SUBMITTED TO: MADAM S.

VICTOR VICE-PRINCIPAL COLLEGE OF NURSING DHAMTARI

SUBMITTED BY: Mrs. Lalita Lal M.Sc. NURSING 1ST YEAR C.O.N., DHAMTARI

Course Subject Unit Topic Group of student Evaluator Name of student teacher Venue Date & Time Method of teaching Audio-Visual aids Previous knowledge students

: : : : : : : : : : : :

M.Sc. Nursing Medical Surgical Nursing Specialty - I Integumentary BURN :

Mrs. S. Victor [Vice-Principal, CON, Dhamtari, C.G.] Mrs. Lolita Lal Class Room

Lecture, Discussion, Questions. LCD, Charts, Posters, OHP, Black Board Student had a basic knowledge regarding Burn.

 CENTRAL OBJECTIVE : At the completion of teaching the learner will be able to get the knowledge regarding Burn.  GENERAL OBJECTIVE At the completion of teaching the learner will be able to:1. Define burn. 2. Relate incidence. 3. List down a cause. 4. Distinguish a classification of burn. 5. Explain local and systemic responses to burns. 6. Dialogue the pathophysiology. 7. Identify the clinical features/use assessment tools. 8. Distinguish the medical management in acute phase. 9. Describe surgical management/ pre-operative/post-operative care. 10. Differentiate the nursing management in various phases. 11. Use a nursing process. 12. Recognize disorders of wound healing and its management. 13. Accomplish a rehabilitation phase. 14. Rule out the preventive tips for burn. 15. Know the survival of burn.

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 INTRODUCTION OF THE TOPIC:y BURNS Disrupting the structure and functions of the skin caused by heat, cold, electricity, lionizing radiation an corrosive chemicals and strong acid or alkali ROSS and Wilson Transferring of energy from a heat source to the body Brunner y INCIDENCE It is a 3rd heading cause of death among children and old age people. Up to 6 months - 5 years People over 70 years of age. all ages, all races. Both sexes are same. y CAUSES OF BURN - Smoke - Scalding - Cold burn - Corrosive - Electrical burn - Strong acid and alkaline - Ingestion of chemicals - Sun burn y CLASSIFICATION OF BURNS It is classified according to the depth of the burn extent of body surface area injured. 1. Burn depth : according to tissue destruction - How the injury occurred - Causative agent, such as flame or scalding liquid. - Temperature of burning agent - Duration of contact with the agent.

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- Thickness of the skin 2. SIZE OF BURN : is determined by one of several technique eg RULE OF NINES HUND AND BROWDER METHOD. SURFACE AREA ( TBSA ) RULE OF NINES - 9% Head neck - 9% Rt upper extremity - 9% Lt upper extremity - 18% Anterior trunk - 18% Posterior trunk - 18% Rt lower extremity - 18% Lt lower extremity - 1% Perinium TOTAL BURN

y y y y y y y y

2. Hund and Browder Method : it is based on body segment

by clients age. y It takes a more time to calculate than the rules of nine e.g. : the head and the neck area of achild includes a larger segment of the body surface than that of an adult. It uses diagram of the body divided into sections. Grid corresponding the body with the % of the body surface area represent for ages 1 year through adult. It bases on grid assessment and depth of a burn than calculation made for each area and the total percentage of burned area

y y

3. BURN LOCATION : y The location of a burn is significant in determining its severity.

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 BURNS THE UPPER PART OF THE BODY CARRY THE HIGHEST MORTALITY RATE y Burns of the neck, head and chest often lead to pulmonary complications. y Ear burns may produce chondritis and detoriation and loss of cartilage from infection. y Circumferential burn lead to circulation occlusion to a body area because of edema. 4. AGE A persons age affects not only the security of burn, but often its outcome. Mortality, contractures, deformities varies accordance of age.  LOCAL AND SYSTEMIC RESPONSE TO BURNSBurn > 25% TBSA total burn surface area < 2% TBSA total burn surface area May produce both a local and systemic responses to A. Cardio vascular responseHypovolemia fluid loss Decreasing perfusion and o2 delivery Cardiac output decreased blood pressure drops results burn shock than sympathetic nervous system Releases catecholomines vasoconstriction increased pulse rate- decreased cardiac output than myocardium releases cytokine necrosis factor

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y y

Generally the greatest volume of fluid leak occurs in the 1st 24-36 hrs after the burn peaking by 6 8 hrs as soon as the capillaries begin to refill burn shock resolves and fluid return to the vascular area. Fluid is reabsorbed from the intestinal tissue into the vascular compartment. Urine output increases.

