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Burning pain 3

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  • Estimate percent (%) of body surface burned in order to estimate isotonic fluid requirements "Rule of Nine". This formula divides the body into parts considered to be 9% (arms, head) to 18% (legs, front, back) of total body skin surface in adults. The small child has a different surface area breakdown. The burn size  (as % of total) can then be used in the resuscitation formula.
  • Burns are among the most excruciatingly painful physical injuries. Even a relatively minor burn can be intensely painful. A burn occurs when the skin, and often other bodily organs, come in contact with heat, radiation, electricity or chemicals for a period long enough to cause damage.
  • Scald Burns - usually from hot water, are the most common cause of burns in civilian practice. Flame burns - the second most common mechanism of thermal injury. Flash burns are next in frequency. Explosions of natural gas, propane, butane, petroleum distillates, alcohols, and other combustible liquids, Contact burns result from contact with hot metals, plastic, glass, or hot coals. Chemical burns – usually industrial accidents; ex. Acid, alkali, hydrocarbons.Usually deeper than it looks as the skin is destroyed mainly by chemicals.  Appearance is often brown to gray as opposed to the typical white or char with a flame burn. - Continue to get deeper and later appearance is usually worse. - Severe persistent pain is often present indicative of ongoing skin damage.      
  • Burn Severity is determined by: 1.Burn depth. 2. Burn size. 3. Burn location
  • A Normal skin is a very complex organ with a wide variety of properties mainly protective barriers, which are critical to survival. Loss of these barrier function occurs with a skin burn. Understanding of these alterations in skin function will greatly assist in initial management. A skin burn is the damage to the skin caused by heat or other caustic materials like chemicals. The most immediate and obvious injury is one due to heat. Excess heat causes rapid protein denaturation and cell damage. The depth of heat injury is dependent on the depth of heat penetration . Wet heat (scald) travels much more rapidly into tissue than dry heat (flame). A surface temperature of over 156°F (68°C) by wet heat produces immediate tissue death as well as vessel clotting. A higher temperature would be required with dry heat (flames). The dead tissue on the surface is known as eschar. When heat is applied to the skin, the depth of injury is proportional to the temperature applied, duration of contact, and thickness of the skin. The depth of the burn is dependent on the temperature of the heat insult, the contact time, and the medium (air-water). In addition, the thickness of the skin layer is critical as the thinner the skin, the deeper the burn. Children and the elderly have very thin skin. Chemicals destroy skin by chemically killing the tissue. It is now clear that toxic agents released by inflammation.
  • Though for a layman any burn might seem the same, there are diversities, when considered from the medical point of view. Different types of burns are categorized as per the intensity of skin or tissue damage. This in turn depends on the number of skin layers affected throughout.This determines the type of burn injuries, which can be mild as well as severe and may need medical assistance. These types of burns are first, second and third degree burns burns. The burn category indicates the severity of the burn along with the amount of body area covered by the burn injury. Partial thickness: is a second degree burn consisting of injury to part if the dermis Full thickness: is a third degree burn consisting of injury to both layers SECOND-DEGREE BURN: This degree burn destroys the epidermal layer and portions of the dermis. Since it does not extend through both layers, it is termed a partial thickness burn. Superficial Second-Degree Burn: Involves the entire epidermis and no more than the upper third of the dermis is heat destroyed. Rapid healing occurs in 1-2 weeks, because of the large amount of remaining skin and good blood supply. Scar is uncommon. Initial pain is the most severe of any burn, as the nerve endings of the skin are now exposed to the air. . Second degree burns may take from one to three weeks to heal but are considered minor if they cover no more than 15% of the total body area in adults and 10% body area in children. If a deep second-degree burn is not properly treated, swelling and decreased blood flow in the tissue can result in the burn becoming a third-degree burn.
