INTRODUCTION

A burn is a type of injury to flesh or skin caused by heat, electricity, chemicals, friction, or radiation. Burns that affect only the
superficial skin are known as superficial or first degree burns. When damage penetrates into some of the underlying layers, it is a
partial-thickness or second-degree burn. In a full-thickness or third-degree burn, the injury extends to all layers of the skin. A fourth-
degree burn additionally involves injury to deeper tissues, such as muscle or bone.

The characteristics of a burn depend upon its depth. Superficial burns cause pain lasting two or three days, followed by peeling of
the skin over the next few days. Individuals suffering from more severe burns may indicate discomfort or complain of feeling
pressure rather than pain. Full-thickness burns may be entirely insensitive to light touch or puncture. While superficial burns are
typically red in color, severe burns may be pink, white or black. Burns around the mouth or singed hair inside the nose may indicate
that burns to the airways have occurred, but these findings are not definitive. More worrisome signs include: shortness of breath,
hoarseness, and stridor or wheezing. Itchiness is common during the healing process, occurring in up to 90% of adults and nearly all
children. Numbness or tingling may persist for a prolonged period of time after an electrical injury. Burns may also produce
emotional and psychological distress.

The size of a burn is measured as a percentage of total body surface area (TBSA) affected by partial thickness or full thickness
burns. First-degree burns that are only red in color and are not blistering are not included in this estimation. Most burns involve less
than 10% of the TBSA.
There are a number of methods to determine the TBSA, including the "rule of nines", Lund and Browder charts, and estimations
based on a person's palm size. The rule of nines is easy to remember but only accurate in people over 16 years of age. More
accurate estimates can be made using Lund and Browder charts, which take into account the different proportions of body parts in
adults and children. The size of a person's handprint (including the palm and fingers) is approximately 1% of their TBSA.

Resuscitation begins with the assessment and stabilization of the person's airway, breathing and circulation. If inhalation injury is
suspected, early intubation may be required. This is followed by care of the burn wound itself. People with extensive burns may be
wrapped in clean sheets until they arrive at a hospital. As burn wounds are prone to infection, a tetanus booster shot should be
given if an individual has not been immunized within the last five years. In those with poor tissue perfusion, boluses of isotonic
crystalloid solution should be given. In children with more than 10-20% TBSA burns, and adults with more than 15% TBSA burns,
formal fluid resuscitation and monitoring should follow. The Parkland formula can help determine the volume of intravenous fluids
required over the first 24 hours. The formula is based on the affected individual's TBSA and weight. Half of the fluid is to be
administered over the first 8 hours, and the remainder given over the following 16 hours. The time frame is calculated from the time
at which the burn occurred, and not from the time at which fluid resuscitation was begun. Children require additional maintenance
fluid that includes glucose. Additionally, those with inhalation injuries require more fluid.
Early cooling (within 30 minutes of the burn) reduces burn depth and pain, but care must be taken as over-cooling can result in
hypothermia. It should be performed with cool water 10–25 °C (50.0–77.0 °F) and not ice water as the latter can cause further
injury. Chemical burns may require extensive irrigation. Cleaning with soap and water, removal of dead tissue, and application of
dressings are important aspects of wound care.
Common medications for burns are analgesic, antibiotics, antipyretics if there is fever, vitamin C to boost the patient’s immune
system and multivitamins.
Wounds requiring surgical closure with skin grafts or flaps (typically anything more than a small full thickness burn) should be dealt
with as early as possible. Circumferential burns of the limbs or chest may need urgent surgical release of the skin, known as
anescharotomy. This is done to treat or prevent problems with distal circulation, or ventilation. It is uncertain if it is useful for neck
or digit burns. Fasciotomies may be required for electrical burns.
 PATIENT’S PROFILE

