THERMAL BURN

Case Presentation (Group A)

FIRST CITY PROVIDENTIAL COLLEGE

COLLEGE OF NURSING

CASE STUDY
“BURN INJURY”

BACULI, IRISH ANN

CRUZ, ANGELIQUE
CRUZ, NIÑA MARIE
CUEVAS, MAUREEN NASKA
BERSAMIRA, JAYSON
FRANCISCO, FRANZ IVAN
HEMBRA, LADY ANN
IMSON, MELINDA
MADRIAGA, JOVIC
MEJORADA, ALICE
NORVA, JOANNE
QUIAMBAO, KRISTINE
PAPAGAYO, ROD LORENZ
SARTO, ANA MARIS
SOMIDO, MA. ROSARIO
VALDRIZ, LORIE ANN

INTRODUCTION
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Case Presentation (Group A)

Burns are injuries to tissues caused by heat, friction, electricity, radiation, or chemicals.

Burns are characterized by degree, based on the severity of the tissue damage.

A first-degree burn causes redness and swelling in the outermost layers of skin
(epidermis).

A second-degree burn involves redness, swelling and blistering, and the damage may
extend beneath the epidermis to deeper layers of skin (dermis).

A third-degree burn, also called a full-thickness burn, destroys the entire depth of skin,
causing significant scarring. Damage also may extend to the underlying fat, muscle, or
bone.

The severity of the burn is also judged by the amount of body surface area (BSA)
involved. Health care workers use the "rule of nines" to determine the percentage of BSA
affected in patients more than 9 years old: each arm with its hand is 9% of BSA; each leg
with its foot is 18%; the front of the torso is 18%; the back of the torso, including the
buttocks, is 18%; the head and neck are 9%; and the genital area (perineum) is 1%. This
rule cannot be applied to a young child's body proportions, so BSA is estimated using the
palm of the patient's hand as a measure of 1% area.
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Case Presentation (Group A)

Related symptoms of a burn:

 abdominal pain

 cloudy, red, or watery eyes

 dizziness

 headaches

 seizures

 unconsciousness, which occurs with severe chemical exposure

 visual impairments

Symptoms of an airway burn:

 burns to the head, face, and neck

 coughing

 mucus that is stained black or a dark color

 shortness of breath or difficulty breathing

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 wheezing

STATISTICS
Nationwide
According to data from the United States Fire Administration, each year more than 4,000
Americans die as a result of fires and more than 23,000 are injured seriously enough to
require hospitalization. Here are some additional facts about burn injuries and deaths:

• 1.25 million- burn injuries per year.

• African Americans and Native Americans = 27 percent of fire deaths.
• Twice as many men have died in fires as women.
• very young and very old = higher risk of death and injury from fire than other
groups.
• In 1998 alone, 3,100 children below 15 years old. were injured and 750 were
killed in fires. Children accounted for 13 percent of all fire injuries and 19 percent
of all fire deaths.
• Approximately 2,550 older adults (65 and older) were injured and 1,035 killed.
This group accounted for 11 percent of fire injuries and 26 percent of fire deaths.
• By a wide margin, the leading cause of residential fires that result in child injuries
and fatalities is children playing. The victims, however, are not necessarily the
instigators of the fire: more than half of children fatalities and injuries occur when
the child is asleep.
• Smoking is the leading cause of death to older adults and the second leading cause
of their injury, behind cooking. As with young children, a large proportion of
older adult fatalities occur while the victim is asleep.

Local

Extrapolated Incidence Population Estimated Used

114,304 86,241,6972
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GENERAL OBJECTIVES
 The general objectives for conducting the case study are for students

to incorporate concepts and enhance knowledge in medical surgical

nursing.
 To apply the appropriate nursing management for patients with burn
accurately and efficiently.
 Aims to develop the skills that are applied for the care of patient with
this condition.

SPECIFIC OBJECTIVES
 Define burn

 Discuss briefly the causative factors that may have precipitated the
onset of the condition
 Discuss thoroughly the signs and symptoms manifested by patient
 Discuss the different drugs, indications, mechanism of action, adverse
effect and contraindications
 Discuss the nursing care plan appropriate in providing care to alleviate
the manifestation of the patient’s symptoms
 Identify and provide the health teachings needed for the continuum of
care
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Case Presentation (Group A)

PATIENT’S PROFILE

NAME: C.P

SEX: FEMALE

AGE: 74y/o

STATUS: MARRIED

RELIGION: ROMAN CATHOLIC

OCCUPATION: NONE

ADDRESS: Blk. 64 Area I, Sto. Niño II Sapang Palay, Bulacan

ADMISSION: JULY 19, 2010

TIME OF ADMISSION: 2:30pm

ADMITTING DIAGNOSIS: THERMAL BURN

ATTENDING PHYSICIAN: DR. COMIA

NURSING HEALTH HISTORY

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Case Presentation (Group A)

Biographic Data

Pt CP a 74 y/o, female, married and presently residing at B64 Area I Sto. Niño S.
Palay SJDM Bulacan. Admitted for the first time at OLSJDM at around 2:30pm.

