NURSING CARE

ELECTRICAL BURN INJURY IN ICU

BANJARMASIN ULIN HOSPITAL

2ND Group :

Esmy Maulidya

M. Nurmajid

Nurlailatul Khairiyyah

H. M. Syafi’i

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. Client’s 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 , client’s 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 , pupil’s 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 doesn’t 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 person’s skin weighs

10 pounds and has a surface area of almost 20 square feet. Skin forms the

body’s 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 skin’s 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, keratin-filled 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 body’s outermost organ, the skin is able to regulate

the body’s 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

body’s 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 body’s 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 body’s 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 7-dehydrocholesterol.

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 skin’s 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

2. Second degree of combustio

- 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. Client’s 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, Client’s 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

4

Strength further reduced such that joint can be moved only against gravity with examiner's resistance completely removed.

3

Muscle can onlly move if resistance of gravity is removed. 2Only a trace or flicker of movement is seen or felt, or fasciculations are observed,

1

No movement 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 29,25100

= 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 Client’s BW is 71 kg and client’s 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 : Independent

2 : Need help and monitoring by others

3 : Need the simple help and monitoring by others

4 : Need help, monitoring by others, and the aid stuff

5 : Totally dependent

(Robert Priharjo,2001 :159, Pengkajian Fisik Keperawatan. Jakarta : EGC)

Supporting Examination

HematologyHemoglobin 12.8 14.00 – 18.00 g/dl MethodLeukocyte 11.2 4.0 – 10.5 k/ul Impedance

Erytrocytes 4.95 4.50 – 6.00 Million/ul ImpedanceHematocryte 42.9 42.00 – 52.00 Vol% Analyzer

CalculatesThrombocyte 256 150 – 450 k/ul ImpedanceRDW-CV 11.5 11.5 – 14.7 % Analyzer

CalculatesMCV 86.7 80.0 – 97.0 Fl Analyzer

calculatesMCH 29.8 27.0 – 32.0 Pg Analyzer

CalculatesMCHC 34.4 32.0 – 38.0 % Analyzer

CalculatesGran% 83.8 50.0 – 70.0 % ImpedanceLymphocytes% 11.5 25.0 – 40.0 % ImpedanceMID% 4.7 4.0 – 11.0 % ImpedanceGran# 15.00 2.50 – 7.00 k/ul ImpedanceLymphocytes# 2.1 1.25 – 4.0 k/ul ImpedanceMID# 0.8 k/ul Impedance

PROTHROMBIN TIMEPT result 11.3 9.9-13.5 second NephelometryINR 0.99 NephelometryNormal Control of PT

11.4 Nephelometry

APTT result 29.3 22.2-37.0 second NephelometryNormal Control of APTT

26.1 Nephelometry

CHEMISTRYUreum 20 10-50 Mg/dl Modif-berchelotCreatinine 0.9 0.7-1.4 Mg/dl JaffeELECTROLYTENatrium 141.4 135-146 Mmol/l ISEKalium 3.9 3.4-5.4 Mmol/l ISEChlorida 105.0 95-100 Mmol/l ISE

CHEMISTRY

FAT AND HEART FAALLDH 450 225 – 450 U/L Optimised ( C )

CKMB 23 0 – 24 U/L Optimised ( C )

Arterial Blood Gases ExaminationExamination Result Normal Range UnitChemistryBlood Gas AnalysisTemperature 37,0 36,5 – 37,5 CelciusPH 7,4 7,350 – 7,450PACO2 46,8 35,0 – 45,0 mmHgPAO2 78,0 80,0 – 100,0 mmHg

HCO3 26,5 22,0 – 26,0 Mmol/lSPAO2 80,3 75,00 – 99,00 %BE 1,1 -3,00 – 3,00 Mmol/lNatrium Blood Gases

137,0 135,0 – 148,0 Mmol/l

Kalium blood Gases

3,9 3,50 – 4,50 Mmol/l

Chloride Blood Gases

100,4 98,0 – 107,0 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 (2500-

5000 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 body’s

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. Ineffective airway clearance related to Injury of inhalation2. Impaired Gas Exchange related to change of capillary-alveolar membrane3. Ineffective Peripheral Tissue Perfusion related to low Oxygen supply

secondary to edema4. Acute pain related to Injury agent secondary to the wound

5. Impaired Physical Ability related to contracture6. Impaired Skin Integrity related to Injury in the Skin Secondary Intention.7. Risk for Imbalance Fluid Volume8. Risk for Infection

