PHYSICAL ASSESSMENT

Date assessed: March 2 (pre-op) and 9 (post-op), 2012; 4pm

BODY PART

Techniqu e used

NORMAL FINDINGS

ACTUAL FINDINGS (March 2, 2012) Burned site is cyanotic in color. Blisters seen at the right thigh, buttocks and surrounding skin of the genitalia with peeling skin. Skin on burned site is dry and with watery discharge Patient is warm to touch

Actual Findings (March 9, 2012) Burned site is fleshy pink in color

ANALYSIS

Skin

Inspection

Uniform in color No abrasions or any lesions

Inspetion

Palpation

Well moistened skin.

Eschar is A blister is a "bubble" present in the in the skin filled burned area with serous fluid as part of the body's reaction to the heat and the subsequent inflammatory reaction. It is due to Skin is slowly increase capillary returning back permeability. to its normal (wikipedia.org/wiki/B state urn; Med.-Surg. Nursing.) Patient is warm to touch

Palpation

Nails

Inspection

Normal temperature of the skin ranges from mildly cool to slightly warm depending on the environment Nails should be pink in color, slightly convex Nails should be

Bluish in color, Flat on nail bed

Bluish discoloration in Pink in color, nails may indicate flat on nail bed hypoxia or shock due to the injury of the cliet.

Nails are long and dirt

Nails are long and dirt

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short and clean Healthy nails return to its color instantly for about 1-3 seconds HEAD SKULL & FACE Inspection Palpation Round or normocephali c; smooth, absence of nodules or masses; Symmetric facial movements. Hair color depends on the race, age, and genetics. Usually, Asians have dark/black hair color and is commonly changing when aging Round or normocephali c; smooth, absence of nodules or masses; Symmetric facial movements. Hair is mostly black in color Round or normocephali c; smooth, absence of nodules or masses; Symmetric facial movements. Hair is mostly black in color Capillary refill return within 3 seconds Capillary refill return within 3 seconds

HAIR

Inspection

Eyebrow

Inspection

Even Even distribution of distribution hair, resilient of hair, thick hair resilient thick with no signs hair with no of infections signs of or infections or infestations. infestations. Evenly Evenly distributed distributed hair; hair; eyebrows eyebrows symmetrically symmetricall aligned; y aligned;

Even distribution of hair, resilient thick hair with no signs of infections or infestations. Evenly distributed hair; eyebrows symmetricall y aligned;

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Eyes

Inspection

Eyelashes

Inspection

Lids close Lids close symmetricall symmetrically y ; shiny smooth, pale-pink shiny smooth, conjunctiva pinkish No edema or conjunctiva tenderness. Eyes were No edema or able tenderness. coordinate with the Eye muscles movement of are both the penlight coordinated ( examined with Pupils the use of six constrict as cardinal eyes focus on movements test the penlight. ) Equally Pupils distributed, constrict as Curled eyes focus on slightly the penlight. outward Skin intact, No discharge No discoloration, Lids close symmetricall y

Lids close symmetricall y shiny smooth, pale-pink conjunctiva No edema or tenderness. Eyes were able coordinate with the movement of the penlight Pupils constrict as eyes focus on the penlight Equally distributed, Curled slightly outward Skin intact, No discharge No discoloration, Lids close symmetricall y

Eyelids

Inspection

Equally distributed, Curled slightly outward

Pupils (color , shape and symmetry

Inspection

Black in Skin intact, color, equal No discharge, in size No normally 3 -7 discoloration, mm in Lids close diameter, symmetrically Round smooth border, Iris flat and

Black in color, equal in size normally 3-7 mm in

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of size) Black in color, equal in size normally 3-7 mm in diameter, Round smooth border , iris flat and round. color same as facial skin symmetrical; mobile, firm and not tender; No notable discharges normal voice tones audible Symmetric and straight; no discharge or flaring

round.

diameter, Round smooth border , iris flat and round

EAR

Inspection

color same as facial skin symmetrical; mobile, firm and not tender; No notable discharges normal voice tones audible

color same as facial skin symmetrical; mobile, firm and not tender; No notable discharges normal voice tones audible Symmetric and straight; no discharge or flaring Not tender, no lesions. Uniform in color Air moves freely as the patient breaths through the nares. No tenderness in maxillary and frontal sinuses Uniform in pink color;

NOSE AND SINUSES

Inspection

MOUTH

Inspection

Symmetric and straight; no discharge or flaring Not tender, Not tender, no no lesions. lesions. Uniform in Uniform in color color Air moves Air moves freely as the freely as the patient patient breaths breaths through the through the nares. nares. No tenderness in No tenderness maxillary and in maxillary frontal and frontal sinuses sinuses Uniform in Uniform in pink color; pink color;

