Endorsement 812
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College of Nursing and Midwifery
STAFF ENDORSEMENT SHEET Room no: _812___ grafting . Diet: DAT_ Name of Patient: _Moises, Miguel , Jr.___________________ Cruz______Age: 35 y/o_ Sex_Male_____ DOCTOR’S ORDER
No New Doctors Order
Diagnosis: Full thickness burn 15% TBSA S/P thickness skin
NURSE’S NOTES Received patient conscious and coherent. Vital Signs taken and recorded. Due meds. Given. Kept safe and comfortable. Needs attended. Endorsed.
Attending Physician: _Dr. Nicomedes IVF MEDICATIONS Paracetamol 500mg.Q6 PRN Chlorphenamine 4mg.1tab.PRN Vit.B Complex 1 tab. BID Oxacillin 500mg. QID
INTAKE/OUTPUT Urine -3 times Stool – (-)
Prepared by: _Genoveva Sharon Muyco Margallo___ Staff Nurse
LAB EXAMS/PROCEDURES
No Laboratory Request
Noted by: Head Nurse
College of Nursing and Midwifery
NURSING CARE PLAN Patient’s Initial: _Mr. M. M.___ Room: __812__ ASSESSMENT SUBJECTIVE: “Extreme anxiety restlessness; pain, as verbalized by the patient.” OBJECTIVE: •
•
•
•
Changes in appearance of skin indicate degree of burn. Electrolyte imbalance: cellular destruction result initially in hyperkalemia. Elevated hematocrit as a result of fluid loss. Presence of symptoms of hypovolemic shock caused by circulatory failure resulting from seepage water, plasma, proteins, and electrolytes into burned area.
Diagnosis: Full thickness burn 15% TBSA, S/P thickness skin grafting
DIAGNOSIS •
•
Pain related to exposed nerve endings. Fluid volume deficit related to fluid loss through burn wound and shift of fluid out of intravascular compartment.
PLANNING •
•
•
•
•
•
Monitor vital signs, CVP, intake and output (hourly urine output), and specific gravity as ordered. Observe for signs of electrolytes imbalance (calcium, potassium, and sodium) and metabolic acidosis. Observe for signs of infection (rising temperature and white blood cell count, odor) Monitor respiratory function: characteristics of respirations breathe sounds, and arterial blood gases. Give medication for pain as ordered and particularly before dressing change. Keep room temperature warm
INTERVENTION •
•
• • •
Establishment of airway and administration of oxygen; mechanical ventilation as needed. IV replacement (electrolyte solutions and colloids such as blood and plasma) to maintain circulation. Skin grafting to limit fluid loss. Vital signs monitored every 15 minutes. Tetanus toxoid booster administration; tetanus human immune globulin for passive immunity if not previously immunized.
RATIONALE •
•
• • •
To maintain or restore pulmonary ventilation and oxygenation. To maintain or restore normal balance of electrolytes in the intracellular and extracellular compartment. To promote wound healing. For early assesstment of abnormalities. Prevention from tetanus.
EVALUATION • • • • •
Maintains respiratory function. Maintains fluid balance. Remains free of infection. Expresses feelings about altered body image. Goal partially met.
• VITAL SIGNS:
and humidity high. Give realistic reassurance.
Temp. -36.5 C PR. – 80 b/ min. RR. -21 count / min. BP. -120/80 mmHg.
Prepared by: _Genoveva Sharon Muyco Margallo_ Staff Nurse
Noted by: Marianne Cherry Lazo__ Head Nurse
STAFF ENDORSEMENT SHEET Room no: _812___ grafting . Diet: DAT_ Name of Patient: _Moises, Miguel , Jr.___________________ Cruz______Age: 35 y/o_ Sex_Male_____ DOCTOR’S ORDER
No New Doctors Order
Diagnosis: Full thickness burn 15% TBSA S/P thickness skin
NURSE’S NOTES Received patient conscious and coherent. Vital Signs taken and recorded. Due meds. Given. Kept safe and comfortable. Needs attended. Endorsed.
Attending Physician: _Dr. Nicomedes IVF MEDICATIONS Paracetamol 500mg.Q6 PRN Chlorphenamine 4mg.1tab.PRN Vit.B Complex 1 tab. BID Oxacillin 500mg. QID
INTAKE/OUTPUT Urine -3 times Stool – (-)
Prepared by: _Genoveva Sharon Muyco Margallo___ Staff Nurse
LAB EXAMS/PROCEDURES
No Laboratory Request
Noted by: Head Nurse
College of Nursing and Midwifery
NURSING CARE PLAN Patient’s Initial: _Mr. M. M.___ Room: __812__ ASSESSMENT SUBJECTIVE: “Extreme anxiety restlessness; pain, as verbalized by the patient.” OBJECTIVE: •
•
•
•
Changes in appearance of skin indicate degree of burn. Electrolyte imbalance: cellular destruction result initially in hyperkalemia. Elevated hematocrit as a result of fluid loss. Presence of symptoms of hypovolemic shock caused by circulatory failure resulting from seepage water, plasma, proteins, and electrolytes into burned area.
Diagnosis: Full thickness burn 15% TBSA, S/P thickness skin grafting
DIAGNOSIS •
•
Pain related to exposed nerve endings. Fluid volume deficit related to fluid loss through burn wound and shift of fluid out of intravascular compartment.
PLANNING •
•
•
•
•
•
Monitor vital signs, CVP, intake and output (hourly urine output), and specific gravity as ordered. Observe for signs of electrolytes imbalance (calcium, potassium, and sodium) and metabolic acidosis. Observe for signs of infection (rising temperature and white blood cell count, odor) Monitor respiratory function: characteristics of respirations breathe sounds, and arterial blood gases. Give medication for pain as ordered and particularly before dressing change. Keep room temperature warm
INTERVENTION •
•
• • •
Establishment of airway and administration of oxygen; mechanical ventilation as needed. IV replacement (electrolyte solutions and colloids such as blood and plasma) to maintain circulation. Skin grafting to limit fluid loss. Vital signs monitored every 15 minutes. Tetanus toxoid booster administration; tetanus human immune globulin for passive immunity if not previously immunized.
RATIONALE •
•
• • •
To maintain or restore pulmonary ventilation and oxygenation. To maintain or restore normal balance of electrolytes in the intracellular and extracellular compartment. To promote wound healing. For early assesstment of abnormalities. Prevention from tetanus.
EVALUATION • • • • •
Maintains respiratory function. Maintains fluid balance. Remains free of infection. Expresses feelings about altered body image. Goal partially met.
• VITAL SIGNS:
and humidity high. Give realistic reassurance.
Temp. -36.5 C PR. – 80 b/ min. RR. -21 count / min. BP. -120/80 mmHg.
Prepared by: _Genoveva Sharon Muyco Margallo_ Staff Nurse
Noted by: Marianne Cherry Lazo__ Head Nurse
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