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INTRODUCTION
C. Chief complaint
During the anal stage, Freud believed that the primary focus of the libido
was on controlling bladder and bowel movements. The major conflict at this
stage is toilet training--the child has to learn to control his or her bodily needs.
Developing this control leads to a sense of accomplishment and
independence.
According to Freud, success at this stage is dependent upon the way in which
parents approach toilet training. Parents who utilize praise and rewards for
using the toilet at the appropriate time encourage positive outcomes and help
children feel capable and productive. Freud believed that positive experiences
during this stage served as the basis for people to become competent,
productive, and creative adults.
However, not all parents provide the support and encouragement that
children need during this stage. Some parents' instead punish, ridicule, or
shame a child for accidents. According to Freud, inappropriate parental
responses can result in negative outcomes. If parents take an approach that
is too lenient, Freud suggested that an anal-expulsive personality could
develop in which the individual has a messy, wasteful, or destructive
personality. If parents are too strict or begin toilet training too early, Freud
believed that an anal-retentive personality develops in which the individual is
stringent, orderly, rigid, and obsessive.
02-02-08
re-insert IVF to continue IVF treatment
IVFTF: plain LR 1L @ 30cc/hr provide fluid and electrolyte
Repeat CXR-APL now to check chest X-ray
Continue meds to continue treatment
Change dressing to prevent infection
May give paracetamol for fever
100mg/ml 1.2 ml RTC
02-03-08
IVFTF: plain LR 1L @ 30cc/hr provide fluid and electrolyte
Continue meds to continue treatment
Dressing done to prevent infection
Shift cefazolin to ceftazidine for antibiotic treatment
265mg IVTT every 8H
Will endorse patient to respi for co-management
service (Dr. Austria/Aranggo)
02-04-08
IVFTF: plain LR 1L @ 30cc/hr provide fluid and electrolyte
Continue meds to continue treatment
Dressing done to prevent infection
02-05-08
Please re-insert IVF to continue IVF treatment
IVFTF: plain LR 1L @ 30cc/hr provide fluid and electrolyte
Continue meds to continue treatment
Repeat CBC today for lab study
B. Drug Study
Generic Date Classification Dose/ Mechanism Specific Contra- Side Nursing
Name of Ordered Frequenc of Action Indication indication Effects/ Precaution
Ordered y/ Route Toxic
Drug Effects
ranitidine 01-29-08 Histamine2 10 mg Competitivel Short term Contraindic Derma: Take drug
antagonist IVTT y inhibits the treatment of ated with rash, with meal
every 8 action of active duodenal allergy to alopecia. and at
hours histamine at ulcer. ranitidine. CNS: bedtime.
the h2 Treatment of Use headache, Therapy
receptor heartburn, acid cautiously malaise, may
basal gastric ingestion, sour with dizziness, continue for
acid stomach. impaired somnolenc 4-6 wks or
secretion renal or e, insomia, longer
that is hepatic vertigo
stimulated function
by food
insulin,
histamine,
cholinergic
antagonist,
gastrin and
pentagastrin
Generic Date Classification Dose/ Mechanism Specific Contra- Side Nursing
Name of Ordered Frequenc of Action Indication indication Effects/ Precaution
Ordered y/ Route Toxic
Drug Effects
Children younger than 2 years have thinner layers of skin and insulating
subcutaneous tissue than older children and adults. As a result, they lose more
heat and water than adults do, and they lose these more rapidly than adults. In
very young children, temperature regulation is partially based on nonshivering
thermogenesis, which further increases metabolic rate, oxygen consumption, and
lactate production. In addition, because of disproportionately thin skin, a burn that
may initially appear to be partial thickness in a child may instead be full thickness
in depth. Thus, the child's thin skin may make initial burn depth assessment
difficult.
VI. NURSING ASSESSMENT
NURSING SYSTEM REVIEW CHART
Name:____x ________________________________________ Date:__02-04-08____
Temp.:_39.5 C____ Pulse Rate:_92bpm___ Height:_50cm___ Weight:_7 kgs_____
INSTRUCTIONS: Place an [X] in the area of abnormality. Comment at the space provided. Indicate the location of the
problem in the figure using [X].
