OUR LADY OF FATIMA UNIVERSITY

Valenzuela Campus
120 McArthur Highway, Marulas, Valenzuela City
College of Nursing

A CLINICAL CASE STUDY ABOUT

CARE OF PATIENTS WITH
EXPERIENCED OF FLAME BURN

Submitted By: Jhon Ryshudel d.L Angeles

Submitted To: Mr. Bryan L. Munoz, RN
Course: Bachelor of Science in Nursing
Section and Year level: BSN3 - YA – 2
Subject: NCMB 312 – Care of Clients with Problems in Oxygenation, Fluid,
& Electrolytes, Infectious, Inflammatory, and Immunologic
Response, Cellular Aberrations, Acute and Chronic –
Medical and
Surgical Ward Duty – East Avenue Medical Center (EAMC)

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 OUR LADY OF FATIMA UNIVERSITY
Valenzuela Campus
120 McArthur Highway, Marulas, Valenzuela City
College of Nursing

TABLE OF CONTENTS

I. OBJECTIVES

GENERAL and SPECIFIC OBJECTIVES

II. INTRODUCTION

III. EPIDEMIOLOGY

IV. ANATOMY AND PHYSIOLOGY

V. PATHOPHYSIOLOGY

VI. PATIENT’S PROFILE

PRESENT and PAST MEDICAL HISTORY

VII. GORDON’S FUNCTIONAL HEALTH PATTERN

VIII. DIAGNOSTIC AND LABORATORY EXAMINATIONS

IX. DRUG STUDY

X. NURSING CARE PLAN

XI. RECOMMENDATIONS / DISCHARGE PLAN

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 OUR LADY OF FATIMA UNIVERSITY
Valenzuela Campus
120 McArthur Highway, Marulas, Valenzuela City
College of Nursing

I. Objectives

General Objective:

The general objective of this case study is to provide information and data
regarding cases both locally and internationally as well as causes and prevention of flame burn-
related injuries.

Specific Objectives:

 To discuss structural and functional changes occurring in individuals with

flame burn injuries.
 To discuss individualized care of patients with flame burn-related injuries
depending on the severity.
 To identify drugs and other medication necessary for the treatment of burn-
related injuries.
 To formulate primary prevention as well as intervention for individuals
experiencing a flame burn injuries.

II. Introduction

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 OUR LADY OF FATIMA UNIVERSITY
Valenzuela Campus
120 McArthur Highway, Marulas, Valenzuela City
College of Nursing

Flame burns happens due to direct or indirect contact/exposure of individual to a flame

source. These flames could happen in variety of sources such as ignition, oxidizing agent and
fuel source. Aside from flame, there are other causes of burn related injuries such as through
electrical, chemical and radiation.

Burn injury is a persistent global public health concern, and is a significant cause of
morbidity and mortality worldwide. It is a distinct form of trauma considered to be one of the
most severe injuries that can happen to an individual, and is an extremely stressful experience for
both the burn victim and his/her family. In spite of the extraordinary advances in the
management of burns, the profound impact of burn injuries to a patient's physical, social,
psychological and emotional well-being cannot be overemphasized. Burns physically disfigure,
inflict pain, and limit function and activities of daily living among patients. One of the worst
tragedies a person can suffer and endure. The social and economic consequences on the victim
and his/her family may be devastating and life changing.

The Global Burden of Disease 2004 Update of the World Health Organization reports
186 million fire related deaths (female-male ratio 7:1) and 6.6 million disability-adjusted life
years lost due to fires in low and middle-income countries in South East Asia alone. Ninety-five
percent of all fatal fire-related burns occurred in low and middle-income countries. South East
Asia also accounts for just over one-half (53%) of the total number of fire-related burn deaths
worldwide and for more than 50% of total number of disability-adjusted life years lost to fire-
related burns. Strategies in disaster prevention, health and hospital policies put burn-related
injuries at the bottom priority for most developing countries. There is paucity of epidemiologic
data available in the local setting to allow lawmakers and health policy practitioners to come up
with reasonable recommendations regarding burn care and management.

