A patient with extensive third-degree burns covering the anterior torso, upper limbs, and portions of the face presents with severe metabolic acidosis, oliguria, and elevated lactate levels. Which nursing intervention is most critical in the immediate management of this patient's condition?

B) Administering bronchodilators to relieve bronchospasm

C) Providing high-flow oxygen to manage potential inhalation injury

D) Starting broad-spectrum antibiotics to prevent infection

A patient with extensive third-degree burns over the anterior torso, upper limbs, and portions of the face is in the burn unit. The patient is experiencing metabolic acidosis, elevated lactate levels, and oliguria. Which nursing intervention is the highest priority to address the patient's current condition and prevent further complications?

A) Administer bronchodilators to address bronchospasm and improve respiratory function.

C) Provide high-flow oxygen therapy to improve tissue oxygenation.

D) Administer broad-spectrum antibiotics to prevent infection.

A patient with severe burn injuries is experiencing hemodynamic instability, persistent hypotension, and metabolic acidosis despite aggressive fluid resuscitation. Given the current clinical picture, which of the following interventions should the nurse prioritize to stabilize the patient's condition?

B) Administer vasopressors to maintain an adequate mean arterial pressure.

A) Increase the rate of intravenous fluids to enhance tissue perfusion.

B) Administer vasopressors to maintain an adequate mean arterial pressure.

C) Initiate renal replacement therapy to address worsening renal function.

D) Provide mechanical ventilation support due to suspected ARDS.

A patient with severe burn injuries is showing signs of septic shock despite aggressive fluid resuscitation. Given her hemodynamic instability, rising lactate levels, and suspected ARDS, what is the most appropriate immediate nursing intervention to prioritize her care?

B) Initiate vasopressor support to maintain mean arterial pressure above 65 mmHg.

A) Increase the rate of fluid administration to improve hemodynamic stability.

B) Initiate vasopressor support to maintain mean arterial pressure above 65 mmHg.

C) Start high-dose corticosteroids to address the systemic inflammatory response.

D) Administer sodium bicarbonate to correct the metabolic acidosis.

A patient is experiencing septic shock, acute respiratory distress syndrome (ARDS), acute kidney injury (AKI), and potential disseminated intravascular coagulation (DIC) 36 hours post-admission. Given the patient's current condition, which of the following nursing interventions should be prioritized to address the patient's respiratory compromise?

A) Administering a diuretic to manage fluid overload and reduce pulmonary edema

C) Increasing the rate of IV fluids to enhance perfusion and support blood pressure

D) Initiating a transfusion of fresh frozen plasma to address coagulopathy and stabilize the patient

A patient admitted with septic shock has developed acute respiratory distress syndrome (ARDS) and acute kidney injury (AKI), with laboratory results indicating potential disseminated intravascular coagulation (DIC). Blood cultures are positive for Pseudomonas aeruginosa. Despite antibiotic therapy and norepinephrine support, the patient's oxygen saturation is critically low, and intubation is being considered. Which of the following actions should the nurse prioritize to address the patient's current critical condition?

B) Initiate mechanical ventilation to improve oxygenation and reduce respiratory distress.

A) Administer a higher dose of norepinephrine to improve blood pressure and perfusion.

B) Initiate mechanical ventilation to improve oxygenation and reduce respiratory distress.

C) Increase fluid administration to counteract hypotension and support renal perfusion.

D) Prepare for the administration of fresh frozen plasma and platelets to manage coagulopathy.

A 65-year-old female with septic shock and ARDS is experiencing difficulty maintaining adequate blood pressure despite high doses of norepinephrine. Her arterial blood gas reveals severe metabolic acidosis, and CRRT has been initiated. Which of the following interventions should the nurse prioritize to address her hemodynamic instability and support her recovery?

B) Initiate vasopressin as an adjunct vasopressor therapy.

A) Increase the current dose of norepinephrine.

B) Initiate vasopressin as an adjunct vasopressor therapy.

