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Case Study

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hilary young

on 17 November 2014

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Transcript of Case Study

A.N's Current Lab Values
As you perform your initial assessment, you note superficial partial-thickness burns on A.N.'s right anterior leg, left anterior and posterior leg, and anterior torso. Draw the affected areas, then using the “rule of nines,” calculate the extent of A.N.'s burn injury.
You are working in the emergency department (ED) of a community hospital when the ambulance arrives with A.N., an 18-year-old woman who was caught 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 15 L/min per nonrebreather mask and started a 16-gauge IV with lactated
Ringer's solution. On arrival to the ED, her vital signs are 100/66, 125, 34, Sa O 2 93%. An additional
16-gauge IV is inserted. She appears anxious and in pain.
Case Study
#136 Burns
Hilary Young Chris Absure

Scenario
MS. A.N.
Rule Of "Nines"
by using the rule of
nines method, A.N.'s was burnt 45%
By using the rule of
nines method, A.N.'s was burnt 45%
Signs of Smoke Inhalation

patient having severe burns to face
patient having intra-oral charcoal especially in gums and
teeth
patient may have singed scalp hair, nasal hair, and eyelids.
patient may be coughing up carbonaceous sputum.
the patient will experience a brassy cough or hoarseness.
the patient will experience poor oxygenation.
the nurse will assess for wheezing.
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

Interpretation of A.N.'s Lab Values
Hgb 20 g/dL, Hct 51%: Both of these are increased due to the fluid loss A.N has obtained.
K 4.9 mEq/dL: Her potassium level is within normal range
Na 133 mEq/dL: Her sodium level is slightly decreased due to the sodium beign trapped in the edema fluid and lost through the plasma leakage.
Cl 100 mEq/dL: A.N.'s Chloride is within normal range

Glu 159 mg/dL: A.N.'s glucose is elevated as a result of the stress repsonse and altered uptake across injured tissues

BUN 28 mg/dL: Bun is elevated as a result of fluid loss.

Cre 1.0 mg/dL: A.N's creatinine is within normal range.
Interpretation of Lab Values Cont....
4. A.N. is undergoing burn fluid resuscitation using the standard Baxter (Parkland) formula.

She was admitted at 0400. She weighs 110 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.
Parkland Baxter Formula


Crystalloid only (Lactated Ringer's
4mL/kg/%TBSA burn
4ml/50kg/45%=9000mL or 9 Liters within 24 hours. First half will be given within first 8 hours from time of burn
Drug of Choice For Burns
Morphine sulfate, hydromorphone (Diladud), Fentanyl and non opriod analgesics. During the resuscitation phase, Intravenous route is used for giving medication due the problem of absorption of the drug at this point. When given IM or Subcutaneous the medication will remain in the tissue space and does not relieve pain.
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 psychological support.
Priority nursing include using principles of a sepsis to prevent infection transmission, providing a safe environment, and monitoring for early detection of infection
Burn wound conditions promote the growth of Clostridium tetani, tetanus toxiod 0.5mL given IM enhances immunity to this infection.
Use of topical antimicrobial drugs
Use of topical antibiotics


Monitor CBC frequently, particularly the white blood cells.
Do not allow her to bathe for the initial 72 hours following injury.
Apply a 1⁄16-inch film of medication, covering entire burn.


Complications of circumferential burns
When a circumferential burn occurs blood flow is decreased due to tight eschar. Compartment syndrome is one of the major complications of a burn. To monitor for this syndrome, reassess pulse motor sensory distal to the burn, also check for swelling.

