7 P skin stiffness and muscle fatigue, but type of
T nociceptors exercise depends on location and extent of
BP: 130/90 cpm
U that respond to injury.
RR: 28
A heat 5. Maintain comfortable environmental
PR: Radial L (thermorecept temperature, provide heat lamps, heat
pulse is absent ors), retaining body coverings. R> Temperature
Apical P mechanical regulation may be lost with major burns.
A distortion
 60

HR: 120 bpm T (mechanorece External heat sources may be necessary to

T ptors) and a prevent chilling.
O2 Sat.: 94%
E selection of 6. Assess reports of pain, noting location
R stimuli and character and intensity (0–10 scale).
N including R> Changes in location, character, intensity
chemical of pain may indicate developing
stimuli – complications (limb ischemia) or herald
exogenous improvement and/or return of nerve function
(e.g. and sensation.
hydrofluoric 7. Provide medication and/or place in
acid) and hydrotherapy (as appropriate) before
endogenous performing dressing changes and
(e.g. debridement. R> Reduces severe physical
inflammatory and emotional distress associated with
mediators, dressing changes and debridement.
notably 8. Encourage expression of feelings about
histamine, pain. R> Verbalization allows outlet for
serotonin, emotions and may enhance coping
bradykinin, mechanisms.
leukotrienes 9. Involve patient in determining schedule
and for activities, treatments, drug
prostaglandins administration. R> Enhances patient’s
). sense of control and strengthens coping
mechanisms.
10. Administer analgesics as indicated. R>
The burned patient may require around-the-
clock medication and dose titration. IV
 61

method is often used initially to maximize

drug effect.
11. Promote uninterrupted sleep periods.
R> Sleep deprivation can increase
perception of pain/reduce coping abilities.
 62

Date/Ti
Cues Need Diagnosis Objectives Intervention Evaluation
me
Decemb Subjective: N Risk for deficient Short- term: 1. Monitor vital signs, central Short- term
er 11, -“Nasunog U fluid volume venous pressure (CVP). Note goal:
Within the
2017/ tanan iyahang T related to capillary refill and strength of Within the span
span of
7:30pm katawan except R increased peripheral pulses. R> Serves of nursing
nursing
sa ari niya” as I capillary as a guide to fluid replacement intervention the
intervention
verbalized by T permeability and needs and assesses patient was not
the patient will
the mother of I evaporative cardiovascular response. able to show
be able to:
the client. O losses from burn 2. Estimate wound drainage any progress in
Objective cues: N wound. and insensible losses. R> his current
- Demonstrate
-2nd degree burn A Increased capillary state due to the
improved
injuries 45% L permeability, protein shifts, lack of time of
fluid balance
TBSA - inflammatory process, and nursing
as evidenced
-Loss of fluid M evaporative losses greatly monitoring and
by
through ruptured E affect circulating volume and care. ( Not
individually
blister in the T urinary output, especially achieved)
adequate
burned. A during initial 24–72 hr after
urinary
-Thirsty B burn injury.
output with
-Dry and pale O 3. Maintain cumulative record
normal
lips L of amount and types of fluid
specific
I intake. R. Massive or rapid
gravity,
 63

-Dry mucous C stable vital replacement with different

membranes signs, moist types of fluids and fluctuations
P mucous in rate of administration require
A membranes. close tabulation to prevent
T constituent imbalances or fluid
.
T overload.
E 4. Weigh daily. R> Fluid
R replacement formulas partly
N depend on admission weight
and subsequent changes. A
15%–20% weight gain can be
anticipated in the first 72 hr
during fluid replacement, with
return to pre-burn weight
approximately 10 days after
burn.
5. Measure circumference of
burned extremities as
indicated. R> May be helpful in
estimating extent of edema and
fluid shifts affecting circulating
volume and urinary output.
 64

6. Investigate changes in
mentation. R> Deterioration in
the level of consciousness may
indicate inadequate circulating
volume and reduced cerebral
perfusion.
7. Insert and maintain
indwelling urinary catheter. R>
Allows for close observation of
renal function and prevents
urinary retention. Retention of
urine with its by-products of
tissue-cell destruction can lead
to renal dysfunction and
infection.
8. Insert and maintain large-
bore IV catheter as ordered. R>
Accommodates rapid infusion
of fluids.
9. Administer calculated IV
replacement of fluids,
electrolytes, plasma, albumin.
 65

