UNIVERSITY OF SOUTH FLORIDA
COLLEGE OF NURSING
Student: Casey Stevens
PATIENT ASSESSMENT TOOL .
Assignment Date: 02/20/13
Agency: Tampa General Hospital
Patient Initials: T,V
Age: 51
Admission Date: 02/19/13
Gender: Male
Marital Status: Married
Primary Medical Diagnosis with ICD-10 code:
Chemical Burn 949
Primary Language: English
Level of Education: High School Graduate
Other Medical Diagnoses:
Occupation (if retired, what from?): Terminal Operator
Leukocytosis 288.60
Number/ages children/siblings:
Children: 2 daughters: ages 20, 21
Siblings: 2 brothers: ages 60, deceased
Code Status: Full
Living Arrangements: Lives at home with his wife.
Advanced Directives: No
Surgery Date: 02/19/13
Culture/ Ethnicity /Nationality: Caucasian
Procedure: Excision grafting wound
Religion: Christian
Type of Insurance: “Workers Comp”
 2 CC:
“ I came into the hospital to get a skin graft done on my sulfuric acid burn.”
 3 HPI: (OLD CART)
O: The patient stated that his pain began on January 24th 2013.
L: The patient stated that the location of his burn is on his right ear, neck, scalp and face.
D: The patient stated that there is a constant pain in some areas, like around his ear.
C: The patient stated that the pain is a sharp throbbing pain.
A: The patient stated that he has no associated or aggravating factors.
R: The patient stated that his pain does not radiate anywhere else. What relieves his pain is his pain medications.
T: The patient stated that his pain medication is Percocet and he can take it ever 4 hours.
S: The patient stated that on a 0-10 scale his pain is ranked at a 10 without the use of pain medications but when taking
them he ranked his pain at a 5.
The patient is a 51-year-old male presenting with sulfuric acid burns to the right ear, scalp, neck, and face. The patient
stated that he got the chemical burn on January 24th 2013 and presented to the hospital right away. February 19th 2013, he
was admitted for an excision grafting wound procedure to the affected areas. February 20th 2013 the patient was first day
post op, with a skin graft to his right ear and neck. The affected areas are all wrapped up along with donor site, which is
located on his right upper thigh. The patient stated that the pain he is currently in is a constant, sharp, throbbing pain that
will go away for the most part after being administered his pain medication. The patient stated that when he takes his pain
medication on time that the pain is manageable. The medication that he is on is Percocet and his order allows him to take
it every 4 hours. When asked about his pain on a 0-10 scale that patient stated his pain is a 5 with the use of pain
medication but without it is easily a 10.
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 2 PMH/PSH Hospitalizations for any medical illness or operation
Date
Operation or Illness
Management/Treatment
Burn Injury
2008
Vasectomy
Dental Surgery
Father
Mother
70
Tumor
Stroke
Stomach Ulcers
Seizures
Heart Trouble
Gout
Glaucoma
Diabetes
Cancer
Bleeds Easily
Asthma
Arthritis
Anemia
Environmental
Allergies
Cause
of
Death
(if applicable)
Alcoholism
Age (in years)
 2 FMH
Kidney
Problems
Mental Health
Problems
Excision grafting wound
Hypertension
Burn Debridement
(angina, MI, DVT etc.)
02/19/2013
“Old age”
Aneurysms
Brother
Sister
relationship
relationship
relationship
Comments:
 1 IMMUNIZATION HISTORY
YES
NO
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
Adult Tetanus (Date) Patient is unsure
Influenza (flu) (Date): 2/19/13
Pneumococcal (pneumonia) (Date)
Have you had any other vaccines given for international travel or
occupational purposes? Please List
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 1 Allergies or
Adverse Reactions
NAME of
Causative Agent
Type of Reaction (describe explicitly)
No known allergies.
Medications
Other (food, tape,
dye, etc.)
 5 PATHOPHYSIOLOGY: (include APA reference) (include any genetic factors impacting the diagnosis,
prognosis or treatment)
Burn injury results in dramatic changes in most physiologic functions of the body within the first few minutes after
the event. The effect of burns depends on two parameters: the extent of the body surface and the depth of the cutaneous
injury. Burns exceeding 40% TBSA in most adults are considered to be major burn injuries and are associated with
massive evaporative water loss and fluctuations of large amounts of fluid, electrolytes, and plasma proteins into the body
tissues, manifested as generalized edema, circulatory hypovolemia, and hypotension.