Burns continue to be a big burden to developing countries. To confront the burden of

burns especially in developing countries like the Philippines, key primary preventive measures
should be implemented and be a priority for public health advocates.

III. Epidemiology

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 OUR LADY OF FATIMA UNIVERSITY
Valenzuela Campus
120 McArthur Highway, Marulas, Valenzuela City
College of Nursing

According to study conducted in the University of the Philippines – Philippine General

Hospital Alfredo T. Ramirez Burn Center happened from August 2013 up until July 2015. The
age groups most commonly involved were <1 year old (24%), 2 to 14 years old (25%) and 25 to
44 years old (25%), majority (71%) of whom were males. The most common etiology was scald
burns (43%), and most patients were burn in their homes (71%). Majority (89%) were admitted
within 24 hours from injury. Half underwent operative management. Ninety-one percent (91%)
of the admitted burn patients improved; Nine percent (9%) of the patients died. The most
common cause of death was multiple organ dysfunction syndrome (40%). Significant factors
associated with mortality included: 1) percent total body surface area, 2) Inhalation Injury and 3)
involvement of the head, lower extremities and perineum.

In the Philippines, there are only five hospitals with burn units, Philippine General
Hospital, Jose Reyes Memorial Medical Center, East Avenue Medical Center, Quirino Memorial
Medical Center and Southern Philippines Medical Center in Davao City. It means that there are
approximately 40-45 beds for more than 100 million Filipino patients.

The Alfredo T. Ramirez (ATR) Burn Center of the Philippine General Hospital (PGH),
established in 1967, is currently at the forefront of burn care in the country. A primary referral
burn center in the country, it has been a pioneer in the comprehensive and multidisciplinary care
for patients suffering from burn injuries. As a center of excellence in burn treatment, the Center
caters to both adult and pediatric cases, with around 300 admissions, 2,000 outpatient consults,
and 300 operations a year. From an original two-bed facility, it has evolved and expanded into a
12-bed center serving the country.

In the UP-PGH ATR Burn Center, burn patients are admitted base on the American Burn
Association Classification (Figure 1). Which includes the following: all acute burn patients
classified with moderate and major injuries, those less than 2 years of age regardless of percent
total body surface area (% TBSA), those with injuries to the hands, face, feet, and perineum, all
patients with electrical and chemical burns, and those with smoke inhalational injury, other
associated medical illnesses, or with multiple trauma. Comprehensive and multidisciplinary care
is provided to patients by highly trained staff and personnel.

The UP-PGH ATR Burn Center adheres to the guidelines recommended by the Philippine
Society of Burn Injuries and International Society of Burn Injuries. Initial assessment and
stabilization are conducted based on the ABC's of burn injury (airway, breathing, circulation / C-
spine / compartment syndrome, disability / deficits, exposure). Immediate and comprehensive

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 OUR LADY OF FATIMA UNIVERSITY
Valenzuela Campus
120 McArthur Highway, Marulas, Valenzuela City
College of Nursing

evaluation of burn patients using systematic primary and secondary survey is key to appropriate
management. Appropriate fluid resuscitation, wound care, and surgical management, if needed,
are instituted in a timely and organized manner. The Parkland Formula is use to resuscitate
acutely burned patients; and early tangential excision and skin grafting is being practiced in the
institution as part of the definitive management for the burn injuries.

Published studies regarding the profile of burn injuries in the Philippines are inadequate
and this study aimed to document the current trend and profile among admissions in the UP-PGH
ATR Burn Unit from August 2013 to July 2015. Specifically, this study aimed to describe the
profile of patients admitted to the UP-PGH ATR Burn Center from August 2013 to July 2015, in
terms of age, gender, percent total body surface area (% TBSA), severity, anatomic involvement,
etiology of burn, place of injury, length of time prior to consult, number of operations, length of
stay, morbidity and mortality. This investigation also aimed to correlate clinical epidemiologic
data with outcomes of burn injury. The general objectives of this study were: 1) to describe the
epidemiologic profile of burn patients admitted at the UP-PGH ATR Burn Center for the last 2
years, 2) to determine the relationship of identified clinical variables with mortality.