EENT:
[ ] impaired vision [ ] blind [x] pain __________________
[ ] reddened [ ] drainage [ ] gums __________________
[ ] hard of hearing [ ] deaf [ ] burning __edema___________
[ x] edema [ ] lesion [ ] teeth __________________
Assess eyes, ears, nose throat for abnormalities. __________________
[ ] no problem __________________
X ______
RESPIRATORY: __________________
[ ] asymmetric [ ] tachypnea [ ] apnea __________________
[ ] rales [ ] cough [ ] barrel chest __________________
[ ] bradypnea [ ] shallow [ ] rhonchi __________________
[ ] sputum [ ] diminished [ ] dyspnea __________________
[ ] orthopnea [ ] labored [ ] wheezing __________________
[ ] pain [ ] cyanotic __________________
Assess resp. rate, rhythm, pulse blood breath sounds, comfort __________________
[ x] no problem __________________
__________________
CARDIOVASCULAR: __________________
[ ] arrhythmia [ ] tachypnea [ ] numbness __________________
[ ] diminished pulses [ ] edema [ ] fatigue __________________
[ ] irregular [ ] bradycardia [ ] murmur __________________
[ ] tingling [ ] absent pulses [ ] pain __________________
Assess heart sound, rate, rhythm, pulse, blood pressure. _plain LR 1L @30cc/hr
circulation, fluid retention, comfort __________________
[ ] no problem __________________
__________________
GASTROINTESTINAL TRACT: __________________
[ ] obese [ ] distention [ ] mass __________________
__________________
MUSCULOSKELETAL AND SKIN: __________________
[ ] appliance [ ] stiffness [ ] itching __________________
[ ] petechiae [x] hot [ ] drainage __________________
[ ] prosthesis [ ] swelling [ ] lesion __________________
[ ] poor turgor [ ] cool [ ] deformity __________________
[ ] wound [ ] rash [ ] skin color
[ ] flushed [ ] atrophy [x] pain
[ ] ecchymosis [ ] diaphoretic [ ] moist
assess mobility, motion, gait, alignment, joint function
skin color, texture, turgor, integrity
[ ] no problem
NURSING ASSESSMENT II
SUBJECTIVE OBJECTIVE
COMMUNICATION: [ ]Glasses [ ]
[ ]Hearing loss Comments “dili na languages
[x]Visual changes lagi kakita iyang [ ]Contact lenses [ ]
[ ]Denied isa ka mata kay hearing aid
Naghubag” R L
Verbalized by the Pupil size 2-3 mm □speech difficulties
Father of the Reaction PERRLA
patient
OXYGENATION:
[ ]Dyspnea Comments: “wala Resp. [x] regular [ ]irregular
[ ]Smoking history gaubo akong anak” Described: Breathing are regular
[ ]Cough as verbalize by the
[ ]Sputum father R equal expansion
[x]denied L equal expansion
CIRCULATION: Heart rhythm [x] regular □ irregular
[ ]Chest pain Comments: “sakit Ankle edema ___none_________
[x]Leg pain daw ang iyang tiil Pulse Car. Rad. DP. Fem*
[ ]Numbness of sa may sunog dapit” R + + + +
Extremities as verbalized by L + + + +
[ ]Denied patients father Comments: all pulse are palpable
*If applicable
NUTRITION:
Diet diet for age_ [ ]Dentures [ x ]none
[ ]N [ ]V Comments:
Character ” kusog pa man Full partial with
[ ] Recent change in giyapon siya patient
Weight, appetite mukaon” Upper [x] [ ] [ ]
[ ]Swallowing verbalized by Lower [x] [ ] [ ]
Difficulty the patients
[x]denied father
ELIMINATION:
Usual bowel pattern urinary frequency Comments Bowel sounds
1 x a day________ diaper_____ Patient has irregular audible
[ ]Constipation [ ]urgency Elimination process Abdominal
Remedy [ ]dysuria distention
None [ ]hematuria Present □yes □no
date of last BM [ ]Inconsistence Urine* (color,
02-05-08 [ ]Polyuria consistency, Odor)
[ ]Diarrhea [ ] foly in place _______________
Character [x ]denied ___no foley in __
___placed_______
_______________
If foley is in place
Bfiefly described the patient’s ability
MGT. OF HEALTH & ILLNESS: to follow treatments (diet, meds, etc.)
[ ]Alcohol [x]denied for chronic health problems (if
(amount frequency) present)
______none_____________ The patient is closely monitored and
□SBE Last Pap Smear n/a compliant to medications.
LMP__n/a__________
SKIN INTEGRITY:
□Dry Comments “wala man Dry cold pale
□Itching sad kapangatul ang Flushed x warm
□Other iyang lawas ”as Moist cyanotic
□denied by the patients *rashes, ulcers, decubitus(described
father size, location, drainage) superficial
partial thickness burn.
