COLLEGE OF HEALTH SCIENCES

DEPARTMENT OF NURSING
HOLY NAME UNIVERSITY
CITY OF TAGBILARAN

NURSING CARE PLAN

Name of Patient: _Mr. John Kanaman_______________________ Age: _42___ Status:_Single___________________

Address: _Dampas District, Tagbilaran City, Bohol___________________ Date: 11/9/21 Ward: Burn Unit Bed No: 2____
Impression: Stage 3 burn wounds on his anterior and posterior torso and entire left arm with stage 2 burns on his anterior neck.

ASSESSMENT/ DIAGNOSIS PLANNING INTERVENTION

PROBLEM RATIONALE OF THE DESIRED BEHAVIORAL NURSING RATIONALE EVALUATION
CUES/NRSG. DX PROBLEM OUTCOME(S) OUTCOME(S) INTERVENTIONS
Nursing Dx: Ineffective airway After 5 days of After 3 days of Dependent: After 5 days of
clearance occurs when nursing nursing nursing
Ineffective Airway an artificial airway is intervention, the intervention, the  Administer  Medications are intervention, the
Clearance related to used because normal patient will be able patient will be able medication as required to help patient has
Tracheobronchial mucociliary transport to maintain clear, to: per physician’s prevent further maintained clear
Obstruction secondary mechanisms are open airways as order. complications. and open airways
to effects of smoke bypassed and impaired. evidence by  demonstrate as evidenced by
inhalation as evidenced Nursing assessment and normal breath clear breath absence of stridor
by stage 3 burn intervention are the keys sounds, and sounds Independent: breath sounds,
wounds on his anterior to maintaining airway normal rate and  demonstrate  Immediately  Exposure to and normal range
and posterior torso, patency in the patient depth of increased air assess the materials burn of respiratory
stage 2 burns on his with an artificial airway respiration. exchange patient’s airway, can cause rate.
anterior neck and in place.  respiratory rate breathing, and inhalation
presence of stridor within normal circulation. Be injury.
breathing pattern. range especially alert
for signs of
smoke
inhalation, and
 pulmonary
Subjective Data: damage: singed
nasal hairs,
“Aray! Aray! Sakit mucosal burns,
akong bukton!” as voice changes,
verbalized by the coughing,
patient. wheezing, soot
in the mouth or
Patient also states he nose, and
feels dizzy and weak. darkened
sputum.
Objective Data:
 BP= 90/50mmhg  Monitor  Tachypnea, use
 HR= 112 respiratory rate, of accessory
 RR= Ambu bag rhythm, depth: muscles,
(AB) note presence of presence of
 Temp= 36.4°C pallor or cyanosis, and
 Weight=75 kg cyanosis and changes in
 Height 5’6” carbonaceous or sputum suggest
 Oxygen saturation pink-tinged developing
of 92% sputum. respiratory
 Facial Grimace distress or
pulmonary
edema and
need for
medical
intervention.

 Auscultate  Airway
lungs, noting obstruction
stridor, and/or
wheezing or respiratory
crackles, distress can
 diminished occur very
breath sounds, quickly or may
brassy cough. be delayed,
e.g., up to 48 hr
after burn.

 Note presence of  Suggests

pallor or cherry- presence of
red color of hypoxemia or
unburned skin. carbon
monoxide.

 Elevate head of  Promotes

bed. Avoid use optimal lung
of pillow under expansion or
head, as respiratory
indicated. function. When
head or neck
burns are
present, a
pillow can
inhibit
respiration,
cause necrosis
of burned ear
cartilage, and
promote neck
contractures.

 Encourage  Promotes lung

coughing or expansion,
deep breathing mobilization
 exercises and and drainage of
frequent secretions.
position
changes.

 Provide and  Chest

assist with chest physiotherapy
physiotherapy drains
and incentive dependent areas
spirometry. of the lung, and
incentive
spirometry may
be done to
improve lung
expansion,
thereby
promoting
respiratory
function and
reducing
atelectasis.
 COLLEGE OF HEALTH SCIENCES
DEPARTMENT OF NURSING
HOLY NAME UNIVERSITY
CITY OF TAGBILARAN

DRUG STUDY

Name of Patient : _Mr. John Kanaman____ Address : Dampas District, Tagbilaran City, Bohol
Impression: Stage 3 burn wounds on his anterior and posterior torso and entire left arm with stage 2 burns on his anterior neck.
Date Admitted / Seen : _11/9/21______ Ward : _Burn Unit_________ Room : Burn Unit Status : Single Age : _42____ Sex : Male_

