A patient with extensive facial burns and evidence of inhalation injury is experiencing refractory burn shock despite aggressive fluid resuscitation, along with signs of respiratory distress and a deteriorating Glasgow Coma Scale score. Which of the following interventions should the nurse prioritize to stabilize the patient's condition?

C) Perform immediate endotracheal intubation to secure the airway.

A) Increase the rate of fluid resuscitation according to the Parkland formula.

B) Initiate vasopressor therapy to improve hemodynamic stability.

C) Perform immediate endotracheal intubation to secure the airway.

D) Begin renal replacement therapy to prevent acute kidney injury.

A patient has been admitted to the burn unit with significant inhalation injury and is exhibiting signs of refractory burn shock, respiratory distress, and decreased mental status. After securing the airway with endotracheal intubation and initiating mechanical ventilation, what is the most critical next step in the management of this patient to address the potential development of Acute Respiratory Distress Syndrome (ARDS) and multi-organ dysfunction syndrome (MODS)?

C) Start vasopressor support to maintain hemodynamic stability and improve tissue perfusion.

A) Administer high-dose corticosteroids to reduce systemic inflammation.

B) Initiate continuous renal replacement therapy (CRRT) to prevent renal complications.

C) Start vasopressor support to maintain hemodynamic stability and improve tissue perfusion.

D) Increase ventilator settings to improve oxygenation and decrease PaCO2 levels.

A critically ill patient with severe burn injuries has been initiated on mechanical ventilation and vasopressor support, yet continues to exhibit signs of multi-organ dysfunction syndrome (MODS), including renal failure and new-onset atrial fibrillation. Which intervention should the nurse prioritize to address the patient's hemodynamic instability?

A) Increase the norepinephrine infusion rate to maintain a mean arterial pressure above 70 mmHg.

B) Administer a bolus of intravenous fluids to improve blood pressure and perfusion.

C) Initiate a continuous amiodarone infusion to manage the atrial fibrillation.

D) Prepare for the initiation of extracorporeal membrane oxygenation (ECMO) for advanced circulatory support.

A patient in the ICU with severe burn injuries is receiving mechanical ventilation, vasopressor support, and continuous renal replacement therapy. The patient develops new-onset atrial fibrillation and shows signs of multi-organ dysfunction. Which of the following nursing interventions should be prioritized to manage the patient's current condition?

C) Adjust the ventilator settings to improve ventilation and oxygenation, taking into account the patient's blood gas results.

A) Increase the rate of norepinephrine infusion to improve blood pressure stability.

B) Initiate a fluid bolus to address potential hypovolemia and improve renal perfusion.

C) Adjust the ventilator settings to improve ventilation and oxygenation, taking into account the patient's blood gas results.

D) Administer fresh frozen plasma and platelets to correct coagulopathy and prevent further bleeding.

A patient in the ICU presents with acute respiratory distress syndrome (ARDS), worsening metabolic acidosis, and new neurological changes. In coordinating care for this patient, what should be the primary nursing intervention to address the immediate risk to the patient's life?

D) Administer vasopressors to stabilize hemodynamics and improve perfusion.

A) Initiate high-dose corticosteroids to manage systemic inflammation.

B) Collaborate with the healthcare team to prepare for potential surgical intervention to relieve abdominal compartment syndrome.

C) Increase respiratory support by adjusting ventilator settings to improve oxygenation.

D) Administer vasopressors to stabilize hemodynamics and improve perfusion.

A patient with acute respiratory distress syndrome (ARDS) and suspected abdominal compartment syndrome is experiencing worsening metabolic acidosis, increasing lactate levels, and a decreased Glasgow Coma Scale (GCS) score. Considering these complications, what is the nurse's priority intervention to address the patient's critical needs?

B) Collaborate with the healthcare team to prepare the patient for potential surgical intervention.

A) Increase the rate of intravenous fluids to improve perfusion.

B) Collaborate with the healthcare team to prepare the patient for potential surgical intervention.

C) Administer a higher dose of bicarbonate to correct the metabolic acidosis.

D) Initiate continuous renal replacement therapy (CRRT) to manage renal function.

A patient with severe neurological impairment and cardiogenic shock is being managed in the ICU. The patient has a GCS of 6, diffuse cerebral edema, a mean arterial pressure of 55 mmHg, and an ejection fraction of 35%. Despite interventions, lactate levels remain elevated. Which nursing intervention is priority to address both the patient's cerebral and cardiovascular complications?

