NURSING CARE ELECTRICAL BURN INJURY IN ICU BANJARMASIN ULIN HOSPITAL

2ND Group : Esmy Maulidya M. Nurmajid Nurlailatul Khairiyyah H. M. Syafii Nor Amali Hidayatni Khairunisa

Banjarmasin Muhammadiyah Health College International Class Of Nursing Diploma Program Academic Year 2013 / 2014

Objectives

After accomplished this case, the student will be Select the appropriate nursing theory and apply its principles in rendering nursing care to a patient with suffering second degree burn wound prior. Discuss the anatomy and physiology of the integumentary system that are directly affected in a second degree burn and relate the concept to the actual situation to the patient Explain the pathophysiology of a burn wound infection Determine the nursing priorities and nursing management requisite and executable in a second degree burn case, and incorporate these data with nursing care plan. Distinguish the different pharmacologic actions of the drugs involved in treatment of a second degree. Formulate elevant health teachings and outpatient care for a patient with a second degree after being discharge

Nursing Care Of Nursing Clinical Practice International Class Of Nursing Diploma Program Banjarmasin Muhammadiyah Health College

A. SHORT HISTORY OF CLENT In the assessment on December 24th, 2013 at 11.00 a.m. Clients name is Mr. A. He is 30 years old. He is a moslem. He is a dayakese. His job is an electrical repairer. He lives on Basarang, Kapuas, Kalimantan Tengah. Client was hospitalized with the medical diagnosis Electrical burn injury (combustio) grade III (Full Thickness) 29,25% with inhalation trauma. Health history of client, on December 23th, 2013 at 02.00 p.m. the client repaired the trafo in Batulicin that was mispredicted as light off but actually not, because that is client duty as a electrical repairer in central-south kalimantan so he did his job, when client repaired the trafo and cut the cable, suddenly client got electrical shock and it burned half of his face and chest, his left wrist and left leg. After that client was admitted to the nearest hospital by people around there . During the way to the hospital client was fainting and was hospitalized on emergency room for about 5 hours and because client had a bad condition the doctor decided to move the client to the banjarmasin ulin general hospital and stayed on emergency room for debridement in surgical room and immeadietly moved to the ICU room on December 24th, 2013. The data that were found on the client during assessment are client concioussness level is Composmentis , GCS : E4V5M6 , clients blood pressure is 110/70 mmHg, pulse is 90x/minutes , RR is 31x/minutes and temperature is 36,8C, heart sound is I and II , chest auscultation sounds wheezing, abdomen is palpable flat, soft , liver/lymph within normal limit , peristaltic sound is 10x/m , neurological status : pupil is isocor , pupils diameter 3/3 , pupil reflex is positive , motor : muscle strength on upper extremities are 4444/3333 and on lower extremities is 4444/4444 , there is catheter installation on December 24th 2013, client wear oxygen mask 8 lpm, finger saturation is 65% , based on rule of nine form found : 29.25% on the half of face
(2.25%) the front of the chest (9%), the majority of the left hand (9%), and the right hand (9%).

Diagnostic examination; CT-Scan (-), thorax photo is normal, laboratorium examination result on December 24th 2013; Hb: 14,8, leucosit 17,9, eritrosit 4,95, trombosit 256, MCV 86,7, MCH 29,8, MCHC 34,4, ureum 20, kreatinin 0,9, GDS 145, kalium 3,9, chlorida 105, natrium 141,4, blood gas analysis; pH: 7,4, PACO2: 46,8, PAO2: 78,0, O2 saturation: 80,3, BE: 1,1, HCO3: 26,5, lactate Dehydrogenises 450, CKMB 23 .

Client said that never know of this disease before. And client said that he has never been treated in hospital. The client doesnt have a history of hypertension or diabetes mellitus.

Client said that was no client family who have suffered the same disease that client suffering now. And families who have no other serious illnes.

B. ANATOMY OF INTEGUMENTARY SYSTEM

The integumentary system is an organ system consisting of the skin, hair, nails, and exocrine glands. The skin is only a few millimeters thick yet is by far the largest organ in the body. The average persons skin weighs 10 pounds and has a surface area of almost 20 square feet. Skin forms the bodys outer covering and forms a barrier to protect the body from chemicals, disease, UV light, and physical damage. Hair and nails extend from the skin to reinforce the skin and protect it from environmental damage. The exocrine glands of the integumentary system produce sweat, oil, and wax to cool, protect, and moisturize the skins surface.

Epidermis The epidermis is the most superficial layer of the skin that covers almost the entire body surface. The epidermis rests upon and protects the deeper and thicker dermis layer of the skin. Structurally, the epidermis is only about a tenth of a millimeter thick but is made of 40 to 50 rows of stacked squamous epithelial cells. The epidermis is an avascular region of the body, meaning that it does not contain any blood or blood vessels. The cells of the epidermis receive all of their nutrients via diffusion of fluids from the dermis. The epidermis is made of several specialized types of cells. Almost 90% of the epidermis is made of cells known as keratinocytes. Keratinocytes develop from stem cells at the base of the epidermis and begin to produce and store the protein keratin.

Keratin makes the keratinocytes very tough, scaly and water-resistant. At about 8% of epidermal cells, melanocytes form the second most numerous cell type in the epidermis. Melanocytes produce the pigment melanin to protect the skin from ultraviolet radiation and sunburn. Langerhans cells are the third most common cells in the epidermis and make up just over 1% of all epidermal cells. Langerhans cells role is to detect and fight pathogens that attempt to enter the body through the skin. Finally, Merkel cells make up less than 1% of all epidermal cells but have the important function of sensing touch. Merkel cells form a disk along the deepest edge of the epidermis where they connect to nerve endings in the dermis to sense light touch. The epidermis in most of the body is arranged into 4 distinct layers. In the palmar surface of the hands and plantar surface of the feet, the skin is thicker than in the rest of the body and there is a fifth layer of epidermis. The deepest region of the epidermis is the stratum basale, which contains the stem cells that reproduce to form all of the other cells of the epidermis. The cells of the stratum basale include cuboidal keratinocytes, melanocytes, and Merkel cells. Superficial to stratum basale is the stratum spinosum layer where Langerhans cells are found along with many rows of spiny keratinocytes. The spines found here are cellular projections called desmosomes that form between keratinocytes to hold them together and resist friction. Just superficial to the stratum spinosum is the stratum granulosum, where keratinocytes begin to produce waxy lamellar granules to waterproof the skin. The keratinocytes in the stratum granulosum are so far removed from the dermis that they begin to die from lack of nutrients. In the thick skin of the hands and feet, there is a layer of skin superficial to the stratum granulosum known as the stratum lucidum. The stratum lucidum is made of several rows of clear, dead keratinocytes that protect the underlying layers. The outermost layer of skin is the stratum corneum. The stratum corneum is made of many rows of flattened, dead keratinocytes that protect the underlying layers. Dead keratinocytes are constantly being shed from the surface of the stratum corneum and being replaced by cells arriving from the deeper layers.

