NURSING CARE TO Mrs.M WITH COMBUSTIO

CHAPTER II

THEORY REVIEW

A.    Definition

According to Doenges (2001: 809) Combustio (burns) is defined as  the damage or death of the skin, mucosa and deeper tissues caused by thermal, chemical and electrical.

Smeltzer (2001:1912) stated that Combustio (burns) is  the destruction or damage of tissue, skin and mucosa caused by the transfer of energy from a heat source to the body caused by thermal, chemical or radiation.

From the definition it can be conclude that Combustio (burns) is  the destruction or damage of tissue, skin and mucosa caused by the transfer of energy from a heat source to the body caused by thermal, chemical, electrical or  radiation.

B.     Etiology

Causes of injury according to Smeltzer (2001 : 1912) include:

1.      High temperature (thermal), can be a fire, hot water or contact with objects.    Exposure for 15 minutes with hot water temperature is 56.1 ° C resulted in full thickness injury.

2.      A chemicals, such as alcohol

3.      Electric shock

4.      Radiation

C.    Classification

1.      Based on the degree burns

a.       first-degree wounds (superficial partial thickness burns)

Burns involve only the epidermis, the wound looks bright pink to red with minimal edema and no blisters, the skin is often dry or warm.

b.      Second degree burns ( partial thickness burns)

Burns involve the epidermis and dermis. The wound seemed to pale pink with edema and blisters were. The wound is more dry than partial thickness burns.

c.       Third degree burns (full thickness burns) / full-thickness

Burns involve all layers of skin, subkutan and may involve muscle, nerve and  blood circulation. The wound seems have variation from white, red, to brown or black, with  the blisters are not general . The wound is dry, a texture like leather.

2.      Based on the cause burns

a.       Thermal burns, the agent can cause a fire, hot water, or contact with hot         objects

b.      Chemical root injuries (chemical burn), the causative agent of such a high         concentration of alcohol

c.       Electrical burns

d.      Radiation burns

(Doenges, 2000: 804)

D.    Pathophysiology

The burn is caused by the diversion Energy from a heat source to the body. Heat can be transferred via conductive or electromagnetic radiation. Tissue destruction occurs due to coagulation, protein denaturation or ionization of the contents of cells of skin and upper respiratory tract mucosa is the site destruction. tissue necrosis and organ failure may occur

1.      Systemic Response

Patofisiologik changes caused by severe burns during the begining  period of shock, burns covering organ hypoperfusion that occurs secondary to decreased cardiac output followed by a phase of hyperdynamic and hypermetabolic.

2.      Cardiovascular response

Cardiac output will decrease before significant changes in blood volume seen clearly. Due to the continued loss of fluid and decrease in vascular volume, then cardiac output will continue to decreased  and a decline in blood pressure. This situation is a shock onset burns. In response, the sympathetic nervous system releases catecholamines which increase peripheral resistance and pulse frequency. Furthermore, the blood vessels peripheral vasoconstriction lowering cardiac output.

3.      Effects on fluid electrolyte and blood volume

Circulating blood volume will decrease dramatically in the event of burns shock. Besides loss of  fluid from passing evaporase burns can reach 3 to 5 L or more over a period of 24 hours before the  burning skin surface covered.

Immediately after the burn, hyperkalemia aakan encountered as a result of massive cell destruction. Hypokalemia may occur later with the transfered of fluids and inadequate fluid intake.

During shock, burns, hyponatremia usually occurs because the water will move from the interstitial space into the vascular space.

4.      Pulmonary response

In severe burns, the consumption of oxygen by body tissues of patients will increase two-fold as a result of hipermetabolisme state and local response.

                                                                                    (Price,2002)

E.    Pathway

                  

                                                        

                                          

                                          

                                                                                                 

F.     Clinical manifestations

Here are the signs and symptoms of burns (burns characteristics) according to its depth :

1. first-degree burns (superficial)

Symptoms: tingling, hiperestisia (supersensitivitas), the pain subsided Jida chill

Signs : reddened wounds, become white when pressed, minimal or no edema. Complete healing within one week, exfoliation

2. Second-degree burns (partial - thickness)
   Cause: The boiling water scalded, fire

Symptoms: pain, hiperestesia, sensitive to cold air

Signs: - blisters, cuts base speckled red, cracked epidermis, the surface of moist wound

-          Edema

-          Recovery within 2-3 weeks

-          Formed a sikatrik and depigmentation

-          Infection can be change to third-degree

3. Third degree burns (full - thickness)

Causes: flame, allow the boil liquid in a long time, electric shock
Symptoms: - does not feel pain, shock, hematuria, and possibly also hemolysis. There is the possibility of entry and exit wounds (on electrical burns)

Signs: - dry, burns white cracked leather-like material with the visible fat

-          Edema

-          Establishment of esker

-          For the healing needed a transplant

-          Establishment of sikatrik and loss of  kontour formation and function of the skin

(Smeltzer, 2001: 1917)