PATIENT’S INITIAL: O.F

AGE: 22

DATE OF BIRTH: April 10, 1992

GENDER: Male

BIRTH PLACE: Antipolo City

ADDRESS: Antipolo City

HEIGHT: 5’5

WEIGHT: 73kg

DIALECT: Tagalog

CIVIL STATUS: Single

EDUCATIONAL ATTAINMENT: High School Graduate

RELIGION: Roman Catholic

NATIONALITY: Filipino

OCCUPATION: Construction Worker

CHIEF COMPLAINT: Electrical Burn

DATE OF ADMISSION: May 01, 2014

TIME OF ADMISSION: 12:51 PM

INITIAL DIAGNOSIS: Electrical Burn

SOURCE OF INFORMATION: Patient, Chart

 NURSING HEALTH HISTORY

History of Present Illness

Few hours prior to admission, O. F was holding a rod and accidentally hit the open wire that causes his burn. Immediately
after the incident, his co-worker brought him to Saint Dominic Hospital but the institution has no Burn Unit, so they transferred him
at Philippine General Hospital unfortunately there was no Burn Unit again. There were no interventions done on both hospitals so
they transferred again at Jose R. Reyes Memorial Medical Center, where he is currently admitted.

History of Past Illness

Patient O.F. has no known allergy to any food or medications. He completed his vaccines or immunizations during his childhood
and there is a scar of BCG vaccine in his right deltoid. The patient experienced childhood illnesses such as cough and colds, chicken
pox and mumps. No past history of any confinement or hospitalization because of any diseases or vehicular accidents. He stated that
he is healthy and uses over the counter medications such as alaxan for pain, paracetamol for fever, solmux for cough and neozep for
colds. He does not use any vitamin supplement.

Family Health History

The patient is the second child among his five siblings. No family history of hypertension, diabetes mellitus, drug addiction/drug
dependency, asthma and cancer. His parents are still alive and healthy according to the patient.

GORDON’S 11 FUNCTIONAL PATTERN

HEALTH PERCEPTION- HEALTH MANAGEMENT PATTERN

BEFORE HOSPITALIZATION

According to the patient being healthy is tantamount to being able to perform his role unaided and being strong. He stated that
he is compliant with regards to his health as he says “Kailangan kong maging malakas, mahirap kasi ang maging construction
worker”. He also claims that whenever he experiences common diseases such as fever, cough and body ache, he uses over the
counter drugs such as alaxan for pain, paracetamol for fever and solmux for cough. Whenever he feels something wrong with his
health, he usually manages his condition at home and rarely goes for consultation.

DURING HOSPITALIZATION

According to the patient he is no longer able to do all his routine activities due to his present disease condition. He also added
that his disease truly affected his activities of daily living. He is given antibiotics, pain reliever and multivitamins as prescribed by his
physician. His body parts that are affected are regularly cleansed and frequently changed the dressing.

NUTRITIONAL METABOLIC PATTERN

BEFORE HOSPITALIZATION

Patient eats three times a day with snacks in between. His breakfast usually composed of a cup of coffee, 1 to 2 cups of rice,
hotdog or fried egg. For his lunch and dinner he usually consumes 2 to 4 cups of rice, 2 to 4 glass of water and vegetable cooked in
fish sauce (dinengdeng). The patient prefers water and fruit juices for his beverage and he seldom eats meat. He drinks liquor
occasionally in a maximum of 1 bottle and he usually smokes 9 stick per day. He does not take any vitamin supplement. No difficulty
in chewing and swallowing. He weighs 73 kg and stands approximately 5’5” tall.

DURING HOSPITALIZATION

Patient eats what the staff of the dietary department offered him which is a high protein diet. His regular breakfast is composed
of 1 piece of bread, boiled egg and 1 cup of rice. His lunch and dinner usually composed of meat or a piece of fried fish, 1 cup of rice
and a slice of fruit or a piece of banana. He usually drinks approximately 1.5 liters of water per day. He seldom drinks juice. No
difficulty in chewing and swallowing. He has difficulty in feeding himself by his own due to the discomfort he feels when moving.