Chief Complaint

Burn in face, neck, anterior trunk, right hand and left knee.

History of Present Illness

11:00am pt had preparing their food for their lunch. She heated the frying pan
with cooking oil and suddenly she felt syncope and followed by loss of consciousness.
Unexpected happened she tapped the pan with cooking oil. When she awakened she
noticed a burn on her different parts of her body including right hand, anterior trunk, left
knee and etc. and noting the pan placed on her arm. She immediately rushed to the ER on
JULY 19, 2010 at around 2:30pm. Hence, for admission and Admitted on surgical ward.

Past Medical History

Pt. CP had never experienced hospitalization except on her first admission on

OLSJDM on July 19, 2010.
But her previous illness was UTI. She consulted on the near health center. She
prescribed a medication to treat the illness. But the SO can’t recall the name of the Drug.

Family History

Pt had known history of hypertension, DM and asthma on the paternal side and no
known to the maternal side.

Socio-economic

Pt remains only on their house together with her husband and 12 y/o grandson.
She always preferred of cooking. Both of them had no job. Her daughter and son living
with their own family and working outside the country sustain their daily needs every
3months worth 10,000 only. For them this is not enough on their daily needs. That’s why
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Case Presentation (Group A)
foods that are usually prepared are fried fish and sometimes fried chicken. Pt likes fried
food.
Pt CP always attending Sunday church and when times she had a problem she
involves her whole family as a part of her coping mechanism to stress or sometimes she
smoke to trim down problem. She consumed 2 sticks/day for 58 years or diverts her
attention on household choirs
Her rest and sleep is still normal according to her. She had her rest for
13hours/day including night and day rest or nap.

GORDON’S 11 HEALTH
FUNCTIONAL PATTERN
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GENERAL SURVEY
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Physical assessment
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COURSE IN THE WARD

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Case Presentation (Group A)

DAY1 (July 19, 2010) 2:30 pm

On the first day patient was admitted at surgery ward secure consent for
admission. The doctor requested to monitor Vital Signs and I&O every shift and recorded
properly, Diet as Tolerated with IV Fluid requested PLR 1L q 6hrs, PLR 1L q 6hrs AND
PLR 1L q 8Hhrs, requested for Laboratory Exams like ECG, CBC, BT, FBS and
CREATININE, patient was refer for clearance pin to debiduct for pass debridement
under GA on Wed July 21, 2010 once CP cleared L/O Dr. Velasquez. Refer OR inform
Anesthesiologist. With Medications of Cefuroxime 750mg IV q8 (-) ANST (3:20 – 4:10),
Tramadol 200mg in D5W 500cc to run at 20ugtts/min, Ketanov 30mg IV q8 (-) ANST,
ATS 4,500 units IM now (-) ANST, Tetanus Toxoid 1 Amp IM now.

DAY2 (July 20, 2010) 8:00 am

At day 2, doctor requested to fast drip PNSS 500cc then regulated @ 40

gtts, and the doctor hold Tramadol. Follow up CBC.

July 20, 2010 4:15pm

Patient has an IVF of PLR 1L regulated @ 30gtts/min, patient was

medically cleared for debridement under GA.

DAY3 (July 21,2010) 7:00 am

At this point of time patient adviced for debridement and was placed on
NPO.

July 21, 2010 1: 45 pm

Post Operative Orders:

Monitored Vital Signs every 30 minutes for 2 hours and then every 1 hour
until stable, with o2 inhalation via Nasal Cannula @ 2 LPM, I and O taken and recorded,
with diet as tolerated. Patient has an IV Fluid of D5W 1L to run for 12 hrs. With
medication of Cloxacillin 500mg 1cap every 6 hrs, Celecoxib 200mg 1cap BID after
meals, patient was encourage deep breathing.

DAY 4 ( July 23, 2010)

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Case Presentation (Group A)
Continue Medication

DAY 5 ( July 24, 2010)

Continue Medication

DAY 6 ( July 24 2010)

At this time patient was able to Bath with application of Flemniazine,

patient also requested to increase protein intake and drink 1 glass of sustagen BID.
Doctor ordered Diclofenac STAT.

DAY 7 (July 25, 2010) 1:30 pm

Patient was given Paracetamol 1 ampule TIV now because of fever 38.9 c.

DAY 8 ( July 26, 2010)

HAMA

Course in the O.r

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Case Presentation (Group A)

DAY3 (July 21,2010) 7:00 am

At this point of time patient adviced for debridement and was placed on
NPO.

July 21, 2010 1: 45 pm

Post Operative Orders:

Monitored Vital Signs every 30 minutes for 2 hours and then every 1 hour
until stable, with o2 inhalation via Nasal Cannula @ 2 LPM, I and O taken and recorded,
with diet as tolerated. Patient has an IV Fluid of D5W 1L to run for 12 hrs. With
medication of Cloxacillin 500mg 1cap every 6 hrs, Celecoxib 200mg 1cap BID after
meals, patient was encourage deep breathing.

