SOUTHERN LUZON STATE UNIVERSITY

College of Allied Medicin

CASE STUDY
BURNS
Table of Contents
GROUP 3
GAZA | GONZALES | JARIEL | NORBE

OBLEFIAS | ONG | ORTEGA | PALMARIA

ROSALES | SACDALAN | SALUMBIDES | SAMONTE
CASE STUDY........................................................................................................................................................2

Southern Luzon State University

COLLEGE OF ALLIED MEDICINE
OBJECTIVES..........................................................................................................................................................4
INTRODUCTION...................................................................................................................................................5
REVIEW OF RELATED LITERATURE..............................................................................................................7
BURNS................................................................................................................................................................7
THORACIC DRAINAGE...................................................................................................................................8
CONTINUOUS RENAL REPLACEMENT THERAPY..................................................................................9
ESCHAROTOMY............................................................................................................................................11
ANATOMY & PHYSIOLOGY............................................................................................................................12
SKIN..................................................................................................................................................................12
Hair Follicle...................................................................................................................................................13
Sweat Glands.................................................................................................................................................13
Sebaceous Gland...........................................................................................................................................14
THORAX..........................................................................................................................................................14
LUNGS..............................................................................................................................................................15
KIDNEY............................................................................................................................................................15
UPPER LIMBS.................................................................................................................................................16
LOWER LIMB MUSCLES..............................................................................................................................17
ABDOMEN.......................................................................................................................................................21
PATHOPHYSIOLOGY........................................................................................................................................22
NURSING CARE PLAN......................................................................................................................................23
DRUG STUDY.....................................................................................................................................................38
PHYSICAL EXAMINATION..............................................................................................................................45
LABORATORY EXAMINATION & DIAGNOSTIC TESTS...........................................................................50
Computed Tomography Scan............................................................................................................................50
Magnetic Resonance Imaging...........................................................................................................................52
HISTORY OF PATIENT......................................................................................................................................55
References.............................................................................................................................................................56
CASE STUDY
Aaron, a 29-year-old guy, fell asleep while using charcoal as a heat source, became
poisoned by carbon monoxide, and went into a coma for an unknown period of time. He fell into
the charcoal fire and was discovered about 3 hours later. He was transferred to the local central
hospital's burn unit in the department of surgery for treatment. The patient developed
pneumothorax and acute renal failure two days after the incident, which were managed with
thoracic drainage and continuous renal replacement treatment (CRRT). The patient's vital signs
were steady upon entrance. The burn wounds were spread over the right anterior and posterior
thorax, bilateral hips, bilateral lower limbs, and upper right limbs, with a total burn surface area
of 17 percent (TBSA). The majority of the burn wounds were covered in a tough, black, leather-
like eschar. There was deep necrotic fascia and muscle tissue apparent. His skin was warm, and
his blood flow to his distal limbs was adequate. On admission, the patient's diagnoses were as
follows: (1) thermal burns (from charcoal flame, 17% TBSA; deep second-degree burns, 2%
TBSA; third-degree burns, 15% TBSA), (2) acute renal failure, and (3) bilateral lower lung
infection. The patient’s visual analog scale score for pain was 7. Analgesic medications such as
Flurbiprofen, Midazolam and Tramadol were used in succession to relieve his pain.

On the third day after admission, computed tomography and magnetic resonance imaging
(MRI) of the chest and abdomen revealed a right pneumothorax, bilateral lower lung infection,
and bilateral pleural effusion; a right abdominal wall soft-tissue defect, suspected right chest wall
soft tissue defect into the abdominal cavity, and blood effusion in the pelvis; and multiple muscle
injuries on the right chest wall, hips, and pelvic cavity.

On the fourth day following admission, a multidisciplinary team met to develop treatment
regimens that included wound care, CRRT, infection control, respiratory support, nutrition, and
rehabilitation. Because the right abdominal wall defect had probably progressed into the
abdominal cavity, conservative debridement was required. The calorie intake from enteral and
parental nourishment was around 2,000 to 2,200 kcal per day. Under the supervision of
rehabilitation therapists, multidisciplinary rehabilitation therapies such as anticontracture
positioning, passive and active range-of-motion exercises, transfer training, and tilt table training
were administered in the burn ICU. Meanwhile, the patient received psychological interventions
such as rational-emotional therapy and music therapy to help with anxiety and depression.

The patient had escharectomy under general anesthesia on the sixth day after admission.
The intraoperative findings revealed necrosis of the majority of the right chest muscles
(including his intercostal muscles) and a portion of the ribs, as well as exposure of a portion of
the pleura. Conservative debridement was conducted with the help of thoracic and general
surgeons to better protect the tissues in the chest cavity. The majority of the abdominal muscles,
including the external and internal oblique muscles and the majority of the rectus abdominis,
were necrotic. The iliac bone was necrotic in parts. To avoid entering the abdominal cavity, the
muscles and soft tissues near the peritoneum were retained.

Physical examination on the 12th day after admission revealed that the wounds on the
patient's abdomen were well covered by the xenogeneic dressings, with red granulation visible in
the wound bed.

The sixth intercostal arteries in the right chest wall hemorrhaged on the 17th day
following admission, and the wounds were closed with allogeneic skin patches after the
hemorrhagic blood vessels were sutured.

Forty-four days following admission, the patient had general anesthetic debridement and
meshed skin grafting to seal lesions on his torso and part of his lower extremity.

On day 65, the right necrotic ribs (6-12) were removed with the assistance of thoracic
surgeons. The chest wall was punctured (1 cm), and the right lung tissue was visible through the
rupture, which was subsequently sutured closed. To cover the chest wall wound, an autologous
meshed dermal scaffold extracted using an air-driven dermatome was employed, and an
epidermal skin sheet was inserted in situ to cover the donor area.

On day 103 following admission, the right necrotic iliac bone was removed, and the
surgical site was covered with a preprepared autologous dermal scaffold before being dressed.
 A sural neurovascular flap was employed to treat the right heel incision on day 115 after
admission. Even with constant dressing changes, a refractory sinus tract on the right chest wound
remained.

As a result, on day 179 following hospitalization, autologous PRP was injected into the
thoracic sinus tract, which recovered two weeks later.

The patient was discharged on the 195th day following admission when his kidney and
lung functions had recovered and all wounds had healed.

OBJECTIVES
This case study aims to discuss, explain, and establish an understanding of the disease

process. In addition, it will also include the care management (nursing or medical management)

applicable to the condition. At the end of this case study, the students aim to acquire more

knowledge regarding the condition, enhance their skills in terms of developing nursing

processes, and develop their attitude associated with managing the condition. 

Specifically, this case study aims to:

1. To learn about the disease process associated with burn injury.

2. To define and determine the causes, risk factors, clinical manifestations, diagnostic tests,

and nursing/medical management of the disease process.

3. To gather new knowledge in terms of research and studies associated with the disease

process.

4. To describe the structures and functions of the affected organs (skin, thorax, lungs,

kidney, upper limbs, lower limbs muscles, and abdomen.)

5. To trace the pathophysiology of the disease process.

6. To use the nursing process as a framework for care of the patient with burn injury.
 7. To determine the action, indications, contraindications, side effects, and the nursing

responsibility of the medications appropriate for the disease condition.

8. To provide a complete and thorough physical assessment of the patient.

9. To evaluate the results of the laboratory examinations and determine the appropriate

nursing responsibilities.

10. To determine the history of the client’s condition.

INTRODUCTION
Burns are potentially devastating injuries with many consequences ranging from
physical, functional, and occupational to cosmetic and psychosocial damage. It is a tissue
damage caused by heat, chemicals, electricity, sunlight, or nuclear radiation. The most common
burns are those caused by hot liquid or steam, building fires, and flammable liquids and gasses.

Burn Mechanisms:

● Heat — The depth of the thermal injury is related to contact temperature, duration of
contact of the external heat source, and the thickness of the skin. Because the thermal
conductivity of skin is low, most thermal burns involve the epidermis and part of the
dermis. The most common thermal burns are associated with flames, hot liquids, hot solid
objects, and steam.

● Electrical discharge — Electrical energy is transformed into heat as the current passes
through poorly conducting body tissues. Electroporation (injury to cell membranes)
disrupts membrane potential and function. The magnitude of the injury depends on the
pathway of the current, the resistance to the current flow through the tissues, and the
strength and duration of the current flow.

● Friction — Injury from friction can occur due to a combination of mechanical disruption
of tissues as well as heat generated by friction.
 ● Chemicals — Injury is caused by a wide range of caustic reactions, including alteration
of pH, disruption of cellular membranes, and direct toxic effects on metabolic processes.
In addition to the duration of exposure, the nature of the agent will determine injury
severity. Contact with acid causes coagulation necrosis of the tissue, while alkaline burns
generate liquefaction necrosis. Systemic absorption of some chemicals is life-threatening,
and local damage can include the full thickness of skin and underlying tissues.

● Radiation — Radio frequency energy or ionizing radiation can cause damage to skin and
tissues. The most common type of radiation burn is the sunburn. Radiation burns are most
commonly seen today following therapeutic radiation therapy and are also seen in
patients who receive excessive radiation from diagnostic procedures.

Burns are defined by how deep they are and how large an area they cover. A large burn
injury is likely to include burned areas of different depths. Deep burns heal more slowly, are
more difficult to treat, and are more prone to complications such as infections and scarring. Very
deep burns are the most life-threatening of all and may require amputation. Types of burns
include:

● First-degree burns damage the outer layer (epidermis) of the skin. These burns usually
heal on their own within a week. A common example is a sunburn.

● Second-degree burns damage not only the outer layer but also the layer beneath it
(dermis). These burns might need a skin graft—natural or artificial skin to cover and
protect the body while it heals—and they may leave a scar.

● Third-degree burns damage or completely destroy both layers of skin including hair
follicles and sweat glands and damage underlying tissues. These burns always require
skin grafts.

● Fourth degree burns extend into fat, fifth degree burns into muscle, and sixth degree
burns to bone.