B. BURN EDEMA : - presence of excessive fluid in the tissue spaces buster formation edema it subside after 1-2 days completely resolved in 7-10 days post injury Management Avoiding excessive fluid during the early post burn period. Because in circumferential burns, pressure on small blood vessels and nerves in the distal extremities cause obstruction of blood flow and ischemia complication compartment syndrome. Management surgically escharotomy. [devitalized tissue resulting from a burn ] to relive the constricting effect of the burned tissue. C. EFFECTS ON FLUIDS, ELECTOLYTES AND BLOOD VOLUME y Evaporative fluid through the burn wound may reach 3 to 5 L or more over a period of 24 hrs until the burn surfaces are covered Sodium depletion hyponatremia y Hyperkalemia because of massive cell destruction later on hypokalemia because of fluid shifts and inadequate K replacement

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y y y

Anemia - because of some red blood cells may be destroyed. Haematocrit elevated because of plasma loss / thrombocytopenia Management blood volume expanders to maintain blood volume.

D. PULMONARY RESPONSE it is a leading cause of death in fire victims. Where smoke is reduced at atelectases Expectoration of carbon particles in the sputum is the cardial sign of the injury. y Carbon himooxide mainly responsible for combustion of organic materials result oxyhemoglobin death carbo-

Management early intubation with 100% oxygen Restrictive defects results from edema under full thickness burn it Encircle the neck and thorax.

 OTHER SYSTEMIC RESPONSES:y Renal function it may be altered as a result of decreased blood volume free Hb in urine because of destruction of RBC. Myoglobin from the muscle ( if muscle damage ) release in the urine management goal replacement of fluid volume if no Hb and myoglobin occlude the renal tubules

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Result acute tubular necrosis and renal failure Affected tissues releases Powerful thromboxine vasoconstrictors

Histamine y

serotonin

Result 02 starvation catecholamine alters peripheral Blood flow hypoxic tissue

Pulmonary injuries falls in various categoriesA. Upper airways below the glottis Result carbon monoxide and restrictive defects hypoxia management nasotracheal or endotracheal intubation. B. Lower respiratory injury : Results from inhaling the products of complete combustion noxious gases eg : carbon mono-oxide, sulfur oxides, nitrogen oxide, cyanide, ammonia chlorine and halogens aleveolar duct injured hyper secretion of cough odema and brancho spasam pulmonary surfactant. y Immunologic responses for burn: Diminished resistance to infection

sepsis

Researchers suggest that burn injury results in loss of Thelper cell Lymphocytes (from bone marrow) impairment of the production and release of granulocytes and macrophages from bone marrow.

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Intugumentary: inability to maintain body temperature hypermetabolism resets - Core temperature - Loss of skin integrity, sore, ulcers Gastro intestinal paralytic ileus: - Curling ulcer [ gastric or duodenal erosion ] - Abdominal distension - G.I. bleeding because of inhaled organ mater - Coffee ground vomit

 CLINICAL FEATURES:- Air hunger Sngednaca hair Pain Restless Red and swollen area Smoky breath, smell, inspiratory breath Chest excursion Blood tinged mucous --- anxious Strider Increased inspiratory rate Less or no urine

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 PATHOPHYSIOLOGY:Burn occur > 30% TBSA Cell lysis hemolysis and myoglobin in urine Hyperkalemia Burn leads to increased capillary permeability Na, H2o and protein shift from intra-vascular to interstitial spaces hyponatremia increased blood viscosity Cardiac output decreased tissues perfusion Tachycardia y WHEN BURN SHOCK OCCURS- Myocardial depress out factorSympathetic nervous system activation Adrenal corticoid hormones and catecholamine release Vasoconstrctim Tachycardia, hyperglycemia, increased catabolism, risk of Cushings ulcer, increased metabolism [after burn shock resolves] Tissue perfusionwith decreased GI blood flow (risk of items) tissue damage, cellular dysfunction Potential tissue necroses Anarobic metabolism cell swelling metabolic acidosis