Dermis The dermis is the deep layer of the skin found under the epidermis. The dermis is mostly made of dense irregular connective tissue along with nervous tissue, blood, and blood vessels. The dermis is much thicker than the epidermis and gives the skin its strength and elasticity. Within the dermis there are two distinct regions: the papillary layer and the reticular layer. The papillary layer is the superficial layer of the dermis that borders on the epidermis. The papillary layer contains many finger-like extensions called dermal papillae that protrude superficially towards the epidermis. The dermal papillae increase the surface area of the dermis and contain many nerves and blood vessels that are projected toward the surface of the skin. Blood flowing through the dermal papillae provide nutrients and oxygen for the cells of the epidermis. The nerves of the dermal papillae are used to feel touch, pain, and temperature through the cells of the epidermis. The deeper layer of the dermis, the reticular layer, is the thicker and tougher part of the dermis. The reticular layer is made of dense irregular connective tissue that contains many tough collagen and stretchy elastin fibers running in all directions to provide strength and elasticity to the skin. The reticular layer also contains blood vessels to support the skin cells and nerve tissue to sense pressure and pain in the skin.

Hypodermis Deep to the dermis is a layer of loose connective tissues known as the hypodermis, subcutis, or subcutaneous tissue. The hypodermis serves as the flexible connection between the skin and the underlying muscles and bones as well as a fat storage area. Areolar connective tissue in the hypodermis contains elastin and collagen fibers loosely arranged to allow the skin to stretch and move independently of its underlying structures. Fatty adipose tissue in the hypodermis stores energy in

the form of triglycerides. Adipose also helps to insulate the body by trapping body heat produced by the underlying muscles.

PHYSIOLOGY OF THE INTEGUMENTARY SYSTEM Keratinization Keratinization, also known as cornification, is the process of keratin accumulating within keratinocytes. Keratinocytes begin their life as offspring of the stem cells of the stratum basale. Young keratinocytes have a cuboidal shape and contain almost no keratin protein at all. As the stem cells multiply, they push older keratinocytes towards the surface of the skin and into the superficial layers of the epidermis. By the time keratinocytes reach the stratum spinosum, they have begun to accumulate a significant amount of keratin and have become harder, flatter, and more water resistant. As the keratinocytes reach the stratum granulosum, they have become much flatter and are almost completely filled with keratin. At this point the cells are so far removed from the nutrients that diffuse from the blood vessels in the dermis that the cells go through the process of apoptosis. Apoptosis is programmed cell death where the cell digests its own nucleus and organelles, leaving only a tough, keratinfilled shell behind. Dead keratinocytes moving into the stratum lucidum and stratum corneum are very flat, hard, and tightly packed so as to form a keratin barrier to protect the underlying tissues.

Temperature Homeostasis Being the bodys outermost organ, the skin is able to regulate the bodys temperature by controlling how the body interacts with its environment. In the case of the body entering a state of hyperthermia, the skin is able to reduce body temperature through sweating and vasodilation. Sweat produced by sudoriferous glands delivers water to the surface of the body where it begins to evaporate. The evaporation of sweat absorbs heat and cools the bodys surface. Vasodilation is the process through which smooth muscle lining the blood vessels in the dermis relax and allow more

blood to enter the skin. Blood transports heat through the body, pulling heat away from the bodys core and depositing it in the skin where it can radiate out of the body and into the external environment. In the case of the body entering a state of hypothermia, the skin is able to raise body temperature through the contraction of arrector pili muscles and through vasoconstriction. The follicles of hairs have small bundles of smooth muscle attached to their base called arrector pili muscles. The arrector pili form goose bumps by contracting to move the hair follicle and lifting the hair shaft upright from the surface of the skin. This movement results in more air being trapped under the hairs to insulate the surface of the body. Vasoconstriction is the process of smooth muscles in the walls of blood vessels in the dermis contracting to reduce the flood of blood to the skin. Vasoconstriction permits the skin to cool while blood stays in the bodys core to maintain heat and circulation in the vital organs.

Vitamin D Synthesis Vitamin D, an essential vitamin necessary for the absorption of calcium from food, is produced by ultraviolet (UV) light striking the skin. The stratum basale and stratum spinosum layers of the epidermis contain a sterol molecule known as 7dehydrocholesterol. When UV light present in sunlight or tanning bed lights strikes the skin, it penetrates through the outer layers of the epidermis and strikes some of the molecules of 7-dehydrocholesterol, converting it into vitamin D3. Vitamin D3 is converted in the kidneys into calcitriol, the active form of vitamin D.

Protection The skin provides protection to its underlying tissues from pathogens, mechanical damage, and UV light. Pathogens, such as viruses and bacteria, are unable to enter the body through unbroken skin due to the outermost layers of epidermis containing an unending supply of tough, dead keratinocytes. This protection explains the necessity of cleaning and covering cuts and scrapes with bandages to prevent

infection. Minor mechanical damage from rough or sharp objects is mostly absorbed by the skin before it can damage the underlying tissues. Epidermal cells reproduce constantly to quickly repair any damage to the skin. Melanocytes in the epidermis produce the pigment melanin, which absorbs UV light before it can pass through the skin. UV light can cause cells to become cancerous if not blocked from entering the body.

Skin Color Human skin color is controlled by the interaction of 3 pigments: melanin, carotene, and hemoglobin. Melanin is a brown or black pigment produced by melanocytes to protect the skin from UV radiation. Melanin gives skin its tan or brown coloration and provides the color of brown or black hair. Melanin production increases as the skin is exposed to higher levels of UV light resulting in tanning of the skin. Carotene is another pigment present in the skin that produces a yellow or orange cast to the skin and is most noticeable in people with low levels of melanin. Hemoglobin is another pigment most noticeable in people with little melanin. Hemoglobin is the red pigment found in red blood cells, but can be seen through the layers of the skin as a light red or pink color. Hemoglobin is most noticeable in skin coloration during times of vasodilation when the capillaries of the dermis are open to carry more blood to the skins surface.

Cutaneous Sensation The skin allows the body to sense its external environment by picking up signals for touch, pressure, vibration, temperature, and pain. Merkel disks in the epidermis connect to nerve cells in the dermis to detect shapes and textures of objects contacting the skin. Corpuscles of touch are structures found in the dermal papillae of the dermis that also detect touch by objects contacting the skin. Lamellar corpuscles found deep in the dermis sense pressure and vibration of the skin. Throughout the dermis there are many free nerve endings that are simply neurons with their dendrites

spread throughout the dermis. Free nerve endings may be sensitive to pain, warmth, or cold. The density of these sensory receptors in the skin varies throughout the body, resulting in some regions of the body being more sensitive to touch, temperature, or pain than other regions.

Excretion In addition to secreting sweat to cool the body, eccrine sudoriferous glands of the skin also excrete waste products out of the body. Sweat produced by eccrine sudoriferous glands normally contains mostly water with many electrolytes and a few other trace chemicals. The most common electrolytes found in sweat are sodium and chloride, but potassium, calcium, and magnesium ions may be excreted as well. When these electrolytes reach high levels in the blood, their presence in sweat also increases, helping to reduce their presence within the body. In addition to electrolytes, sweat contains and helps to excrete small amounts of metabolic waste products such as lactic acid, urea, uric acid, and ammonia. Finally, eccrine sudoriferous glands can help to excrete alcohol from the body of someone who has been drinking alcoholic beverages. Alcohol causes vasodilation in the dermis, leading to increased perspiration as more blood reaches sweat glands. The alcohol in the blood is absorbed by the cells of the sweat glands, causing it to be excreted along with the other components of sweat.

