SISTER NIVEDITA GOVT.

NURSING COLLEGE

I.G.M.C., SHIMLA

SUBJECT- ADVANCE NURSING PRACTICE

HEALTH ASSESSMENT: POST BURN CONTRACTURE

SUBMITTEDTO: SUBMITTED BY

MRS. POOJA SOOD ARCHITA

SHARMA

LECTURER M.SC (N) 1STYEAR

SNGNC, IGMC SNGNC, IGMC

SHIMLA SHIMLA

SUBMITTED ON:
HISTORY OF PATIENT
IDENTIFICATION DATA

Cr No.: - 202303162990
Name: - Muskan

Age: - 3 years

Sex: - Female child

Ward- Surgery Super Speciality ward

Bed no-13

Education- Play school.

Nationality -Nepalese

Dietary habits - Non-Vegetarian

Marital status- Unmarried

Religion: - Hindu

Family income: – 10000/month

Address- Gumma, Tehsil- Kotkhai, Shimla, H.P.

Informant – Parents

Date and time of admission- 12:15 PM on 22/11/2023

Diagnose: - Post Burn Contracture.

Surgical Notes: -

 Operation – Contracture Release Rt. Little finger with K- wire insertion raw area
covered with full thickness graft.
 Steps – Part clean and drapped.
Skin marking done.
Contracture release and finger straightened & K- wire insertion done.
 Full thickness graft placed over the raw area.

Doctors- Dr. Rajesh, Dr. Pushpender, Dr. Rajan.

Chief complaint: - Patient came to IGMC, hospital with chief complaints of:

 Pain in right little finger x 5 months.

 Bent in right little finger x 5 months.

Present medical history: - Patient is having complaints pain and bent in right little finger
for 5 months. Now she is undergoing treatment in Indira Gandhi Medical College Shimla.

On admission vital signs was: -

 Temperature: 98.40F
 Pulse: 80 beats/min
 Respiration: 22 breaths/min
 SPO2: 98%

Present surgical history: - Patient is having present surgical history of post burn contracture
release.

Past medical history: - Patient is having past medical history of burn at 2.5 years when she
was playing near challah.
Past surgical history: - Patient had not any surgical history related to disease condition.

Allergic history: - Patient is not allergic to any drug.

Marital history: - Unmarried

Personal history: - Client is non vegetarian.

FAMILY HISTORY: -

Family medical history: - There is no significant medical history of client’s family. All the
members of patient’s family are healthy.

Family surgical history: - No significant surgical history of client’s family.

Family types and family members: - Client is having nuclear family and there are three
family members.

Family Tree: Keys:

Parkash (25 year/MA) Sapana (22 year/FA) MALE-

FEMALE-

Muskan (3 year/FCH)
CLIENT-

Family Composition:

Sr. Name Age Sex Relation Education Marital Occupation Health

No status status
Status

1 Parkash 25 MA Father - Married Labourer Healthy

yrs

2 Sapana 22 FA Mother 8th Married Housewife Healthy

 yrs

3 Muskan 3 yrs FC Client - Unmarried - Unhealthy

H

Socioeconomic status: - Client belongs to lower class family.

Client’s lives in a rental house with adequate water and electricity supply.

1.Physical examination

General appearance: -patient looks fatigue.

Orientation: -patient is oriented to time place and person.

Nourishment: -patient looks adequately nourished.

Body built: -patient body built is adequate.

Activity: -patient activities are normal.

Hygiene: -patient hygiene is maintained.

Level of consciousness: -patient is conscious.

Speech: -speech of the patient is normal.

Look: -patient looks active.

Height: -70 cm

Weight: - 9 kg

BMI: - 18.4

2.HEAD TO TOE EXAMINATION: -

ORGAN ASSESSMENT FINDING

HAIR 1. Hair Color: Brown in color

 2. Hair Distribution: Equally distributed

HEAD 1. Scalp: Normal,

No dandruff present.

FACE 1. Face: Normal face.