NURSING PROBLEM

OUTCOME CRITERIA NURSING INTERVENTION RATIONALE EVALUATION

Ineffective airway clearance related to injury of inhalationSubjective Data:Patient stated that he had shortness of breathObjective data:-Patient used Accessory muscle of breathing- RR : 31 bpm-Nose mucus burnt up- Nose hair was burnt up- Breathing sound is wheezing- PAO2 : 78,0 mmHg

1. the airway is patent2. RR at normal range ( 12-20)3. absence the use of accessory muscle of breathing4. breathing sound is vesicular5. Normal result of analysis blood gas6. saturation of oxygen up to 90%

1. Assess airway for patency.

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.

5. Facilitate the patency of

1. Maintaining the airway is always the first priority, especially in cases of trauma, acute neurological decompensation, or cardiac arrest.

2. Abnormality indicates respiratory compromise.

3. These promote better lung expansion and improved air exchange.

4. To provide for adequate oxygenation

5. The additional stuff for keeping the patency of airway from any obstruction possibility

6. The normal result of blood gas

- The airway was unclear, there is secret

- RR 28 tpm, using the accessory muscle of breathing, chest expansion isn’t optimal, relaxed breathing at semifowler position

- Oxygen administration decreased 2 l/m saturation is 93%

- Breathing sound is vesicular

- PAO2 : 82,0 mmHgPACO2 : 44,6 mmHgSPAO2 : 80,4

-

PACO2 : 46,8 mmHgSPAO2 : 80,3Finger saturation is 65%Oxygen 8 lpm

airway through oropharyngeal tube

6. Measure the blood gas analysis

7. Do the suctioning if needed

analysis shows the effectiveness of airway patency

7. Over secretion of mucous could obstructs the airway it needs to be removed

Impaired Gas Exchange related to change of capillary-alveolar membraneSubjective data:Patient said that he had Shortness of breathObjective data :CRT > 3 seconds SPAO2 : 80,3 HB : 12,8 g/dlPAO2 : 78,0

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.

2. Monitor vital signs.

3. Monitor arterial blood gases (ABGs) and note changes.

4. Use pulse oximetry to monitor O2 saturation and pulse rate continuously.

5. Assess skin color for development of cyanosis.

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

- RR:28x/m the pattern is regular

ABG showed PAO2 : 82,0 mmHgPACO2 : 44,6 mmHgSPAO2 : 80,4

- There’s no Cyanosis or pale

CRT <2 secondsHB : 12,8 g/dl

- CRT 93%

mmHgPACO2 : 46,8 mmHgRR : 31 bpm

6. Monitor chest x-ray reports

7. Maintain oxygen administration device as ordered, attempting to maintain O2 saturation at 90% or greater.

8. Administer medications as prescribed.

hypoxia and/or hypercapnia becomes more severe, BP may 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/thrombolytics for pulmonary embolus,

analgesics for thoracic pain).

Ineffective Peripheral Tissue Perfusion related to low oxygen supply secondary to edemaSubjective DataPatient felt numbness on both of handsObjective DataEdema on the handsCRT > 3Cold on peripheral areaWeak pulse : 58 bpmOxygen saturation is 65%

Patient maintains optimal tissue perfusion tovital organs, as evidenced by strongperipheral 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 humidified oxygen via appropriate mode, e.g., face mask.

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/decreased cardiac output).

2. in order to allow time for autoregulatory mechanisms to adjust to the change in the distribution of blood associated with an upright position

- The skin color wasn’t 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

Oxygen 8 lpm

3. oxygen supplies will fulfill the optimal tissue perfussion

Acute pain related to post of debridement action

Subjective data :Patient said that he felt painP: the wound on the skinQ : stabbingR : wound areaS : 2 ( 1-5)T : 15 minutes

Objective data :- Patient

looked winced in pain

Report pain reduced/controlled.

Display relaxed facial expressions/body posture.

1. Assess reports of pain, nothing location/character and intensity (0–5 scale).

2. Teach the deep breathing technique

3. Change position frequently.

4. Administer analgesics ( Ketorolac)

1. 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.

