SISTER NIVEDITA GOVT.

NURSING COLLEGE

I.G.M.C., SHIMLA

SUBJECT- ADVANCE NURSING PRACTICE

HEALTH ASSESSMENT: POST BURN CONTRACTURE

SUBMITTEDTO: SUBMITTED BY

MRS. POOJA SOOD ARCHITA

SHARMA

LECTURER M.SC (N) 1STYEAR

SNGNC, IGMC SNGNC, IGMC

SHIMLA SHIMLA

SUBMITTED ON:
HISTORY OF PATIENT
IDENTIFICATION DATA

Cr No.: - 202303162990
Name: - Muskan

Age: - 3 years

Sex: - Female child

Ward- Surgery Super Speciality ward

Bed no-13

Education- Play school.

Nationality -Nepalese

Dietary habits - Non-Vegetarian

Marital status- Unmarried

Religion: - Hindu

Family income: – Rs. 10000/month

Address- Gumma, Tehsil- Kotkhai, Shimla, H.P.

Informant – Parents

Date and time of admission- 22/11/2023 at 12:15 PM

On admission vital signs were: -

• Temperature: 98.40F

• Pulse: 80 beats/min

• Respiration: 22 breaths/min

• SPO2: 98%
Diagnose: - Post Burn Contracture.

Operation: - Post Burn Contracture Release.

Surgical Notes: -

 Operation – Contracture Release Rt. Little finger with K- wire insertion raw area
covered with full thickness graft under local anesthesia.
 Steps – Part clean and drapped.
Skin marking done.
Contracture release and finger straightened & K- wire insertion done.
Full thickness graft placed over the raw area.

Doctors- Dr. Rajesh, Dr. Pushpender, Dr. Rajan.

Chief complaint: - Patient came to IGMC, hospital with chief complaints of:

 Pain in right little finger x 5 months.

 Bent in right little finger x 5 months.

Present medical history: - Patient is having complaints pain and bent in right little finger
for 5 months. Now she is undergoing treatment in Indira Gandhi Medical College Shimla.

On admission vital signs was: -

 Temperature: 98.40F
  Pulse: 80 beats/min
 Respiration: 22 breaths/min
 SPO2: 98%

Present surgical history: - Patient is having present surgical history of post burn contracture
release.

Past medical history: - Patient is having past medical history of burn at 2.5 years when she
was playing near challah.

Past surgical history: - Patient had not any surgical history related to disease condition.

Allergic history: - Patient is not allergic to any drug.

Marital history: - Unmarried

Personal history: - Client is non vegetarian.

FAMILY HISTORY: -

Family medical history: - There is no significant medical history of client’s family. All the
members of patient’s family are healthy.

Family surgical history: - No significant surgical history of client’s family.

Family types and family members: - Client is having nuclear family and there are three
family members.

Family Tree: Keys:

Parkash (25 year/MA) Sapana (22 year/FA) MALE ADULT-

FEMALE ADULT -

Muskan (3 year/FCH)
CLIENT-
Family Composition:

Sr. Name Age Sex Relation Education Marital Occupation Health

No status status
Status

1 Parkash 25 MA Father - Married Labourer Healthy

yrs

2 Sapana 22 FA Mother 8th Married Housewife Healthy

yrs

3 Muskan 3 yrs FC Client - Unmarried - Unhealthy

H

Socioeconomic status: - Client belongs to lower class family.

Client’s lives in a rental house with adequate water and electricity supply.

1.Physical examination

General appearance: -patient looks fatigue.

Orientation: -patient is oriented to time place and person.

Nourishment: -patient looks adequately nourished.

Body built: -patient body built is adequate.

Activity: -patient activities are normal.

Hygiene: -patient hygiene is maintained.

Level of consciousness: -patient is conscious.

Speech: -speech of the patient is normal.

Look: -patient looks active.

Vital Signs: - On 28/11/2023 at 9:00 AM

Sr. Vital Sign Patient’s Value Normal Value Remarks

No.

1. Temperature 98.20 F 970 F- 990 F Normal

2. Pulse 84 beats/min 80-120 beats/min Normal

3. Respiration 26 breaths/min 24-40 breaths/min Normal

4. SPO2 98% 95-100% normal

Height: -70 cm

Weight: - 9 kg

BMI: - 18.4

2.HEAD TO TOE EXAMINATION: -

ORGAN ASSESSMENT FINDING

HAIR 1. Hair Color: Brown in color

2. Hair Distribution:
Equally distributed

HEAD 1. Scalp: Normal,

No dandruff present.