ACTIVITY/SAFETY:
[ ]Convulsion Comments: “dili LOC and orientation Patient is highly
[ ]Dizziness lagi siya maka- conscious and well oriented
[x]Limited motion lihok-lihok kay Galt: [ ]walker [ ]cane [
Of joints sakit daw” as ]others
Limitation in verbalized by the [x]Steady [ ]unsteady_______
ability to patients father [ ]Sensory and motor losses in face
[x]ambulate or extremities
[x]bathe self No sensory or motor losses in
[ ]other extremities
[ ]denied [ ]ROM limitations Patient has
limited range of motion due to burn
injury
COMFORT/SLEEP/AWAKE:
[x]Pain Comments: “sakit [x]Facial grimaces
(location) lagi ang parte sa [ ]Guarding
Frequency lawas na nasunog” [x]Other signs of pain Verbalization of
Remedies) verbalized by the pain and crying
[ ]Nocturia patients father [ ]Siderail release form signed (60+
[ ]Sleep difficulties years)
[ ]denied Not applicable
COPING:
Occupation none Observed non-verbal behavior
Members of Household 6 patient is compliant to this treatment
Most supportive person father plan
Subjective: Risk for At the end of >monitor v/s, cvp. Note >serves as a guide
defiecient fluid 8 hours the capillary refill and to fluid replacement
“nahadlok gali mi volume r/t loss patient will strength of peripheral needs and assass
basig of fluid demonstrate pulses cardiopulmonary
madehydrate Through improved response
siya tungod sa abnormal fluid balance >monitor urinary output >generally fluid
iyang mga route like burn as evedince and specifies gravity. replacement should
sunog”as wounds. by Observe urine color and be titrated to ensure
verbalized by the individually hematest as indicated average urinary
father adequate output of 30-
urinary output 50ml/hr(in adults)
with normal >estimate wound >increase capillary
specific drainage and insensible permeability, protein
gravity,stable losses shift, inflammatory
v/s, moist process and
Objective: mucous evaporative losses
membrane greatly affect
- burn wonds
circulatory volume
- dry mucous and urinary output
>observe gastric >stress ulcer occurs
membrane
distention, tarry stool in up to half of all
severely burn client
>administer medication >to enhance urinary
as indicated: output and prevent
diuretics necrosis
ASSESSMENT NURSING OBJECTIVE INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Subjective: Risk for At the end of >monitor v/s, cvp. Note >serves as a guide At the end of 8
defiecient fluid 8 hours the capillary refill and to fluid replacement hours the
“nahadlok gali mi volume r/t loss patient will strength of peripheral needs and assass patient was
basig of fluid demonstrate pulses cardiopulmonary demonstrate
madehydrate Through improved response improved fluid
siya tungod sa abnormal fluid balance >monitor urinary output >generally fluid balance as
iyang mga route like burn as evedince and specifies gravity. replacement should evedince by
sunog”as wounds. by Observe urine color and be titrated to ensure individually
verbalized by the individually hematest as indicated average urinary adequate
father adequate output of 30- urinary output
urinary output 50ml/hr(in adults) with normal
with normal >estimate wound >increase capillary specific
specific drainage and insensible permeability, protein gravity,stable
gravity,stable losses shift, inflammatory v/s, moist
v/s, moist process and mucous
Objective: mucous evaporative losses membrane
membrane greatly affect
- burn wonds
circulatory volume
- dry mucous and urinary output
>observe gastric >stress ulcer occurs
membrane
distention, tarry stool in up to half of all
severely burn client
>administer medication >to enhance urinary
as indicated: output and prevent
Diuretics necrosis
ASSESSMENT
NURSING OBJECTIVE INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE: Acute pain r/t At the end of >cover wound as soon >temperature At the end of 8
“sakit daw kayo destruction of 8 hours the as possible unless changes and air hours the
iyang mga sunog skin/ tissue patient will be open-air exposure burn movement can cause patient was be
samot na kung edema able to report care method required great pain to expose able to report
malihok” formation reduced pain, nerve endings reduced pain,
verbalized by the display >elevate burned >elevation may display relaxed
father relaxed facial extremities require initially to facial
expression reduce edema expression
participates in formation participates in
OBJECTIVE: activities and > maintain comfortable >temperature activities and
-report of pain sleep/rest environmental regulation may be sleep/rest
- distraction/ appropriately. temperature provide lost with major burn. appropriately.
guarding heat lamp, heat External heat
ASSESSMENT NURSING OBJECTIVE INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE: Risk for at the end of >implement dependent on at the end of 8
“ginahilantan infection r/t 8 hours the appropriate isolation type/extent of wound hours the patient
lagi ni siya, ug inadequate patient will technique as indicated and the choice of was be able to
basig primary be able to wound treatment achieve timely
mainfectiction defense achieve > emphasize/model >prevents cross wound healing
siya tungod sa destruction of timely wound good handwashing contamination, free from
inyang mga skin barriers healing free technique for all reduce risk of exudates and
sunog” from individuals coming in acquired infection was afebrile
verbalized by exudates contact with client
the father and be >use gown, gloves, >prevent exposure
afebrile mask and strict aseptic to infectious
OBJECTIVE: technique during direct organism
-febrile- 39.5 C wound care and
-break in skin provide sterile or
surface freshly laundrered bed
linens/gowns
>monitor and limit >prevebt cross
visitors, if necessary. If contamination from
isolation is used, visitors, concern for
explain procedure to risk of infection
visitors. should be balanced
against client needs
for family support
and socialization
>place IV/ invasive >decrease risk of
lines in non burned infection at insertion
areas site
“ginahilantan lagi ni siya, ug basig mainfectiction siya tungod
sa inyang mga sunog” verbalized by the father
S
-febrile- 39.5 C
-break in skin surface
O
Risk for infection r/t inadequate primary defense destruction of
A skin barriers
-report of pain
- distraction/ guarding behavior
O
-anxiety
-fear
-restlessness
-crying
I
3. estimate wound drainage and insensible losses
After two days of duty in the hospital and taking care of the patient, I was able to
help in the healing process of the patient and give some teaching regarding the
proper things to do in management of wound care and proper healing.
X. BIBLIOGRAPHY
http://www.nlm.nih.gov/medlineplus/burns.html
http://www.medicinenet.com/burns/article.htm
http://familydoctor.org/online/famdocen/home/healthy/firstaid/after-
injury/638.html