Burn injuries are under-appreciated injuries that are associated with substantial morbidity
and mortality. Burn injuries, particularly severe burns, are accompanied by an immune and
inflammatory response, metabolic changes and distributive shock that can be challenging to
manage and can lead to multiple organ failure. Of great importance is that the injury affects not
only the physical health, but also the mental health and quality of life of the patient. Accordingly,
patients with burn injury cannot be considered recovered when the wounds have healed; instead,
burn injury leads to long-term profound alterations that must be addressed to optimize quality of
life. Burn care providers are, therefore, faced with a plethora of challenges including acute and
critical care management, long-term care and rehabilitation.

REVIEW OF RELATED LITERATURE

BURNS
Burns, as define by the World Health Organization (WHO), is an injury in the skin or
other organic tissue resulting from exposure to heat or due to radiation, radioactivity, electricity,
friction, or contact with chemicals. It is known to be one of the most common types of traumas
around the world with over 11 million cases that needs medical attention and approximately
180,000 deaths in the world annually. In addition to this, 90% of burns occurs withing low- or
middle-income countries where availability of specialist for acute and long-term care for burns
are limited. Furthermore, women and children are more likely to sustain burn injuries inside the
home where as men are more likely to sustain them in a work setting or during outdoor
recreational activities.

According to Masood et. al (2016) burn injury happens once some or all the cells within
the skin or tissues area unit is broken by hot flame, solids and liquids. Additionally, the
complications of the injury vary up to a great extent depending on the affected location, tissue
and the degree of severity. Furthermore, systemic and local both type of complications is caused
by burn. Fluid loss and breakdown of skin integrity is major contributor of systemic
complications. Contractures, scarring and eschars are the local complications of burn injury. The
risk of developing systemic complications is directly proportional to the total body surface area
(TBSA) involved in burn injury. Following are the risk factors of severe systemic complications
and mortality. In addition to that, eschar “rigidness and death of tissue caused by deep burns”.
Respiration can be compromise by an eschar around the thorax and viability of limbs and digits
is endangered by ischemia.
 Douglas, Dunne, and Rawlins (2017), stated that Patients with small superficial burns
may be managed in the emergency department with appropriate first aid, analgesia, cleaning of
the burn, debridement of blisters and the application of a dressing. However, patients with large
burns will be transferred to a burns center for continued resuscitation, critical care and wound
management. Appropriate fluid resuscitation aims to ensure that all tissues are perfused
adequately and the burn is not allowed to ‘extend’ or deepen due to hypovolemia and
hypotension. Similarly, fluid resuscitation should not be excessive and contribute to an already
edematous state, as increasing edema prevents adequate blood flow to the wound that is trying to
heal. Furthermore, burnt arms and legs should be elevated above the level of the heart.
Physiotherapy in the form of active and passive range of movement exercises is essential for
maintenance of strength, joint mobility and to reduce edema. Moreover, patients with burns over
10-15% BSA require dietary support to reduce the catabolic effects of the burn injury and
maintain immune function. Nasogastric feeds or supplemental protein shakes can be used to
supplement oral diet. Patients with very large burns, airway or inhalational injuries may require
intensive care support.

THORACIC DRAINAGE
Major burn injuries can have local and systemic effects in the body. Such effects on the
pulmonary system is pneumothorax. As stated by Daley (2020), the presence of air or gas in the
pleural cavity is referred to as pneumothorax (i.e., the potential space between the visceral and
parietal pleura of the lung). The clinical outcome is determined by the degree of lung collapse on
the afflicted side. The insertion of a chest tube or thoracic drainage is one of the therapeutic
options for pneumothorax. A chest tube is a flexible plastic tube that is inserted into the pleural
space or mediastinum via the chest wall. It is used to remove air from the intrathoracic space in
the event of pneumothorax, or fluid from the intrathoracic space in the case of pleural effusion,
blood, chyle, or pus when empyema develops.

The chest tube is attached to a closed chest drainage system, which allows air or fluid to
be drained while keeping air or fluid out of the pleural area. The system is airtight to prevent
ambient pressure from entering. Because the pleural cavity is generally under negative pressure,
allowing for lung expansion, any tube linked to it must be sealed so that no air or liquid may
enter the area where the tube is attached. There are different types of chest drainage systems.
These are one-bottle system, two-compartment system and three-compartment system/traditional
chest drainage system. Among these systems, the traditional chest drainage is the most common.

The traditional chest drainage system typically has three chambers; the collection
chamber, water-seal chamber and wet or dry suction control chamber. The chest tube connects
directly to the collection chamber, which collects pleural cavity drainage. The chamber has been
calibrated to measure drainage. The chamber's exterior surface contains a "write-on" surface for
recording the date, time, and amount of fluid. This chamber is normally located on the system's
far right side. Following that, the water-seal chamber features a one-way valve that enables air to
depart the pleural cavity during exhale but does not allow it to re-enter during inhalation due to
chamber pressure. To guarantee effective operation, it should be filled with sterile water and kept
at the 2 cm mark, and it should be checked on a regular basis. The water in the water-seal
chamber should rise with inhale and descend with exhale (a phenomenon known as tidaling),
indicating that the chest tube is patent. Continuous bubbling might be an indication of an air leak,
and modern systems incorporate a leak measurement system – the higher the number, the worse
the air leak. Intrathoracic pressure can also be measured using the water-seal chamber. Finally, to
provide consistent suction for the patient, the dry suction system employs a self-controlled
regulator that regulates the amount of suction and responds to air leakage. Suction is not required
for all patients. If a patient is given suction, a wet suction system is normally regulated by the
amount of water in the suction control chamber, which is typically set at -20 cm for adults. There
is less suction when there is less water. The quantity of suction varies with the patient and is
regulated by the chest drainage system rather than the suction source.

As with any medical procedure, thoracic drainage also has its complications. The
complications of chest tube placement are respiratory distress, air leak, accidental removal of
chest tube, accidental disconnection, bleeding at insertion site, subcutaneous emphysema,
drainage suddenly stops and sudden increase in bright red drainage. Depending on the institution,
the incidence of these problems ranges from 1% to 10%. Smaller chest tubes have been
introduced over the last two decades, which are not only easier to install but also cause
substantially less discomfort than previous chest tubes. (Ravi & McKnight, 2021)
CONTINUOUS RENAL REPLACEMENT THERAPY
Continuous renal replacement therapy (CRRT) is a widely used treatment for critically ill
patients with acute kidney damage, particularly those who are hemodynamically unstable. In the
therapy of the critically sick patient with kidney failure, many methods of renal support may be
employed. CRRT, conventional intermittent hemodialysis (IHD), and prolonged intermittent
renal replacement treatments (PIRRTs), which are a hybrid of CRRT and IHD, are among them.
All of them utilize essentially comparable extracorporeal blood circuits and differ largely in
terms of therapy duration and, as a response, the speed of net ultrafiltration and solute clearance.
Furthermore, dialysis therapies rely heavily on diffusive solute clearance, whereas convection is
used to remove solutes during hemofiltration.

As studied by Hanafusa, 2015, While first conceived as an arteriovenous treatment, the

majority of CRRT is now conducted utilizing pump-driven venovenous extracorporeal circuits.
Although this adds some complexity, such as pressure monitors and air detectors, the pump-
driven venovenous circuit delivers greater and more continuous blood flows while eliminating
the risks associated with extended arterial cannulation with a large-bore catheter. Several
methods for administering CRRT have been devised. The treatment is known as slow continuous
ultrafiltration when used just for volume management. More commonly, CRRT provides both
solute clearance and volume removal when delivered as continuous venovenous hemofiltration
(CVVH), continuous venovenous hemodialysis (CVVHD), or continuous venovenous
hemodiafiltration (CVVHDF), with the differences between these modalities relating to the
mechanisms for solute clearance.

As with all medical interventions, CRRT is not without its risks. Starting CRRT
necessitates the installation of a large-bore central venous catheter, which may need to be kept in
place for an extended period of time. Vascular or visceral damage leading in bleeding,
pneumothorax, hemothorax, and arterio-venous fistula development are among well-known
consequences of catheter insertion. Long-term catheter usage is linked to venous thrombosis or
stenosis. Blood exposure to the extracorporeal circuit may result in acute allergy or delayed
immunologic responses as a result of cytokine activation. If air is trapped into the circuit beyond
the return line air detector, air embolization can occur during catheter insertion or removal, as
well as at any moment during treatment.

Circuit clotting is the most prevalent problem during CRRT, and the most common cause
of circuit clotting is insufficient catheter performance, which results in flow restriction and
pressure alarms that block blood flow. If a blood flow rate of 200 to 300 mL/min cannot be
maintained, a catheter replacement should be performed as soon as possible. Excessive filtration
fraction can cause hemoconcentration inside the hemofilter, which can contribute to filter
clotting. If there is no catheter failure, blood flow is maximized, and the filtration percentage is
greater than 20%, anticoagulation should be initiated or intensified. Complications of heparin
anticoagulation might include bleeding and heparin-induced thrombocytopenia. Citrate
anticoagulation may cause citrate toxicity due to citrate buildup, overt hypocalcemia due to
insufficient calcium replacement, and both metabolic acidosis and metabolic alkalosis.
Electrolyte abnormalities (hypophosphatemia, hyponatremia, hypernatremia, hyperkalemia) and
hypotension are other typical consequences. (Tandukar, S., & Palevsky, P. M., 2019).

As stated by Bosslet, et al (2015), issues related to the clinical and ethical appropriateness
of initiation or continuation of RRT often occur in patients with acute kindey injury (AKI).
Discussions of initiation and discontinuation of therapy with patients and/or their
family/surrogate decision-makers should be framed in light of the overall prognosis and goals of
care, and need to consider other life-sustaining treatments in addition to RRT. To enable the
process of shared decision-making, it is critical that both the primary management service and
the nephrology specialists supervising the RRT give an uniform evaluation of prognosis and
treatment choices, delivered in a straightforward yet empathetic manner. The high mortality rate
of AKI in the setting of critical illness, as well as the complicated and highly emotional features
of decisions about commencing or withdrawing renal assistance, imply that early participation of
palliative care services may be beneficial.