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symmetrical lips. TONGU E Inspection in central position; pink in color moves freely with no tenderness Smooth tongue base with prominent veins Smooth with no palpable nodules Uvula positioned in midline of soft palate. gag reflex present TEETH Inspection 20 deciduous teeth, smooth, white, shiny tooth enamel

symmetrical lips. in central position; pinkish-white in color moves freely with no tenderness Smooth tongue base with prominent veins Smooth with no palpable nodules Uvula positioned in midline of soft palate. gag reflex present 16 deciduous teeth molar has signs of tooth decay, smooth, white, shiny tooth enamel

symmetrical lips. in central position; pink in color moves freely with no tenderness Smooth tongue base with prominent veins Smooth with no palpable nodules Uvula positioned in midline of soft palate. gag reflex present 16 deciduous teeth molar has signs of tooth decay, smooth, white, shiny tooth enamel Deciduous teeth are the first set of teeth in the growth development of humans, it is later on replaced by the permanent set of teeth so sudden shedding of teeth in children is considered normal (Anatomy and Physiology)

Palpation

no retraction of gums

no retraction of gums
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no retraction of gums

NECK MUSCLE S

Inspection Palpation

Coordinated, smooth movement with no discomfort. Has equal muscle strength. Not palpable Muscle: Equal size on both sides of the body No contractures

Coordinated, smooth movement with no discomfort. Has equal muscle strength. Not palpable

Coordinated, smooth movement with no discomfort. Has equal muscle strength.

Lymph nodes Upper extremiti es

Palpation

Not palpable

Inspection Palpation

Muscle: Equal size on both sides of the body No contractures Bones: No skeletal deformities Joints: No swelling, tenderness, crepitation or nodules. Moves freely

Muscle: Equal size on both sides of the body No contractures

Bones: No skeletal deformities. Joints: No swelling, tenderness, crepitation or nodules. Moves freely Posterior thorax: Inspection Auscultati on Palpation

Bones: No skeletal deformities Joints: No swelling, tenderness, crepitation or nodules. Moves freely

Thorax and Lungs

Symmetry: Spine Symmetry: Spine vertically vertically aligned; aligned; Spinal column is Spinal straight column is Right and left straight shoulders hips are the Right and left same in shoulders hips height.

Symmetry: Spine vertically aligned; Spinal column is straight Right and left shoulders hips are the same in height.

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are the same in height. Skin intact; uniform temperature No tenderness and no presence of masses Vesicular and bronchoVesicular breath sounds

Skin intact; uniform temperature No tenderness and no presence of masses Vesicular and bronchoVesicular breath sounds Anterior thorax: Quite, rhythmic, and effortless respirations No tenderness and no presence of masses

Skin intact; uniform temperature No tenderness and no presence of masses Vesicular and bronchoVesicular breath sounds

Anterior thorax: Quite, rhythmic, and effortless respirations No tenderness and no presence of masses Unblemished skin Uniform in color Flat, rounded or scaphoid Symmetric movement caused by respiration Audible bowel sound GENITA LS
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Anterior thorax: Quite, rhythmic, and effortless respirations No tenderness and no presence of masses

Abdomen

Inspection Auscultati on Palpation

Unblemished skin Uniform in color Flat, rounded or scaphoid Symmetric movement caused by respiration Audible bowel sound

Unblemished skin Uniform in color Flat, rounded or scaphoid Symmetric movement caused by respiration Audible bowel sound

Scrotum

Asymmetric Asymmetric (left testis is (left testis is usually lower) usually no lesions, lower) nodules, no lesions, swellings and nodules, inflammation swellings and inflammation no enlargement, no nodules No swelling; no palpable bulges

Asymmetric (left testis is usually lower) no lesions, nodules, swellings and inflammation

Prostate gland Inguinal no enlargement, no nodules No swelling; no palpable bulges Muscle: Equal in size on both sides of the body No contractures. No lesions, swelling and inflammation

no enlargement, no nodules No swelling; no palpable bulges Muscle: Equal in size on both sides of the body No contractures. Eschar is present in the site of injury

Lower extremiti es

Inspection Palpation

Muscle: Equal in size on both sides of the body No contractures Blisters seen in right thigh, buttocks and genital

Bones: No skeletal deformities. Joints: No swelling, tenderness, crepitation or nodules and moves freely

Bones: No skeletal deformities. Joints: No swelling, tenderness, crepitation or nodules and moves freely but patient experience bearable pain when moving due to injury

Bones: No skeletal deformities. Joints: No swelling, tenderness, crepitation or nodules and moves freely but still patient feels a minimal, bearable pain when moving

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due to the injury site.

