2nd degree burn - Nursing Case Study

Pathophysiology

• Primary mechanism: 2nd degree burns cause damage to both the epidermis and the upper layer of the dermis. The burn is characterized by erythema, blisters and edema due to the destruction of the capillary network, causing fluid leakage into surrounding tissues.

• Secondary mechanism: The inflammatory response is activated to limit the damage and initiate healing. This response includes increased blood flow to the area (hyperemia), release of inflammatory mediators (like histamines, causing itchiness and pain), and recruitment of leukocytes to fight potential infection.

• Key complication: Infection is a serious risk due to the loss of the skin's barrier function. Immune response and local edema can delay wound healing. Extensive burns may lead to systemic complications, such as shock, due to fluid loss.

Patient Profile

Demographics:

45-year-old male, Firefighter

History:

• Key past medical history: Diagnosed with Type 2 Diabetes, mild hypertension

• Current medications: Metformin, Lisinopril

• Allergies: Penicillin

Current Presentation:

• Chief complaint: 2nd-degree burns on both arms and chest

• Key symptoms: Pain, Swelling, Redness, Blisters, Fever, Chills, Fatigue

• Vital signs: Blood Pressure 165/95, Heart Rate 110, Respiratory Rate 24, Temperature 101.5 F, Oxygen Saturation 94% on room air.

Section 1

Change in Patient Status:

Over the next 48 hours, the patient's condition began to deteriorate. His temperature spiked to 103.6 F and his heart rate increased to 120 beats per minute. In addition, his blood pressure dropped to 100/70 mmHg and his oxygen saturation fell to 88% on room air. The patient reported increasing fatigue, difficulty breathing, and a worsening pain in his burned areas that was not relieved by his current pain management regimen.

On physical examination, his burned areas appeared increasingly erythematous and edematous, and the blisters had begun to rupture and discharge a purulent substance. His chest auscultation revealed decreased breath sounds in the lower lobes bilaterally, suggestive of developing pneumonia. These findings indicate a worsening of his condition and potential systemic infection (sepsis), inclusive of burn wound infection and pneumonia. The patient's underlying diabetes and hypertension may also be contributing factors to the severity of his response to the burns. Immediate reevaluation of his treatment plan is critical to prevent further deterioration.

Section 2

New Diagnostic Results:

Lab results returned with a marked increase in white blood cell count at 18,000 cells/mm3, indicating an ongoing infection. Blood cultures were positive for Staphylococcus aureus, a common pathogen in burn wound infections and pneumonia. The patient's blood glucose levels were also elevated at 250 mg/dL, likely a combination of his underlying diabetes and the stress response to his injuries. His arterial blood gas (ABG) results showed a pH of 7.30, PaCO2 of 50 mmHg, and PaO2 of 60 mmHg, indicative of respiratory acidosis and hypoxemia, further supporting the suspicion of pneumonia.

Given these findings, the patient was diagnosed with sepsis secondary to burn wound infection and pneumonia. The severity of his condition was further complicated by the patient's diabetes and hypertension. The immediate priority was to manage the infection and stabilize his condition. The medical team decided to initiate broad-spectrum antibiotics, aggressive fluid resuscitation, and supplemental oxygen to manage the sepsis, pneumonia, and hypoxemia. His diabetes and hypertension would also need to be closely monitored and managed to prevent further complications.

Section 3

Change in Patient Status:

In the following 24 hours, the patient's condition continued to deteriorate. His level of consciousness started to decrease, showing signs of confusion and delirium. His blood pressure dropped to 90/60 mmHg, and his heart rate increased to 120 beats per minute. These changes were indicative of a worsening infection and possible septic shock. His respiratory rate also increased to 30 breaths per minute, and his oxygen saturation dropped to 88% on 2 L/min of supplemental oxygen, indicating worsening hypoxemia.

Furthermore, his blood glucose levels continued to rise, now at 300 mg/dL, despite receiving insulin. His latest lab results also showed a further increase in white blood cell count to 22,000 cells/mm3, and his repeat ABG results were pH 7.25, PaCO2 55 mmHg, and PaO2 55 mmHg, suggesting a worsening respiratory acidosis and hypoxemia. His urine output also decreased to less than 30 ml/hour, suggesting possible acute kidney injury. These clinical changes signaled a significant deterioration in the patient's condition, heightening the urgency to stabilize his vital signs and manage the underlying infections, respiratory distress, and uncontrolled diabetes. The nursing team would need to reassess the effectiveness of the current interventions and possibly initiate new ones.

Section 4

Change in Patient Status:

In the subsequent 12 hours, the patient's condition further declined. His level of consciousness further decreased, becoming lethargic and unresponsive to verbal commands. His blood pressure further dropped to 80/50 mmHg, and his heart rate now reached 140 beats per minute, indicative of worsening septic shock. His respiratory rate increased to 35 breaths per minute with shallow breathing, and his oxygen saturation further dropped to 82% on 3 L/min of supplemental oxygen, signaling progressive respiratory failure.

New Diagnostic Results:

The latest laboratory results were alarming. His blood glucose levels were persistently high at 320 mg/dL, despite aggressive insulin therapy. Repeat ABG showed pH 7.20, PaCO2 60 mmHg, and PaO2 50 mmHg, indicative of severe respiratory acidosis and hypoxemia. His white blood cell count skyrocketed to 28,000 cells/mm3, suggestive of a severe systemic infection. His creatinine levels were also elevated at 2.5 mg/dL from a baseline of 0.9 mg/dL, and his urine output continued to decrease to less than 20 ml/hour, indicating acute kidney injury. The worsening clinical and laboratory findings confirmed the progression of septic shock, respiratory failure, uncontrolled diabetes, and now, acute kidney injury. This would require the nursing team to reassess and reevaluate the current interventions and possibly initiate more aggressive ones.

Section 5

New Complications:

The nurse returned to the patient's room and found him increasingly agitated. He appeared to be trying to remove his oxygen mask and IV line, indicative of escalating levels of discomfort and possible delirium. His skin color had turned a grayish hue, and he seemed to be in significant respiratory distress. The nurse quickly assessed his vital signs, revealing a heart rate of 160 beats per minute and a blood pressure that had further dropped to 70/40 mmHg. His oxygen saturation had decreased to 78% despite the supplemental oxygen.

Upon auscultation, the nurse noted the presence of crackles and decreased breath sounds in both lungs, suggestive of developing pulmonary edema. The patient's capillary refill was delayed, and his extremities were cool to the touch, indicating poor peripheral perfusion. The nurse also noted a significant increase in the patient's abdominal girth and firmness, raising concerns for abdominal compartment syndrome, a life-threatening complication often seen in patients with severe burns and septic shock due to increased intra-abdominal pressure. These new complications required immediate medical attention and further escalated the complexity of the patient's condition. The nurse promptly reported these findings to the healthcare provider and prepared for immediate interventions.