ARRANGED BY :

Dwi Hadisantoso 1614201110072

A. ASSESSMENT
 Date of Assessment: December 7, 2018
 Room: Rose
 1. Client Identity
 Name : Mrs. S
 Age : 30 years old
 Gender : Female
 Address : Sungai Miai , Banjarmasin
 Religion : Islam
 Status : Married
 Tribe / Nation : Banjar / Indonesia
 Job : Private
 Medical diagnosis : Vulnus Combostio
 Medical record number : 18.11.55
 Entry date : December 7, 2018
 2. Responsible Identity
 Name : Mr. A
 Gender : Male
 Address : Miai River, Banjarmasin
 Relationship with clients : Husband
1. Medical history
Review the main complaints and ask the cause of
burns - clams, thermal or electrical, time of burns
(important for the need for resuscitation, fluid which
is calculated from the time of burn injury, not from the
time of arrival to the hospital), where burns occur
(open area or closed) and allergies.
2. Physical examination
a. General state
Assess your level of consciousness and vital signs.
b. Integumentary system
Skin:
deep tissue destruction may not occur for 3- 5
days in connection with the microvascular
thrombus process in some wounds. Unburned
skin areas may be moist / cold, pale, with slow
capillary filling in a decrease in cardiac output,
due to fluid loss.
Fire injury:
There is an area of mixed internal injury due to the
intensity of the heat produced by the burning clot.
Burned nose hair, dry nasal and mouth mucosa, red,
blisters on the posterior pharynx, and edema of the
mouth and nasal circumference.

Chemical injury:
Looks vary according to the cause of the wound. The
skin may be yellowish brown with a texture like fine
leather; blisters, ulcers, necrosis, or thick scarring.
General injury is deeper than it seems, percutaneously
and tissue damage can continue for up to 72 hours
after injury.
Electrical injury:
External cutaneous injury is less than under
necrosis. Appearance of wounds can vary
including in / out (explosive) flow wounds, burns
from proximal closed body flow movements, and
thermal wounds associated with burning clothing.
Examine burns for breadth by using Lund and Browder or
Rule of nine graphics.
Examine wound depth, which can:
a) Superficial partial thickness - involving the epidermis;
characterized by tenderness, slight swelling, and erythema
that pales with pressure.

b) Partial thickness - loaded with the epidermis and

dermis; characterized by erythema, dryness, or moist sore
sores, edema, and formation of blisters.

c) Full thickness - adds all layers of the skin, often

extending to subcutaneous tissue and muscles;
characterized by dry, hard, unharmed, white or black skin.

d) Ego integrity
Anxiety, crying, challenging, denying, withdrawal and
anger.
c. Activity / rest
Limited susceptibility to motion in the affected
area, muscle mass disorders and tone changes.
d. Respiratory system
Assess the presence of hoarseness, coughing
wheezing, carbon particles in sputum, inability to
swallow oral secretions and cyanosis, indicative of
inhalation injury. Thoracic swelling may be
limited to chest circumference burns. Airway over
straidor or wheezing (obstruction associated with
laryngospasm, laryngeal edema). Breath sounds:
ringling (pulmonary edema), stridor (laryngeal
edema), airway secretions (ronhi).
e. Digestive system
Decreased bowel sounds or none, especially in
cutaneous burns greater than 20% as stress
reduction in gastric / peristalsis. Assess for
anorexia, nausea and vomiting.
f. Cardiovascular system
In burns of more than 20% APTT, hypotension
(shock) is found, decreased distal peripheral pulse
in the injured limb; general peripheral
vasoconstriction with loss of pulse, white and cold
skin (electric shock). Tachycardia (shock, anxiety,
pain), dysrhythmias (electric shock).
g. Neurosensory
Seizure activity (electric shock), corneal
laceration, retinal damage, decreased visual acuity
(electric shock). Tympanic membrane rupture
(electric shock), and paralysis (electrical injury to
nerve flow).
h. Elimination
Urinary bowel decreased / absent during the
emergency phase. The color may be reddish black
when myoglobin occurs, indicating deep muscle
damage. Diuresis (after capillary leakage and
liquid mobilization into the circulation).
 B. DATA ANALYSIS
DATA ETIOLOGY PROBLEM
DS: Burn injury Impaired comfort pain

- Clients say pain 

DO: Disconnected network continuity
- Grimacing face 
- Tense postur Stimulates the release of histamine,
- TTV... bradykinin, serotinin and prostatglandin
- Scale of pain ... from (1-5) enzymes

Stimulates nerve fibers

Spinal cord

Thalamus

Cortex cerebri

Pain
C. NURSING CARE PLAN
OUTCOME

• After nursing actions for patients for 2x24 hours,it is

expected that the disruption of comfort can be
overcome
• Able to control ansiety
• Comfort status increases
 INTERVENTION
 Use a calming approach
 Encourage patients to express
feelings,fears,perceptions
 Instruct patients to use relaxation techniques
 Gie medication to reduce ansiety
 RASIONAL
 To build a trusting relationship so that it is easier to
work together
 So that we know the patient’s ansiety level
 Increase patient comfort
 To reduce ansiety if the nurse’s actions do not succeed
in reducing patient ansiety
D. IMPLEMENTATION
NO DAY/DATE TIME NURSING IMPLEMENTAT EVALUATION Nurs
DIAGNOSIS ION OF ACTIONS
e’s
Sign
1 Sunday / 8 th 09.00- Impaired Using a S : The
July.2018 09.10 Comfort calming patient say a
approach little more
calm.
O : The
patient
looks a little
calm.
A : The
problem is
slightly
resolved.
P:
Intervention
continued.
NO DAY/DATE TIME NURSING IMPLEMENTAT EVALUATION Nurs
DIAGNOSIS ION OF ACTIONS
e’s
Sign
2 Sunday / 8 th 09.10- Impaired Encourage S : The
July.2018 09.20 Comfort patients to patient say
express all
feelings,fears information
,perceptions about
feelings,fear
s,perceptioN
s
O : The
patient
looks open
in
communicat
ion
A : The
probem is
slightly
resolved.
P:
Intervention
continued
NO DAY/DATE TIME NURSING IMPLEMENTAT EVALUATION Nurs
DIAGNOSIS ION OF ACTIONS
e’s
Sign
3 Sunday / 8 th 09.40- Impaired Instruct S : Patient
July.2018 10.00 Comfort patients to say more
use calm and
relaxation comfortable
techniques O : The
patient
looks
comfortable
and relaxed
A : The issue
is resolved
P:
Intervention
continued
NO DAY/DATE TIME NURSING IMPLEMENTAT EVALUATION Nurs
DIAGNOSIS ION OF ACTIONS
e’s
Sign
4 Sunday / 8 th 10.10-10.30 Impaired Giving S : The
July.2018 Comfort medication patient say
to reduce calmer after
ansiety taking
medicine
O : The
patient
looks calm
and
comfortable
A : The
issue is
resolved.
P:
Intervention
completed
E. EVALUATION
NO DAY/DAT TIME NURSING EVALUATION
E DIAGNOSIS
1 Sunday / 09.00 Impaired S : The patient Says a litte more calm
8 th Comfort and comfortable.and says all
July.2018 information about
feelings,fears,perceptions.and says
calmer after taking medicine.
O : The patient looks a little
calm,open in communication,relaxed
and comfortabe
A : The problem is resolved.
P : - Using a calming
approachEncouragering patients to
express
feelings,fears,perceptions.Instruct
patient to use relaxation
techniques.Giving medication to
reduce ansiety.
TERIMA KASIH…...