C. PATHOPHYSIOLOGY The pathophysiology of the burn wound is characterized by an inflammatory reaction leading to rapid oedema formation, due to increased microvascular permeability, vasodilation and increased extravascular osmotic activity. These reactions are due to the direct heat effect on the microvasculature and to chemical mediators of inflammation. The earliest stage of vasodilatation and increased venous permeability is commonly due to histamine release. Damage to the cell membranes partly caused by oxygen-free radicals released from polymorphonuclear leucocytes would activate the enzymes catalyzing the hydrolysis of prostaglandin precursor (arachidonic acid) with rapid formation of prostaglandin as the result. Prostaglandins inhibit the release of norepinephrine and may thus be of importance in modulating the adrenergic nervous system which is activated in response to thermal injury. The morphological interpretations of the changes in the functional ultrastructure of the bloodlymph barrier following thermal injury seem to be an increase in the numbers of vacuoles and many open endothelial intercellular junctions. Furthermore changes of the interstitial tissue after burn trauma are of great importance. The continuous loss of fluid from the blood circulation within the thermally damaged tissue causes increased haematocrit levels and a rapid fall in plasma volume, with decreased cardiac output and hypoperfusion on the cellular level. If the fluids are not adequately restored burn shock develops. Furthermore, the burn wound provides a vast area of entry of surface infection with a high risk of septic shock. Four main principles are of utmost importance in the current management of patients with severe thermal injury, namely early wound closure, prevention of septic complications, adequate nutrition and control of the external environment. (Ann Chir Gynaecol. 1980)

Degree of Combustio: 1.

First degree of combustio Skin still infarction, redness, not found bullae, and pain Second degree of combustio

2.

- Damage includes epidermis and dermis, a reaction accompanied by inflammatory exudation process. - Encountered of bulae. - Pain due to irritation of nerve endings. - The wound is red or pale, often located higher above the normal skin - Second degree of combustio Looks bullae, basic wound redness (degrees IIA), basic pale whitish (degrees IIB), severe pain primarily on the degree of IIA Second degree combustio are divided into 2 (two), they are: 1. Grade II shallow (superficial) - Damage to the superficial part of the dermis. - Organs of the skin such as hair follicles, sweat glands, sebaceous glands are still intact. - Healing occurs spontaneously within 10-14 days. 2. Grade II (deep) - Damage on almost all parts of the dermis. - Organs of the skin such as hair follicles, sweat glands, sebaceous glands remains largely intact. - Healing occurs over time, depending on the remaining epithelium. Healing usually occurs over a month. Third degree of combustio - Damage includes all layers of the dermis and deeper layers. - Organs of the skin such as hair follicles, sweat glands, sebaceous glands were damaged. - Not found bulae. - The skin is combustio gray and pale. Because dry skin than the lower lying around. - Occurs coagulation proteins in the epidermis and dermis are known as escar. - There were no pain and loss of sensation, because the sensory nerve endings damage / death. - Healing occurred long as there is a process of spontaneous epithellization of the wound.

Third degree of combustio There bullae, skin necrosis appeared, basic black injuries, less severe pain, sometimes visible tissue under the skin (Muscle, bone, etc.)

Based on the seriousness of injuries American Combustio Association classifies combustio into three categories, they are: Major Combustio - With extensive combustio over 25% in adults and more than 20% in children. - Full thickness combustio over 20%. - There were combustio on the hands, face, eyes, ears, feet, and perineum. - There inhalation trauma and multiple injury regardless of the degree and extent of injuries. - There are high-voltage electrical combustio. moderate combustio - With extensive combustio 15-25% in adults and 10-20% in children. - Full thickness combustio less than 10%. - There are no combustio on the hands, face, eyes, ears, feet, and perineum. Minor Combustio - Minor combustio as defined by Trofino (1991) and Griglak (1992) are: extensive combustio with less than 15% in adults and less than 10% in children. - Fullthickness combustio less than 2%. - There are no combustio on the face, hands, and feet. - Wounds not sirkumfer. - There is no inhalation injury, electrical, fracture. (Hudak & Gallo, 1996, 542) The size of the combustio area In determining the size of the combustio area we can use several methods: Rule of Nine - Head and neck: 9% - Chest front and rear: 18% - Abdomen front and rear: 18% - The right hand and the left: 18% - The right thigh and left: 18% - The right leg and left: 18% - Genital: 1%

Symptoms Symptoms depend on many things, including:

Type and strength of voltage How long you were in contact with the electricity How the electricity moved through your body Your overall health

Symptoms may include:

Changes in alertness (consciousness) Broken bones Heart attack (chest, arm, neck, jaw, or back pain) Headache Problems with swallowing, vision, or hearing Irregular heartbeat Muscle spasms and pain Numbness or tingling Breathing problems or lung failure Seizures Skin burns

THE INDICATION OF CLIENT WITH COMBUSTION IN INTENSIVE CARE UNIT According to Wirman 2007 , he stated that the criteria of client with combustion in intensive care unit, they are :
The combustion with II-III degree and up to 25% The client of combustion with injury of inhalation which has up to 80 % possibility of low oxygen supply in blood bring it up to the death of tissue all over the body Client of combustion which needs the debridement treatment through the treatment results high possibility to infection. The rehydration needs to be fulfilled for client with combustion within special formula and need the intensive monitoring for its effectiveness Client with combustion has the imunosupression caused by lost of skin function for the body protection and it needs special action of keep the best aseptic antiseptic technic which is easier to be done in intensive care unit Client of combustion needs intensive care to keep it away from secondary or complication for the prevention into worse condition in intensive care unit (the consciousness level and all of the physical examination).

D. ASSESSMENT

1.

Rational Assessment

a.

Clients Identity

Assessment of the patient's identity is important to improve the accuracy of the information and coordination. (Barkaukass, et.al, 1994). In these cases, the patients were male, aged 30 years old, a Muslim, worked as an electrical repair, is married and has two children, lived in Basarang, Kapuas, Central Kalimantan. b. Hospital Entrance Data

This is important because of the data obtained in this section can be a major problem or the main reason patients come to the health services (Smeltzer, 2005). This data will also be directed some nursing interventions to address priority problems or major complaints of patients. (Barkaukass et.al, 1994). Assessment is the initial stage of the nursing process and is a systematic process of collecting data from multiple data sources to evaluate and identify the client's health status (Nursalam, 2000). Assessment is the first step of the nursing process which aims to collect data both subjective and objective data the data. Subjective data was obtained based on the results of interviews with clients or others, while the objective data acquired by observation and physical examination. The initial step is to conduct an assessment of the client's biographical data includes name, age, gender, occupation, race, and others. Upon further review of biographical data, among others, on the assessment conducted extensive combustio. To determine the extent of combustio can use one of the existing methods, the method of "rule of nine" or method "Lund and Browder". And the depth of combustio can be classified into four types, they are degree combustio I, stage II, stage III and IV. Combustio about certain places require special attention, therefore consequently can cause a variety of problems. Like, if the combustio on the face, neck and chest can interfere with the airway and chest expansion caused by edema of the larynx. Whereas if the limb, it can cause a decrease in circulation to the extremities due to the formation of edema and scar tissue. Therefore, assessment of the airway (airway) and respiratory (breathing) and circulation (circulation) is indispensable. Combustio of the eye can cause corneal laceration, retinal damage and decreased visual acuity. Location of combustio can also sensitize staff on the possibility of inhalation injury. The nurse should assess the following findings: Fur nose combustio, combustio oral or pharyngeal mucous membranes, combustio perioral area, or throat, cough or hoarse voice changes, a history of combustioing in a confined area. And to assess pain / comfort, examples of first degree combustio are eksteren sensitive to touch; pressed; air movement and temperature changes; thickness combustio were second degree is very painful;