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Decreased renal blood flow Risk of acute renal failure  ASSESSMENT: y Medical history does this include and systemic disease eg : renal cardiac, allergies psychiatric alcohol abuse. (1) Age elderly or young or aging to rule out the recovery. (2) Pre-burn body weight for later interventions. (3) Assessment of the burn depth thany Height y Weight y ABG y Hematocrit y Electrolyte values y Blood alcohol level y Urinalysis y Chest X-ray y ECG y Drug panel y Photograph may be taken in this stage y Consent  more detailed assessment follows - Take vitals every 15 mts. - Look for signed nasal hair, dark sputum - Assessment through informant ( eye witness ) - Others information such as Time of injury - fluid therapy for the 1st 24 hr is
Based on time.

How the injury occurred nature of accident Circumstances of the burn was it accidental or Intentional?

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Was there any smoke? How long was the person exposed to the source of burn?

Previous treatment what kind of 1st aid was given?

Flames and cool the wound quickly this may minimize burn depth and reduce pain.

Chemical bur brush off dry chemicals and immediately rinse with a lot of clean, cool water - Remove clothing and again rinse it with cool water for 15-20 minutes. Be sure remove the contact lense if present. For electric burn turn off the source of energy. - Separate the person from the source of electricity by using wooden dry rod. - Contact the electrical utility company or authorized person. - Quickly assess cardio pulmonary function and start CPR if necessary.  MEDICAL MANAGEMENT:  FIRST AID AND IMMEDIATE INTERVENTION ON-SITE BURN MANAGEMENT: the sooner burned people get appropriate treatment for serious burn, the greater are their chances of survival y MAJOR GOALS OF Ist AID: - Stop the burning - Assess airway breathing, circulation and start CPR if necessary. - Conserve body heat

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Minimize wound contamination Transport the person quickly. remove the person from the

FOR THERMAL BURNS source of burning.

FOR FLAME BURN Drop the person to the ground log-roll the person to extinguish the flames and use lots of water ( if available )to douse.

y Was tetanus prophylaxis given ? Transfer to burn center is depends upon the depth and extent of the burn. Before transfer the client following - Secure intravenous catheter with ringers located solution 30 ml/mt - Patient airway is ensured - Do not apply ointments or creams to a burn at this time - dont give anything by mouth. y Fluid replacement therapy Output totals of 30-50 ml/hr have been used as goals and if BP systolic. Exceeding 100 mm Hg and/or a pulse rate less than 110/mt. Client individual response is the key to assessing the adequacy of fluid replacement eg : ringers 2-4 ml x kg body weight x % TBSA A. Half to be given in 1st 8 hrs remaining half to be given over next 16 hours ( consensus formula ). -

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B. Brooke Army Formula- Colloids 0.5 ml x kg body weight x% TBSA - Ringers 1.5x kg body wt - Glucose 5% 2.000 ml to be given in 1 st 8 hrs. - Remaining half our next 16 hours. y Evans formula :- Colloids 1 ml x kg body wt x % TBSA. - Electrolytes (saline) 1 ml x body wt - Glucose 5% in water 2.000 ml for insensible loss. Baxter formula:- Lactated ringer .5 4ml x kg body wt - Hypertoxic saline solution:- Nacl and lactate with concentration of 25- - 300 mEg of sodium /L. dont increase the infusion rate during the 1 st 8hrs. of post burn. - Serum sodium must be monitored closely. Purposes = why do give hypertonic saline? Wounds are covered with a clean dry sheet and the patient is kept comfortably warm. edema and prevent pulmonary complications. Eg.- 70 kg client wt. General formula 2 4 ml /kg % TBSA 2 x 70 x 50 % burn = 7,000 ml x 24 hrs.

Increase serum sodium level and osmolality to reduce

So in 1 st 8 hrs. 3.500 ml or 437 ml / hr. Next 16 hrs. 3.500 ml, 219 ml/hr.