C) Administer a rapid infusion of isotonic saline.

D) Increase the settings on the mechanical ventilator to improve oxygenation.

A patient in the ICU is experiencing severe septic shock with refractory hypotension despite high-dose norepinephrine. Her arterial blood gas indicates a severe metabolic acidosis, and she is on mechanical ventilation due to worsening ARDS. The healthcare team is considering the addition of vasopressin and initiating continuous renal replacement therapy (CRRT). What is the most critical nursing intervention to prioritize at this stage of her management?

C) Prepare to titrate vasopressin infusion while monitoring hemodynamic status closely.

A) Monitor the patient’s urine output hourly to evaluate kidney function.

B) Adjust ventilator settings to improve oxygenation and reduce acidosis.

C) Prepare to titrate vasopressin infusion while monitoring hemodynamic status closely.

D) Implement a strict infection control protocol to prevent further infection.

A patient with septic shock is receiving vasopressin and norepinephrine to stabilize her mean arterial pressure, which is now 60 mmHg. Despite these interventions, her urine output remains less than 20 mL/hour, and her serum creatinine and BUN are elevated. The patient's ARDS is worsening, with an oxygen saturation of 88% despite ventilator adjustments. Which interdisciplinary intervention should the healthcare team prioritize next to address her complex condition?

B) Initiate prone positioning to improve oxygenation and reduce ventilator-induced lung injury.

A) Increase the dosage of norepinephrine to further raise her mean arterial pressure.

B) Initiate prone positioning to improve oxygenation and reduce ventilator-induced lung injury.

C) Administer diuretics to enhance urine output and reduce fluid overload.

D) Begin high-dose corticosteroids to reduce systemic inflammation and improve respiratory function.

A patient with acute respiratory distress syndrome (ARDS) and acute kidney injury (AKI) is being managed with vasopressors, continuous renal replacement therapy (CRRT), and mechanical ventilation. Despite interventions, the patient's oxygen saturation has decreased, and urine output remains critically low. Which of the following actions should the nurse prioritize to address the patient's current clinical status?

B) Implement prone positioning to enhance oxygenation.

A) Increase the dose of norepinephrine to improve renal perfusion.

B) Implement prone positioning to enhance oxygenation.

C) Adjust CRRT settings to increase fluid removal.

D) Administer a diuretic to encourage urine output.

burns - Nursing Case Study

Pathophysiology

• Primary mechanism: Cellular injury from thermal, chemical, or electrical sources causes protein denaturation and cell membrane disruption, leading to cell death and tissue necrosis.

• Secondary mechanism: Inflammatory response triggers the release of cytokines and mediators, increasing vascular permeability, resulting in fluid shifts and edema that contribute to hypovolemia and shock.

• Key complication: Severe burns disrupt skin integrity, impairing the barrier function and increasing the risk of infection and sepsis, which can lead to multi-organ failure if not promptly managed.

Patient Profile

Demographics:

35-year-old female, firefighter

History:

• Key past medical history: Asthma, Hypertension

• Current medications: Albuterol inhaler, Lisinopril

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Severe burns sustained during a fire rescue

• Key symptoms: Extensive third-degree burns on 50% of body, severe pain, difficulty breathing

• Vital signs: Blood pressure 90/50 mmHg, heart rate 130 bpm, respiratory rate 28 breaths per minute, temperature 102.3°F, oxygen saturation 85% on room air

Section 1

As the medical team begins the initial assessment, the patient is transferred to the burn unit for immediate stabilization. The team notes the presence of extensive third-degree burns covering the anterior torso, upper limbs, and portions of the face. The skin appears leathery and charred, with areas of white waxy texture indicative of full-thickness burns. The patient is conscious but in significant distress, exhibiting rapid shallow breathing and struggling to speak due to intense pain. The chest auscultation reveals diminished breath sounds bilaterally and wheezing, suggestive of possible inhalation injury and bronchospasm, compounded by her history of asthma.