smentara response on second-degree combustio thickness depends on the integrity of nerve endings; wound third-degree combustio are not painful. (Brunner & Suddarth, 1996) The combustio is an injury caused by heat, electrical current, chemicals and lightning of the skin, mucosa and deeper tissues. Combustio skin and tissue will become necrotic tissue (Maluegha, 2007). Electric combustio (electrical) caused by heat is moved from the delivered electrical energy through the body. Severity of injury is influenced by the length of exposure, and high voltage electrical waves that way until about the body.(Huddak and Gallo, 2010). As described in the brief history of the patient Mr. A when the client repaired the trafo in batu licin that mispredicted as light off but was actually not. Client got electrical shock and it combustio half of his face and chest, his left wrist and left leg. When viewed from the history then we can conclude that Mr. A suffered electrical combustio injury. c. History of Previous and Family Disease

Past medical history is needed to identify the health problems of patients who have passed. Analysis is intended to look at is there a match between the health problems in the past with the present health problems or not. While family health history is to identify various genetic diseases, heredity, and natural environment that affect patients' health problems at this time (Barkaukass, et.al, 1994). Past medical history of patients, the data to be obtained are several factors that make complications or the patient's condition becomes more severe condition. Complications of the disease can be considered earlier. (Www.unca.com, 2006). Clients say never experienced a disease that now affects, and because the lien did not experience other serious illnesses. Clients who have never experienced pain to be hospitalized. Clients say does not exist between family members who suffer from the same disease as the client and no family members who suffer from infectious diseases and hereditary diseases such as tuberculosis, hepatitis, diabetes, etc. d. Neuromuscular System

It is well known that electrical injury can cause damage to the central nervous system, affecting both the brain and spinal cord. Both acute and delayed neurological syndromes have been reported in Victims of electrical injury involving a variety of symptoms, Including loss of consciousness, seizures, aphasia, visual disturbances,

headaches, tinnitus, paresis, and memory disturbance. Neurologic sequel can occur Whether or not the head is a point of direct contact with the electrical current. Central nervous system damage results from direct thermal and mechanical effects of electrical shock, and histopathological changes in the central nervous system such as coagulation necrosis (death of tissue due to clotting of blood vessels), reactive gliosis (increase of in nonneural support cells within the central nervous system as a response to injury), demyelinization (destruction of the protein covering to many nerves), vacuolization (small holes within the brain tissue), and perivascular hemorrhage (small areas of bleeding) have been documented. Centra l nervous system damage may also occur from anoxia due to cardiorespiratory arrest or ischemic damage resulting from thrombosis. Cause of death in fatal cases is Generally ascribed to ventricular fibrillation with subsequent cardiorespiratory arrest. Other neurologic status is the level of awareness of both qualitative and quantity, studied as a reference in a more intensive handling of patients, because these factors may be a clue the damage (Vincent, 2005). When damage to the frontal lobe damage in studying the possibility of something, a memory or a higher intellectual functions. Cognitive impairment is the limited level of patient attention to something, it is difficult to understand something, quickly forgotten, and lack of motivation. While psychological problems characterized by emotional lability, frustration and lack of co-operative attitude. Both laboratory investigations, ECG and other vital because to determine the extent of organ functions impaired. (Tjokronegoro & Henderson, 2002) and (Black & Hawk, 2005). At Mr. A said that he felt numbness on both hands, Clients pupil is isokor, the pupil diameter of 3 mm / 3 mm, the pupillary light reflex direct + / +, pupillary reflexes to light indirectly + / +, Babinski + / +, GCS score: E4M6V5, level of consciousness composmentis. Communication skills and well-sensory perception, can do a full assessment because the patient is awake the superior extremity muscle strength 4444/3333 and lower extremities 4444/4444. Description of muscle strength : Muscle contracts against full resistance Strength reduced, but contraction can still move joint against resistance Strength further reduced such that joint can be moved only against gravity with examiner's resistance completely removed. Muscle can onlly move if resistance of gravity is

4 3 2

removed. Only a trace or flicker of movement is seen or felt, or fasciculations are observed, No movement

1 0

e.

Urinary System

Assessment of urinary system do nurses need to obtain the data if there are any changes in the structure and function of the urinary system. Subjective assessment primarily focused on three things: the pain, changes in the pattern of urination, and urinary tract complaints. While physical examination by inspection, palpation, and percussion to look over the suitability of the patient's complaints. If there is a complaint and the complaint finding that reinforces the data on this system show that there has been a change in this system, at least in the urinary system function. (Smeltzer & Bare, 2005). In combustio patients do not experience urinary problems except the combustio area until the genital area or have combustio on up muscles and nerves in the urinary system. In this case, the patient is catheterized. Urine out with clear yellow color, there is no sediment or blood. The position of the catheter was not bent / no obstacles. Oral fluid intake of 1200 cc / 24 hour, RL IV fluid line 2500cc / 24 hours, the output of fluid through foley cathether the output 1600cc / 24 hours installed on December 24th 2013. Laboratory tests on 24 december 2013: sediment; 1 + epithelial cells, 3-5/lpb leukocytes, erythrocytes lot, cylindrical (-), crystal (-), bacteria (-), BJ 1.015, pH 7.0, protein (-), negative ketones, blood (-), bilirubin negative, uroblingen 0.2 mmol / L, negative nitrite, leukocyte esterase (-). Blood chemistry;. urea: 20 mg / l, creatinine: 0.9, acetone: -, Potassium: 3.90 mmol / l, Sodium: 141.1 mmol / L, chloride: 105 mmol / l, analysis results of urinary system is good. Rehydration : Baxter : 15 cc x Kg of BW x percent of combustion : 15 x 71 x 29,25 % : 15 x 71 x = 3641 cc /24 hours IWL : 15 cc x Kg of BW : 15 cc x 71 Kg = 1065 cc /24 hours f. Breathing

Examination of the respiratory system organ and needs to be done to assess the structure of the respiratory system as well as the overall system function. In general, the assessment is directed at the signs and symptoms of respiratory disorders such as dyspnoea (difficulty breathing), cough, sputum production, chest pain, the presence of wheezing and Ronchi, and cyanosis. Nurses are reviewing this section should relate to the examination of the heart and blood vessels so there is a connection because both of them. The presence of clinical manifestations indicate that there are changes in the structure and function of the respiratory system. (Barkaukass, et.al, 1994). A history of smoking is important we examine as a risk factor. An inability cough / airway barrier, or the onset of irregular breathing. In Mr.A respiratory assessment is important because of the combustio on the neck and chest. In physical examination of Mr.A patient said that he had shortness of breath with respiration rate: 31 bpm, the nose mucus is burn and redness , the nose hair is burnt up, the use of accessory respiratory muscles, resonant percussion, auscultation is wheezing. The results of examination of the piston 24 december 2013 were CRT 65%. Test results of blood gas analysis was pH: 7.4, PACO2: 46.8, PAO2: 78.0, HCO3: 26.5., O2 Saturation: 80.3%., BE: 1.1., Blood Gas Sodium: 137., Potassium Gas Blood: 3.9., Chlorida Blood Gas: 100.4. g. Cardiovascular