ESCHAROTOMY
Zhang et. al (2021) stated in their study that early surgical intervention by doing
escharotomy can prevent these detrimental consequences and improve the outcome of the
patient. Escharotomy, as defined in the study, is an emergency surgical procedure involving
incising through areas of burnt skin to release the eschar and its constrictive effects, restore distal
circulation, and allow adequate ventilation. Furthermore, escharotomies often are performed as
part of a burn victim's resuscitation care, and the decision is made based on clinical assessments
of the patient and their response to treatment provided before that assessment. Generally, an
escharotomy is performed when full circumferential thickness (and sometimes partial thickness)
burns result in circulatory or respiratory compromise. Moreover, it is usually performed within
the first 48 hours of injury, due to initial injury from the primary source, and secondarily due to
resuscitation and development of tissue edema.

Tam and Luo (2019) mentioned in their study that, early excision of the burn eschar has
been one of the most significant advances in modern burn care. As early as in 1920s, people
recognized the importance to remove early the necrotic and denatured tissues in the burn wound
treatment, and gradually this method became the main treatment way of deep burn wounds.
Additionally, the early escharotomy or tangential excision of deep burn wounds can be divided
into three types, i.e., primary stage, prompt stage, and early stage. The primary stage means the
surgery carried out within 24 hours after burn injury. The prompt stage refers to 24–72 h after
burn, while the early stage refers to 3–5 days. Moreover, extensive totally escharotomy on severe
burn patients at within or around 24 hours after burn injury, which achieved good outcome not
only in wound healing but also in decreasing incidences of different complications and mortality.
This method is still used in clinical practice in some burn centers. It is necessary to evaluate
carefully the general status, especially the circulation stability, before this kind of operation.

ANATOMY & PHYSIOLOGY

SKIN
The skin is the largest organ of the
body, with a total area of about 20
square feet. The skin protects us from
microbes and the elements, helps
regulate body temperature, and permits
the sensations of touch, heat, and cold.

Skin has three layers:

1. Epidermis, the superficial layer made up keratinized stratified squamous epithelium that
provides a waterproof barrier and creates our skin tone. It does not have any blood
vessels within it.

Most of the skin can be classified as thin skin, which has four layers of. From
deep to superficial, these layers are the stratum basale (basal layer), stratum spinosum
(spinous layer), stratum granulosum (granular layer), and stratum corneum (cornified
layer). While the “thick skin” is found only on the palms of the hands and the soles of the
feet. It has a fifth layer, called the stratum lucidum, located between the stratum corneum
and the stratum granulosum

Most cells of the epidermis are keratin-producing cells or keratinocytes.

Keratinocytes produce keratin, a tough, protective protein that makes up the majority of
the structure of the skin, hair, and nails. The keratinocytes in the stratum corneum are
dead and regularly slough away, being replaced by cells from the deeper layers. The
entire epidermis is replaced every 30 to 40 days. The renewal process becomes slower
with age but faster in injured skin, when cell proliferation is accelerated for wound
healing.

2. Dermis is a connective tissue layer of mesenchymal origin located deep to the epidermis
and superficial to the subcutaneous fat layer. It contains blood and lymph vessels, nerves,
and other structures, such as hair follicles and sweat glands. The dermis is made of two
layers of connective tissue that compose an interconnected mesh of elastin and
collagenous fibers, produced by fibroblasts.

Two layers:

a. The papillary dermis is the superficial layer, lying deep to the epidermis. The
papillary dermis is composed of loose connective tissue, which means the
collagen and elastin fibers of this layer form a loose mesh. This superficial layer
of the dermis projects into the stratum basale of the epidermis to form finger-like
dermal papillae.
b. The reticular layer is the deep layer, forming a thick layer of dense connective
tissue that constitutes the bulk of the dermis. This layer is well vascularized and
has a rich sensory and sympathetic nerve supply.

3. Hypodermis is the deeper subcutaneous tissue made of fat and connective tissue. It is not
part of the integumentary system. It is just a fatty layer underneath the dermis that help our
body warm.
Hair Follicle
The hair follicle is a tube-shaped sheath that surrounds the part of the hair that is under the skin
and nourishes the hair. It is located in the epidermis and the dermis. The hair shaft is the part of
the hair that is above the skin. Hair is a keratinous filament growing out of the epidermis. It is
primarily made of dead, keratinized cells.

Sweat Glands
When the body becomes warm, sudoriferous glands produce sweat to cool the body.
Sweat glands develop from epidermal projections into the dermis and are classified as merocrine
glands; that is, the secretions are excreted by exocytosis through a duct without affecting the
cells of the gland.

Two types of sweat glands:

a. An eccrine sweat gland is a type of gland that produces hypotonic sweat for
thermoregulation. These glands are found all over the skin’s surface but are especially
abundant on the palms of the hand, the soles of the feet, and the forehead

b. An apocrine sweat gland is usually associated with hair follicles in densely hairy areas,
such as armpits and genital regions. Apocrine sweat glands are larger than eccrine sweat
glands and lie deeper in the dermis, sometimes even reaching the hypodermis.

Sebaceous Gland
Is a type of oil gland that is found all over the body and helps to lubricate and waterproof
the skin and hair. Most sebaceous glands are associated with hair follicles. They generate and
excrete sebum, a mixture of lipids, onto the skin surface, thereby naturally lubricating the dry
and dead layer of keratinized cells of the stratum corneum. The fatty acids of sebum also have
antibacterial properties, and prevent water loss from the skin in low-humidity environments.

THORAX
The thoracic wall is composed mainly
of the ribs, the sternum and the thoracic
muscles.

a. The ribs are arc-shaped, flat

bones that protect thoracic
organs such as the heart and
lungs, and provide attachment

This Photo by Unknown Author is licensed under CC BY-SA

 points to muscles of the back, chest and proximal upper limb. They are 12 pairs of ribs,
attached posteriorly to the thoracic vertebrae.

The ribs can be divided into groups based on their distal attachment points. The first seven
pairs of ribs articulate directly with the sternum through their costal cartilages and are known as
the true ribs or vertebrosternal ribs. The 8th-10th ribs unite anteriorly via their costal cartilages
and articulate indirectly with the sternum via the 7th rib; they are known as false ribs or
vertebrocostal ribs. The 11th and 12th ribs are known as floating ribs as they do not attach to the
sternum in any manner and are particularly short and have no necks nor tubercles.

b. The sternum is a flat, elongated bone located centrally in the anterior thoracic wall. It’s
made up of three main parts: the manubrium, body and xiphoid process. It articulates
with the clavicles at the sternoclavicular joints and with the cartilages of the first seven
pairs of ribs through the sternochondral/sternocostal joints. The sternum anchors the right
and left ribs to stabilize the rib cage, and has various functions including the protection of
the heart and lungs from mechanical damage.

c. The muscles of the thoracic wall are defined as muscles attached to the bony framework
of the thoracic cage. They maintain the stability of the thoracic wall, and play a role in
respiration. The muscles of the thoracic wall include the following muscle groups:

● Serratus posterior muscles

● Levatores costarum muscles
● Intercostal muscles
● Subcostal muscles
● Transversus thoracis muscles

LUNGS
The lungs are the major organs of the
respiratory system, and are divided into
sections, or lobes. The right lung has three
lobes and is slightly larger than the left lung,
which has two lobes.

The lungs are separated by the

mediastinum. This area contains the heart,
trachea, esophagus, and many lymph nodes.
The lungs are covered by a protective
This Photo by Unknown Author is licensed under CC BY
membrane known as the pleura and are separated from the abdominal cavity by the muscular
diaphragm.

With each inhalation, air is pulled through the windpipe (trachea) and the branching
passageways of the lungs (the bronchi), filling thousands of tiny air sacs (alveoli) at the ends of
the bronchi. These sacs, which resemble bunches of grapes, are surrounded by small blood
vessels (capillaries). Oxygen passes through the thin membranes of the alveoli and into the
bloodstream. The red blood cells pick up the oxygen and carry it to the body's organs and tissues.
As the blood cells release the oxygen, they pick up carbon dioxide, a waste product of
metabolism. The carbon dioxide is then carried back to the lungs and released into the alveoli.
With each exhalation, carbon dioxide is expelled from the bronchi out through the trachea.

KIDNEY
The kidneys are the primary
functional organ of the renal
system. They are essential in
homeostatic functions such as the
regulation of electrolytes,
maintenance of acid–base balance,
and the regulation of blood
pressure. They serve the body as a
natural filter of the blood and
remove wastes that are excreted
through the urine.

They are also responsible for

the reabsorption of water, glucose,
This Photo by Unknown Author is licensed under CC BY-NC-ND and amino acids, and will maintain
the balance of these molecules in the body. In addition, the kidneys produce hormones including
calcitriol, erythropoietin, and the enzyme renin, which are involved in renal and hematological
physiological processes.

The kidneys are bean-shaped, reddish brown paired organs, located behind the abdomen and
on either side of the spine.

There are three major regions of the kidney:

a. Renal cortex - The kidneys are surrounded by a renal cortex, a layer of tissue that is also
covered by renal fascia (connective tissue) and the renal capsule.

b. Renal medulla - The medulla is the inner region of the parenchyma of the kidney.
The medulla consists of multiple pyramidal tissue masses, called the renal pyramids, which are
triangle structures that contain a dense network of nephrons.

c. Renal pelvis - The renal pelvis contains the hilium. The hilum is the concave part of the
bean-shape where blood vessels and nerves enter and exit the kidney; it is also the point of
exit for the ureters—the urine-bearing tubes that exit the kidney and empty into the urinary
bladder.