Date Brand Generic DOSAGE Route & Classification/ Indication Contraindications Nursing Evaluation
Ordere Name Name Frequency Mechanism of Responsibilities
d Action
Roxanol Morphine 2 mg IV ; every Morphine binding to Morphine is Hypersensitivity to Monitor blood The patient
Sulfate 4 hrs PRN opioid receptors indicated for the morphine; respiratory pressure prior to has
11/9/21 blocks transmission relief of severe insufficiency or administration. responded
of nociceptive acute and severe depression; severe Hold if systolic well to the
signals, signals pain- chronic pain. CNS BP < 100 mm Hg medication
modulating neurons depression;attack of or 30 mm Hg as
in the spinal cord, bronchial asthma; below baseline. evidenced
and inhibits primary heart failure by relief of
afferent nociceptors secondary to chronic Monitor patient's pain from
to the dorsal horn lung disease;cardiac respiratory rate brun
sensory projection arrhythmias;increase prior to wounds.
cells. Morphine has d intracranial or administration.
a time to onset of 6- cerebrospinal
30 minutes. pressure;head Reassess pain
 injuries;brain tumor; after
acute alcoholism; administration of
delirium tremens; morphine.
convulsive disorders;
after biliary tract Monitor for
surgery; suspected respiratory
surgical abdomen; depression and
surgical anastomosis; hypotension
concomitantly with frequently up to
MAO inhibitors or 24 hours after
within 14 days of administration of
such treatment. morphine.
Silvaden Silver 1% Apply Produced by Prevention and Hypersensitivity to Observe for and The patient
e Sulfadiazine affected reaction of silver treatment of other sulfonamides; report has
11/9/21 area ; nitrate with sepsis in second- G6PD deficiency; hypersensitivity responded
twice a day sulfadiazine. and third-degree pregnancy (category reaction: Rash, well to the
Mechanism of action burns. C), pregnant women itching, or medication
differs from that of at term, lactation, burning sensation as
either component. premature infants and in unburned evidenced
Silver salt is released neonates <2 mo areas. by healing
slowly and exerts of burn
bactericidal effect Lab tests: Obtain wounds.
only on bacterial cell serum sulfa
membrane and wall, concentrations,
rather than by urinalysis, and
inhibiting folic acid kidney function
synthesis; tests when drug is
antibacterial activity applied to
is not inhibited by p- extensive areas.
aminobenzoic acid Significant
(PABA). Contact quantities of drug
with sodium may be absorbed.
chloride in body
 tissues and fluids Observe patient
results in slow for reactions
release of attributed to
sulfadiazine, which sulfonamides.
may be systemically
absorbed from Note: Analgesic
application site. may be required.
Occasionally,
pain is
experienced on
application;
intensity and
duration depend
on depth of burn.

Continue
treatment until
satisfactory
healing or burn
site is ready for
grafting, unless
adverse reactions
occur.
Tetanus Tetanus 0.5 ml IM ; now Tetanus prophylaxis Tetanus Toxoid History of serious Observe the 12 The patient
Toxoid action: Tetanus Adsorbed allergic reaction (i.e., rights in giving has
11/9/21 toxoid promotes vaccine is anaphylaxis) to the medication. responded
active immunity by indicated for vaccine components well to the
inducing production active or encephalopathy Monitor vital medication
of tetanus antitoxin. immunization of (e.g., coma or signs. as
Absorption: children 7 years prolonged seizures) evidenced
Absorbed slowly. of age or older, not attributable to an Allow the patient by absence
Nonabsorbed and adults, identifiable cause to lie down to of infection
formulation provides against tetanus, within 7 days of prevent vomiting. from burn
 quicker booster wherever administration of a wounds.
effect. combined vaccine with Educate the
antigen pertussis components patient to increase
preparations are (this is a fluid intake to
not indicated. contraindication for prevent
This vaccine the pertussis dehydration.
should not be components; Td can
used for be used) Educate patient
immunizing that pain and
children below 7 tenderness in the
years of age. injection site may
occur.
Zantac Ranitidine 50 mg IVTT ; Ranitidine is a Ranitidine is Ranitidine is Potential toxicity The patient
11/9/21 every 8 competitive inhibitor used to treat contraindicated in results from has
hours of histamine H2- ulcers of the any patient decreased responded
receptors. The stomach and hypersensitive to the clearance well to the
reversible inhibition intestines and drug or its (elimination) and medication
of H2-receptors in prevent them components. Cross- therefore as
gastric parietal cells from coming sensitivity in this prolonged action; evidenced
results in a reduction back after they class of compounds greatest in the by
in both gastric acid have healed. has been observed, so older adult prevention
volume and This medication ranitidine should be patients or those of stress
concentration. is also used to administered with with hepatic or ulcers due
treat certain caution to patients renal dysfunction. to burn
stomach and with a history of H2- wounds.
throat blocker Lab tests:
(esophagus) hypersensitivity. Periodic liver
problems (such functions.
as erosive Monitor
esophagitis, creatinine
gastroesophageal clearance if renal
reflux disease- dysfunction is
GERD, present or
Zollinger- suspected. When
Ellison clearance is <50
syndrome). mL/min,
manufacturer
recommends
reduction of the
dose to 150 mg
once q24h with
cautious and
gradual reduction
of the interval to
q12h or less, if
necessary.

Be alert for early

signs of
hepatotoxicity
(though low and
thought to be a
hypersensitivity
reaction):
jaundice (dark
urine, pruritus,
yellow sclera and
skin), elevated
transaminases
(especially ALT)
and LDH.