Electrolytes
March 7, 2012 Sodium Potassium Chloride Analysis : Major burns greater than 25% TBSA causes cell lysis which causes the potassium to be exaggerated ( hyperkalemia) and a sodium , H20 and proteins shift from intravascular to interstitial spaces which causes hyponatremia. Result 129.4 6.21 Reference range 135-148 mmol/L 3.5-5.3 mmol/L 98-107 mmol/L

Hematology Component Hemoglobin Hematocrit Result 156q/L 0.85 Reference range (adult) M=130-180q/L M =0.37-0.54

march 6, 2012 Interpretation Normal Increase

WBC count Platelet Differential count Neutrophil Lymphocyte Monocyte Hematology Component Hemoglobin

13.2 x 10 /L 93 x 10/L o.84 0.10 0.06

4.6 x 10 /L 150-450 x 10 /L 0.30-0.70 0.22-0.40 0.00- 0.05

Increase Normal Increase Decrease increase February 24, 2012

Result 106q/L

Reference range (adult) Interpretation M=130-180q/L F=125- Normal 165q/L

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Hematocrit

0.49

M =0.37-0.54 0.42 4.6 x 10 /L 150-450 x 10 /L 0.30-0.70 0.22-0.40 0.00- 0.05

F= 0.37- increase

WBC count Platelet Differential count Neutrophil Lymphocyte Monocyte

24.3 x 10 /L 53.6 x 10/L 0.83 0.33 0.06

Increase Normal Increase Decrease increase

Analysis: In response to infection laboratory results shows an elevated WBC since the patient needs to combat pathogens and as immune response to protect body against invading microorganisms ; Neutrophils increase in acute infections phagocytes microorganism and other foreign substances; Lymphocytes play an important role in bodys immune response, their diverse activity involve the production of antibody and other chemicals that destroy microorganism and, regulates immune system; Monocytes phagocytes bacteria, it decreases with the use of corticosteroid. Hematocrit increases in response to dehydration and shock. And the rest of the values are normal.

COURSE IN THE WARD

Date and Time/Assessment/Course March 02, 2012 Received pt. awake in bed. Conscious and coherent. IVF of D5 .3 PLR 58 ml/hr via soluset, infusing well Activity CA VS taken and recorded. Temp.: C PR: 105 bpm RR: 28 bpm Due meds given. Oxacillin 150 gms. TIV q6 Silver Sulfadiazine, OD after every bath. Daily bath done. Daily wound care and dressing done. Seen frequently. Kept safe.

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For referral to pedia for management. I & O taken and recorded. Endorsed.

March 03, 2012 Received patient awake in bed. On DFA (diet for age). With IVF of PLR 58ml/hr via soluset, infusing well. Activity CA VS taken and recorded. Temp.: C PR: 110 bpm RR: 28 bpm Due meds given. Oxacillin 150 gms. TIV q6 Silver Sulfadiazine, OD after every bath. Daily bath done. Daily wound care and dressing done. Seen frequently. Kept safe. For referral to pedia for management. I & O taken and recorded. Endorsed

March 09,2012 Received pt. awake in bed. Conscious and coherent.. On DFA (diet for age) With IVF of D5 .3 NaCl 500 ml x 38 ugtts/min., infusing well. Activity PA VS taken and recorded. Temp: C PR: 110 bpm RR: 20 bpm Due meds given. Oxacillin 150 gms. TIV q6 Silver Sulfadiazine, OD after every bath., Daily bath done. Daily wound care and dressing done. Seen frequently. Kept safe. I & O taken and recorded.

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Endorsed

March 10,2012 Received patient awake in bed. Conscious and coherent. On DFA (diet for age) IVF D5 .3 NaCl 500 ml x 38 uggts/min., infusing well. . Activity PA VS taken and recorded. Temp: C PR: 122 bpm RR: 28 bpm Due meds given. Oxacillin 150 gms. TIV q6 Silver Sulfadiazine, OD after every bath. Daily bath done. Daily wound care and dressing done. Seen frequently. Kept safe. I & O taken and recorded. Endorsed

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ANATOMY AND PHYSIOLOGY

Our skin is the largest organ of the human body. The integument or skin makes up 15% to 20% of the bodys weight. Intact skin is the bodys primary defense system. It protects us from invasion by organisms, helps to regulate body temperature, manufactures vitamins and provides our external appearance. Skin has three primary layers (i.e., epidermis or outer layer; the dermis or inner layer and the hypodermis or subcutaneous layer) as well as epidermal appendages (i.e,eccrine glands, apocrine glands, sebaceous glands, hair follicles and nails).The skin is the most prominent organ containing epithelium, which is composed of cells that provide a continuous barrier between the body contents and the outside the environment. Epithelial cells also cover the Gastrointestinal tract, pulmonary airways and alveoli, renal tubules and the urinary system, and the ducts that empty onto the surface of the skin of the GI and respiratory systems. Epithelial cells allow the selective transport of ions, nutrients, and metabolic wastes and have a permeability to water that is partially regulated.