ELIMINATION PATTERN

BEFORE HOSPITALIZATION

The patient stated that he usually urinates 3 to 5 times a day with an amount of approximately 700-1200 ml a day, with a light
yellow to amber colour and aromatic odor. No episodes of painful and difficulty in voiding. The patient regularly defecates once a
day with yellow -orange to light brown in color, bulky in consistency and no difficulties in defecation. He does not use enema,
suppositories and laxative to aid in defecation.

DURING HOSPITALIZATION

Currently, the patient is catheterized. According to the patient he doesn’t feel any burning and painful urination. He stated
the his voiding and defecating habits, frequency and routine including the color and consistency of the feces and the color, odor of
the urine are the same as what he has before the hospitalization.

ACTIVITY- EXERCISE PATTERN

BEFORE HOSPITALIZATION

As a construction worker the patient need to be physically fit and he considered his work as an exercise because his work
includes lifting bricks, rods and mixing cements. According to him doing this work makes him feel better because it does not only
make him fit but it helps a lot in their financial needs. During his free time, he used to watch dramas over the television and play
basketball.

DURING HOSPITALIZATION

Due to this condition the patient cannot do his routine activities or exercises. He entertains himself by chatting to his
roommates, watching TV and listening to music. He is able to do his ADL’s such as eating, going to the comfort room for toileting and
self-care activities but he needs some assistance. He lies on his bed almost all the time to have a sufficient rest to conserve his
energy but sometimes he perform active range of motion to prevent contractures.

SLEEP-REST PATTERN

BEFORE HOSPITALIZATION

Before hospitalization, the patient had 8 hours of sleep and he feels satisfied with those ample hours of sleeping. According
to him, “natutulog ako mga 9 ng gabi pag nagsawa na ako sa pinapanuod ko tapos gumigising ako at around 5 na ng umaga para
magtrabaho”. He doesn’t have difficulties or disturbances with regards to his sleeping pattern. He takes daytime nap during his free
time. He does not use any sleeping pills, no special rituals before sleeping. According to him he preferred to sleep with lights off and
easily fall asleep.
DURING HOSPITALIZATION

According to him, he sleeps most of the time in the hospital to divert the pain and to have enough rest but it is interrupted
due to an every hour vital signs monitoring and giving medications . He does not use any sleeping pills and no rituals to aid in
sleeping.

COGNITIVE- PERCEPTUAL PATTERN

BEFORE HOSPITALIZATION

The patient has no problem with his senses, can remember recent memories such as what is the content of her breakfast
today and he can remember remote memories such as who is the first female president of the Philippines. The patient stated that
he has no problem in perception of things, can reason out himself and happenings, he can think clearly and can decide critically
related situation. No episodes of forgetfulness and hearing or seeing things that are not seen by others.

DURING HOSPITALIZATION

The patient has no problem with his five senses. The patient is in pain with pain scale of 6/10. No changes in the cognitive
status and perception ability of the patient. According to him there are no changes as what he had before hospitalization and what
he has during hospitalization.

SELF PERCEPTION - SELF CONCEPT PATTERN

BEFORE HOSPITALIZATION

According to him, he considers himself as a strong and healthy person because he is able to perform his responsibilities as an
individual. He is satisfied on his body figure and appearance. He stated that he loves to chat with others and he rarely gets into
trouble or conflicts with other people. He prioritizes what his parent’s opinions on every matter.

DURING HOSPITALIZATION

The client had a multiple burn injury on the posterior and anterior chest and abdominal area, left arm and both left and right
lower extremities; with dry and intact dressing and can’t move freely. He said that his disease condition affects him a lot. He thinks
that he is now unhealthy because he is not able to do the things that he wants to do. He thinks that because of his condition, he is a
burden in their family.
COPING - STRESS PATTERN

BEFORE HOSPITALIZATION

The patient manages stress in the work area by sleeping or listening to music. He rarely open work related stress to his family
because he does not want his family to worry. According to him sleeping gives him the time to think on what to do. When the stress
is somehow personal involving the family, then that is the time to talk together and settle the problem. He stated that during
decision making his parents do almost the final decision but sometimes he makes decisions by his own.

