A patient with severe burns on her right arm presents with elevated white blood cell count and serum lactate levels, indicating potential sepsis. She is receiving fluid resuscitation with lactated Ringer's solution. Which of the following assessments should the nurse prioritize to determine the effectiveness of the fluid resuscitation?

B) Measuring urine output and blood pressure

A) Monitoring respiratory rate and oxygen saturation

B) Measuring urine output and blood pressure

C) Assessing skin turgor and mucous membrane moisture

D) Checking serum electrolyte levels and blood glucose

A patient with extensive blistering burns on the right arm and hand is exhibiting signs of a potential secondary infection and sepsis. Which nursing intervention is the priority to prevent further complications?

A) Administer prescribed broad-spectrum antibiotics immediately

B) Initiate wound care by debriding the blisters

C) Monitor and record urine output every hour

D) Conduct a detailed assessment of respiratory status due to asthma history

A patient with a burn injury and confirmed Staphylococcus aureus infection is showing signs of septic shock, including increased heart rate and reduced blood pressure. What is the priority nursing intervention to address the patient's hemodynamic instability?

C) Increase fluid resuscitation to improve hemodynamic status

A) Administer supplemental oxygen to maintain adequate tissue oxygenation

B) Initiate vasopressor therapy to increase blood pressure

C) Increase fluid resuscitation to improve hemodynamic status

D) Administer antipyretics to reduce fever and metabolic demand

A patient with a burn injury has developed a Staphylococcus aureus infection, and despite broad-spectrum antibiotic therapy, her vital signs indicate potential septic shock. Which nursing intervention is most critical at this time to stabilize the patient's condition?

C) Increase fluid resuscitation to improve hemodynamic stability.

A) Administer supplemental oxygen to maintain adequate tissue perfusion.

B) Initiate a high-calorie diet to promote healing and prevent malnutrition.

C) Increase fluid resuscitation to improve hemodynamic stability.

D) Schedule immediate surgical debridement to prevent further infection.

A patient with severe sepsis and suspected acute respiratory distress syndrome (ARDS) is being managed with non-invasive positive pressure ventilation. Considering her elevated heart rate, fluctuating blood pressure, and decreased kidney function, what is the most important nursing action to prioritize?

B) Monitor respiratory status and adjust ventilation settings as needed

A) Increase the rate of fluid resuscitation to stabilize blood pressure

B) Monitor respiratory status and adjust ventilation settings as needed

C) Prepare for immediate surgical debridement to prevent further infection

D) Initiate renal support therapies to address acute kidney injury

A patient with severe sepsis and suspected acute respiratory distress syndrome (ARDS) is showing signs of respiratory distress and decreased oxygen saturation. What is the most appropriate nursing intervention to prioritize at this time?

A) Administer a bronchodilator to alleviate wheezing

B) Prepare the patient for surgical debridement

D) Increase the rate of intravenous fluid resuscitation

A patient with worsening pulmonary edema, acute kidney injury, and severe sepsis is being managed in the ICU. Despite non-invasive ventilation and broad-spectrum antibiotics, the patient's condition continues to decline with decreased urine output and increased respiratory distress. What is the most appropriate nursing action to prioritize at this time?

C) Initiate continuous renal replacement therapy (CRRT) as ordered

A) Increase the rate of oxygen delivery via the non-invasive ventilator

B) Prepare the patient for surgical debridement of the necrotic burn wound

C) Initiate continuous renal replacement therapy (CRRT) as ordered

D) Administer diuretics to manage fluid overload

A patient with severe sepsis is being managed with non-invasive positive pressure ventilation, but continues to have suboptimal oxygen saturation and worsening pulmonary symptoms. In addition, the patient exhibits signs of fluid overload and deteriorating renal function. Which nursing intervention should be prioritized to address the patient's respiratory status and prevent further complications?

B) Prepare the patient for possible intubation and mechanical ventilation.

A) Increase the FiO2 on the non-invasive ventilation device to improve oxygenation.

B) Prepare the patient for possible intubation and mechanical ventilation.

C) Administer diuretics to reduce fluid overload and improve respiratory status.

D) Encourage deep breathing exercises to enhance lung expansion and gas exchange.

A patient undergoing continuous renal replacement therapy (CRRT) develops hemodynamic instability with a blood pressure of 88/54 mmHg and signs of respiratory distress. Which of the following interventions should the nurse prioritize to address the patient's current condition?

B) Prepare for the initiation of vasopressin to support blood pressure.

A) Increase the rate of intravenous fluids to manage hypotension.

B) Prepare for the initiation of vasopressin to support blood pressure.

C) Reposition the patient to improve ventilation and oxygenation.

D) Administer sodium bicarbonate to correct respiratory acidosis.

