College of Nursing and Midwifery

STAFF ENDORSEMENT SHEET

Room no: _812___ Diagnosis: Full thickness burn 15% TBSA S/P thickness skin
grafting . Diet: DAT_
Name of Patient: _Moises, Miguel , Jr.___________________ Attending Physician: _Dr. Nicomedes
Cruz______Age: 35 y/o_ Sex_Male_____

DOCTOR’S ORDER NURSE’S NOTES IVF

 Received patient conscious and MEDICATIONS
 No New Doctors Order coherent. Paracetamol 500mg.Q6 PRN
 Vital Signs taken and recorded.  Chlorphenamine 4mg.1tab.PRN
 Due meds. Given.  Vit.B Complex 1 tab. BID
 Kept safe and comfortable.  Oxacillin 500mg. QID
 Needs attended.
 Endorsed.

INTAKE/OUTPUT LAB EXAMS/PROCEDURES

Urine -3 times  No Laboratory Request

Stool – (-)

Prepared by: _Genoveva Sharon Muyco Margallo___ Noted by:

Staff Nurse Head Nurse
 College of Nursing and Midwifery

NURSING CARE PLAN

Patient’s Initial: _Mr. M. M.___ Diagnosis: Full thickness burn 15% TBSA, S/P thickness skin grafting
Room: __812__

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: • Pain related to • Monitor vital signs, • Establishment of • To maintain or • Maintains

“Extreme anxiety exposed CVP, intake and airway and restore pulmonary respiratory
restlessness; pain, as nerve endings. output (hourly administration of ventilation and function.
verbalized by the •
patient.” • Fluid volume
urine output), and
specific gravity as
oxygen;
mechanical •
oxygenation.
To maintain or
Maintains fluid
balance.
deficit related to ordered. ventilation as restore normal • Remains free of
OBJECTIVE: fluid loss through
burn wound and • Observe for signs
needed. balance of infection.
shift of fluid out of of electrolytes • IV replacement electrolytes in the
intracellular and
• Expresses feelings
intravascular imbalance (electrolyte about altered body
• Changes in extracellular
compartment. (calcium, solutions and image.
appearance of skin compartment.
potassium, and colloids such as • Goal partially met.
indicate degree of • To promote wound
burn. sodium) and blood and plasma)
metabolic acidosis. to maintain healing.
• Electrolyte • Observe for signs circulation. • For early
imbalance: cellular of infection (rising • Skin grafting to assesstment of
destruction result temperature and limit fluid loss. abnormalities.
initially in white blood cell • Vital signs • Prevention from
hyperkalemia. count, odor) monitored every tetanus.
• Elevated
hematocrit as a
• Monitor 15 minutes.
• Tetanus toxoid
result of fluid loss. respiratory
function: booster
• Presence of characteristics of administration;
symptoms of respirations tetanus human
hypovolemic shock breathe sounds, immune globulin
caused by and arterial blood for passive
circulatory failure gases. immunity if not
resulting from previously
• Give medication
seepage water, immunized.
for pain as ordered
plasma, proteins, and particularly
and electrolytes before dressing
into burned area. change.
• Keep room
temperature warm
 and humidity high.
• Give realistic
reassurance.
VITAL SIGNS:

Temp. -36.5 C
PR. – 80 b/ min.
RR. -21 count / min.
BP. -120/80 mmHg.

Prepared by: _Genoveva Sharon Muyco Margallo_ Noted by: Marianne Cherry Lazo__
Staff Nurse Head Nurse