DURING HOSPITALIZATION

According to the patient this is one of the most severe stress he had encounter so far in his entire life because he cannot
help his family for their daily needs. The patient manages stress and boredom by chatting to the person near his bed (roommate),
but the most effective so far that can remove his stress is by sleeping or sometimes watching television.

ROLE-RELATIONSHIP PATTERN

BEFORE HOSPITALIZATION

According to the patient he is a supportive to his parents and siblings. He provides them the emotional and financial needs
they needed. He had never been into conflicts with his parents because as a son he needs to bend his head forward to his parents,
as a way of giving respect. According to the patient they don’t have any misunderstanding with his siblings.

DURING HOSPITALIZATION

According to him, he helps his family for their daily needs. He says that temporarily, he can’t perform his full duty as a
responsible son to his parents and a helpful brother to his siblings due to his condition.

SEXUALITY REPRODUCTIVE PATTERN

BEFORE HOSPITALIZATION

The patient is satisfied with his sexuality being a man. He believes that he fulfils the role of a man. According to him to be
able to provide for your own family and be independent in life is one of the characteristics of being a man. According to him he had
been circumcise at the age of 10 in their province. He has no known STDs and any reproductive related diseases.

DURING HOSPITALIZATION
 The patient says being able to be strong despite what happened is still tantamount to being a great man.

VALUE BELIEF PATTERN

BEFORE HOSPITALIZATION

Patient is a Roman Catholic. He has a great faith in God. He seldom goes to church with his family but he often ask on his own
for the protection of his family. He believes that everything happens have a purpose.

DURING HOSPITALIZATION

According to patient, the condition he had now made his faith to Almighty God stronger and considers this as a test of life.
He prays more often to Him that he can recover faster and may that his family be safe always.
 PHYSICAL ASSESSMENT

Date of Assessment: May 6, 2014

Time of Assessment: 6:00 PM

General Appearance:
The patient is dressed with patient’s gown, sitting on bed, conscious and coherent with ongoing venoclysis of PLRS 1L
X30gtts/min at 150cc level infusing well at the right brachial, with Indwelling Foley Catheter connected to urine bag and with an
intact and dry dressings at the arm, trunks, leg and feet. His fingernails are well trimmed and kempt.

Mental Status:
The patient is oriented to time, place, and person. He maintained eye contact and very cooperative with the student nurses.
He talks in a clear, understandable and moderate tone of voice.

Vital Signs during Physical Assessment:

Temperature: 38.4° C
RR: 23 cpm
BP: 100/60 mmHg
PR: 96 bpm

AREA METHOD
NORMAL FINDINGS ACTUAL FINDINGS REMARKS
ASSESSED USED

SKIN
Color Inspection Varies from light to deep Light to deep brown Normal
brown (depending on
race)
Uniformity Inspection Generally uniform except Uniform, except in areas exposed to Normal
in areas exposed to sun; sun
areas of lighter
pigmentation are palms,
lips, nail beds in dark
skinned people

Integrity Inspection Intact skin 36% TBSA disrupted Due to electrical burn

Moisture Palpation Moisture in the skin folds Moisture in the skin folds and axilla , Normal
and axilla (varies with varies with environmental
environmental temperature and humidity , feels
temperature and smooth and firm with even surface.
humidity, body
temperature and activity)
feels smooth & firm with
even surface
Texture Palpation Feels smooth & firm with Feels smooth and firm with even Normal
even surface surface