IV. Anatomy and Physiology

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 OUR LADY OF FATIMA UNIVERSITY
Valenzuela Campus
120 McArthur Highway, Marulas, Valenzuela City
College of Nursing

A burn is 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 liquid
and gases. 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 burn include:

 First Degree Burn – damage the outer layer

(epidermis) of the skin. These burns usually heal on their own within a week. A
common example is sunburn.
 Second Degree Burn – 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. This type of burn may leave scars.
 Third Degree Burn - damage or destroy both layers of skin including hair
follicles and sweat glands and damage underlying tissues. These burns always
require skin grafts.
 Fourth Degree Burn - extend into fat, fifth degree burns into
muscle, and sixth degree burns to bone.

Severe burns cause serious, body-wide problems. At the root of most of these problems is
the body’s explosive inflammatory response.
A normal inflammatory response protects the body from invaders, such as bacteria,
viruses, fungi, cancerous cells, toxins, and foreign materials. It activates in response to infection,
injury, or other threat. It is design to destroy the cause of the problem, contain the damage, and
clean up the mess left by dead cells and other debris. However, when faced with large or deep
burns, it can overreact, often making the injury more severe and harming the heart, lungs, blood
vessels, kidneys, and other organ systems.

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 OUR LADY OF FATIMA UNIVERSITY
Valenzuela Campus
120 McArthur Highway, Marulas, Valenzuela City
College of Nursing

During this inflammatory response, there is fluid loss that can cause a sharp and
potentially deadly drop in blood pressure known as shock. Fluid can also become trap inside the
body, leading to swelling known as edema. If tissues and organs do not receive enough oxygen
because of shock, edema, or something else, they suffer damage and can fail. The lungs, heart,
brain, and kidneys are particularly susceptible.
Infection is also a major concern. Burns damage the skin’s protective barrier, meaning
bacteria and other foreign invaders can sneak in. Burns also weaken the immune system, so the
body is less able to fight off threats. Infections can take hold not only in the injured area, but also
in organs such as the lungs (pneumonia) and bloodstream (sepsis), where they are potentially
lethal.

V. Pathophysiology

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 OUR LADY OF FATIMA UNIVERSITY
Valenzuela Campus
120 McArthur Highway, Marulas, Valenzuela City
College of Nursing

The pathophysiology of the burn wound is characterize by an inflammatory reaction

leading to rapid edema formation, due to increased microvascular permeability, vasodilation and
increased extravascular osmotic activity. These reactions are due to the direct heat effect on the
microvasculature and to chemical mediators of inflammation. The earliest stage of vasodilatation
and increased venous permeability is commonly due to histamine release. Damage to the cell
membranes partly caused by oxygen-free radicals released from polymorph nuclear leucocytes
would activate the enzymes catalyzing the hydrolysis of prostaglandin precursor (arachidonic
acid) with rapid formation of prostaglandin as the result. Prostaglandins inhibit the release of
norepinephrine and may thus be of importance in modulating the adrenergic nervous system that
is activated in response to thermal injury. The morphological interpretations of the changes in the
functional ultrastructure of the blood lymph barrier following thermal injury seem to be an
increase in the numbers of vacuoles and many open endothelial intercellular junctions.
Furthermore, changes of the interstitial tissue after burn trauma are of great importance. The
continuous loss of fluid from the blood circulation within the thermally damaged tissue causes
increased hematocrit levels and a rapid fall in plasma volume, with decreased cardiac output and
hypo perfusion on the cellular level. If the fluids are not adequately restored burn, shock
develops. Furthermore, the burn wound provides a vast area of entry of surface infection with a

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 OUR LADY OF FATIMA UNIVERSITY
Valenzuela Campus
120 McArthur Highway, Marulas, Valenzuela City
College of Nursing

high risk of septic shock. Four main principles are of utmost importance in the current
management of patients with severe thermal injury, namely early wound closure, prevention of
septic complications, adequate nutrition and control of the external environment.