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 SURGICAL MANAGEMENT:  Goal:- To remove tissue contaminated by bacteria and foreign bodies. - To remove devitalized tissue or burn ash or in preparation for grafting and wound healing. A. WOUND DRESSES: y Wound Debridement:i. Natural debridement:- The dead tissue separates from the underlying viable tissue spontaneously, proteolytic enzymes are responsible further after 2 weeks of burn injury. B. MECHENICAL DEBRIDEMENT:- It involves using surgical instruments to remove eschar. It can be performed by skilled nurses and technicians. C. SURGICAL DEBRIDEMENT: - It is an operative procedure involving either primary excision, of the full thickness of the skin down to the fascia or shaving the burned skin layers gradually down to freely bleeding viable tissue. This may be performed when pt. is hemodynamic stable and edema has decreased. - Than wound is covered immediately with a skin graft. If needed. - This procedure creates a high risk of intensive blood loss [.100- 125ml] per % body surface excised.

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y GRAFTING THE BURN WOUND: Goal:- To make chart earlier recovery contractures.

and

reduces

a. Auto graft:- If wound are deep [full thickness] extensive spontaneously epithelialization is not possible then auto graft is necessary. b. Hetro graft:- Or xenografts: skin taken from pigs [very rare] because more chances of rejection by immune reaction. c. Amniotic membrane graft:- from the human placenta can also be used are biological dressing.

d. Bio synthetic dressings:biobrane composed of a nylon, silastic membrane combined with collagen fibre. The material is semi transformed. It adheres to the wound fibrin which binds to the nylon collagen material, within 5 days. Cell migrate into the nylon mesh. It will remain over the wound for 3 4 weeks until the epithelialization and wound healing occur. It is also useful for intermediate or long term closure of a surgically excised wound until an auto graft becomes available. Richly vascular granulation tissue is pink, firm, shiny free of exudates and debris. It should have a bacterial cochi- 100,000/gram of tissue to optimize graft take. It the wound is not ready for skin grafting the burn wound is excised and allowed to granulate.

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BIOLOGIC [HOMO GRAFTS AND HETRO GRAFTS]:It is commonly used in clients with large areas of burn. - It provide temporary immediate courage for clean, superficial burns and decrease the wound evaporative water and protein loss. - Decrease pain by protecting nerve endings. They stay in place for varying lengths of time but are removed in instances of infection or reaction. HOMO GRAFT:- are skin obtained from recently decreased human [skin bank]. DERMAL SUBSTITUTES: -

o Artificial skin [integra] A dermal analog, it is made up of 2 layer epidermis consisting of rilastic acts as a bactreal barrier. 2nd = dermal layer is composed of animal collagen it allows migration of fibroblaste and capillaries into the material. This neoderma becomes a permanent structure. This dermis layers is bio degraded and reabsorbed but epidermis layer is removed 2 -3 wks after application instead of that pts own epidermis layer place [graft]. Most importantly integra has resulted in less hypertropic scarring. o Alloderma:- from human cadaver skin both epidermis/ dermis. It is a permanent dermal layer replacement less scarring less contractures. o Cultured epithelial auto graft:- It is a common at several burn centers. This involves a biopsy of the pts skin in an unburned area. Kerotiocytes are then isolated and epithelial are cultured in a lab. The original epithelial cell sample can multiply 10 10,000 times its original size our

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30 days than it apply over the client own wound. Varying degree of success have been reported. o WOUND CLEANING :- Hydro therapy - Shower bath - Warm bath temperature 100 F and the same time room temp. maintained 85 C - Eshar to be debride as required. - Patient comfort should be maintained During bath assessed for signs of chilling. Fatigue, changes in hemodynamic status and pain management by analgesic and relaxation therapy maintained. o Topical antibacterial therapy:- Topical antibacterial agent is not sterilize the burn wound but simply reduces the number of bacteria. - The 3 most commonly used topical agents are silver sulfadiazine, silver nitrate, sulphamylon. o WOUND DRESSING: when the wound is clean the burned area are patted dry and the prescribed agent is applied. o OCCULUSIVE METHOD OF DRESSING:- Dressings are changed in client room after an analgesic period is over approximmatley 20 mts . - A most goggles, have cover gown, gloves are warm. The outer dressings are slit with blunt scissor, and the sailed dressing are removed and disposed properly. - Inspect the wound color, odor, size, exudates, signs of re-epithelialization and the Escher and any changes from the previous dressing change are noted.

