Lecobu-an, Mae Arra G.

BSN 2-G

Case Scenario: Burns

Mrs. Tan arrived on the hospital with her husband. When the nurse asks what happened states
that she burned herself while transferring a boiling pot while she was cooking. Upon inspection
it reveals that Mrs. Tan has 2nd to 3rd degree burn on her anterior chest and abdomen, it was
noted TBSA 18% and also reveals that the burned area has reddened discoloration with moist
weeping surface and edema. She was irritable while being interviewed.

Her vital signs reveal a temperature of 37. 4 °C, respiratory rate of 18 breaths per minute, a
pulse rate of 120 beats per minute and blood pressure of 130/90mmHg. After inspection the
nurse makes sure to manage the patient and treat the affected area. The doctor also ordered to
administer IV fluids to the patient.

Continuous monitoring of vital signs and preventing infections, pain and supported was made in
order to promote healing. Health teachings and wound care was made before discharging the
patient.
ASSESSMENT NURSING DIAGNOSIS OBJECTIVES NURSING RATIONALE EVALUATION
INTERVENTION
SUBJECTIVE: Impaired skin Short term: Independent: After each nursing
“I got burned while integrity related to After 5 hours of interventions the
transferring the burns. nursing intervention Assess and document Provides baseline goals were met the
boiling pot while the patient will be the skin, identify the information and plan patient’s skin
cooking” as Nursing Diagnosis able to understand type and degree of appropriate integrity was
verbalized by the Handbook An her condition and burn. interventions. improved as
patient. evidence-based participate on evidenced by
guide to planning therapies and Monitor vital signs. Baseline data absence of edemas,
OBJECTIVE: care 11th edition page interventions needed regular wound
 2nd and 3rd 34 to be done. Provide burn care Reduces risk for healing and skin
degree burn and infection infection and tissues regenerated.
over the Long term: controls. prepares grafting.
abdomen and After 7 days of
chest. nursing intervention Assess blood supply To evaluate if there is
 TBSA 18% the patient will be and sensation on the an impairment of
 Reddened able to verbalize burned area. circulation.
discoloration comfort with an
with moist absence of edema. Keep affected area To promote natural
weeping surface The patient will also clean and dry. skin repair.
on the affected achieve wound
area. healing and show Apply appropriate To promote healing.
 Patient was tissue regeneration. wound dressing.
irritable.
Vital signs: Remove wet and Potentiates skin
 Temp: 37. 4C wrinkled linens near breakdown.
 RR: 18breaths the burned area.
per min.
 PR: 120bpm Emphasize the To provide comfort.
 BP: importance of
130/90mmHg appropriate clothing.
Educate patient the
importance of foods To aid for tissue
rich in vitamin C and healing.
proper protein
intake.

Teach patient and

perform hygienic To prevent infection
practices on burned and improve skin
skin care. integrity.

Dependent:

Administer IV fluids
as ordered by the To replace loss fluids.
doctor.