The immediate systemic physiologic consequences of major burn injury focus on the profound, life-threatening,
hypovolemic shock that occurs in conjunction with cellular and immunologic disruption within a few minutes of injury.
Burn shock in a condition consisting of a hypovolemic cardiovascular component and cellular component.
Cellular metabolism is disrupted with onset of the burn wound, resulting in altered cell membrane permeability and
loss of normal electrolyte homeostasis. Many cytokines and inflammatory mediators in burn serum play a role in these
cellular processes. The cardiovascular and systemic responses to burn injuries are integrated with the cellular response but
are presented here as discrete entities.
 5 MEDICATIONS: (Include both prescription and OTC)
Name: Diphenhydramine (Benadryl)
Concentration
Dosage Amount: 25-50 mg
Route: Intravenous
Frequency: Every 6 hours PRN
Pharmaceutical class: Antihistamine
Home
Hospital
or
Both
Indication: Relief of allergic symptoms caused by histamine release.
Side effects/ Adverse effects: Drowsiness, dizziness, headache, blurred vision, hypotension, anorexia, dry mouth, constipation, nausea, urinary retention,
photosensitivity, pain at IM site
Name: Enoxaparin (Lovenox)
Concentration
Dosage Amount: 30 mg
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Route: Subcutaneous
Frequency: Every 12 hours
Pharmaceutical class: Antithrombotic
Home
Hospital
or
Both
Indication: Prevention of venous thromboembolism in surgical or medical patients.
Side effects/ Adverse effects: Dizziness, headache, insomnia, edema, constipation, nausea, vomiting, rash, hyperkalemia, bleeding, anemia, erythema at injection
site, hematoma, irritation, pain, fever.
Name: Lactated Ringers Infusion
Concentration
Dosage Amount: 100 mL/hr
Route: Intravenous
Frequency: 100mL/hr
Pharmaceutical class: Hypotonic solution
Home
Hospital
or
Both
Indication: Replace electrolytes
Name: Multivitamin (Thera vitamin)
Concentration
Dosage Amount: 1 tablet
Route: Oral
Frequency: Daily
Pharmaceutical class: Vitamin
Home
Hospital
or
Both
Indication: Treatment and prevention of vitamin deficiencies.
Side effects/Adverse effects: Urine discoloration, allergic reactions to preservatives, additives or colorants.
Name: Ondansetron HCI (Zofran)
Concentration
Dosage Amount: 4mg/2ML
Route: Intravenous
Frequency: Every 4 hours PRN
Pharmaceutical class: Five ht3 antagonists
Home
Hospital
or
Both
Indication: Prevention of nausea and vomiting
Side effects/Adverse effects: Headache, dizziness, drowsiness, fatigue, weakness, constipation, diarrhea, dry mouth
Name: Oxycodone (Percocet)
Concentration
Dosage Amount:1-2 tablets
Route: Oral
Frequency: 4 hours PRN
Pharmaceutical class: Opioids agonists
Home
Hospital
or
Both
Indication: moderate to severe pain
Side effects/Adverse effects: Confusion, sedation, dizziness, hallucinations, headache, blurred vision, respiratory depression, orthostatic hypotension,
constipation, dry mouth, nausea, vomiting, flushing, sweating.
Name: Pantoprazole (Protonix)
Concentration
Route: Oral
Dosage Amount: 40 mg
Frequency: Daily
Pharmaceutical class: Proton pump inhibitor
Home
Hospital
or
Both
Indication: Erosive esophagitis associated with GERD
Side effects/Adverse effects: Headache, abdominal pain, diarrhea, hyperglycemia, hypomagnesemia, bone fracture.
Name: Vitamin C tablet
Concentration
Dosage Amount: 500 mg
Route: Oral
Frequency: Twice daily
Pharmaceutical class: Water soluble vitamin
Home
Hospital
or
Both
Indication: Treatment and prevention of vitamin deficiencies.
Side effects/Adverse effects: Bright yellow urine, anaphylaxis, allergic reactions to preservations.