B) Titrate dobutamine to improve cardiac output and monitor for changes in hemodynamic stability.

A) Increase the infusion rate of mannitol to further reduce cerebral edema.

B) Titrate dobutamine to improve cardiac output and monitor for changes in hemodynamic stability.

C) Administer additional hypertonic saline to manage intracranial pressure.

D) Implement passive leg raising to improve venous return and cardiac preload.

A patient with severe cerebral edema and cardiogenic shock is being treated with mannitol, hypertonic saline, and dobutamine. Despite these interventions, the patient's lactate levels remain elevated. What is the most appropriate nursing action to prioritize at this time?

B) Monitor for signs of fluid overload and adjust fluid management accordingly.

A) Increase the rate of hypertonic saline infusion to further reduce cerebral edema.

B) Monitor for signs of fluid overload and adjust fluid management accordingly.

C) Prepare for possible intubation to secure the airway and improve oxygenation.

D) Assess for signs of improved cardiac output by evaluating peripheral perfusion.

A patient in critical care is diagnosed with a multidrug-resistant Pseudomonas aeruginosa infection and is experiencing acute kidney injury (AKI) and moderate acute respiratory distress syndrome (ARDS). The healthcare team must prioritize interventions to stabilize the patient. Which nursing intervention is most critical in managing this complex case?

D) Advocate for prone positioning to improve oxygenation in ARDS, while closely monitoring renal function.

A) Initiate the recommended combination antibiotic therapy immediately, despite potential nephrotoxicity, to control the infection.

B) Collaborate with the respiratory therapist to adjust the ventilator settings, focusing on lung-protective strategies to manage ARDS.

C) Implement continuous renal replacement therapy (CRRT) to manage fluid overload and support renal function.

D) Advocate for prone positioning to improve oxygenation in ARDS, while closely monitoring renal function.

A patient in the ICU with a confirmed multidrug-resistant Pseudomonas aeruginosa infection is experiencing acute kidney injury with a creatinine level of 2.5 mg/dL and reduced urine output. The patient also presents with moderate ARDS, indicated by a PaO2/FiO2 ratio of 150. The critical care team must balance infection control with renal preservation. Which of the following interventions should the nurse prioritize to address both the infection and organ support while minimizing the risk of further complications?

D) Implement prone positioning to improve oxygenation in ARDS and consult with the infectious disease team to adjust antibiotic therapy based on renal function.

A) Initiate continuous renal replacement therapy (CRRT) to manage fluid balance and allow for higher doses of nephrotoxic antibiotics.

B) Adjust ventilator settings to increase tidal volume and reduce PEEP to enhance oxygenation and support respiratory function.

C) Administer a single, high-dose broad-spectrum antibiotic to rapidly control the infection despite potential nephrotoxicity concerns.

D) Implement prone positioning to improve oxygenation in ARDS and consult with the infectious disease team to adjust antibiotic therapy based on renal function.

burns - Nursing Case Study

Pathophysiology

• Primary mechanism: Thermal injury causes direct damage to skin and underlying tissues, leading to protein denaturation and cell death. This disrupts the skin's barrier function, resulting in fluid loss and increased risk of infection.

• Secondary mechanism: Inflammatory response triggers the release of cytokines and vasoactive mediators, causing systemic capillary leak syndrome. This leads to hypovolemia, edema, and possible multi-organ dysfunction due to inadequate perfusion and oxygenation.

• Key complication: Severe burns can result in burn shock, characterized by a combination of hypovolemic and distributive shock, necessitating aggressive fluid resuscitation to prevent organ failure and promote tissue recovery.

Patient Profile

Demographics:

34-year-old male, firefighter

History:

• Key past medical history: Hypertension, Type 2 Diabetes

• Current medications: Lisinopril, Metformin, Insulin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Severe burns sustained during a rescue operation

• Key symptoms: Extensive third-degree burns over 50% of body surface area, severe pain, difficulty breathing, altered mental status

• Vital signs: Temperature 102°F, Heart Rate 140 bpm, Respiratory Rate 32 breaths/min, Blood Pressure 85/50 mmHg, SpO2 88% on room air

Section 1

Change in Patient Status:

Shortly after arrival to the burn unit, the patient demonstrated a significant change in status. Despite aggressive fluid resuscitation following the Parkland formula, his blood pressure remained critically low at 80/45 mmHg, prompting concerns about refractory burn shock. His heart rate increased to 150 bpm, and his respiratory rate rose to 36 breaths per minute, with increasing accessory muscle use suggesting respiratory distress. Arterial blood gas analysis revealed a pH of 7.28, PaCO2 of 58 mmHg, and PaO2 of 60 mmHg, indicating a combined metabolic and respiratory acidosis. These findings were consistent with deteriorating respiratory function and inadequate tissue perfusion, necessitating immediate intervention to address both oxygenation and perfusion deficits.

