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History and Physical
Judy Lemon is a 69 year-old female who is admitted right now through the ER. She is a trauma patient and was burned by the explosion of a paint can that was thrown into her outdoor burn pile.
Past Medical History
MI 7 years ago
Accupril 20 mg PO Daily
Lasix 20 mg PO Daily
Pravachol 40 mg PO Daily
The client is awake and oriented but agitated and unable to report about the accident. Her voice is raspy, and she says she is cold. She is shivering. Hair on her head and arms are singed. She has areas of redness, waxiness and blisters covering her face, anterior neck, all her right arm, chest, abdomen, and anterior surface of her left arm. She weighs 135 pounds. She is reporting severe pain in her face, neck, and right arm.
Blood pressure (BP) is 110/52 (taken on her left thigh)
Heart rate is 132 bpm
Respiratory rate is 36
Question #1. Look at the case presented above and put the following list of interventions in order of priority. Make sure you are using your ABCD framework for help here.
Administer IV Morphine
Administer IV fluids
Administer 100% humidified O2
Administer prophylactic tetanus toxoid
Establish IV access
Initiate appropriate wound care
Insert indwelling urinary catheter
Prepare for endotracheal intubation
Estimate body surface area burned
Question #2. You are the ER Nurse. You have accomplished the above interventions and now you need to continue to closely assess and monitor your client. Complete the table below with listing the assessment abnormalities you will need to NOTICE and relate
|Assessment||What abnormalities will you need to NOTICE?||What would it mean?|
|Core Body Temperature|
Question #3. The case progresses and the physician orders fluid replacement according to the Parkland formula. Calculate the goal amount of Lactated Ringer’s solution to be infused for this client. in the first 24 hours and again for the first 8 hours.
**Note: You can use either the Rule of Nines or the Lund Browder method. Please relate which method you will be using and show your work.
Question #4: Explain to the husband, in lay terms, why you will be running this large amount of fluid so fast.
Question #5: As you are running the fluids into this client, please relate with full explanation (the reason why this is the priority) the top 3 priority assessments.
Question #6: The case progresses, and your client is now intubated. She also has a new central subclavian catheter for fluid administration. Finally, she has an NG tube placed. List the top six high priority nursing interventions that you will do with this new information.
Question #7: During the emergent phase, J.L. experiences significant edema in burn and non-burn areas. One result is that she cannot open her eyes. She becomes agitated and is groping around on the bed. Describe how the nurse can comfort her. Include nursing interventions, collaborative care, and verbal and non-verbal interventions.
Question #8: What is Curling’s ulcer? Why is your client at risk for this? What do you need to ensure you do to prevent Curling’s ulcer in this client?
Question #9: This burns unit uses a team nursing approach, including RNs and CNAs. Which of the following tasks can be assigned to the CNA?
- Perform capillary blood glucose testing.
- Apply SCD’s to legs after her bath
- Assess J.L.’s pain after IV analgesic administration
- Measure J.L.’s blood pressure using thigh cuff
- Record urine output for the shift
- Perform dressing changes on J. L’s graft sites
Question #10: After J.L.’s edema has subsided and her endotracheal tube has been removed, she refuses to participate in self-care and talks about not wanting to be “seen like this.” Describe ideas for therapeutic communication to help J.L.
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