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 NURSING MANAGEMENT FOR EMERGENT PHASE: - Collect all the emergency equipment. - Vitals monitored frequently /ABC. - Cardiac monitored closely. - Doppler device to be use to check BP. - Elevation of burned extremities is crucial to decrease edema. - Large bore 18 or 16 gauzed intravenous line inserted. - Indwelling urinary catheter is placed. - Urine output, consistency, color to be checked and report it if needed. - Infusion pump and rate of the drip should be closely monitored. - Use universal precautions. - Neurological assessment LOC psychological status, pain, anxiety, and behavior to be assessed.  INTERMEDIATE PHASE OF NURISNG CARE OF BURN:- It starts 48 to 72 hours after the burn injury. In this phase, attention is directed toward continued assessment and maintenance of respiratory and circulatory status. Fluid and electrolyte balance and GIT function burn wound care. Eg. wound cleaning - Checked ABG - Strict aseptic technique to be followed. - Maintain skin integrity. - Observe for pedal edema, lingsond.  INFECTION PREVENTION:The burn wound is an excellent medium for growth and

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proliferation, eg. Staphylococcus, prateus, pseudomonas, E.coli, klebriella. Especially eshar area, because 10.5 bacteria per gram of tissue, inflammation, sledging and thrombosis of dermal blood vassals. Use cap, gown, mask, gloves, are worn while caring the patient with open burn wounds. Tissue culture to be send oftenly. Along with these sputum, urine, stool, blood to be culture. Microbial agent should be us.  PAIN MANAGEMENT: A. Background pain : is pain that exists on a 24 hr. basis. B. Procedural pain: Is pain caused by procedure dressing. C. Break through pain: When blood levels of analgesic agents fall below the level required to control background pain. - Management: Optical analgesic administration in the IV route. - Morphine, anti-anxiety drugs. - Relaxation techniques, deep breathing exercise. Distraction. - Guided imagery - Hypnosis - Therapeutic touch - Music therapy - Allow patient for self expression.

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y Nutritional management: - the most important  Objectives:- Is to provide adequate nutrition and calories to decrease catabolism. - Protein:- 1.5 to 4.0 gms of per kg of body weight every 24 hrs. - Carbohydrates:- 5,000 Kcal/day Therefore adult 25 Kcal x kg body wt. Plus 40 Kcal x % burn Eg.- 60 kg body wt client is burn protein 2.640 gm protein + 5000 car.  NURSING PROCESS DURING ACUTE PHASE:1. Ineffective breathing pattern related to smoke inhalation secondary to infested organic material. y y Goal:- To improve breathing pattern. Plan:- Assess the breathing pattern - Airway management position, turning, drainage. - Keep client in a open ventilated room. - NPO - CPR if needed. - Remove mucous, secreations.

postural

2. Alteration in comfort related to temperature control. y y

inadequate body

Goal:- To maintain body normal temperature. Plan:- provide a warm, humidified environment. - Keep room temperature at 34c (93.2f). Ensuring warmth with blankets, thick dressing

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Provide radiant heat and minimize the danger of further burns.

3. Alterations in comfort related to pain. y y Goal:- To minimize a pain by giving comfort. Plan:- Psychological support is needed. - Diversion technique - Relaxation technique - Consult with health care team members for assistance.

4. Fluid volume excess related to resumption o capillary integrity secondary fluid shift from intessitial to intravascular compartment. y y Goal:- Maintenance of optimal fluid balance. Plan:- Monitor vitals - Intake output record 30ml/hr. - Weight daily - Check JVD - Maintain parenteral IV rate/volume. - Administer diuretics as prescribed and assess response.

5. Ineffective individual coping related to fear and anxiety grieving. y y Goal:- Use a appropriate coping strategies to deal with post burn problems. Plan:- Assess pts for coping abilities. - Provide positive feedback and support. - Assist patient to set achievable short term goals.

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 PRE-OPERATIVE DEBRIDEMENT:y

CARE

CLIENT

UNDERGONE

NURSING DIAGNOSIS:-

1. Fear and anxiety it outcome of the surgery secondary to fear of disfigurement. y Plan:o To assess the level of anxiety o Clear his/her doubt regarding surgery. o Realistic while informed about fact. o Tell him to importance of surgery. o Psychological support. o Never leave the patient alone.

