A patient with partial-thickness burns covering 25% of the total body surface area is admitted to the burn unit. The nurse notes elevated heart rate, low urine output, and electrolyte imbalances. What is the nurse's priority intervention at this time?

B) Initiate aggressive fluid resuscitation

A) Apply topical antimicrobial ointment

B) Initiate aggressive fluid resuscitation

C) Administer prophylactic antibiotics

D) Prepare for immediate intubation

A patient with partial-thickness burns covering 25% of his total body surface area (TBSA) is admitted to the burn unit. He presents with signs of hypovolemic shock, including elevated heart rate, low urine output, and electrolyte imbalances. Which of the following interventions should the nurse prioritize to address his fluid volume deficit and prevent shock progression?

A) Administering lactated Ringer's solution intravenously

B) Initiating oral rehydration therapy

C) Applying ice packs to burned areas to reduce fluid loss

D) Restricting fluid intake to prevent edema

A patient in the burn unit is showing signs of worsening respiratory distress, with an increased respiratory rate and decreased oxygen saturation. Despite supplemental oxygen, arterial blood gas analysis reveals hypoxemia and respiratory acidosis. Which nursing intervention is most appropriate to address the patient's current respiratory status?

B) Prepare the patient for intubation and mechanical ventilation.

A) Increase the flow rate of the supplemental oxygen.

B) Prepare the patient for intubation and mechanical ventilation.

C) Encourage the patient to perform deep breathing exercises.

D) Administer a bronchodilator to improve airway patency.

A patient in the burn unit is showing signs of acute respiratory distress with a respiratory rate of 30 breaths per minute and oxygen saturation at 88% on room air. Arterial blood gases reveal a PaO2 of 58 mmHg and PaCO2 of 48 mmHg. What is the priority nursing intervention to ensure adequate oxygenation and ventilation?

C) Prepare for endotracheal intubation and mechanical ventilation.

A) Increase the rate of fluid resuscitation to improve cardiac output.

B) Initiate high-flow nasal cannula oxygen therapy to improve oxygenation.

C) Prepare for endotracheal intubation and mechanical ventilation.

D) Administer diuretics to reduce pulmonary edema.

A patient in the burn unit is suspected of developing septic shock. Despite aggressive fluid resuscitation, the patient's blood pressure remains low, and norepinephrine is initiated. Which nursing action is the highest priority in this situation?

B) Assessing the patient's urine output hourly to evaluate renal perfusion.

A) Monitoring the patient's blood glucose levels to prevent hypoglycemia.

B) Assessing the patient's urine output hourly to evaluate renal perfusion.

C) Performing passive range of motion exercises to prevent contractures.

D) Administering antipyretics as ordered to reduce the patient's fever.

A patient with severe burns is demonstrating signs of hemodynamic instability with increased heart rate, low blood pressure, and decreased urine output. Laboratory results indicate elevated lactate levels and mixed acidosis. What is the most appropriate immediate nursing intervention to prioritize?

B) Increase fluid infusion rate to improve circulatory volume.

A) Administer a vasopressor to increase blood pressure.

B) Increase fluid infusion rate to improve circulatory volume.

C) Prepare for renal replacement therapy to address oliguria.

D) Consult with the infectious disease team for antifungal therapy.

A patient with persistent hemodynamic instability, despite ongoing interventions, presents with tachycardia, hypotension, cool extremities, and oliguria. Laboratory results indicate a mixed respiratory and metabolic acidosis with elevated lactate levels and an increased white blood cell count. Which nursing intervention is the priority to address the patient's current condition?

B) Prepare for the administration of vasopressin to support blood pressure and renal perfusion

A) Administer a bolus of intravenous fluids to improve blood pressure

B) Prepare for the administration of vasopressin to support blood pressure and renal perfusion

C) Increase the frequency of vital signs monitoring to every 15 minutes

D) Consult with the dietitian to optimize the patient's nutritional support

A patient in the intensive care unit is receiving vasopressin to support blood pressure and improve renal perfusion. Despite initial treatment efforts, the patient's urine output remains low, and creatinine levels are elevated. The team is considering initiating renal replacement therapy. Which of the following nursing interventions is most important to perform before starting renal replacement therapy?

A) Assess the patient's weight and fluid balance status

B) Administer prescribed antifungal medication

C) Measure the patient's blood glucose levels

D) Check the patient's recent complete blood count results

A patient with an immunocompromised state is being treated for suspected sepsis with vasopressin and a broad-spectrum antimicrobial regimen. Despite these interventions, the patient's urine output remains low, and lactate levels are elevated. Which intervention should the nurse prioritize to address the patient's ongoing renal insufficiency and tissue hypoperfusion?