VI. Patient’s Profile

Personal Profile
Patient’s Name: Cayago, Erikson Y. Date of Birth: October
23, 1975
Gender: Male Age: 47 years old
Date Admitted: October 27, 2022 / Flame Burn Injury Religion: Catholic
Source of Data Collected: Patient himself

Present Medical History

1 Assessment:
st

Patient manifests immediate response to stimuli with gradual feeling of pain, shows
effortless breathing and absence of fever as well as good blood circulation as evidenced by
Respiratory rate of 16cpm, Pulse rate of 98bpm, Temperature of 36.6 and Blood pressure of
130/70.

Medication Taken at Hospital:

Paracetamol 500mg/IV q 6 hours
Cefuroxime 750mg/IV q 8 hours
Silver Sulfadiazine on Affected Area

2nd Assessment:
o Admitted last 27th day of October due to Flame Burn Injury caused by flammable
lacquer thinner that affects left forearm and both right and left foot.
o Patient verbalizes no known history of any allergies related to foods, drinks and
any medications.
o There is no history of any self-administered medication taken at home as well as
no history of any related injuries in both maternal and paternal side.
o Patient frequently ate vegetable and fish at hospital and at home.

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 OUR LADY OF FATIMA UNIVERSITY
Valenzuela Campus
120 McArthur Highway, Marulas, Valenzuela City
College of Nursing

Pain Assessment:
o Patient verbalizes that the feeling of pain occurs when parts of the body affected
by burn move.
o Pain increases during time of removal and changing of bandage.
o The feeling of pain started from the upper affected area (arm) that radiates down
to the lower extremities (both right and left foot).
o Patient describes the feeling of pain using pain scale of 1 to 10. Whereas, patient
felt 8 as the most severe (when the body moves and removal, changing of
bandages occur) and pain scale of 5 as tolerable (when no stimuli that increases
the pain exists).

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 OUR LADY OF FATIMA UNIVERSITY
Valenzuela Campus
120 McArthur Highway, Marulas, Valenzuela City
College of Nursing

VII. Gordon’s Functional Health Pattern

The Patient practice roman catholic as religion that

VALUE AND BELIEF
COPING AND STRESS TOLERANCE
ROLE AND RELATIONSHIP
SELF-PERCEPTION
SELF-REST
ACTIVITY – EXERCISE
ELIMINATION
HEALTH PERCEPTION/HEALTH
MANAGEMENT
NUTRITIONAL/METABOLIC
serves as guidance and hope throughout healing
process and life.
The patient verbalizes continuous cooperation to
recover and willing to accept lifestyle changes such
as regular diet and taking of medication.
The patient expresses changes in his daily activities,
which affects his role as father and husband.
However, the patient’s relationship with his family
stay the same like before hospitalization.
The patient views his current condition as accident
and no one wants it to happen. He verbalizes his
belief that he will be able to perform again as
before.
The patient verbalizes that he is able to rest
adequately during hospitalization, which sometimes
interrupted by scheduled taking of medications and
pain.
The patient expresses that he will not be able to
perform and cannot tolerate the activities performed
before during his current condition. (anything that
requires a lot of movement)
The patient states that he was able to eliminate solid
wastes same as before. However, frequent urination
occurs.
The patient expresses his desire to recover from his
current condition.
The patient daily food intake stay the same as
before which includes Fruits and Vegetables.

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 OUR LADY OF FATIMA UNIVERSITY
Valenzuela Campus
120 McArthur Highway, Marulas, Valenzuela City
College of Nursing

VIII. Laboratory / Diagnostic Examinations

Physical Examination
Airway
Breathing
Circulation
Severity of Burn Injury
Degree of Burn Injury
Total Body Surface Area (TBSA) – Rule of Nines
- Method used to estimate the body surface affected by burn.