Name: Zinc sulfate
Concentration
Dosage Amount: 50 mg
Route: Oral
Frequency: Daily
Pharmaceutical class: Trace metal
Home
Hospital
or
Both
Indication: Replacement and supplementation therapy in patients who are at risk for zinc deficiency including patients on long term parenteral nutrition.
Side effects/Adverse effects: Gastric irritation, nausea, vomiting.
Name: Silver sulfadiazine (Silvadene)
Concentration
Dosage Amount: Cream 1 %
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Route: Topical
Frequency: Daily
Pharmaceutical class: Sulfonamides
Home
Hospital
or
Both
Indication: Prevention and treatment of wound sepsis in patients with 2 nd and 3rd degree burns
Side effects/Adverse effects: Burning, itching, pain, rash, skin discoloration, skin necrosis, leukopenia.
Name: Bacitracin- polymyxin b (Polysporin)
Concentration
Dosage Amount:
Route: Topical
Frequency: 2 times daily
Pharmaceutical class: Anti-infective
Home
Hospital
or
Both
Indication: Treatment of localized infections due to susceptible organisms.
Side effects/Adverse effects: Rash, pseudomembranous colitis, nausea, vomiting, renal failure.
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 4 NUTRITION: (Include: type of diet, 24 HR average home diet, 24 HR diet recall, your nutritional analysis)
Diet ordered in hospital? Regular diet
Diet pt follows at home?
Breakfast: Cereal, eggs, toast, pancakes
Lunch: “I skip this meal normally.” Hot pocket, something
quick.
Dinner: Meat, vegetables, sides, salad.
Analysis of home diet (Compare to food pyramid and
Consider co-morbidities and cultural considerations):
Recommended amounts for a 51 year old male
Fruits: 2 cups
Vegetables: 2 1/2 cups
Grains: 6 ounces
Protein: 5 ½ ounces
Dairy: 3 cups
Oils: 6 teaspoons
Snacks: “Everything bad for me.” Popcorn, chips, ice
cream, little Debbie’s.
My patient’s diet at home needs to improve nutritionally.
Although he does get some of the required amounts from
the food pyramid he is not getting enough for him to get all
the nutrients recommended. He needs to improve his fruit
and vegetable intake; The patient even stated that his wife
has to force him to eat a minimal amount of vegetables. It
seems he gets enough protein but it would not be a bad
thing to increase his consumption. His BMI is 22, which is
within normal range so it would not hurt to increase all of
the recommended amounts.
2 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? “My wife
How do you generally cope with stress? or What do you do when you are upset?
“ I try to not let it effect me”
“When I become upset I get a bad temper, but I have tried to change my ways and control it better.”
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
“Depressed from my illness.”
+2 DOMESTIC VIOLENCE ASSESSMENT
Consider beginning with: “Unfortunately many, children, as well as adult women and men have been or currently are
unsafe in their relationships in their homes. I am going to ask some questions that help me to make sure that you are
safe.”
Have you ever felt unsafe in a close relationship? No
Have you ever been talked down to? No
Have you ever been hit punched or slapped? No
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you? No
If yes, have you sought help for this?
Are you currently in a safe relationship? “Yes, my wife and I have been married for 5 years now.”
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 5 DEVELOPMENTAL CONSIDERATIONS:
Erikson’s stage of psychosocial development:
Inferiority
Identity vs.
Role Confusion/Diffusion
Trust vs. Mistrust
Intimacy vs. Isolation
Autonomy vs.
Generativity vs.
Doubt & Shame
Initiative vs. Guilt
Industry vs.
Self absorption/Stagnation
Ego Integrity vs. Despair
Give the textbook definition of both parts of Erickson’s developmental stage for your patient’s age group:
Generativity means transmitting something positive to the next generation. This can be done through roles of parenting,
teaching, or through social activism. Generativity is about leaving a legacy to the next generation. Stagnation is the feeling
of having done nothing to help the next generation or failure to leave a legacy.
Describe the characteristics that the patient exhibits that led you to your determination:
My patient is in the generativity stage because he is generally happy with the way his life has been. He has two daughters
who he has custody over for their whole lives. He feels like he has given back by always having a job and has always
cared for others. He said that he would not change a thing about how he has lived his life. He said nothing he has done is a
mistake because it has made him the man he is today. His first marriage, which did not work out, gave him his daughter
and has lead him to marrying the true love of his life. My patient was humble and a pleasure to work with.
Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life:
My patient’s condition has enabled my patient from working for the time being. He wants to be able to work and provide
for his family. He wants to get better as soon as he can so he can get back to work. This shows that my patient is in the
generativity stage because he still has ambition and is thinking positively.
+3 Cultural Assessment:
“What do you think is the causes of your illness?”
“Working in a dangerous work environment.”
What does your illness mean to you?
“ It means I cant work and help provide for my family.”
+3 Sexuality Assessment: (the following prompts may help to guide your discussion)
Consider beginning with: “I am asking about your sexual history in order to obtain information that will screen for
possible sexual health problems, these are usually related to either infection, changes with aging and/or quality of life.
All of these questions are confidential and protected in your medical record”
Have you ever been sexually active? Yes
Do you prefer women, men or both genders? Women
Are you aware of ever having a sexually transmitted infection? No
Have you or a partner ever had an abnormal pap smear? “Not that I know of.”
Have you or your partner received the Gardasil (HPV) vaccination? No
Are you currently sexually active? Yes
When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended
pregnancy? “We do not take any measures, I have had a vasectomy.”
How long have you been with your current partner? 5 years.
Have any medical or surgical conditions changed your ability to have sexual activity? No.
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
No
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+3 SMOKING, CHEMICAL USE, OCCUPATIONAL/ENVIRONMENTAL EXPOSURES:
1. Does the patient currently, or has he/she ever smoked or used chewing tobacco?
If so, what?
How much?
Cigarettes
0.25 packs a day
Yes
No
For how many years? 15 years
(age
thru
)
If applicable, when did the
patient quit?
Does anyone in the patient’s household smoke tobacco? If
so, what, and how much? No
Has the patient ever tried to quit?
2. Does the patient drink alcohol or has he/she ever drank alcohol?
What? Beer
How much?
On occasion
Yes
No
For how many years?
(age
thru
)
If applicable, when did the patient quit?
3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
No
If so, what?
How much?
For how many years?
(age
Is the patient currently using these drugs?
Yes No
thru
)
If not, when did he/she quit?
4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks
“Yes, working being sulfuric acid terminal operator I am exposed to many elements like sulfuric acid fumes, dust, and rust.
I have to be careful at work and not let something like this happen again.”
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 10 REVIEW OF SYSTEMS
General Constitution
Gastrointestinal
Recent weight loss or gain
Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen
SPF:
Bathing routine: Once a day
Comments: Burns to his head, neck, ears,
face, and chest.
Nausea, vomiting, or diarrhea
Constipation
Irritable Bowel
GERD
Cholecystitis
Indigestion
Gastritis / Ulcers
Hemorrhoids
Blood in the stool
Yellow jaundice
Hepatitis
Pancreatitis
Colitis
Diverticulitis
Appendicitis
Abdominal Abscess
Last colonoscopy?
Other:
HEENT
Difficulty seeing
Cataracts or Glaucoma
Difficulty hearing
Ear infections
Sinus pain or infections
Nose bleeds
Post-nasal drip
Oral/pharyngeal infection
Dental problems
Routine brushing of teeth
Routine dentist visits
Vision screening
Other:
Genitourinary
nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination: 5 x/day
Bladder or kidney infections
Comments: none
2 x/day
1x/year
Immunologic
Chills with severe shaking
Night sweats
Fever
HIV or AIDS
Lupus
Rheumatoid Arthritis
Sarcoidosis
Tumor
Life threatening allergic reaction
Enlarged lymph nodes
Other:
Hematologic/Oncologic
Anemia
Bleeds easily
Bruises easily
Cancer
Blood Transfusions
Blood type if known:
Other:
Metabolic/Endocrine
Diabetes
Type:
Hypothyroid /Hyperthyroid
Intolerance to hot or cold
Osteoporosis
Other: None
Pulmonary
Difficulty Breathing
Cough - dry or productive
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies
last CXR?
Other: None
Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when?
Other: None
Central Nervous System
WOMEN ONLY
Infection of the female genitalia
Monthly self breast exam
Frequency of pap/pelvic exam
Date of last gyn exam?
menstrual cycle
regular
irregular
menarche
age?
menopause
age?