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Structure of the Integumentary System

EPIDERMIS The epidermis consists of four distinct layers: the stratum corneum, the stratum granulosum, the stratum spinosum and the stratum basale. The stratum corneum is the outermost covering and consists of 15-20 layers. Stratum granulosum consists of flattened nucleated cells containing
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distinctive cytoplasmic inclusions called kerato hyalin granules. Stratum spinosum is comprised of severallayers of a polyhedral type cell that lie above the germinal layer of cells.stratum basale is germinative layer of the epidermis. The epidermis is the thin, stratified layer that is in direct contact with the external environment. The thickness of the epidermis ranges from 0.04mm on the eyelids to 1.6mm on the palms and soles. Desmosomes (point of intracellular attachment that are vital for cell-to-cell adhesion) are found in the epidermis. Keratinocytes, the principal cells of epidermis, produce keratin in a complex process. The cells begin in the basal layer and change constantly, moving upward through the epidermis. On the surface, they are sloughed off or lost by abrasion. Thus the epidermis constantly regenerates itself, providing a tough keratinized barrier. Epidermal appendages Epidermal appendages are down growths of epidermis into the dermis. They consist of eccrine glands, apocrine glands, sebaceous glands, hair and nails. Eccrine glands- produce sweat and play an important role in the thermo regulation.They are more numerous on the palms, soles, forehead and axillae. These are stimulated by heat as well as by exercise and emotional stress. The eccrine gland also responds to sympathetic and parasympathetic stimulation. Apocrine glands- occur primarily in the axillae, breast, areolae, anogenital area, ear canals, and eyelids. Mediated by adrenergic innervations, secrete a milky substance that becomes odoriferous when altered by skin surface bacteria. Sebaceous glands- are found throughout the skin except on the palms and soles and are most abundant on the face, scalp, upper back, and chest. Androgen is responsible for sebaceous gland development. Hair- is a nonviable protein end product found on all skin surfaces except the palm sand soles. About 50-100 hairs are lost each day. Nails- are horny scales of epidermis. The nail matrix is the source of specialized, non keratinized cells. They differentiate into keratinized cells, which make up the nail protein. A
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damaged nail matrix, which may result from trauma or aggressive main curing, produces distorted nail. DERMIS The dermis, a dense layer of tissue beneath the epidermis, gives the skin most of its substance and structure. The dermis contains fibroblasts, macrophages, mast cells and lymphocytes. The skins lymphatic, vascular, and nerve supplies, which maintain equilibrium in the skin, are in the dermis. The dermis is divided into two parts: papillary and reticular. The papillary dermis, which contains increased amounts of collagen, blood vessels, sweat glands, and elastin, is in contact with the epidermis. The reticular dermis also contains collagen but with increased amounts of mature elastic tissue. The dermis houses many specialized cells, blood vessels, and nerves. Dermis - Specialized Structures Nerve endings Blood vessels Sweat glands Oil glands - keep skin waterproof, usually discharges around hair shafts Hair follicles - produce hair from hair root or papilla Each follicle has a small muscle (arrectus pillorum) which can pull the hair upright and cause goose flesh