G.    Management

There are  the phase in burn care :

1.      Resucitation phase an emergency or immediate

Starting from the onset of injury until the completion of resuscitation fluid. Priority care:

a.       First aid

b.      Prevention of shock

c.       Prevention of respiratory distress

d.      Detection and treatment of injuries that accompany

e.       Wound assessment and preliminary treatment

2.      Acute Phase

From the start of diuresis until almost the completion of wound closure process. Priority care:

a.       Care and wound dressing

b.      Prevention or treatment of complications including infections

c.       Nutrition Support

3.      Rehabilitation Phase

From the dressing of  a large wound to return to the level of physical and psychosocial adjustment is optimal. Priority treatment is:

a.       Prevention of establishment of sikatrik and  contractures

b.      Physical rehabilitation, occupational and vocational

c.       Functional and cosmetic reconstruction

d.      Psychosocial counseling

(Smeltzer, 2001: 1919)

H.    Complication

Potential complications in the emergency phase / resuscitation treatment of burns according to Smeltzer (2001: 1925) includes the following circumstances :

1.      Acute respiratory fail

2.      Circulatory shock

3.      Acute renal failure

4.      Kompatemen Syndrome

5.      Ileus paralitic

6.      Curling ulcer

NURSING CARE

1. Assessment

1.      Activity / Rest

Signs : - Decreased strength, resistance

-          Limited range of motion

-          Disorders of muscle mass, changes in tonus

2.      Circulation

Signs : - Hypotension (Shock)

-          Decreased peripheral pulse distal in the injured ekstremity

-          Tachycardia, dysrhythmias (electric shock)

-          Establishment of  tissue edema (all burns)

3.      Elimination

Signs : -  urine output decreased during the emergency phase

-          Diuresis (after the capillary leak and transfer of fluid  into the circulation)

-          Decreased intestine peristaltic

4.      Food / Fluids

Signs : - General Edema

-          Anorexia, nausea / vomiting

5.      Neurosensori

Symptoms: Area free, tingling

Signs : - change orientation, effects, behavioral

-          Decreased tendon reflexes in the injured extremity

-          Convulsion (electric shock)

-          Rupture of membranes timpanik (electric shock)

-          Paralysis (injury to the flow of electricity)

6.      Pain

Symptoms: A variety of painful, example of the first-degree burns are extremely sensitive to touch, pressure, movement and temperature changes, second degree burns  are very painful, while the response to third-degree burns do not exist (no pain)

7.      Respiratory

Symptoms: locked in an enclosed space (possible inhalation injury)

Signs : - Hoarseness, cough wheezing, unable to swallow oral secretions, cyanosis

-          Development of  thorax  may be limited to the trap wound burn

-          The sound of breathing, splashing (pulmonary edema), stridor (laryngeal edema), airway secretions (rhonchi)

2. Diagnosis and Intervention

1.      Risk of the lack of fluid volume is related to from fluid loss through evaporation from the burn area

Intervention:

a.       Supervise urine output

Rational: in general, fluid replacement should be infiltrate  to convince the average urine output  30-50 ml / hour (for adults)

b.      Maintain infusion and organize drops according to program
Rational: adequate fluid  provision is required to maintain fluid and electrolyte balance

c.       Raise the head of the patient's bed and elevate burned extremities
Rational: Elevation will increase the circulation of blood through veins

d.      Colaboration : supervised laboratory tests (hemoglobin, hematocrit, electrolytes)

Rational: identifying blood loss and need for fluid and electrolyte replacement

(Doenges, 2000: 810)

2.      Pain is related to the effects of nerve tissue injury and emotional injury

Intervention :

a.       Cover the wound as soon as possible unless the exposure method of burn care in the open air

Rational: the temperature change and air movement can cause severe pain at the exposure of nerve endings

b.      Give examples of basic comfort measures massage area with no pain, with frequent position changes

Rational: increase relaxation, decrease muscle tension and general fatigue

c.       Provide therapeutic activities appropriate to age / condition
Rational: to help reduce the pain experienced by the concentration

d.      Increase the period of uninterrupted sleep

Rational: lack of sleep can increase of  perception of pain / coping ability decreased

e.       Collaboration: give analgesics as indicated

Rational: to help reduce pain

3.      Damage to the integrity related to trauma : damage to the skin surface due to destruction of skin layers

a.       Review color and depth of the wound

Rational: provides basic information about needs and about circulation in the area of ​​graft

b.      Give proper treatment of burns and infection control measures
Rational: prepare the tissue for the graft  and reduce the risk of postoperative infection

c.       Keep the wound closure as indicated, for example: dressing biosintetik

d.      Evaluation of the color of the graft and donor

Rational: to evaluate the effectiveness of the circulation and identify the occurrence of complications

4.      Risk of  infection related to  loss of skin barrier and damage the immune response

Intervention:

a.       Teach good hand washing technique

Rational: to prevent cross-contamination, reduce the risk of infection

b.      Use gloves, masks and aseptic techniques for wound care directly
Rationale: prevent exposure to infectious organisms

c.       Check the wound trap days / note the change in appearance, smell and drainage quantity

