Gina M. Ortiz Lpez NURS Prof.

Aixa Quijano Case Study of a Burned Patient Using the rule of nines, the patients total body surface area burned equals 27% (left arm 9% + chest and abdomen 18% = 27%). The clinical manifestations that can be observed in a patient sustaining 27% TBSA of second and third degree burns on the neck, chest and abdomen are the following: Hypovolemia due to fluid loss which leads to decreased perfusion and oxygen delivery, decreased cardiac output due to vasoconstriction, and increased pulse rate. As a result of these burns, red blood cells might be destroyed resulting in anemia. Hematocrit may be elevated due to plasma loss, thrombocytopenia, prolonged clotting and PT can occur. Other clinical manifestations are edema within four hours after injuries and up to eighteen hours in deeper burns. Blister formations can also be observed in the injuries site. Hyponatremia is common during burn shock and during the first week after injuries have occurred. Hyperkalemia is present during the first week and hypokalemia may occur later. Bronchoconstriction and chest constriction can be observed in patients severely burned in the anterior section of the body. Hypoxia is another clinical manifestation that can be observed. Free hemoglobin could be observed in the urine. Loss of skin integrity can lead to infection and sepsis. Low body temperature can be observed due to the loss of skin which regulates it (in early stage it could lead to hypothermia). In the post burn period hypothermia may continue. Absence of intestinal peristalsis may occur due to paralytic ileus. Gastric distention, infections and bleeding are other common GI complications. The priority regarding nursing diagnosis for this patient is the impaired gas exchange related to carbon monoxide poisoning, smoke inhalation, and upper airway obstruction. This patient is already intubated and on a mechanical ventilator to maintain a respiratory rate between 12 and 20 breaths/minute. The second should be ineffective airway clearance related to edema and the effects of smoke inhalation and the goal is to maintain patent airway and adequate airway clearance. The third nursing diagnosis would be fluid volume deficit related to increased capillary permeability and evaporative losses from burn wound. The goal is to restore optimal fluid and electrolyte balance and perfusion of vital organs. Pain related to tissue and nerve injury and emotional impact of injury is another priority when treating a burned patient. The nurses goal is to control pain by administering analgesics as ordered by a physician and providing emotional support. Hypothermia related to loss of skin microcirculation and open wounds should also be considered a priority and the goal is to maintain an adequate body temperature by providing a warm environment to the patient. Collaborative problems for this patient include: acute respiratory failure, distributive shock, acute renal failure, compartment syndrome, paralytic ileus, and Curlings ulcer; the goal is to be sure that complications wont occur.