Skin Palpation Warm to touch Very warm to touch Increased temperature due to
Temperature pathophysiologic changes
caused by disruption of the skin
and alterations to the tissue
beneath the surface causing lose
of normal functioning of the skin
Turgor Palpation When pinched, skin Skin springs back 1 to 2 seconds when Normal
springs back to 1-2 pinched
seconds
Edema Palpation No edema Peripheral edema (on left hand) Decreased blood flow

Lesions Inspection No lesion and abnormal With lesion Due to wound burn
discolorations

HEAD
Size and Inspection Appropriate to body size Appropriate to body size and age Normal
circumferenc and age
e
Shape Inspection Round and symmetrical, Round and symmetrical, no bulging Normal
no bulging and swelling and swelling
Hair Inspection Equally distributed Equally distributed Normal
HAIR
Color Inspection Depends on race Black Normal
Distribution Inspection Evenly distributed hair Evenly distributed hair Normal
Texture Palpation Silky, shiny, and resilient Silky, shiny and resilient Normal
Presence of Inspection ( - ) infestation no flakes (-) infestation no flakes Normal
infestation
and flakes

SCALP
Symmetry Inspection Symmetrical Symmetrical Normal

Appearance Inspection Absence of seborrhoea Absence of seborrhoea and lesions Normal

and lesions

FACE
Symmetry, Inspection Symmetrical features, Symmetrical features, symmetrical at Normal
movements symmetrical at rest rest
Color Inspection Varies from light to deep Brown Normal
brown
Presence of Inspection Absent Absent Normal
facial Palpation
periorbital
edema
Distribution Inspection Presence of beard Presence of beard Normal
of hair (for male) (for male)

EYEBROWS
Distribution Inspection Hair evenly distributed; Hair evenly distributed; skin is intact Normal
skin intact

Alignment Inspection Aligned Aligned Normal

EYELIDS
Ability to Inspection Has the ability to blink Has the ability to blink bilaterally; 20 Normal
blink bilaterally: 15-20 blinks/ minute
blinks/min
Surface Inspection Skin intact, no discharge, Skin is intact, no discoloration, no Normal
characteristic no discoloration discharge

EYELASHES
Direction of Inspection Slightly curled outward Slightly curled outward Normal
curl
Distribution Inspection Equally distributed Equally distributed Normal

EYES
Conjunctiva Inspection Pink palpebral conjunctiva Pink Normal
Sclera Inspection White White Normal

Cornea Inspection Transparent Transparent Normal

PUPILS
Color Inspection Black Brown Normal

Reaction to Inspection PERRLA PERRLA Normal

light
Visual field Inspection When looking straight When looking straight ahead can see Normal
ahead can see objects in objects in the periphery
the periphery
Visual acuity Inspection Able to read newspaper Can read letters, the smallest font Normal
with small fonts at a size on his cell phone at a distance of
distance of 14 inches 14 inches without any visual aids.
without the help of visual
aids (eyeglasses, contact
lenses)

EARS
Symmetry in Inspection Symmetrical to the head Symmetrical to the head and face. Normal
size and face. Equal in size. Equal in size

Color Inspection Same with the color of Same with the color of the face Normal
 the face
Presence of Inspection Absence of cerumen, Absence of cerumen, lesions, pus Normal
cerumen, lesions, pus
lesions and
pus
Ability to hear Inspection Can hear sound (soft and Can hear sounds soft and loud Normal
loud)

NOSE
Symmetry Inspection At midline of the face, At midline of the face, nares are Normal
nares are symmetrical symmetrical

Color Inspection Same with the color of Same with the color of the face Normal
the face
Discharge/ Inspection No discharge/ flaring No discharge and flaring Normal
flaring
Tenderness Palpation Not tender; no lesions Not tender; no lesions Normal