  • Estimate percent (%) of body surface burned in order to estimate isotonic fluid requirements "Rule of Nine". This formula divides the body into parts considered to be 9% (arms, head) to 18% (legs, front, back) of total body skin surface in adults. The small child has a different surface area breakdown. The burn size  (as % of total) can then be used in the resuscitation formula. RULE OF PALM     The rule of palm uses the patient's palm and fingers for the assessment. Each "palm" is equal to 1% TBSA. Practically, the rule of palm may be most useful for estimating small or isolated burns. Use the patient's palm, not the provider's. 2,3,13,15 LUND AND BROWDER     The Lund and Browder chart is considered a more accurate tool for assessing TBSA and fluid replacement. It is most commonly used in hospital settings, including burn centers. While the chart is very accurate, it may not be practical in the prehospital setting, as it may require additional time for use and field calculations. 13,15     The Lund and Browder chart assesses burn severity based on the patient's size and age. It involves drawing on charts to indicate the burn's severity, such as red or blue to indicate partial- and full-thickness burns. The percentage of affected TBSA is then determined. This tool is effective for both burn size estimates and recommending the correct amount of fluid that should be considered
  • Burns to high risk areas are defined as those which have a high risk of complications and potential disability both functional and cosmetic. These burns should usually be managed in a burn care facility.   Face Ear Perineal Foot Hand
  • Assure adequate ventilation and perfusion: 100% O2 inhalation ,intubation for airway obstruction, Circulation Assess adequacy of circulation with vital signs, skin color and temperature (Hypovolemic shock is usually not present in the immediate post burn period). Maintain body temperature to prevent hypothermia. Give adequate IVF & IV pain reliever.   removal of constricting objects, like jewelry. deep chemical burn can produce constriction of local blood flow similar to thermal burn Remove heat source and any constricting items Disability Absorption of some chemicals can lead to impaired brain function  seizures   Unconscious state Altered consciousness can also be due to head injury (if explosion) Assess and document level of consciousness Expose & Examine: Remove clothing and constricting objects        ·       Cool water for small second degree burns only ·       Assess size and depth “Rule of Nine” ·       Tetanus Prophylaxis
  • First Aid for Severe Burns: (Second & Third-Degree) 1. DO NOT remove burnt clothing (unless it comes off easily), but do ensure that the victim is not in contact with burning or smoldering materials. 2. Make sure the victim is breathing. If breathing has stopped or the victim's airway is blocked then open the airway and if necessary begin CPR. 3. If the victim is breathing, cover the burn with a cool moist sterile bandage or clean cloth. DO NOT use a blanket or towel; a sheet is best for large burns. DO NOT apply any ointments and avoid breaking blisters. 4. If fingers or toes have been burned, separate them with dry sterile, non-adhesive dressings. 5.Elevate the burned area and protect it from pressure or friction. 6.Take steps to prevent shock. Lay the victim flat elevate the feet about 12 inches, and cover the victim with a coat or blanket. DO NOT place the victim in the shock position if a head, neck, back, or leg injury is suspected or if it makes the victim uncomfortable. 7.Continue to monitor the victim's vital signs (breathing, pulse, blood pressure).
  • Loss of plasma volume is rapid after a burn injury as fluid collects in the burn tissue. The magnitude of loss can be easily underestimated as plasma is not visibly lost from the surface but rather is hidden beneath the burn. Early fluid resuscitation is required for burns exceeding 20% of body surface. Rule of Nine- that a formula is only an estimate and adjustments need to be made based on patient’s status.
  • Begin Ringer’s Lactate. Estimate initial rate according to the estimated percent of total body skin surface burned (%TBS). Estimated body weight (4cc/kg/%TBS burn in 24 hours giving half of the estimate in 1-8 hours.) As burns approach 20% TBSA, local proinflammatory cytokines enter the circulation and result in a systemic inflammatory response. 38 The microvascular leak, permitting loss of fluid and protein from the intravascular compartment into the extravascular compartment, becomes generalized. Cardiac output decreases as a result of burn shock and myocardial injury. 39 The resulting intense sympathetic response leads to increased systemic vascular resistance and decreased perfusion to the skin and viscera. Decreased flow to the skin may convert a zone of stasis to one of coagulation, thereby increasing the depth of burn. Decreased cardiac output may depress central nervous system (CNS) function, and in extreme cases, ultimately lead to cardiac failure in healthy patients or to myocardial infarction in patients with premorbid coronary artery atherosclerosis. Impairment in CNS function manifests as restlessness, followed by lethargy, and finally by coma. If resuscitation is inadequate, burns of 30% TBSA frequently lead to acute renal failure, which in the case of a severe burn almost invariably results in a fatal outcome.
  • Regardless of whether colloid is used or not, patients should receive appropriate maintenance fluids. The total daily maintenance fluid requirement in the adult patient is calculated by the following formula, where m2 is square meters of TBSA:
  • Gastric Decompression Many burn centers begin enteral feeding on admission to reduce the risk of gastric ulceration (Curling's ulcer), a Foley catheter placed and urine output monitored hourly, the goal being 30 mL/h in adults and 1.0 mL/kg per hour in young children.
