Case 1

Balbit is a 23-year old man with a history of schizophrenia, which was diagnosed 10 years
ago. He has been taking risperidone 4mg twice a day sice the diagnosis and this generally
controls most of his symptoms. Balbit smokes about one packet of cigarettes a day but, apart
from his mental health, is otherwise a healthy young man. He lives with his mother, father
and two younger sisters. His elder brother attends a university in another state. Balbit has
completed a plumbing apprenticeship and is about to start work with the local council as a
junior plumber.
Balbit had been feeling very well and decide to stop taking his medication. As a result, three
days later he started to hallucinate and thought that he had ‘bad spirits’ in his body. During
the night he woke up and was determined to rid his body of these beings and so went to the
back shed of the house, doused himself in kerosene and set himself in fire.
His father was woken up by the sound of the shed door opening/ He ran out to find Balbit on
the lawn with his clothes on fire. Balbit’s father yelled out to his family and extinguished the
fire with water from a nearby house. An ambulance was called.

1. Schizophrenia is described as having either ‘positive’ or ‘negative’ symptoms. What

do positive symptoms mean in relation to a diagnosis of schizophrenia?
a. Positive symptoms are psychotic symptoms such as delusions, hallucinations
and disorganized behavior. Negative symptoms are restricted emotions, flat
effect, inability to start or continue productive activity.
b. Positive symptoms are happy, positive mood. Negative symptoms are sad,
negative thoughts, with a tendency to self-harm.
c. Positive symptoms are behavior that is friendly toward other people and is
productive. Negative symptoms are behavior that is aggressive towards other
people and is non-productive.
d. Positive symptoms are increased heart rate and blood pressure and a tendency
to eat more. Negative symptoms are decreased heart rate and blood pressure,
and general malaise.
2. What is the first aid for a person who has been burned?
a. Check ABC. Put ice on the burn for 30 minutes to cool the area, then wrap the
area in a wet blanket.
b. Check ABC. Place patient under cold shower until the ambulance arrives.
Wrap in a towel to transport.
c. Check ABC. Run water over the burn for at least 20 minutes, cover the person
to keep them warm, then wrap the burned area in a plastic cling wrap.
d. Check ABC. Put a cold piece of meat on the burned area, if available, to soak
up the heat, then wrap in a bandage.

Phase I
Balbit was taken to the local hospital’s emergency department by ambulance, where he was
triaged as ‘Red’ category. Balbit was taken directly into the resuscitation room, where he
immediately underwent a primary and a secondary assessment, which were completed both a
doctor and a nurse.
During the primary assessment, it was noted that he did not appear to have an inhalation
injury. However, this would be continually assessed over the following 24-48 hours.
The secondary assessment established that Balbit had suffered burns to 15% of his body,
mainly to his chest, with a small burn to his left hand. After the burns were washed, the
Wallace rule of nines was used to assess them. An initial assessment of the depth of each
burn was made. As Balbit’s face was not burned, an airway injury was not suspected, but this
would be monitored.
A central venous catheter was inserted, and fluid replacement was commenced using the
Parkland formula of 3 ml/kg/% total body surface area (TBSA) burn. This volume was to be
given in the first 24 hours following the burn injury. IV morphine 15mg was given to relieve
Balbit’s pain, which he scored as 11/10. A tetanus toxoid injection was given, as this type of
burn injury is considered dirty. A urinary catheter was inserted to monitor his urine output.
The wounds were further cleansed, and the depth of the burn assessed again. There was no
full-thickness burn, with about 10% being superficial in nature and 5% partial thickness.
Dressings were applied to form a barrier to infection and soak up the burn exudate. Balbit’s
left hand was elevated on a pillow to minimize swelling.
During the assessment process, the family were interviewed by nursing staff. Balbit’s past
history of schizophrenia was disclosed at this time.

3. In the initial phase after a burn injury, the most dangerous complication is the fluid
and electrolyte shift. What interventions were put into place to monitor and treat this
shift?
4. How is the Wallace rule of nines used to calculate the total body surface area that is
burned?

Phase II
Balbit had burns to 20% of his total body surface area. The senior medical officer telephoned
the Burn unit to enquire if Balbit would be suitable for transfer. As Balbit had a significant
area of injury that was superficial and there were no visible signs of an inhalational injury, it
was decided to keep him the same unit.
Balbit was transferred to the surgical ward, accompanied by his parents and a sister. Here a
full nursing assessment was completed with the assistance of his family. The nurse asked
about his physical, psychological, sociocultural, spiritual and environmental norms. Once the
assessment was completed, the nurse set about writing Balbit’s care plan for the following 24
hours.
For the care plan, Balbit was considered to be in the emergent phase of burn injury and so the
focus was on fluid replacement, wound care, pain management, psychosocial care,
physiotherapy and nutritional needs.

5. Why would an inhalation injury require specialist treatment at the Burn Unit?
6. Following the nurse’s assessment of Balbit, she documented his care plan for the next
24 hours. What priorities of care should be considered when documenting the plan?

Phase III
The next day Balbit developed oedema over his chest wall. Large blisters had formed on the
parts of the chest wall, while other parts exuded plasma fluid. As a result of the plasma
exudes, two further dressing changes were required in the next 24 hours. Because of the 15%
TBSA damage to the skin, the nurse knew that Balbit was prone to invading organisms. A
great emphasis was placed on hand washing, aseptic technique when changing dressings and
removal of any contaminants from the wound, including loose skin.
Fluid replacement therapy continued, and Balbit was eating protein-rich food and drinking
fluids. The urine catheter meant that an accurate output could be documented. The urine
output was more than 50 ml every hour. His vital signs continued to be monitored, paying
particular attention to any elevation in his temperature, which might indicate infection. A
physiotherapist visited him three times to ensure that he was deep breathing without any
difficulty. A referral to the psychiatrist unit for the assessment of Balbit’s current mental
health. A social worker visited Balbit to talk about the job he was to scheduled to begin with
the local council. She assured him that he would not lose the position and that she would
organize the appropriate certificates for his workplace.

7. Other tan the actual burn injury, what else places Balbit at the risk of infection?
8. In relation to Balbit’s mental health, what nursing measures should be taken?

Answers
1. Positive symptoms are psychotic symptoms such as delusions, hallucinations and
disorganized behavior. Negative symptoms are restricted emotions, flat effect,
inability to start or continue productive activity.
2. Check ABC. Run water over the burn for at least 20 minutes, cover the person to keep
them warm, then wrap the burned area in a plastic cling wrap.
3. Central venous catheter, vital signs monitoring, establishing the TBSA that was
burned, commencement of fluids, insertion of urinary catheter with urine output
monitoring, dressing to soak up exudates, elevation of hand.
4. The total body surface area is divided onto areas of 9% and the extent of injury within
these areas is then calculated.
5. The airway is at risk of obstruction because of the swelling in the oropharyngeal area
after breathing in hot air. The patient may require ventilatory support.
6. Replacement of fluids, pain relief, hygiene, nutritional support, infection control,
anxiety, resumption of medication.
7. Balbit is in hospital and therefore potentially exposed to numerous pathogens. He has
other invasive devices, such as urinary catheter and central venous catheter, that can
be the source of infection. The injury causes impaired function of lymphocytes,
monocytes and neutrophils, thus making the patient more susceptible to infection.
8. Make sure that staff and family understand that each time they enter Balbit’s room he
must be told why that person is there. Explain all treatments, give reassurance and
watch medications being taken.