Question

1. You are assigned to care for a 34-year-old female patient who has sustained second- and third-degree burns over her neck, chest, abdomen, and left arm. The burn injury occurred during a fire in her home; her spouse did not survive the fire, but, due to the patient’s critical condition, she is not aware of his death. She is currently in the surgical intensive care unit. Her body temperature is 36.6° C. Her pulse is 126. Her respiration rate is 12. Her blood pressure is 104/60. She is sedated with a continuous infusion of Propofol and is intubated and on a mechanical ventilator. She has a right femoral triple lumen catheter and a right radial arterial line. The patient weighs 50 kilograms.

1. Using the rule of nines, calculate the patient’s total body surface area burned.

2. Based on a calculation of _______ body surface area burned, and using the Parkland Formula, how much fluid resuscitation should the patient receive in the 24 hours (Give the breakdown of how much fluid in the first 8 hours and then the next 16 hours).

3. What clinical manifestations would be expected based on the extent and location of her burn injuries?

4. Prioritize nursing diagnoses and collaborative problems for this patient (Please list two for this acute phase of the burn along with at least 4 interventions).

Answer 1

A) Based on the rule of nine method ,the percentage of body surface area burner is

Burn on chest ,neck and abdomen = 18%

Left arm burn = 4.5(anterior) + 4.5 ( posterior) = 9%

Total body surface area burned = 27% .

B) Parkland formula = 4ml× total body surface area of burn ×weight in kg

= 4ml ×27× 50

= 5400ml

First half in 8hrs

Second half in 16hrs

5400 /2 = 2700ml in 8hours ,then another 2700ml in 16hrs .

C) Clinical manifestations :-

- upper to lower part damage of the epidermis ,dermis and subcutaneous tissue

- severe body fluid loss

- shock sign and symtoms like tachycardia , hypotension etc

- severe pain

- dehydration

D)1. Nursing diagnosis- Risk for shock related to severe fluid loss

Nursing interventions :-

- assess the vital signs of the patient

- provide the patient Trendelenburg position if in shock .

- immediate IV access or central line access

- transfusion of IV fluids

- transfusion of blood products

2. Risk for infection related to the damage to the skin integrity

Nursing interventions are :-

- Use of aseptic technique and universal precautions while providing care to the patient

- hand washing

- limit visitors to avoid infection

- monitoring for sign and symptoms of infection and administration of antibiotics .