Laboratory Tests

Complete Blood Count ABG Measurement

Blood Typing and Cross match Blood Coagulation Profile

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 OUR LADY OF FATIMA UNIVERSITY
Valenzuela Campus
120 McArthur Highway, Marulas, Valenzuela City
College of Nursing

IX. Drug Study

Generic Name and Drug Class: Acetaminophen/Paracetamol

Brand Name – Perfalgan

MECHANISM OF ACTION
It has analgesic and antipyretic actions in the central nervous system. It inhibits
prostaglandin synthetase in the hypothalamus, prevents synthesis of spinal prostaglandin, and
inhibits inducible nitric oxide synthesis in macrophages. In therapeutic doses, inhibition of
prostaglandin synthesis is not significant in peripheral tissues, so paracetamol has minimal anti-
inflammatory action.
Intravenous paracetamol infusion provides onset of pain relief within five to ten
minutes after the start of administration. The peak analgesic effects is obtained in one hour and
the duration of this effect usually four to six hours. Fever is reduced within 30 minutes after the
start of administration. Duration lasts at least six hours.

INDICATIONS
o For relief of mild to moderate pain, where the enteral route of administration is not
clinically appropriate.

CONTRAINDICATIONS
o Hypersensitivity to paracetamol.
o Patients with severe hepatocellular insufficiency, hepatic failure or decompensated
active liver disease.

SIDE EFFECTS
o Blood/Black, Tarry Stool
o Bloody/Cloudy Urine
o Skin Rash/Hives or itching
o Sore Throat
o Unusual bleeding/bruising
o Unusual tiredness/fatigue
o Pain in the lower back/side

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 OUR LADY OF FATIMA UNIVERSITY
Valenzuela Campus
120 McArthur Highway, Marulas, Valenzuela City
College of Nursing

o Yellow eyes/skin

Generic Name and Drug Class: Cefuroxime - Cephalosporin

Brand Name: Ceftin

MECHANISM OF ACTION
It is a second generation cephalosporins are more effective in treating Gram-negative
bacilli compared to first generation cephalosporins, which have a greater coverage for Gram-
positive cocci.
Like penicillin antibiotics, contain a β-lactam ring structure. Works as bactericidal
antibiotic by binding to penicillin-binding proteins (PBPs), It inhibit the last step of the bacterial
wall synthesis. Once the β-lactam ring binds to PBPs, cross-linking between peptidoglycan units
is inhibited.

INDICATIONS
It is used to treat certain infections caused by bacteria, such as bronchitis, gonorrhea
and infections of the skin, ears, sinuses, throat, tonsils and urinary tract. Cefuroxime is in a
class of medications called cephalosporin antibiotics. It works by stopping the growth of
bacteria.
Antibiotics such as cefuroxime will not work for colds, flu, or other viral infections.
Using antibiotics when they are not needed increases your risk of getting an infection later that
resists antibiotic treatment.

SIDE EFFECTS
Most Common Serious side effects:
o Diarrhea - Severe Stomach Pain
o Nausea - Diarrhea
o Vomiting - Yellowing of the skin or eyes.
o Unusual taste in your mouth - Seizure
- Severe tingling

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 OUR LADY OF FATIMA UNIVERSITY
Valenzuela Campus
120 McArthur Highway, Marulas, Valenzuela City
College of Nursing

Generic Name and Drug Class: Silver Sulfadiazine - Antibiotics

Brand Name: Silvadene

MECHANISM OF ACTION
Silver sulfadiazine disrupts bacteria by damaging the cell membrane and the cell wall
rather than by inhibiting folic acid synthesis. Silver sulfadiazine has a wide spectrum of
bactericidal activity against both gram-positive and gram-negative organisms.

INDICATIONS
Silvadene Cream (silver sulfadiazine) is a topical antimicrobial drug indicated as an
adjunct for the prevention and treatment of wound sepsis in patients with second and third –
degree burns.

SIDE EFFECTS
o Red spots on the skin
o Red/Swollen Skin
o Skin Rash
o Blistering/Loosening of the skin
o General body swelling
o Blue-green to black skin discoloration
o Increased sensitivity to sunlight
o Sores, ulcers or white spots in the mouth/lips

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 OUR LADY OF FATIMA UNIVERSITY
Valenzuela Campus
120 McArthur Highway, Marulas, Valenzuela City
College of Nursing