FACE 1. Face: Normal face.

No puffiness is there
EYES 1. Eyebrows: Symmetrical in shape

2. Eyelashes:
Lashes are present, no sty
3. Eyelids: present.

Normal eyelids
4. Eyeballs:
Eyeballs are normal, no sunken
5. Conjunctiva: eye balls
6. Sclera:
Absence of conjunctivitis

7. Cornea and iris: No signs of jaundice

Normal eye cornea and iris

8. Pupils:
Dilations of pupils are normal

9. Lens:
10. Vision: Lens is normal

Normal vision

EAR 1. External ear: Normal external ears

Normal hearing
2. Hearing:
No abnormal discharge
3. Discharge:

NOSE 1. External Nares: Normal external nares.

Normal
2. Nostrils:
3. Discharge: No abnormal discharge
MOUTH 1. Lips: Color of the lips are pink

No complaints of gingivitis
2. Gums:
3. Teeth: No cavities are present.

Teeth enamel are white in color

4. Tongue:
Pink in color.

No complaint of stomatitis.

5. Throat and Normal throat and pharynx no

Pharynx enlargement of the tonsils

NECK 1. Lymph nodes: Normal, no enlargement of

lymph nodes

2. Thyroid glands No enlargement of thyroid glands

3. Range of motion
Normal range of motion

CHEST 1. Breath sounds Normal

Heart S1 and S2 sounds are

2. Heart
normal, no murmur sound heard
on auscultation.

1. Inspection: On inspection abdomen shows

normal
ABDOMEN
2. Auscultation: No abnormal sounds present
3. Palpitation:
No enlargement of the liver
 4. Percussion: Normal bowel sounds were
present.

SKIN 1. Color: No bluish discoloration

2. Texture:
Dry texture.

3. Temperature: Cold extremities

4. Lesions:
No lesion present in the skin

5. Scars: No scars

Stitches present on right hand.

6. Stitches
GENITALIA 1. External genitalia Normal in appearance.
2. Discharge
There is no abnormal discharge.

UPPER EXTREMITIES 1. Inspection Bandaging and splint present in

right arm.
2. Range of motion
Restricted range of motion of
right arm.

Range of motion is intact in left

arm.

LOWER EXTREMITIES 1. Inspection Both right and left lower

extremities are normal in
appearance.

2. Range of motion Normal range of motion.

3. SYSTEMIC EXAMINATION:

RESPIRATORY 1. Inspection Shape of the chest is bilaterally

SYSTEM symmetrical.
2. Palpation
No abnormal mass present.
 No tenderness on palpation.

3. Percussion No air or fluid accumulation in

lungs.

Breathing sounds are normal.

4. Auscultation
Respiratory rate: 18-20 resp/
min.

CARDIOVASCULAR 1. Pulse rate: 80 beats/ mins.

SYSTEM 2. Heart sounds: S1 and S2 sounds are normal.
3. Abnormal sounds:
No murmur heard on
auscultation.

GESTROINTESTINAL Abdomen: -
1. Shape: Abdomen is symmetrical.
SYSTEM
2. Abdominal No bulging or distension ruled
distension: out.

3. Bowel activity: Bowel activity is normal.

MUSCULOSKELETAL 1. Spinal curvature: Spinal curvature is symmetrical.

SYSTEM
2. Posture: Posture is normal.
3. Extension and Extension and flexion of upper
flexion of upper right extremity is restricted
and lower while extension and flexion of
extremities: lower extremities is normal.

Range of motion is normal in all

4. Range of motion: extremities except right upper
extremity.

NERVOUS SYSTEM 1. Orientation Oriented to time, place and

person.
Patient is conscious and co-
 operative.
2. Consciousness
No motor or sensory deficit.
3. Motor sensory
deficit Reflexes are normal.
4. Reflex: -
ENDOCRINE SYSTEM No investigations done to rule
out hormone level.

INTEGUMENTARY 1. Inspection Stiches present on right thigh.

SYSTEM Good.
2. Skin turgor
Soft and hydrated.

3. Texture
GENITOURINARY 1. Urinary pattern Passes urine 3-4 times during
SYSTEM day time.
2. Bowel pattern. Normal.
No complaint of constipation or
diarrhea.

INVESTIGATION: -
SR. NAME OF NORMAL PATIENT’S REMARKS
NO INVESTIGATION VALUE VALUE
.