Date of last Mammogram &Result:
Date of DEXA Bone Density & Result:
MEN ONLY
Infection of male genitalia/prostate?
Frequency of prostate exam?
Date of last prostate exam?
BPH
Urinary Retention
CVA
Dizziness
Severe Headaches
Migraines
Seizures
Ticks or Tremors
Encephalitis
Meningitis
Other:
Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other:
Musculoskeletal
Injuries or Fractures
Weakness
Pain
Gout
Osteomyelitis
Arthritis
Other:
Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever
Chicken Pox
Other:
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REVIEW OF SYSTEMS NARRATIVE
General Constitution
Pt’s perception of health:
The patient stated that he has changes in the appearance of skin because of his accident. He has burns and scars
all over his body. The patient stated having difficulty seeing due to getting older; he says he has to wear glasses
to read. He also stated having difficulty hearing because of having his ears wrapped up in gauze. The patient
said that he tries to see the dentist at least once a year along with vision screening. The patient stated that with
being in the hospital he has been constipated and has been experiencing night sweats. The patient stated that he
is slightly depressed because his wife has had cancer for the past two years and finally is cancer free. The day
she got to come home was the day he had his accident, he said it seems like they can’t catch a break.
Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
No
Any other questions or comments that your patient would like you to know? No
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±10 PHYSICAL EXAMINATION:
Orientation and level of Consciousness: Alert and Oriented x 3
General Survey: Patient was Height: 5’7
Weight: 145 lb. BMI: 22.7 Pain: (include rating & location)
5- ear, head
awake and pleasant.
Pulse: 70
Blood
Pressure: 137/76
Temperature: (route taken?) Respirations: 16
(include location) Right arm
Oral
SpO2: 98
Is the patient on Room Air or O2: Room air
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps
Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other]
awake, calm, relaxed, interacts well with others, judgment intact
Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other]
clear, crisp diction
Mood and Affect:
pleasant
cooperative
cheerful
apathetic
bizarre
agitated
anxious
tearful
Other:
Integumentary
Skin is warm, dry, and intact
Skin turgor elastic
No rashes, lesions, or deformities
Nails without clubbing
Capillary refill < 3 seconds
Hair evenly distributed, clean, without vermin
Comments: Skin had burns and scars on the chest, face,
arms. Patient’s donor sight was located on his right upper
thigh. It had some drainage.
talkative
withdrawn
quiet
boisterous
aggressive
hostile
flat
loud
Peripheral IV site Type: 18 gage
Location: Left hand/Metacarpal vein
Date inserted: 02//19/13
no redness, edema, or discharge
Fluids infusing?
no
yes - what? Lactated ringers
Peripheral IV site Type: 18 gage
Location: Lateral left arm/ Basilic vein
Date inserted: 02/19/13
no redness, edema, or discharge
Fluids infusing?
no
yes - what?
Central access device Type:
Location:
Date inserted:
Fluids infusing?
no
yes - what?
HEENT:
Facial features symmetric
No pain in sinus region
No pain, clicking of TMJ
Trachea midline
Thyroid not enlarged
No palpable lymph nodes
sclera white and conjunctiva clear; without discharge
Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness
left eye with corrective lenses
Functional vision: right eye left eye without corrective lenses right eye Functional vision both eyes together: with corrective lenses or NA
PERRLA pupil size / 3 mm
Peripheral vision intact
EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right ear- None inches & left ear- 6 inches
Weber test, heard equally both ears
Rinne test, air
time(s) longer than bone
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition:
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Comments: Patients right ear was covered with bondage.