B) Initiate renal replacement therapy to manage oliguria

A) Increase the vasopressin dosage to further support blood pressure

B) Initiate renal replacement therapy to manage oliguria

C) Administer a fluid bolus to improve tissue perfusion

D) Continue to monitor and wait for culture results before making changes

Burns - Nursing Case Study

Pathophysiology

• Primary mechanism: Thermal injury causes coagulation of proteins and cellular damage, leading to loss of skin integrity and barrier function. This results in increased permeability, fluid loss, and risk of infection.

• Secondary mechanism: The inflammatory response is activated, releasing cytokines and mediators, causing vasodilation and increased capillary permeability, which leads to edema and hypovolemia. This systemic response can result in burn shock if not managed.

• Key complication: Loss of fluid and proteins from the vascular compartment can cause hypovolemic shock, characterized by decreased cardiac output and tissue perfusion, necessitating prompt fluid resuscitation to stabilize the patient.

Patient Profile

Demographics:

32-year-old male, construction worker

History:

• Key past medical history: Hypertension, smoker for 10 years

• Current medications: Lisinopril 10 mg daily

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Severe pain and blistering on arms and chest after a workplace accident

• Key symptoms: Redness, swelling, blister formation, fever, and increasing pain in affected areas

• Vital signs: Temperature 101.3°F, Heart rate 110 bpm, Blood pressure 145/90 mmHg, Respiratory rate 22 breaths per minute

Section 1

As the patient is admitted to the burn unit, an initial comprehensive assessment is conducted to evaluate the severity and extent of his injuries. Upon examination, the burned areas on the arms and chest are classified as partial-thickness burns, with significant blistering and erythema covering approximately 25% of his total body surface area (TBSA). The blisters are tense and fluid-filled, indicating that the dermis is still viable, but there is a risk of progression to deeper damage if not properly managed. Additionally, his skin is hot and dry to the touch, correlating with his elevated temperature, suggesting a systemic inflammatory response and potential infection.

Laboratory results reveal elevated white blood cell count at 15,000/mm³, supporting the suspicion of an infectious process possibly developing in the burn wounds. Electrolyte imbalances are noted with hyponatremia at 132 mEq/L and hyperkalemia at 5.6 mEq/L, indicating the body's loss of fluids and electrolytes due to increased capillary permeability and fluid shifts. These findings, combined with his elevated heart rate and low urine output of 20 mL/hr, highlight early signs of hypovolemic shock. The priority is aggressive fluid resuscitation using lactated Ringer's solution to restore intravascular volume and prevent shock progression.

The patient's pain remains severe, and he reports difficulty breathing as edema worsens, potentially compromising airway patency. The multidisciplinary team discusses the necessity for close monitoring of respiratory status and the potential need for intubation if respiratory distress continues to escalate. The nursing team implements an analgesic regimen tailored to his needs and collaborates with the burns team to initiate debridement and topical antimicrobial therapy to minimize infection risk. As the patient’s condition evolves, the team remains vigilant for further complications such as acute respiratory distress syndrome (ARDS) or sepsis, necessitating ongoing reassessment and intervention adjustments.

Section 2

As the patient's care progresses in the burn unit, the clinical team observes a change in his status, marked by worsening respiratory distress. Despite initial interventions, his respiratory rate has increased to 30 breaths per minute, and oxygen saturation has dropped to 88% on room air. Auscultation reveals diminished breath sounds in the lower lobes with the presence of crackles, indicating fluid accumulation and possible pulmonary complications. The nursing team promptly administers supplemental oxygen, but concerns about airway compromise and the potential development of acute respiratory distress syndrome (ARDS) prompt a reassessment of his respiratory management plan.

Further diagnostic results from arterial blood gas analysis indicate a partial pressure of oxygen (PaO2) of 58 mmHg and a partial pressure of carbon dioxide (PaCO2) of 48 mmHg, confirming hypoxemia and respiratory acidosis. This suggests the patient's ventilation is inadequate, likely due to the increasing edema and inflammatory response affecting lung function. The multidisciplinary team, including a respiratory therapist and intensivist, convenes to discuss the urgent need for mechanical ventilation. Intubation is performed to ensure airway protection and to provide adequate oxygenation and ventilation support.

Meanwhile, the patient's hemodynamic status shows slight improvement with fluid resuscitation, as his heart rate stabilizes to 96 beats per minute, but urine output remains low at 25 mL/hr, signaling ongoing renal hypoperfusion. Attention turns to optimizing fluid management, while continuing vigilant monitoring for signs of sepsis and other potential complications. Continuous reassessment of the patient's response to these interventions will be crucial in guiding further treatment decisions, ensuring a comprehensive approach to mitigate the risk of additional complications such as multi-organ dysfunction.

