2017, Number 12
CuidArte 2017; 6 (12)
Nursing process to a patient with third grade burns based on the gordon theory
Barrera MLJ
Full text
Language: Spanish
References: 18
Page: 56-77
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ABSTRACT
The present study involves a nursing care process applied to a 70-year-old patient at Dr. Victorio de la Fuente Narváez Hospital for Traumatology, Orthopedics, and Rehabilitation’s highly specialized medical unit, May 2–5, 2017. The burn was caused by direct contact with fire. Per Wallace’s rule of nines, the burn, located on the left hip at the back of the thigh, was 4% of the body surface. Because of its depth, it was a third-degree burn. The bed burn was dark brown and painless. The patient showed signs of hypertension and diabetes mellitus type 2 with a lack of adherence to the prescribed pharmacological, dietetic, and physical treatment. Vital signs as measured were: heart rate, 77 bpm; respiratory rate, 24 breaths per minute; blood pressure, 154/97 mmHg; average blood pressure, 116 mmHg; body temperature, 37ºC; VAS pain scale, 8/10. A lack of vesicular murmur in the base of the lung field was observed, as well as hematuria (likely prostatic hyperplasia as evaluated by the urology service), a negative hydric balance of 300 cc, constipation which had begun four days earlier, and pulmonary edema (+++ on Godet’s scale) in the thoracic members, the pelvis and the scrotum. The patient was emotionally irritable, showed signs of depression, and expressed a wish to die. The main interventions performed were pain control, handling of hydric balance, checking for signs of infection, monitoring respiration, ozone therapy, emotional support, bedridden patient care, and infection prevention.REFERENCES
Aguilar-Ruíz E. C., Ramírez-Gutiérrez N., Camaño-Vicente E. C., Hernández-Corral S. Intervenciones de enfermería especializada en un adulto con alteraciones de la marcha ocasionadas por quemadura eléctrica. Enferm. univ [revista en la Internet]. 2013 Dic [citado 2017 Jul 10]; 10( 4 ): 139-146. Disponible en: http://bit.ly/2wqJluL