Burn Case Study

Burn Case Study Leave the first rating Students also studied Terms in this set (12) Save STAT 330 - Chapter 9 33 terms dylmann15Preview NCLEX 127 terms ssutherland11Preview Vocab Quiz 1 15 terms kaylabayazitoglu Preview u.s stat 50 terms niki The nurse in the ED is using the Rule of Nines to assess the patient's body surface area (BSA) that is burned. What is the Ms. Underwood's total BSA area that is burned?Up to 31.5%.The patient has burn areas on right side of face and head (4.5%); right shoulder, arm, and hand (9%); and right side of chest and back (18%).How is the Rule of Nines different for pediatrics? Calculating total body surface area (TBSA) burned in children. The standard "rule of nines" and standard body surface charts must be adapted because of the difference in body proportions between adults and children.What is the TBSA assessment important for the patient? The size of the injury is important not only for diagnosis and prognosis but also for calculating drug doses, fluid replacement volumes, and caloric needs.Explain the Parkland formula for fluid resuscitation. Parkland Formula for fluid resuscitation is 4 mL/kg/% TBSA of a crystalloid solution. First 50?ministered within the first 8 hours following the burn and the remaining 50% over the next 16 hours. Crystalloids are used, large-bore catheter, Fluid replacement formulas are calculated from the time of injury and not from the time of arrival at the hospital.What are the priorities in the initial nursing management of the patient's burn injuries?Assess for airway patency Administer 02 as needed Cover patient with a blanket Keep patient NPO Elevate extremities if no fractures present Obtain v/s Initiate IV line, & begin fluid replacement Administer tetanus toxoid for prophylaxis Perform head-to-toe assessment

McKinney: initial assessment focus on primary survey (Airway, breathing,

circulation) After an airway & IV access have been established, catheter for hourly urine output & NG tube to prevent aspiration

What are the assessment priorities of the patient's burn injuries? List by system.

• Respiratory assessment: at risk for respiratory problems if major burn injuries or

inhalation injury. Continuous airway assessment is a nursing priority. Rate, rhythm, depth, lung sounds, cough 02 sat, voice quality.

b. Cardiovascular assessment: hypovolemic shock is a common cause of death in

the resuscitation phase in patients with serious injuries. Monitor degree of edema & assess cardiac status by measuring central and peripheral pulses, blood pressure, cap refill & pulse oximetry. Repeat ECGs to identify any abnormalities from baseline due to electrolyte imbalances or conduction problems.

c. Kidney/urinary assessment: decreased blood flow & cellular debris affect

kidney function. Myoglobin is released from damaged muscle & circulates to kidneys. Damaged cells release uric acid. A "sludge" forms that blocks kidney blood & urine flow & may cause kidney failure. Measure output hourly. Provide fluid resuscitation to maintain urine output at 30 to 50 mL or 0.5 mL/kg per hour.Assess response to fluid resuscitation by measuring urine specific gravity, blood urea nitrogen (BUN), serum creatinine, and serum sodium levels in addition to hourly urine output. Examine the urine for color, odor, and the presence of particles or foam

• Skin assessment: measure size & depth of injury. Determine TBSA affected by

the burn in using the rule of 9s.

e. GI assessment: decreased blood flow & sympathetic stimulation reduce GI

motility & promote development of paralytic ileus. Assess bowel sounds. Assess for N/V & abdominal distention. Patients with 25% TBSA or who are intubated generally require NG tube inserted to prevent aspiration & remove gastric secretions. Assess tube for placement & patency after insertion. Risk for ulcer so examine stool for blood. Later in the care of Ms. Underwood, may see an H2 Blocker or proton pump inhibitor to help prevent ulcers which are common after burns

• Pain Assessment: Drug therapy for pain usually requires opioid analgesics (e.g.,

morphine sulfate, hydromorphone [Dilaudid], fentanyl) and nonopioid analgesics.Although these drugs may provide adequate pain relief when no procedures are being performed, they rarely offer more than moderate relief during painful procedures. They may depress respiratory function and reduce intestinal motility.Nonpharmacologic interventions also are needed for the burn patient. During the resuscitation phase, the IV route is used for giving opioid drugs because of problems with absorption from the muscle and stomach . When given IM or subcutaneously, these drugs remain in the tissue spaces and do not relieve pain.When edema is present, all the doses are rapidly absorbed at once when the fluid shift is resolving. This delayed but rapid absorption can result in lethal blood levels of opioids What are the emergency interventions for a patient with facial burns if the nurse notices a change in the

respiratory pattern that include the following:

Becoming progressively hoarse Developing a brassy cough Drooling or having difficulty swallowing Producing sounds on exhalation that includes audible wheezes, crowing, & stridor?Any of these changes may mean the patient is about to lose their airway.Immediately apply oxygen and notify the provider.Patients with severe inhalation injuries may have such rapid obstruction (from edema & inhalation injury) that, within a short time, they cannot force air through the narrowed airways. As a result, the wheezing sounds disappear. This finding indicates impending airway obstruction and demands immediate intubation.

What does the nurse suspect in a patient with major burns and suspected inhalation injury with manifestations such as confusion, drowsiness, and pale to reddish purple skin?Carbon monoxide (CO) is one of the leading causes of death from a fire. It is a colorless, odorless, tasteless gas released in the process of combustion.Inhalation injury is a risk for carbon monoxide poisoning.CO is rapidly transported across the lung membrane and binds tightly to hemoglobin in place of oxygen to form carboxyhemoglobin (COHb), which impairs oxygen unloading at the tissue level. Even though the oxygen-carrying capacity of the hemoglobin is reduced, the blood gas value of partial pressure of arterial oxygen (PaO2) is normal. The vasodilating action of carbon monoxide causes the "cherry red" color (or at least the absence of cyanosis) in these patients. Symptoms vary with the concentration of COHb.What is the emergency intervention for a patient with major burns and suspected inhalation injury if the nurse notes crackles upon auscultation and dyspnea in the supine position?Pulmonary edema can occur even when the lung tissues have not been damaged directly. Other damaged tissues release such large amounts of inflammatory mediators, causing capillary leak, that even lung capillaries leak fluid into the pulmonary tissue spaces.Circulatory overload from fluid resuscitation may cause congestive heart failure.This problem creates high pressure within pulmonary blood vessels that pushes fluid into the lung tissue spaces. Excess lung tissue fluid makes gas exchange difficult. The patient is short of breath and has dyspnea in the supine position.Crackles are heard on auscultation.Elevate HOB to at least 45 degrees, apply humidified oxygen, & notify the provider What do you think is happening to your patient when they have the following signs and symptoms?Hypoxemia that persists even with 100% oxygen Decreased pulmonary compliance Dyspnea Noncardiac-associated bilateral pulmonary edema Dense pulmonary infiltrates on x-ray?Acute Respiratory Distress Syndrome (ARDS) The trigger is a systemic inflammatory response. The alveolar membrane becomes more permeable to large molecules, allowing debris, proteins, & fluid into the alveoli.The patient has complains of severe pain. What nursing interventions might be implemented?Continually assess patient's pain level, use appropriate pain-reducing strategies, and prevent complications.Drug therapy: opioids & non-opioid analgesics. IV during resuscitation phase.Problems with absorption from GI, IM remains in tissues too long with edema the doses rapidly absorb when fluid shift occurs. This delayed but rapid absorption can be lethal.Complementary and alternative therapy: examples: environmental changes: quiet, nonpainful tactile stimulation, increase patient control What are some other complications that burn victims can encounter?Pneumonia leading to respiratory failure, infection, sepsis, contractures, fluid imbalance, self-concept alteration.