Section 3

As the patient's care continues in the burn unit, the clinical team notices a significant change in his hemodynamic status. Despite aggressive fluid resuscitation, the patient's blood pressure begins to drop, measured at 88/56 mmHg, indicating potential onset of shock. Concurrently, laboratory results reveal elevated lactate levels at 4.2 mmol/L, suggesting tissue hypoxia and metabolic acidosis. These findings prompt the team to consider the possibility of septic shock, given the patient's extensive burn injuries and compromised skin barrier, which increase his risk for infection.

In response to these developments, the medical team initiates a sepsis protocol, starting with broad-spectrum antibiotics to target potential pathogens. Additionally, a norepinephrine drip is administered to support his blood pressure and improve perfusion to vital organs. The nursing team closely monitors the patient's vital signs, urine output, and mental status, noting any changes that could indicate further deterioration or improvement. The patient's temperature is recorded at 38.9°C, consistent with a possible infectious process, further supporting the diagnosis of sepsis.

As the patient is transitioned to mechanical ventilation, careful titration of sedation is required to ensure patient comfort while maintaining optimal respiratory support. The multidisciplinary team emphasizes the importance of vigilant monitoring and reassessment to adjust the treatment plan as necessary. Ongoing collaboration between nursing, respiratory therapy, and medical staff is crucial in managing the complex interplay of the patient's pulmonary and hemodynamic challenges. The team's immediate priority is to stabilize the patient, prevent progression to multi-organ dysfunction, and pave the way for gradual recovery.

Section 4

As the medical team continues to manage the patient's care, a change in his status is noted during the next shift assessment. Despite ongoing interventions, the patient's heart rate has increased to 125 beats per minute, and his blood pressure remains on the lower side at 90/58 mmHg, indicating persistent hemodynamic instability. The nursing staff observes that the patient's peripheral perfusion is poor, with cool, clammy extremities and capillary refill time extending beyond 3 seconds. Additionally, the patient's urine output has decreased to 20 mL/hour over the past three hours, raising concerns about renal perfusion and potential acute kidney injury.

Laboratory tests reveal a further increase in lactate levels to 5.0 mmol/L, suggesting worsening metabolic acidosis and insufficient tissue oxygenation. The white blood cell count is elevated at 18,000/mm³, supporting the hypothesis of an infectious process despite antibiotic therapy. Arterial blood gas analysis indicates a pH of 7.31, PaCO2 of 32 mmHg, and HCO3- of 16 mEq/L, confirming a mixed respiratory and metabolic acidosis. These findings suggest that the patient is not responding optimally to the current treatment regimen, prompting the team to consider additional interventions.

The multidisciplinary team gathers to reassess the situation, contemplating the addition of vasopressin to further support blood pressure and improve renal perfusion. An infectious disease specialist is consulted to evaluate the need for antifungal coverage, given the high risk of opportunistic infections in burn patients. The team also discusses the possibility of initiating renal replacement therapy if oliguria persists, aiming to prevent further renal compromise. The immediate goal is to stabilize the patient's hemodynamic status, optimize tissue perfusion, and mitigate the risk of multi-organ dysfunction, while continuously reassessing the effectiveness of the current treatment plan.

Section 5

As the multidisciplinary team implements the revised treatment plan, including the addition of vasopressin to support blood pressure and improve renal perfusion, the patient's condition is closely monitored for signs of stabilization. Over the next few hours, the nursing staff notes a slight improvement in blood pressure readings, now at 98/64 mmHg, although the heart rate remains elevated at 120 beats per minute. Peripheral perfusion continues to be a concern, with the patient's extremities remaining cool and clammy. Capillary refill time shows minimal improvement, now at approximately 3 seconds. Despite these efforts, urine output remains low at 25 mL/hour, suggesting persistent renal insufficiency.

The infectious disease specialist recommends broadening the antimicrobial regimen to include antifungal coverage due to the patient's immunocompromised state and risk for opportunistic infections. A preliminary culture report indicates the presence of gram-positive cocci, raising concerns about a potential bloodstream infection that may be contributing to the patient's hemodynamic instability. In response, the team initiates a targeted antibiotic therapy while awaiting final culture and sensitivity results. Concurrently, the possibility of initiating renal replacement therapy is revisited, given the ongoing oliguria and elevated creatinine levels, which have increased to 2.1 mg/dL.

Despite these adjustments, the patient's lactate levels remain elevated at 4.8 mmol/L, indicating ongoing tissue hypoperfusion. The arterial blood gas analysis shows a slight improvement with a pH of 7.34, PaCO2 of 30 mmHg, and HCO3- of 18 mEq/L, suggesting a partial compensation of the metabolic acidosis. The team remains vigilant, recognizing the fine balance between stabilizing the patient's hemodynamics and preventing further complications. The next steps will involve continuous monitoring and reassessment of the patient's response to the expanded antimicrobial regimen and vasoactive support, with a focus on preventing the progression to multi-organ dysfunction syndrome.