16/9/2011:

Mr C, 63 YO got a bomb in Sungai kolok

Chanif 5310420031
Blast injury: Burn in the face, chest,
Physiological effect back, feet Psychological effect

Burn in the face Inhalation CO Burn in the skin Amputation Anxiety

Tissue and mucous Intoxication CO Impairment skin Pain r/t tissue damage
damage integrity  Burn wound in the chest, back, face
 Large burn is 50 %
 CPOT: Pain score is 7
Laryngeal edema  Doctor prescribe fentanyl increase from 20
CO destruct Hb
Increase evaporation mcg, then 50 mcg, the last be 75 mcg q 1 hr

Obstruct the Hb is low, not enough Risk for infection r/t low primary and
airway Loss water and secondary immune
to bind O2
electrolyte  Burn wound in the chest, back, face
 Large burn is 48 %
Intubation OET Decrease O2 in the  Alb (L) 2.2
brain: Hypoxia, Hb Hypovolemic shock  Hb (L) 9.4
(L) 2.2 gr/dl

Pain r/t intubation procedures Low of Decrease fluid body r/t loss Electrolyte imbalance
 Intubation OET consciousness of water from the body r/t loss of electrolyte
 CPOT: Pain score is 7  Intake >output from the body
 Doctor prescribe fentanyl  Tachycardia HR Chemistry: 19/9/2011
increase from 20 mcg, then In effective clearance airway r/t 110x/minute  Cl- (H) 107.3
50 mcg, the last be 75 mcg low of consciousness  HCt is high (34.1%)  Ca (L) 6.8
q 1 hr  Cough
 Phos (L) 1.9)
 Hipersecret
 stridor
 Chanif 5310420031
High risk infection r/t invasive
procedures, low immunity
Planning:
Goal:
Patient free from infection
Nursing outcomes:
Patient will:
 Remain free from symptoms
of infection
 State symptoms of infection
of which to be aware
 Demonstrate appropriate care
of infection-prone site
 Maintain WBC count and
differential within normal
limits
Nursing intervention:
1. Observe and report sign of
infection such as redness,
warmth, discharge, fever
2. Note and report laboratory
value (WBC)
3. Asses skin for color,
moisture, texture, and turgor
in the wound
4. Use strategy to prevent
nosocomial infection:
Wound care in the steril
room (OR) as planning
5. Follow standard precaution
and wear gloves during
contact
6. Use sterile technique in
wound care
Pain r/ tissue damage,
intubation (OET), ICU
procedures
Planning:
Goal
Patient free from pain
Nursing outcomes:
 The pain level is mild pain
 Patient has high tolerance
with pain
 Patient has coping
mechanism to reduce pain
Intervention:
1. Assess pain score
2. Assess source of pain
3. Collaboration with physician
to prescribe pain medication,
such as fentanyl as planning.
4. Perform non-
pharmacological
intervention, such as simple
breathing relaxation to
reduce pain (Jong, 2006).
5. Teach patient to perform
relaxation, deep breathing by
him self
6. Monitoring side effect of
fentanyl
Electrolyte and body fluid
imbalance r/t loss of electrolyte
from the body
Planning:
Goal
Electrolyte and body fluid is
balance
Nursing outcomes:
Result of laboratory findings
electrolyte in normal range.
 Calcium
(8.1 – 10.4 mg %)
 Phosphate
(2.7 – 4.5 mg %)
 Cl
(98-106 mmol/L)
 Intake =Output
Nursing intervention:
1. Monitor vital sign each hour
2. Assess the etiology of
electrolyte imbalance
3. Monitor laboratory studies
of electrolyte
4. Collaborate with the doctor
for administer as indicated
for example isotonic
solution, e.g. 0.9% NaCl
(Normal saline),
5. Monitor intake and output
fluid of the body.
In effective clearance airway r/t
low of consciousness,
hipersecretion
Planning:
Goal
Airway is clear
Nursing outcome
 Patient will demonstrate
clear breath sounds
 free of cyanosis and dyspnea
Patient will maintain airway
clearance at all times.
Nursing Intervention:
1. Auscultate breath sound
2. Monitor respiratory pattern
3. Monitor blood gas value
4. Help the client to deep
breath
5. Assist with the suctioning