2. To reduce the pain3. Movement and

exercise reduce joint stiffness and muscle fatigue, but type of exercise depends on location

- 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

and extent of injury4. 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

Impaired Physical Mobility related to contracturSubjective Data :Patient said that he couldn’t move his right hand

Maintain position of function as evidenced by absence of contractures.

Maintain or increase strength and function of

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

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 contractures.

- 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

Objective Data:Contractor on right handMuscle strength

4444

3333

4444

4444

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

affected and/or compensatory body part.

Verbalize and demonstrate willingness to participate in activities.

Demonstrate techniques/behaviors that enable resumption of activities.

consistently, initially passive, then active.

5. Encourage family/SO support and assistance with ROM exercises.

6. Encourage patient participation in all activities as individually able.

3. To analyze the strength of each extremity

4. Prevents progressively tightening scar tissue and contractures; enhances maintenance of muscle/joint functioning and reduces loss of calcium from the bone.

5. Enables family/SO to be active in patient care and provides more constant/consistent therapy.

6. 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

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3333

4444444

4Activity scale is 2 (need help and

monitoring by others)

-

Impaired Skin Integrity related to Injury in the Skin Secondary Intention.

Subjective data :The client said

Wound Healing: Secondary Intention (NOC)

Demonstrate tissue regeneration.

Achieve timely healing of

1. Assess/document size, color, depth of wound, noting necrotic tissue and condition of surrounding skin

2. Change burn dressing using the topicals and dressing materials

1. Provides baseline 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 recommendation

- 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

That he felt pain on the wound area of skinObjective 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

burned areas 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

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 patient’s nutritional status needs to be improved

- Nurses kept the hygiene and used the aseptic technique before and after the nursing action.

- Patient wasn’t having bleeding, the wound became dried showed the regeneration of tissue

Risk for Imbalance Fluid

Demonstrate improved fluid balance as evidenced

1. Monitor vital signs, central venous pressure (CVP). Note capillary refill and

1. Serves as a guide to fluid replacement needs and assesses cardiovascular

- Vital signs was normal BP : 110/80 mmhgRR : 20 bpmHR : 78 bpm

VolumeObjectiveIntake : Oral : 1200 cc/ 24 hours Parenteral :2500 cc /24 hours- Output :IWL = 1.065 cc/24 hoursUrine : 1600 cc / 24 hours

-client has combustion all over the skin of 29.25%SPAO2 : 80,3 PAO2 : 78,0 mmHgPACO2 : 46,8 mmHg

by individually adequate urinary output with normal specific gravity, stable vital signs, moist mucous membranes.

Balance of Electrolyte and PH

strength of peripheral pulses.

2. Monitor intake and urinary output. Observe urine color and Hematest as indicated.

3. Insert/maintain indwelling urinary catheter.

4. Administer calculated IV replacement of fluids

5. Monitor laboratory studies (e.g., Hb/Hct, electrolytes, random urine sodium and blood PH).

response. Note: Invasive monitoring is indicated for patients with major burns, smoke inhalation, or preexisting cardiac disease, although there is an associated increased risk of infection, necessitating careful monitoring and care of insertion site.

2.  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 75–100 mL/hr to reduce risk of tubular damage and renal failure

3. Allows for close observation of renal

T : 36,5 C- CRT refilling time is < 2

seconds- The color of urine isn’t

pure yellow as clear- Installed cathether since

December 24th 2013- Installed the IV line since

24th 2013- Intake :

Oral : 1200 cc/ 24 hoursParenteral :2500 cc /24 hours- Output :IWL = 1.065 cc/24 hoursUrine : 1600 cc / 24 hours

-client has combustion all over the skin of 29.25%

PAO2 : 82,0 mmHgPACO2 : 44,6 mmHgSPAO2 : 80,4

function and prevents urinary retention. Retention of urine with its by-products of tissue-cell destruction can lead to renal dysfunction and infection.

4. Fluid resuscitation replaces lost fluids/electrolytes and helps psrevent complications, e.g., shock, acute tubular necrosis (ATN).

5. Identifies blood loss/RBC destruction and fluid and 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 isn’t 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 wasn’t 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

4

44

4

3

333

4

44

4

4

444

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 wasn’t 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

isn’t 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.