Laboratory results reveal a concerning picture: arterial blood gas analysis shows severe metabolic acidosis with a pH of 7.25, PaCO2 of 30 mmHg, and HCO3- of 14 mEq/L. Lactate levels are elevated at 5 mmol/L, indicating tissue hypoperfusion. The complete blood count shows leukocytosis, raising suspicion for an early inflammatory response or underlying infection. Serum electrolytes reveal hyponatremia and hyperkalemia, consistent with fluid shifts and cellular injury. The patient is also experiencing oliguria, with urine output dropping to less than 0.5 mL/kg/h, pointing towards acute kidney injury secondary to hypovolemia and potential rhabdomyolysis from muscle damage.

In response to these findings, the medical team initiates aggressive fluid resuscitation using the Parkland formula to address the profound hypovolemic shock. High-flow oxygen is administered, and intubation is considered due to the risk of airway compromise from facial burns and inhalation injury. A bronchodilator is administered to alleviate bronchospasm, and broad-spectrum antibiotics are started to prevent infection. The patient's status remains critical, and continuous monitoring is essential to identify any further complications, such as acute respiratory distress syndrome (ARDS) or sepsis, that could exacerbate her condition. The next steps in her care will focus on meticulous wound management, ongoing hemodynamic support, and vigilant assessment for signs of multi-organ dysfunction.

Section 2

As the medical team continues to monitor and manage the patient, a notable change in her status emerges within the first 24 hours. Despite aggressive fluid resuscitation, the patient remains hemodynamically unstable, with persistent hypotension at 85/50 mmHg and tachycardia with a heart rate of 130 beats per minute. Her urine output remains scant, and creatinine levels have increased to 3.2 mg/dL, indicating worsening renal function. Repeat arterial blood gas analysis demonstrates a continued severe metabolic acidosis with a pH of 7.22, PaCO2 of 32 mmHg, and HCO3- of 12 mEq/L. Additionally, the patient's lactate levels have risen to 7 mmol/L, revealing ongoing tissue hypoperfusion and possibly evolving into septic shock.

In parallel, new diagnostic imaging and laboratory tests reveal further complications. A chest X-ray shows bilateral infiltrates, raising suspicion for acute respiratory distress syndrome (ARDS), a concern given her existing inhalation injury. The patient's white blood cell count has climbed to 18,000/mm^3, and a procalcitonin test is markedly elevated, suggesting a systemic inflammatory response potentially due to an infectious process. Blood cultures are pending, but the clinical picture is suggestive of sepsis, necessitating immediate escalation of her antibiotic regimen and consideration of vasopressors to maintain adequate mean arterial pressure and organ perfusion.

The patient's critical trajectory emphasizes the need for advanced critical thinking and clinical judgment. The team must balance aggressive support for her respiratory and renal functions while addressing the systemic inflammatory response and potential infection. Continuous reassessment of fluid status, electrolyte balance, and organ function is imperative to prevent further deterioration. This evolving situation underscores the complexity of managing severe burn injuries, highlighting the necessity for multidisciplinary collaboration and meticulous attention to detail as the patient navigates through this precarious phase of her care.

Section 3

As the medical team intensifies their efforts to stabilize the patient, a notable change in her status occurs 36 hours post-admission. Despite the administration of broad-spectrum antibiotics and initiation of norepinephrine to support her blood pressure, the patient develops a new onset of fever, with her temperature rising to 39.5°C (103.1°F). Her heart rate remains elevated at 132 beats per minute, and she begins to exhibit increased respiratory distress, with a respiratory rate climbing to 30 breaths per minute. Oxygen saturation has decreased to 88% on a non-rebreather mask, prompting the team to consider intubation and mechanical ventilation to ensure adequate oxygenation.