R> Fluid resuscitation replaces

lost fluids and electrolytes and
helps prevent complications
10. Assess skin turgor and oral
mucous membranes for signs
of dehydration. R> Signs of
dehydration are also detected
through the skin. Skin of elderly
patients losses elasticity,
hence skin turgor should be
assessed over the sternum or
on the inner thighs.
Longitudinal furrows may be
noted along the tongue.
 66

Date/Time Cues Need Diagnosis Objectives Intervention Evaluation

December Objective cues: A Ineffective tissue Short-term: 1. Assess color, sensation, Short-term goal:
11, 2017/ -Hypovolemia C perfusion related Within the movement, peripheral pulses, and Within the span of
7:40pm - No palpation on T to the reduction of span of capillary refill on extremities with the nursing
both radial and I venous blood flow nursing circumferential burns. Compare intervention client
pedal pulses. V secondary to a intervention: with findings of unaffected limb. was able to exhibit
-Oxygen I 45% TBSA Client will be R> Comparisons with unaffected growing tolerance
saturation 94% T second degree able to exhibit limbs aid in differentiating to activity through
-Presence of Y superficial full- growing localized versus systemic the normalizing of
blisters - thickness burns. tolerance to problems. vital signs, and
-Skin E activity. 2. Elevate affected extremities, as has improved
discoloration(writ X appropriate. Remove jewelry or circulation.
e color) E Client shows arm bands Avoid taping around a (GOALv MET)
-skin cold to R no further burned area. R>

touch C worsening/rep 3. Investigate reports of deep or

I etition of throbbing ache, numbness. R>

S deficits. Indicators of decreased perfusion

E and/or increased pressure within
Client
enclosed space, such as may
engages in
P occur with a circumferential burn
behaviors or
A of an extremity.
actions to
T
 67

T improve tissue 4. Encourage active ROM

E perfusion. exercises of unaffected body
R parts. R> Promotes local and
N systemic circulation.
5. Maintain fluid replacement per
protocol. R> Maximizes
circulating volume and tissue
perfusion.
6. Monitor electrolytes, especially
sodium, potassium, and calcium.
Administer replacement therapy
as indicated. R> Losses or shifts
of these electrolytes affect cellular
membrane potential and
excitability, thereby altering
myocardial conductivity,
potentiating risk of dysrhythmias,
and reducing cardiac output and
tissue perfusion.
7. Obtain BP in unburned
extremity when possible. Remove
BP cuff after each reading, as
indicated. R> If BP readings must
be obtained on an injured
 68

extremity, leaving the cuff in place

may increase edema formation
and reduce perfusion, and
convert partial thickness burn to a
more serious injury.
8. Maintain comfortable
environmental temperature,
provide heat lamps, heat retaining
body coverings. R> Temperature
regulation may be lost with major
burns. External heat sources may
be necessary to prevent chilling.
9. Use pulse oximetry to monitor
oxygen saturation and pulse rate.
R> Pulse oximetry is a useful tool
to detect changes in oxygenation.
10. Check for optimal fluid
balance. Administer IV fluids as
ordered. R> Sufficient fluid intake
maintains adequate filling
pressures and optimizes cardiac
output needed for peripheral
tissue perfusion.
69
 70

IX. NURSING THEORIES

Nightingale’s Environmental Theory

The Environmental Theory by Florence Nightingale defined Nursing as “the act
of utilizing the environment of the patient to assist him in his recovery.” It involves the
nurse’s initiative to configure environmental settings appropriate for the gradual
restoration of the patient’s health, and that external factors associated with the patient’s
surroundings affect life or biologic and physiologic processes, and his development.
Human beings are not defined by Nightingale specifically. They are defined in relationship
to their environment and the impact of the environment upon them. Therefore, the
Environmental Theory of Nursing is a patient-care theory. It focuses in the alteration of
the patient’s environment in order to affect change in his or her health. Caring for the
patient is of more importance rather than the nursing process, the relationship between
patient and nurse, or the individual nurse. In this way, the model must be adapted to fit
the needs of individual patients. The environmental factors affect different patients unique
to their situations and illnesses, and the nurse must address these factors on a case-by-
case basis in order to make sure the factors are altered in a way that best cares for an
individual patient and his or her needs.
Application
Altering the environment with the participation of the client and the client’s family
will provide an environment and conducive to the health maintenance and personal
development of the client and client’s family. Especially now, that the clients need a
special environment that would enable the client to be better. Special precautions are
given because the client has impaired skin integrity that is directly exposed from the
environment. Environmental hazards can probably affect the condition and the healthcare
team should cooperate with the client and client’s family to avoid problems that may arise.
The environment is an important and relevant part for the betterment of the client’s health
and personal development. The theory will be just the right theory to be taught and given
importance by the client due to its relevance in the development and personal health of
the client.
 71