X. Nursing Care Plan

ASSESSMENT DIAGNOSI PLANNING NURSING RATIONAL EVALUATION

S INTERVENTION E
Subjective Impaired Short Term Independent Independent Short Term
“Sumasakit yung physical Goal - Continuously - Provides Goal
mga sugat ko mobility After 10 – 20 assess and monitor baseline data Evaluation:
madalas kapag related to burn minutes of vital signs of the that are After 15 – 20
nagagalaw” as wound edema, nursing patient q 4 hours / as significant for minutes of
verbalized by the pain, and joint intervention, the necessary. the progress of nursing
patient. contractures. patient will be the patient and intervention, the
able to: - Provide patient his condition. patient was able
Objective - decrease comfort and needs - Contributes in to:
BP – feeling/ level of for both physical and providing safety Achieved
130/70mmHg pain from 8 to 4 physiological and alleviation decrease level of
PR – 98bpm out of 10 using function. of patient’s pain from 8 down
O2Sat – 91% numerical rating suffering. to 4 out of 10 as
Pain Scale – 8/10 scale (NRS). - Prevent verbalized by the
complication of - Lack of patient.
Long Term immobility by deep physical
Goal breathing exercises, mobility during Long Term
After 1 – 2 turning and proper hospitalization Goal
week(s) of positioning. especially in Evaluation
nursing burn injuries After 1 – 2
intervention, the could cause week(s) of
patient will be severe nursing
able to: - Initiate passive and complications intervention, the
- Achieve active range of and disease patient was able
optimal physical motion exercises such as pressure to:
mobility within prescribed ulcers. - Demonstrate
throughout limitations. optimal physical
hospitalization - It provides mobility and was
and healing Dependent good blood able to move

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 OUR LADY OF FATIMA UNIVERSITY
Valenzuela Campus
120 McArthur Highway, Marulas, Valenzuela City
College of Nursing

processes. - Provide medication circulation affected body

appropriate for the within body parts in
patient needs as parts affected moderation and as
prescribed/ordered and prevents tolerable.
by the physician. pressure ulcers -
to occur.

Dependent
- Scheduled
medication
enhances
healing process
and avoid other
diseases
existence.
-

ASSESSMEN DIAGNOSI PLANNIN NURSING RATIONAL EVALUATION

T S G INTERVENTIO E
N
Subjective Risk for Short Term Independent Independent Short Term Goal
“Madalas akong infection Goal - Monitor for early - Early Evaluation:
maihi sa related to loss After 10 – 15 signs of infection. detection After 20 – 30 minutes
sitwasyon ko of skin barrier minutes of provides early of nursing
ngayon, hindi and impaired nursing treatment, intervention, the
katulad noon na immune intervention, which will patient was able to:
wala pa ako rito response. the patient prevent - feel comfort and
sa hospital” as will be able - Practice aseptic progress of verbalizes reduce
verbalized by the to: technique for wound infection. level of pain.
patient. - feel comfort, care and invasive
clean and procedures. - Aseptic
Objective shows technique
BP – absence of provides
130/70mmHg accumulation - Provide a clean and protection for

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 OUR LADY OF FATIMA UNIVERSITY
Valenzuela Campus
120 McArthur Highway, Marulas, Valenzuela City
College of Nursing

PR – 98bpm of skin safe environment. both patient and

O2Sat – 91% secretions. health care Long Term Goal
Pain Scale – 8/10 provider. Evaluation:
Long Term - Protect patient After continuous
Goal from all sources of nursing intervention,
After contamination. the patient was able
continuous (Equipment, to:
nursing Visitors, Other staffs Experienced no
intervention, and patients). - Prevents localized or systemic
the patient contamination infection.
will be able and provides -
to: comfort for the
Experience no Dependent patient.
localized or - Administer
systemic appropriate - Avoidance of
infection. medication as prevention of
prescribed by the the through
physician. prevention of
various mode of
transmission.

Dependent
- Timely and
scheduled
medication
enhances
healing process.