Rationale: Early detection of infection of burns

d.      Keep an eye on vital signs to fever

Rational: indicator of sepsis

e.       Collaboration: Give antibiotics within their indications

Rational: to control the pathogen / against pathogens to prevent sepsis

5.      Changes in tissue perfusion related  to decreased blood circulation of arterial / venous

Intervention:

a.       Level with the right extremity pain

Rational: to increase the systemic circulation / venous return and lowers  edema

b.      Encourage  active range of motion exercises on the body that are not sick

Rational: to increase local circulation and systemic

c.       monitor  the pulse on a regular basis

Rational: cardiac dysrhythmias may occur due to movement of electrolyte, electrical injury or eliminating depressan  factors

d.      Collaboration

-          Monitor electrolytes, especially sodium, potassium and calcium

Rational: eletrolyte displacement may decrease cardiac output / tissue perfusion

-          Avoid infections IM / SC
Rational: changes in tissue perfusion and edema formation interfere with drug absorption

CHAPTER III

CASE OVERVIEW

I.       ASSESSMENT

This assessment was done on Monday, August 1^st, 2011 at 11 am  in Cempaka room Sunan  Kalijaga Demak District Hospital with Method Autoanamnesa and Allowanamnesa.

A.    Identity

1. patient’s  identity

Name                           : Mrs. M
Age                             : 80 years old
Religion                       : Islam            
Marital Status              : Married
Medical Diagnose       : combustio spacious grade II 20%
Register Number         : 11 40 28
Address                       : Donorejo Rt 2 / 3 Karang Tengah, Demak

2. identity Responsible

Name                           : Mr. A
Age                             : 52 years old
Religion                       : Islam
Relationships with patients     : Children
Address                       : Donorejo Rt 2 / 3 Karang Tengah, Demak

B.     Health History

1. Main complaint

Patient said pain in the affected limb burns (left hand and left rear thigh)

2. Present  Health History

About 2 days before hospitalized, patient  splashed boiling water on the left hand and the left rear thigh. Then patient went to the infirmary glottal and had infused, but the day before hospitalized  patient experience increased pain burns. Eventually the patient was taken to the Emergency Room in Sunan Kalijaga Demak District Hospital on July 21^st  2011. In the ER patients received intravenous infusion of RL 20 TPM, Ciprofluxacin 2x500 gram.

3. Past Medical History

The patient had never had this disease before, never an accident, had never been treated and operated on previously. The patient had no history of hypertension, diabetes or degenerative diseases and other infectious diseases. The patient had no history of allergies, drug or environmental factors.

4. Family Health History

Patient’s families  have no infectious diseases (hepatitis, tuberculosis) or herediter disease (hypertension, DM)

Genogram:                      

 

Information
     : Female
     : Male
     : Living a home
    : Dead
     : Patient

C.    Residential Environmental History

Type of residence              : The house is pretty big
Number of rooms              : 3 rooms
Number of Occupants       : 4 People
Living conditions              : Clean

D.    Assessment of Body Systems

General condition             : Weak
Level of consciousness     : Komposmentis
GCS                                  : E4 M6 V5     : 15
Vital signs                         : BP: 110/60 mmHg, RR: 24x/menit

  Pulse : 80x/menit, Temperature: 37.50 C

1. Respiratory System

Subjective Data:

Patients said  no shortness of breath, not exposed to air pollution, not smoking and not knowing cough effectively.

Obytektive  Data :

a.       Respiratory  : Frequency: 24x/menit,  normal depth, regular rhythm

b.      No visible use breathing muscles apparatus and breathing cuping nose.

c.       Patient no cough, no cyanosis, and restless.

d.      Fremitus tactile vibrating, right lung and left alike.

2. Cardiovascular System

Subjective Data:

Patient said  didn’t have history of hypertension or heart problems, history of edema, coughing up blood, tingling and chest pain.

Objective data:

a.       Blood Pressure : 110 /90 mmHg, radial pulse: 80x/menit

b.      S1 and S2 heart sound is single, no murmurs

c.       Esktermity: cold temperatures, brownish color, CRT: 2 seconds, no Phlebitis.

d.      an anemis Conjunctiva.

3. Neurosensoric and Musculoskeletal System

Subjective data:

Patient said didn’t have  history of accident, history of head injury, and spinal cord, history of cerebrovascular disease and  injury headache, joint pain and spasms.

Objective Data:

-          Awareness: composmentis, GCS : E4 M6 V5  : 15

-          Patient had no paralysis, no lethargy, long-term memory is somewhat reduced, both short-term memory.