A patient undergoing continuous renal replacement therapy (CRRT) presents with acute respiratory acidosis and hemodynamic instability. The intensivist plans to initiate invasive mechanical ventilation. Which nursing intervention is most critical to prioritize at this time to optimize the patient's respiratory and circulatory status?

C) Adjust ventilator settings to provide lung-protective ventilation strategies and assess for improvement in gas exchange.

A) Administer a loading dose of vasopressin to quickly stabilize hemodynamic status.

B) Titrate sedation to ensure the patient is deeply sedated, minimizing any ventilatory asynchrony.

C) Adjust ventilator settings to provide lung-protective ventilation strategies and assess for improvement in gas exchange.

D) Increase fluid administration to improve blood pressure and counteract vasopressor effects.

Burn - Nursing Case Study

Pathophysiology

• Primary mechanism: Thermal injury causes direct tissue damage, leading to protein denaturation and cell membrane disruption, resulting in immediate cell death and release of inflammatory mediators.

• Secondary mechanism: The inflammatory response increases capillary permeability, causing fluid to shift from the intravascular space to interstitial tissues, leading to edema and hypovolemia.

• Key complication: Hypovolemic shock can develop due to massive fluid loss, compromising organ perfusion and requiring fluid resuscitation to maintain hemodynamic stability.

Patient Profile

Demographics:

32-year-old female, chef

History:

• Key past medical history: Asthma, mild anxiety

• Current medications: Albuterol inhaler as needed, Sertraline 50 mg daily

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Severe pain and blistering on right arm and hand

• Key symptoms: Redness and swelling, blister formation, moderate pain, difficulty moving fingers, signs of infection (pus formation, increased warmth)

• Vital signs: Temperature 101.3°F, Heart rate 98 bpm, Respiratory rate 20 breaths per minute, Blood pressure 128/84 mmHg

Section 1

The initial assessment reveals that the patient's right arm and hand are severely blistered, with blisters varying in size and some having ruptured, exposing raw, sensitive tissue. The skin around the affected area is markedly erythematous and swollen, indicating a significant inflammatory response. Palpation of the area elicits severe tenderness, and there is a noticeable decrease in the range of motion in her fingers due to pain and swelling. The patient reports difficulty performing tasks that require fine motor skills, such as holding utensils, which is particularly concerning given her occupation as a chef.

Laboratory results show elevated white blood cell count, suggesting an ongoing infection. Additionally, her serum lactate level is elevated, indicating tissue hypoperfusion and potential sepsis. Her hemoglobin and hematocrit levels are slightly decreased, likely due to fluid shifts and possible hemoconcentration. Blood cultures are pending, but empirical broad-spectrum antibiotics have been initiated to address the suspected infection. The patient's respiratory status is stable, although her history of asthma requires careful monitoring, especially given the stress of the injury and infection on her body.

Given these findings, the clinical team is concerned about the development of a secondary infection at the burn site and the risk of systemic complications such as sepsis. Fluid resuscitation has been initiated with lactated Ringer's solution to address hypovolemia and maintain perfusion. The patient's vital signs are being closely monitored, with particular attention to urine output, blood pressure, and heart rate, as indicators of her intravascular volume status. Further diagnostic imaging may be warranted to assess the depth and extent of the burn injury, guiding potential surgical intervention, such as debridement, if necessary. The interprofessional team, including a burn specialist, is involved in her care to optimize recovery and prevent further complications.

Section 2

As the clinical team continues to monitor the patient, new diagnostic results arrive, revealing critical insights into her condition. The blood cultures return positive for Staphylococcus aureus, confirming a bacterial infection at the burn site. The infectious disease specialist recommends adjusting the antibiotic regimen to target the specific pathogen more effectively. Despite the initiation of broad-spectrum antibiotics, the patient's vital signs indicate increasing instability: her heart rate has risen to 112 beats per minute, and her blood pressure has dropped to 90/60 mmHg, raising concerns about septic shock. Additionally, her respiratory rate has increased to 24 breaths per minute, and she reports feeling more fatigued and lightheaded, suggesting a potential worsening of the systemic inflammatory response.

The team decides to escalate care by increasing fluid resuscitation and closely monitoring the patient's hemodynamic status. Her oxygen saturation remains stable at 95% on room air, but given her history of asthma and the current stress on her body, supplemental oxygen is considered to ensure adequate tissue oxygenation. Repeat laboratory tests show a further increase in serum lactate levels to 3.2 mmol/L, reinforcing the suspicion of inadequate perfusion and the need for aggressive intervention to prevent progression to severe sepsis or multi-organ dysfunction.

To address the growing concerns about the depth and extent of the burn injury, a consultation with a burn surgeon is scheduled for potential surgical debridement. The interprofessional team collaborates to reassess her pain management regimen, aiming to improve comfort and facilitate better range of motion in her affected hand. The patient's difficulty with fine motor skills remains a priority, as it directly impacts her quality of life and ability to perform her duties as a chef. The evolving clinical picture necessitates vigilant monitoring and timely adjustments to the care plan, emphasizing the importance of interdisciplinary communication to optimize outcomes and prevent further complications.

