Priority #2 Ineffective airway clearance related to

Priority #1: Deficient Fluid Volume related
to increased capillary
Subjective Data:
. Patient states she feels thirsty, weak and
dizzy, complains of nausea and has difficulty
moving due to eschar formation.
Objective Data:
-3rd degree burn on face, anterior
chest, abdomen both forearm and
anterior thigh
-Edema
-Capillary refill of 4 seconds
- eyes look sunken
Urinalysis
-Urine output: 15ml/hr
-Specific Gravity: 1.600
Serum Electrolytes
Potassium – 2.5 mEq/L,
Magnesium - 4.5 Eq/L,
Chlorine – 75 mEq/L
Sodium – 180 mEq/L
Phosporus – 1.5 mEq/L
BUN – 25 mg/dl
VS:
PR: 122 BPM
ECG: Sinus tachycardia
exposure to smoke associated with full-thickness
permeability burns of the face, anterior chest and abdomen
neck, thorax, and chest
Subjective
Patient states she feels thirsty, weak and dizzy,
complains of nausea
Objective
Patient Name: Patient B
Diagnosis: 3rd Degree burn
- Nasal flaring.is noted
Complaints:
-difficulty in breathing is noted and pt uses her
- Severe burn; pt states she
accessory muscles in breathing.
doesn’t feel pain on the
burned area - 3rd degree burn on face, anterior chest, abdomen
both forearm and anterior thigh
- Complains of nausea
- Feels thirsty, weak and dizzy
ABG
pH – 7.25
pCO2 – 45mmHg
HCO3 – 17mmol/L
SaO2 – 80%
VS:
PR: 122 BPM
RR: 13 CPM
O2 Sat: 80%
Chest X-ray: impression show signs of pleural
effusion, left
Priority #3 Ineffective peripheral tissue Priority #4 Risk for Infection related Priority #5 Impaired Skin Integrity
perfusion to 3rd degree burn injury. related to damaged and destroyed
Subjective Data Subjective Data skin and subcutaneous tissue
She feels thirsty, weak and dizzy.
- Complains of nausea
She also complains of nausea. She Subjective Data
- Feels thirsty, weak and dizzy has difficulty moving due to eschar
- Appears confused formation She has difficulty moving due to eschar
Objective Data Objective Data formation
- 3rd degree burn on face, anterior -Edema
chest and abdomen, both her -Capillary refill of 4 seconds Objective Data
forearm and both anterior thigh. - 3rd degree burn on face,
anterior chest and abdomen, both - 3rd degree burn on face,
- Difficulty moving due to eschar
her forearm and both anterior anterior chest and abdomen,
formation thigh. both her forearm and both
- Pulse is weak and thread
anterior thigh.
- Capillary refill time was 4 seconds
CBC - Skin is dry and leathery, tissue,
- GCS: 13/15
WBC – 16,000K/mL fat and blood vessels were
Hct – 60.4% visible
VS Hgb – 20g/Dl\
HR – 122 bpm - Neck is a little reddish
BP- 100/70 mm/hg
CBC
Priority #6 Disturbed body Image
ABG RBC – 4.8 M/mL related to traumatic event
pH – 7.25 Subjective:
Plt – 50 K/mL -Complains of nausea
pCO2 – 45mmHg
HCO3 – 17mmol/L -Feels thirsty, weak and dizzy
SaO2 – 80% -Appears confused
Objective:
PTT - upon assessment 3rd degree
- 60 seconds(Prolonged) burn on face, anterior chest
and abdomen, both her
ECG: Impression: Sinus tachycardia with a forearm and both anterior
heart rate of 110 beats per minute. thigh.
- Breast is burned badly,
Showing T wave inversion, and ST
nipples and areola were
segment depression and presence of U unidentifiable
wave are noted. - Patient appears to be in
shock and traumatized
- Covered in wounds in all her
body