-          Cranial nerve function

a.       NC I             :  Patient was able to identify the smell of food, fruit

b.      NC II           :  Patient read the book with a distance of 7.30 cm

c.       NC III          :  Pupillary reaction was positive, decreases when exposed to light, the size is 2 mm

d.      NC IV          : The patient was able to move the eyeball upward and downward

e.       NC V           : Because of the positive reflex (blinking when touched cotton), a positive tactile sensation, the patient was  able clenched teeth.

f.       NC VI          : The patient was able to move the eyeball sideways.

g.      NC VII        : The patient was able to smile, puffed cheeks, eyebrows rising down, the patient was able to identify the flavor at the front tongue.

h.      NC VIII       : The patient was able to hear the words spoken

i.        NC IX          : The patient was able to identify a sense of  back tongue, swallowing abilities well.

j.        NC X           : The ability to swallow properly, talk to the client rather weak.

k.      NC XI          : The patient was able to lift the shoulders and turned her head to the side which retained the examiner passively.

l.        NC XII        : The patient was able to remove the tongue and move from side to side.

-          The function of sensory nerves, temperature, light touch of both (normal).

-          Motoric function:

a.       Normal posture, there was no abnormal movement

b.      The ability to walk less because of combustion of the thigh

c.       Good coordination ability, no tremors, less ability to mobilize

d.      Muscle tones: Medium, muscle strength 

1111	4444
1111	4444

e.       There was no joint swelling and contractures

f.       Excitatory meningeal signs: neck stiffness, laseque, Kernig, brudzinski I and II were negative.

4. Integumentary System

Subjective Data:

Patient said  had  no history of skin disorders and do not itch

Patient  said pain in the burn area.

Objective Data:

a.       There was  a burn on his left hand and left thigh and buttocks of the patient.

b.      The wound bed color: pink, stage burns, second degree as 20%

c.       There were no signs of infection

d.      No abnormality of  nails and skin.

5. Urinary system

Subjective Data:

Patient  said didn’t have  history of renal impairment, history of  diuretics drug use, there was  no difficulty urinating, urinating 4 times / day.

Objective Data:

-          There was no urinary retention or urinary incontinence

-          Characteristics of urine: color : clear yellow, typical smell and no sediment.

6. Gastrointestinal System

Subjective Data:

The patient said there was no food abstinence, 3x daily eating habits, diit rice, patient said decreased appetite, eating out ¼ servings, patient didn’t  nausea and vomiting, no pain in the lower liver, have no interference and swallowing, not sore tooth, bowel frecuency 1 time/day , no constipation and no diarrhea.

Objective Data:

-          Weight      : 49 kg

-          No halitosis, caries dental conditions exist, the tongue is rather dirty.

-          Abdominal examination:

I: flat, there are no lesions
A: peristaltic intestine  17x/menit
P: timpani
P: no tenderness, liver and lymph nodes are not enlarged.

-          There is no hernia, anus clean, no hemeroid.

-          Patterns of bowel : 1x/day, color : yellow, regular consistency.

7. Sensing Systems

Subjective Data:

The patient said had no history of eye infections / ear or a history of other eye diseases. Patient has decreased vision and decreased heard ability. Patient  did not experience any pain nose / ears. Sensation of  tasting good.

Objective Data:

Eye exam:

-          Field of view area, good movement ekstraokuler

-          Ananemis Conjunctiva, sclera anikterik, isokor pupil, the size is  2 mm, positive  reaction to light, the cornea is clear.

-          No oedema at the orbital area, no hematoma.
Examination of  the nose:

-          Nose symmetrical, normal form, no lesions, and enlargement of the polyps, nose clean, no discharge and epistaxis.

-          No changes anatomical, and no pain.
Ear examination:

-          Ear symmetrical, clean, no lesions, mass and wax.

-          There is no tenderness.

8. Endocrine System

Subjective Data:

Patient  said it has no growth disorder and developmental history, history of diabetes mellitus, not infertile, no menstrual cycle disorders, no diaphoresis occurs.

Objective Data:

Shape and body proportions, not abnormality  structure, shape and  face. Symmetrical neck, does not happen hyper / hypopigmentation of skin, no tremor, enlargement of the thyroid gland does not happen.

9. Fluid  and electrolyte system

Subjective Data:

The patient said he was thirsty, do not feel the muscle twitch, not a seizure.

Objective Data:

a.       Intake of fluids

Infusion                             : 1.500 cc

Eating                                : 150 cc

Drinking                            : 600 cc

Metabolic oxidation          : 300 cc

Total                                  : 2.550 cc
Output
Urine                                 : 1. 200 cc
Faeces                               : 100 cc
Sweat                                : 50 cc
IWL                                  : 900 cc

Total                                  : 2.250 cc

b.      Fluid balance         : input –output  =  2.550 – 2.250 = + 300 cc

c.       Patient no nausea and vomiting, skin turgor is good, slightly rough texture of the skin, mucous membranes moist.

d.      There was edema in both manus and pedis, there was no ascites.

10. Immunity System

Subjective Data:

Patient  said  didn’t have  history of allergy, changing the previous immunity.

Didn’t have  a history of  PMS,  history of adult immunization, history of surgery and a history of chronic infection.