2. Imbalance nutrition less than body requirement related to loss of appetite secondary to bad odour from a wound. y Goal:- improve nutritional status. y Plan:- Provide, high calorie, high protein diet. - Provide nutritional supplement. - Monitor weight daily. - Administer enteral or parenteral nutrition per protocol. - Report abdominal distention, bowel sounds or diarrhea and constipation to physician. 3. Impaired skin integrity related to open burn wounds. y Goal:- Demonstration of improved skin integrity. y Plan:- Clean wounds body and hair daily. - Provide clean environment - Provide clear linen, bed sheets, gown - Nail care itrimming. - Scrub bath of donor site.

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Provide adequate nutritional support. Assess wound condition eg.- debris, pus, discharged.

 POST OPERATIVE CARE AFTER DEVRIDEMENT OF BURN WOUND:A. Ineffective breathing pattern related to effect of anesthesia. y Goal:- Maintain adequate breathing pattern. y Plan:- Collect all the emergency articles drug at bed side locker. - Assess the respiratory rte, pattern - Monitor vitals - Suction as needed - Position - Check pulse oxymetry - Monitor SPoz - Observe sign of choking labored - Breathing B. Fluid volume deficit related loss of blood and fluid during surgical procedure. y Goal:- To replace fluid and electrolyte and blood. y Plan:- vitals monitor. - Observe peripheral coolness, pulse refilling time. - Check wound every 15 mts. - Urine output record and reported. - Fluid therapy monitor as well as oral intake is so. - Notify to physician immediately of decrease urine output. - Fall BP - ABG changes - Decrease SPO2

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Increase CO2 Intensity of pain not relieving after had analgesic.

C. Pain related to emotional and physical discomfort. y y Goal:- To minimize a pain. Plan:- Use pain intensity scale differentiate from hypoxic pain. - Administer opiod analgesic as order. - Provide emotional support and reassurance. - Elimination pattern observe.

D. Knowledge deficit related to course of burn treatment. y Goal:- verbalization and demonstration of the course of burn treatment. y Plan:- Assess readiness of client and family to learn. - Explain importance of pts participation in care. - Reassure and explain the length of recovery period. E. Potential for CCF, pulmonary edema, sepsis, ARDS. y Goal:- absence of complication. y Plan:- Monitor vitals - Check jugular vein distension - Assess for crackles on lung CCF - Position client with 45 or 60 Assess for fever. Increase pulse Flushed, dry skin Monitor wound condition Administer fluids Monitor for therapeutic response

Sepsis

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Assess respiratory rate Breath sound Chest expansion Monitor pulse oxymetry Spoz monitor document and report if needed.

ARDS

F. Risk for infection related to loss of skin barrier and decreased immune response. y Goal:- Absence of systemic infection. y Plan:- Use asepsis in all aspects of client care. - Screen visitors for respiratory, GIT, integumentary infections. - Provide isolation gown, mask, cap to them - Exclude plant and flower in water form pts room. - Inspect wound carefully. - Monitor WBC count culture and sensitivity results Administer antibiotics if needed. - Vitals monitor. - Urine color, odor, consistency - Regular lined change.  HEALTH EDUCATION:- Maintain adequate posture - Demonstration about exercise - Strengthen coping strategies - Rehabilitation - Follow up  DISORDERS OF WOUND HEALING/ COMPLICATION:y SCARS:- one of the most devastating sequelac of a burn injury in the formation of hypertrophic scars. It is to believe that this is a result of aver abundant collogen matrix

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formation. It occurs mostly in deep burn. y Management:- wear a pressure garments. Applying ilastic pressure garments loosens collagen bundles and encourages paraller orientation of the collagen to the skin surface, with the surface modules. Keloids:- A large heaped up mass of scar tissue. Management:- surgical incised Contractures:- The burn wound tissue shortens because of the force exerted by the fibroblasts and the flexion of muscles in natural wound healing. Management:- passive exercise at a time of acute phase. Proper position. Analgesics.

y y y

 REHABILITATION PHASE OF BURN CARE:- Rehabilitation begins immediately after the burn has occurred as early as emergent period- and often extends for years after injury. - Psychological and vocational counseling and referral to support groups may be helpful to promote recovery and quality of life. - Cosmetic surgeries - Employment - Prestige. - Social participation These are all issues should be discussed with client before discharged from the hospital.

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 Dietary Management For Burn Client: y Goal:- To maintenance of fluid and electrolyte balance. - To provide adequate calorie protein intake - To promote wound healing and resumption of normal activities.  ONE DAY MENU PLAN TOTAL :y Calorie :- 3970 x 24 hrs.