  • Keloid scars - overgrowth of scar tissue. The scar will grow beyond the site of the injury. These scars are generally red or pink and will become a dark tan over time. Hypertrophic scars are red, thick and raised, however they differ from Keloid scars in that they do not develop beyond the site of injury or incision. A contracture scar is a permanent tightening of skin that may affect the underlying muscles and tendons that limit mobility and possible damage or degeneration of the nerves. Contractures develop when normal elastic connective tissues are replaced with inelastic fibrous tissue. This makes the tissues resistant to stretching and prevents normal movement of the affected area.
  • Physical Therapy, pressure and exercise in many cases can aid in controlling contracture burn scars. If these treatments do not control the effects of contracture scars, surgery may be required. A skin graft or a flap procedure may be performed. There are two major types of Surgical Procedures that can help to conceal scarring and replace lost tissue for severe burn victims: Dermabrasion and Skin Grafts.

Transcript

  • 1. Department of Family & Community Medicine Perpetual Succour Hospital Presentor: LIZA D. MARIPOSQUE, M.D. 3 rd Year Famed Resident May 27, 2010 The Burning Pain
  • 2. OBJECTIVES
    • GENERAL OBJECTIVES:
    • To discuss the family profile of Tim-tim & Martinez Family.
    • To present a case of thermal burn injury (kerosene).
  • 3. SPECIFIC OBJECTIVES
      • To establish the family diagnosis of Tim-tim & Martinez Family using family assessment tools.
      • To briefly discuss the management, prevention and complications of thermal burn injury.
  • 4.
    • E. T.,44 y.o, female,Single, sari-sari store vendor owner, from Upper Laguerta, Lahug, Cebu City.
    • CC: oozing & infected burned skin of the L side of the face, neck & L arm
  • 5. Past Medical History
    • (-) HPN, DM, BA
    • No known allergies
    • No Previous Hospitalization
  • 6. History of Present Illness
    • 2 wks PTC – while cooking food, sustained burn on the L side of the face, neck and L arm upon gas (kerosene) stove explosion.
      • Spicy vinegar & water applied on the wound.
  • 7.
    • Hospitalized 1 week discharged w/ (VSMMC) home meds:
            • TT 0.5 ml IM
            • TIG 250 IU IM
            • Ciprofloxacin 500mg 1tab BID x 10 days.
            • Silver Sulfadiazine Cream (Flammazine) apply to affected area OD.
            • Tramadol 50mg 1tab q 8Hr prn for pain.
    INTERVAL HISTORY
  • 8.
    • Ff-up check-up: 1 wk after discharged
      • Cont. Ciprofloxacin 500mg 1tab BID x 3 days more.
      • Cont. Flammazine cream OD.
      • Cont. Tramadol 50mg 1tab TID prn for pain.
      • Vit. C 500mg 1tab OD.
      • Vit. B-complex 1tab BID.
  • 9. Physical Examination
    • Conscious, coherent, not in respiratory distress.
      • BP: 120/90-130/80 mmHg T: 37.2 0 C
      • HR: 75 bpm
      • RR: 20 cpm Wt: 55 kg
  • 10.
    • Skin: dry, dark, warm
    • HEENT: Pinkish burn scar, wet & w/ purulent burn surface on the anterior neck . No lymphadenopathies
    • C/L: Equal chest expansion, No chest retractions, Clear breath sounds , No rales .
  • 11.
    • CVS: Distinct heart sounds, normal rate & regular rhythm, no murmur
    • Abd: Flabby, normoactive bowel sounds, soft, non-tender, no masses palpated, no hepatomegaly
    • Ext: No edema, (+) pinkish and wet burn on the medial side of the L arm , no limitation in movement, strong pulses
    • CNS: Within normal limits
  • 12. Final Diagnosis
    • 2 nd Degree Burn,14.5% TBSA, on the L side of the Face, neck, & L arm
  • 13. Estimating the size of the Burn as a % of the Total Body Surface (TBS)
  • 14. DISCUSSION
  • 15.
    • A burn occurs when the skin, and often other bodily organs, come in contact with the ff:
    BURNS Heat Radiation Electricity Chemicals Tissue Damage
  • 16. Kinds of Burns
    • Scald Burns - hot water
    • Flame burns - thermal injury.