MOUTH
Lips Inspection Uniform pink color Uniform, pink in color, soft, moist and Normal
(varies) smooth in texture
soft, moist and smooth in
texture
Ability to Inspection Can purse lips Can purse lips Normal
purse lips
Buccal Inspection Moist, smooth, soft and Moist, smooth, soft and glistening, Normal
mucosa glistening, pink in color pink in color

Teeth Inspection Teeth are white, no With dental caries Due to poor hygiene
tartars , no dental caries, ( 2 molars)
complete set of adult
teeth(32)
Gums Inspection Pink in color, moist and Pink Normal
firm
Tongue Inspection Freely moving; centered Freely moving; centered roughened Normal
roughened from papillae, from papillae, no lesions
no lesions
Uvula Inspection Uvula is positioned in the Uvula is positioned in the midline Normal
midline

NECK
Position Inspection Centrally located between Centrally located between the Normal
the shoulders shoulders

Mobility Inspection Can move spontaneously
in all directions
Lymph nodes Palpation No tenderness or
inflammation present; no
pain during palpation
Can move spontaneously in all Normal
directions
No tenderness or inflammation Normal
present; no pain during palpation

THORAX AND LUNGS

>Posterior Inspection Chest symmetric in size Chest symmetric in size Normal
Thorax
Symmetry

Scapula Inspection Symmetrical Symmetrical Normal

Spinal column Inspection Straight; vertically aligned Straight; vertically aligned Normal

Chest wall Inspection Intact; no tenderness; no Intact, no tenderness, no masses Normal

masses
Chest Palpation Full and symmetric chest Full and symmetric chest expansion Normal
expansion expansion
Anterior Inspection Chest expands Chest expands Normal
Thorax symmetrically during symmetrically during respiration;
Symmetry respiration; effortless effortless respiration
respiration

Breathing Inspection No difficulty No difficulty Normal

pattern Breathing Breathing
Rate Inspection 12- 20 cpm 23 cpm

Rhythm Inspection Regular Regular Normal

Breath Auscultation Bronchovesicular breath Bronchovesicular breath sounds Normal
sounds sounds

HEART
Cardiac rate Auscultation 60-100bpm 91bpm Normal

Heart sounds Auscultation No murmurs No murmurs Normal

ABDOMEN
Skin condition Inspection Brown or follows general Follows general body color Normal
body color
Lesions and Inspection No lesion or discoloration Wound on the left side of the Due to electrical burn
discolorations abdomen
Integrity Inspection Intact skin Wound on the left side of the Due to electrical burn
abdomen

Abdominal Inspection Flat, round, scaphoid Flat Normal

contour
Umbilicus Inspection Midline & inverted , no Midline & inverted , no sign Normal
sign of discoloration
of discoloration

UPPER EXTREMITIES
Skin color Inspection Tan; depends on race Brown Normal

Skin Inspection Warm and equal Very warm temperature, with wounds Increased temperature due to
characteristic Palpation temperature; no edema and edema on left hand pathophysiologic changes
,tenderness and bruises caused by disruption of the skin
and alterations to the tissue
beneath the surface causing lose
of normal functioning of the skin

Symmetry Inspection Symmetrical Left hand slightly bigger Decreased blood flow
Hair Inspection Evenly distributed Evenly distributed Normal
distribution
Lesion and Inspection Absence of lesion and With lesion on the left arm and palm Due to wound burn
discoloration discolorations
ROM Inspection Full ROM without pain Full ROM without pain Normal

LOWER EXTREMITIES
Skin color Inspection Tan; depends on race Brown Normal
Skin Palpation Warm and equal Very warm temperature and wounds Increased temperature due to
characteristic temperature; no edema pathophysiologic changes
and tenderness and caused by disruption of the skin
bruises and alterations to the tissue
beneath the surface causing lose
of normal functioning of the skin
Symmetry Inspection Symmetrical Left leg is slightly bigger than the Decreased blood flow
right leg
Hair Inspection Evenly distributed Evenly distributed Normal
distribution
ROM Inspection Full ROM without pain Limited ROM on the left leg and foot Due to pain caused by wound
burn

