ASSESSMENT Subjective: Ang sakit ng mga binti kong nasunog. As verbalize by patient.

. Objective: - Noticeable guarding behavior and protective gestures. - Restless and irritable. - Observed facial mask of pain.

DIAGNOSIS Acute pain related to damage tissue Of surface area.

PLANNING After 30 minutes of nursing intervention, the patient will be able to explore methods for allevation and control of pain.

INTERVENTION - Determine the clients acceptable level of pain/pain control goals. - Determine factors in clients lifestyle (e.g. alcohol/ other drug abuse and use.) -Note when pain occurs (e.g. only with ambulation,every evening). -Provide comfort measures like touch,repositioning,use of heat/cold packs,nurse presence,quiet environment and calm activities. - Instruct or encourage use of relaxation techniques such as focused breathing, Imaging and music therapy. -Review procedures/expectations and tell client when treatment may cause pain. -Position the patient to Semi-Fowlers position.

RATIONALE - Pain experience varies with individual and situation. - Affects response to analgesics and/or choice of interventions for pain management. -To medicate prophylactically as appropriate.

EVALUATION After nursing intervention, the patient was now able to explore methods for control of pain.

- To promote nonpharmalogical pain management.

-To distract attraction and reduce tension.

Vital Signs: BP- 130/90 Temp- 37.9 PR- 88 RR- 29

-To reduce concern of unknown and associated muscle tension. - To promote lung expansion.

-Administer analgesics as indicated to maximum dosage as needed.

- To maintain acceptable level of pain. Notify physician if regimen is inadequate to meet pain control goal.

ASSESSMENT Subjective: Masyadong makati at makirot ang sugat sa tuhod ko. As verbalized by patient. Objective: - Burned skin surface area. ( 1st degree burn).

DIAGNOSIS Impaired skin integrity related to disruption of skin surface area.

PLANNING After 2 hours of nursing intervention, the patient will be able to correct and minimize condition and promote optimal healing.

INTERVENTION -Inspect skin on a daily basis, describing wound/lesion characteristics and changes observed. -Periodically remeasure/photograph wound and observe complications. -Keep the area clean/dry, carefully dress wounds and stimulate circulation to surrounding area. -Assist with debridement/enzymatic therapy as indicated.

RATIONALE - This will serve as baseline data of the patient.

EVALUATION The patient was now able to know the correction of the disrupted skin surface. And also able to know how to promote optimal healing.

-To monitor progress of wound healing.

- To assist bodys natural process of repair. -To remove non viable, contaminated or infected tissue. It promotes skin regeneration.

Vital Signs: BP- 120/80 Temp- 37.5 PR- 84 RR-22

-Limit/avoid use of plastic material. Remove wet/wrinkled linens promptly. -Encourage early ambulation/mobilization.

-Moisture potentiates skin breakdown.

-Promotes circulation and reduces risks associated with immobility.

-Provide optimum nutrition including Vitamins A,C,D and E and increase protein intake.

-To provide a positive nitrogen balance to aid in skin/tissue healing and to maintain general good health. - To assist with developing plan of care for problematic or potentially serious wound.

- Consult with wound/stoma specialist as indicated.

ASSESSMENT Subjective: Nanghihina at matamlay ako sa mga nagdaang araw. As verbalized by patient.

DIAGNOSIS Risk for infection secondary to disruption of primary defense.

PLANNING After 1 hour of nursing intervention, the patient will be able to identify the ways on how to prevent or reduce risk for infection.

INTERVENTION -Assess and document skin condition. - Stress proper hand hygiene by all caregiver between therapies/clients. -Monitor clients visitors/caregivers for respiratory illnesses. Offer masks and tissue pads when coughing. -Recommend routine of bed bathing when indicated. -Maintain sterile technique for all invasive procedures like IV and Catheter. -Encourage early ambulation,deepbreathing exercise, coughing, and position changes.

RATIONALE - Serves as the baseline data. - A first-line defense against healthcare associated infection.

EVALUATION Goal met. The patient was able to response to interventions, teachings and actions performed.

Objective: - Flame burn 15% total body surface area. - Irritable and restless.

- To limit exposure thus reduce cross contamination.

- To reduce bacterial colonization.

- To prevent contamination and infection.

Vital Signs: BP- 120/70 Temp- 37.7 PR- 82 RR- 24

-For mobilization of the respiratory secretions and prevention of aspiration/respiratory infections. - To avoid bladder distention/urinary stasis.

- Maintain adequate hydration,stand/sit to void and catheterize if necessary. - Provide regular urinary catheter/perineal care.

- Reduces risks of ascending urinary tract infection.