Blood filtration and urine formation take place in the nephrons, the functional units of the
kidneys. Within each nephron, the glomerulus filters the blood, allowing smaller molecules and
debris (filtrate) to pass through, and into the renal tubule, while keeping larger molecules and
cells inside the blood vessels. As the filtrate travels through the renal tubule, necessary
substances such as nutrients and water are returned to the blood. Additional waste is also
secreted into the filtrate. At that point, the filtrate has become urine, and it flows through the
collecting duct, into the renal pelvis, and out through the ureter.

UPPER LIMBS
The upper limb is divided into 4 main parts -
shoulder, arm, forearm and hand. The shoulder
contains two important regions: the deltoid
region and the axillary (armpit) region. The arm
and forearm contain two regions each that
correspond to their anterior and posterior
surfaces. Found between the arm and forearm are
the anterior and posterior cubital regions. Below
the forearm is the carpal region, which connects
the forearm with the hand. Lastly, the hand
consists of the palm anteriorly, and dorsum of the
hand posteriorly. The hand can be subdivided
into the metacarpal region and the digits. The
digits are numbered 1-5 from the thumb to the
little finger.

a. The shoulder is where the upper limb attaches to the trunk. Its most important part is the
glenohumeral joint; formed by the humerus, scapula and clavicle. The shoulder joint is
reinforced with two groups of muscles, superficial and deep. Superficial muscles include the
deltoid and the trapezius, whereas the deep group contains the supraspinatus, infraspinatus,
teres minor and subscapularis muscles.

b. The arm is the area between the shoulder and the elbow. The muscles are grouped into
anterior and posterior compartments by the septa that attach to the humerus. The anterior
compartment contains the coracobrachialis, brachialis and biceps brachii muscles. While the
posterior compartment contains only one muscle, the triceps brachii.
 c. The forearm has twenty muscles, and two bones (radius and ulna). When in anatomical
position (supination), the radius is found laterally while the ulna is medially in the forearm.
The muscles of the forearm are grouped into anterior and posterior compartments, with the
anterior compartment containing mostly flexors, and the posterior, extensors. The anterior
compartment contains superficial, intermediate and deep layers, whilst the posterior
compartment contains superficial and deep layers.

d. The hand is probably the finest product of human evolution from the aspect of our body
mechanics. The intrinsic muscles of the hand are the: palmaris brevis, interossei (palmar and
dorsal), adductor pollicis, thenar, hypothenar and lumbrical muscles.

Basic parts of the hand

• the wrist (carpus)

• the metacarpus

• the digits

LOWER LIMB MUSCLES

HIP AND THIGH MUSCLES

The hip muscles encompass many muscles of the hip and thigh whose main function is to act

on the thigh at the hip joint and stabilize the pelvis. Without them, walking would be impossible.

They can be divided into three main groups:

 Iliopsoas group

 Gluteal muscles

 Hip adductors

Iliopsoas group Muscles: iliacus, psoas major, and psoas minor

Main function: flexion of the trunk and thigh, lateral flexion of the

trunk (excluding psoas major and minor only)

Innervation: anterior rami of spinal nerves L1-L3 and femoral nerve

 (L2-L4) (iliacus only)

Gluteal muscles Muscles: gluteus maximus, gluteus medius, gluteus minimus, and

(superficial) tensor fasciae latae

Main function: varied – extension, external and internal rotation,

abduction and adduction of the thigh

Innervation: superior (L4, S1) and inferior (L5-S2) gluteal nerves

Gluteal muscles Muscles: piriformis, gemellus superior, obturator internus, gemellus

(deep) inferior, obturator externus, and quadratus femoris

Main function: external rotation and abduction of the thigh;

stabilizes head of femur

Innervation: varied – nerve to piriformis (S1-S2), nerve to obturator

internus (L5-S2), nerve to quadratus femoris (L4-S1), obturator

nerve (L3-L4)

Hip adductors Muscles: Gracilis, pectineus, adductor longus, adductor brevis,

adductor magnus, and adductor minimus

Main function: Adduction of the thigh at the hip joint

Innervation: Obturator nerve (L2-L4) and femoral nerve (L2-L3)

(pectineus only)

LEG MUSCLES
 The anterior (dorsiflexor) compartment, which consists of the tibialis anterior, extensor

digitorum longus, fibularis tertius and extensor hallucis longus muscles. Crossing the ankle from

the anterior aspect, these muscles primarily cause dorsiflexion of the foot.

The lateral (fibular) compartment, which houses the fibularis longus and fibularis brevis

muscles. The major function of this compartment is to evert the foot.

The posterior (plantar flexor) compartment, which is divided into the superficial and deep

parts. The former contains the triceps surae (gastrocnemius + soleus), and plantaris muscles, while

the latter consists of the popliteus, tibialis posterior, flexor digitorum longus and flexor hallucis

longus muscles. The main function of this compartment is to plantar flex the foot.

Anterior compartment Tibialis anterior, extensor digitorum longus, fibularis tertius, extensor

hallucis longus 

Lateral compartment Fibularis longus, fibularis brevis  

Posterior compartment Superficial part: Triceps surae (gastrocnemius + soleus), plantaris 

Deep part: Popliteus, tibialis posterior, flexor digitorum longus, flexor

hallucis longus 

Ankle and foot muscles

The central plantar group. This group is placed between the lateral and medial muscles on

the plantar aspect of the foot and is comprised of 13 muscles. These muscles include: flexor

digitorum brevis, quadratus plantae, 4 lumbricals, 3 plantar interossei and 4 dorsal interossei

muscles. The following 3D video will explain these muscles in more detail.
 The second muscle group is the medial plantar group. These muscles work

simultaneously to produce the movements of the big toe. These muscles are the abductor

hallucis, adductor hallucis and flexor hallucis brevis muscles. Now watch the following 3D video

that will give you a comprehensive overview of this muscle group, including their anatomy,

innervation and function.

The third group includes the lateral muscles of the foot. This group is also comprised of

three muscles that work together to produce movements of the fifth or the "little" toe. These

muscles include the abductor digiti minimi, flexor digiti minimi brevis and opponens digiti

minimi muscles.

Lastly, the fourth group are the dorsal muscles of the foot. As their name suggests, they

are located on the dorsal aspect of the foot and include only two muscles: the extensor digitorum

brevis, extensor hallucis brevis muscles.

Central muscles of Flexor digitorum brevis, quadratus plantae, lumbrical muscles I-IV,

the sole of the foot plantar interossei muscles I-III, dorsal interossei muscles I-IV

Lateral muscles of Abductor digiti minimi, flexor digiti minimi brevis, opponens digiti

the sole of the foot minimi

Medial muscles of Abductor hallucis, adductor hallucis, flexor hallucis brevis

the sole of the foot

Dorsal muscles of Extensor digitorum brevis, extensor hallucis brevis

foot
ABDOMEN
The abdomen is the lower part of the anterior trunk, located right below the thorax. The

abdomen is divided into several regions that allow for precise communication about the location

of anatomical structures within it, as well as any pathologies. There are two ways to categorize

the abdomen. The first divides the regions into four quadrants, while the second and more

common way, divides it into nine regions.

The anterolateral muscles are those that compose the front and the sides of our abdomen.

There are five muscles in this group (deep to superficial): transversus abdominis, internal

abdominal oblique, rectus abdominis, external abdominal oblique, and pyramidalis muscles.

The posterior abdominal muscles are those that compose the back portion of your abdomen.

The posterior group consists of one true posterior wall muscle, the quadratus lumborum, as well

as the iliopsoas muscle group which continues into the lower limb.

These muscles not only compose the walls of the abdomen, but they also support the

abdominal viscera and participate in the formation of important anatomical passageways that

allow structures from the abdomen and pelvis to reach the perineum and lower limb
PATHOPHYSIOLOGY

NURSING CARE PLAN

Admission
Nursing Nursing Goal
Assessment Nursing Intervention Rationale Evaluation
Diagnosis Planning