NAILS
Shape Inspection Convex curvature; angle Convex curvature; angle of nail plate Normal
of nail plate about 160 about 160

Texture Palpation Smooth Smooth Normal

Color Inspection Highly vascular and pink Pink Normal
in light-skinned clients;
dark-skinned clients may
have brown or black
pigmentation in
longitudinal streaks
Tissues Inspection Intact epidermis Intact epidermis Normal
surrounding
nails
Capillary Palpation Prompt return of pink or
usual color generally less
 than 3 seconds

NEUROLOGIC
Level of Inspection 15, alert and completely 15,responds to stimuli including Normal
consciousness oriented; express ideas verbal commands
logically
MENTAL
STATUS:
ORIENTATIO
N
Time Inspection Oriented Oriented Normal
Place Inspection Oriented Oriented Normal
Person Inspection Oriented Oriented Normal
CEREBELLAR
FUNCTION
Posture Inspection Good posture Slouch posture Due to pain
Motor Inspection Good Decreased Due to pain
function
Balance Inspection Good balance Uncoordinated Due to pain
Muscle tone Inspection Normal muscle tone Decreased Due to pain
Speech Inspection Has the ability to Has the ability to comprehend spoken Normal
comprehend spoken and and written language (Tagalog,
written language, speech English)
is fluent
 ANATOMY AND PHYSIOLOGY

The integumentary system consists of the skin, hair, nails, the subcutaneous tissue below the skin and assorted glands. The most obvious
function of the integumentary system is the protection that the skin gives to underlying tissues. The skin not only keeps most harmful
substances out, but also prevents the loss of fluids.
A major function of the subcutaneous tissue is to connect the skin to underlying tissues such as muscles. Hair on the scalp provides
insulation from cold for the head. The hair of eyelashes and eyebrows helps keep dust and perspiration out of the eyes, and the hair in our
nostrils helps keep dust out of the nasal cavities. Any other hair on our bodies no longer serves a function, but is an evolutionary remnant.
Nails protect the tips of fingers and toes from mechanical injury. Fingernails give the fingers greater ability to pick up small objects.
There are four types of glands in the integumentary system:
Sudoriferous glands are sweat producing glands. These are important to help maintain body temperature. Sebaceous glands are oil
producing glands which help inhibit bacteria, keep us waterproof and prevent our hair and skin from drying out. Ceruminous glands produce
earwax which keeps the outer surface of the eardrum pliable and prevents drying. Mammary glands produce milk.
Skin is an organ of the integumentary system made up of a layer of tissues that guard underlying muscles and organs. It plays the most
important role in protecting against pathogens. Its other main functions are insulation and temperature regulation, sensation and vitamin D
and B synthesis. Skin is considered one of the most important parts of the body.
Skin has pigmentation, melanin, provided by melanocytes, which absorbs some of the potentially dangerous radiation in sunlight.
The skin has two major layers which are made of different tissues and have very different functions.