Procedural
Definition

Debridement is the process of removing dead (necrotic) tissue or foreign material from
and around a wound to expose healthy tissue.

Purpose

An open wound or ulcer can not be properly evaluated until the dead tissue or foreign
matter is removed. Wounds that contain necrotic and ischemic (low oxygen content)
tissue take longer to close and heal. This is because necrotic tissue provides an ideal
growth medium for bacteria, especially for Bacteroides spp. and Clostridium perfringens
that causes the gas gangrene so feared in military medical practice. Though a wound may
not necessarily be infected, the bacteria can cause inflammation and strain the body's
ability to fight infection. Debridement is also used to treat pockets of pus called
abscesses. Abscesses can develop into a general infection that may invade the
bloodstream (sepsis) and lead to amputation and even death. Burned tissue or tissue
exposed to corrosive substances tends to form a hard black crust, called an eschar, while
deeper tissue remains moist and white, yellow and soft, or flimsy and inflamed. Eschars
may also require debridement to promote healing.

Surgical debridement

Surgical debridement (also known as sharp debridement) uses a scalpel, scissors, or other
instrument to cut necrotic tissue from a wound. It is the quickest and most efficient
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Case Presentation (Group A)
method of debridement. It is the preferred method if there is rapidly developing
inflammation of the body's connective tissues (cellulitis) or a more generalized alized
infection (sepsis) that has entered the bloodstream. The physician starts by flushing the
area with a saline (salt water) solution, and then applies a topical anesthetic or antalgic
gel to the edges of the wound to minimize pain. Using forceps to grip the dead tissue, the
physician cuts it away bit by bit with a scalpel or scissors. Sometimes it is necessary to
leave some dead tissue behind rather than disturb living tissue. The physician may repeat
the process again at another session.

Anesthesia

Anesthesia may be used for deep pressure ulcers or other wounds. Local anesthesia will
numb the area. General Anesthesia will allow you to sleep through the procedure

Forceps in Surgeon's Hand

Risk Factors for Complications During the Procedure

• Bleeding
• Infection
• Pre-existing medical conditions
• Smoking
• Diabetes
• Use of steroid or other immunosuppressive medications
• Poor nutrition
• Poor circulation
• Immune disorders

LABORATORY
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BLOOD CHEMISTRY

RESULT NORMAL INTERPRETATION

FBS 4.90mmol/L 3.8 – 6.0 Normal

CREATININE 46.6mmol/L 36.4 – 123.8 Normal

HEMATOLOGY

RESULT NORMAL INTERPRETATION

HEMOGLOBIN 110 F = 120 – 150 g/L Decreased level would
M = 140 – 170 g/L suggest anemia, acute
blood loss, and severe
hemorrhage
HEMATOCRIT 0.35 F = 0.37 – 0.47 Decreased level would
M = 0.40 – 0.50 suggest anemia
WBC 10.7 5-10x109 Normal

DIFFERENTIAL COUNT

RESULT NORMAL INTERPRETATION

SEGMENTERS 0.62 0.50-0.70 Normal

LYMPHOCYTES 0.38 0.20-0.40 Normal

ANATOMY PHYSIOLOGY
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The skin is made up of three layers and is the largest organ of the body

(1) Epidermis

(a) The surface or outer layer

(b) Serves as a barrier between our body and the environment

(2) Dermis

(a) Thick layer of collagen connective tissue below the thin epidermis

(b) Contains the important support structures and sensory nerves, i.e.,
hair follicles, sweat glands, oil glands

(3) Subcutaneous

(a) Layers of fat tissue and soft tissue beneath the dermis

(b) Serves as a barrier for shock absorption and insulation

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(4) Functions of the skin

(a) A protective barrier sealing fluids inside and preventing bacteria

and other microorganisms from entering the body

(b) Important sensory organ providing input to the brain on general

and specific environmental data; serving as a primary role in
temperature regulation

(5) When heat or caustic chemicals come in contact with the skin, damaging
its chemical and cellular components, you have burn-damaged tissue and
inflammatory responses to the skin

PATHOPHYSIOLOGY
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Predisposing factor
Precipitating factor
- older adult -cook

Exposure to heat

Cellular damage

Inflammatory response

Loss of capillary permeability increase

WBC

Fluid shifting
( intravascular to interstitial space)
phagocytosis

Blister formation hypothalamus leukotrien

release of inflammatory
bradykinin mediators

Skin is pink and moist fever

Prostaglandin

pain
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DRUG INDEX
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NURSING CARE PLAN

D PLA ON EVA

Subjective:

Objective:
-
-
-

ASSESSME DIAGNOSI PLANNIN INTERVETIO EVALUATIO

NT S G N N
Subjective:

Objective:
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Case Presentation (Group A)

ASSESSME DIAGNOSI PLANNIN INTERVETIO EVALUATIO

NT S G N N
- Subjective:

Objective:
-

ASSESAPE DIAGNOSI PLANNIN INTERVETIO EVALUATIO

NT S G N N
Subjective: -

Objective:
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DISCHARGE PLANNING
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