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Pulmonary/Thorax:
Respirations regular and unlabored
Transverse to AP ratio 2:1
Chest expansion symmetric
Lungs clear to auscultation in all fields without adventitious sounds
CL – Clear
Percussion resonant throughout all lung fields, dull towards posterior bases
WH – Wheezes
Tactile fremitus bilaterally equal without overt vibration
CR - Crackles
Sputum production: thick thin
Amount: scant small moderate large
RH – Rhonchi
Color: white pale yellow yellow dark yellow green gray light tan brown red
D – Diminished
S – Stridor
Ab - Absent
Cardiovascular:
No lifts, heaves, or thrills PMI felt at: 5th intercostal space midclavicular line
Heart sounds: S1 S2 Regular
Irregular
No murmurs, clicks, or adventitious heart sounds
Rhythm (for patients with ECG tracing – tape 6 second strip below and analyze)
No JVD
Calf pain bilaterally negative
Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse:
Carotid:
Brachial:
Radial:
Femoral:
Popliteal:
DP:
PT:
No temporal or carotid bruits
Edema:
[rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema:
pitting
non-pitting
Extremities warm with capillary refill less than 3 seconds
GI/GU:
Bowel sounds active x 4 quadrants; no bruits auscultated
No organomegaly
Liver span
cm
Percussion dull over liver and spleen and tympanic over stomach and intestine
Abdomen non-tender to palpation
Urine output:
Clear
Cloudy
Color:
Previous 24 hour output:
mLs N/A
Foley Catheter
Urinal or Bedpan
Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness
Last BM: (date 02
/ 18
/ 13
)
Formed
Semi-formed
Unformed
Soft
Hard
Liquid
Watery
Color: Light brown
Medium Brown
Dark Brown
Yellow
Green
White
Coffee Ground
Maroon
Bright Red
Hemoccult positive / negative
Genitalia:
Clean, moist, without discharge, lesions or odor
Not assessed, patient alert, oriented, denies problems
Other – Describe:
Comments: Patient stated that he was constipated and had not had a bowel movement while in the hospital. The patient
stated that his last bowel movement was 02/18/13 and it was formed.
Musculoskeletal:  Full ROM intact in all extremities without crepitus
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Strength bilaterally equal at ___5____ in UE & ___5____ in LE
[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]
vertebral column without kyphosis or scoliosis
Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or parathesias
Comments:
Patients gait was intact.
Neurological: Patient awake, alert, oriented to person, place, time, and date
Confused; if confused attach mini mental exam
CN 2-12 grossly intact
Sensation intact to touch, pain, and vibration
Romberg’s Negative
Stereognosis, graphesthesia, and proprioception intact
Gait smooth, regular with symmetric length of the stride
DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus]
Triceps:
Biceps:
Brachioradial:
Patellar:
Achilles:
Ankle clonus: positive negative Babinski: positive negative
±10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well
as abnormals, include rationale and analysis. List dates with all labs and diagnostic tests):
BMP:
Sodium: 137, within normal range
Potassium: 4.0, within normal range
Glucose: 113, elevated. Normal values: 70-110
BUN: 10, within normal range
Creatinine: 1.0, within normal range
Calcium: 8.6, within normal range
CBC:
WBC: 14.2, elevated. Normal values: 3.8- 10.8
RBC: 4.33, Decreased. Normal values: 4.2-5.6
Hemoglobin: 13.8, within normal ranges
Hematocrit: 40.4, low. Normal values: 45-52%
The BMP and CBC lab results are pertinent values because the values would show if there was an infection or
moisture from his chemical burn injury. His hemoglobin level is pertinent because his donor site was bleeding.
+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES:
Skin graft: 02/19/13
Prevent infection
Diet: Regular diet
Apply dry gauze dressing over affected area (daily)
Bed rest with bathroom privileges
Follow PACU protocol including pulse ox and O2 sat to maintain O2sat above 90%
Head of bed at 30 degrees or higher
Neurovascular checks: every 4 hours
POCT glucose: 4 times daily before meals and bedtime
Skin assessment
Vital signs
Dressing change at donor site (right upper thigh)
Keep skin free from pressure
Maintain wound covering as indicated
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 2 Medical Diagnoses
(as listed on the chart)
1. Chemical Burn
 8 Nursing Diagnoses
and potential - listed in order of priority)
1. Impaired skin integrity related to epithelial skin loss.
(actual
2. Leukocytosis
2. Risk for infection related to loss of skin integrity and
impaired nonspecific and specific immunity.
3.
3. Acute pain related to chemical burn as evidence by
patient verbalizing his pain as a 10 on a 0-10 scale.
4.
4. Deficient fluid volume related to increased capillary
permeability, increased intravascular hydrostatic pressure,
and increased evaporative loss.
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± 15 for Care Plan
Nursing Diagnosis: Risk for infection related to loss of skin integrity and impaired nonspecific and specific immunity.