Orem’s Self-Care Deficit Theory

Orem’s self-care deficit theory is based on the idea that people have the innate
ability, right, and responsibility to care for themselves. It reflects a concept of human
development that maturation is accompanied by self-reliance, a desire to be self-directing,
and to encourage others to be so. Self-care is seen as a behavior learned throughout a
person’s lifetime from childhood where it is learned and in adulthood where it is
maintained or perpetuated in the succeeding years. It contains those activities one does
and performs to maintain the optimum well-being. The nurse role is therefore, to assist
the client with self-care activities and to maximize one’s capability to care for themselves.
It specifies when nursing care is needed too. Nursing is needed when the client cannot
continuously maintain one’s daily living pattern and activities to sustain one’s own life and
health, to recover from a condition, or to cope with its effects. There are instances wherein
patients are encouraged to bring out the best in them despite being ill for a period of time.
This is very particular in rehabilitation settings, in which patients are entitled to be more
independent after being cared for by physicians and nurses. Therefore the theory is used
to identify when patients should receive help to meet their healthcare needs, to what
degree the client needs help, and to allow the patient to care for themselves.
Application
The client currently needs intensive care. The client’s condition may be stabilize
already but the attention given shouldn’t be decreased and should be maintained because
there are many risk that the client may get. Most people who die from burns does not die
from the direct exposure to burn but from the after effects of it such as hypoxia,
dehydration, etc. If they are able to recover, they still need moderate care because burns,
specially 2nd or 3rd degree burns are deep enough to damage tissues that enable humans
to live. The client will undergo rehabilitation and that the client’s cooperation is a must
throughout the holistic care.
Prevention is better than cure. Although there is already a presenting problem, it
may complicate and worsen into a more sophisticated and severe problem. In terms of
knowledge regarding the problem, the healthcare team or the nurses and doctors know
more about what is best for the client. Simple intervention and ways can decrease the
chance of complications arising. Cooperating with the family of the client may very well
 72

improve the overall health of the client. To also maximize the time in teaching the family
they will be taught the importance of caring oneself to open their minds and thus be more
aware of themselves for the betternment of the client’s health. Orem’s theory can very
well be related to the problem as it identifies and is able to give guide to the care that
should be given to the client.

Patricia Benner (Novice to Expert Theory)

This nursing theory proposes that expert nurses develop skills and understanding
of patient care over time through a proper educational background as well as a multitude
of experiences. Dr. Benner's theory is not focused on how to be a nurse, rather on how
nurses acquire nursing knowledge - one could gain knowledge and skills ("knowing how"),
without ever learning the theory ("knowing that"). She used the Dreyfus Model of Skill
Acquisition as a foundation for her work. The Dreyfus model, described by brothers Stuart
and Hubert Dreyfus, is a model based on observations of chess players, Air Force pilots,
army commanders and tank drivers. The Dreyfus brothers believed learning was
experiential (learning through experience) as well as situation-based, and that a student
had to pass through five very distinct stages in learning, from novice to expert.

Dr. Benner's Stages of Clinical Competence

Stage 1 Novice: This would be a nursing student in his or her first year of clinical
education; behavior in the clinical setting is very limited and inflexible. Novices have a
very limited ability to predict what might happen in a particular patient situation. Signs and
symptoms, such as change in mental status, can only be recognized after a novice nurse
has had experience with patients with similar symptoms.
Stage 2 Advanced Beginner: Those are the new grads in their first jobs; nurses have had
more experiences that enable them to recognize recurrent, meaningful components of a
situation. They have the knowledge and the know-how but not enough in-depth
experience.
Stage 3 Competent: These nurses lack the speed and flexibility of proficient nurses, but
they have some mastery and can rely on advance planning and organizational skills.
 73