Physical examination of the heart needs to be done because it aims to obtain data on the effectiveness of the heart pumps, the volume and filling pressure, cardiac output, and cardiac compensatory mechanisms and blood vessels. (Smeltzer & Bare, 2005). Immediately after a combustio injury, released vasoactive substances (catecholamine, histamine, serotonin, leukotrienes, and prostaglandins) from tissue injury experience. These substances cause increased capillary permeability so that plasma seeps into the surrounding tissue. Heart rate increased in response to the release catecholamin and the relative hypovolemia, which began fall of cardiac output. Increase hematocrit levels of expenditure that shows hemoconcentration intravascular fluid. Besides spending evaporation of liquids through injuries occur 4-20 times greater than normal. While the normal discharge in adults with normal body Temperature per day is 350 ml. This can lead to a decrease in organ perfusion. If not filled the intravascular space back to the intravenous fluids hypovolemic shock and threat of death for patients with extensive combustio may occur.

In electrical combustio, Passage of high voltage electricity through the network led to its conversion into heat energy, he raises not only combustio the skin and sub-cutis tissue, but also all the networks on the electrical flow path. Electrical combustio are usually caused by contact with a high voltage power source. Limb is contact with hands and arms are more frequently injured than the legs and feet. Contacts often lead to heart problems and or respiratory and cardiopulmonary resuscitation is often required at the time the accident occurred. Injuries to the local influx of electric current is usually combustio and looked haggard. In this case there are no signs and symptoms related to the cardiovascular system change. In physical examination there was no heart enlargement, heart sounds S1 and S2 regular, gallops (-), nuts (-), percussion dullness. Blood pressure 110/90 mmHg, pulse: 60 x / min regular, Temperature: 36.30 C. CRT >3 seconds. hematology laboratory results 24th december 2013 were; Hb: 12.8 g / l, Ht: 42.9%, erythrocyte: 4.95 million / ul, leukocytes: 11.200/ul, platelets 256.000/ul, MCV: 86.7 g / dl, MCH: 29.8 g / dl, MCHC : 34.4 g / dl. PT: 11.3 sec, PT control: 11.4 sec, APTT: 29.3 sec, APTT control: 26.1 seconds, fibrinogen level 512 mg / dl, LDH: 450 U / l, CKMB: 23 u / l.

h.

Digestion In this case the patient is not using the NGT for feeding, Liquid diet Nitrisol

200cc/4hours via oral. High protein high calorie 2700 kcal. RL infusion installed 20 dpm. There is no difficulty when the food sucked. Abdominal palpation no palpable faecal mass. Patients wear a diaper. On examination dated 24-12-2013 AST: 415, ALT: 85, GDS: 145 Clients BW is 71 kg and clients BH is 165 cm. Antropometric Data: BW : 71 Kg BH : 165 cm IBW : (165 100 ) (165 100 ) . 10% : 65 6,5 65 + 6,5 : 58,5 kg 71,5 kg i. Integument

Nurses need to assess the integument system to obtain data related to dermatological disorders. Subjective assessment of complaints directed at the primary, cause, duration of complaints, location, pain, etc..Physical examination by

inspection and palpation directed at the general appearance, skin disorders such as redness, itching, cyanosis, change in color; lesions on skin, vascularization and hydration, nails and hair.(Smeltzer & Bare, 2005: Black & Hawk, 2005). In combustio patients will be damaged the integrity of the skin, damage that occurs in people not only on the skin only, tissue custody order starting from the low of nerves, blood vessels, muscles, skin, tendons and bones. On a network that prisoners would be much higher current through it, then the heat will be raised higher. Because epidermis thicker, palms and feet have a higher electrical resistance that combustio occurred also heavier when the area is exposed to an electric current. At the time of assessment Mr.A found a second-degree combustion as much as 29.25% on the half of face (2.25%) the front of the chest (9%), the majority of the left hand (9%), and the right hand (9%). good skin turgor , Moisture skin: dry, smooth skin texture , the wound had black colored, edema on upper extremities , the peripheral area is cold . Anatomy of combustion :

j.

Daily activities at home. These data further elucidate the behavior of the patient's health in meeting daily

needs at home. This data is needed to be adjusted later in the preparation of strategic planning in hospital nursing. (Smeltzer & Bare, 2005). This section also describes the activity patterns and exercises that patients can do at home. This needs to be studied because of the pattern of activity in the home can affect and can assist nurses in determining the activity or activities in accordance with the habits of the patient. (Barkaukass et.al, 1994).

In this case, the patient's family said that the activity or activities of the day - the day before the home done by the patient's pain, elimination patterns BAK good no complaints, either defecation pattern and no complaints, own shower 2 times a day, wash hair 3 days, brushing teeth 2 times a day, a good appetite, eating 3 meals a day, regular diet, drink 6 glasses of water a day, never exercise, sleep about 6-8 hours a day. Currently in meeting all the needs of activities of daily living (ADL) assisted by nurses and family because there is a combustio patient's leg and bandage elastice. Daily activities in the hospital Client is swab once a day by nurse within the oral hygiene and genitalia hygiene, urinate facilitate by foley cathether the output 1600cc / 24 hours installed on December 24th 2013, defecation facilitate by diapers, diet is Nutrisol 200cc/ 4 hours sucked with straw, sleep for about 8-9 hours in a day. The activities are need help and monitoring by others with the scale of 2. Activity scale :
1 2 3 4 5 : : : : : Independent Need help and monitoring by others Need the simple help and monitoring by others Need help, monitoring by others, and the aid stuff Totally dependent

(Robert Priharjo,2001 :159, Pengkajian Fisik Keperawatan. Jakarta : EGC) Supporting Examination
Hematology Hemoglobin Leukocyte Erytrocytes Hematocryte Thrombocyte RDW-CV MCV MCH MCHC Gran% Lymphocytes% MID% Gran# Lymphocytes# MID# PROTHROMBIN TIME PT result INR

12.8 11.2 4.95 42.9 256 11.5 86.7 29.8 34.4 83.8 11.5 4.7 15.00 2.1 0.8

14.00 18.00 4.0 10.5 4.50 6.00 42.00 52.00 150 450 11.5 14.7 80.0 97.0 27.0 32.0 32.0 38.0 50.0 70.0 25.0 40.0 4.0 11.0 2.50 7.00 1.25 4.0

g/dl k/ul Million/ul Vol% k/ul % Fl Pg % % % % k/ul k/ul k/ul

Method Impedance Impedance Analyzer Calculates Impedance Analyzer Calculates Analyzer calculates Analyzer Calculates Analyzer Calculates Impedance Impedance Impedance Impedance Impedance Impedance

11.3 0.99

9.9-13.5

second

Nephelometry Nephelometry

Normal Control of PT APTT result Normal Control of APTT CHEMISTRY Ureum Creatinine ELECTROLYTE Natrium Kalium Chlorida CHEMISTRY FAT AND HEART FAAL LDH CKMB

11.4 29.3 26.1

22.2-37.0

second

Nephelometry Nephelometry Nephelometry

20 0.9 141.4 3.9 105.0

10-50 0.7-1.4 135-146 3.4-5.4 95-100

Mg/dl Mg/dl Mmol/l Mmol/l Mmol/l

Modif-berchelot Jaffe ISE ISE ISE

450 23

225 450 0 24

U/L U/L

Optimised ( C ) Optimised ( C )

Arterial Blood Gases Examination

Examination Chemistry Blood Gas Analysis Temperature PH PACO2 PAO2 HCO3 SPAO2 BE Natrium Blood Gases Kalium blood Gases Chloride Blood Gases Result Normal Range 36,5 37,5 7,350 7,450 35,0 45,0 80,0 100,0 22,0 26,0 75,00 99,00 -3,00 3,00 135,0 148,0 3,50 4,50 98,0 107,0 Unit

37,0 7,4 46,8 78,0 26,5 80,3 1,1 137,0 3,9 100,4

Celcius mmHg mmHg Mmol/l % Mmol/l Mmol/l Mmol/l Mmol/l

k.

