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Burn Case Study Directions: Work with a partner to complete this case study. Read the entire patient scenario before you begin; provide concise answers in the context of this patient situation. This assignment will apply information from current and previous readings in adult health, pharmacology and pathophysiology. Paper Guidelines: List question number and enter answers with rationale. Please use tables when requested. 50 points. John, a 28-year-old male is brought to ER by EMS personnel. He was at home welding in his shop when a fire erupted and quickly destroyed the premises. Assessment reveals extensive burns covering the majority of his anterior arms, hands, face and upper anterior chest. The burns are a combination of intact and open blisters with reddened bases and shiny weepy surfaces. John is alert and oriented X3. He complains of severe pain & sensitivity to cold air. You note that nasal hairs are singed as well as his eyebrows and eyelashes. His speech is hoarse and he has a brassy sounding cough, nonproductive. The paramedics obtained the following history in route. He has a history of seasonal allergies. No allergies have been identified. He has no scheduled medications, but takes occasional Tylenol for headaches. He had his Tetanus immunization 3 years ago. 1. Estimate the percentage of burns the patient has sustained, using the rule of nines, Explain how you derived your answer. 2. ABGs on admission are pH 7.50, PaCO2 29, PaO2 82, HCO3 30. Interpret these results. Include possible etiology for this finding. 3. Fluid resuscitation is a priority for this patient. This patient was admitted at 1130 following an injury that occurred at 0945. Utilize the TBSA you calculated in question 1 and Johns reported weight of 172 lbs to calculate the following: a. Use the Parkland formula and calculate the amount of IV fluids to be administered in the first 24 hours (show calculations) b. The physician order Lactated Ringers as the IV solution. Why is this the best choice during this phase of injury? c. What will be the rate of infusion in the first 8 hours. 4. What patient factors will you assess to determine if a. The rate of the infusion is being tolerated b. The fluid replacement is adequate
5. Burn patients are at risk for a number of complications during this phase of injury. Based on Johns presenting signs and symptoms, what key complication, other than burn shock, can occur? a. What evidence supports the possibility of this complication developing? b. What is the pathophysiology of the complication? c. How will you intervene if this problem occurs? (Include anticipated orders and nursing interventions). 6. Based on assessment information provided, what type of burns did the patient likely experience? Include supporting evidence for your assessment. 7. List in priority order, the key current nursing diagnosis for this patient. (Minimum of 5) Nursing Diagnosis Rationale for Priority Placement
8. During the early emergent phase, what do you anticipate for lab results for the following tests: Hct, serum sodium, serum potassium, blood glucose, specific gravity? Indicate if values will be (N) normal, (I) increased, or (D) decreased and provide an explanation of the lab values. (Use Table format. Adjust size as needed). Lab Value: N, I, or D Hct Serum NA Serum K Blood Glucose Specific Gravity Explanation of Lab Values
9. Prior to transfer to the ICU, prophylactic intubation will be done. What is the reason for intubation prior to any actual signs/symptoms of acute respiratory problems? John is admitted to the Burn ICU at 1300. He was intubated in the ER and stabilized prior to transfer. His wife Sarah has arrived and you ask her to wait until you have assessed John. Assessment findings include: hypoactive bowel sounds, extensive facial and body edema, upper body skin that is taunt and shinny in appearance, radial pulses difficult to palpate (left radial pulse is 2+/3 and a Doppler is required to obtain pulse on right arm. He denies numbness or tingling in arms. 10. What is the reason for the extensive edema John is experiencing? How will you prepare his wife for this visit? 11. Given his current assessment, list the one priority Nursing Diagnosis and the key potential complication for this patient.
It is 1500 and John is scheduled for the hydrotherapy tank for wound cleansing. 12. The physician has ordered morphine sulfate 5 10 mg IVP q 1-3 hours prior to hydrotherapy and for pain. Prior to administering this medication, what will you need to do? 13. How will you monitor this patient during hydrotherapy? 14. After the completion of hydrotherapy, what do you anticipate for immediate wound care? On Johns second day in the ICU, a feeding tube is placed in the jejunum and he is started on tube feedings. Family members ask you why he has not received any nutrition before. How will you respond to this question? 15. Why if the feeding tube in the jejunum and not the stomach? 16. How will you determine if the tube feedings are meeting Dales metabolic needs? John moves into the acute phase of injury with mobilization of fluids and diuresis. During the next four weeks he has surgical debridement and skin grafting (autograft) on his right hand and arm. Other burn injuries continue to heal with hydrotherapy cleaning and prescribed topical agents. 17. Why might John have required skin grafting and debridement for burn wounds on his right hand and arm? 18. What patient education would you have provided regarding graft site selection and care after grafting?
19. Review Johns hospital course. What possible complication(s) remain during both the acute and rehabilitation phase? Provide Rationale. (Minimum of 3 potential complications).
