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  • Morning Report Burn Injury

    Diunggah oleh

    Febrian Putra
    89 tayangan27 halaman
    Ms. N, a 14-year-old female, was admitted to the hospital with burn injuries covering 32% of her body caused by a fire from a stove. Her primary survey found she had a clear airway, breathing, circulation, and no neurological deficits. She had visible burn injuries on her head, neck, both hands and left leg. Her secondary survey revealed she sustained the burns two hours prior when trying to put out a fire from a pan. She has been diagnosed with second degree burns over 32% of her body from the fire and will receive fluid therapy, antibiotics, pain medication and debridement during her hospital stay.

    Deskripsi Asli:

    Burn Injury Grade 2

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    Ms. N, a 14-year-old female, was admitted to the hospital with burn injuries covering 32% of her body caused by a fire from a stove. Her primary survey found she had a clear airway, breathing, circulation, and no neurological deficits. She had visible burn injuries on her head, neck, both hands and left leg. Her secondary survey revealed she sustained the burns two hours prior when trying to put out a fire from a pan. She has been diagnosed with second degree burns over 32% of her body from the fire and will receive fluid therapy, antibiotics, pain medication and debridement during her hospital stay.

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    Attribution Non-Commercial (BY-NC)
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    89 tayangan27 halaman

    Morning Report Burn Injury

    Diunggah oleh

    Febrian Putra
    Ms. N, a 14-year-old female, was admitted to the hospital with burn injuries covering 32% of her body caused by a fire from a stove. Her primary survey found she had a clear airway, breathing, circulation, and no neurological deficits. She had visible burn injuries on her head, neck, both hands and left leg. Her secondary survey revealed she sustained the burns two hours prior when trying to put out a fire from a pan. She has been diagnosed with second degree burns over 32% of her body from the fire and will receive fluid therapy, antibiotics, pain medication and debridement during her hospital stay.

    Hak Cipta:

    Attribution Non-Commercial (BY-NC)
    Unduh sebagai PPTX, PDF, TXT atau baca online dari Scribd
    Tandai sebagai konten tidak pantas
    dari 27

    Morning Report

    Burn injury
    By : Febrian Putra 0908113658

    Anamnesis
    Ms. N , 14 years old, Female, came to Arifin Achmad General Hospital on October 19th, 2013 Chief Complain : Her body blistered because of fire 2 hours before admitted to hospital.

    PRIMARY SURVEY
    ward

    Airway
    Objective Gurgling (-) stridor (-) airway obstruction(-) Assesment Clear airway

    Breathing
    Objective Breathing spontaneously RR : 20 x/mins chest wall move symetrically Assesment Clear breathing

    Circulation
    Objective IVFD attached (1 line) HR: 90x/ minutes, regularly TD: 110/70 mmHg CRT: < 2 second warm extremity Assesment stable hemodynamic , clear circulation

    Disability
    Objective GCS 15 isokhor pupil, d : 3 mm. light reflect (+/+) motoric power : 5 5 5 5 Assesment clear mini neurologic assesment.

    Exposure
    Objective T : 36,5 0C Visible burn injury on head-neck, both right and left hand, and left leg.

    Head - Neck

    Right Hand

    Left Hand

    Left Leg

    Assesment hypothermia (-) fever (-) burn injury grade II A 32 %

    SECONDARY SURVEY
    ward

    Trauma Mechanism
    2 hours before admitted to hospital, patient got burn injury because of fire from the stove . Patient wanted to shut the fire off from the pan, but it attacked her head-neck, both of her hands, and left leg. Patient wore T-shirt and short pants when the incident happened. After that, patient flushed with water by his family and took to hospital in 30 minutes

    Past Illness history


    No past illness history related to patients complain.

    Physical examination
    General condition: seemed mild illness Conciousness: compos mentis Vital sign:
    Blood pressure : 110/70 mmHg HR: 90x / minutes RR: 20x/ minutes Temp : 36,5 0C

    Head and neck Thorax Abdomen Extremity Lymph node Genitourinary

    : Localized Status : normal : normal : Localized Status : normal : normal

    Localized Status
    Inspection:
    Seemed burn injury on head-neck, both hand, and left leg of the patient . The color of the wound is red and the edge is black. Bula (+)

    Palpation:
    Tenderness on the wound (+).

    Head-Neck Right Hand Left Hand Left Leg

    : 7% : 10% : 5% : 10% + 32 %

    Working diagnosis
    Burn injury grade II A 32% caused by fire

    Further examination
    - Blood electrolyte, and albumin

    Laboratorium result
    Wbc: 7200 /ul Hb : 13,4 g/dl Ht : 42,4 % Plt: 234000 /ul

    Na: 141,1 mmol/l K: 3,56 mmol/l Cl: 109,9 mmol/l Alb : 3,5 g/dl

    Definitive Diagnosis
    Burn injury grade II A 32% caused by fire

    Therapy Planning
    Fluid therapy (Baxter): Body weight 45 kg 10 x 45 x 4 = 1800 ml IVFD RL Day 1 : 1800 ml in first 8 hours 1800 ml in next 16 hour Day 2 : 1800 ml for second day

    Ceftriaxone 2x1 inj Ketorolac 3x1 inj Hospitalized Pro debridement

    Thank you

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