Reference no: EM133568242
Situation - You are assigned to Yasmeen Goganji is a 32-year-old female who arrived at the Emergency Department with burns on a large part of her upper body. She is orally intubated and receiving oxygen at 100% and has an #18-gauge catheter in the left forearm and is receiving a fluid bolus of 1,000 mL of lactated ringer's solution running wide open. The paramedics were able to remove her burned clothes and hijab.
Background - Yasmeen has two children and has been living in a mobile home that is in need of repairs, however it is all she can afford at this time. She was cooking dinner to break her fast during Ramadan when a gas leak resulted in an explosion in the kitchen. Her kids were out playing in the front yard when they heard the explosion. Her eldest daughter immediately ran to her neighbor's house and asked them to call 911. Upon arrival to the scene, firefighters rescued Yasmeen and emergency medical technicians (EMTs) were able to assist her in removing her burned clothing and hijab. As a result, the patient was intubated with 100% oxygen enroute to the hospital for airway protection due to inhalation injury and the edema from facial burns.
Assessment - She is conscious, alert and following commands, but sustained significant burn injuries to her face, front of her neck, anterior torso (chest and abdomen), her right arm front half, her left arm front half, her perineal area and the front of both of her legs.
Vital signs were as follows: Heart Rate: 130, Blood Pressure: 160/85 (110), Temperature: 97.4° F (36.3° C), Pain: 4 points on CPOT, Weight is 70 kg.
A chest X-ray confirmed accurate placement of the ET tube. Fluid resuscitation was continued in the ED with LR.
Points to assess: Is this Acute or Chronic? Is the patient Unstable or Stable? Is this Urgent or Nonurgent?
Recommendation(s) -
What do you think are the primary alterations in health with this patient (diagnosis)?
What is the pathophysiology related to the patient's problems?
What are the risk factors for this patient, and do they contribute to the current primary problem?
What assessment(s) (expected finding) should be your focus? (Hint: Identify the relevant information first to determine what is most important.)?What signs and symptoms are commonly seen with this diagnosis?
What data should you analyze (laboratory and diagnostic procedures) and report to the health care provider? (Hint: Think about priority collaborative problems that support and contradict the information presented in this situation.) What lab values may be abnormal?
What would your plan (nursing care) and recommendation(s) be to the health care provider? (Hint: Consider all possibilities and determine their urgency and risk for this client.)
What intervention(s) (therapeutic procedures and/or medications) would be your priority with this patient? (Hint: Determine the desired outcome first to decide which interventions are appropriate and those that should be avoided.)?Which intervention would be best for this patient?
What data/clinical information would you evaluate to support the plan to improve the patient's outcome? (Hint: Think about signs that would indicate an improvement, decline, or unchanged client condition.)?What changes to the patient's condition would I expect to see happen or have happened?
What interprofessional care would be involved in the care of the patient? (Other disciplines - RT, ECG, social worker, etc.)
What patient education would be important for this patient?
Are there any specific safety considerations that should be included in your care?
What is the rule of nines for burn calculation? -
What does TBSA? -
Calculate the percentage of body burn for the patient - her face and neck, anterior torso (chest and abdomen), her front half of both arms, her perineal area and the front half of the front of both legs.
How do you calculate the amount of fluid the patient would receive in the first 24 hours using the Parkland formula?
What percentage would be administered in the first 8 hours and the second 16 hours??How much would he receive in the first eight hours?
In this case what classification of Burn Injury and Burn Center Referral Criteria does Yasmeen fall into?
What is capillary leak syndrome?
Why is it important to check inside someone's mouth and nose when they have burns to their face?
What is the CPOT pain scale?
What is the largest organ of the body?
What are the types of burns?
What can affect the severity of burns?
What are the three phases of burn care?
What type of GI ulcers may occur in someone with a burn injury?
What electrolyte imbalance may occur in someone with burns?
What type of medication would be ordered to treat the burns?
What is an escharotomy?
What is a fasciotomy?
What are the three types of debridement that may be used?
What are four possible complications of burn injuries?
What is the worst possible/most likely complication(s) to anticipate based on the primary problem (to prevent death)?
What nursing assessments/interventions will identify this complication EARLY if it develops?