The patient's altered mental status progressed to a semi-comatose state, with a Glasgow Coma Scale score dropping to 8, further complicating the clinical picture. Given the extensive facial burns and evidence of inhalation injury, there was a high suspicion of airway compromise. Fiberoptic bronchoscopy was performed, revealing significant airway edema and soot deposition, confirming inhalation injury. This discovery necessitated urgent endotracheal intubation to secure the airway and facilitate mechanical ventilation. The critical care team initiated protective lung ventilation strategies to address the acute respiratory failure and prevent further lung injury.

The patient's evolving hemodynamic instability and deteriorating respiratory status raised the possibility of developing Acute Respiratory Distress Syndrome (ARDS) and multi-organ dysfunction syndrome (MODS). These complications underscored the need for continuous monitoring and advanced critical care interventions, including vasopressor support and potential renal replacement therapy, to support organ function and optimize recovery. This change in status challenged the clinical team to reassess their approach and adapt the treatment plan to address the complex interplay of respiratory compromise, shock, and systemic inflammation.

Section 2

Response to Interventions:

Despite the initiation of mechanical ventilation and vasopressor support, the patient's condition continued to deteriorate. The critical care team implemented a norepinephrine infusion, titrated to maintain a mean arterial pressure above 65 mmHg. However, the patient's hemodynamic status remained unstable, with fluctuating blood pressures and persistent tachycardia at 145 bpm. Repeat arterial blood gas analysis showed minimal improvement with a pH of 7.30, PaCO2 of 55 mmHg, and PaO2 of 65 mmHg, indicating ongoing respiratory compromise despite ventilatory support. The lactate level was elevated at 5.5 mmol/L, suggesting inadequate perfusion and tissue hypoxia.

In response to the patient's deteriorating renal function, evidenced by rising creatinine levels at 2.1 mg/dL and decreasing urine output to less than 0.3 mL/kg/hr, the team initiated continuous renal replacement therapy (CRRT). This decision was made to manage fluid overload and support renal function, given the patient's oliguric state and fluid resuscitation needs. Despite these interventions, the patient developed new-onset atrial fibrillation, further complicating the clinical picture. This arrhythmia required the addition of amiodarone infusion to the treatment regimen to control the heart rate and prevent hemodynamic compromise.

As the patient's condition progressed, the clinical team remained vigilant for signs of multi-organ dysfunction syndrome (MODS), characterized by worsening liver function tests with elevated AST and ALT levels, as well as coagulopathy with an INR of 2.0. The possibility of disseminated intravascular coagulation (DIC) emerged, prompting the initiation of fresh frozen plasma and platelet transfusions to address the coagulation abnormalities. The complexity of the patient's condition necessitated frequent reassessment and adjustments to the therapeutic approach, highlighting the challenges of managing severe burn injuries complicated by systemic inflammatory response and organ dysfunction. The team's focus remained on stabilizing the patient while preventing further complications, emphasizing the critical need for continuous monitoring and advanced support measures.

Section 3

As the clinical team continued to manage the complex condition of the patient, new diagnostic results revealed further deterioration in the patient's status. A follow-up chest X-ray showed progressive bilateral infiltrates, consistent with acute respiratory distress syndrome (ARDS), adding another layer of complexity to the respiratory challenges already faced. The CT scan of the abdomen, performed due to increasing abdominal distension and tenderness, identified significant bowel edema and early signs of ischemia, raising the concern for impending abdominal compartment syndrome. This finding necessitated a multidisciplinary discussion about the potential need for surgical intervention to relieve intra-abdominal pressure and prevent further organ compromise.

Laboratory tests indicated worsening metabolic acidosis with a pH dropping to 7.25, despite maximal ventilatory support and bicarbonate administration. The patient's lactate level continued to climb, now at 7.2 mmol/L, underscoring the severity of systemic hypoperfusion. Liver function tests showed a marked increase, with AST and ALT levels tripling from previous values, suggesting acute hepatic injury likely secondary to hypoperfusion and systemic inflammatory response. The patient's renal function showed no improvement despite CRRT, with creatinine levels escalating to 3.5 mg/dL and urine output remaining critically low. These findings prompted the team to prioritize optimizing hemodynamic support and reassess the current fluid management strategy, considering the delicate balance needed to avoid exacerbating fluid overload while ensuring adequate perfusion.