    • Flash burns – explosion
    • Contact burns - hot metals, plastic, glass, or hot coals.
    • Chemical Burns
    • Electrical Burns
    • Cold Injuries – hypothermia & Frosbites
  • 17. Burn Severity is determined by:
    • Burn depth
    • Burn size
    • Burn location
  • 18. Burn Depth – destruction of skin layers by the heat source.
    • Depth of injury -proportional to the temperature, duration of contact, and thickness of the skin.
    http://www.burnsurgery.org/
  • 19. Categories of Burns: 4 th Degree : involves all layers
  • 20. Estimating the size of the Burn as a % of the Total Body Surface (TBS)
  • 21. High Risk areas for Burns http://www.burnsurgery.org/
  • 22. tREATMENT & aSSESSMENT
  • 23.
    • Airway
    • Breathing
    • Circulation
    • Disability
    • Expose & Examine
    A B C D E
  • 24. First Aid for Severe Burns: (2 nd & 3 rd Degree Burns)
    • DO NOT remove burnt clothing.
    • Make sure the victim is breathing.
    • Cover the burn with a cool moist sterile bandage or clean cloth.
    • If fingers or toes have been burned, separate them with dry sterile, non-adhesive dressings.
    • Elevate the burned area and protect it from pressure or friction.
    • Prevent shock
    • Continue to monitor the victim's vital signs
  • 25. RESTORING & MAINTAINING HEMODYNAMIC STABILITY
    • Loss of plasma volume is rapid after a burn injury as fluid collects in the burn tissue.
    • Early fluid resuscitation is required for burns exceeding 20% of body surface.
    • Estimate percent (%) of TBSA burned in order to estimate isotonic fluid requirements using "Rule of Nine".
  • 26. Fluid Resuscitation Protocol
    • Burns >20% TBSA require initial fluid resuscitation
    • Start Lactated Ringer’s solution.
    • Estimate initial rate according to the estimated %TBS. Estimated body weight (4cc/kg/%TBS burn in 24 hours giving half of the estimate in 1-8 hours.)
  • 27.
    • Total Maintenance Fluid = (1500mL/m 2 )
    • + Evaporative Water Loss [(25+%TBSA Burn) x m 2 x 24]
    • m 2 is square meters of TBSA
    Schwartz's Surgery, Part I. Chapter 7. Burns Copyright ©2007 The McGraw-Hill Companies . 
  • 28.
    • Foley catheter
    • Nasogastric tube
    • Maintain: Systolic Blood Pressure >90
      • Urine output 0.5-1.0ml/kg/hr
      • Pulse <130
      • Temperature >37°C
  • 29.
    • Modify protocol in the presence of massive burns, inhalation injury, shock, and in elderly patients:
    • - Fluid requirements are greater to prevent burn shock
    • - Include colloid: either Hespan or Albumin in the patients from the beginning
  • 30. Three major types of burn related scars
    • Keloid scars - overgrowth of scar tissue.
    • - The scar will grow beyond the site of the injury.
    • Hypertrophic scars - are red, thick and raise & do not develop beyond the site of injury or incision.
    • Contracture scar - is a permanent tightening of skin that may affect the underlying muscles and tendons.
    http://www.burnsurgery.org/
  • 31.  
  • 32.  
  • 33.  
  • 34.