Competent nurses recognize patterns and nature of clinical situations more quickly and
accurately than advanced beginners.
Stage 4 Proficient: At this level, nurses are capable to see situations as "wholes" rather
than parts. Proficient nurses learn from experience what events typically occur and are
able to modify plans in response to different events.
Stage 5 Expert: Nurses who are able to recognize demands and resources in situations
and attain their goals. These nurses know what needs to be done. They no longer rely
solely on rules to guide their actions under certain situations. They have an intuitive grasp
of the situation based on their deep knowledge and experience. Focus is on the most
relevant problems and not irrelevant ones. Analytical tools are used only when they have
no experience with an event, or when events don't occur as expected.

Application
Everyone goes through the beginning. Learning from the book is different from
learning through experiences. Although it is also a need to gain information regarding the
topic on what you will be exposed to, to be able to be prepared but sometimes there are
some things that you cannot find in the books. As a student nurse being exposed to a
burn patient is really new, as an emergency case I still don’t know what to do during the
actual event. Nursing students also commit mistakes; moreover, there is nothing wrong
with it unless you don’t learn at all. You cannot be the best at it right away. Handling burn
patients, needs a competent nurse because they need to be monitored strictly due to the
effects of being burned to the body. The burn doesn’t kill but the effects on the body does
such as dehydration. Once you do, a nurse would be able to recognize and get things
done efficiently and effectively.
 74

XIV. RECOMMENDATIONS

This case review has improved vital knowledge and perceptions on burns, and garnered
wisdom on the said condition: types, signs and symptoms, factors/etiology, and also the
pathophysiology. The propoent would like to recommend the following:

a. Patient and Family

To L.C.L., I recommend him to continue fighting against his illness and to find ways
to ease the discomfort that comes with it and not give up with the challenges of life. I
encourage him to see the brighter side of life and apply the therapeutic interventions that
I have given that would temporarily alleviate his feelings of discomfort, and to continue in
seeking help from the people around him and in the hospitals or clinics if he will be in
need of medical attention. Also, I hope that in time, the patient would get well and live a
life that he is genuinely happy of and that gives meaning to his life. I hope for the best in
terms of health for our client. To my client’s family, I also hope that they would continue
to offer a helping hand and actually make a move in seeking healthcare for their family
member’s current condition. May God let it sink in their hearts that their family member’s
is in dire need of their help, and also, in need of their utmost care and support.

b. Nursing Education

I would like to recommend the Ateneo de Davao University School of Nursing and
their mentors on teaching the group of nursing students with academic excellence through
the teachings and spirituality of Saint Ignatius Loyola. The gathered knowledge would be
the nursing student’s vital source or basis of appreciating and comprehending such
circumstances that is, and will happen in our hospital and community exposures.
 75

c. Nursing Practice

Experience is the best mentor when it comes to nursing practice. I would like to
commend my clinical instructors for the unending guidance and wisdom in conquering
problems and challenges the nursing students face in both their hospital and community
setting.

I would also like to acclaim the Southern Philippines Medical Center for serving as
the training ground for a student nurse in enhancing our expertise through performing
patient-oriented interventions with the supervision of my dearest clinical instructors.

d. Nursing Research

I would like to recommend the Ateneo de Davao University Library to supply more

updated nursing-related Philippine version of books, which can used as references and

can be applicable for clinical exposures because most of the books are in American

version.
 76

XV. BIBLIOGRAPHY

Baxter CR. Fluid volume and electrolyte changes of the early postburn period. Clin Plast

Surg. 1974; 1(4):693–703. [PubMed]

Herndon D. Total burn care. 2nd ed. London: WB Saunders, 2002

Inancsi WI, Guidotti TL. Occupation related burns: five-year experience of an urban

burn center. J Occup Med. 1987. 29:730.

Kidd BL, Urban LA. Mechanisms of inflammatory pain. Br J Anaesth 2001; 87: 3–11

Porth, Carol, and Mary Pat Kunert. 2012. Pathophysiology: concepts of altered health

states. Philadelphia: Lippincott Williams & Wilkins.

Uchinuma, E; Koganei, Y; Shioya, N; Yoshizato, K (1988). "Biological evaluation of burn

blister fluid". Annals of Plastic Surgery. 20 (3): 225–30. PMID 3358612.

doi:10.1097/00000637- 198803000-00005.