1. HB 12.0- 15.0 g/dl 12. 7 g/dl Normal

2. RBC 3.5- 5.5 106/uL 4.61 106/uL Normal

3. WBC 4.0- 10.0 103/uL 6.3 103/uL Normal

4. PLATELET COUNT 150- 410 103/ uL 306 103/ uL Normal

5. MCV 83.0- 101.0 fl 91.6 fl Normal

6. HCT 36.0-46.0 % 33.0% Normal

X-Ray:

MEDICATION: -
SR. DRUG/ DOSE/ INDICATIO CONTRA- ACTION SIDE NURSING
NO N INDICATION EFFECT RESPONSIBILIT
FREQUENCY
. Y
/

ROUTE

1. Tab. Pantop To reduce acid Hypersensitivit Proton -Blurred -Assess the

reflux. y to products of pump vision. patient’s medical
10 mg/ OD/
formulation. inhibitor history.
Orally. To treat ulcers -flushed,
that
in stomach. Severe hepatic dry skin. -Monitor for side
decreases
or renal effects.
As part of the -increased
dysfunction.
treatment to amount of hunger. -Monitor for drug
get rid of H. acid interactions.
-increased
Pylori produced
thirst. -Evaluate the
bacteria. in the
patient’s nutritional
stomach.
status.

2. Syrup Susceptible History of Antibiotic Abdominal -Observe for

pain
Augmentin infections allergy to works by anaphylaxis.
including penicillin. stopping -Allergy
475 mg/5
sinusitis, otitis the growth - Ensure that the
ml/TDS/ Orally Hepatic -Vomiting
media, of patient has adequate
dysfunction. -Nausea
bacteria. fluid intake during
Skin structure
Steven Johnson -Diarrhea any diarrhoea
infections,
Syndrome. attack.
UTIs.

-If the patient

develops a rash,
wheezing, itching,
fever or swelling in
the joints, this could
indicate an allergy
and should be
 reported.

3. Injection Respiratory History of Antibiotic -Black, -Observe for

tarry,
tract allergy to works by anaphylaxis.
cefoperazone stools
infections. penicillins, interfering
sulbactam -bluish
sulbactam, with - Ensure that the
UTI. colour of
250 mg/ BD/ cefoperazone or bacterial the skin patient has adequate
Orally Peritonitis. other wall fluid intake during
-chills
cephalosporin synthesis, any diarrhoea
Septicemia. -cough
antibiotics. leading to attack.
the -dark urine
destructio
-difficulty -If the patient
n of the in
develops a rash,
bacteria. breathing
or wheezing, itching,
swallowin
fever or swelling in
g
the joints, this could
indicate an allergy
and should be
reported.
NURSING DIAGNOSIS

1. Acute pain related to post burn contracture release as evidenced by facial pain rating
scale.
2. Impaired physical mobility related to surgical release of contracture as evidenced by
reduced activities.
3. Impaired physical comfort related to pain and restricted activities as evidenced by
verbalization of client.
4. Anxiety related to hospital stay and treatment regimen as evidenced by facial
expressions.
5. Knowledge deficit related to treatment regimen as evidenced by asking questions
from the parents.

SHORT TERM GOALS

1. To relieve pain.
2. To assist in activity of daily living.
3. To provide comfort.

LONG TERM GOALS

1. To reduce anxiety.
2. To provide knowledge regarding treatment regimen.
 NURSING CARE PLAN

ASSESSMENT DIAGNOSIS GOAL PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective Acute pain To reduce Assess the level Assessment done by This will provide Pain level reduced up to
related to post level of pain. of pain. using facial pain rating base line data. some level evidenced by
Data: facial pain rating scale.
burn contracture scale i.e. 4.
Patient complains that she release as
Vital signs monitored
is having pain in right evidenced by Monitor vital This will provide
i.e. Temperature 990F
arm. facial pain rating signs at regular information of vital
scale. interval. Pulse: 84 beats/min organ functioning.
Objective Data:
Respiration: 22
Observed pain by using
breaths/min
Facial Pain scale.
SPO2: 98%

Pillow is given under

Provide This will enhance the
the right arm.
comfortable rest.
device to client

Provide play Play therapy i.e.