    • Physical Therapy, pressure and exercise
    • Surgery:
    • - Dermabrasion – smoothen skin
    • - Skin Grafts
    • Pressure Garments
    • Nutrition
    • Medications
    http://www.burnsurgery.org/
  • 35. MEDICATIONS
    • Tetanus prophylaxis
    • Pain relievers
    • Antibiotics
  • 36. Topical Antimicrobial Agents for Burn Wound Care Silver Nitrate Mafenide Acetate Silver Sulfadiazine Active component   0.5% in aqueous solution 11.1% in water-miscible base 1.0% in water-miscible base Spectrum of antimicrobial activity   Gram-neg.—good Gram-neg.—good Gram-neg.—variable Gram (+)—good Gram (+) —good Gram (+) —good Yeast—good Yeast—poor Yeast—good
  • 37. Silver Nitrate Mafenide Acetate Silver Sulfadiazine   Method of Wound care   Occlusive dressings Exposure Exposure or single-layer dressings Advantages   Painless No hypersensitivity reaction No gram-negative resistance Dressings reduce evaporative heat loss Greater effectiveness against yeasts
      • Penetrates eschar
      • Wound appearance
      • readily monitored
      • Joint motion unrestricted
      • No gram-negative resistance
      • Painless
      • Wound appearance
      • readily monitored
      • when exposure method used
      • Easily applied
      • Joint motion
      • unrestricted
      • when exposure
      • method used
      • Greater
      • effectiveness
      • against yeast
  • 38. Silver Nitrate Mafenide Acetate Silver Sulfadiazine DISADVANTAGES
      • Deficits of sodium, potassium, calcium, and chloride
      • Painful on partial-thickness burns
      • Neutropenia and thrombocytopenia
      • No eschar penetration
      • Susceptibility to acidosis as a result of carbonic anhydrase inhibition
      • Hypersensitivity—infrequent
      • Limitation of joint motion by dressings
      • Hypersensitivity reactions in 7% of patients
      • Limited eschar penetration
      • Methemoglobinemia—rare
      • Argyria—rare
      • Staining of environment and equipment
  • 39. FAMILY PROFILE
  • 40.
    • Eliza Tim-tim
    • 44 yrs old, female, single
    • Education: Primary
    • Sari-sari store vendor owner
    • Index patient
  • 41. Walanita Martinez
    • 59 yrs old, Female, widow
    • Relative of Eliza,Significant Other
    • Education: Primary
    • Unemployed
    • Living with her 2 children: JR & Nieves
    • No known medical health problem
  • 42.
    • 40 yrs. Old, female, single
    • Education: Primary
    • Laundry girl of Genee Laudryshop
    • Family Head.
    • No Known medical health problem.
    Nieves Martinez
  • 43. JR MARTINEZ
    • 15 Yrs old, male, single
    • Son of Walanita
    • 4 th year High-school student
    • No known medical health problem
    • 15 Yrs old, male, 4th year HS
    • Walanita’s Son
    • No known medical health problem
  • 44. Jason Tim-tim
    • 17 yrs old, male, single, 4 th year HS
    • Eliza’s nephew
    • Unemployed
    • No known medical health problem
  • 45. Jian Hilardino
    • 10 yrs old, male, Grade III student
    • Eliza’s Nephew
    • No known medical health problem
  • 46.  
  • 47.  
  • 48. ELIZA SIMA MILAN ANGELINA MARIO LUIS LEONA ROGER ELSIE JUNIE MERLYN FAMILY ASSESSMENT TOOLS
  • 49. TIM-TIM & MARTINES FAMILY Upper Laguerta Lahug Cebu City As of Nov. 2009 Index Patient Sima 100+ Milan ? Angelina 80 ? 80’s I III II Luis 70 Leona 60 Roger 47 Junie 42 Merlyn 37 HPN Eliza 44 Elsie 48 FALL Walanita 59 Nieves 40 Jian 10 JR 15 Jason 17 Doling miyay Eliong Dolfin Amadeo 60’s Maning Erineo Timoteo Candido Peling melanio Rheumatoid arthritis Thyroid CA 2 5 jc
  • 50. E liza N ieves J ason J R J ian W alanita M erlyn E lsie R oger BETTY J unie FAMILY CIRCLE
  • 51. A P G A R ELIZA Almost always (2) Some of the time (1) Hardly ever (0) ADAPTATION: I am satisfied that I can turn to my family for help when something is troubling me  PARTNERSHIP: I am satisfied with the way my family talks over things with me and shares problems with me  GROWTH: I am satisfied that my family accepts and supports my wishes to take on new activities and directions  AFFECTION: I am satisfied with the way my family expresses affection and responds to my emotions  RESOLVE: I am satisfied with the way my family and I share time together 
  • 52. A P G A R
    • 9
    Highly Functional
  • 53.
