Patient with impaired exercise activity pattern associated with deep second degree burns

Abstract

This work is a Nurse Process applied to patient V. G.  Rosa 67 years old at Burns Unit inside of Hospital de Traumatology y Orthopedic, Lomas Verdes, in a period beginning from 5 to 9 May 2014. The percentage of the burn under Rule 9 given by Browder is 18% focusing on lower limb and left forearm being these deep second degrees, causal agent was hot liquid (butter). They’re in reepithelialization-cicatrization phase and they are stimulus responsive. The valuation was fulfilled on May 5th using as reference to Marjory Gordon and her 11 functional patterns, vital signs were obtained: F.C. 70/min. F.R. 18/min. T/A 130/180 mmHg and T.C. of 36.4°C. As relevant data we have: Glasgow 15, EVA 4, lung fields with rales both lung apices and occurrence of secretions, 2 seconds capillary refill, peripheral vascular access right forelimb permeable and without evidence of infection, high calorie diet and high protein diet, amber yellow urine smell ammonia slightly, uresis 750 ml, solid dregs dark brown once by turn, limitation and pain on movement. A holistic care was provided, hierarchizing diagnoses were made according to functional patterns major alteration and were implemented nursing actions both independent and interdependent timely manner favoring with this the speedy recovery of the patient.