DRUG NAME

MECHANISM OF ACTION

ADMINISTRATION

INDICATION

CONTRAINDICATION

ADVERSE EFFECTS

NURSING RESPONSIBILTY

Generic name: Cefuroxime

Classification: Cephalosporin

Dosage: 750mg/Tab Route: Oral Frequency: Every 8 hours for 7 days.

Mode of action: Brand name: Kefurox,Zinacef Anti-biotic that primarily kills Staphylococcus aureus.

Useful to patient with urinary tract infection and to prevent infection with burn patient.

Patients with: -Hepatic disease -Renal impairment -Pregnant 3-4 months. - Patients with allergy to any drug or antibiotic.

It can cause: -Gastric irritation -Nausea/ vomiting -can cause platelet dysfunction. -Overdose can cause seizures. -Pain in injection site -Phlebitis and thrombophlebi tis

* Advised patient to take it in full stomach. * Check for bleeding time or prothrombin time. Check CBC. * Give medication to patient observing 9 R s. * Take Vital signs before and after administration of the drug. * Give medication ANST.

DRUG NAME Generic name: Omeprazole

MECHANISM OF ACTION

ADMINISTRATION

INDICATION They are effective in treating severe erosive esophagitis. They are in the shortterm treatment of active peptic ulcer disease.

CONTRAINDICATION

ADVERSE EFFECTS - headache - diarrhea

NURSING RESPONSIBILTY * Advised patient to take it in full stomach.

Classification: Protein pump inhibitor

Dosage: 40mg/vial Route: Intravenously Frequency: Every 6 hours for 6 days.

Patients with: -Hepatic disease -Renal impairment -Pregnant 3-4 months. - Patients with allergy to any drug or antibiotic.

Brand name: Mode of action: Prilosec It blocks the enzymes that pumps hydrogen ion into the luminal side of the parietal cells of the stomach.

* Give medication nausea/vomitin to patient g observing 9 R s. -abdominal pain -pain irritation * Take Vital signs before and after administration of the drug. * Give medication ANST.

DRUG NAME Generic name: Tramadol

MECHANISM OF ACTION

ADMINISTRATION

INDICATION Long term treatment of chronic pain syndromes,c ancer pain,lower back pain, neuropathic pain and orthopedic and joint conditions.

CONTRAINDICATION

ADVERSE EFFECTS headache - diarrhea -nausea/ vomiting -abdominal pain -pain irritation

NURSING RESPONSIBILTY Advised patient to take it in full stomach. * Give medication to patient observing 9 R s. * Take Vital signs before and after administration of the drug. * Give medication ANST.

Classification: Dosage: Non-opioid drug 50mg/vial Route: Intravenously Frequency: Every 8 hours for 5 days.

Mode of action: Brand name: Tramadol It binds the muopioid receptor and inhibiting norepinephrine and serotonin uptake.

Hypersensitivi ty to reactions of opioid agonistantagonist drugs. -Hepatic disease -Renal impairment -Pregnant 3-4 months.

DRUG NAME Generic name: Nalbuphine

MECHANISM OF ACTION

ADMINISTRATION

INDICATION It is used for analgesia during labor for sedation before surgery and have little anti-tussive action.

CONTRAINDICATION

ADVERSE EFFECTS - headache - diarrhea -nausea/ vomiting -abdominal pain -pain irritation - Lightheadedness -visual hallucinations -disorentation -euphoria -confusions -insomnia

NURSING RESPONSIBILTY *Give medication to patient observing 9 R s. * Take Vital signs before and after administration of the drug. * Give medication ANST.

Classification: Mixed agonistantagonist and partial agonist.

Dosage: 10mg/vial Route: Intravenous Frequency: PRN if severe pain occurs

Brand name: Nubaine

Hypersensitivi ty to reactions of opioid agonistantagonist drugs. -Hepatic disease -Renal impairment -Pregnant 3-4 months.

Mode of action: These drugs act as agonist at kappa opiod receptors and as partial antagonists at mu receptors.

DRUG NAME Generic name: Silver sulfadiazine and cerium nitrate

MECHANISM OF ACTION

ADMINISTRATION

INDICATION For moderate to severe burned skin cases. To avoid further infection to disrupted skin layer and regain the skin-layer structure normally

CONTRAINDICATION

ADVERSE EFFECTS

NURSING RESPONSIBILTY

Brand name: Flammacerium

Mode of action: An anti-biotic topical drug that protects the burned body surface area from pathogens and regenerates skin surface area.

Dosage: see Topical use instruction Route: Skin Frequency: 2 times a day ( morning and evening)

-Patients with allergy to such drug.

-Skin irritation - skin heat and itchiness - Pain upon administration

*Give medication to patient observing 9 R s. * Take Vital signs before and after administration of the drug. * Observe the burned skin area before and after administration.