Subjective Impaired gas Short-Term Independent: Short-Term

exchange After 8 hours of After 8 hours of
The SO states:  Establish rapport to the  To gain the trust.
related to effective nursing effective nursing
- Family use of SO.
cellular intervention, the intervention, the
charcoal inside asphyxia  Position the client  To provide good airway
their home. patient will: comfortably. patient will:
secondary to circulation.
- It happened carbon  Demonstrate  Auscultate breath sounds, A. Demonstrated
when they left monoxide improved note areas of  In this nursing diagnosis, improved
their house exposure as ventilation decreased/adventitious ventilatory effort is ventilation and
Aaron was evidenced by and adequate breath sounds as well as insufficient to deliver adequate
sleeping besides elevated oxygenation enough oxygen or to get oxygenation of
fremitus.
the fire. And
about 3 hrs. later rid of sufficient amounts
COHb of tissues. tissues.
found out that he of carbon dioxide.
 Demonstrate B. Demonstrated
fell on the fire. Abnormal breath sounds
decrease decrease amount
is indicative of numerous
amount of of COHb.
Objective  Assess level of problems.
COHb C. Was referred to
- Unconscious consciousness and physician for the
… the significant other  A decreased in level of
- Peripheral mentation changes. presence of
will: consciousness can be an
cyanosis complications.
- Cherry-red  Verbalize indirect measurement of
 Assess for s/s of inhalation impaired oxygenation. … the significant
coloration of skin understanding injury such as damage to  These surrounding other will:
- Thermal burns of causative the circumoral mucosa, structures are also
in the right chest factors and D. Verbalize
burns along the nostrils, important in air
- GCS: 6/15 appropriate understanding of
face, or neck. exchange and may cause
interventions. causative factors
Vital Signs disruption in airway and appropriate
Long-Term  Monitor vital signs and when injured or interventions.
- Temperature: damaged.
After days of effective cardiac rhythm.
37.6 °C (axillary)  All vital signs are
- HR: 112 bpm. nursing intervention, impacted by changes in
- RR: 26 bpm. the patient:  Monitor and adjust Objective
oxygenation.
- BP: 120/80 ventilator setting as  The mode of ventilation - Seen patient lying
 Decrease or
mmHg indicated and ventilation settings on bed unconscious
eliminate the
- SpO2: 95% need for are determined by the - Unequal breath
supplemental specific needs of the sounds
Lab. /diagnostic oxygen client, which are - Hyperresonant in
results: therapy. determined by clinical right thorax
- ABG: metabolic  Laboratory evaluation and blood gas - Distended jugular
acidosis values are parameter. vein distension
- COHb: 65% within normal  To determine - Tracheal deviation
- ECG: cardiac values. oxygenation and levels of - Thermal burns
ischemia and  Evaluate pulse oximetry carbon dioxide spread into anterior
dysrhythmia and capnography; evaluate retention; to assess lung & posterior right
the lung volumes and mechanics, capacities, thorax with TBSA of
forced vital capacity. and function. 17%
- GCS: 6/15
 Provide psychological  To reduce anxiety.
support to the SO and Vital Signs
active-listen questions/
 concern. - Temperature: 37.6
 Review risk factors, °C (axillary)
particularly home/  To promote prevention - HR: 116 bpm.
environmental related. or management of risk. - RR: 26 bpm.
- BP: 120/80 mmHg
 Teach/encourage the SO  To prevent the - SpO2: 95%
to avoid cooking or occurrence of the same
starting a fire inside the problem Lab. /diagnostic
home, and to avoid leaving results:
the fire unattended. - ABG: metabolic
 Encourage the SO for acidosis
 To help alleviate the
verbalization of feelings - COHb: 10%
worry and to identify
about the incidence, such - CXR:
areas of concern. To
as concern about pneumothorax
maintain cellular
tolerating treatment, oxygenation and not
anxiety, and pessimistic cause further damages.
thought.
Dependent:  To speed up the healing
of carbon monoxide
 Provide supplemental
poisoning.
oxygen regulated as
 To rapidly restore or
prescribed and by
sustain circulating
laboratory results.
volume, electrolyte
 Provide hyperbaric oxygen
balance.
therapy (HBOT) as
 To make an immediately
indicated.
interventions to not
 Administer IV fluids and
cause complications.
electrolytes as per
physician ordered.
 Refer to physician for any
untoward signs and
symptoms.
Collaborative:  To determine the
 Review other pertinent physiologic status of the
laboratory data (ABGs, client and to serves as
COHb, CXR) baseline of interventions.

 Collaborate in treatment of
 underlying condition and
referral for presence of  To ensure continuous
complications. and collaborative care of
critically ill patient.

3rd Day
On the third day after admission, computed tomography and magnetic resonance imaging (MRI) of the chest and abdomen revealed a right
pneumothorax, bilateral lower lung infection, and bilateral pleural effusion; a right abdominal wall soft-tissue defect, suspected right chest wall soft tissue
defect into the abdominal cavity, and blood effusion in the pelvis; and multiple muscle injuries on the right chest wall, hips, and pelvic cavity.

Nursing Nursing Goal

Assessment Nursing Intervention Rationale Evaluation
Diagnosis Planning

Subjective Data Impaired gas Short-Term Independent: Short Term

exchange After 8 hours of
Patient is still in  To assist in creating an After 8 hours of
related to effective nursing  Check the patient's vital
coma. accurate plan and nursing intervention,
lung infection intervention, the signs and respiratory
monitor effectiveness the patient:
as manifested patient will: characteristics at least
by shortness every 4 hours. of medical treatment.  Verbalizes
Objective Data  Verbalize  Respiratory distress understanding
of breath,  Monitor respiratory
- Peripheral stabbing chest understanding of therapeutic
cyanosis and pain, cyanosis, of oxygen and function, paying attention and changes in vital regimen.
bluish abnormal other to rapid or shallow signs occur because of “Kailangan
discoloration of breath therapeutic breathing, dyspnea, "air physiological stress talaga ay may
lips and oral sounds, sooty interventions. hunger" sensations, the and pain or may nakakabit na
mucosa was sputum,  Participate in development of cyanosis, indicate development oxygen sa akin
noted tachycardia, a treatment and changes in vital signs of shock due to para hindi na
tachypnea, regimen hypoxia or ako kapusin
- Diminished (breathing  Listen for areas of hemorrhage
and fever sap ag hinga.”
breath sound is exercises, diminished or absent  Decreased airflow  Actively
heard on the effective airflow, as well as occurs in areas participates in
right side of the coughing, use abnormal breath sounds consolidated with the treatment
thorax of oxygen) like crackles and wheezes, fluid. Bronchial breath regimen
- Wheezing is within level of when auscultating the lung sounds can also occur demonstrates
heard on the left ability or fields. in consolidated areas. willingness to
side of the situation. Crackles, rhonchi, and cooperate.
thorax during  Have a vital wheezes are heard on  Vital Signs
exhalation sign and ABG inspiration and - BP: 120/80
values within expiration in response mmHg
- Sooty sputum tolerable to fluid accumulation, - T: 37 ̊C
is coughed by levels (as thick secretions, and - PR: 97 bpm
the client appropriate to airway spasm or - Respiration:
client’s  Assess mental status. obstruction 26 bpm
condition)  Restlessness, - O2 Saturation:
Vital Signs irritation, confusion, 95%
- Blood Pressure: Long-Term and somnolence may - ABG values
140/100 mmHg reflect hypoxemia or are as follows:
 Maintains
decreased cerebral - pH: 7.25
- Temperature: optimal gas
oxygenation. - PaCO2: 50
39.4 ̊C exchange as  Keep track of the chest  Chest excursion is mmHg
evidenced by excursion and the position
- Pulse Rate: 113 unequal until the lung - PaO2: 70
usual mental of the trachea.
bpm re-expands. Trachea mmHg
status,
deviates from the
- Respiration: 39 unlabored
affected side with
bpm respirations at
tension Long Term
12-20 per
- O2 Saturation: pneumothorax.
minute,  Maintains
89%  ABGs and pulse oximetry  Assesses status of gas
oximetry optimal gas
should be monitored and exchange and
 results within exchange as
normal range, graphed on a regular basis. ventilation and need evidenced by
Laboratory and blood gasses Review vital capacity and for continuation or usual mental
Diagnostic within normal tidal volume readings as alterations in therapy. status,
Results: range, and needed. unlabored
- MRI reveals baseline HR  Increased chest pain,  Delayed recovery or respirations.
right for patient. unusual heart sounds, increase in severity of  Manifests
pneumothorax,  Manifests altered sensorium, symptoms suggests clear lung
bilateral lung clear lung recurrent fever, and resistance to fields and
infection, and fields and changes in sputum antibiotics or does not have
bilateral pleural remains free characteristics should all secondary infection, or incidence of
effusion of signs of be looked into. complications. respiratory
respiratory  On a frequent basis, assist  Deep breathing distress.
- CT scan shows the individual with deep facilitates maximum
distress.  Vital Signs
suspected right breathing exercises. expansion of the lungs - BP: 120/80
chest wall soft Demonstrate and assist the and smaller airways mmHg
tissue defect client as needed. - T: 37 ̊C
into the  Only suction when  Stimulates cough or - PR: 88 bpm
abdominal absolutely necessary, such mechanically clears - Respiration: 19
cavity as when oxygen airway in a client who bpm
- ABG values are desaturation is induced by is unable to do so - O2 Saturation:
as follows: airway secretions. because of an 99%
ineffective cough or  ABG values
→ pH: 7.05 decreased level of are as follows:
→ PaCO2:  Change position frequently consciousness. - pH: 7.40
60 mmHg and make sure there are  Promotes - PaCO2: 40
adequate pulmonary expectoration, clearing mmHg
→ PaO2: restrooms. of infection. - PaO2: 90
55 mmHg  Elevate the head of the mmHg
→ HCO3: bed.  Head elevation helps - HCO3: 23
33 mEq/L improve the expansion mEq/L
of the lungs, enabling
the patient to breathe
more effectively.
 Implement isolation  Depending on type of
procedures as appropriate infection, response to
during client contact antibiotics, client’s
 (masks, gloves, and
possibly gowns).
Dependent:  Difficulty breathing
 Administer oxygen as
indicated. Keep an eye out
for asynchronous
respiratory patterns.
Changes in airway
pressures should be noted.
 Administer medication as  To treat pain, fever,
ordered. (Analgesic,
antipyretic, sedative, and
antibiotic)
Collaborative:
 Assist with lung re-  Although numerous
expansion therapy if
necessary (observation
without oxygen,
supplemental oxygen
administration, needle
aspiration, one-way valve
device, thoracostomy with
chest tube placement with
chest tube drainage unit
general health, and
development of
complications,
isolation techniques
may be instituted to
prevent spread and
protect client from
other infectious
processes.
with a ventilator or
increasing airway
pressures suggests
worsening of
condition and
development of
complications, such as
a tension
pneumothorax.
and infection.
treatment options for
lung re-expansion are
available (depending
on the cause, location,
and size of the
pneumothorax), tube
thoracostomy is the
definitive treatment
for secondary
spontaneous
 [CDU] and with or without pneumothorax and
suction). tension pneumothorax