Concurrent laboratory results reveal a further deterioration in her renal function, with creatinine levels surging to 4.5 mg/dL and a significant drop in platelet count to 80,000/mm^3, indicating potential disseminated intravascular coagulation (DIC). The patient's blood cultures return positive for Pseudomonas aeruginosa, confirming the presence of a severe infection. The multidisciplinary team faces the challenge of managing this complex interplay of septic shock, ARDS, and acute kidney injury, necessitating a reassessment of her current antibiotic regimen to ensure coverage for multidrug-resistant organisms.

The patient's evolving clinical picture demands an urgent review of her fluid management strategy, balancing the risk of fluid overload against the need to optimize perfusion and prevent further renal compromise. The team must also consider the implications of her coagulopathy, exploring the use of fresh frozen plasma and platelet transfusions to address her bleeding risk. This precarious situation highlights the critical need for ongoing, dynamic clinical reasoning and the importance of close communication among the healthcare team to navigate the complexities of her condition and guide her towards stabilization.

Section 4

As the healthcare team works tirelessly to address the patient's critical condition, a significant change in her status emerges. Following intubation and initiation of mechanical ventilation, her oxygenation improves slightly, with oxygen saturation rising to 92%. However, within the next few hours, her blood pressure becomes increasingly difficult to maintain, despite escalating doses of norepinephrine. Her mean arterial pressure drops to 55 mmHg, signaling worsening shock and raising concerns about inadequate tissue perfusion.

New diagnostic results provide further insights into her deteriorating condition. An arterial blood gas analysis reveals a severe metabolic acidosis with a pH of 7.22, bicarbonate level at 14 mEq/L, and a base deficit of -12. These findings suggest a profound lactic acidosis, likely secondary to ongoing septic shock and inadequate perfusion. Additionally, a chest X-ray indicates diffuse bilateral infiltrates consistent with worsening acute respiratory distress syndrome (ARDS), complicating her respiratory management.

In response to these alarming developments, the team deliberates over potential interventions to stabilize her hemodynamics and address her metabolic derangements. The consideration of vasopressin as an adjunct to norepinephrine is proposed to optimize vasopressor support. Concurrently, continuous renal replacement therapy (CRRT) is initiated to manage her acute kidney injury and help correct the metabolic acidosis. The team remains vigilant for further complications, recognizing the need for dynamic decision-making and close monitoring of her evolving situation. This juncture in her care pathway underscores the critical importance of a coordinated, multidisciplinary approach to navigate her complex array of challenges and guide her towards recovery.

Section 5

As the team implements the proposed interventions, they closely monitor the patient's response. Within the first few hours of initiating vasopressin alongside norepinephrine, her mean arterial pressure begins to stabilize slightly, rising to 60 mmHg. However, this marginal improvement is tempered by new complications that arise, demanding astute clinical judgment. Despite the stabilization efforts, the patient's urine output remains critically low, less than 20 mL/hour, indicating persistent renal hypoperfusion despite the commencement of continuous renal replacement therapy (CRRT).

Laboratory tests reveal a further decline in renal function, with her serum creatinine climbing to 3.5 mg/dL and blood urea nitrogen (BUN) increasing to 85 mg/dL. These findings confirm the severity of her acute kidney injury and underscore the need for ongoing renal support. Additionally, repeat arterial blood gas analysis shows a slight improvement in her metabolic acidosis, with a pH of 7.28 and bicarbonate level increasing to 16 mEq/L, yet her base deficit remains at -10, indicating ongoing metabolic challenges.

Amidst these developments, the patient's respiratory status deteriorates further. Despite adjustments to her ventilator settings, her oxygen saturation drops again to 88%, and her work of breathing increases, suggesting worsening ARDS. The team decides to escalate her ventilatory support, considering prone positioning to enhance oxygenation and reduce ventilator-induced lung injury. This decision reflects the complexity of her condition and the necessity for ongoing, dynamic reassessment of her therapeutic regimen. As they navigate these challenges, the healthcare team remains acutely aware of the precarious balance between managing her acute complications and preventing further deterioration, requiring an unwavering commitment to interdisciplinary collaboration and vigilant monitoring.