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HYPODERMIS The subcutaneous layer is a specialized layer of connective tissue. It is sometimes called the adipose layer because of its fat content. This layer is absent in some sites, such as eyelids, scrotum, areola and tibia. Subcutaneous fat is generally thickest on the back and buttocks, giving shape and contour over the bone. This layer functions as insulation from extremes of hot and cold, as a cushion to trauma, and as a source of energy and hormone metabolism. FUNCTION OF THE INTEGUMENTARY SYSTEM PROTECTION The skin protects the bodys against many forms of trauma. The intact tough epidermal layer is a mechanical barrier. Bacteria, foreign matter, other organisms and chemicals penetrate it with difficulty. The oily and slightly acid secretions of its sebaceous glands protect the body further by limiting the growth of many organisms. HOMEOSTASIS Skin forms a barrier that prevents excessive loss of water and electrolytes from the internal environment and also prevents the subcutaneous tissues from drying out. The effectiveness of this impermeable membrane is readily recognized when one observes the extreme loss of fluids that occurs with damage to the skin, as with burns and other injuries. Insensible loss of water and electrolytes occurs only though pores in this effective barrier. THERMOREGULATION Body temperature represents the balance between heat regeneration and heat loss processes. The skin, with its ability to alter the rate of heat loss, is the major point of regulation of body temperature. The rate of heat loss depends primarily on the surface temperature of the skin,
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which is in turn a function of the skins blood flow. The flow of blood to the skin is derived in two processes. Direct perfusion is from capillary beds entering in lateral directions. Skin is also perfused vertically from vessels that enter from the muscle and fascia supporting it. In general, the vessels dilate during warm temperatures and constrict during cold. The hypothalamus is partly responsible for regulating skin blood flow, particularly to the extremities, the face, ears, and the tip of the nose. Maintenance of the thermal balance allows the internal temperature of the body to remain at approximately 37 degree Celsius. SENSORY PERCEPTION Apart from sight and hearing, the major human sensory apparatus is in the skin. Sensory fibers responsible for pain, touch and temperature form a complex network in the dermis. The skin contains specialized receptors to detect discriminative touch and pressure. Touch is sensed by Meissners corpuscles; pressure by Merkel cells and Ruffini endings; vibration by Pacinian corpuscles; and hair movement by hair follicle endings .A second grouping of nerves communicates information about temperature and pain to the somato sensory cortex via the anterolateral pathways. Temperature is sensed by specific thermo receptors in the epidermis, and pain is sensed by free nerve endings throughout the epidermal, dermal, and hypodermal layers. VITAMIN D REPRODUCTION The epidermis is involved in synthesis of vitamin D. In the presence of sunlight or ultraviolet radiation, a sterol found on the malpighian cells is converted to form cholecalciferol (Vitamin D3). It assists in the absorption of calcium and phosphate from ingested foods.

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PROCESSING OF ANTIGENIC SUBSTANCES Langerhans cells are scattered among the keratinocytes located primarily in the epidermis; however, they can also be seen in the dermis. These cells originate in the bone marrow and migrate to the epidermis. Langerhans cells play a role in the cell-mediated immune responses of the skin through antigen presentation. Cells in both the epidermis and dermis of the skin are important in the immune function. Skin is now recognized not only as a physical barrier but also as a participant in immunologically mediated defense against various antigens.

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Thermal burn
Predisposing Factors: -Children ages 4 and under -Male child>female child -Older adults, children and adolescent

Precipitating factor - Careless cooking - heat/ hot surfaces, boiling water reachable by children

(Scalding Burn Injury 16%)

Exposure to Hot Water

Damage in the upper portion of the epidermis and the dermis

Symphathetic Activation

Loss of skin integrity (Barrier to infection)

Vasoactive substance are released from the injured tissue

Lab result: Neutrophil count:

Abnormal inflammatory factors, altered level of immunoglobin, Impared neutrophil function

0.84

Initiate changes in capillary Integrity (increased capillary permeability)

immunosuppresion

Increased risk for sepsis Increase hydrostatic pressure forcing water, protein, and electrolytes (potassium) into the interstitial 20 | P a spaces ge

Na+ and water shifts out of the cell, K+ shifts in

Hematology: Na+:129.4mmol/L K+: 6.21mmol/L

EDEMA

As manifested by blister

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Exposure to Hot Water

Damage in the upper portion of the epidermis and the dermis

Change in microcirculation in the area of injury including vasodilation, increase vascular permeability and leukocytic cellular infiltration

Five Cardinal signs of Inflammation The pressure of fluids on the nerve endings and to direct irritation of nerve endings by chemical mediators (bradikinin) at the site.

increased blood flow through the microcirculation Vascular permeability increases and the plasma fluids leaks into the inflamed tissue

Redness

Local Heat

Swelling

Pain

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Loss of Function

Pain scale :10 by Wong baker faces pain scale

PATHOPHYSIOLOGY Thermal or chemical burns lead to the destruction of the skin and blood vessels. The blood capillaries at the site become dilated and more permeable causing loss of fluid, electrolytes and plasma proteins into the tissues. This causes edema and formation of blisters. Fluid loss causes dehydration and hypovolemic shock. The blood vessels around the burn become thrombosis resulting in a decrease in circulation to the area thereby aggravating the tissue damage. Sodium is lost into the edema fluid. Further loss of blood proteins into the fluid promotes edema, causing decrease in intravascular colloidal osmotic pressure. Potassium is lost from the damaged cells leading to temporary hypokalemia. More of the potassium is excreted by the kidneys. Hypoxia develops as a result of the hypovolamia, thrombosed blood vessels and sluggish circulation which cause decrease tissue perfusion. The ensuing hypoxia leads to metabolic acidosis. Fluid and sodium loss cause an increase in the production of aldosterone and the antidiuretic hormone (ADH). The aldosterone causes the kidneys to conserve sodium, while the ADH brings about conservation of water resulting in the passage of scanty, concentrated urine (oliguria). Injury to the skin and nerve endings produces severe pain and loss of function of the skin. Pain is severe in partial thickness burns, but in full thickness burns there is loss of sensation. The open wound created ensures an easy access for micro-organisms which infect the wound. With infection, there is the release of toxins which cause pyrexia, malaise and delayed wound healing. Absorption of decomposed products from dead tissues leads to toxemia. Inhalation of smoke and chemical fumes leads to damage of the respiratory tract causing swelling and irritation of the larynx. This may bring about airway obstruction and severe respiratory insufficiency. Hemolysis of red blood cells occurs as a result of trapping of heat during the time of the burn injury, causing immediate decrease in the amount of RBC in circulation. This is made worse by the hemoconcentration occurring from the reduction in the intravascular volume. As a result, there is a false in hematocrit and hemoglobin levels. The massive destruction of red blood cells and tissues may bring about the liberation of large quantities of hemoglobin and myoglobin which may block the renal tubules causing renal shutdown. The presence of hemoglobin and myoglobin in the urine is indicated by the passage of brownish black urine.