No puffiness is there

EYES 1. Eyebrows: Symmetrical in shape

Lashes are present, no sty

2. Eyelashes:
present.

3. Eyelids: Normal eyelids

Eyeballs are normal, no sunken

4. Eyeballs:
eye balls

5. Conjunctiva: Absence of conjunctivitis

6. Sclera:
No signs of jaundice

7. Cornea and iris: Normal eye cornea and iris

8. Pupils:
Dilations of pupils are normal

Lens is normal
9. Lens:
Normal vision
10. Vision:

EAR 1. External ear: Normal external ears

Normal hearing
2. Hearing:
No abnormal discharge
3. Discharge:
NOSE 1. External Nares: Normal external nares.

Normal
2. Nostrils:
3. Discharge: No abnormal discharge

MOUTH 1. Lips: Color of the lips are pink

No complaints of gingivitis
2. Gums:
3. Teeth: No cavities are present.

Teeth enamel are white in color

-Pink in color.
4. Tongue:
-No complaint of stomatitis.

-Normal throat and pharynx no

enlargement of the tonsils
5. Throat and
Pharynx

NECK 1. Lymph nodes: Normal, no enlargement of

lymph nodes

2. Thyroid glands No enlargement of thyroid glands

3. Range of motion
Normal range of motion

CHEST 1. Breath sounds Normal

Heart S1 and S2 sounds are

2. Heart
normal, no murmur sound heard
 on auscultation.

1. Inspection: On inspection abdomen shows

normal
ABDOMEN
2. Auscultation: No abnormal sounds present
3. Palpitation:
No enlargement of the liver

4. Percussion: Normal bowel sounds were

present.

SKIN 1. Color: No bluish discoloration

2. Texture:
Dry texture.

3. Temperature: Cold extremities

4. Lesions:
No lesion present in the skin

5. Scars: No scars

Stitches present on right thigh.

6. Stitches
GENITALIA 1. External genitalia Normal in appearance.
2. Discharge
There is no abnormal discharge.

UPPER EXTREMITIES 1. Inspection Bandaging and splint present in

right arm.
2. Range of motion
Restricted range of motion of
right arm.

Range of motion is intact in left

arm.

LOWER EXTREMITIES 1. Inspection Both right and left extremities are

 2. Range of motion normal in appearance.

Normal range of motion.

3. SYSTEMIC EXAMINATION:

RESPIRATORY 1. Inspection Shape of the chest is bilaterally

SYSTEM symmetrical.
2. Palpation
No abnormal mass present.

No tenderness on palpation.

3. Percussion No air or fluid accumulation in

lungs.

Breathing sounds are normal.

4. Auscultation
Respiratory rate: 18-20 resp/
min.

CARDIOVASCULAR 1. Pulse rate: 80 beats/ mins.

SYSTEM 2. Heart sounds: S1 and S2 sounds are normal.
3. Abnormal sounds:
No murmur heard on
auscultation.

GESTROINTESTINAL Abdomen: -
1. Shape: Abdomen is symmetrical.
SYSTEM
2. Abdominal No bulging or distension ruled
distension: out.

3. Bowel activity: Bowel activity is normal.

MUSCULOSKELETAL 1. Spinal curvature: Spinal curvature is symmetrical.

SYSTEM Posture is normal.
2. Posture: Extension and flexion of upper
3. Extension and right extremity is restricted
flexion of upper while extension and flexion of
and lower lower extremities is normal.
 extremities: Range of motion is normal.

4. Range of motion:

NERVOUS SYSTEM 1. Orientation Oriented to time, place and

person.
Patient is conscious and co-
2. Consciousness operative.

3. Motor sensory No motor or sensory deficit.

deficit
4. Reflex: - Reflexes are normal.
ENDOCRINE SYSTEM No investigations done to rule
out hormone level.

INTEGUMENTARY 1. Inspection Stiches present on right thigh.

SYSTEM Good.
2. Skin turgor
Soft and hydrated.