6 am: cereals - 1 serve Milk - 500 ml Egg - 1 Brown bread - 4 slice 10 am: fruit juice - 25 ml 12 pm : Dal - 200 ml Roti 2 Curd 100 gm Rice puffed - 1 serve Salad 4 pm: Biscuits - 4 Tea 150 ml 8 pm : Soya bean 1 serve Chapatti 2 Egg 1 Apple 1 10 pm : orange juice 25 ml

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 PREVENTIVE TIPS FOR BURN: - Keep matches and lighters out of the reach of children. Never leave children alone around or in bathroom/bath tub. Maintain smoke detector in the home. It is good to teach all of the family members home exist fire drill. Do not throw flammable liquids onto an already burning fire. Do not use flammable liquids to start a fire. Do not remove radiator lap form a hot engine. Watch for overhead wire and under ground when working outside. Use caution when cooking tie you hairs. Every 6 months call electrician to check all the electric wire especially before start rainy season.

RECAPTULIZATION: 1. What will be a burn management in intensive phase. 2. After skin graft as a nurse what would be your responsibility to prevent for further complications. 5 5

BIBLIOGRAPHY:

1. Brunner And Siddharath, Textbook Of Medical Surgical Nursing. 10th Ed. Philadelphia. P.P.No. 1704 1739. 2. Black M. Joyce; The Text Book Of Medical Surgical Nursing. 1997. P.P.No. 2233 - 2264. 3. Barbara C. Long; Essential Of Medical Surgical Nursing. 8th Ed. 1985. P.P.No. 1129 1136. 4. B.T.Basavanthappa; Medical Surgical Nursing. 2nd Ed. 2009. P.P.No. 216 226. 5. Luckmann And Sorenson; Medical Surgical Nursing. 3rd Ed. 1987. P.P.No. 1614 - 1638. 6. Lippincott; Manual Of Nursing Practice. 6th Ed. 1996, Philadelphia. P.P.No. 906 - 920. 7. Mosbys; Nursing Drug Reference. 2009. 22nd Ed. P.P.No. 269 - 270. 8. M. Swaminathan; Food And Nutrition. Vol. 2, 1985. P.P.No. 44 46. 9. Ross And Wilson; Anatomy And Physiology In Health And Illness. 10th Ed. P.P.No. 364 - 367. 10. T.K. Indrani; Nursing Manual Of Nutrition And Therapeutic Diet. 1st Ed. 2005. P.P.No. 34.

 GENERAL OBJECTIVE : At the end of teaching, listeners will be able to gain knowledge regarding Pulmonary Tuberculosis.

 SPECIFIC OBJECTIVE At the end of teaching student will be able to1. Give the introduction of Pulmonary tuberculosis. 2. Define the term Pulmonary tuberculosis. 3. Enlist the causes of tuberculosis. 4. Describe the mode of transmission. 5. List the clinical manifestation of tuberculosis. 6. Explain the preventive measures of tuberculosis. 7. Enumerate the promoting activity & adequate nutrition. 8. Explain the teaching & home care. 9. List the complication of tuberculosis.

SUBMITTED TO: MRS. S.S.NIHALA LECTURER COLLEGE OF NURSING DHAMTARI SUBMITTED BY: MRS. ANJUM NOVEL M.Sc. NURSING 1ST YEAR C.O.N., DHAMTARI

BIBLIOGRAPHY:

1. Brunner And Suddarths ; Text Book Of Medical - Surgical Nursing. 10th Ed., Published By Lippincott Williams & Williams. 2004. P.P.No. 587 595.

2. Black, M. Joyce, Medical Surgical Nursing: Clinical Management For Positive Outcomes. 8th ed. W.B. Saunders Company. P.P. No. 2004 - 2021. 3. Lippincott, Manual Of Nsg. Practice; 8th Ed. Published By J.B.Lippincott, Company Philadelphia, 1986. P.P.No. 940 - 944. 4. Luckman And Sorensens; Medical Surgical Nursing; Published By W.B. Saunders, 4th Ed. P.P.No.- 1021 1026.

5. Lewis Heskemper Dirksen; Book Of Medical Surgical Nursing. Published By Mosbys Publication. P.No. 1374 1377.