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When there is severe thermal injury there is increase in energy requirement. The body loses heat through water evaporation. The body mobilizes energy stores to meet the demand for energy. Therefore glucose and fat stores are broken down thereby making the body to start protein catabolism. This is further increased by adrenocortical hyperactivity. Protein is then lost through catabolism and also from burn exudates bringing about a negative nitrogen balance. This makes the individual to lose weight. Congestion in the mucosal capillaries leads to gastric dilatation, depressed gastrointestinal peristalsis, nausea and vomiting. This leads to a phenomenon known as "Stress Ulcer" (Curling's ulcer) in the gastric mucosal lining which usually presents with haematemesis or melena. In full thickness burns the skin stretches to cover the wound as healing progresses. This brings about contracture which usually accounts for limitation of range of motion and impairment in movement co-ordination. Formation of severe scar alters the individual's aesthetic appearance.

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DRUG STUDY

Drug Classification Silver Sulfadiazine (Flamazine)

Classification and Indication Anti-microbial Prevention and treatment of wound sepsis in patients with second- and third-degree burns.

Dosage/Route/ Frequency topical; skin

Mechanism of Action prevents the growth of a wide array of bacteria, as well as yeast, on the damaged skin

Contraindication

Side Effects

Nursing Responsibilities 1. Prepare the medication as prescribed. 2. Maintain sterility when preparing and administering the medication. 3. Administer the prescribed. 4. Document the procedure and note the patients reaction.

Contraindicated in patients who are hypersensitive to silver sulfadiazine or any of the other ingredients in the preparation.

Skin necrosis, Erythema multiforme, skin discoloration, Burning sensation, rashes, and interstitial nephritis.

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Drug name

Drug Classification Antibiotic Penicillinaseresistant penicillin

Therapeutic Action Bactericidal: Inhibits cell wall synthesis of sensitive organisms, causing cell death.

Indications

Dosage

oxacillin sodium

Infections due to Penicillinase-producing staphylococci; may be used to initiate treatment when a staphylococci infection is suspected Contraindications: Contraindicated with allergies to penicillins, Cephalosporins or other allergens. Use cautiously with renal disorders, pregnancy and lactation (may cause diarrhea or candidiasis in infants).

Maximum recommended dosage is 6 g/day. Adults and pediatric patients weighing 40 kg or more: 250500 mg every 46 hr IM or IV. Up to 1 g every 46 hr in severe infections. Pediatric patients weighing less than 40 kg Neonates weighing less than 2 kg: 2550 mg/ kg every 12 hr IV or IM. Neonates weighing 2 kg or more: 25 50 mg/kg every 8 hr IV. Children weighing less than 40 kg: 50 100 mg/ kg/day IV or IM in equally divided doses every 4-6 hrs.

Side effects/ Adverse effects Anemia Thrombocyto penia Leucopenia Neutropenia Prolonged bleeding time (more common than with other Penicillinaseresistant penicillins) Anaphylaxis

Nursing Considerations Culture infection before treatment; reculture if response is not as expected. Continue therapy for at least 2 days after infection has disappeared, usually 710 days. Keep epinephrine, IV fluids, vasopressors, bronchodilators, oxygen, and emergency equipment readily available in case of serious hypersensitivity reaction.

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NURSING CARE PLAN ASSESSMENT Subjective: sakit sa binti ko as verbalized by the patient. - The client is pointing on the injured site DIAGNOSIS Acute pain related to destruction of skin/tissues as evidenced by facial mask of pain. INFERENCE Stimulation of skin nociceptors that respond to heat (thermoreceptors). PLANNING After 1 hour of nursing intervention the patient will be able to display relaxed facial expressions. INTERVENTION 1. Maintain comfortable environmental temperature, provide heat lamps, heatretaining body coverings. 2.Assess reports of pain, noting location/character and intensity (010 scale). RATIONALE 1.Temperature regulation may be lost with major burns. External heat sources may be necessary to prevent chilling. EVALUATION After 1 hour of nursing intervention the patient was able to report pain reduced/controlled and display relaxed facial expressions/body posture.