Objective data:

The skin and mucosal lesions were didn’t have  purpura or inflammation, there was no redness in the skin lymph nodes, not enlarged.

11. Reproductive System

a.       Menarche age: 14 years, duration 6 days, irregular cycles and didn’t have  menstrual disorders

b.      There was no vaginal discharge that comes out.

c.       Never do breast examinations and pap smear.

E.     Additional data

1. Activity patterns, Rest and Sleep.

Subjective Data:

Patient said  just lay in bed, feeling tired, feeling limited mobility because of the condition, patient's usual night's sleep for 5-6 hours, 1-2 hours nap, sleep discomfort due to pain in the burn area.
Objective Data:

Restless mental status, the eye is not red, not black eyelids, look no yawning.

2. Ego Integrity (psychosocial status)

Subjective Data:

Patient do not experience stress, relationship status with others well,  patient said she  felt helpless with her condition. Had good relationships with family members, people who  support her are her  husband and family.

Objective Data:

Emotional status : anxiety, speak clearly, not aphasia and not using the tools to talk.

3. Personal Hygiene

Subjective Data:

Patients said  their daily activities such as eating, bathing, dressing and mobility t assisted by the family.

Objective Data:

Patient seem weak, underweight cleanliness.

4. Discomfort 

Subjective Data:

Patient  said   pain in burns, pain such as tingling, hot , duration is  10 minutes continuously, the pain increased pain when moving and when exposed to cold.

Objective Data:

Patient  appear wrinkled face, seemed to keep the area of pain and heard moaning in pain.

5. Learning

Subjective Data:

Patient was told not know how the  wound  care, patient is  usually treated to the medical team if the pain and hope the team gets better in the health ministry.

Objective Data:

Patient  and families often looked confused and asked the nurse about the patient's current condition.

F.     Examinatinon

1.      Laboratory examination
Lab Inspection Results dated July 21^st  2011

Type of examination	Result	Normal Value	Analysis
Hemoglobin	11,8             g%	12 – 15	Low
Leucocytes	19.000         /mm3	4.000 – 10.000	High
LED 1 hours          2 hours	45               mm/hour 68               mm/hour	< 20	High High
Hematocrit	35                %	37 – 43	Low
Trombocyte	249.000	150.000 – 400.000	Normal
Calculate the type of leukocyte :  Basophils  Eosinophils  n.Batang  n.Segmen  Limfocyte	0 % 0 0 68 12	0 – 1 1 – 3 2 -6 50-70 20-40	Normal Low Low Normal Low
Natrium	136             U/i	134-155	Normal
Kalium	3,5              mmol/L	3,5 – 5,5	Normal
Calcium	7                 mg/dl	8,1-10,4	Low
Magnesium	2,28            mg/dl
GDS	117	75-125	Normal
Ureum	33              mg%	0-40	Normal
Creatinin	0,7             mg%	0,5-1,2	Normal
Albumin	2,6               g%	3,7-5,2	Low

2.      Therapy
- Infus RL 20 drops / minute
- 2x Cefazollin Injeksi 1A
- Injeksi Gentamisin 2x1A
- Metronidazole 3x500mg

G.    Data analysis

Patient’s name : Mrs.M                       Reg. Number               : 114028

Room              : Cempaka                   Medical Diagnose       : Combustio grade II

No	Data Focus	Etiology	Problem
1.	Subjective Data: -          Patient said pain in the burn area Objective Data : -          Patient appear grimaced and frowned   P : pain increased if it moved   Q :                R : on the left hand and left thigh   S : 8   T : 10 minutes continuous -          Patient seem to keep the painful burns	Burn   tissue destruction Stimulates the hypothalamic release of vasoactive substances Stimulates free nerve endings sensation of pain	Pain
2.	Subjective Data :  Patient said his body warm Objevtive Data : -          Temperature : 37,5 °C -          Leukocytes:  19 000 (4000-10000) -          Lymphocytes: 12 (20-40)	Burn (combustion) tissue destruction Loss of skin barrier Damage to the immune response Risk of infection	Risk of infection
3.	Subjective Data :   Patient said she could not do ADL independently Objective Data : -          Patient looks weak -          ADL assisted the family	burns   tissue destruction pain Patients unable to do ADLs independently Impaired mobility	Impaired of physical mobility

                                        

II.    NURSING DIAGNOSIS

                  

1.      Pain related to  tissue injury and nerve injury .

2.      Risk of infection related to  loss of skin barrier and impaired immune response

3.      Impaired physical mobility related to  pain due to burns.

III. INTERVENTION

Patient’s Name            :Mrs.M                                    Reg. Number         : 114028

Room                          :Cempaka                                Medical Diagnose : Combustio Grade II

