GROUP 4

FaizahShofiya Ningrum 172303101051

YuniaLusi 172303101060
Nabillah 172303101065
YeniMaulinaNingsih 172303101070
Citra Putri Lestari 172303101077
PingkanMaulidaYuliaHapsari 172303101080
Rahasan 172303101090
•ASSESSMENT
ASSESSMENT OF APRIL 15, 2002, HOUR 10.00 WIB
ROOM: SURGERY G
•IDENTITY
Name : Mrs. Jm
Age : 35 years
Gender : Female
Tribe / Nation : Java / Indonesia
Religion : Islam
Job : Not working (housewife)
Education : SD (not graduated / grade 5)
Address : SepetKulon 38 Surabaya
MRS date : 3 April 2002
•Reasons to be treated:
Templek lights burned because suddenly unconscious and fell.
•Previous major complaints:
The wound on his burning butt didn't heal.
•Efforts that have been made:
Treatment at the hospital in the Wiyung area did not heal, finally checked with Dr. Soetomo Surabaya.
•Therapy / surgery ever done:
February 2002 underwent surgery for the mandibular region due to open fracture of the sequential
mandible
B. NURSING DIAGNOSES
 Some burn injuries can be the primary diagnosis and diagnosis of injury
during suffering from common (additive) burns. Diagnosis that is
common in clients who are hospitalized with burns of more than 25% of
the total body surface area is:
 Cardiac output reduction associated with increased capillary
permiability.
 Fluid volume deficit is associated with electrolyte imbalance and loss of
plasma volume from blood vessels.
 Changes in tissue perfusion are associated with decreased cardiac
output and edema.
 The ineffectiveness of breathing patterns is associated with a decrease in
respiratory distress from inhalation trauma, airway obstruction and
pneumonia.
 Changes in comfort: pain associated with exposure to nerve endings on
damaged skin.
 Impaired skin integrity associated with burns.
 Potential infections associated with impaired skin integrity.
 Changes in nutrition: nutrition is less than the body's needs associated
with an increase in the average metabolism.
 Disruption of physical mobility associated with burns, scars and
contractures.
 Disorders of body image associated with changes in physical
appearance.