Skin is composed of the epidermis and the dermis. The outermost epidermis consists of stratified squamous keratinizing epithelium with an
underlying basement membrane. It contains no blood vessels, and is nourished by diffusion from the dermis. The main type of cells which
make up the epidermis are keratinocytes, with melanocytes and Langerhans cells also present. The epidermis can be further subdivided
into the following strata (beginning with the outermost layer): corneum, lucidum, granulosum, spinosum, basale.
The dermis lies below the epidermis and contains a number of structures including blood vessels, nerves, hair follicles, smooth muscle,
glands and lymphatic tissue. It consists of loose connective tissue otherwise called areolar connective tissue - collagen, elastin and reticular
fibers are present. Erector muscles, attached between the hair papilla and epidermis, can contract, resulting in the hair fiber pulled upright
and consequentially goose bumps. The main cell types are fibroblasts, adipocytes (fat storage) and macrophages.
The dermis is made of an irregular type of fibrous connective tissue consisting of collagen and elastin fibers. It can be split into
the papillary and reticular layers. The papillary layer is outermost and extends into the epidermis to supply it with vessels. It is composed of
loosely arranged fibers. Papillary ridges make up the lines of the hands giving us fingerprints. The reticular layer is more dense and is
continuous with the hypodermis. It contains the bulk of the structures (such as sweat glands). The reticular layer is composed of irregularly
arranged fibers and resists stretching.
The hypodermis is not part of the skin, and lies below the dermis. Its purpose is to attach the skin to underlying bone and muscle as well as
supplying it with blood vessels and nerves. It consists of loose connective tissue and elastin. The main cell types are fibroblasts,
macrophages and adipocytes (the hypodermis contains 95% of body fat). Fat serves as padding and insulation for the body
PATHOPHYSIOLOGY
 LABORATORY RESULTS

May 01, 2014

TEST NORMAL VALUES RESULTS INTERPRETATION

Hemoglobin 14.1 – 18.1 g/dl 6.7 Decrease due to blood loss.

Hematocrit 43.5 – 53.7 47 % Normal
RBC 4.7 – 6.1 x 108/uL 5.48 Normal
MCV 80 – 97 fL 86.1 Normal
MCH 27 – 31 pg 30.6 Normal
MCHC 31.8 – 35.4 35.5 Normal
WBC 4.6 – 10. 2 x 103/uL 23.95 Increase may be due to infection.

Differential count

TEST NORMAL VALUES RESULTS INTERPRETATION

Neutrophils % 37- 80 82.4 Increase due to possible infection

Lymphocytes % 10- 50 8.6 Decrease due to possible infection
Basophils % 0-1.5 .2% Normal
Monocytes 0-14 8.2 Normal
Eosinophils 0-7 0.6 Normal
Platelet 130-140 x 103/uL 297 x 103/uL Normal

May 01, 2014

URINALYSIS
TEST NORMAL VALUES RESULT INTERPRETATION
Color Yellow/amber Yellow Normal
Characteristics clear clear Normal

PH 5–6 5.5 Normal

Specific Gravity 1.015– 1.030 1.025 Normal
Protein Negative +1 Abnormal may be to increased systemic capillary
permeability
RBC 0 – 2/hpf 2-4/hpf Normal
WBC 0-5.hpf 0-1 Normal

May 01, 2014

TEST NORMAL VALUES RESULTS INTERPRETATION

Creatinine 45-104 umol/L 79.5 Normal

Sodium 135-143 mmol/L 138.40 Normal
Potassium 3.4- 4.82 2.9 Normal

May 02,2014

TEST NORMAL VALUES RESULTS INTERPRETATION

Potassium 3.4- 4.82 3.99 Normal
DRUG STUDY
 NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Alteration in body After 30 minutes of Provided comfort To promote non Goal met:
“ masakit yung mga comfort:Acute pain nursing intervention measures such as touch pharmacological pain After 30 minutes the
paso ko kung related to traumatized the patient will report and offered company. management. patient verbalized a
nagagalaw o nerve ending secondary relieved of pain from decreased in pain
napwepwersa”, as to electrical burn. 6/10 to 2/10 or Instructed in and To distract attention and scale from 6/10 to
verbalized by the below. encouraged use of reduce tension. 2/10 as evidenced by
patient. relaxation techniques decrease in episode
Objective: such as focused of facial grimacing.
 Pain scale of breathing or deep
6/10 ( 10 breathing exercises and
being the listening to light.
highest pain
and 1 being Promoted less To decrease friction or
the lowest). stimulation in the pressure applied on the
 Facial affected side during vital affected area.
grimacing signs monitoring.
when burn
area is touch
or when he Administered Tramadol For past relieved of pain.
moves. 50 mg/ IV as ordered.