DX.No	GOAL	Intervention	Rational	Signature
I	After performed implementation  for 2 x24 hours are expected that pain is decrease or can be adapted to the expected result : a.       Patient do not winced and frowned b.      Scale of pain is decrease become 4-5	1.      close the wound as soon as possible 2.      Give basic comfort measures, such as: massage area without pain. 3.      Teach pain management techniques such as relaxation breathing  and imagination 4.      increase the period of uninterrupted sleep 5.      collaborations : give analgesics as indicated	-        Changes in temperature and air movement can cause severe pain in the exhibition of the nerve endings -        increase relaxation, decrease muscle tension and general fatigue -        increase relaxation -        lack of sleep can increase the perception of pain -        help to reduce pain
II	After implementation for 2 x 24 hours is expected no infection with expected result : a.       temperature : 36,5-37ºC b.      leucosytes : 4.000-10.000/mm3 c.       Limphosytes : 20-40	1.      measure  vital signs 2.      Encourage good hand washing for everyone before contact with patients. 3.      check the combustion everyday,record the changes in appearance and smell 4.      do wound care and wound dressing daily 5.      use  gloves and masks during treatment aseptic technique 6.      collaborations : give antibiotics as indicated	-        as an indicator of sepsis -        prevent cross-contamination lowers the risk of infection -        detect self-infection of burns -        reduce the risk of infection -        prevent exposure to infectious organisms -        to control the pathogen or against pathogens to prevent sepsis
III	After implementation for 2 x 24 hours is expected that patient experienced greater physical mobility  with expected result : a.       patient participated in the activities of daily living b.      patient is not weak	1.      Adjust the position of the patient carefully to prevent fixed positions on the burn area 2.      help the patient to sit and early ambulation 3.      encourage self-care until an appropriate level of patient tolerance 4.      encourage families to help the patient activity 5.      implement range of motion exercises several times a day	-        the correct setting position  will reduce the risk of flexion contractour -        Early mobility encourage increased use of muscles -        self-care and independence would accelerate the increase in activity -        reduce stress in patients -        do range of motion will minimize muscle atrophy

IV. IMPLEMENTATION

Name of  Patient         : Mrs. M                      Reg.No                        : 114028

Room                          : Cempaka                   Medical diagnose        : Combustio Grade II

Date and Time	Number	Implementation	Respon and Result	Signature
Tuesday, August 2nd 2011 8.30 am 8.40 am 8.45 am 08.50 am 12.00 am	I	1.      close the wound as soon as possible 2.      providing basic comfort measures such as massage areas that are not pain 3.      teach relaxation breathing techniques in pain management and imagination 4.      increasing periods of uninterrupted sleep 5.      collaboration : give analgesic	-          patient is comfortable if the wound was closed immediately -          patients feel comfortable -          patients want to do relaxation breathing -          patients sleep 7-8 hours a day -          patient cooperative
Tuesday , august 2nd 2011 12.30 am 12.35 am 09.00 am 09.00 am 09.05 am 12.05 am	II	1.      measuring vital signs 2.      Encouraged to people around the patient to wash their hands well before contact with patient. 3.      check the wound and noting changes in color and odor 4.      give  wound care and dressing change 5.      using masks and gloves aseptic technique during wound 6.      collaborations give antibiotics	BP : 110 /90 mmHg Temperature : 37,5° C RR: 24x/minute Pulse : 80x/minute -          people around the patient want to wash their hands -          the colour is pink -          the wound have wound care and wound dressing -          aseptic technique can be maintained -          patient get antibiotic and cooperative
09.50 am 09.55 am 10.00 am 10.05 am 10.10 am	II	1.      Adjust position the patient carefully 2.      helping the patient to sit and early ambulation 3.      encourage self-care patients to the appropriate level of patient tolerance 4.      encourage families to help the patient activity 5.      implement the range of motion exercises twice a day	-          sleeping position of patient is side to the right -          patient want to sit and want to do early ambulation -          patients have not been able to perform self-care -          family want to help the patient activity -          patient want to do range of motion
Wednesday, August 3rd 2011 08.00 am 08.10 am 12.00 am	I	1.      providing basic comfort measures such as massage areas that are not pain 2.      teach relaxation breathing techniques in pain management and imagination 3.      collaboration : give analgesic	-          patients feel comfortable -          patients want to do relaxation breathing -          patient get analgesic
08.20 am 08.25 am 08.30 am 12.00 am	II	1.      check the wound and noting changes in color and odor 2.      give  wound care and dressing change 3.      using masks and gloves aseptic technique during wound 4.      collaborations give antibiotics	-          the colour is pink -          the wound have wound care and wound dressing -          aseptic technique can be maintained -          patient get antibiotic
09.00 am 09.05 am 09.10 am 09.20 am 09.40 am		1.      Adjust position the patient carefully 2.      helping the patient to sit and early ambulation 3.      encourage self-care patients to the appropriate level of patient tolerance 4.      encourage families to help the patient activity 5.      implement the range of motion exercises twice a day	-          sleeping position of  patient is side to the right -          patient want to sit and do earlt ambulation -          patient have not been able to perform self-care -          family want to help the patient activity -          patient want to do range of motion