Pharmacological Therapy

Therapeutic dated December 24, 2013 as follows; IUVD RL 2500 / 24hours . Oral intake 1200/24hours (Nutrisol) Oxygen 8 lpm Inj. Ceftriaxone 2x1 gr Cetorolac 3x30 mg 2x50 mg Ranitidine Debridement

Information about drug:

Ceftriaxone ( Cephalosporin ) Indication:

Infections caused by pathogens that is sensitive to Ceftriaxone, such as respiratory tract infection, ENT infection, urinary tract infection, sepsis, meningitis, bone infection, joint and soft tissue, intra-abdominal infection, genital infection (including gonorrhea), perioperative prophylaxis , and infection in patients with the disorder the body's defenses. Contra indication: Hypersensitivity to cephalosporin and penicillin (as a cross allergic reaction). Cetorolac ( Non-steroidal anti-inflammatory drug ) Indication: Cetorolac is indicated for the short-term management of acute moderate to severe pain after surgical procedures. Cetorolac total duration should not be more than five days. Parenterally administered cetorolac is recommended immediately after surgery. Should be changed to alternative analgesics as soon as possible, as long as cetorolac therapy should not exceed 5 days. Cetorolac is not recommended to be used as an obstetrical preoperative medication or for obstetric analgesia because adequate studies have not been conducted on this subject, and because it is known to have the effect of inhibiting the biosynthesis of prostaglandins or uterine contractions and fetal circulation. Contra Indication: - Patients that have had a previous allergic to this drug, because there is the possibility of cross-sensitivity. - Patients that demonstrate a serious allergic manifestation due administration of aspirin or nonsteroidal anti-inflammatory drugs other. - Patients hat suffering from active peptic ulcer. - Cerebrovascular disease that suspected and that it is definitely. - Hemorrhagic diathesis including coagulation disorder.

Syndrome complete or partial nasal polyps, angioedema or bronchospasm. Concomitant therapy with ASA and other NSAID. Hypovolemia due to dehydration or other causes. Moderate renal impairment to severe (serum creatinine> 160 mmol / L). History of asthma.

- The postoperative patient with a high risk of bleeding or incomplete

hemostasis, patient with anticoagulant including low dose heparin (25005000 units every 12 hours). Concomitant therapy with Ospentyfilline, Probenecid or lithium salts. During pregnancy, labor, delivery or lactation. Children <16 years. patient that have a history of Steven-Johnson syndrome or rash vesikulobulosa. Giving neuraxial (epidural or intrathecal). Prophylaxis prior to major surgery or intra-operative hemostasis if absolutely necessary because of the high risk of bleeding.

Ranitidine (antacid, anti-reflux drug and anti-ulceration) Indication: - Short-term treatment of intestinal ulcers that Twelve fingers is active, active stomach ulcers, reduce the symptoms of reflux esophagitis. - Maintenance therapy after healing intestinal ulcers of twelve fingers, peptic ulcers. - Treatment of pathological hypersecretory state (eg: Zollinger Ellison syndrome and systemic mastocytosis). - Ranitidine injection is indicated for inpatients in a state hospital with pathological hypersecretion or twelve fingers ulcers that are difficult to overcome, or as an alternative treatment of short-term oral administration to patients who can not take oral Ranitidine. Contra Indication: - Patients who are hypersensitive to Ranitidine.
Debridement Debridement is the removal of unhealthy tissue from a wound to promote healing it can be done by surgical, chemical, mechanical or autolytic (using your bodys own processes) the removal tissue. Purpose of debridement Debridement is used to clean dead and contaminated material from your wound to aid in healing. The procedure is most often the following reasons : To remove tissue contaminated area, foreign tissue, dead cells, or crusting)

To create a neat wound edge to decrease scarring To aid in the healing of vey severe burns or pressure sores (decubitus sores) To get a sample of tissue for testing and diagnosis

Possible Complications Pain Bleeding Infection Delayed healing Removal of healthy tissue with mechanical debridement

PROBLEM PRIORITY OF NURSING DIAGNOSIS

1. 2. 3. 4. 5. 6. 7. 8.

Ineffective airway clearance related to Injury of inhalation Impaired Gas Exchange related to change of capillary-alveolar membrane Ineffective Peripheral Tissue Perfusion related to low Oxygen supply secondary to edema Acute pain related to Injury agent secondary to the wound Impaired Physical Ability related to contracture Impaired Skin Integrity related to Injury in the Skin Secondary Intention. Risk for Imbalance Fluid Volume Risk for Infection

NURSING PROBLEM Ineffective airway clearance related to injury of inhalation Subjective Data: Patient stated that he had shortness of breath Objective data: -Patient used Accessory muscle of breathing - RR : 31 bpm -Nose mucus burnt up - Nose hair was burnt up - Breathing sound is

OUTCOME CRITERIA 1. the airway is patent 2. RR at normal range ( 12-20) 3. absence the use of accessory muscle of breathing 4. breathing sound is vesicular 5. Normal result of analysis blood gas 6. saturation of oxygen up to 90%

NURSING INTERVENTION

RATIONALE

EVALUATION The airway was unclear, there is secret RR 28 tpm, using the accessory muscle of breathing, chest expansion isnt optimal, relaxed breathing at semifowler position Oxygen administration decreased 2 l/m saturation is 93% Breathing sound is vesicular - PAO2 : 82,0 mmHg PACO2 : 44,6 mmHg SPAO2 : 80,4 -

1. Assess airway for

patency.

1. Maintaining the airway

is always the first priority, especially in cases of trauma, acute neurological decompensation, or cardiac arrest. Abnormality indicates respiratory compromise. These promote better lung expansion and improved air exchange. To provide for adequate oxygenation The additional stuff for keeping the patency of airway from any obstruction possibility

2. Assess respirations;
note quality, rate, pattern, depth, flaring of nostrils, dyspnea on exertion, evidence of splinting, use of accessory muscles, position for breathing. 3. Use positioning (if tolerated, head of bed at 45 degrees; sitting in chair, ambulation). 4. Maintain oxygen administration device as ordered, attempting to maintain O2 saturation at 90% or greater.

2.

3.

4. 5.

