Professional Documents
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Burn IE
Burn IE
GENERAL INFORMATION
Name: G.D
Age: 22 y
Sex: Female
Address: San Fernando, La Union
Civil Status: Single
Citizenship: Filipino
Handedness: ®
Occupation: Teacher
Religion: Christian
Attending Unit: OPD
Attending Dr.: B.Z
Rehab Dr.: A.B
Date of Consultation: September 22, 2020
Date of Referral: September 26, 2020
Diagnosis: 2 and 3 degree burns
SUBJECTIVE:
Informant: Pt
Reliability: Good
Educational Attainment: College Graduate
c/c: pt complains of sustained 2 & 3 degree burns over the ® side of her face and neck, ® side of the
anterior trunk, 2/3 of lower ® thigh, and right arm.
HPI
pt present condition started on September 22, 2021, transferred via ambulance to the hospital after a
fire in pt.'s apartment. pt was asleep when the fire started and managed to make her way out of the
apartment through the smoke. pt sustained 2 and 3 degree burns over the R side of her face and neck,
R side of the anterior trunk, 2/3 of L right thigh, and right arm pt In the emergency department with Dr.
B.Z, pt was on a 100 % oxygen non-rebreather mask.
It was promptly pt received a tetanus shot, morphine for pain, and 2 L of IV fluids. intubated with an oral
7.5 ETT because of suspected inhalation burns. Appropriate analgesics and IV fluids were
administered, and the patient was placed on mechanical ventilation.
pt was immediately taken to the burn unit to begin the resuscitation protocol. Over the course of the
next 4 weeks, the patient slowly improved. pt developed pleural effusion on the R and R upper lobe
pneumonia. Weaning from mechanical ventilation was attempted via CPAP trials. Two weaning
attempts failed. Pseudomonas was cultured from his sputum. Escharotomy was required on all ten
fingers. Debridement and skin grafting proceeded without complications. The patient received a
tracheotomy during the fourth week and is now on a tracheostomy collar throughout the day with
mechanical ventilation support (AC) at night.
MEDICATION:
PAST MEDICATION
Other medication:
2 L of IV fluids.
oral 7.5 ETT
PMHx:
FMHx:
Paternal Maternal
PSEHx:
Pt is a non-smoker, an occasional alcohol beverage drinker (three glasses of wine per week), and no hx
of drug abuse. Pt. drives to work every Monday to Saturday. Pt has an active lifestyle and spends his
time reading and working out at her house and walking the dog.
Home station:
Pt’s Goal: Pt wants her body to return to how it was before and breathing will be normal, completing
her daily activities and work.
OBJECTIVE:
Height: 160 cm
Weight: 50kg
BMI: 19.6 (Normal Weight)
V.S
VS: Before During After
OI:
Pt is ambulatory
Pt is Alert/ Coherent / Cooperative
Endomorph (50 kg)
Physique: Mesomorph
(+) Shortness of breath
(-) Diaphoresis
(-) contractures
PALPATION:
(-) Lesions
(-) Adhesions
ROM
All major joints on ® UE / LE, neck and trunk were measured actively and passively, pain free, c (N)
end- feel were WNL
Significance: Pt will have difficulties in performing ADLS; Pt has decreased ROM d/t muscle weakness
MMT
Grade Definition
All on ® UE & LE
R SH FLEXOR 3-/5
R SH EXTENSORS 3-/5
R SH ABDUCTORS 3-/5
R SH ADDUCTORS 3-/5
R FA SUPINATORS 3-/5
R FA PRONATORS 3-/5
R WRIST RD 3-/5
R WRIST UD 3-/5
SHOULDERS Rounded
SHOULDERS Rounded
Findings: Pt has a slight forward head posture, trunk slightly leans to ® elbow is slightly flexed, ® hip is
slightly higher, ® knee is slightly flexed.
Significance: 2 o to muscle weakness and habitual posture
DTR:
ADL:
ADL Score
MOTOR ITEMS
Self-care
Feeding 7
Grooming 7
Bathing N/A
Mobility
Bed Mobility
● Roll to Right 6
● Roll to Left 6
● Supine to Sit 6
● Sit to Supine 6
Chair Mobility 7
Toilet Transfer 7
Ambulation 7
COGNITIVE ITEMS
Communication
Comprehension 7
Expression 7
Reading 7
Speech Intelligibility 7
Psychosocial Adjustment
Social Interaction 7
Emotional Status 7
Adjustment to Limitation 7
Employability 7
Cognitive Function
Problem Solving 7
Memory 7
Orientation 7
Attention 7
Finding: pt has In upper garment modified index in ADL as to bed mobility specifically in rolling to right
and left, supine to sit , sit to supine.
Significance: 2 to burn injury and edema
Wound Assessment
Location ® UE & LE
Full-thickness burn
Type of wound
Shape Irregular
Size Length: 13 cm
Width: 10 cm
Depth: 5 cm
Right Arm 9%
Left Arm 0%
Right Hand 9%
Left Hand 0%
Trunk 18%
Groin 0%
Left Leg 0%
Total: 63%
Findings: All R parts of body has 9% but trunk and R leg has 18%, shows signs of Full-thickness
burn.
Sig. Pt’s has TBSA percentage of 63% full-thickness burn on R UE & LE
ASSESSMENT
PT Impression:
G.D is 22 y/o Filipino, female who complains of sustained 2 & 3 degree burns over the right side
of her face and neck, right side of the anterior trunk, 2/3 of lower right thigh, and right arm. Pt.
has shortness of breath, swelling R UE, wound R UE, Edema R UE. Pt has LOM on R UE and
LE. pt has In upper garment modified index in ADL as to bed mobility specifically in rolling to
right and left, supine to sit, sit to supine. Pt has hyporeflexia on R UE / LE. Pt has a slight
forward head posture, trunk slightly leans to ® elbow is slightly flexed, ® hip is slightly higher, ®
knee is slightly flexed. MMT grade 3-/5 on all muscles on R UE /LE
Rehab Potential and Prognosis: Pt have a good rehabilitation because pt is willing to undergo
therapy, she is still young and have supportive family
Procedural Intervention: PT will make up for any remaining strength, in order to accomplish
the patient's goal and avoid further complications that could worsen the patient's current
condition.
PROBLEM LIST STG ( 3x for 1 years ) LTG ( 3x for 2 years )
Pt has grade 3-/5 on R UE To increase MMT from 3-/5 to To get to normal MMT on R
and LE 4/ 5 on R UE and LE UE and LE
Pt 2 and 3 degree burn To improve wound from 2 To get normal skin, no burn
wound and 3 degree to 1 and 2 or wound
degree
PLAN
• Whirlpool bath for 103-110 F on R UE for 20 minutes to reduces pain and stimulate
wound healing.
• Positioning with dynamic splint on the R UE&LE to minimize edema formation.
• Deep friction massage on the R UE to decrease scar thickness and improve scar
appearance.
• Stretching exercises on R UE hold for 30 sec x 3 sets to increase flexibility.
• Deep breathing exercises hold for 30 sec x 10 rep, to strong breathing muscles.
• AROME exercises on R UE&LE for 10 rep x 1 set to increase ROM
HIP:
• Pt & family education about the pt.’s condition
• Postural and positioning re-education
• Proper transfers and early mobilization
• Family education about how to assist the pt through AROME, resistance exercises, and
other
• elements of the management program.
• Risk factors re-education
HEP
• Proper Bed Positioning
• Breathing exercises
• Holding squeeze small ball
• Balance exercises
Precaution:
• Do not soak the burn in water or apply ointments or butter, which can cause infection.