V.    EVALUATION

Name of Patient          :Mrs.M                        Reg.No                        : 114028

Room                          :Cempaka                    Medical Diagnose       : Combustio Grade II

Date and Time	Number	Evaluation	Signature
Wednesday , august 3rd 2011 13.00 am	I	S  :patient  said the burned patient still feels pain O : - patient appears grimaced and frowned -scale pain 7 A  : problem is not resolved                 P  : continue the intervention 1,2 and 3
Wednesday , august 3rd 2011 13.30 am	II	S : patient said that her body was still warm O : Temperature : 36,60C         leucocyte : 19.000 /mm3         Limfosit   : 12       A : the problem is resolved in part P : continue the intervention -        check the wound every day record the changes     in appearance and odor -        do wound care and dressing change today -        wear gloves and masks aseptic technique during wound care
Wednesday , august 3rd 2011 13.40 am	III	S : patients said they were not able to perform independently ADL O : - patient appeared frail -ADL assisted families         - patients participate in daily activities A : the problem is resolved in part P  : continue interventions -        help the patient sitting and early ambulation -        encourage self-care until the appropriate limits of tolerance -        range of motion exercises done daily

CHAPTER IV

DISCUSSION

In this chapter the author will discuss about Nursing at Ny.M with combustio at Cempaka Room Hospital Sunan Kalijaga Demak. The nursing problems discussed are as follows:

1.      Pain in Mrs.M related to tissue injury

Pain is define as sensory and emotional experience of the unpleasant consequences of the actual tissue damage or potential (Smeltzer, 2002)

Tamsuri(2007) stated that pain a condition that affects a person and the extensions are known when someone has experienced it.

According to the International Association for the Study of Pain (IASP): subjective sensory and emotional unpleasant obtained related to actual or potential tissue damage or describe the condition of the damage.

Characteristic  of pain :

a.       Pain is tiring and requires a lot of energy.

b.      Pain is individual.

c.       Pain can not be assessed objectively.

d.      Nurses can assess patients' pain just by looking at behavioral and physiological changes of client statements.

e.       Only the client knows when the pain arises and what it's like.

f.       Pain is a physiological defense mechanism.

g.      Pain is a warning sign of tissue damage.

h.      Pain disability began.

i.        The false perception that pain causes pain management is not optimal.

In Mrs. M diagnosis arises because the subjective data obtained: patients said pain in his left hand and the left rear thigh. Objective data: the patient looks grimaced and wrinkled face. Assessment of pain, P: pain increased when actuated, Q: like in the pin-prick, R: on the left hand and rear left thigh, S: 7, T: 10 minutes continuously.

The author raised this diagnosis is first placed on the diagnosis because, according to Maslow is a second requirement.

The implementation that  do is close the wound as soon as possible with the rational that the temperature and air movement can cause severe pain at the exposure of nerve endings (Doenges, 2000: 810). Patient's wound was closed as soon as possible. Teach pain management techniques like deep breathing and relaxation with a rational imagination can reduce pain and increase relaxation (Doenges, 2000:811). When done  the implementation the patient wanted  to do deep breathing  in accordance to the teaching. Giving injections of analgesic aimed at helping the analgesic reducing pain (Doenges, 2000: 812). When done impementation patient would be injected and also cooperative.

After implementation above can be  evaluated as follows, in which patient  say the area of burn still feels the pain. And objective data is the patient appears grimaced and wrinkled face, the pain scale of 7. From the analysis of data can be in the evaluation that the problem is not resolved and implementation that must be followed is: close the wound as soon as possible, teach pain management techniques like deep breathing relaxation and imagination, provide appropriate analgesic indicated.

2.      Risk of infection related to loss of skin barrier and disturbance of immune response.

Infection is the invasion and propagation of microorganisms in body tissues, especially those causing local cellular injury due to competitive metabolism, toxins, intracellular replication or antigen antibody response (Novak, 1998:555)

According to Potter-Perry (2005:933) infection is define as invation of patogen or microorganisms that can cause ill.

Type of infection :

a.       Colonization
Is a process where the seed microorganisms to flora residing / resident flora. Microorganisms can grow and proliferate but can not cause disease. Infection occurs when microorganisms were settled successfully invade / attack the host body / human defense system ineffective and the pathogen causing tissue damage.

b.      Local infection: specific and limited to any part of the body where the microorganisms to live.Systemic infection: occurs when microorganisms  spread to other parts of the body and cause damage.

c.       Bacteremia: occurs when the bacteria found in the blood

d.      Septicemia: multiplication of bacteria in the blood as a result of systemic infection

e.       Acute infection: infections that arise in a short time

f.       Chronic infections: infections that occur later in the period of time (in a matter of months to years)

In Mrs.M obtained this diagnosis arise because of the subjective data obtained: the patient said  his body warm. Objective data: patient's body temperature is 37.5 ° C,  leukocyte : 19.000/mm³, lymphocytes : 12.