4th Day

Nursing Nursing Goal Nursing

Assessment Rationale Evaluation
Diagnosis Planning Intervention
Subjective data: Infection related to Short term: Monitor V/S most To obtain baseline Short term:
“Iyah ay baling sakit burn progression of After 8 hours of especially data for comparison After 8 hours of
baga ng sugat ko tas right abdominal wall effective nursing temperature effective nursing
parang pansin ko defect into the intervention, the Fever may indicate interventions the
nga ay medyo abdominal cavity patient will be able infection patient was able to:
lumalalim lalo” as to:  Identify
verbalized by the px  Identify Assess wound for Changes in measures to
 measures to appearance, odor, appearance, odor prevent the
Objective data: prevent or and quantity of and drainage could risk for
Vital signs: reduce the drainage indicate onset of infection
BP: 130/90 mmHg risk for infection
T: 38.2 C infection SO verbalized, “Ay
RR: 25 bpm Monitor WBC Elevated WBC ganun pala ang
PR: 120 bpm Long term: indicates infection tamang paglilinis ng
 The patient sugat ano, ay sya
Open wound at will be able Practice and First line defense sige at ganun na ang
right abdomen to achieve emphasize constant against healthcare- gagawin ko para di
timely and proper hand associated infection maimpeksyo ang
Wound on the right wound hygiene (HAI’s) sugat niya”
abdominal wall healing
progresses to the Implement Helps in minimizing
abdominal cavity appropriate isolation the risk of cross- Long term:
techniques as contamination and  The patient
Wound were indicated. spread of bacterial was able to
covered in a tough, contamination achieve
black, leather-like timely
eschar Maintain sterile To prevent cross- wound
technique for all contamination healing
Has deep necrotic invasive procedure
fascia like IV insertion, “Ay mabuti nga at
urinary nababahaw na aring
catheterization, etc. aking sugat at di na
Prevent skin-to-skin Identifies presence nagkaimpeksyon” as
surface contact of healing and verbalized by the
provides for early patient
detection of burn-
wound infection. Current vital signs:
Vital signs:
Infection in a BP: 120/80 mmHg
partial-thickness T: 36.8 C
burn may cause RR: 18 bpm
 conversion of burn PR: 80 bpm
to full-thickness
injury.
Remove dressings
and cleanse burned Early excision is
areas in a known to reduce
hydrotherapy or scarring and risk of
whirlpool tub or in a infection, thereby
shower stall with facilitating healing.
handheld shower
head

Debride necrotic or Promotes healing.

loose tissue Prevents auto
contamination.

Instruct the px/SO Promotes

regarding the continuous care and
techniques to promote timely
protect the integrity healing
of the skin, care for
lesions, and prevent
the spread of
infection

Educate clients and Knowledge of ways

SO (significant to reduce or
other) about eliminate germs
appropriate reduces the
cleaning, likelihood of
disinfecting, and transmission.
sterilizing items.
Proper nutrition and
Encourage intake of a balanced diet
 protein-rich and support the immune
calorie-rich foods systems’
and encourage a responsiveness and
balanced diet. enhance the health
of all the body’s
tissues.

Adequate nutrition
enables the body to
maintain and
rebuild tissues and
helps keep the
immune system
functioning well.

6th Day

Nursing Nursing Goal Nursing

Assessment Rationale Evaluation
Diagnosis Planning Intervention
Subjective Impaired tissue After nursing  Establish rapport with  To gain patient’s After effective
Patient verbalized integrity related interventions, the the patient’s caregiver trust and nursing
“Napaka init pa to trauma (burn patient will be able to caregiver. cooperation. interventions the
rin ng balat ko injury) as  Periodically monitor  To identify risk for patient was able to:
pag evidenced by 2nd Short term: site of the wound. infection and
hinahawakan” and 3rd degree Participate in monitor wound Short term:
burn on various prevention measures healing. Participated in
Objective parts of 17% of and treatment  Remove wet and  To prevent infections prevention
 Redness in the body program of wound soiled linens and and further skin measures and
localized area care. clothing. damage treatment program
 Destroyed  Emphasize  To prevent infection of wound care.
tissue found in Long term: importance of good and to enhance  Seen patient and
 right chest - Demonstrate hygiene, wound care understanding and SO practicing
muscle tissue and wound dressing. cooperation. proper hygiene
by washing
 portion of the regeneration.  Practice aseptic  Reduce risk of
hands before
ribs - Achieve technique for infection and/or touching px’s
 abdominal timely healing cleansing and failure to heal. skin
muscles in burned dressing.
 rectus areas.  Encourage diet that  To provide a positive
abdominis has high amounts of nitrogen balance to
 iliac bone vitamin A, C, D and aid in skin and tissue Long term:
increase protein healing and to -Demonstrate
intake. maintain general tissue regeneration.
good health. -Achieved timely
 Encourage adequate  To limit metabolic healing in burned
periods of rest and demands, maximize areas.
sleep. energy available for
healing and meet
comfort needs.
 To promote
 Promote early and circulation and
ongoing mobility. prevent excessive
Assist with or tissue pressure.
encourage position
changes.  Increases patient’s
 Encourage patient to self-esteem and to
verbalize feelings and help patient deal
discuss how or if it with situation.
 affects self-esteem.

12th Day
Nursing Nursing Goal Nursing
Assessment Rationale Evaluation
Diagnosis Planning Intervention
Subjective: Risk for At the end of 8 hour  Examine wounds  Indicators of sepsis After a successful
Infection related nursing intervention daily, note and (often occurs with nursing
Verbalized to inadequate the patient/SO will: document changes in full-thickness intervention:
"Minsan e hindi -identify appearance, odor, or burn) requiring
primary
sinasadya kong interventions to quantity of drainage prompt evaluation The patient
defenses:
nahahawakan prevent or reduce and intervention. remained afebrile
'yong dressing ng destruction of risk for infection Note: Changes in with Temp of 37°C
sugat ko"  skin barrier, -be afebrile sensorium, bowel
traumatized habits, and Pt and SO
Objective tissues Long term respiratory rate demonstrated
 red - -Achieve usually precede actions that
granulation timely wound fever and alteration
reduces risk for
visible in the healing free of of laboratory
infection.
studies
wound bed purulent  Examine unburned  Eyes may be
exudate areas (such as groin, swollen shut
neck creases, mucous and/or become
membranes) infected by
drainage from
surrounding burns

 Water softens and

 Monitor vital signs aids in removal of
for fever, increased dressings and
respiratory rate and eschar (slough
depth in association layer of dead skin
with changes in or tissue). Sources
sensorium, presence vary as to whether
of diarrhea, bath or shower is
decreased platelet best. Bath has
count, and advantage of water
hyperglycemia with providing support
glycosuria for exercising
extremities but
may promote
cross-
contamination of
wounds. Showering
enhances wound
inspection and
prevents
contamination
from floating
debris.
 Dependent on type
 Implement or extent of
appropriate isolation wounds and the
techniques as choice of wound
 indicated treatment (open
versus closed),
isolation may range
from simple wound
and/or skin to
complete or reverse
to reduce risk of
cross
contamination and
exposure to
multiple bacterial
flora
 Prevents cross
 Emphasize and contamination;
model good reduces risk of
handwashing acquired infection
technique for all
individuals coming
in contact with
patient
 Prevents exposure
 Use gowns, gloves, to infectious
masks, and strict organisms
aseptic technique
during direct wound
care and provide
sterile or freshly
laundered bed linens
or gowns
 Prevents cross-
 Monitor and/or limit contamination
visitors, if necessary. from visitors.
If isolation is used, Concern for risk of
explain procedure to infection should be
 visitors. Supervise balanced against
visitor adherence to patient’s need for
protocol as indicated family support and
socialization
Dependent

 Debride necrotic or  Promotes healing.

loose tissue Prevents
(including ruptured autocontamination
blisters) with scissors . Small, intact
and forceps. Do not blisters help
disturb intact blisters protect skin and
if they are smaller increase rate of re-
than 1–2 cm, do not epithelialization
interfere with joint unless the burn
function, and do not injury is the result
appear infected of chemicals (in
which case fluid
contained in
blisters may
continue to cause
tissue destruction)

 Photograph wound  Provides baseline

initially and at and documentation
periodic intervals of healing process

 Administer topical  It help control

agents as indicated bacterial growth
and prevent drying
of wound, which
can cause further
tissue destruction
 Administer other  Tissue destruction
 medications as and altered defense
appropriate: mechanisms
Subeschar clysis or increase risk of
systemic antibiotics; developing tetanus
Tetanus toxoid or or gas gangrene,
clostridial antitoxin, especially in deep
as appropriate burns such as those
caused by
electricity
 Place IV and/or  Decreased risk of
invasive lines in non infection at
burned area insertion site with
possibility of
progression to
septicemia
 Obtain routine  Allows early
cultures and recognition and
sensitivities of specific treatment
wounds and/or
of wound infection
drainage
17th Day
Assessment Nursing Nursing Goal Nursing Rationale Evaluation
Diagnosis Planning Intervention
Subjective Data: Ineffective breathing Short Term: Independent: Short Term:
“Medyo nahihirapan pattern related to Within 8 hours of After 8 hours of
po akong huminga sutured hemorrhagic nursing Establish rapport. To gain and trust nursing
gawa ng tahi sa aking blood vessels on the interventions, the and cooperation. interventions, the
dibdib” as verbalized 6th intercostal patient’s respiratory Monitor vital signs. To obtain baseline patient’s respiratory
by the patient arteries as rate remains within data rate remains within
manifested by established limits. established limits.
Assess and record It is important to
Objective Data: shortness of breath
respiratory rate and take action when
 Shortness of Long Term: “Medyo may kirot pa
depth at least every 4 there is an alteration
breath Patient maintains an rin po yung tahi ko
hours. in breathing patterns
 sixth effective breathing pero medyo
to detect early signs
intercostal pattern, as evidenced nakakahinga na ako
of compromise on
arteries in by relaxed breathing nang maayos
the respiratory
the right at normal rate and kumpara kanina” as
system.
chest wall depth and absence of verbalized by the
Assess ABG levels This monitors
hemorrhaged dyspnea. patient.
according to facility oxygenation and
  The policy. ventilation status.
hemorrhagic Observe breathing Unusual breathing Vital Signs:
blood vessels patterns. patterns may imply T> 36 C
were sutured. an underlying P> 79 bpm
disease process or R> 19 bpm
Vital Signs: dysfunction. BP> 100/20 mmHg
T> 36 C Check out Respiratory distress
P> 89 bpm respiratory function, and changes in vital
R> 14 bpm noting rapid or signs may occur as a
BP> 100/70 mmHg shallow respirations, result of
dyspnea, reports of physiological stress
“air hunger,” and pain or may
development of indicate the
cyanosis, changes in development of
vital signs. shock due to hypoxia
or hemorrhage.
Assist patient with Supporting chest
splinting painful and abdominal
area when coughing, muscles make
deep breathing. coughing more
effective and less
traumatic.
Maintain a calm Assists patient to
attitude, assisting deal with the
the patient to “take physiological effects
control” by using of hypoxia, which
slower and deeper may be manifested
respirations. as anxiety or fear.
 Dependent:

Administer Aids in reducing

supplemental oxygen work of breathing;
via cannula, mask, or promotes relief of
mechanical respiratory distress
ventilation as and cyanosis
indicated. associated with
hypoxemia.