This will divert mind
therapy. building blocks is
from pain.
provided.
Promote periods
Fatigue can
 of rest for the Parents are told to help contribute to pain.
patient. patient in taking naps Rest will allow
between periods of patient to relax and
playing. reduce pain.
Provide paper
Paper and colors are This will divert
and colors to the provided to the patient
patient’s mind from
patient for for drawing.
pain.
drawing.
Provides a sense of
Promote safety and security to
comfort holds
Parents are advised to the patient, decreases
like hugging by give a comfort hold movement and

a parent. (hug) to the patient allows parents to

during pain episode. appropriately
participate in care.

ASSESSMENT DIAGNOSIS GOAL PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective Impaired To improve Assess degree of Patient is not able to This will provide Physical mobility is
physical and help in immobility produced move her right forearm. base line data. improved to some
Data:
mobility physical by injury/treatment. extent as evidenced by
Patient complains that related to mobility. active range of motion.
she can’t move her surgical release
This will increase
right arm. of contracture Encourage
Client is encouraged to patient’s interest to
as evidenced participation in take part in
watch poems and
by reduced diversional/recreational activities.
perform gestures with
activities. activities.
the lyrics.
Objective Data:

Observed by Maintain stimulating This will stimulate

Patient is provided with
environment, e.g., patient’s activities.
 Restricted cartoon dance videos.
radio, TV, pictures etc.
movement of Regular stretching
Patient is assisted in
right arm. Promote passive helps in preventing
regular passive
 Restlessness stretching of the right contractures due to
stretching of the right
arm. immobility of joints.
arm.

Assist patient with Increases blood flow

Patient is assisted with
active/passive ROM to muscles and bone
active range of motion
 exercises of affected i.e. flexion, extension, to improve muscle
and unaffected circumduction starting tone.
extremities. with unaffected
extremity.
Rest periods are
Short rest periods are
Provide the client with essential in
provided to the patient.
rest periods in between conserving energy.
activities.

Position the affected Pillow is given under

Provides comfort
limbs using assistive right arm.
and prevent
devices.
contracture
formation.

ASSESSMENT DIAGNOSIS GOAL PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective Impaired To provide Assess the general General condition of Provides the Comfort level of patient
 physical physical condition of the the patient was poor. baseline data of the is improved to some
comfort related comfort to the patient. patient’s condition. extent as evidenced by
Data:
to pain and patient. verbalization and facial
Assess the physical Helps in knowing
Patient complains restricted Physical cause of expressions.
causes of discomfort. the cause of
that she is not feeling activities as discomfort assessed i.e.
discomfort.
comfortable due to evidenced by Splint and IV cannula.
surgery of her right verbalization of The nurse could be
Interact with the client Spoke with the client in
hand. client. the most important
in a therapeutic a calm and non-
comfort
manner. judgmental manner.
intervention for
Objective Data: meeting client’s
needs.
Observed by:
This will promote
 Facial Provide comfort Pillow under the arm is
physical comfort.
expressions. measures to the given.
 Irritability. patient.
 Restlessness.
Keep the environment This will reduce the
Stress free environment anxiety and
stress-free.
provided by allowing discomfort of the
patient.
the parent to stay with
patient.
 Parents are allowed to
stay with the patient. Allowing parents to
Allow parents to stay
stay with patient
with patient and
will provide a sense
console her. of satisfaction,
safety and relief.
Patient is given
Provide diversional cartoons to watch.
This will shift
therapy to the patient. patient’s focus from
discomfort to the
alternative activity.
HEALTH EDUCATION

1. Hygiene

Educate the patient and family:

 To maintain proper hygiene regularly.

 To take bath daily and change undergarments daily.
 To do proper hand washing before taking food.
2. Diet

Educate the patient and family:

 To take frequent meal.

 To avoid spicy food.
 To take diet high in proteins, calcium and vitamin D.
 To avoid food items high in sugar.
 To include vitamin E in diet to promote tissue healing.
3. Exercise-

Educate the patient and family:

 To do range of motion exercise daily.

 To avoid strenuous activities to avoid excessive physical exertion.
 Advice for deep breathing exercise.
 Encourage for regular physical activity.
4. Medication and follow up-

Educate the patient and family:

 To take medicine daily at regular time.

 For regular follow up whenever needed.
 Advice for regular taking medicines according to doctor’s prescription.
REFERENCES:

 https://fadavispt.mhmedical.com/content.aspx?
bookid=1873&sectionid=139004611
 https://nurseslabs.com/burn-injury/
 https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/
Nursing_management_of_burn_injuries/