Patient Goals/Outcomes
Nursing Interventions to
Rationale for Interventions Evaluation of Interventions
Achieve Goal
Provide References
on Day care is Provided
Effective infection prevention:
Burn will not be colonized by
organisms
Healing s noted by wound closure
Skin integrity will be restored.
Asses for infection and document
with each dressing change
To prevent spread of infection.
Dressing change was not done
while I was there.
Assess for drainage: exudate, color, Factors that indicate infection.
odor, and amount.
Dressing change was not done
while I was there.
Notify health care provider of
presence of infection or wound
enlargement.
To facilitate medical intervention.
Patient complained of feeling
something pop under his dressing.
Nurse called provider and let him
know
Monitor serum WBC daily.
Increased WBC indicated presence
of infection.
Checked WBC count and it was
slightly elevated at 14.2.
Maintain nutritional therapies.
Malnutrition increases the risk of
infection.
Patient ate majority of all meals
given to him during my shift.
Monitor and record temperature
hourly.
Indicates infection.
Temperature remained within
normal ranges.
Culture wounds and body
secretions per protocol.
To assess for infection.
± Discharge Planning: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Perform daily cleansing and dressing changes for open areas.
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Teaching:
Elevate areas where edema formation occurs.
Avoid scratching the healed areas, as this could cause breakdown.
Avoid sunlight, as it can cause, healed wounds to discolor and darken permanently.
Wear loose fitting, soft, clothing.
Assess availability of, knowledge of, and compliance with treatment regimen.
Assess discharge placement needs: Home, rehabilitation facility, extended care facility.
Assess for professional home health needs.
Assess for follow up appointments.
Assess for infection of open wound breakdown with each dressing change and report as necessary.
Explain sigs and symptoms that require medical attention.
Assess environmental risk factors.
Maintain a high-calorie diet, high-protein diet.
Continue taking vitamins and mineral supplements as ordered.
Assess pain level and report any increase in pain.
Wean patient off pain medications when pain lessens.
Encourage both partners to express fears and concerns.
Consider the following needs:
□SS Consult
□Dietary Consult
□PT/ OT
□Pastoral Care
□Durable Medical Needs
□F/U appts
□Med Instruction/Prescription
 □ are any of the patient’s medications available at a discount pharmacy? □Yes □ No
□Rehab/ HH
□Palliative Care
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± 15 for Care Plan
Patient Goals/Outcomes
Normal wound healing to
reestablish skin integrity:
Burn wounds will heal
spontaneously or by surgical
closure as evidence by no open
wound, no drainage, and no odor.
Absence of clinical manifestations
of wound infections.
Nursing Diagnosis: Impaired skin integrity related to epithelial skin loss.
Nursing Interventions to
Rationale for Interventions Evaluation of Interventions
Achieve Goal
Provide References
on Day care is Provided
Cleanse and debride wound
Determines treatment and
prognosis
Dressing change was not done
while I was there. Patient had
surgical debridement on his burns.
Asses wound for depth, location,
and dimensions
Determines treatment and
prognosis
Dressing change was not done
while I was there.
Elevate affected areas.
To decrease edema
The patient’s head of bed remained
at a 30 degree or higher throughout
the day.
Position therapeutically
To prevent contracture formation
Kept the patient very still.
Apply antibiotic cream and/or
dressing change per health care
providers order.
Prevent infection
Provider’s orders were to wait a
day before doing a dressing
change.
Monitor blood glucose
Blood glucose was 113
Monitor donor site for infection
May convert sight to a full
thickness injury
Performed a dressing change on the
donor site. Some drainage but not
much.
Administer vitamins and minerals
per order.
To promote wound healing
Patient was given a multivitamin
(Thera vitamin), and vitamin C at
0800. Vitamin C is twice daily and
the multivitamin is only daily.
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References
Osborne, K.S., Wraa, C.E. &Watson, A.B. (2010). Medical –Surgical Nursing: Preparation for Practice.
Upper Saddle River, NJ: Pearson.
Huether, S.E., & McCance, K.L. (2012). Understand Pathophysiology (5th ed.).
St. Louis, MO: Mosby.
Nursing, C (2011, April 28). Burns. Retrieved from
http://nursing.unboundmedicine.com/nursingcentral/ub/view/Diseases-and-Disorders/73542/all/burns
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