44th Day
65th Day

103rd Day
Assessment Nursing Nursing Goal Nursing Rationale Evaluation
Diagnosis Planning Intervention
Subjective Data: Deficient knowledge After 4 hours of Assessed patient Helps health care After 4 hours of
“Pinipilit kong igalaw related to post- nursing level of provider to adjust nursing interventions,
pero di ko masyadong surgical precautions interventions, the understanding. and make health the patient is able to
magalaw tong sa may as evidenced by patient will be able to teaching suitable for show understanding
parting balakang ko” forceful movement. verbalize the patient. about his condition
as verbalized. understanding about Explained to the and is able to act with
the post-operative patient about his To help the patient accordance to post-
Objective Data: care needs prior to current condition. catch up with his operative needs.
 Forceful recovery. condition and allow
movement of him to help himself.
extremities. Instructed the patient
 Inability to and SO about the Enhance patient’s
follow proper postoperative understanding which
instructions. care especially the helps the patient to
 Frequent hygiene and incision understand the
questioning care. needed actions.

Emphasized to the
patient about the Postoperatively, bed
need of bed rest. rest is important for
the patient to avoid
compromising the
surgical site which
can lead to
Encouraged the postoperative
patient to ambulate complications.
and gave emphasis
that he cannot Ambulation
forcefully move after promotes healing and
the operation. helps to prevent
complications but too
Gave strict much movement may
instructions on the cause complication.
importance of
following the Post-operative
treatment regimen medication and other
and the importance therapy are important
of his post op for recovering from
medication. the surgical
procedure.
Instructed the patient
and SO to inform
medical staffs Immediate medical
immediately when assistance is a must if
there are problems there are any post-
occurring in the operative
patient such as signs complications.
of infection, opening
of the incision site,
difficulty of
 breathing, sudden
neurological
problems, and severe
pain that do not go
away.

179th Day
Assessment Nursing Nursing Goal Nursing Rationale Evaluation
Diagnosis Planning Intervention
S – “Ang sakit nung Acute pain After 8 hours of Obtain baseline data - These V/S can be - After 8 hours of
sa parte tinurukan related to nursing intervention for V/S for future affected in several nursing
ako, hindi ako injection of the patient will be comparison every ways. interventions, the
mapakali dahil platelet-rich able to lessen his after interventions. patient verbalizes
dine” as verbalized plasma as pain by client’s “nabawasan na yung
evidenced by statement of Assess pain duration, - To aid in sakit ng injection
Pain scale: 7/10 facial mask decreased pain of intensity, location, understanding reason site ko”
3/10. and frequency for severity of pain
O – Facial grimace, associated with the Pain scale: 3/10
guarding behavior condition
of putting his hand
on the injection Encourage - To evaluate coping
site, irritability verbalization of abilities and to
feelings about the identify areas of
V/S = pain, anxiety and additional concern.
T: 36.8C pessimistic thoughts
P: 112 bpm - To promote healing
R: 25 bpm Encourage to drink
BP: 130/90 plenty of water
- Applying ice or heat
Apply ice pack or heat within 72 hours post-
to the injection site procedure is
after 3 days of the contraindicated
procedure because inflammation
is and important part
of healing process

- Promotes rest and

Provide quiet enhances coping
environment and abilities.
reduce stressful
stimuli
- To assist client to
Promote explore methods for
nonpharmacological alleviation or control
pain management: of pain.
- use of relaxation
techniques (focused
breathing)
- diversional activities
(television and
socialization with
others)
- To maintain
Administer analgesics, acceptable level of
as indicated, to pain. Notify physician
maximum dosage, as if regimen is
needed. inadequate to meet
pain control goal.
195th Day
DRUG STUDY
Name of the Mechanism of Indication Contraindication Side Effects Nursing Responsibilities
Drug Action

Generic Flurbiprofen, a Mild to Severe renal and Headache Assessment

Name: propionic acid moderate hepatic
derivative, is an pain impairment Drowsiness History: Hypersensitivity, heart failure,
flurbiprofen NSAID that PAD, CV diseases, and diabetes.
reversibly inhibits Hypersensitivity Dizziness
cyclooxygenase-1 to aspirin & other Physical: Assess VS, BP, pain.
Brand Name: and 2 (COX-1 and - NSAIDs Abdominal
2) enzymes, pain/cramps Lab test: Monitor CBC, chemistry
resulting in Epithelial herpes profile, and LFT.
Drug Class simplex keratitis Diarrhea
decreased formation
Interventions
of prostaglandin Nausea
NSAIDs GI bleeding or
precursors. May be given with food.
perforation r/t
NSAID therapy Dyspepsia/
indigestion Advise to avoid alcohol and aspirin.
Pharmacokinetics: GI inflammatory
disease (ulcerative Edema Advise to avoid activities that require
colitis, Crohn’s mental alertness (driving, operate
Absorption: Rapidly disease), machinery).
absorbed in (80%) ulceration,
GI tract. Report to physician for any s/s of
hemorrhage
persistent stomach pain, skin
Onset: 2 hr.; peak: 2 rash/itching, vomiting blood. Rapid
hr. weight gain, swelling, changes in urine
pattern, fever, unexplained tiredness,
 flu-like symptoms
Duration: 6-8 hrs.

Metabolism:
metabolized in the
liver

Excretion: via urine

and some biliary
excretion. Half-life:
4.7 - 5.7 hrs
Name of the Mechanism of Indication Contraindication Side Effects Nursing Responsibilities
Drug Action

Generic Midazolam, Sedation Acute narrow- Coughing Assessment:

Name: intensifies activity of angle glaucoma
GABA, a major Oversedation History: Alcohol or drug abuse, CHF,
midazolam inhibitory Severe respiratory COPD, chronic kidney failure.
neurotransmitter of insufficiency & Headache
Brand Name: failure Physical: Assess VS, airway integrity,
the brain, by
interfering with its Drowsiness oxygen sat.
reuptake and Acute respiratory
Drug Class: depression Bronchospas Interventions:
promoting its
accumulation at
Hypnotics & neuronal synapses. m
Sedatives Myasthenia gravis Administer slowly and not as single
Pharmacokinetics VS bolus IV - may cause respiratory
Sleep apnea fluctuation depression.
Onset: 1-5 mins. syndrome
(IV) Decrease Inform that this may cause sedation and
Severe hepatic respiratory impaired concentration.
Absorption: Rapidly impairment rate and tidal
absorbed. peak: 20- volume Advise to avoid alcohol and CNS
60 Concomitant use depressant.
with CYP3A4 Apnea
Metabolism: Advise to avoid operating machinery or
Extensively not to drive.
metabolized in the
liver Have oxygen and resuscitative
equipment readily available in the event
Excretion: Via urine of respiratory depression.
(appx. 24 hrs.); feces
(5 days). Half-life: Report immediately to physician for s/s
1-3 hrs. of confusion, hallucination, chest pain,
difficulty in breathing, and changes in
mood or behavior.
Name of the Mechanism of Indication Contraindication Side Effects Nursing Responsibilities
Drug Action

Generic Tramadol is a Management Management of Nausea Assessment:

Name: centrally acting of moderate moderate to
analgesic that has to moderately moderately severe Dizziness History: Seizure, alcohol disorder, ICP,
tramadol opioid agonist severe pain pain hepatic & renal impairment, and mental
properties. It binds Headache health condition.
Brand Name: to opiate receptors in Moderate to Moderate to
the CNS resulting in moderately moderately severe CNS Physical: Assess VS, pain, mental
inhibition of severe chronic pain stimulation status.
ascending pain chronic pain
Lab test: Monitor renal, LFTs,
 pathways, thus
Drug Class: altering the Ataxia electrolytes, ECG.
perception of and
Analgesics response to pain. Its Sedation/ Interventions:
(Opioid) inhibition of somnolence
neuronal uptake of Ask the patient for herbal med. intake,
norepinephrine and Vertigo especially St. John’s wort.
enhancement of
Itching/ Assess bowel and bladder function,
serotonin release
pruritus report urinary frequency or retention.
may also contribute
to its analgesic Constipation Monitor for signs of orthostatic
effect. hypotension, CNS depression, serotonin
syndrome, and withdrawal.
Pharmacokinetics:
Advise to stand up slowly from
Onset: 30-60 mins.
sitting/lying down position.
Duration: 3-7 hrs.
Advise to not take alcohol or OTC
Absorption: agents
Absorbed in GI.
Advise to not increase or exceed the
Peak: appx. 2 hrs.
prescribed dosage.
Metabolism:
Provide seizure precautions for patient
Extensively
with history of seizure.
metabolized in the
liver. Notify the physician for s/s of
hypersensitivity, confusion,
Excretion: Via urine.
hallucination, shallow breathing, severe
Elimination half-life:
constipation and discontinue the drug.
6-7 hrs.
Report to physician s/s of overdose
(e.g., respiratory depression, lethargy,
coma) and progress to cardiac arrest and
death.

If overdosage occurs, maintain

oxygenation, provide naloxone, and
supportive measure.
PHYSICAL EXAMINATION

GENERAL DATA

Bed Number: 236 Patient’s name: Aaron

Age: 29y/o Sex: Male

Birthdate: February 2, 1993 Birthplace: Lucena City

Marital Status: Single Nationality: Filipino

Admitting Date: 03-27-2022 Chief Complaint: Burn

Diet: High Protein Diet IVF: Plain NSS

GENERAL APPEARANCE

The patient is in coma upon admission with presence of burns in the right anterior and
posterior thorax, bilateral hips, bilateral lower limbs, and upper right limbs.