Interventions to Help Peripheral Tissue Perfusion
Elevate circumferential burns of the extremities on pillows above the level of the heart to reduce dependent edema if no obvious fracture is present
Diuretics increase the risk of hypovolemia and are generally avoided as a means of decreasing edema.
A.N.'s legs should be elevated 15-20 degrees of abduction with a small pillow.
She should also be laying in supine position

Diet Recommendations
Nutritional requirements for a patient with a large burn area can exceed 5000 kcal/day. In addition to high calorie intake, the burn patient requires a diet high in protein for wound healing.
Nutrition Interventions
calculating the calorie need for the patient.
provide an adequate daily source of calories to meet those calorie needs
coordinate with a certified dietitian to help meet the nutritional needs of the patient.
Vital Signs:
Blood pressure 90/50 mm Hg
Heart rate 110 beats/min
Respiratory rate 24 breaths/min

Case Study Progress:

Eighteen hours after the injury, the NAP reports these vital signs for A.N. and states that the urine output for the past hour was 20 mL
Complications
Hypovolemic shock could be occurring as evidence by oliguria and hypotension
Patient’s urine output is decrease possibly due to decreased blood flow and cellular debris could be a contributing factor to the decreased urinary output. This debris can cause an obstruction in tubulars of the kidneys that can block kidney blood flow and urine flow which can lead to kidney damage.
Treatment
Continuous monitoring of urinary output hourly. Due to A.N’s slightly decreased level of Na, diuretic use is contraindicated because it decrease circulating volume and cardiac output by pulling fluid from the circulating blood volume to enhance diuresis.
Rapid infusion of IV fluids or “fluid resuscitation” to maintain sufficient blood flow for normal cardiac output, MAP, and tissue oxygenation
Half of the calculated fluid volume for 24 hours be given in the first 8 hours after injury. The other half is given over the next 16 hours for a total of 24 hours.
Lab Values
Hgb 24 g/dL

Hct 59%

K 5.3 mEq/dL

Cre 1.9 mg/dL
Na 128 mEq/dL

Cl 92 mEq/dL

Glu 122 mg/dL

BUN 38 mg/dL


Interpretation of Lab Values
Answer 14
Appearance and Psychological Issues
Answer 15
Decreasing Stress About Visible Scars
There are many options that are nonsurgical and surgical. Assess patient's grieving stage. Recommend counseling if necessary or a support group.
Surgical
There is reconstructive and cosmetic surgery which can be performed. Many patients have unrealistic expectations of surgery. Make sure they fully understand the outcome of cosmetic surgery.
Nonsurgical
Time, collagen injections, steroid injections, scar guard, microdermabrasion
Interventions To Decrease Infection
Priority nursing include using aseptic technique to prevent infection, providing a safe environment and watching for early S/S of infection.
Interventions When Using Silver Sulfadiazine (Silvadene).
Hgb/Hct has increased due to rapid IV infusion.
K+ is slightly elevated possibly due to IV fluid which cause cellular shift of potassium.
Na and Cl has decreased from admission possibly due to the increase blood volume and peripheral blood flow to the vital organs.
Glucose has decreased to normal range.
BUN and Cre has increased because of the increase blood flow and oxygen to the kidneys.
Leakage of fluid and electrolytes from vascular spaces continues, causing extensive edema, even in areas that haven’t been burned. Fluid shifts with excessive height gain occurs in first 12 hrs after the burn and can continue up to 36 hours. The amount of fluid shift depends on extent and severity of injury. This is not permanent.
Butcher, M., & Swales, B. (2012). Assessment and management of patients with burns . Nursing Standards, 50-56.

Goncalves, A. d., Echevarria-Guanilo, M. E., Goncalves, N., Rossi, L. A., & Farina Junior, J. A. (2012). Characteristics of patients treated at a burn unit and their actions at the time of the accident . Revista Electronica de Enfermagem, 866-872.

Ignatavicius, D. D., & Workman, M. L. (2013). Medical Surgical Nursing Patient Centered Collaberate Care 7th Edition . St. Louis : Elsevier and Saunders.

Medline Plus . (2014, October 27). Silver Sulfadiazine. Retrieved from National Institues of Health : http://www.nlm.nih.gov/medlineplus/druginfo

Model Systems Knowledge Tranlation Center. (n.d.). Psychological Distress after Burn Injury . Retrieved from Model Systems Knowledge Tranlation Center: www.msktc.org/burn/factsheets/Psychological-Distress- After- Burn- Injury

Pagana, P. (2012). Mosby's Diagnostic and Laboratory Test References 11th Edition . St Louis : Elesvier .

Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2013). Fundamentals of Nursing 8th Edition . St. Louis : Elsevier.
References
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