3. Texture
GENITOURINARY 1. Urinary pattern Passes urine 3-4 times during
SYSTEM day time.
2. Bowel pattern. Normal.
No complaint of constipation or
diarrhea.

INVESTIGATION: -
SR. NAME OF NORMAL PATIENT’S REMARKS
NO INVESTIGATION VALUE VALUE
.

1. HB 12.0- 15.0 g/dl 12. 7 g/dl Normal

2. RBC 3.5- 5.5 106/uL 4.61 106/uL Normal

3. WBC 4.0- 10.0 103/uL 6.3 103/uL Normal

4. PLATELET COUNT 150- 410 103/ uL 306 103/ uL Normal

5. MCV 83.0- 101.0 fl 91.6 fl Normal

6. HCT 36.0-46.0 % 33.0% Normal

X-Ray:
 MEDICATION: -

SR. DRUG DOSE/ ROUTE ACTION SIDE NURSING

NO. FREQUENCY EFFECT RESPONSIBILITY

1. Tab. Pantop 10 mg/ OD Orally Proton -Blurred -Assess the

pump vision. patient’s medical
inhibitor history.
-flushed,
dry skin. -Monitor for side
effects.
-increased
hunger. -Monitor for drug
interactions.
-increased
thirst. -Evaluate the
patient’s nutritional
status.

2. Syrup 5ml/TDS Orally Antibiotic Abdominal -Observe for

pain
Augmentin anaphylaxis.
-Allergy

-Vomiting - Ensure that the

patient has adequate
-Nausea
fluid intake during
-Diarrhea
any diarrhoea attack.

-If the patient

develops a rash,
wheezing, itching,
fever or swelling in
 the joints, this could
indicate an allergy
and should be
reported.

3. Injection 250 mg/ BD Orally Antibiotic -Black, -Observe for

tarry,
cefoperazone stools anaphylaxis.

sulbactam -bluish
colour of - Ensure that the
the skin
patient has adequate
-chills fluid intake during
any diarrhoea attack.
-cough

-dark urine
-If the patient
-difficulty develops a rash,
in
breathing wheezing, itching,
or fever or swelling in
swallowin
g the joints, this could
indicate an allergy
and should be
reported.

NURSING DIAGNOSIS

1. Acute pain related to post burn contracture release as evidenced by facial pain rating
scale.
2. Impaired physical mobility related to surgical release of contracture as evidenced by
reduced activities.
3. Impaired physical comfort related to pain and restricted activities as evidenced by
verbalization of client.
4. Anxiety related to hospital stay and treatment regimen as evidenced by facial
expressions.
 5. Knowledge deficit related to treatment regimen as evidenced by asking questions
from the parents.

SHORT TERM GOALS

1. To relieve pain.
2. To assist in activity of daily living.
3. To provide comfort.

LONG TERM GOALS

1. To reduce anxiety.
2. To provide knowledge regarding treatment regimen.
3. To build adherence to treatment regimen.
HEALTH EDUCATION

1. Hygiene

Educate the patient and family:

 To maintain proper hygiene regularly.

 To take bath daily and change undergarments daily.
 To do proper hand washing before taking food.
2. Diet

Educate the patient and family:

 To take frequent meal.

 To avoid spicy food.
 To take diet high in proteins, calcium and vitamin D.
 To avoid food items high in sugar.
 To include vitamin E in diet to promote tissue healing.
3. Exercise-

Educate the patient and family:

 To do range of motion exercise daily.

 To avoid strenuous activities to avoid excessive physical exertion.
 Advice for deep breathing exercise.
 Encourage for regular physical activity.
4. Medication and follow up-

Educate the patient and family:

 To take medicine daily at regular time.

 For regular follow up whenever needed.
 Advice for regular taking medicines according to doctor’s prescription.
REFERENCES:

 https://fadavispt.mhmedical.com/content.aspx?
bookid=1873&sectionid=139004611
 https://nurseslabs.com/burn-injury/
 https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/
Nursing_management_of_burn_injuries/