5. Facilitate the patency of airway through oropharyngeal tube 6. Measure the blood gas analysis 7. Do the suctioning if needed

6. The normal result of blood gas analysis shows the effectiveness of airway patency 7. Over secretion of mucous could obstructs the airway it needs to be removed

wheezing - PAO2 : 78,0 mmHg PACO2 : 46,8 mmHg SPAO2 : 80,3 Finger saturation is 65% Oxygen 8 lpm Impaired Gas Exchange related to change of capillaryalveolar membrane Subjective data: Patient said that he had Shortness of breath Objective data :

The client will experience adequate O2/CO2 exchange as evidenced by: a. unlabored respirations at 12 - 20/minute b. oximetry results within normal range c. blood gases within normal range.

1. Assess respirations:
note quality, rate, pattern, depth, and breathing effort. Monitor vital signs. Monitor arterial blood gases (ABGs) and note changes. Use pulse oximetry to monitor O2 saturation and pulse rate continuously. Assess skin color for development of cyanosis. Monitor chest x-ray reports Maintain oxygen administration

1. Both rapid, shallow

breathing patterns and hypoventilation affect gas exchange. Shallow, "sighless" breathing patterns postsurgery (as a result of effect of anesthesia, pain, and immobility) reduce lung volume and decrease ventilation. 2. With initial hypoxia and hypercapnia, blood pressure (BP), heart rate, and respiratory rate all rise. As the hypoxia and/or hypercapnia becomes more severe, BP may

RR:28x/m the pattern is regular ABG showed PAO2 : 82,0 mmHg PACO2 : 44,6 mmHg SPAO2 : 80,4

2. 3. 4.

Theres no Cyanosis or pale

5. 6. 7.

CRT <2 seconds HB : 12,8 g/dl CRT 93%

CRT > 3 seconds SPAO2 : 80,3 HB : 12,8 g/dl PAO2 : 78,0 mmHg PACO2 : 46,8 mmHg RR : 31 bpm

device as ordered, attempting to maintain O2 saturation at 90% or greater. 8. Administer medications as prescribed.

drop, heart rate tends to continue to be rapid with arrhythmias, and respiratory failure may ensue with the patient unable to maintain the rapid respiratory rate 3. Increasing PaCO2 and decreasing PaO2 are signs of respiratory failure. As the patient begins to fail, the respiratory rate will decrease and PaCO2 will begin to rise. Some patients, such as those with COPD, have a significant decrease in pulmonary reserves, and any physiological stress may result in acute respiratory failure. 4. Pulse oximetry is a useful tool to detect changes in oxygenation. O2 saturation should be maintained at 90% or greater. 5. Chest x-rays may guide the etiologic factors of the impaired gas exchange. Keep in mind that radiographic studies of lung water

lag behind clinical presentation by 24 hours. 6. To provide for adequate oxygenation 7. The type depends on the etiologic factors of the problem (e.g., antibiotics for pneumonia, bronchodilators for COPD, anticoagulants/thrombo lytics for pulmonary embolus, analgesics for thoracic pain).

Ineffective Peripheral Tissue Perfusion related to low oxygen supply secondary to edema Subjective Data Patient felt numbness on both of hands

Patient maintains optimal tissue perfusion to vital organs, as evidenced by strong peripheral pulses, normal ABGs, alert LOC, and absence of chest pain

a. Assess color, sensation, movement, peripheral pulses, and capillary refill on extremities with circumferential burns. Compare with findings of unaffected limb. b. discourage positions
that compromise blood flow in lower extremities c. Administer

1. Edema formation can readily compress blood vessels, thereby impeding circulation and increasing venous stasis/edema. Comparisons with unaffected limbs aid in differentiating localized versus systemic problems (e.g., hypovolemia/decrease d cardiac output). 2. in order to allow time

The skin color wasnt pale, the numbness is lessen CRT is fine <2 seconds At semifowler position, the extremities put low in line with heart pulse 84 times a minute Oxygen saturation 93% Oxygen 2 lpm

Objective Data Edema on the hands CRT > 3 Cold on peripheral area Weak pulse : 58 bpm Oxygen saturation is 65% Oxygen 8 lpm

humidified oxygen via appropriate mode, e.g., face mask.

for autoregulatory mechanisms to adjust to the change in the distribution of blood associated with an upright position 3. oxygen supplies will fulfill the optimal tissue perfussion

Acute pain related to post of debridement action Subjective data : Patient said that he felt pain P: the wound on the skin Q : stabbing

Report pain reduced/controll ed. Display relaxed facial expressions/bod y posture.

1. Assess reports of

1. Pain is nearly always present

pain, nothing location/character and intensity (05 scale). 2. Teach the deep breathing technique 3. Change position frequently. 4. Administer analgesics ( Ketorolac)

to some degree because of varying severity of tissue involvement/destruction but is usually most severe during dressing changes and debridement. Changes in location, character, intensity of pain may indicate developing complications (e.g., limb ischemia) or herald improvement/return of nerve function/sensation.

Patient reported the pain is a bit relived. The scale is 1 (mild)

P: the wound on the skin Q : stabbing R : wound area S : 1 ( 1-5) T : 15 minutes Patient showed relax facial expression and distracted from the onset pain The pain was bearable after changing the position

R : wound area S : 2 ( 1-5) T : 15 minutes Objective data : - Patient looked winced in pain

2. To reduce the pain 3. Movement and exercise

reduce joint stiffness and muscle fatigue, but type of exercise depends on location and extent of injury 4. The burned patient may require around-the-clock medication and dose titration. IV method is often used initially to maximize drug effect. Concerns of patient addiction or doubts regarding degree of pain experienced are not valid during emergent/acute phase of care, but narcotics should be decreased as soon as feasible and alternative methods for pain relief initiated

After administering via IV ketorolac 3x30 mg, the pain was relieved . as pprevention for side effect of ketorolac, given injection Ranitidine 2x50mg

Impaired Physical Mobility related to contractur Subjective Data :

Maintain position of function as evidenced by absence of contractures. Maintain or increase

1. Maintain proper body alignment with supports or splints, especially for burns over joints. 2. Note circulation, motion, and sensation of digits frequently. 3. Assess the muscle strenght 4. Perform ROM exercises consistently, initially passive,

1. Promotes functional positioning of extremities and prevents contractures, which are more likely over joints. 2. Edema may compromise circulation to extremities, potentiating tissue necrosis/development of

Bandage on contracture hand The circulation, motion and sensation are good Muscle strength is low on the right hand Patient was doing ROM cooperatively as procedure. With passive ways then active

Patient said that he couldnt move his right hand Objective Data: Contractor on right hand Muscle strength 4444 4444 3333 4444

strength and function of affected and/or compensatory body part. Verbalize and demonstrate willingness to participate in activities. Demonstrate techniques/beha viors that enable resumption of activities.

then active. 5. Encourage family/SO support and assistance with ROM exercises. 6. Encourage patient participation in all activities as individually able.

3. 4.

5.

6.

contractures. To analyze the strength of each extremity Prevents progressively tightening scar tissue and contractures; enhances maintenance of muscle/joint functioning and reduces loss of calcium from the bone. Enables family/SO to be active in patient care and provides more constant/consistent therapy. Promotes independence, enhances self-esteem, and facilitates recovery process.

