Nursing Process to a patient with third grade burns based on the Gordon Theory

Abstract

The present study involves a nursing careprocess applied to a 70-year-old patient at Dr. Victoriode la Fuente Narváez Hospital for Traumatology,Orthopedics, and Rehabilitation’s highly specializedmedical unit, May 2–5, 2017. The burn was causedby direct contact with fire. Per Wallace’s rule ofnines, the burn, located on the left hip at the backof the thigh, was 4% of the body surface. Becauseof its depth, it was a third-degree burn. The bedburn was dark brown and painless. The patientshowed signs of hypertension and diabetes mellitustype 2 with a lack of adherence to the prescribedpharmacological, dietetic, and physical treatment.Vital signs as measured were: heart rate, 77 bpm;respiratory rate, 24 breaths per minute; bloodpressure, 154/97 mmHg; average blood pressure,116 mmHg; body temperature, 37ºC; VAS painscale, 8/10. A lack of vesicular murmur in the baseof the lung field was observed, as well as hematuria(likely prostatic hyperplasia as evaluated by theurology service), a negative hydric balance of 300cc, constipation which had begun four days earlier,and pulmonary edema (+++ on Godet’s scale) inthe thoracic members, the pelvis and the scrotum.The patient was emotionally irritable, showed signsof depression, and expressed a wish to die. Themain interventions performed were pain control,handling of hydric balance, checking for signs ofinfection, monitoring respiration, ozone therapy,emotional support, bedridden patient care, andinfection prevention.