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 OUR LADY OF FATIMA UNIVERSITY
Valenzuela Campus
120 McArthur Highway, Marulas, Valenzuela City
College of Nursing

ASSESSMENT DIAGNOSIS PLANNING NURSING RATIONAL EVALUATION

INTERVENTION E
Subjective Disturbed Short Term Independent Independent Short Term
“Lalong sumasakit body image Goal - Provide patient and Goal
yung mga sugat ko related to After 1 – 2 his family with Evaluation:
kapag mainit ang altered hour(s) of health education After 1 – 2 hour
panahon at appearance nursing about his current (s) of nursing
tinatanggal ang and self- intervention, the condition. intervention, the
bandage para concept. patient will be - Health patient was able
linisan” able to: Education and to:
- feel comfort family support - verbalized
Objective and safety as provides feeling of comfort
BP – well as reduce - Advise the family knowledge and and reduce level
130/70mmHg level of pain. to provide emotional of pain.
PR – 98bpm continuous support stability to the
O2Sat – 91% to the patient patient that will Long Term
Pain Scale – 8/10 throughout healing help him cope Goal
process and life. with the Evaluation:
Long Term - Refer patient to a Situation. After 1 – 2
Goal support group to months of nursing
After 1 – 2 develop coping intervention, the
months of strategies to deal patient was able
nursing with losses. to:
intervention, the - adapt and adjust
patient will be to the changes
able to: related to body
- Adapt and image and self-
adjust to concept caused by
changes in body the injury.
image and self-
concept.

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 OUR LADY OF FATIMA UNIVERSITY
Valenzuela Campus
120 McArthur Highway, Marulas, Valenzuela City
College of Nursing

Dependent Dependent
- Continuous -Administration
administration of of Medication
medication as ordered by the
ordered by the physician
physician. boosts the
healing process.

XI Recommendations/Discharge

Medications
Have all the necessary medicines and take it on scheduled time as prescribed by the
physician. Gather all the significant information regarding the medication to be taken at home
and take medication as essentials so that healing processes will be ensured and further
complication may prevent.
Taken at the hospital
o Silver Sulfadiazine on Affected Area.
o Paracetamol 500mg q 6 hours / as necessary.
o Cefuroxime 750mg q 8 hours

Exercises
o Range of Motion enhancement exercises at home.
o Deep Breathing Exercises
o Ambulation with support and as tolerated.

Treatment
o Continuous application of topical ointment
o Rehabilitation Therapy

Health Teaching

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 OUR LADY OF FATIMA UNIVERSITY
Valenzuela Campus
120 McArthur Highway, Marulas, Valenzuela City
College of Nursing

o Taking of medication must always be on time and continuous treatment, exercises at

home will help throughout the healing process.
o Advise the family to support and provide the needs of the patient.
o Provide information regarding the medication prescribed at home.
o Teach the client and family to practice aseptic technique when taking care of the burn
injury.
o Have the patient always supported in all aspects such as physical, physiological and
psychological.
o Provide knowledge about the further complication that could occur so that immediate
response and intervention will be provided.
o Provide contact information.

Outpatient/Observation
o Have scheduled regular follow check up with the physician.
o Assists the patient in Activities of daily living.
o Advise the family to note for any changes that the patient manifests.
o Always place the client in comfortable environment and place.

Diet
o Green Leafy Vegetables
o Fruits
o Meat rich in vitamins and nutrients.
o Avoidance of fatty and oily foods as well as fast and junk foods.

Spiritual
o Ensure that the patient always have someone to talk to, promote activities that will
enhance spiritual and over-all well-being.

REFERENCES
https://pcs.org.ph/wp-content/uploads/2022/03/PCS-v72-no2-1-profile_patients1.pdf
https://www.bhs.org.au/bhsapps/govdoc/gdhtml/gddrg0020-26855-60608.pdf

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 OUR LADY OF FATIMA UNIVERSITY
Valenzuela Campus
120 McArthur Highway, Marulas, Valenzuela City
College of Nursing

https://www.reliasmedia.com/articles/84953-the-burned-patient-assessment-diagnosis-and-
management-in-the-ed#:~:text=Diagnostic%20Studies&text=Basic%20laboratory%20studies
%20should%20be,a%20pregnancy%20test%2C%20when%20appropriate.
https://www.mayoclinic.org/drugs-supplements/silver-sulfadiazine-topical-route/side-effects/
drg-20068819?p=1

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