VITAL SIGNS
Temperature: 38.8°Cׄ Heart Rate: 120 bpm Respiration Rate: 27bpm

Blood Pressure: 130/110 bpm O2 sat: 94% Pain Scale: 7/10 (VAS)

HEALTH HISTORY

History of Present The patient is in coma upon admission with presence of burns in the
Health Concern right anterior and posterior thorax, bilateral hips, bilateral lower
limbs, and upper right limbs. Acute renal failure and bilateral lower
lung infection.

Past Health History No medical and surgical history. No known allergies.

Family Health History Maternal grandparent- diabetes

Mother- diabetes
Paternal grandmother- breast cancer, several high cholesterol, high
BP
 ASSESSMENT

Skin · Poor skin turgor

· Skin appeared bright red

· Burn wounds appear dry, moist, and blistered

· Other wounds appear leathery, charred, and with eschar

· Deep second-degree burns (2% TBSA)

· Third-degree burns (15% TBSA)

· Warm to touch; temperature: 38.8°Cׄ

Hair · Patient is bald

Nails · Nails are hard and immobile

· 1-2 seconds on capillary refill

Head · Normocephalic

· Head is round and smooth

· Face is symmetric

Eyes · Eye movement is smooth and symmetric

· Skin on both eyelids has redness, no swelling, or lesions.

 · Eyeballs are symmetrically aligned in socket without protruding or
sinking

· Yellowish sclera and nodules on the bulbar conjunctiva

· Pupils are equal, round, and reactive to light accommodation

(PERRLA)

Ears · Equal in size bilaterally.

· Color is consistent with the facial tone

· No discharge present

Nose · Nose is symmetric and midline, with septum dividing the nostrils and
nasal cavity.

· Color is consistent with the facial tone.

· No discharge or tenderness is present

· Nasal mucosa are pink, moist, and free of exudate

· Presence of soot in nostrils

Mouth · Lips are reddish and dry

· Tongue smooth without palpable lesions

Neck · Neck is symmetric with head centered and without bulging masses.

· Thyroid gland is slightly palpable

· Trachea is midline

· No bruits are auscultated

 - Mucosal edema

Chest · Right portion of the thorax were minimally swollen

· With prominent discoloration due to sustained burns from the

right anterior and posterior thorax.

Lungs · Respiratory rate is reduced, with decreased tidal volume.

· Lungs are unable to ventilate properly.

- Inspiratory and expiratory wheezes

· Respiratory rate of: 27 bpm

Abdomen - The majority of the burn wounds were covered in a tough, black,
leather-like eschar
- Deep necrotic fascia and muscle tissue apparent

Extremities · Legs are not symmetric and equal due to 1+ to 2+ swelling noted

· Presence of burns on the bilateral hips, bilateral lower limbs and

bilatereal upper limbs.

LABORATORY EXAMINATION & DIAGNOSTIC

TESTS
Computed Tomography Scan
Test Normal Findings Result
Computed Tomography
Scan (Thoracic)
The lungs and airways are Right pneumothorax,
normal. No pleural effusion bilateral lower lung infection,
or thickening. Heart size is and bilateral pleural effusion
normal. No pericardial
effusion. The mediastinum
structures have normal
configuration. Chest wall is
unremarkable.

Nursing Responsibilities
Right Pneumothorax

→ Examine respiratory function, noting rapid or shallow breathing, dyspnea, symptoms of

"air hunger," cyanosis development, and changes in vital signs.

→ When utilizing a mechanical ventilator, keep an eye out for asynchronous respiratory
patterns. Changes in airway pressures should be noted.

→ Take note of the chest excursion and trachea's location.

→ When the client is coughing or deep breathing, assist them in splinting the uncomfortable
spot.

→ Maintain a comfortable position, usually with the head of the bed elevated. Transfer the
weight to the affected side.

→ Maintain a cool demeanor while supporting the client in "regaining control" by using
slower, deeper breathing.

→ Assist with lung re-expansion treatment as needed (observation without oxygen,

supplemental oxygen administration, needle aspiration, one-way valve device,
thoracostomy with chest tube placement with chest tube drainage unit [CDU] and with or
without suction).
 → Serial ABGs and pulse oximetry should be monitored and graphed. Where indicated,
review vital capacity and tidal volume measurements.

→ As needed, use analgesics and sedatives.

Bilateral Lower Lung Infection

→ Examine the breathing rate and depth, as well as the chest movement.

→ Assess mental status.

→ Auscultate the lung fields, listening for areas of reduced or absent airflow, as well as
unusual breath sounds like crackles and wheezes.

→ Keep an eye out for symptoms of respiratory failure, such as cyanosis or severe
tachypnea.

→ Assist the client with deep breathing techniques on a regular basis. As needed,
demonstrate and assist the client.

→ Suction only when necessary, such as in the case of oxygen desaturation caused by
airway secretions.

→ Observe hypotension, copious volumes of pink or bloody sputum, pallor, cyanosis,

change in level of awareness, severe dyspnea, and restlessness as signs of exacerbation.

→ Instruct client concerning the disposition of secretions (rising and expectorating versus
swallowing) and documenting changes in color, quantity, and odor of secretions.

→ Frequently change positions and ensure enough pulmonary toilet.

→ During client contact, implement isolation precautions as needed (masks, gloves, and
possibly gowns).

→ Increased chest pain, additional heart sounds, changed sensorium, recurring fever, and
changes in sputum characteristics should all be investigated.

→ Administer the prescribed pain medications and assess response at least 30 minutes after
drug administration.
Bilateral Pleural Effusion

→ At least every 4 hours, check the patient's vital signs and respiratory characteristics.

→ Assess the patient's pain level, as well as the features and location of the pain, using a 0-
10 pain rating scale (sharp, dull, or crushing,)

→ Examine the patient's everyday activities, as well as any actual or perceived limitations to
physical exercise. Inquire about any type of activity he or she used to perform or would
want to attempt.

→ Raising the head of the bed is a good idea.

→ Administer the specified pain drugs and wait at least 30 minutes before evaluating the
results.

→ Teach the patient how to use deep breathing and relaxation techniques.

Magnetic Resonance Imaging

Test Normal Findings Result

Magnetic Resonance No soft tissue defect, no Suspected right abdominal

Imaging abnormal masses, with blood
flow dynamics (but no
hemorrhage), no malformed
lymph, no malignancies, and
normal anatomy.
wall soft tissue defect,
suspected right chest wall
soft tissue defect into the
abdominal cavity, and blood
effusion in the pelvis; and
multiple muscle injuries on
the right chest wall, hips, and
pelvic cavity

Nursing Responsibilities
Suspected right abdominal wall soft tissue defect

→ Examine and record the size, color, and depth of the wound, as well as any necrotic tissue
and the status of the surrounding skin.
 → Listen for bowel sounds. Take note of any bowel sounds that aren't lively or aren't
present.

→ Supports or splints might help to maintain normal body alignment.

→ Avoid putting pressure on skin.

→ Changes in bowel habits should be given special attention because they are a common
symptom of gastrointestinal disease. Bowel movements should be evaluated for
frequency, color, and regularity.

Suspected right chest wall soft tissue defect into the abdominal cavity

→ Evaluate the patient's airway, breathing, and circulation right away.

→ Pre-existing respiratory problems and a history of smoking should be noted.

→ Keep track of the breathing rate, rhythm, and depth, as well as any pallor or cyanosis and
carbonaceous or pink-tinged sputum.

→ Examine the lungs for stridor, wheezing, or crackles, reduced breath sounds, and a brassy
cough.

→ Examine any changes in behavior or cognition, such as restlessness, agitation, or a shift

in LOC.

→ Suction with utmost caution (if necessary) while preserving sterile technique.

Blood Effusion in the Pelvis

→ Keep an eye on the patient's vital indicators, especially his or her blood pressure and heart
rate. Keep an eye out for symptoms of orthostatic hypotension.

→ Examine the skin and mucous membranes for petechiae, bruising, hematoma formation,
or blood seeping.

→ CBC values should be monitored.

→ Keep an eye on the hematocrit (Hct) and hemoglobin levels (Hgb).

 → Begin the intravenous therapy as directed. It's possible that electrolytes will need to be
supplied intravenously.

→ If a transfusion is required, be prepared.

Multiple Muscle Injuries on the Right Chest Wall, Hips, and Pelvic Cavity

→ Determine the client's capacity to walk and the risk of falling.

→ Assist the patient in becoming familiar with their surroundings. Place the call light within
easy reach and teach how to use it to summon help.

→ Physical and chemical restraints should be avoided. If restraints are required, obtain a
physician's order.

→ Placing the patient in a room close to the nurses' station is a good idea.

→ Before doing any technique, such as lifting the head of the bed or tucking elbows in,
consider the fundamentals of appropriate body mechanics.

→ To aid in the healing of an injury, provide the best nourishment possible.

HISTORY OF PATIENT

Biographic Data

Name: Aaron

Address: Brgy. Dalahican, Lucena City, Philippines

Phone Number: 09172233621

Birthdate: 1993

Nationality: Filipino

Educational Level: College Graduate

Occupation: Baker

Current Symptoms The patient is in coma upon admission with presence of burns
in the right anterior and posterior thorax, bilateral hips, bilateral
lower limbs, and upper right limbs.

History of Present Fell asleep while using charcoal as a heat source, became
Concern: poisoned by carbon monoxide, and went into a coma for an
unknown period of time.

Fell into the charcoal fire and was discovered about 3 hours
later.

Transferred to the local central hospital's burn unit in the

department of surgery for treatment.

Past History  No past diagnoses

 No hospitalizations
 No surgeries
 No known allergies (foods and drugs)

Family History  Maternal grandparent- diabetes

 Mother- diabetes
 Paternal grandmother- breast cancer, several high
cholesterol, high BP

Lifestyle and Health No history of smoking; occasional drinking

Practices
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