Patient was motivated to do the ROM exercise, ADL and being optimistic for recovery

Muscle strength 4444 4444 3333 4444

Activity scale is 2 (need help and monitoring by others) -

Activity scale is 2 (need help and monitoring by others)

Impaired Skin Integrity related to Injury in the Skin Secondary Intention. Subjective data :

Wound Healing: Secondary Intention (NOC) Demonstrate tissue regeneration. Achieve timely healing of burned areas

1. Assess/document

1. Provides baseline

size, color, depth of wound, noting necrotic tissue and condition of surrounding skin
2. Change burn dressing using the topicals and dressing materials

information about need for skin grafting and possible clues about circulation in area to support graft.
2. Some topicals perform better if they are change once a day or twice a day, etc. It is important to follow the prescribed order and the company's

Patient is having 3 degree of burn injury, the color is pink and the surface area of wound is 29,25% skin surrounds wounds are redness The burn injury was cleaned and poured with NaCl and covered with sterile gauze,

The client said That he felt pain on the wound area of skin Objective data : There was an electrical burnt on chest ( 9%) left hand (9%) right hand (9%) half of face ( 2,25%) total (29,25%) The depth of wound was 3 Degree (full thickness) The wound area had black colored

ordered, at the prescribed frequency. 3. maintain sterile technique. 4. observe the burn area for evidence of healing (i.e. sloughing of burn eschar, bleeding, budding evidence of new skin cell regeneration and wound closure). While dressing

recommendation regarding the topical ordered. 3. good sterile technique during dressing changes assists in preventing burn wound infections. 4. As the burn heals the practitioner may need to change the burn topical or skin care regimen. Evidence of poor wound healing may indicate the burn is becoming infected or the patients nutritional status needs to be improved

once a day Nurses kept the hygiene and used the aseptic technique before and after the nursing action. Patient wasnt having bleeding, the wound became dried showed the regeneration of tissue

Risk for Imbalance Fluid Volume

Objective Intake : Oral : 1200 cc/ 24 hours Parenteral

Demonstrate improved fluid balance as evidenced by individually adequate urinary output with normal specific gravity, stable

1. Monitor vital signs, central venous pressure (CVP). Note capillary refill and strength of peripheral pulses. 2. Monitor intake and urinary output. Observe urine color and Hematest as indicated. 3. Insert/maintain indwelling

1. Serves as a guide to fluid

replacement needs and assesses cardiovascular response. Note: Invasive monitoring is indicated for patients with major burns, smoke inhalation, or preexisting cardiac disease, although there is an

Vital signs was normal BP : 110/80 mmhg RR : 20 bpm HR : 78 bpm T : 36,5 C

CRT refilling time is < 2 seconds The color of urine isnt pure yellow as clear

:2500 cc /24 hours - Output : IWL = 1.065 cc/24 hours Urine : 1600 cc / 24 hours -client has combustion all over the skin of 29.25% SPAO2 : 80,3 PAO2 : 78,0 mmHg PACO2 : 46,8 mmHg

vital signs, moist mucous membranes. Balance of Electrolyte and PH

urinary catheter. 4. Administer calculated IV replacement of fluids 5. Monitor laboratory studies (e.g., Hb/Hct, electrolytes, random urine sodium and blood PH).

2.

3.

4.

5.

associated increased risk of infection, necessitating careful monitoring and care of insertion site. Generally, fluid replacement should be titrated to ensure average urinary output of 30 50 mL/hr (in the adult). Urine can appear red to black (with massive muscle destruction) because of presence of blood and release of myoglobin. If gross myoglobinuria is present, minimum urinary output should be 75100 mL/hr to reduce risk of tubular damage and renal failure 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. Fluid resuscitation replaces lost fluids/electrolytes and helps psrevent complications, e.g., shock, acute tubular necrosis (ATN). Identifies blood loss/RBC destruction and fluid and

Installed cathether since December 24th 2013 Installed the IV line since 24th 2013 Intake : Oral : 1200 cc/ 24 hours Parenteral :2500 cc /24 hours - Output : IWL = 1.065 cc/24 hours Urine : 1600 cc / 24 hours -client has combustion all over the skin of 29.25%

PAO2 : 82,0 mmHg PACO2 : 44,6 mmHg SPAO2 : 80,4

electrolyte replacement needs. Urine sodium less than 10 mEq/L suggests inadequate fluid resuscitation. Note: During first 24 hr after burn, hemoconcentration is common because of fluid
shifts into the interstitial space.

Risk for Infection Objective data : WBC : 11,2 k/ul Hb : 12,8 g/dl There was electrical burn wound (29.25%) Client would get the invasive procedure

Patient will achieve timely wound healing free of purulent exudate and be afebrile

1. Observe the sign and symptom of infection 2. Proper hand washing technique (6 ways ) 3. Use aseptic technique when do the procedure 4. Check lab result of leucocytes 5. Give antibiotic as indication

1. To detect the early sign of infection 2. Prevent bacterial transmitted 3. To maintain the hygiene and prevent infection 4. The increase of leucocytes as indicate of infection 5. To reduce infection.

administering the antibiotics injection of ceftriaxone 2x1 gr Through there is no sign of infection or exudates Nurses keep the aseptic and antiseptic technic Nurse clean the wound once a day There is no sign of inflammation ; rubor, kalor, dollor, tumor, or function laysia.

THE LAST CONDITION OF CLIENT BEFORE MOVE INTO THE WARD

The airway was unclear, there is secret, RR 28 tpm, using the accessory muscle of breathing, chest expansion isnt optimal, relaxed breathing at semifowler position, Oxygen administration decreased 2 l/m saturation is 93% , Breathing sound is vesicular, PAO2 : 82,0 mmHg, PACO2 : 44,6 mmHg, SPAO2 : 80,4, The skin color wasnt pale, the numbness is lessen, CRT is fine <2

seconds, pulse 84 times a minute, Patient reported the pain is a bit relived, The scale is 1 (mild), P: the wound on the skin, Q : stabbing, R : wound area, S : 1 ( 1-5), T : 15 minutes, Patient
showed relax facial expression and distracted from the onset pain, The pain was bearable after changing the position, After administering via IV ketorolac 3x30 mg, the pain was relieved . as pprevention for side effect of ketorolac, given injection Ranitidine 2x50mg, Bandage on contracture hand, The circulation, motion and sensation are good, Muscle strength is low on the right hand, Patient was doing ROM cooperatively as procedure. With passive ways then active, Patient was motivated to do the ROM exercise, ADL and being optimistic for recovery.

Muscle strength 444 4 444 4 4444 3333

Activity scale is 2 (need help and monitoring by others), Patient is having 3 degree of burn injury, the color is pink and the surface area of wound is 29,25% skin surrounds wounds are redness, The burn injury was cleaned and poured with NaCl and covered with sterile gauze, once a day, Nurses kept the hygiene and used the aseptic technique before and after the nursing action, Patient wasnt having bleeding, the wound became dried showed the regeneration of tissue, Vital signs was normal : BP : 110/80 mmhg, RR : 20 bpm, HR : 78 bpm, T : 36,5 C. The color of urine isnt pure yellow as clear, Installed cathether since December 24th 2013, Installed the IV line since 24th 2013, Intake : Oral : 1200 cc/ 24 hours, Parenteral :2500 cc /24 hours Output : IWL = 1.065 cc/24 hours, Urine : 1600 cc / 24 hours. administering the antibiotics injection of ceftriaxone 2x1 gr, Through there is no sign of infection or exudates, Nurses keep the aseptic and antiseptic technic, There is no sign of inflammation ; rubor, kalor, dollor, tumor, or function laysia.