Objective: Reports of pain Facial mask of pain Restlessness, Irritability, Sighting

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.

2. Pain is nearly always present 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. 3. Refocuses attention, promotes relaxation,

3. Provide basic comfort measures,

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e.g., massage of uninjured areas

and enhances sense of control, which may reduce pharmacological dependency.

4. Encourage use of 4. Helps lessen stress management concentration on pain techniques, e.g., progressive relaxation, experience and refocus deep breathing, attention. guided imagery, and visualization. 5. Promote uninterrupted sleep periods. 5. Sleep deprivation can increase perception of pain/reduce coping abilities. 6. The burned patient may require around-theclock 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

6. Administer analgesics (narcotic and nonnarcotic) as indicated.

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should be decreased as soon as feasible and alternative methods for pain relief initiated.

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ASSESSMENT Subjective: Yung nasunog sa binti nya ang laki as verbalized by the patients mother

DIAGNOSIS Impaired skin integrity related to disruption of skin surface with destruction of skin layers (partial thickness burn)

INFERENCE Burn

PLANNING After 3 days of nursing intervention the patient will be able achive timely healing of burned areas.

INTERVENTION 1. Provide appropriate burn care and infection control measures. 2. Administer topical wound dbridement ointment, as indicated

RATIONALE 1. Reduces risk of infection

EVALUATION After 3 days of nursing intervention the patient was able to demonstrate tissue regeneration and achieve timely healing of burned areas.

Damaged epidermis, upper dermis, portion of deeper dermis

Objective: Destruction of skin surface (epidermis, upper dermis, portion of deeper dermis)

Devitalized tissue or burn eschar Resulting an impaired skin 3. Maintain wound covering as indicated

2. Early dbridement of burn eschar is beneficial to wound healing and some treatment centers suggest use of these products to promote healing. 3. Used to cover clean partial-thickness wounds and clean donor sites. 4. Movement of tissue can dislodge it, interfering with optimal healing. 5. Promotes circulation and prevents ischemia/necrosis

4. Maintain desired position and immobility of area when indicated. 5. Keep skin free from pressure.

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ASSESSMENT Risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.

DIAGNOSIS Risk for infection related to scalding burn injury.

INFERENCE Burn

PLANNING Short term objective: After 8 hours of nursing the Open burn wound will protected from contamination of infectious microorganism that may affect the wound healing process. And the burn will be monitor from any unusual development and it will be free of purulent exudates and debris. Long term objective: After 3 days of nursing intervention the patient condition will be protected from localized or systemic infection and the patient will

INTERVENTION 1. Emphasize/model good hand washing technique for all individuals coming in contact with patient. 2. Use gowns, gloves, masks, and strict aseptic technique during direct wound care and provide sterile or freshly laundered bed linens/gowns. 3. Examine wounds daily, note/document changes in appearance, odor, or quantity of drainage. 4.Examine unburned areas (such as groin, neck creases, mucous membranes) routinely.

RATIONALE 1. Prevents crosscontamination; reduces risk of acquired infection.

EVALUATION Short term: After 8 hours of nursing intervention the patient was protected from contamination of infectious microorganism that may affect the wound healing process. And the burn was monitored from any unusual development and free of purulent exudates and debris. Long term: After 3 days of nursing intervention the patient condition was protected from localized or systemic infection and the was able to appreciate the fast healing process of the open burn wound.

Loss of skin removes their ability to protect themselves from the environment.

2. Prevents exposure to infectious organisms.

Burn wound is an excellent medium for bacterial growth and proliferation.

3.This measures reduce potential bacterial colonization of burn wound.

4. Opportunistic infections (e.g., yeast) frequently occur because of depression of the immune system and/or proliferation of normal body flora during systemic

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appreciate the fast healing process of the open burn wound

antibiotic therapy. 5. Monitor vital signs for fever, increased respiratory rate/depth in association with changes in sensorium, presence of diarrhea, decreased platelet count, and hyperglycemia with glycosuria. 5. Indicators of sepsis (often occurs with full-thickness burn) requiring prompt evaluation and intervention.

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Assessment S: Di po ako masyado makagalaw. Pt verbalized O: With burn wound at glutteal area Pt more than 5 days in hospital Pt seldom mingle with guardian Pt lying in prone position

Diagnosis Deficient diversional activity related hospitalization secondary to burn injury.

Scientific Rationale Burn injury Hospitalization Deficient diversional activity

Planning After 8 hrs of nursing intervention, pt will be able to: Engage in satisfying activities within personal limitations while staying in the hospital unit.