The author raised this diagnosis because of the laboratory data showed an increase in leukocytes and lymphocytes, which is an indication of  inflamation response.

The implementation that was  done  is check the wound every day, noting changes in appearance and odor by the rationale for early detection of infection (Doenges, 2000:812). Normal wound appearance, the color pink, a bit smelly. Give  wound care and wound dressing c every day with a rationale for lowering the risk of infection (Doenges, 2000: 812). When done the implementation of patient winced in pain but still cooperative. Using gloves, masks, and aseptic techniques during treatment with a rational way to prevent exposure to infectious organisms. Giving antibiotics to control pathogens in order to prevent sepsis (Doenges, 2000: 812). Patients want to  be injected and cooperative.

After implementation above can be evaluated as follows,  patients say his body was still warm, the objective data: body temperature 36.6 ° C, leukocytes :19.000/mm³ and lymphocytes 12. From the analysis of data can be evaluated that the problem is resolved in part and interventions that should be continued is check the wound every day and record the changes in appearance and odor, do wound care and dressing change 2 times a day, wear gloves, masks and aseptic techniques for wound care, give antibiotics as indicated.

3.      Impaired physical mobility related to pain due to burns

Damage to physical mobility is a state where a person experiences physical limitations but rather on the state of mobility (Doenges, 2000: 316)

According to Carpenito (2006: 285) physical mobility is a state when an individual has limited physical movement.

According to Potter and Perry (2005: 1193) is defined as impaired physical mobility as a situation when the individual is experiencing or at risk of physical motion limitations. Arrangements coordinated movements of the body movement is an integrated function of the skeletal system, skeletal muscle, and nervous system.

Defining characteristics by Carpenito (2001: 285) is a major (80% -100%) decreased ability to move purposefully in the environment (eg: mobility in bed, move, ambulation), the limited range of motion. Minor (50% -80%) restrictions on movement are in force, do not want to move.

In Ny.M diagnosis arises because the data obtained subjective: the patient says can not perform ADLs independently. Objective data: patients appear weak, the ADL at the family helped.Patients experiencing restrictions on movement due to pain in the burn area.

The author raised this diagnosis is placed on the third diagnosis because of this problem resulted in restriction of motion in the form of bed rest.

The implementation that was done is: set the position carefully to prevent a fixed position on the burn area with the rational can reduce the risk of flexion contractures (Doenges, 2000: 324). And the patient is side sleeping position to right. Helping the patient to sit and early ambulation that serves to encourage increased pamakaian muscles (Doenges, 2000: 324). Patients also want the help to sit down and want to do early ambulation. Helped conduct range of motion exercises aimed at improving the mechanics of the body, minimizing muscle etrifi (Doenges, 2000:324). Response time of the implementation of co-operative patients and patients also want to follow the recommended motion. Encouraging self-care to the limit of tolerance with the rational that will accelerate the independence of self-care and increased activity (Doenges, 2000: 324). Patient tolerance of activity corresponding to eat and drink independently.

After implementation above ca be  evaluated  as follows, in which patients said they were not able to perform ADLs independently and objective data is the patient appeared frail, ADL assisted the family, patients participate in daily activities. From the data analysis in the evaluation that the problem can be partially teratasii and implementation should be continued are: to continue to help the patient sitting and ambulation early, encouraging self-care until the appropriate limits of tolerance, assist range of motion exercises.
The factors supporting the implementation is done when the patient's family and paien very cooperative when performed nursing actions. Inhibiting factor is not very understanding family.

CHAPTER V
CLOSING

A.    Conclusion

From some understanding can be concluded that the notion combustio is damage or death of the deeper skin tissue caused by the transfer of energy from a heat source to the body caused by thermal, electrical, chemical or radiation.

Here the authors take three diagnoses of disorders related to comfort pain or nerve tissue injury due to burns, Resti infection associated with loss of skin barrier and impaired immune response, impaired physical mobility related to pain from burns.

Of the three problems, there are some things that have not resolved the patient still complained of pain due to damaged skin tissue. For the problem of infection of patients still at risk of infection because the wounds are still wet. In addition, Impaired physical mobility problems associated with pain due to injury has not been resolved, the inhibiting factor is the patient did not want to obey the rules of nurses to perform the activity as tolerated, patients would only do if assisted by a family activity.

B.     Suggestion

1.      Clients and families

When patients experienced burns immediately with cool running water and immediately taken to the health service to get further help. And the family always expected to provide support to the patient.

2.      Nurse

It is hoped that intensive care nurses provide to patients with combustio to avoid infection and other complications.

3.      For society

Expected by society to be more careful with things that can cause burns (combustio) that the incidence of burns can be avoided.

4.      For Sunan Kalijaga District Hospital

Expected to improve services for patients with burns (combustio), both in handling the acute phase and after his treatment.

5.      For Educational institutions

Able to continue to evaluate the extent to which students in nursing care in a comprehensive set on pasie with burns (combustio).