Section 3

As the clinical team continues to manage the patient's care, they notice a concerning change in her status. The increased fluid resuscitation initially stabilizes her blood pressure, but it soon becomes apparent that she is not responding as expected. Her heart rate remains elevated at 118 beats per minute, and her blood pressure fluctuates, dropping again to 85/58 mmHg. Despite supplemental oxygen, her oxygen saturation dips to 93%, and she begins to exhibit signs of respiratory distress, with a persistent cough and wheezing that suggest her asthma may be exacerbating her current condition.

The team quickly reassesses her treatment plan, considering the possibility of acute respiratory distress syndrome (ARDS) secondary to sepsis. A chest X-ray reveals bilateral infiltrates, raising the suspicion of pulmonary involvement. The decision is made to initiate non-invasive positive pressure ventilation to improve her oxygenation and reduce respiratory workload. Meanwhile, the burn surgeon evaluates the wound site and notes increased redness and swelling, indicative of deepening infection and necrosis. Surgical debridement is scheduled to prevent further deterioration.

Laboratory results return, showing a marked increase in serum creatinine to 2.0 mg/dL, suggesting acute kidney injury likely due to hypoperfusion. The patient's condition is now classified as severe sepsis, with multi-organ involvement requiring a coordinated response. The clinical team discusses the need for renal support and considers the potential initiation of dialysis if kidney function continues to decline. This multidimensional crisis highlights the critical need for ongoing reassessment and adaptation of the treatment strategy to address the dynamic challenges of the patient's evolving condition.

Section 4

As the day progresses, the patient's condition continues to evolve, presenting new challenges for the clinical team. Despite the initiation of non-invasive positive pressure ventilation, her oxygen saturation remains suboptimal, hovering between 90% and 92%. Her respiratory rate has increased to 28 breaths per minute, and she exhibits pronounced accessory muscle use, indicating significant respiratory effort. The team notes that her wheezing has intensified, and auscultation reveals diffuse crackles across both lung fields, suggesting worsening pulmonary edema and possible fluid overload.

The interdisciplinary team reconvenes to evaluate her current status and strategize further interventions. Repeat laboratory tests show a further decline in renal function, with serum creatinine rising to 2.8 mg/dL and blood urea nitrogen (BUN) increasing to 40 mg/dL. The patient's urine output has also decreased significantly, reinforcing the suspicion of acute kidney injury progression. In light of these findings, the nephrology team is consulted, and continuous renal replacement therapy (CRRT) is considered to provide gentle and effective fluid and solute removal, aiming to stabilize her hemodynamics and manage electrolyte imbalances.

Concurrently, the patient's inflammatory markers, including C-reactive protein (CRP) and procalcitonin, are markedly elevated, reinforcing the diagnosis of severe sepsis. Blood cultures are repeated to identify any potential secondary infections, and broad-spectrum antibiotics are adjusted accordingly. The burn wound appears increasingly necrotic, prompting the team to expedite surgical debridement. The integration of these multidisciplinary efforts aims to address the multifaceted complications affecting the patient's recovery trajectory, underscoring the importance of dynamic, evidence-based clinical reasoning in managing her complex condition.

Section 5

As the clinical team evaluates the patient's evolving condition, a new complication emerges, demanding immediate attention. Despite the initiation of continuous renal replacement therapy (CRRT) and adjustments to fluid management protocols, the patient's hemodynamic status becomes increasingly unstable. Her blood pressure drops to 88/54 mmHg, prompting concerns of septic shock exacerbated by fluid shifts and systemic inflammatory response. The intensivist adjusts the vasopressor support, increasing the dosage of norepinephrine to maintain mean arterial pressure above 65 mmHg, while the team considers adding vasopressin to further stabilize her circulation.

In parallel, the patient's respiratory distress escalates. Arterial blood gas analysis reveals a pH of 7.28, PaCO2 of 55 mmHg, and PaO2 of 60 mmHg, indicating acute respiratory acidosis secondary to hypoventilation. The decision is made to transition from non-invasive support to invasive mechanical ventilation to optimize oxygenation and ventilation. The team carefully selects lung-protective strategies, mindful of her underlying pulmonary edema and risk of barotrauma. Sedation is titrated to ensure synchrony with the ventilator while minimizing sedation-related complications.

These developments necessitate a reevaluation of her treatment approach, integrating ongoing renal support, escalated respiratory management, and robust hemodynamic monitoring. The team prioritizes repeated assessments and early recognition of further complications to tailor interventions dynamically. As they navigate this critical phase, the emphasis remains on preserving organ function and preventing further deterioration, setting the stage for potential improvement in the face of complex systemic challenges.