Implementation 1. Establish nurse-client relationship covering an attitude of caring.

Rationale Establishing a nurse-client relationship will enable the client to openly communicate with the nurse which plays a major role in treatment especially in a pediatric client. Considering age/developme ntal level and gender of client in planning activities will provide the nurse a perception of what the pt thinks as fun or leisurely. Determining clients ability enables the pt to maximally

Evaluation After 8 hrs of nursing intervention, goals were met. The pt: Engaged in satisfying activities within personal limitations while staying in the hospital unit.

2. Consider age/developme ntal level and gender of client in planning activities.

3. Determine clients actual ability to participate in

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available activities, noting attention span, physical limitations and tolerance to activity. 4. Encourage clients guardian to bring items at home that will promote diversional activity to client (toys, cell phones, etc.) 5. Collaborate with mother and client on managing clients time in the hospital to give way to leisurely activities. 6. Provide pt colorful educational materials and
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participate in a given activity.

Bringing of patients toys and materials at home enables the client to partially, if not fully, do the things he used to do at home. Collaborating on management of treatment will aid the family along with the patient to maximize time for activities. Colorful educational materials and toys to be

toys to be played while waiting for treatment.

played is one of the many ways to promote diversional activities of the pt.

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Assessment S: Nagkalapnuslapnus na ang balat ng anak ko Pt guardian verbalized O: Wound appears moist Blisters are present.

Diagnosis Impaired skin integrity related to burn injury.

Scientific Rationale Burn injury tissue damage Impaired skin integrity.

Planning After 8 hrs of nursing intervention, pt will be able to: Display timely healing of skin lesions / wound without symptoms of complication s.

Implementation 1. Provide optimal nutrition.

Rationale Providing optimal nutrition will aid the clients timely healing Applying topical bacteriostatic agents will inhibit bacterial growth. Cleansing wound and changing dressing twice daily is essential in order to properly assess and clean the wound.

Evaluation After 8 hrs of nursing intervention, goals were met. The pt: Displayed timely wound healing of skin lesions / wound without complication .

2. Apply topical bacteriostat ic agents as ordered.

3. Cleanse wound and change dressing twice daily

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Assessment S: Lagi akong nakadapa. Pt verbalized O: With burn wound at glutteal and thigh area Pt always lie in prone position Moves slowly from one side of the bed to the other with help of mother.

Diagnosis Impaired mobility related to burn injury.

Scientific Rationale
burn injury difficulty ambulating impaired mobility

Planning After 8 hrs of nursing intervention, pt will be able to: Move from prone to side position for 10 min every 1 hr without assistance.

Implementation 1. Assess client for complication related to impaired mobility.

Rationale Assessing client for complication will enable the nurse to alter intervention that suits clients needs. Assisting client in turning from prone to side position will promote mobility and prevention of complication. Administering medication prior to activity will permit maximal involvement to activity.

Evaluation After 8 hrs of nursing intervention, goals were met. The pt: Moved from prone to side position for 10 min. every 1 hr without assistance.

2. Assist client in turning from prone position to side position for 10 min. every 1 hr.

3. Administer medication prior to activity as ordered for pain.

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DISCHARGE PLANNING ( M.E.T.H.O.D.S. ) Medications: o Describe the importance of regularly taking of prescribed medications including the potential unpleasant effects of non compliance o Instruct the mother of patient to continue with follow up medical care. o Advise the patient not to miss the intake of medications given by her physician upon discharge. o Instruct the patient to avoid in playing and be engage in different activities while taking pain medications.

Environment and exercise o Provide clean and comfortable environment. o Maintain a quiet, pleasant, environment to promote relaxation. o Engage in light activity is important for increasing the circulation, preventing loss of muscle strength, and improving general well-being.

Treatment o Continue home medications. o For the follow-up check-up repeat. o Encourage mother of patient to take multivitamins for immunity of patient. o Encourage patient to eat nutritious foods.

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Health Teachings o Explain the underlying disorder and treatment plan. Lifestyle change (proper food preference) general health measures (adequate sleep, proper diet, and maintaining a clean surrounding). o Instruct the mother and patient to limit his activity for 24 to 48 hrs after discharge. o Provide written and oral instructions about activity, diet recommendations, medications, and follow-up visits.

Out Patient o Patient will be advised to go back in the hospital in a specific date to have a follow-up check up after discharge. o Consult doctor for are any problems or complications encountered.

Diet o A well-rounded, nutritious diet with plenty of fluids is important in the healing process. o Advise patient to start with small, frequent meals. o

Spiritual o Nursing actions to help clients meet their spiritual needs include: providing presence supporting religious practices

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assisting clients with prayer

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