The new onset of neurological changes, evidenced by decreased responsiveness and a Glasgow Coma Scale (GCS) score of 8, raised alarms for potential central nervous system involvement, possibly due to hypoxic brain injury or metabolic encephalopathy. The team initiated further neurological assessments, including an urgent CT scan of the head, to rule out intracranial pathology. These developments highlighted the need for reevaluation of treatment priorities, focusing on aggressive management of MODS and intensive monitoring to guide ongoing therapeutic decisions. The complexity of this patient's condition required an integrated, dynamic approach to care, with the recognition that each intervention could have far-reaching implications on the delicate balance of the patient's overall health status.

Section 4

As the medical team continued to address the patient's complex condition, a new complication emerged, further challenging the clinical management strategy. The patient's neurological status deteriorated rapidly, with a Glasgow Coma Scale (GCS) score now slipping to 6, indicating a severe level of impairment. The urgent CT scan of the head revealed diffuse cerebral edema, without any evident mass effect or hemorrhage, suggesting a possible hypoxic-ischemic injury compounded by metabolic encephalopathy. This finding necessitated immediate intervention to mitigate intracranial pressure and prevent further neurological compromise. Mannitol and hypertonic saline were administered as part of a targeted strategy to reduce cerebral edema, while the intensivist team closely monitored for any signs of improvement or further decline.

In parallel, the patient's hemodynamic stability remained precarious. Despite aggressive fluid resuscitation and vasopressor support, the mean arterial pressure hovered around 55 mmHg, indicating persistent shock. A repeat echocardiogram showed a decreased ejection fraction of 35%, suggesting a component of cardiogenic shock contributing to the systemic hypoperfusion. The decision was made to introduce an inotropic agent, dobutamine, to improve cardiac output and support systemic circulation. This intervention required careful titration and continuous hemodynamic monitoring to evaluate its efficacy and avoid exacerbating the patient's fluid overload and pulmonary status.

As these interventions unfolded, the patient's metabolic acidosis showed slight improvement, with the pH rising to 7.30. However, lactate levels remained elevated at 6.8 mmol/L, reflecting ongoing tissue hypoxia. The critical care team recognized the need for ongoing reassessment of the patient's comprehensive management plan, balancing the demands of treating multisystem organ dysfunction syndrome (MODS) against the risks of potential side effects from the aggressive interventions being employed. Multidisciplinary team discussions focused on dynamic treatment strategies, prioritizing interventions that could offer the greatest potential for stabilizing the patient's precarious condition, while remaining vigilant for any new complications that might arise.

Section 5

As the critical care team continued to monitor the patient, new diagnostic results brought additional challenges to the forefront. Blood cultures drawn earlier confirmed the presence of a multidrug-resistant Pseudomonas aeruginosa infection. The infectious disease specialists recommended initiating a combination antibiotic therapy tailored to the sensitivities of the identified strain. However, the team faced a dilemma: the nephrotoxic potential of the chosen antibiotics could exacerbate the patient’s already compromised renal function, evidenced by rising creatinine levels, now at 2.5 mg/dL, and a decreased urine output of less than 0.3 mL/kg/hr. These findings suggested an acute kidney injury (AKI) superimposed on the patient’s existing condition, complicating the balance between effective infection control and renal preservation.

Concurrently, the patient's respiratory status began to deteriorate, with increasing oxygen requirements and development of bilateral infiltrates on a follow-up chest X-ray, raising concerns for acute respiratory distress syndrome (ARDS). The ventilator settings were adjusted to a lung-protective strategy, emphasizing low tidal volumes and adequate positive end-expiratory pressure (PEEP) to prevent barotrauma while maintaining adequate oxygenation. Despite these adjustments, the patient's arterial blood gas showed a PaO2/FiO2 ratio of 150, indicative of moderate ARDS, necessitating consideration of adjunctive treatments such as prone positioning or extracorporeal membrane oxygenation (ECMO) if conventional strategies failed.

Amidst these developments, the multidisciplinary team reevaluated the overall management plan. The focus shifted to optimizing organ support while considering the risk-to-benefit ratio of each intervention. Emphasis was placed on dynamic assessment and early identification of any new complications, ensuring prompt, evidence-based adjustments to the therapeutic approach. This comprehensive and adaptive strategy aimed to navigate the complexities of the patient's critical condition, striving for stabilization and gradual recovery.