    • SOCIAL
    • CULTURAL
    • RELIGIOUS
    • EDUCATIONAL
    • ECONOMICS
    • MEDICAL
    SCREEM
  • 54. SOCIAL Weakness & Strength
  • 55. CULTURAL WEAKNESS & STRENGTH
  • 56. RELIGIOUS Strength
  • 57. EDUCATIONAL STRENGTH
  • 58. ECONOMICS WEAKNESS & STRENGTH
  • 59. ECONOMIC PROFILE Total Monthly Income Php > 10,000 PERCENT ALLOCATION Total Monthly Expenses: Food: Electricity: Water: Medicine: Miscellaneous: 6,200 1,200 560 < 1,000 < 500 62% 12% 5.6% 10% 5% Savings 540-1000
  • 60. MEDICAL WEAKNESS & STRENGTH
  • 61. S C R E E M SOCIAL   CULTURAL  RELIGIOUS  EDUCATIONAL  ECONOMIC   MEDICAL   RESOURCE (STRENGTH) PATHOLOGY (WEAKNESS)
  • 62. Impact of Illness
      • Stage I – Onset of Illness
      • Stage II – Reaction to Diagnosis
      • (Impact phase)
      • Stage III – Major Therapeutic efforts
      • Stage IV – Early Adjustment to Outcome (Recovery)
      • Stage V – Adjustment to the Permanency of the Outcome
  • 63. Smilkstein’s Cycle of Family Function STREESFUL LIFE EVENTS: CRISIS: Inadequate family income
    • EXTRA-FAMILIAL RESOURCES:
    • Financial Assistance from the siblings, relatives & Franciscan Sisters
    • Help from Famed residents
    work BURNS FAMILY IN EQUILIBRIUM DISEQUILIBRIUM ADAPTATIONS SARI-SARI STORE
  • 64. Family diagnosis
  • 65.
    • Tim-tim & MARTINEZ family
      • Blended type of family with low income.
      • Stage of Family Cycle : Family with adolescents
      • Stage in Family illness :
      • Stage IV – Early Adjustment to Outcome (Recovery)
      • APGAR Assessment : Highly Functional
  • 66.
    • Smilkstein’s Family Cycle :
      • Adaptation
    • Evaluation by SCREEM
      • Strength:
        • Religion, Education and Economic
      • Weakness:
        • Social, cultural, Economic & Medical
  • 67. RECOMMENDATIONS
    • To the patient:
      • Teach and demonstrate and encourage range of motion (ROM) exercises daily.
      • Visit Wellness Clinic for regular BP monitoring at least once a week.
      • Advised diet modification: low salt &low fat.
      • Advised to cover her burned skin with clothes if exposed to sunlight.
  • 68.
    • Prescribe Gabapentin and use of Sunblock lotion.
    • Advised to seek help in Franciscan Sisters for free supply of medications during operation.
    • Networking with PCSO and Gov’t health card.
      • Refer and accompany patients for evaluation, release of contractures and possible skin grafting.
  • 69. To Nieves & Walanita
    • Continue supporting Eliza.
    • Visit Wellness Clinic also for regular BP monitoring.
    • Advised for FBS & lipid screening as well as ECG.
  • 70. To JR, Jason & Jian:
    • To continue their support.
    • Stays to be good.
    • Advised to continue their study.
    • Advised to help household chores.
    • Advised to help in tending sari-sari store.
  • 71. To the community
    • Give lectures about safety and fire preventions.
    • Give lectures about first AID for burns and poisoning.
    • Advise to have presence of mind and don’t panic in case of accident.
    • Encourage to visit the Wellness Clinic every Tuesday, Wednesday and Friday.
  • 72.  
  • 73. Family member Problems primary prevention 2ndry prevention Tertiary prevention Eliiza 44 y.o contracture Lectures about Safety & fire prevention, & first aid for burns Surgical referral for release of contrature & grafting Use of Sunblock ROM exercise, low salt, low fat diet Regular monitoring of BP; blood sugar & lipid screening; ECG FLU Vaccine, cervical vaccine; Breast Exam’n, pap smear Networking with VSMMC, Franciscan’s Sister & PCSO
  • 74. Family member Problems primary prevention 2ndry prevention Tertiary prevention Walahita , 59 y.o & Neives, 40 y.o none Lectures about safety & fire prevention , & first aid for burns blood sugar & lipid monitoring Regular monitoring of BP, FLU Vaccine, cervical vaccine; Breast Exam’n, pap smear
  • 75. Family member Problems primary prevention 2ndry prevention Tertiary prevention Jason, 17 y.o, JR, 15 y.o & Jian, 5 y.o none Lectures about fire prevention & first aid for burns Sexual educ. & teen-age pregnancy, lectures about drug addiction, smoking & alcoholism FLU & hepa Vaccine,
  • 76. Thank You!