Acute Burn Injury Scenario

Acute Burn Injury Scenario You are working in the emergency department (ED) of a community hospital when the ambulance arrives with A.N., a 28-year-old woman who was involved in a house fire. She was sleeping when the fire started and managed to make her way out of the house through thick smoke. The emergency medical system crew initiated humidified oxygen at 15L/min per non-rebreather mask and started a 16gauge IV with lactated Ringer's solution. On arrival in the ED, her vital signs are 100/66, 125, 34, Spo2 93%. She appears anxious and in pain. 1. Describe the interventions needed to care for A.N. on her arrival in the ED. Ans: Start with the assessment of ABC’s. Applying supplemental O2 to reduce risk of carbon monoxide poisoning intubation to protect her airway if stridor is present.or if she has facial burns. Assessing circulation and starting 2 large bore IV’s.For additional trauma,obtain medical history and allergies, medicating with narcotic for acute pain, maintaining body temperature,preventing infection and providing emotional support. During the first 48 hours is to maintain circulatory vascular volume. 2. As you perform your initial assessment, you note burns on A.N.'s right anterior leg, left anterior and posterior leg, and anterior torso. Draw/Shade the affected areas, and then, using the rule of nines, calculate the extent of A.N.'s burn injury. 9% Anterior - leg 18% Anterior - torso 9% Anterior - leg 9% Posterior - leg = 45% total burn 3. You suspect that A.N. has sustained deep partial-thickness burns. Which best describes this type of burn? c. The wounds have severe edema, pain may or may not be present, and the color varies. 4. Because you are concerned about possible smoke inhalation, what will you monitor for in A.N.? Chart View Laboratory Test Values Hgb 20 g/dL Hct 51% K 4.9 mEq/dL Na 133 mEq/dL Cl 100 mEq/dL Glu 159 mg/dL BUN 28 mg/dL Cre 1.0 mg/dL 5. Interpret A.N.'s laboratory results. Ans: Hgb and Hct is increased due to fluid loss. K is within normal limits (3.5 5.0), Na is decreased due Na being trapped in fluid which is causing edema.CI is within normal limits, Glucose is elevated of stress response, BUN is elevated as fluid loss, Creatinine is within normal limits 6. A.N. is undergoing burn fluid resuscitation using the standard Baxter (Parkland) formula. She was admitted at 0400. She weighs 154 pounds. Calculate her fluid requirements, specify the fluids used in the Baxter (Parkland) formula, specify how much will be given, and indicate what time intervals will be used. Ans: 4mL/kg% TBSA burned. 4mL/50kg/45% = 9000ml 7. A.N. is in severe pain. What is the drug of choice for pain relief after burn injury, and how should it be given? Ans: morphine sulfate, Dilaudid, Fentanyl, and non-opioid analgesic Case Study Progress A.N. does not exhibit any signs of smoke inhalation injury and is admitted to the medical unit for further treatment. As her nurse, you are concerned about meeting her needs for infection prevention, skin integrity, nutrition, fluids, and psychologic support. 8. Because of her significant burn injury, A.N. is at high risk for infection. What measures will you institute to prevent this? Ans: Providing a safe environment, Monitoring for early detection of infection, Tetanus shot, Use of topical antimicrobial drugs, use of topical antibiotics, Use principles of asepsis to prevent infection transmission 9. A.N.'s burns are being treated by the open method with topical application of silver sulfadiazine (Silvadene). In caring for A.N., which interventions will you perform? Select all that apply. d. Monitor the CBC and WBC with differential frequently e. Do not allow her to bathe for the initial 72 hours after injury f. Apply a 1⁄16-inch film of medication, covering entire burn 10. A.N. has one area of circumferential burns on her right lower leg. What complication is she in danger of developing? How will you monitor it? Ans: Circumferential burns decrease blood flow and circulation is impaired due to the eschars constricted characteristics. Circumferential burns of the extremities can lead to compartment syndrome. Burn areas encircling an extremity can quickly become tight.Document the presence or absence in the extremities and monitor capillary refill. 11. What interventions will facilitate maintaining A.N.'s peripheral tissue perfusion? Ans: Pulse checks, elevate circumferential burns of the extremity above the level of the heart. Lay in supine position. Assess the skin. 12. A.N. is ordered a special burn diet. She has always gained weight easily and is concerned about the size of the portions. What diet-related teaching will you provide? Ans: High protein diet-to heal wounds. Caloric intake should be 2-7 times the normal caloric intake of the normal person’s diet. 13. Describe interventions you can use to assist in meeting A.N.'s nutrition goals. Ans: Calculate exact caloric intake for burn patients. Coordinate with a certified dietician to help meet nutritional needs of the patient. 14. Tissues under and around A.N.'s burns are severely swollen. She looks at you with tears in her eyes and asks, “Will they stay this way?” What is your answer? Ans: Leakage of fluid and electrolytes from the vascular spaces continues which then leads to extensive edema, even in areas that have not been burned. Fluid shifts with excessive weight gain occur within the first 12 hours after burn injury and can continue for up to 36 hours. 15. A.N. is concerned about visible scars. What will you tell her to calm her fears? Ans: Women are more prone to psychosocial issues due to self esteem and self imaging disturbances.There are many options that are nonsurgical and surgical.Assess patients' griefing stage. Recommend counseling if necessary or a support group Chart View Vital Signs Blood pressure 90/50 mm Hg Heart rate 130 beats/min Respiratory rate 24 breaths/min Temperature 99.0° F (37.2° C) Case Study Progress Eighteen hours after the injury, the UAP reports these vital signs for A.N. and states that the urine output for the past hour was 20mL. 16. What do you suspect is occurring, and why does this concern you? Ans: Large drop in intravascular fluid volume which leads to a decrease in BP, and increase in HR/RR and impaired organ infusion. It can lead to hypovolemic shock 17. What treatment do you anticipate? Ans: A patent airway since she has a inhalation injury. Around the clock pain management is going to be a major part of the treatment plan since it can correlate with the patient's respiratory status. Continuous monitoring or urinary output hourly,due to slightly decreased Na level. Rapid infusion of IV fluids to maintain sufficient blood flow for normal CO,MAP and tissue oxygenation. Address psychosocial needs and concerns for the patient. Chart View Laboratory Test Values Hgb 24 g/dL Hct 59% K 5.3 mEq/dL Na 128 mEq/dL Cl 92 mEq/dL Glu 122 mg/dL BUN 38 mg/dL Cre 1.9 mg/dL 18. The physician increases A.N.'s IV rate and orders a new set of lab work. Compare A.N.'s current laboratory results with those from admission. Ans: Hgb and Hct: increased due to fluid resuscitation. K+: slightly elevated due to the cellular shift of K+ due to IV fluids. Na + and CI : decreased due to increase in blood volume and peripheral blood flow to vital organs. Glucose: decreased to normal organ. BUN and Creatinine: increased due to increase blood flow and O2 to kidneys 19. By the end of your shift, which of the following assessment findings would best indicate that A.N. is responding to therapy? d. Blood pressure 104/64; urine output 40mL/hr for past 4 hours