Calamba Shaira Ann V.
Abea 14 yr old, M
BSN 3Y1-3S
 down.
Pathophysiology:
Dx: Burns
Medical history
Risk for electrolyte imbalances related to hyponatremia as
evidenced by decreased of sodium in the body
Patient was taking up furosemide which is a loop diuretic
 Obtain specimens for analysis of altered potassium levels (e.g.,
serum and urine potassium) as indicated.
 Administer prescribed supplemental potassium (PO, NG, or IV)
per policy
 Monitor for neurologic and neuromuscular manifestations
 Weigh daily and monitor trends.
 Maintain accurate I & O record.
 Monitor vital signs as appropriate.
 Patient explains measures that can be taken to treat
or prevent fluid volume loss.

Medications:
Abea 14-year old boy who stoked a fire in a
wood burning stove and was hurt by a
subsequent explosion. He was transported to the
local burn ICU (BICU). He sustained an 82% total
body surface area (TBSA) thermal burn. Abe’s
burns included bilateral full thickness
circumferential burns to his legs and feet, arms,
and hands, genetalia and deep partial thickness
burn to his head and anterior trunk
Medical Management:
 Restrict Fluid
 Treat underlying cause
 IV therapy: Hypotonic, Saline
 Administer Furosemide
 Administration of Demeclocycline
Risk for fall related to orthostatic hypotension as
evidenced by dizziness
Ineffective Therapeutic Management related to
noncompliance to the treatment
Dizziness
 For patients at risk for falls, provide signs or secure a Patient declined chemotherapy
wristband identification to remind healthcare providers to
implement fall precaution behaviors.
 Move items used by the patient within easy reach  Inform patients the benefits of adherence to prescribed
 Respond to call light as soon as possible. regimen.
  Used variety teaching methods
 See to it that the beds are at the lowest possible position.  Introduced complicated therapy one step at the time
 Use side rails on beds, as needed. For beds with split side  Include significance others in explaining the procedures.
rails, leave at least one of the rails at the foot of the bed Encourage their support assistance in following plans this
down. may enhance overall
 Teach client how to safely ambulate at home, including using
safety measures such as handrails in bathroom.
 Patient describe intention to follow prescribed regimen
 Patient will relate the intent to use safety measures
to prevent falls.
